Salt-sensitive hypertension and Classical Chinese Medicine, Part 2
This is the second part in a three part guest article series by Brandon Brown, student at National College of Natural Medicine and Chinese medicine blogger. You can access the first part of the article which covers salt in the macrocosm - nature. 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
Salt in the Microcosm
By preserving meat with salt, mankind was unknowingly creating a vicious cycle that would change the health of all people up to the present day. It is estimated that before the advent of this preservation technique people consumed no more than 0.5 grams of naturally occurring salt per day (g/d). After brining was put to use, daily consumption jumped to an estimated 10 g/d (because even though the meat is soaked in water to reconstitute it, no amount of soaking can remove a large amount of salt). This continued to climb throughout the centuries, upwards to nearly 18g/d (some estimates in Scandinavia indicate consumption near 100g/d) until the advent of refrigeration techniques which brought estimated consumption back down to its present day levels of 10 g/d. It is hypothesized that one reason for the stabilization at 10g/d instead of 0.5g/d is the addictive nature of salt: in the presence of continued salt loads the taste receptors on the tongue down-regulate their sensitivity to the salty flavor. However, as we will see, salt plays a crucial role in the nervous system, and it could be this current cultural bias for all things cerebral that creates our hunger for the briny crystal.
One of the most prolific cellular mechanisms in the body is the sodium-potassium pump. These pumps are found in a number of cells throughout the body, but most importantly in the nerve cells of the Central Nervous System. This mechanism, called Na+/K+-ATPase, regulates cellular chemistry and polarity by using ATP to remove 3 Na+ intracellular ions and replace them with 2 K+ ions. Na+/K+-ATPase is the mechanism that is responsible for the nerve’s ability to achieve the resting potential of approximately -70 mV by removing a net positive charge from the intracellular fluid with each pumping action. The creation of this potential primes the neuron to do work, in this case to release its charge as a rush of electrochemical ions, creating a signal that releases neurotransmitters at the terminal end of the neuron. The charging of this battery comes at a cost of a single phosphate group from ATP (converted to ADP). Because the pump is operating against the normal flow of the concentration gradient, energy is required to create this potential difference. This process is such that a large differential between sodium and potassium is created:
Table 1: Concentration of fluids by ion type (mmol/L)
| Ion | Extracellular | Intracellular |
| Na+ | 150 | 15 |
| Cl- | 110 | 7 |
| K+ | 5 | 150 |
Therefore the exterior of the cell is essentially salt water (NaCl), and the interior of the cell is largely dissolved potassium ions.
This is striking for a couple of reasons. First, in the resting state we see that salt water is kept on the outside of the membrane and only when an action or graded potential occurs is it allowed to rush into the cell. To reach the resting potential the cell must actively store potassium, and excrete sodium. In other words, the movement of salt (in this case sodium) into the cell causes the transmission of an electrochemical action potential. It is this action potential that is thought to give rise to all cognition and movement in the body. The axon, the long transmitting portion of the neuron, propagates the signal through voltage controlled sodium channels. The inward movement of salt is giving birth to movement and thought, whereas the expulsion of salt promotes stillness and thusly, stores great potential.
Secondly, the regular and crystalline lattice structure is perhaps more than metaphorical. In cognitive neuroscience, most theories of the mind involve describing the geometrical structure of the neural lattice as an explanation of functional capabilities. For example, the visual cortex is organized in columnar functional groups that serve to detect edges in the visual field. The creation of memory involves creating a new pathway on an already established lattice. Therefore, as sodium enters the cell it gives its organizational properties over to the cell to provide for the creation of new synaptic connections and lattice-like structures. The lattice-like structure of the salt is reflected in the lattice-like structure of the brain.
Figure 2: Columnar structure of neurons in the visual cortex and the octahedral geometry of sodium chloride
In terms of SSH research, it seems that excess dietary salt may not only change the sodium levels in the plasma but also in the cerebrospinal fluid, inhibiting Na+-K+-ATPase in both locations, perhaps giving rise to cognitive changes (Khalil 2005).
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In the next and last installment of this series, Brandon discusses salt from the perspective of Classical Chinese texts and brings the various ideas together. Please look forward to it tomorrow. -Eric
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Tags: crystal, human physiology, microcosm, nature, organization, salt, Science, waterRelated 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
How the Chinese organ clock yields a more nuanced view of the Heart
Here I will present a basic overview of TCM information concerning the Heart and then add a layer of information gleaned from the Organ clock (a more CCM way of looking at things). I want to do this to demonstrate how the Classical approach yields a more nuanced view than the straight organ-based TCM approach does, including a small aspect of the clinical relevance of this approach. Disclaimer : I’m still a student. :)
The Heart is a central organ system. From the perspective of governmental metaphor, the Heart is most easily compared to the Ruler of feudal society. What does the ruler do? It’s tempting to simply say that he rules and leave it at that. However, most rulers through history have acted less as hands-on managers of their empires and acted more as figureheads - acting as moral compasses, inspiring and motivating the people when needed, acting as interpreters of Divine law and generally providing a center point around which the wheel of government turned. The Heart is said to provide a similar function for the human body. To look at this and say that the Heart is “most important” would be erroneous. The Emperor without his ministers, without the workers, without the land - is nothing. It is an interdependent system. But, still, the Emperor is crucial and a lot of attention should be paid to those things that are crucial. We’ll do so now.
In TCM, the Heart is said to have many functions/associations:
- The Heart contains the Shen, which rules the other “spirits” of the Zang organs
- Shen, as I have explained briefly elsewhere, can be translated as “Spirit” but it contains more meaning than the normal English concept of Spirit. Many contemporary commentators talk about Shen simply as consciousness, but I feel it is more than that.
- The Heart governs the Blood Vessels
- The Heart acts as Ruler of the other organ systems
- The Heart, as related to the brain and consciousness, is in charge of many mental processes (one can see this as similar to the Heart’s function via its relationship to Shen - the fire of consciousness)
- The Heart propels the Blood
- The Heart governs speech
- There are other attributes, but these are the main ones mentioned in a variety of texts.
In truth, despite all of these things, most Heart related pathologies diagnosed in TCM have to do with mental function or, sometimes, heart organ abnormalities (such as blood stasis in the Heart yielding angina). In clinic, I mostly see Heart Qi/Blood deficiency (with palpitations and poor memory) and some version of the confusingly named “Heart Fire” resulting in insomnia, anxiety and some type of vexation. Rarely do I see doctors diagnosing a problem with the heart when there are circulation problems (blood vessels) or speech problems. Further, I think that there should be more attention paid to the fact that, as EMPEROR of the other organ systems, the Heart may be a great place to look when a seemingly unrelated pathology is difficult to cure with the methods we would normally utilize. While I will not focus much on blood vessel or speech problems in this article - I would like to do so in the future.
For now, to help us understand the Heart a little more deeply, I offer a brief exposition of some of the basic symbols associated with the Heart on the Chinese medicine organ clock. I will then describe some ways we can use this understanding to expand on the basic information we learn from TCM literature.
What do we learn about the Heart organ system from the organ clock?
Temporal nature : 11-1pm (High Noon) and the Summer Solstice
At first glance, the pairing of the Heart with high noon makes intuitive sense. This is the time we associate with the zenith of the sun, the burning off of morning fogs, the time when all things are apparent, illuminated, complete. But look again at the symbol for the taiji and superimpose this over the organ clock. Remember these symbol fields are multi-layered and 
while some aren’t meant to be compared one-to-one, the flow of Yin and Yang through the organ clock (and through the days on Earth) is a crucial piece of information in our understanding of organ systems.
This is the time of the birth of the Yin. Which brings us to another temporal aspect of the Heart - it is situated at the time of the Summer solstice. The solstice is the time of the greatest day length - so again, it is all flourishing and awake and alive. However, the hidden principle is the one of the birth of the dark - for the zenith of a thing always brings about its immediate descent into expiration. What goes up must come down.
What does this tell us about the Heart? That while it is a very Yang organ, as the Emperor should be, but it also contains a deep Yin principle within it. Our professor, Heiner Fruehauf, often relates the Heart to the feminine principle - which makes sense given this information. In that way, it may be more accurate for us to think of the Heart as the Empress - or some amalgam of the Emperor and Empress. Here is perfect control, high intelligence, beauty, grace, compassion, mercy and power. It is an intensely active principle - Yang - but with this huge strength of the Yin.
Why do I say that the strength of Yin is large when it is, in reality, just the beginning of the growth of Yin? Because the entire momentum of Yin’s growth starts at this point - it somehow contains the whole force of the future splendor of Yin’s fullness. It is strong in the sense that is young, vital, and on the ascent.
I think this Yin principle is very important. At the height of summer, at the height of noon, this is when we may have the tendency to go all upward and outward - but it is crucially important that we go within, nourish our deep spiritual nature. Some cultural customs bear this out - such as the tradition of the midday siesta and the many spiritual activities that go on around the summer solstice. I think that, in some ways, the failure to do this can be seen in American capitalist culture. The principle of constant up, out, grow, flourish is often not balanced with careful reflection, willingness to “stand down,” controlled descent and respect for the more passive aspects of the universe. This failure has penetrated the consciousness of many American people and others affected by this philosophy and may have something to do with much of the pathology we see today. More about this later.
Earthly Branch Wu : combined with the symbolism of the Horse in the Chinese zodiac
The Earthly branch Wu 午, reinforces what we’ve already discussed about the Summer Solstice - given that it is the Earthly branch associated with that part of the year. It is a picture of either a battering ram or a mortar and pestle, and thus we see again the idea of death or destruction in this life affirming and light giving symbol of the Heart. Wu 午 is also associated with the number five insofar that it is pronounced the same as 五, Wu - “five.”
This brings us to consideration of the association of the number five and the Heart. We should note that we’re talking about the fifth month when we talk about the Heart. The number five is extremely important in Chinese cosmology - witness the deep symbolism of the five elements and a whole variety of other symbolism assocaited with five. There’s just so much that I could say in this realm (and actually did, but then deleted to save your poor eyes) but I will have to stop here for the sake of article length.
The Earthly Branch Wu 午 is related to the Horse in the Chinese Zodiac. Remember, the Earthly Branches were associated with an animal to help them be easier to understand by the common people. The Horse is a particularly fascinating symbol for the Heart, which I could talk for a long time about. But consider just a few simple items. The horse is tireless, constantly galloping away, carrying great loads, even fighting in battle - just as our physical Heart must
persist throughout our lifetimes. The horse seems to share a Shen level connection with the human being - a really close rider and horse seem to read one another’s minds, few verbal commands are needed when the relationship is strong. The horse is one of the most beloved animals in all cultures, people sometimes take better care of their horses than they do their children!
I am certain there is more to understand about the horse - I would love to hear what people come up with in the comments to this post - please post below!
As always, there are many more symbols that we can pull from the organ clock to help us understand the Heart more deeply - but let’s work with what we have so far.
How does this help us understand the Heart more completely?
There’s a lot one could say about these symbols. The most important take-home message I have received is the crucial nature of respecting the Yin nature of the Heart. However, I don’t think you should start dousing your anxiety ridden patients with cooling herbs! On the contrary, they probably need Fu Zi. Which actually brings me to an important relationship and my overall point. You’ll excuse me if I diverge a bit into conjecture and philosophical exploration? Thanks.
We often talk about the relationship of the Heart and Kidney - fire and water. They are obviously related via their Liuqi designation of Shaoyin, or lesser Yin. We learn that the Shaoyin fire of the Heart must descend through the Earth to reach the Shaoyin water of the Kidney. In doing so, the cold Kidney water, the depth of our wisdom and lineage, is animated by the pure fire of Spirit and consciousness. Wisdom without use of that wisdom is nothing but a lifeless puddle. Likewise, the pure Kidney water must be steamed up to cool and contain the sometimes over-exuberant Heart Shen. Consciousness without wisdom quickly becomes tyranny and zealotry.
This is one way that I understand the importance of using Fu Zi even in the case of patients who appear to have lots of flaring Heat - such as patients with intense insomnia and anxiety. So many TCM physicians would balk at serving Fu Zi to such a patient. To provide one example of a powerful use of this principle, let’s go to that little book known as the Shang Han Lun.
下之後．復發汗．晝日煩躁不得眠．夜而安靜．不
嘔不渴．無表證．脈沈微者．乾薑附子湯主之
Xià zhīhòu．fù fāhàn．zhòurì fánzào bùdé mián．yè ér ānjìng．bù
ǒu bù kě. wú biǎozhèng．mài chén wēi, shēn wú dà rè zhě,gān jiāng fùzǐ tāng zhǔ zhī.
When precipitation has been used, yet sweating is then promoted so that the person in the daytime is vexed, agitated and sleepless, but by night time becomes peaceful and retching, thirst, exterios signs and great generalized heat are all absent, and the pulse is sunken adn faint, then Gan Jiang Fu Zi Tang governs (Mitchell/Ye/Wiseman version).
While I would like to think that most doctors would see patient with this picture - particularly the faint pulse - and realize that an intensely warming formula can be indicated, I think that most would still shun such strength and instead use something milder, more cooling, and most likely less effective.
One more point and then I’ll close this article. I believe that this fire-water relationship and the general Yin nature of the Heart leads us to realize the wisdom of having a well-developed spirituality. Only by combining the deep wisdom of contemplation (dwelling in the water) with the animating ecstacy of consciousness (dwelling in the fire) can we have balance. Advising our patients to nourish themselves in this way - of course without necessarily promoting a particular practice or tradition - may go a long way to helping them achieve greater health.
Tags: balance, clinic, earthly branches, fire, heiner fruehauf, horse, insomnia, law, organ system, Organ systems, organ-clock, shang-han-lun, spirituality, symbolism, taiji, traditional-chinese-medicine, waterRelated posts
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