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"This little piggy goes to market, this little piggy stays at home...."
The associations can remain remarkably vivid, even into adulthood, often evoking memories of excitement, anticipation, fear, and ultimately loss of control as we remember dissolving into a delirious state of ticklishness to the inevitable refrain of: "wee wee wee all the way home!". The sensation, though elicited voluntarily and in jest, not only shares some of the qualities of what we call "running piglet" in Chinese medicine but also, coincidentally perhaps, invokes the same image of the frantic, squealing little pig of which we will say more in a moment.
A quick informal survey amongst a dozen colleagues and students of mine recently revealed the following fairly unanimous but no less surprising responses to the question: "What do you know about running piglet syndrome?"
These findings appear to suggest that we, as clinicians, teachers, and students of Chinese medicine, are conversant with the term yet not so clear about what it actually means, from where it derives, and how best to treat it. But it was in response to the last finding, the apparent perception that familiarity with this ancient term and its manifestations no longer seemed relevant to the contemporary clinician, that I decided to write a short article based on my own experience of encountering and treating running piglet.
This article will serve as an introductory overture for my workshop on this topic at the PCOM symposium in November, 2009, and as a primer for two more detailed articles I am submitting for publication later this year in journals here and abroad. It is not my intention here to discuss Diagnosis and Treatment of this condition in any detail. I will reserve that for the workshop and subsequent articles. For now, I wish to identify the main presenting signs and symptoms of running piglet sources as well as entertain some of the possible mechanisms involved. Some contemporary English- language authors have already published useful material, though further research is needed on what I believe to be a widespread disorder particularly prevalent in high-stress, urban populations such as I encounter in my office. In particular, I will be presenting some of the Japanese Kanpo approaches to diagnosing and treating running piglet in the workshop, focusing especially on abdominal diagnosis and the application of appropriate classical formulas.
Origins, Definition & Mechanisms
Let's begin with two contemporary definitions of running piglet from leading authors in the field: "A sensation of qi rushing upwards from the lower abdomen to the chest, epigastrium, and throat. There will generally be concurrent pain discomfort, alternation of heat and cold, and palpitations." "Qi is discharged and rushes up the penetrating channel [chong mai] causing great agitation and anxiety" and "rushes up to the throat with such ferocity that the patient feels he is close to death. It attacks and then remits". As to its classical origins, the term itself, Ben Tun Qi Bing first appeared in the Ling Shu Jing: "When the pulse of the Kidneys is slightly urgent...sometimes the accumulated qi of the Kidneys flares up to the region of the chest...." This passage clearly talks of symptoms originating in the lower abdomen (as confirmed by the Chi position pulse findings) and moving upwards towards the heart (or chest) area which includes the epigastrium.
In channel terms, this involves not only the trajectory of the Kidney channel itself (including its internal branch up to the throat) but also, inevitably, the Chongmai which originates in the "Kidneys" (aka. Uterus, lower abdomen) and travels up the core of the body, anterior to the spine, connecting uro-genital, reproductive, digestive, and circulatory organs and their respective functions. Not surprisingly, therefore, symptoms include abdominal pain and spasms, distention, belching, reflux, palpitations, shortness of breath, chest and throat constriction, and generalized anxiety. These are all characterized by an uncomfortable sensation of upward moving gas or air through the abdomen and chest as is typical of many "counterflow" phenomenon in this case specifically known as Running Piglet qi.
As described in the following passage from the Huang Di Ba Shi Yi Nan Jing: "Kidney accumulation is called running piglet. It emits from the lower abdomen and ascends to reach below the heart. It is pig-like in form." This reference to the image of a pig has been discussed by various authors as possibly referring to the sensation felt by the patient as if little pig feet were trotting up and down their abdomen and chest, or that the subjective sensation of panic often experienced along with the physical signs somehow remind one of a herd of nervous, squealing pigs. There is undoubtedly a hysterical, frantic quality to much of the symptomology that defines this syndrome. In fact, as I will suggest later, many of the Western correlates to running piglet are psycho-emotional in nature.
We also find internal medicine references from classical herbal texts such as this from the Shang Han Za Bing Lun: "The master said: ‘Ben Tun syndrome starts from the lower abdomen and rushes upward to the chest and throat. The attack is very serious and causes the patient unbearable suffering with a feeling that she might die. Fortunately, the symptoms will gradually reduce and subside. The cause of this syndrome is due to fright and terror' ". This passage mentions not only the trajectory of the counterflow sensation but also its intensity, suggesting that the abiding subjective experience is one of abject panic with a genuine sense of impending doom or death. This, in fact, correlates closely with patient reports of some of the symptoms of Panic Attack as defined in the DSM-IV diagnostic criteria. Indeed, experiencing a panic attack "is said to be one of the most intensely frightening, upsetting, and uncomfortable experiences of a person's life". The kind of somatic and cognitive symptoms associated with this disorder, as with running piglet, are intense, often random and abrupt, but always frightening and incapacitating, often resulting in admissions to the ER (even though they are usually short-lived and far from life-threatening).
The text attributes Ben Tun to "fright and terror", which amongst the correspondence theory of the Five Phases are said to "scatter" the qi of the Kidney and Heart, causing disharmony between Fire and Water. Certainly this is one way to understand the manifesting signs and symptoms of running piglet. Another is to realize that mistreatment
(iatrogenesis) may provoke improper movement of the qi, causing counterflow as the following passage suggests: "When red-hot needling (is used to) cause sweating, the needling site contracts cold, and if a red node forms, (the person) will develop running piglet," Here the text points to the role of pathogenic cold in distorting the normal flow of qi once it enters the body, in this case as a result of improper needling, leading to counterflow problems.
The text gives another example of mistreatment leading to running piglet: "When, after sweating has been promoted, the person has palpitations below the umbilicus about to become running piglet, Fu Ling Gui Zhi Gan Cao Da Zao Tang governs." Here, the implication for the cause of running piglet is damage to Heart Yang due to improper sweating or other precipitation. When, as a result, Heart Yang fails to contain Kidney water, there will be improper movement of pathogenic water in the interior, signified by pulsations below the umbilicus causing running piglet qi.
I find these early references to running piglet significant as they derive from both acupuncture and herbal texts of the Han Dynasty (202 BCE - 220 CE), arguably one of the most influential periods in Chinese medical history. Since the literary and clinical traditions of the various branches of Chinese medicine, though related in many aspects, have nonetheless evolved in their unique and distinct ways, we may assume that these common references to running piglet across different clinical disciplines point to the frequency with which it was encountered in the population at the time. In this article it is my assertion that the disorder is as commonplace today as it was then, notwithstanding the different names by which it is known in contemporary clinical terms, as I have mentioned.
In terms of abdominal patterns related to running piglet, it is common to both observe and feel pulsations (Fig.1) anywhere along the midline of the abdomen between the pubic bone and the zyphoid process, and the area around Ren 14/15 can often be swollen or raised, a probable symptom of Renmai Repletion. On palpation, the area between Ren 9 and Ren 15 often feels extremely tight and is uncomfortable to the patient. Such tension in the superficial portions of the fascia may relate to repletion in the Tendino-muscular channel of the Heart, whose trajectory moves through this area. There is also the possibility of accumulation in the Liver channel as it disperses through the intercostal regions, giving rise to findings such as hypochondriac and epigastric tightness and resistance (see figs.2 & 3).
There will be a tendency in some patterns of running piglet, where pathogenic water is present, for confirming the Epigastric Splash Sound (see fig.4) upon percussion of the upper left quadrant of the abdomen. Additionally, there may be a deep emptiness palpated on the midline between the navel and the pubic bone (see fig.5) reflecting Kidney depletion. On the pulse, there is often a hurried quality, whilst there may be a wiriness, especially in the third position (Kidney). The cun positions may be weak (Heart and Lung). The right guan (Spleen & Stomach) may be soft and big.
The above passages go some way to explaining the origin, nature, and manifestations of Running Piglet Syndrome. From a psycho-emotional perspective, the primary cause of running piglet clearly involves trauma of one kind or another and, thus, the primary mechanism of counterflow occurs within the Shaoyin and its related orbit (including Chongmai & Renmai). In terms of a Zang-Fu perspective, the Heart and Kidney relationship seems most affected, whereby depletion of Heart Yang Qi (from sweating, cold damage or shock) fails to control Kidney Water Qi, which may then run counterflow.
Equally, Kidney Yang Qi may be damaged (by cold, taxation fatigue, or fright) with the same resulting counterflow pattern. In a similar pattern, Spleen and Stomach Yang Qi may also be damaged (by cold environment or diet, obsessive-compulsive thinking & behavior), impairing transformation of fluids leading to their counter flow. Conversely, patterns of both depletion and repletion in the Liver can illicit counterflow such as Liver Yin Insufficiency or qi constraint leading to Fire rising.
Differential diagnosis in both Chinese and Western medicine, as well as treatment strategies will be the focus of both the workshop in the fall and the articles I am currently working on. In particular, I will be discussing Kanpo approaches to evaluating running piglet from a qi, Blood, and Fluid perspective as well as acupuncture, Kanpo and Shiatsu treatment protocols. OM
Traditional Asian, Chinese and macrobiotic medicine practitioners often stress that to achieve and maintain good health, one needs to tend to one's physical, emotional, and spiritual well being as well as care for others. Treatments of various forms such as shiatsu/acupressure, acupuncture, energy healing, etc. can help greatly, and at times are deemed necessary.
Yet, they are meant to be conjunct with daily fundamental practices of healthy eating, regular movement, exercise, and active work. These comprise a personally and socially interactive life. Dietary guidelines and recommendations are devised on the basis of traditional Chinese and macrobiotic intake and diagnosis for general use and/or for one's specific and personal health needs of body/mind. Food energetics and diet therapy involve the removal of foods that perpetuate the imbalances at hand, and supplementation with food types that help heal and correct the imbalance.
Chinese medicine and macrobiotics liken the body's environment to that of nature. The practitioner observes and assesses the possibilities of phenomena manifesting within the body. Phenomena include cold, damp, wind, heat, dryness, and yin and yang harmony, along with the synergistic emotional and spiritual manifestations. When these present themselves in what is termed either "excess" or "deficient" amounts, the mind, body, and spirit can be adversely affected.
Each food type is understood to have warming, cooling, drying, moistening, descending/ascending, and yin and yang qualities. Some foods act with more than one energetic influence. For example, if an individual is seen to have internal heat, the practitioner is likely to choose foods that balance and create more internal cooling in order to help disperse the heat appropriately for that person's condition. The guidance includes foods for the particular health concerns if any, the season, emotional needs, and energy needed for daily work and life. The practitioner assesses the person's ability to understand the recommendations and to practically implement them into their lives.
Through the lens of the Five Elements, looking at the whole person and their environment, we apply the way food is chosen, prepared, and consumed, and how this impacts the type of energy-qi-that the body produces. The effect of food on the state of well being is paramount. An understanding of food energetics plays a vital role in creating harmony and is a powerful and very useful tool towards restoring balance. Self-empowerment should be encouraged and inspired to be a goal for the person receiving guidance and treatment.
Food energetics and diet therapy are not necessarily concerned with weight loss, although it is known to help tremendously. It brings about internal organ balance and strengthens the underlined organic weaknesses so that the foods ingested are transformed with the least amount of strain on organ/energy output, while providing the maximum dietary benefit to build essential body essences like qi, fluids, and blood.
While looking at the Five Elements (a magnificent and thought provoking study containing easy and complex insights) and their relationship in health, nutrition, and healing, we need to be cognizant of the reality that there is no fixed or static method to understand others and ourselves. We need to be flexible with our knowledge and to continually activate and be in touch with our intuition and spiritual higher selves for solving problems and for creating the most value from them. "Bearing and nurturing, Creating but not owning, Giving without demanding, This is harmony." Quote from the Tao DeChing Recommendations for Nourishing the Elements:
A preferred time to nourish an element is considered to be through the nourishing/parent element, which is the preceding element/season.
Spring is when living things begin to grow and express expansive yang qi. The external influence of wind may invade a person making one vulnerable to colds, flu, or a relapse of a past illness. The sour taste in moderation nourishes the strength of liver qi as in citrus, lemon, pickles, sauerkraut, yogurt, plum, umeboshi, liver, leeks, barley, wheat, chicken, and leafy greens with especially sharp taste such as watercress and scallions.
If liver qi is stagnated the emphasis is on lightly cooked foods with more sharp and pungent tastes and less dense foods as dairy, meat, and baked flour products. Some recommended foods include lemon, pickles, dandelion, spinach, corn, celery, onion, lettuce, mustard greens, yam, barley, wheat, sesame seeds, dates, peanuts, onions, cilantro, bamboo shoot, mushrooms, and quinoa.
Negative emotions like anger, resentment, frustration, irritability, bitterness, or "flying off the handle" are involved here. There may be a tendency for unresolved frustrations to emerge in inappropriate ways such as arguments, negative expressions towards others, and impatience with oneself often related to unfinished projects or perceived failures. From a Buddhist or psycho-spiritual view, what we feel are failures are potentially great opportunities to re-establish our selfconfidence, to see the benefits of the experience and to create new seeds and goals for our future.
Balanced wood energy is reflected in our ability to manifest patience and compassion, foremost towards ourselves while reaching out to help others from a base of a smooth-unfettered life force to create peaceful, affirming dialogue, relationships, and environments. Also See Water.
In the summer, heat is rising and in order to maintain good health it is important to restore and maintain normal levels of yang as well as to balance one's health with yin, cooling influences, and foods. The bitter taste nourishes the heart qi as in dandelion root and greens, sesame seeds, celery, quinoa, scallions, asparagus, alfalfa, citrus peel, wine, lamb, and apricots. If heart qi is overly yang, the emphasis is on lighter grains and cooking styles, cooler foods like salads with dandelion, lots of alfalfa tea, light leafy greens such as nisuma, sprouts, tofu, natto, and less or no spices, baked foods, or alcohol.
The daily diet should contain more cooling preparations, salads, vegetables, and fruit to stimulate the appetite and provide fluids. One should avoid heavy, oily, and very salty or sweet foods. External influences of summer heat and dampness are common in summer, causing people to be sweatier, thirstier, and more irritable and tired. Emotions, negative-lack of enthusiasm and vitality, mental restlessness, depression. There may be a lack of lightheartedness or ability to laugh and enjoy life; or, the opposite- constant laughter and incessant chatter.
Balanced fire energy is reflected in the ability to emanate joy and to experience and show a love of giving and receiving for oneself and others. The more we honor and put love and joy into our own lives, like a magnet the more love is available to come to us-from various people and sources. Also see Wood.
In late summer, yang is still prevalent while yin qi begins to predominate as we are cooling from summer. Nature is in its central position of balance as it quiets the fire and moves deeper within, preparing for autumn. The sweet taste nourishes spleen and stomach qi as in pumpkins, cooked onions, squashes, sweet potato, peach, dates, apple, cherry, beef, millet, almonds, coconut, and cooking with mirin or maple, barley, or rice syrup. One may increase animal foods as the climate begins to cool. If spleen qi is deficient, the emphasis is on more root vegetables and longer cooking styles, using easy to digest yet strong dishes such as Oden Stew or Congi with brown rice or millet. Avoid dairy and damp, heavy foods such as cakes and ice cream.
The movement of fire-active foods will help replenish. Chewing food and eating smaller meals will strengthen earth energy and therefore our digestion. One should be conscious that eating excess fruits and oils in the summer may give rise to mucus, phlegm, and discomfort in the late summer, affecting the stomach and lungs. Emotions, negative-worry, dwelling or focusing too much on a particular topic, excessive mental activity, and work. Sitting for long periods of time can deplete earth qi. The negative splenic disposition can be one of suspicion, that is, lack of trust in oneself or others. The flip side of this is a tendency to be overly sympathetic and to easily become codependent on others.
Balanced earth energy is manifested by reliability, composure, empathy, and an inner sense of self-value, all which help create trust of, and from, others in our environments. Also see Fire.
Things begin to fall and mature in autumn; yin qi continues to predominate and yang qi to wane. It is advisable to eat more food with pungent, salty, sour, and sweet tastes. The pungent taste nourishes the lung qi as in raw or lightly cooked onions, mustard greens, daikon radish, ginger, less oily fish, mustard, soy beans, lotus root, cloves, cayenne, basil, mint, tofu, rice, salads or steamed veggies with lots of greens, wheatgrass juice, pear and an increase of sea veggies such as hiziki, wakame, and kombu which will strengthen the blood, and circulation of qi.
If lung qi or large colon are sluggish or congested, a remedy is a ginger or mustard compress on the back shu point area-between the shoulder blades-of the Lungs or for the colon on the lower back or Hara-lower abdominal-area. (Use compress only if you know it is safe at that time or if recommended by an experienced guide.) Pungent foods assist the lung qi to disperse. Sour flavors are cool in energy and tend to move downward benefiting the lungs' descending function. Salty foods are necessary in moderation all year and at this time they can be increased to assist the oncoming winter/water season.
One thing to focus on is to moisturize internal dryness caused by lack of body fluid from dry heat and/or a dry climate, and thus help restore normal lung function. Emotions, negative-grief, sadness, detached. There may be a tendency to suffer loss and not feel able to let go when it is time to move on from a challenging situation. Balanced metal energy is manifested in an openness to life's experiences, being flexible, able to forgive, and to truly let go of past painful attachments, to create, and to accept new people and experiences, prosperity, and abundance in one's life. Also see Earth.
This is the time when yang qi becomes latent and yin qi dominates and we need to conserve energy and build strength to be ready for spring. Storing our reserves is vital for the strength of our kidneys. It is advisable to eat more food with salty, sour, and bitter flavors. Eating excess glutinous, uncooked, and cold food damages the kidneys, spleen, and stomach, and should be taken in moderation. Foods with more oils help to retain warmth. The salty taste nourishes kidney qi, as in sea veggies, sea salt, aduki beans, black soybeans, burdock, pork, fish, walnuts, black sesame seeds, dark leafy greens, figs, kombu tea, shiitake, cucumber, reishi, and daikon. If kidney qi is deficient, nourish with combined sea and land vegetable dishes such as dried daikon in stew or dark leafy greens in fish stew. Nourishing kidneys, which are highly active in winter, strengthens their storage function, helping to preserve their essence, which means preserving core life energy.
Although individual sea vegetables can be targeted for nourishing each element, this rich source of minerals is highly important for nourishing and strengthening the kidneys, bones, and blood. Use hiziki, kombu, arame, wakame, dulse, nori, black fungus, kelp and more. Emotions, negative-fearful, weak willpower, insecure, aloof, and isolated. There may be a tendency to hold in one's dreams and goals, to withhold sharing with others, and to have little faith or confidence in one's ability to make things happen in life.
Balanced water is manifested when the desire, will, and courage to manifest movement and changes in life are prevalent. Self-confidence is known to be housed in and reflected by our kidney Qi which becomes strong from foods, exercises such as qi-gong, and spiritual growth, as well as the courage to find, believe in, and move towards our higher goals and dreams. When we positively activate and direct water energy the planning and manifesting, stages of wood and fire become active and the spiral of change continues to flow. Also see Metal. "The Five Elemental Energies of Wood, Fire, Earth, Metal and Water encompass all the myriad phenomena of nature. It is a paradigm that applies equally to humans." The Yellow Emperor's Classic of Internal Medicine (second century bc) OM
Susan Krieger, L.Ac., MS, Diplomate of the NCCAOM in Acupuncture, Oriental Medicine and Shiatsu- Asian Bodywork Therapy, MEA in Health and Macrobiotic Nutritional Counseling and Teaching. Founding Member and Certified Senior Shiatsu Instructor of the AOBTA. Susan has been treating and guiding thousands of people throughout her 30+ years in practice. She is an internationally recognized practitioner, teacher and counselor of Chinese Medicine and Acupuncture, Asian Healing Arts, The Energetics of Foods, Medicinal Remedies, Women's Health, Contemporary- Integrative Macrobiotics, Whole Health Nutrition, Qi-Gong Yoga, Ki-Shiatsu- Acupressure, and Meridian-Self Shiatsu of over 33 years. She teaches in the US and Canada and Europe. She produced The Ki- Shiatsu Instructional DVD and lectures for the UN, universities, acupuncture, cooking and bodywork schools, hospitals, women's organizations, corporations and health and healing groups and centers. Susan has an active private practice in New York City. For queries or to invite Susan to present for your events she can be contacted at firstname.lastname@example.org or phone (212) 242-4217 www.susankriegerhealth.com
May we all be fully nourished with abundant health and blessings.
" When the ancients treated patients, they became familiar with the cycles of yin and yang and of time, and with the exhalations of qi from mountain, forest, river and marsh. They discerned the patient's age, body weight, social status, style of life, disposition, likes, feelings, and vigor. In accordance with what was appropriate to these characteristics, and avoiding what was not, they chose among medicines, moxa, acupuncture, lancing with the stone needle, decoctions and extracts. They straightened out old habits and manipulated patterns of emotions. Feeling their way, missing no opportunity and constantly adapting, in their reasoning there was not a hair-breadth's gap. They would go on to regulate the patient's dress, rationalize his/her diet, change his/her living habits, and follow the transformation of his/her emotions, sometimes treating according to environmental factors, sometimes according to individual factors."
Shen Kuo, Su Shen liangfang/Good Prescriptions by Su and Shen, 12th century
Approaches to Time in Chinese Medicine:
We live in a time where reforming health care is a central issue in the United States. Some of the most pressing problems include the insufficient time that medical professionals spend with their patients, and an over-emphasis on pharmacological or surgical solutions to complex health issues. Chronic, long-term illness has become an increasing demand on health care professionals, requiring more in-depth approaches to care that demand increased time and attention. A small but increasing group of health care professionals are organizing their practices to emphasize more time with patients, and offering tools such as education, lifestyle and dietary counseling, and alternative approaches to managing chronic illness. Chinese medicine has a large role to play in this sector as well, as one of our chief strengths is the comprehensive approach to health care delineated by Shen Kuo in the above quote, nine centuries ago. Even in modern times Chinese medical practitioners tend to spend a greater amount of time with patients and address many of the issues that contribute to their complaints.
When discussing Chinese medicine and its role in modern life, it can be argued that one of its essential strengths is its comprehensive medical philosophy, and specifically its approach to time. In classical Chinese thought, the understanding of change and its transformations in time are a common thread in such texts as the Classic of Change, and expressed in such areas of study as astronomy, agriculture, calligraphy, military strategy, and self-cultivation practices. The view of phenomenal nature as movement and pattern rather than a fixed viewing point is pervasive throughout Chinese history, and is at the core of how the Chinese traditionally viewed medicine before Western medicine and science became a major influence on Chinese culture.
When we study the classical medical texts, we find an emphasis on patterns and cyclic nature of symptoms, leading to stasis, decay, inflammation, exhaustion of yang, depression, accumulation, and distortion of channel flow. In the life cycle of most plants, there is the movement from the core seed stage to sprouting in springtime, to leaves and flowers in summer, to fruition in late summer/early fall, and to decay or death in late autumn/winter, returning back to the original seed state. All living beings, whether plant or animal, follow similar patterns of growth, fruition, and decay. Chinese medicine is based upon observation of these life cycles and their associated transformations, the human being seen as a microcosm and reflection of the greater dynamics in nature. Each living being has a particular life span, heart and breathing rate, metabolism, digestion suitable for specific foods, waking/sleeping cycle that distinguishes it from every other species. In addition, each living organism interacts with the environment in specific ways, and must maintain both internal and external equilibrium in order to prosper, reproduce, and remain healthy. For all life forms other than humanity, this is an automatic process governed by instinct and natural law.
Human beings, gifted with free will, paradoxically must choose to live with or against natural cycles, therefore, we can choose to be healthy or ill. Chinese medicine first and foremost teaches a philosophy of health based on safeguarding and prolonging health. The first three chapters of the Su wen/Simple Questions are based on instructions for living in harmony with the seasons and harmonizing emotions to avoid damage to the body and mind. In Ling shu 71 below, the human being is envisioned as a microcosm of heaven and earth, and subject to the same laws:
"Heaven is round, earth is square. Man's head is round, his feet are square. Heaven has sun and moon; man has a pair of eyes. Heaven has wind and rain; man has joy and anger. Heaven has the four seasons; man has the four limbs. Heaven has five tones; man has the five yin viscera (zang). These are the mutual correspondences between humanity and heaven and earth." Ling Shu (Evil Guests)
Human beings also are influenced by time within the society and culture where they live. For example, whether a society uses a solar or lunar calendar, agricultural rhythms (sowing, cultivating, harvesting), animal herding (nomadic societies), industrial societies (clocks, transportation, assembly lines) and our own informational, post-industrial society in which we live, with its rapid movement of digital information, contributing to excessive speed, stress, and anxiety. One can never catch up in this culture because digital rhythms move faster than biological time. The body clocks become confused and distorted, as in jet lag or night shifts at work, as we become more divorced from natural rhythms.
The Nan Jing and Diagnosis:
The Nan Jing, in Difficult Issue 50, speaks about the transference of internal evils according to five phase cycle via channel between the viscera and bowels. Each viscera/bowel has a terrain of emotions, functions, physiology, etc. that is healthy when operating harmoniously with other visceral systems, and unhealthy when overacting on other systems or weakened so that other systems dominate them. The Nan Jing speaks of five types of internal evils as follows: weak evils, thief evils, replete evils, vacuous evils, and correct evils. Correct evils are defined as those that are contracted by a specific channel or viscera according to predictable evils, such as wind damaging the liver, or fire damaging the heart. The other evils have to do with the generating and controlling cycles of the five phases, and may develop due to emotional, seasonal, or other evils that are transferred according to phase, constitutional factors, or disharmonies of the viscera and bowels that become entrenched. When emotions or functions of the five yin viscera are disturbed by external or internal aberrations, illnesses may follow (see chart).
In Difficult Issue 8, it states "All the channels are connected with the yuan qi/source qi". This source qi fills all of the channels, and circulates through the body, communicating jing/essence from one region to another. The channel system coordinates, supplies, and drains the viscera and the bowels, maintaining a harmonious balance. When there is a loss of communication between the viscera and bowels, due to the channels being blocked, depleted, or shunted in a different direction, this may lead to what we may describe as "illnesses of compensation". In other words, the necessary checks and balancing mechanisms are distorted, leading to over-activity in some viscera, and chaotic flow in the channels. Since the body must always maintain systemic balance, the patient develops a chronic disease of many facets, and because underlying it is a deep-set pattern, it is difficult to resolve without a treatment plan that addresses the underlying complex pathomechanisms. These undesirable patterns can then be addressed through herbal medicine, acumoxa, therapeutic exercises, and diet, along with regulation of daily activities, rest, and emotions.
Just as we humans develop coping strategies emotionally/psychologically, we may also develop these strategies at a physiological level as well. Many of these coping strategies may work temporarily, but end up being damaging to both emotional and physiological health in the long run. The body often serves as a conduit for the emotions, in such symptoms as skin rashes, hemorrhoids, recurrent urinary tract infections, irritable bowel syndrome, or abdominal pain. Thoughts and emotions are sometimes mirrored in physiological processes (and vice versa) in an auto-feedback loop. Fixations and false strategies become embedded in the body, seen in abnormal posture, contracted muscles, arthritis, abnormal bowel rhythms, or marked weight gain.
Just as people develop strategies to deal with emotional overload, they also self-medicate, using coffee, alcohol, recreational drugs, sex, hyper-exercise, over-eating, and special diets to try to find balance or relief, but it is often done in an unconscious or unproductive fashion. It is the job of the Chinese medical physician to replace false strategies with healthy ones, to rectify past issues with the present, and help project healthy new directions for the future.
"The Emperor asked: ‘by what qi are the one hundred illnesses produced? When there is anger, the qi counterflows upwards. When there is elation, the qi becauses relaxed. When there is sadness, the qi disperses. When there is fear, the qi descends. When there is fright, the qi is in chaos. When there is fatigue, the qi is consumed. When there is obsessive thought, the qi is bound." Su Wen 39
The CM physician looks for patterns in handwriting, mode of dress and hairstyle, movement (walking, sitting, loud or soft movements), speech, perfume and makeup. What is the patient projecting about oneself? Is it a true picture of what is inside, or a projection of an ideal? How does the patient approach their treatment? Do they take responsibility for their own health? How many doctor visits have they had? How many procedures? How much medication do they take?
When I treat complex cases, I often will draw a ‘flow chart' for my patients, showing how the condition developed over time, often beginning with an initial, often overlooked, trauma. The homeopaths call this "never been the same since. . ." (fill in the blanks). For example, a woman in her forties whose health never recovered after a bout of mononucleosis in college, suffering from irregular menstrual cycles, severe fatigue, bloating after eating, poor digestion, and disturbed sleep. A number of factors combine from climate, season, emotional stress, constitutional weakness, diet, and unresolved symptoms to create ‘the perfect storm', which manifests as a disease. This can be drawn as a ‘time-line', extending as a string of symptoms/disease factors from the past, to the present pattern, utilizing five phase, viscera/bowel, six channel or other types of pattern differentiation that can be used as a relational model. This model allows both the physician and the patient to intervene in the body/mind system providing new stimuli to open communication in the channels and restore homeostasis.
The value of the above methodology recorded in the Nan Jing is that it allows the physician to view a patient's health and disease patterns as a process, a movement in time, rather than just a snapshot taken at one point in time, and then trying to base a diagnosis and treatment plan on it. The physician, by observing the past, is able to project the future course of health and illness.
In the Nan Jing, acupuncture treatment is designed to restore disturbed order to the channel and visceral systems through sophisticated five phase treatment strategies. Please see Bob Damone's article for more details on use of five phase transporting points (wu xu xue) in Nan Jing acupuncture.
Chronobiology in the Su Wen and Nan Jing/Introductory Thoughts:
"The Chinese applied cyclic ideas of time (to the microcosm of) the life-maintaining order of the human body, in phase with the environment and with the individual's emotional and rational processes. This seemed to constitute a remarkably articulated nest of cycles, with the life trajectory of the mayfly or the diurnal rhythm of the human body representing the smallest wheel, and, as the largest, the practically infinite great cycle-----from the beginning until the end of time-----integrating all the astronomical periods, all the small cycles turning within it like a superbly complicated train of gears".
Nathan Sivin, "On the Limits of Empirical Knowledge in the Traditional Chinese Sciences"
The next aspect to investigate is the periodicity of symptoms. In zi wu liu zhu xue/chronobiology theory, the Chinese recognized that all sentient beings and phenomena had internal clocks that measured cycles of change, birth, growth, decay, and death. Symptom patterns were recognized as being dependent on the variables of the twenty-four hour clock of the internal viscera, seasons, year, and other cycles. Symptoms such as heart palpitations were observed to see when they occurred to associate them with the rise and fall of qi in specific channels and viscera/bowels. Medicines and acupuncture points were chosen to coordinate with the best times vis a vis the rise and fall of qi in treatment. The pulse was also seen to vary at different times of day, season or other natural cycles. As the sun rose from dawn to its zenith in the sky, the yang qi would increase and strengthen in the pulse. As it sank in the sky towards dusk, yang qi would decrease and the yin quiescent qi of nighttime would increase.
In the next section, we will discuss how chronobiology and the ‘time line' of case histories described in such texts as the Nan Jing can be used to develop comprehensive diagnosis and treatment strategies.
Scheid, Volker, Currents of Tradition 1626-2006, Eastland Press, Seattle, Wa. 2007
Modern medicine has evolved to an extent that would have been difficult to imagine, even twenty years ago. Advanced imaging technologies have given radiologists the ability to ‘see' the metabolic activity and location of pee-sized tumors, anywhere in the body. High-tech pharmacology research has led to the development of a vast array of drugs that can be prescribed for almost any named medical condition. And, nearly every day we learn of new genetic discoveries that have been associated with various cancers, heart disease, diabetes, depression, and other health problems.
However, the overall picture of modern medicine is far from perfect... The cost of healthcare, in the United States, is reaching unsustainable levels and, if not adequately addressed in the near future, will lead to an even more troubling state for our nation's health and economy. Highlighting this point, medical bills have become the leading cause of personal bankruptcy, in the U.S. Compared to other industrialized countries, the U.S. spends most of all on health care. Nonetheless, the U.S. ranks relatively low on health care indicators.
Access to healthcare is limited to those fortunate enough to be able to afford it. Preventive care (i.e. counseling and screening) is not always reimbursed and thus limits the ability of providers to offer this essential service. Individuals who have limited access to primary care providers, often do not seek medical attention until their problem has escalated into a serious condition. As a result, our nation's, emergency departments and urgent care clinics unfortunately serve as the healthcare entry point for the majority of individuals who cannot afford primary care. Even when a patient has access to primary care, they may only be allotted a few minutes to focus on one or two of their issues- obviously, this is not conducive for managing complex medical problems (let alone, preventive care counseling.)
Coordination of care between multiple specialty providers is often too time-intensive for primary care providers who are already overburdened. The ability for providers to document and communicate medical information is hindered by the lack of standardized electronic medical record systems, significantly increasing the risk of medical errors and the inefficiency of each encounter. These issues are not simple and will require a paradigm shift in our healthcare system. The new system must focus on an integrated approach to health care, one that addresses the whole person: body, mind and spirit. This is the essence of ‘integrative medicine.' Increasing timely and affordable access to primary care providers is essential in this model. Preventing disease and improving wellness will be financially incentivized in this new system, as opposed to only rewarding providers for offering expensive therapies and procedures. The best of evidencebased conventional and non-conventional therapies are combined in integrative medicine. Whenever there is a choice between equally effective therapies, selecting the least costly and least invasive/toxic option should be offered. This was the focus of the "Summit on Integrative Medicine and the Health of the Public", held at the Institute of Medicine (IOM), in February, 2009.
Traditional Chinese medicine (TCM) is one of many whole health systems (i.e. Ayurvedic medicine, Native American medicine, Tibetan medicine, etc.) that embodies the concept of integrative medicine. A variety of TCM modalities (i.e. acupuncture, tui na, qi gong, herbal formulas, etc.) have been shown to reduce stress, improve fitness and flexibility, decrease pain and inflammation, improve sleep, modulate hormone levels, and improve various quality of life outcomes (physical and psychological.) These dynamic and complex parameters have been associated with numerous disease processes (i.e. cardiovascular disease, diabetes, cancer, depression, etc.).
TCM is one of the first healthcare systems to emphasize the importance of promoting wellness and preventing disease through healthy eating habits, nutrition, exercise, and meditation. The role of TCM in integrative medicine looks very promising. A quick search on MEDLINE demonstrates thousands of studies employing TCM modalities. These studies vary significantly in their quality and reliability. Increasingly, TCM studies
have been more closely adhering to the rigorous design criteria expected in peer reviewed, conventional medical journals (i.e. randomization, thoughtful selection/omission of controls, statistical power calculations, the use of validated assessment instruments, etc.). Collaborative research among investigators of varying
backgrounds (between physicians, chiropractors, TCM practitioners, statisticians, pharmacologists, etc.) can be helpful in designing high-quality trials to study the efficacy, safety, and cost-effectiveness of TCM practices within the integrative medicine model.