Salt Sensitive Hypertension and Classical Chinese Medicine, Part 3
This is the final post in a three part series by Brandon Brown, blogger and student of Classical Chinese Medicine at NCNM. You can read the first two parts here and here, and can read references for the article by visiting Brandon’s site here.
Salt in the Classics
Salt is mentioned a number of times in the classics. In the Neijing Suwen, salt is considered the flavor of the Kidney. But what does this mean exactly? What follows are the most descriptive and instructive references from the Suwen followed by my translations.
Chapter 67
北方生寒，寒生水，水生鹹，鹹生腎，腎生骨髓，髓生肝。其在天為寒，在地為水，在體為骨，在氣為堅，在藏為腎，其性為凜，其德為寒，其用為，其色為黑，其化為肅，其蟲鱗，其政為靜，其令，其變凝冽，其眚冰雹，其味為鹹，其志為恐。恐傷腎，思勝恐，寒傷血，燥勝寒，鹹傷血，甘勝鹹。
“The north generates cold, cold generates water, water generates salty, salty generates kidneys, kidney generates the marrow, marrow generates the liver. In heaven it is cold, on earth it is water, in the body it is bone, its qi is hard, in the Zang it is the Kidney, its nature is cold(shivering), its virtue is cold, it is “use”, its color is black, it changes into solemn-ness(seriousness), it is worms and fish-scales, its government is stillness(jing), it causes, its pathological change is congealing coldness, its natural disaster is ice hail, its flavor is salty, it is will by fear. Fear impairs the kidney, thought defeats fear, cold damages blood, dryness defeats cold, salty damages blood, sweet defeats salty.”
Chapter 3
味過於鹹，大骨氣勞，短肌，心氣抑。
Excess salty flavor, causes great hardening of bone Qi, shortens the muscles, and restrains heart Qi.
Chapter 5
鹹勝苦。
Salty defeats bitter.
Chapter 10
是故多食鹹則脈凝泣而變色 。
Therefore, much eating of salty makes the pulse concrete and the color changing.
Chapter 22
心欲耎，急食鹹以耎之，用鹹補之，甘寫之。
The Heart desires softness, anxious people eat salty that softens it, use salty to mend it, sweet drains it.
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These excerpts from the Suwen indicate the myriad functions of salt. In Chinese Medicine, the Salty flavor is typically used to soften nodules as mentioned in Chapter 22, but we also see in Chapter 3, 10, and 67 that salt can pathologically also create hardness of Bone Qi, restrain Heart Qi, damage blood, and cause the pulse to be very firm. We can read these lines in typical Chinese Medicine fashion: that as a remedy, the salty flavor has a purpose in softening nodules, in moderation salt perhaps allows the Kidney to perform its function of storing, but pathological excess consumption of salt can lead to sclerosis.
In Chinese Medicine, the 5 flavors that go with the 5 organs typically counteract the nature of the targeted organ. For example, the energetic nature of the Liver is up and out whereas the flavor Sour astringes and contracts. The Heart, the fire organ, is up and bitter is down. For the Lung, its nature is contracting down and in, whereas pungent is the opposite: up and out. For the Kidney, as we see in Chapter 67 above, the energetic nature is definitely to store by freezing. Salt, must counteract this freezing nature, as we know that it does from our experience: salt both reduces the freezing point of water and raises the boiling point. The presence of salt liquefies ice, and thus can soften hardness (tumors, goiter, etc.). But because salt has an affinity with the Kidney it counteracts the storing nature of the organ, liquefying the Kidney energy (perhaps Jing) to be used in the body as Qi. Therefore we see again that, salt pushes out from the inside.
In their paper on the Classical Energetics of the Five Flavors (find in references section), Arnaud Versluys and Jessica Atkins describe the therapeutic actions of the five flavors in terms of tonification and purgation. In cases of excess or deficiency, the organs can be respectively purged or tonified with the appropriate flavor as shown in the figure below.
Figure 2: The actions of the 5 flavors
Organ: Excess of, purge with : Deficiency of, tonify with
Fire : Sweet : Salty
Earth : Bitter : Sweet
Metal : Pungent : Sour
Water : Salty : Bitter
Wood : Sour : Pungent
According to their interpretation, the salty flavor purges excess in the Kidneys and tonifies the Heart. In the case of SSH, chronic overexposure to dietary salt may act medicinally and impair or purge the storing function of the Kidney and thus over-tonify the Heart. Because the Kidney is also said to store pre-natal essence if there is no pathological influence to expel in the Kidneys, it is possible that what is purged is actually pre-natal essence (Jing). This essence is circulated throughout the body, transformed to Qi by the Liver function, and transformed and stored as Shen by the Heart. Shen, and thus consciousness, have as a substrate the brain, but Shen is housed in the Heart.
Therefore, the use of salt habitually may increase the Jing-Qi-Shen generation cycle, which makes us sharp and awake, but has the detrimental effect of possibly depleting pre-natal essence if the Kidneys are not constantly tonified. In the Suwen it mentions that at 8 times 7 years (56 years old), the hair (ruled by the Kidney) turns gray and the signs of aging begin to become visible. “The kidneys’ ability to excrete sodium declines gradually with age. If, with age, salt consumption is not reduced, sodium balance is maintained by raising fractional sodium excretion, which requires elevation of BP” (Khalil 2005). The 
accumulation of salt in the ocean over the years has begun to take its toll.
Because purgation of the Kidney in a non-pathological condition also tonifies the Heart, an interesting consequence of excess in the Fire element is that it easily overflows onto its child organ, the Earth. This would lead the Earth to become overwhelmed and thereby inhibiting it to control the Water element, whose function is diminishing due to the natural processes of aging. In CM, we say that the “Earth rules the muscles” and in the SSH case this clearly relates to the smooth muscle of the vasculature losing its ability to contract. Due to an excess in the Heart domain, the smooth muscle becomes dry, stiff, and brittle. The patho-mechanism of this is illustrated below.
The standard American diet is predominantly made of the flavors salty and sweet. The overwhelming absence of bitter (with the exception of Shen disturbing coffee and beer) and the overwhelming abundance of salt and sugar in the standard American diet may explain the danger of increased exposure to dietary salt.
Conclusion
It is not surprising that decreasing daily dietary salt intake will help in treatment SSH. However, what we learn from the classics and the physiology of salt in the body is that Kidney tonification is essential for SSH.
Because the Earth element has become so affected by this chronic exposure to salt, purging the Earth of excess with the bitter flavor will be important. Like a lone neuron in the brain, salt consumption is entangled in the higher social structures that predominate our times: working long hours, using the mind instead of physical labor for generating a living, exposure to a barrage of psycho-sensory information in terms of television, music, and people, along with increasing anxieties about all of it. Seen in this context it really is no wonder why SSH is a modern disease of the “developed” world.
Brandon Brown
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Tags: five phases, heart, human physiology, kidney, liver, lung, metal, nature, neijing, salt, student, translationsRelated posts
Salt-sensitive hypertension and Classical Chinese Medicine, Part 1
Editor intro
This is a Guest Post by 3rd year Classical Chinese Medicine student (and Chinese medicine blogger) Brandon Brown. Brandon is a friend of mine and an excellent student. He approached me with this paper and I immediately knew it would be a fantastic contribution to the site as many folks have asked me for rigorous examinations of the cross-pollination between Western and Chinese science as expressed in medicine. This will be a 3 part series released over the next 3 days, please feel free to leave comments - Brandon is a regular reader of the site. I should note that he has posted references for the entire series on his blog, you can access those references by clicking on this link. -Eric
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Author intro
The following three posts are from a paper I wrote in the Winter of 2008 for Dr. Edward Neal’s Clinical Physical Diagnosis course at NCNM. It is my attempt to apply classical Chinese medical knowledge to a modern disease processes that is pervasive, salt-sensitive hypertension. In looking at all modern diseases, I believe it is extremely beneficial as CCM practitioners to understand the patho-mechanism as presented to us by current research in Western materialism. Because yang (energy) leads and yin (substance) follows, by knowing the yin we can garner important clues that can allow our yang treatments to strike with more clarity, force, and efficacy. I welcome your thoughts and comments. - Brandon
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Salt-sensitive hypertension : Western science and the macrocosmic view
“The highest good is like water, it settles in the lowest place where people do not like to be.”
Dao De Jing
It is estimated that salt-sensitive hypertension (SSH) accounts for over two-thirds of people over 60 who have primary hypertension . Though there are genetic variants to the tolerance of the amount of salt that effects hypertension, dietary sodium is considered the most important environmental influence. This begs the question: why are some people who are hypertensive experience a salt sensitivity and others do not? The answer to this question may lie in the theories of Chinese Medicine and in the fundamental nature of salt, and its relationship to water and the Kidney. I will first give a summary of hypertension in western terms and discuss current research theories. Following this, I will discuss salt: cultural symbology, the natural formation, and specific references in the medical classics. By so doing, I hope to show how an ancient medicine sheds important light on this modern disease, through the connection of the Kidney and the Heart.
Hypertension - a more Western perspective
Primary hypertension is defined as chronically elevated blood pressure where systolic arterial blood pressure consistently exceeds 140 mmHg or greater. To be considered primary, the hypertension must be idiopathic, and not due to secondary factors such as kidney disease or adrenal tumors, for example. Primary hypertension is considered to be a major risk factor for strokes and cardiovascular disease, and is a leading cause of chronic renal failure . Heart disease is the number one killer in the United States, leading to well over half a million deaths per year.
It was observed in a strict rice and low-sodium diet study performed in 1944 that patients with kidney disease and hypertension were able to lower their blood pressure by as many as 100 mmHg in some cases . Current theories of the pathological mechanism of SSH posit abnormalities in renal sodium transport in the nephron structure of the kidneys . The cause for these kidney abnormalities are thought to be caused by both genetic and environmental factors. Because salt generally attracts water through osmosis, increased blood sodium not excreted by the filtering mechanisms in the kidney causes an increase in the water content of the blood, thereby causing the vessels to swell. This increased swelling, is an increase of “total peripheral resistance of the vasculature”, and is thought to create a long-term load on cardiac output ultimately leading to heart failure. Therefore, we can say that the presence of salt in the blood pushes out from the inside. This is contrary to the renin-angiotensin mechanism of the Kidney, which vasoconstrics and thus pushes in from the outside.
Salt in the Macrocosm
“Ye are the salt of the earth; the best of the human race.”
Jesus Christ in Matthew 5:13
The creation story of salt begins with fresh water falling from the sky as rain, and landing on the elevated earth. The nature of water is to always seek the lowest point of any terrain. The rain water falls on the hills at first as drops, which coalesce to form a trickle, which then join to form streams and these eventually join to form massive rivers, which empty into the sea. On this journey, constant erosion takes place as minerals are stripped from the earth and mountains and carried to the ocean. Because of its polar nature, water acts as a solvent to all matter. Place any material in water, and given enough time, transformation will occur. Metal will rust, vegetation will decay, and other liquids will eventually diffuse and become one with the water. The mineral rich streams, which still taste like fresh water to us, empty into the vast oceans that today are heavily salted and totally unpalatable, even though they are only 3.5% salt . The oceans continue to accumulate more and more salts because over millions of years evaporation extracts the water from the ocean, but not the minerals. The minerals are too heavy and earthbound to be steamed up to the heavens. This process is depicted in Figure 1.
Figure 1: The generation of saltwater
Of special interest in Figure 1 is how it reflects the generating cycle of the 5 Phases (五行). That is, Water falls from Heaven onto Earth and Metal, flowing down to Water, where through the energy of Fire, the fresh water is evaporated upwards toward heaven by the process of Wood. What is left behind is a storehouse of salt. Because of this, we would expect to find that places of warmer climate would have oceans with higher salt content. This is in fact the case, as places such as the Mediterranean Sea have a much higher salinity than that of cold water oceans (the Arctic and Northern Pacific, for example).
Salt is very much a dissolved solid from the Metal sphere. It is highly organized and crystalline, and looks almost identical to ice (Figure 2). Salt was the first currency of the civilized world, due to its value as a preserver of meat. As Richard Manning writes in Against the Grain, it was the ability to preserve and store meat which essentially lead to the creation of wealth and signaled the shift from nomadic hunter-gatherer societies to those of sedentary agrarian caste systems. Earlier than 800 A.D., the Yellow Emperor himself is said to have fought the very first war over the precious commodity . In 450 B.C., iron was put to use to boil sea water in huge pots to extract salt, a method that was used for the next 2000 years. By expediting the evaporative process, larger amounts of salt could be garnered more quickly and thus a greater amount of wealth could be amassed. Even in these ancient times salt stored, or preserved, wealth. To this day, the word “salary” comes from the Latin “salarium”, or “to be payed with salt.”
Not surprisingly, then, salt as a symbol of wealth came to symbolize all that is good. It is common practice to throw salt over the shoulder to ward off the devil, sumo wrestlers throw salt in the wrestling ring to purify it before a match, and placing piles of salt in tombs purifies the soul’s journey from earth to heaven, for example. Throughout history and across the world, in almost every culture, salt has been used in religious, medical, and cultural contexts to purify and clean the soul and the body from evil and disease . Ultimately, however, it is argued that salt is a often a cultural metaphor for semen, and the essence of man.
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In the next article in this three part series, Brandon will dive into the microcosm - discussing the mechanisms above as they reflect into the human body. Look for it coming soon.
Tags: disease, environment, heart, kidney, macrocosm, metal, nature, salt, Science, water, western research, western-scienceRelated posts
Learning about the Large Intestine using the Chinese Organ Clock, Part II
In the first part of this post on the Large Intestine organ system, we discussed some basic information including: the name and official related to LI, the five element and six conformation designation and more. In this post, I’d like to dig a little deeper into the symbolism of this important organ system. In particular, I’d like to reflect on the way that the Large Intestine organ system, similar to its Metal partner the Lung, creates a conversation about purity and impurity in the body.
Hexagram 34 : Da Zhuang : 大壯
There was some discussion of this hexagram in Delli’s post about the balance of Wood and Metal energy, and I’d just like to add to that description. Stephen Karcher interprets the name of this hexagram as “Invigorating Strength” in his Total I Ching, others call it variously Great invigoration or Great strength and of course many other translations exist. I think that Karcher puts it well when he interprets the text as indicating,
“The way to deal with it is to focus your strength through a central creative idea. Putting your ideas to the trial will bring profit and insight. Beware of hurting others through excessive use of force” (Karcher 271).
This is, in a way, a perfect encapsulation of all that I talked about in the previous article! In the energy of Large intestine, we have great capacity to focus (transmit the Dao, give birth, get things done - just PUSH) and the danger for that focus and force to turn destructive (the Dictator, great fevers). On a more psychological level, Large Intestine energy gives us the ability to focus our power on a single point and move through any difficulty until our deed is done. This is a great skill whether we are employing it in the bathroom (!) or the boardroom. (Editors note: How could I resist?)
The more esoteric factors come in when we consider the trigrams that this hexagram is composed of - which Delli already elegantly spoke about in the article referenced above. The combination of Wood over Metal, Thunder over Heaven creates a situation of invigoration, movement, excitement and - ultimately - new beginnings. We must clean out the old to bring in the new, and the force that allows us to do this must be up to the task. Heiner Fruehauf would often talk about the Large Intestine as being the purest of the organ systems, because it has to deal with the least pure of substances - it requires great purity to maintain deep purity for the body. We can think about the use of colonics on a base level to represent the essence of this ideal - keep the colon clean and free flowing and your body can detoxify.
More about Metal
Metal has many characteristics and associations that resonate with what we’ve discussed about Large Intestine. The color of Metal is white - the purest color in the spectrum, the reflection of all color back to the observer - nothing “sticking” to the object. Most Western cultures tend to associate white with purity, chastity, even divinity. The scent of Metal is pungent - which I always associate with much incense. Incense and other pungent things can be used to open the mind, to communicate with Spirit. All of these upward, brilliant, pure things infuse the Large Intestine with the ability to deal with impurity - the ability to “transmit the Dao/way” and to create “change and transformation.”
Importantly, the Yin emotion most often associated with Metal is sadness or grief. When people have a great injury to a Metal organ system, they have a tendency to stay in grief, to not let go. This is a malfunction, in a way, of the descending quality of Metal. You are unable to let things fall where they may. On the other hand, we can think of it as becoming dragged down in the filth, unable to let the filthy things leave our view but instead stay there creating toxicity. Of course it is normal to have sadness when a sad event has occurred - but the tendency to hang on to these things is never healthy. We must learn to let go of the things that are ready to pass (Large Intestine) and take in the freshness of the new world we are privileged to live in (Lung).
Large Intestine 1 : Metal point of the Yang Metal channel : 商陽, shāng yáng, the metal note
To show how this can manifest on a very specific practical level, consider the metal point on the Large Intestine channel - LI1, the Jing-well point of the Large Intestine channel. As many Jing-well points, LI-1 is excellent at clearing acute accumulations of heat, but on the Yangming Large Intestine channel, perhaps this effect is even more emphasized. Its use in descending the fire in cases of high fever certainly resonate with what we’ve been discussing so far. It is also known for its ability to descend Qi stagnation in the chest through its connection to the Lung - again we see use of the physiological descending property of the Large Intestine. Some Worsley-style five element acupuncturists use this point to descend mental stagnation, encouraging the patient to “let go” of old emotions that no longer serve. Certainly the rest of us could learn something from this usage.
I will end this article here, though clearly there is much more to say. I’ve only provided a brief glimpse into the symbolism of this mediator of the pure and impure. I’m interested to hear comments from readers - how does this resonate with your picture of Large Intestine and how does it clash? Can you see any practical benefits to working with this kind of knowledge? NCNM students, chime in with your further understanding of this material - we’ve learned so much - let’s share! :)
Eric
Tags: chinese-organ-clock, hexagram, large intestine, metal, organ system, Organ systems, organ-clock, symbolismRelated posts
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