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CHAPTER D

Most of the combinations in this chapter have been taken from the book: ACUPUNCTURE - A COMPREHENSIVE TEXT, by the SHANGHAI COLLEGE OF TRADITIONAL CHINESE MEDICINE.

The majority of the combinations form the back-bone of the clinical knowledge of every practicing acupuncturist, and as such, they should certainly not be expected to be innovations, or rare information. Moreover, the eighteen points-combinations analyzed here, are only a drop in the ocean when compared with the myriad combinations which have evolved throughout the history of T.C.M..

CONSTRUCTION

Points-combinations - general rules

The various laws for combining points

Survey of classical and effective points-combinations

REFERENCES

However, the aim of this analysis, is to understand the principles by which a points-combination has been formed, as well as its clinical value and application.

The functions of the various points, in the following combinations, as well as their classical indications and qualities, were taken from two main sources:

1. The same COMPREHENSIVE TEXT (see above).

2. THE ACTIONS OF ACUPUNCTURE POINTS by Peter Deadman which was published in several parts in the JOURNAL OF CHINESE MEDICINE .

The rest of the material, including the analysis of each point, the theoretical background of the combination, the practical application and the comparison with an herbal prescription, were all taken from my clinical experience and personal observation, unless otherwise stated.

Needless to say, all the case histories in this chapter are of persons treated by me in my practice.

The source for all information presented here regarding herbs, including herbal prescriptions, is the book: CHINESE HERBAL MEDICINE -MATERIA MEDICA of Eastland Press, by Dan Bensky et al. However, comparison of the points-combinations with the herbal prescriptions in this chapter, is mine alone.

1. SANYINJIAO (SP-6), GUANYUAN (CV-4), QIHAI (CV-6).

Main effect and clinical purpose

This points-combination is commonly used as a general tonic for Qi and Blood. It is therefore frequently used in cases of severe lassitude, anemia, impotence, spermatorrhea and the like.

Because of this points-combination's main effect, it is used with a tonifying manipulation and/or moxa.

Points discussion

Sanyinjiao (SP-6) is the point of intersection of the Liver, Spleen and Kidney meridians, and functions to regulate and tonify the Oi in these channels. It also has a strong effect on the reproductive, as well as on the urinary system, and is therefore used to regulate Yin Qi - either to tonify, or drain. Sanhyinjiao belongs to the Spleen meridian, and has a great influence on all the functions of the Spleen organ. That includes: regulating the digestive system, improving appetite, creation of blood, and elimination of Dampness (40).

Guanyuan (CV-4) - The meaning of Guanyuan is "the passage for the Source Qi". This is the point of intersection of the three Yin channels of the leg on the Conception Vessel (41).

Needling this point tonifies the Yuan Qi, which is the prenatal Qi. It therefore strengthens the kidneys, and actually the whole body. Due to its location it is primarily used to tonify Yin Qi, but it can be used to tonify Yang Qi, as well. It Is hardly ever used to sedate. Qihai (CV-6) is also located on the Conception Vessel, Jen Mai. Its name Implies that it controls the sea of Qi, which lies exactly on this spot, known as the "Lower Dan tien". Qihai is therefore used to regulate Qi, especially post-natal Qi (42), and strengthen kidney-Qi, Yin and Yang in general.

Combining Guanyuan and Qihai has a strong strengthening effect on the Qi of the whole body. These points together stimulate pre and post-natal Qi, and the kidneys. Adding Sanyinjiao to these two, gives a further impetus to creation of Yin and blood, improved liver and spleen functioning, thus making the best tonifying points-combination.

There is another similar points-combination, that uses Zusanli (ST-36) instead of Sanyinjiao (SP-6). The difference between these two is that the latter is used mainly for general strengthening purposes, with an emphasis on digestive irregularities, blood, and general stamina. The previous combination has a more uro-genital influence.

For strengthening purposes of general Qi, one generally punctures In this order: Guanyuan, Qihai and then Sanyinjiao. But, if our aim is to strengthen Yin Qi, or treat the urogenital system, Sanyinjiao precedes the other two points.

As we have stated before,, the goal of this combination is primarily to tonify. In order to do so we must use a tonifying manipulation, i.e. penetrate to the point gently in three stages and while manipulating, push into the point more strongly than when withdrawing the needle.

Often we may utilize the "Burning the Mountain" technique. In this technique the needle is first inserted to a superficial level, and is then advanced to a middle, and finally to a deep level. At each level the needle is forcefully thrust, and gently raised, nine times. Then, the needle is left in the superficial level. This manipulation is repeated until the patient experiences a warm or burning sensation.

It is also very common to use moxa on these points, either direct moxa, or "warm needle". Moxa is used mainly in cold/deficient diseases.

It is appropriate to compare the use of Guanyuan and Qihai to radix Panax Ginseng. This herb is mainly used in severe Qi deficiencies, or even collapse. It is also known to tonify the Yuan Qi and both Yin and Yang Qi.

We can also find similarities between Angelica Sinensis, Dan Gui and the actions of Sanyinjiao. This herb, too, is used to tonify the blood and treat urogenital disorders. Along with this, Dang Gui is also used for abdominal pain, constipation, Damp Bi etc., for all of which Sanyinjiao is also useful.

Mr. A.M. of Arab origin, age 27, occupation: building worker, married for two years.

Complaint - infertility, spermatorrhea, especially at night, and premature ejaculation.

1. Red face, cold feet.

2. Feels generally fine, except sometimes dribbling urine.

3. Pulse slippery, big.

4. Tongue pale, soft

5. Abdomen tenderness under umbilicus and right hypochondriac region.

1.Weakness and looseness of the "gate of sperm", and of "Ming Men", due to excessive sexual intercourse and hard labour.

2. Excitement of Heart-Fire.

Treatment

1. Sanyinjiao (SP-6), Gyanyuan (CV-4), Qihai (CV-6) and Taling (P-7).

2. Refrain from sexual intercourse until spermatorrhea subsides.

Sanyinjiao, Guanyuan and Qihai together tonify the Yuan Qi, thus enlivening the sperm, and strengthening the Ming Men. Taling is used to decrease Heart-Fire, and thereby helps the patient control his sexual enthusiasm. Taling was punctured against the flow of Qi, i.e. point proximally, in order to cause sedation.

Results

After two sessions the spermatorrhea ceased.

After three months the patient's wife became pregnant.

Main effect and linical purpose

This is a points-combination based on the law "one point above two points below" (see previous chapter). Its purpose is to clear obstruction from the Yang-Ming system, mainly sinusitis.

It has a clear sedating effect, and is therefore used for excess patterns, characterized by Heat and Damp.

Hegu is one of the most frequently used acupuncture points. It is the strongest point on the hand Yangming channel, and is used vastly for all complaints of the head.

It is used to eliminate Wind-Heat or Wind-cold; Hegu is an analgesic point and it relieves pain. It is antiphlogistic, antipyretic, and used for all inflammatory processes in the head region.

Yingxiang is the last point of the hand-Yangming channel. Its indications are for all diseases of the nose, and to dispel Wind-Heat from the nasal-cavities. It is also an intersection point between the Large Intestine and Stomach meridians.

Zusanli is also one of the most frequently used points. It is the most powerful point on the Stomach meridian, and is used for all digestive complaints. In this context it is used to eliminate Damp and Heat from the Yangming channel. Zusanli may be either tonified, or sedated, depending on the nature of the disharmony.

Thus, among its manifold activities, It may be used to eliminate Wind and Damp, to regulate circulation of Qi and Blood, to tonify weakness and promote anti-pathogenic Qi.

Neiting is a point of choice to treat excess patterns in the Stomach, or stomach meridian. It is mainly used to reduce Heat in the channel, or organs under control of this channel. This includes nasal cavities, upper teeth and gums, stomach and intestines. Its Indications also list: to regulate Qi, and relieve pain.

Xiangu is indicated mainly for facial edema, for pain and elimination of Wind. Sinusitis is characterized as a Wind Heat disease, and it causes accumulation of fluid (Damp) In the face, due to Heat stagnation.

As we have explained in the previous chapter, this type of combination places an emphasis on regulating the Qi in the channel, making it flow more vigorously in the right direction, by utilizing more points on the desired direction.

Thus, points Zusanli, Neiting and Xiangu provide a heavier weight than Hegu and Yingxiang, in order to promote the flow of Qi to their direction. This invigoration of Qi is said to clear the obstruction (sinusitis) where the hand Yangming, and leg Yangming meet (the nasal area).

It is worthwhile mentioning that all of these points have a clear Damp and Heat clearing function, among their other qualities.

Needling sequence is of major importance in this combination. Since the whole idea is to propel the energy along the meridian in the desired direction, we have to stimulate the points in the appropriate order. By needling these points in succession, we propagate both the needle sensation, and the effect towards the oriented direction.

The fact that Nelting is needled before Xiangu is because Neiting is a stronger point than Xiangu, and therefore plays a more important role in the "see-saw" balance of the combination.

The points are naturally manipulated in a reducing, or sedating technique. This may be either anti-clockwise rotation of the needles, or pull-thrust maneuvering.

When an excessive Hot condition is observed, it is possible to perform the "Cooling the Sky" technique. By this technique the needle is inserted to the desired depth, and then forcefully raised up a fraction, and gently inserted again. This manipulation is repeated six times. The procedure is repeated at three different levels, from the deepest to the most superficial position, until the patient senses coolness. This is exactly the opposite procedure to "burning the mountain", which was described under the previous combination (44).

As a rule, for sedation purposes the needle manipulation requires stronger movements by the practitioner, with larger amplitude and angles than tonifying manipulations. In shallow surfaces It is often sufficient to point the needle tip along or against the energy stream, in order to tonify or sedate, respectively.

Case history

Mrs. S.A., age 40, has suffered from chronic sinusitis for 12 years. She had some 4-5 acute incidents each year, for which various antibiotics had been prescribed. Twice she had undergone nasal operation and sinus pumping - without long term satisfactory results.

She came to see me three years ago, suffering an acute attack which did not respond to antibiotic remedies. She had low fever, felt very weak and sick, and had unbearable pain around the supraorbital area, especially of her left eye. Mrs. S.A. had a purulent yellow, foul smelling nasal discharge, dry mouth and constipation.

Both her pulse and tongue indicated an excessive DampHeat condition. Her pulse was also weak, and indicated her general weakness.

Mrs. S. received six treatments. The prescription was built from the above combination, with the addition of Zanshu (B-2). Zanshu was manipulated by a dispersion technique, i.e. was punctured in three directions one after the other, and then was left intact.

Zanshu was chosen due to its local effect, in order to disperse the purulent liquid around the eyes' orbit.

After two treatments Mrs. S. experienced significant relief, and after the fifth appointment, she proclaimed that she was free of all symptoms. Hence, she was given another treatment to consolidate the effect, and the treatment was terminated.

During the last three years, Mrs. S. suffered one more attack, which responded to treatment in the same fashion.

3. JIANYU (LI-15), JIANEILING (EXTRA), JIANLIAO (T-14)

Main effect and clinical purpose

The combination above is a points-cluster of the shoulder. It is frequently used to disperse stagnation in the shoulder joint, and to facilitate the flow of Qi there.

The cluster is usually effective in Cold stagnation of the shoulder, or Damp Bi (cases of frozen shoulder, perifocal inflammation of the shoulder joint etc.). It may also be of value for traumatic pain from sport, or accident.

Jianyu - in Chinese - "shoulder bone", is the main point for all shoulder diseases. Its indications are:

1. to eliminate Wind

2. to remove obstruction from the Jingluo, and promote circulation of Qi and blood.

3. to soothe the Joints, relieve pain and scatter Bi.

Jianyu is either punctured deeply, with the arm abducted, towards Jiquan (H-1), for inflammation of the Joint bones, or along the deltoid muscle, for Damp or cold Bi, affecting the muscles and tendons.

It is often cauterized with moxa, by all the variations: direct (scarring) moxibustion, warm needle technique, and moxa on ginger. These techniques are applied for Cold, or Damp Cold induced problems. For the "frozen shoulder" syndrome, Cold penetrating to the bone level, one may use the "Fire needle" technique. By this technique a long needle is heated by fire, and immediately introduced to the deep level of Jianyu, and then withdrawn. This technique was already mentioned in the "Ling Shu", and the Ming dynasty physician, Wu Hegao, recommended it for Cold-Bi of the shoulder.

In any case, utilization of moxa, or heat at this point, accelerates the flow of Qi, disperses the Cold and Damp stagnations, and returns the joint and muscles to normal functioning. However, it is imperative to stress that any shoulder inflammation exhibiting Heat condition, (i.e. febrile Bi) should not be treated with moxa, which will undoubtedly aggravate the condition.

Jianneiling is an extra point situated exactly between Jianyu and the top of the anterior axillary crease.

Its indications are the same as Jianyu.

Jianliao - "Shoulder Seam" in Chinese, also has exactly the same indications as Jianyu.

Needling these three points together affects the shoulder from three different angles, and causes an acceleration of the Qi that passes through this joint. The various methods of stimulation, when properly applied, deal with the cause and nature of the stagnation accordingly.

The needling sequence in this combination is usually related to the site of the pain. If the pain is in the anterior part of the shoulder, Jianneiling is usually needled first, and then the other two. If the whole shoulder is painful, Jianyu is needled first, as the strongest point of the trio.

Besides moxa stimulation, of which we have already spoken, "cupping" treatment over these points is also beneficial.

Cupping is generally applied on spots where we need to enhance circulation of Qi and Blood, and is widely used in China and in T.C.M. clinics.

Also electrical stimulation of these points is often applied, as shoulder problems usually involve pain. Electrical stimulation is usually applied with a dense-disperse wave, for periods of 10-20 minutes. Cupping is usually applied after needling the points, or over the needles, also for 15-20 minutes.

When "warm needle" technique is utilized, generally only one needle of the trio is cauterized with moxa. It is usually the needle that is situated in the most painful site of the shoulder. This is a small variation of a technique called Qici which was already mentioned in the Nei Jing (45).

Another technique, which is often used to disperse stagnation of Qi and Blood, and to resolve pain quickly, is called "Huici", and has also been mentioned in the Nei Jing.

By this method a 1.5 inch needle is Inserted and manipulated until "Deqi" is obtained. The needle is then raised and redirected to the left or right, and manipulated again for 3 minutes, after which the needle is raised and redirected toward another direction, and manipulated once again. It is then raised to a superficial level, and left intact.

Mrs. D.B., a teacher by profession, was born in 1951. On April 18, 1990 she consulted me, complaining of severe pain in her right shoulder, which hindered her sleep, and disabled her right hand of almost any movement.

X-ray examination at "Rambam" Hospital in Haifa revealed excessive calcium deposits in the shoulder joint, hence she had been advised to undergo calcium-pumping, as well as steroid Injections.

Mrs. D. was reluctant for such "adventures". as she expressed it, and since she had had a previous successful experience in my clinic, for another problem, she made an appointment.

Examination of Chinese medicine brought me to a diagnosis of a Cold-Bi condition in the shoulder, and kidney hypofunctioning (Kidney Yang Xu).

The main signs were:

1. Fear of cold in general, and especially a need for warmth around both shoulders.

2. Pallid face and lips.

3. Pale, wet tongue, with a thin white fur.

4. Thin, soft and deep pulse, weak on third position.

The only sign which did not match the diagnosis entirely, was the pulse, which should have been more tight. Nevertheless, I interpreted the thin pulse as a sign of a Blood-Xu, to some extent due to her Kidney Yang Xu condition, which prevented her proper creation of blood. The relative weakness and depth of the pulse was due to her kidney weakness.

The prescription for treatment was:

Right side: Tiaokou (ST-38), Jianyu (LI-15), Jianliao (T-14), Jianneiling.

Both: TaIxi (K-3), Shenshu (B-23).

Tiaokou is an excellent empirical point for acute shoulder pain. It was inserted toward Chengshan (B-57), and manipulated for 5 minutes (46).

On Jianyu I burnt four moxa balls, on top of the needle, in each session.

The three cluster points of the shoulder were manipulated by the dispersal "Huici" pattern (see above). This was done prior to the application of moxa, and in order to disperse the stagnant Cold which lodged in the area.

Taixi and Shenshu were chosen to stimulate and reinforce Kidney Yang. In order to ensure a full impact on Kidney Yang, three moxa balls were installed over the left Shenshu needle.

Since all the Yang go to the left, and all the Yin go to the right, Shenshu left is also considered to belong to Yang, and was given extra stimulation there.

Mrs. D. experienced significant relief following the first session, and could sleep the whole night through. After the second and third treatments her condition improved even more, and on the fourth, the treatment was performed without moxa.

After the fourth treatment her condition worsened, probably due to a cold change in the weather.

Five more treatments were required to establish a full recovery, all of them with moxa.

Main effect and clinical purpose

This points-combination works primarily on the Liver and Gallbladder channels, and has a strong Yang, or Fire-reducing action, as well as Wind clearing, especially Liver Wind from the head.

As a result of these properties, the combination is widely used to treat hypertension of Liver Yang, or Liver Fire origin. It may also treat headaches, migraine, or pressure behind the eye (glaucoma) of the same etiology.

Fengchi is an important point, situated on the Gall-Bladder meridian, below the occipital bone. It is involved in almost every formula that treats headaches, especially of a Shi nature. The point is indicated to eliminate Wind (external, or an internal Liver Wind), to pacify the Liver and reduce Yang, to clear the mind, brighten the eyes, to benefit the ears, and to reduce Heat.

Fengchi is usually punctured toward the eyeball of the opposite site, with care not to point the tip upward, the direction of the medulla oblongata.

Since its use is most often indicated to calm hyperactive Yang, or sedate Wind, it is manipulated to sedate by a leftward twirling, or withdrawing forcefully and thrusting back gently.

Fengchi is often combined with Hegu (LI-4) for various headaches and this is a basic combination for headaches. Hegu has a strong effect on the face, forehead and the anterior half of the head, whereas Fengchl has the same effect on the posterior half. Both points, therefore, circulate the Qi and Blood of the whole head, and disperse Wind and stagnation.

Taiyang is an extra point situated on both temples. Its indications are also to disperse Wind and Heat from the head and eyes. It is often used for migraine headaches, red and painful eyes, fever or high blood presssure.

Taiyang has a close relationship to the Gall Bladder meridian, firstly because of its location, as well as its functioning.

It is punctured up to a depth of one cun perpendicularly, and it is often pricked with a triangular needle to release a few drops of blood. This is usually done in acute conditions, involving pain, Heat, severe inflammation, etc.

Xinjian has also similar properties. It Is widely used to reduce Liver Fire, but it is located on the other end of the body, i.e. the foot.

Besides draining the excessive Liver Fire, Xinjian is also said to spread the stagnant Qi of the Liver. This is usually a Heat stagnation, which is one of seven stagnations that exist in classical Chinese medicine: Stagnation of Qi, Blood, Damp, Cold, Heat, Phlegm and Food (47).

This stagnation of Heat often involves the Blood too, as it causes the Blood to coagulate. Since Blood and Heat both have a close physiologic link with the concept of Liver in T.C.M., it is not surprising that hypertension in its most common etiology, is treated via the Liver or Gall meridians. Xinjian, therefore, is an important point for this disorder, as it treats both Heat and stagnation.

Yanglinchuan also has the ability to cool Liver Heat, as well as to clear Damp. It regulates and benefits the Liver and Gall bladder, and strengthens the tendons, sinews and bones.

After analyzing each point in the combination, it is clear that this points-combination is built on the concept of mutual assistance. Actually all the above-mentioned points have the quality of lowering Yang, and susbduing Liver Fire.

The most frequently encountered etiology for high blood pressure in T.C.M. is hyperactive Liver Yang. This pattern usually involves symptoms like: headache, glaucoma, red eyes, red face, dizziness, tinnitus, etc., all of which are very common in the modern concept of hypertension.

According to Chinese medical philosophy, when the Liver lacks Yin (due to Kidney deficiency, most often), or Blood (due to spleen deficiency), or its Qi stagnates due to other causes, it creates Heat. Heat tends to climb up, or float to the head region, via the Gallbladder meridian, which is the Liver coupled meridian, or via the internal branch of the Liver meridian itself. The Heat causes expansion of blood, and blood vessels, thus creating the hypertension, as well as the accompanying symptoms.

Needling sequence in this combination is, in general, from above downward, in order to lower, or bring down Liver Yang.

It is therefore necessary to use the head points first, in order to sedate Liver Fire or Wind in the head region, then Xinjian which is more important for this purpose, and finally Yanglingchuan.

Manipulation of the needles is effected to sedate Liver Yang, and therefore the amplitude and strength should be as high as the patient can tolerate. Nevertheless, care must be taken in cases of fragile constitution, or a pattern which includes a Xu condition, at the same time. In this case the practitioner must assess which is predominant, the Shi or the Xu condition, and stimulate accordingly. It is also advised, in any case, not to be too vigorous with the manipulation at the first session.

As we have stated before, in cases which Involve an acute head or eye pain, with inflammation or Fire signs, it is possible to bleed Taiyang, and release a few drops of blood, with the prysmatic needle.

The effect of this points-combination may be compared to the use of Spica Prunella Vulgaris (Xia Ku Cao), together with Flos. Chrysanthemi Morifoli (Ju Hua).

The first herb is Cold in nature and acrid, and is used to clear the Liver and brighten the eyes. Very much like Taiyang and Xinjian. The latter herb is slightly Cold and Bitter, and is used to disperse Wind and clear Heat. It therefore clears Wind Heat in the Liver channel, and pacifies the Liver and relieves headache, dizziness, red and painful eyes, etc. Its action resembles that of Fengchi.

The two herbs together are therefore classically used for headache, dizziness, vertigo, painful and red eyes and high blood pressure.

Mr. G., age 46, businessman, has suffered for the past eight years from hypertension and occipital headaches. During this period he has regularly taken hypotensive drugs (50 mg Convertin), which have affected his sexual abilities adversely. With the drugs, his blood pressure was 140/110 Hg.

Mr. G. had a shiny red face, red eyes and darkish lips. He spoke loudly, and was very talkative.

Examination of the tongue revealed red rims, and a slippery yellow coating.

His pulse was moderate, and first and second positions of his right hand were Shi.

It was apparent that Mr. G. had an excess Heat condition. The problem was whether it was of Liver Yang origin, or Stomach Fire. As neither of these possibilities required the consideration of other symptoms, it was decided to clear Heat from the Yangming system through a combination renowned for this purpose. The combination is: Quchi (LI-11), Zusauli (ST-36) Neiting (ST-44).

Actually the Yangming channel was chosen to operate upon because of the pulse, which showed predominance on the right Guan position.

A few treatments were carried out by this method, but the patient showed no improvement.

The diagnosis was then reconsidered, and changed to hyperactive Liver Yang. The pulse abnormality was thence interpreted as an overactivity of the right Liver channel, rather than both channels, a fact which has shown itself on the right hand pulse.

The formula for treatment was thus changed to the following: Fengchi (G-20), Taiyang, Xinjian (LIV-2), Yanglingchuan (G-34), Qimen (LIV-14) on the right side only, and Fuliu (K-7).

All points, except Qimen and Fuliu, were sedated in a broad angle twirling and raise-thrust manipulation. Qimen was manipulated in an even manner, in order to regulate Liver-Qi, and Fuliu was tonified so as to tonify Kidney-Yin.

After the first treatment, Mr. G's blood pressure decreased to 140/100 Hg., and after five more treatments to 140/90 Hg. He was advised not to take any more hypotensive drugs, advice which he accepted readily, and his blood pressure remains stable.

Since Mr. G. was not prone to anger, he was only advised to regulate his diet, to exclude Yang nourishing foods (coffee, sea food, fried food, pepper, alcohol, etc.), and to tend his business in a more relaxed manner.

5. QUCHI (LI-11), XUEHAI (SP-10), WAIGUAN (T-5)

Main effect and clinical purpose

The above points-combination is widely used to treat skin disorders, mainly characterized by Heat and Wind, of either internal or external origin.

These disorders Include allergic skin reactions, various types of eczema, rash, hives, and other conditions.

With added points like Yinlingchuan (SP-9) , or Sanyinjiao (SP-6), it may also treat skin conditions in which Damp exists, i.e. weeping eczema, furunculosis, etc.

Points discussion

Quchi is the most effective point for skin diseases, especially those characterized by wind and Heat. Its traditional functions are:

1. Eliminates Wind and exterior conditions.

2. Cools Heat and alleviates Dampness.

3. Regulates the Blood.

Quchi is situated on the Large Intestine meridian, a meridian most of whose functions deal with exterior conditions, or with the outer layers of the body, such as: skin, muscles, etc.

As its most pronounced function is to eliminate Heat, and therefore it is used in cases of fever, and since it is very influential at the skin level, Quchi removes Heat from the skin. By removing Heat from the skin, it improves Ching-I (fluid) circulation at the cellular level, thus facilitating skin nutrition.

Quchi is also an important point to clear Heat from the blood. We know that the Large Intestine meridian carries the largest amount of blood in comparison with other meridians, as it belongs to the Yangming system. As a result of this fact Quchi is able to act directly on the blood, regulate it and drain excess Heat therefrom.

In this regard, we should bear in mind that many skin diseases are the result of "Heat entering the blood level", according to T.C.M. The Heat in the blood concept may be paralleled to the western concept of toxins in the blood. This phenomenon of toxins is of a hot energetic nature, often manifesting itself as red skin eruptions of various kinds. In its most extreme variation it is defined even in T.C.M as "Fire-toxin". This definition is often attributed to the western medical diseases such as furunculosis, purulent abscesses and the like.

Xuehai - "Sea of blood" in Chinese, is situated on the Spleen meridian. The Spleen governs the circulation of blood (i.e. keeps the blood in the blood vessels), and governs the volume of blood, as it stimulates its creation.

Xuehai, therefore, is the point which serves to regulate and invigorate blood circulation, on behalf of the Spleen.

In its Indications Xuehai is said to harmonize blood and Ying 0i (nourishing Qi), and to cool Heat. In accordance with these qualities Xuehal is used to tonify blood, improve its circulation, and drain excessive Heat from it.

Waiguan is used in this prescription for its quality to relieve Exterior and Hot conditions. It is called the "Outer Gate" in Chinese, and thus serves as a gate-keeper against external pernicious influences.

* ..."Traditional Chinese Medicine teaches that to control Wind, the blood must first be regulated. Wind subsides by itself when normal blood flow is restored, ie., it is expelled naturally when it has nothing to cling to.

"The use of Xuehai and Waiguan for invigorating the blood and dispersing the Wind, combined with Quchi for clearing the Heat, is an important combination of points for treating the itching due to stagnation of Wind and Heat in the skin." (48).

The needling sequence in this combination is from the upper limb to the lower limb. This follows the general acupuncture rules accordingly:

1. Generally apply needles first to the upper parts of the body, and then to the lower parts.

2. First apply to points situated on the back, and then on the abdomen.

3. Apply needles first to the left side, and then to the right side.

Manipulations of the needles are, in most cases, in order to disperse Wind and Heat, which are Shi conditions. In any case, Xuehai may sometimes be tonified, when the blood is Xu, or Dry, or, more often, be manipulated evenly so as to tonify the blood, and at the same time drain the pathogenic Heat.

In very acute conditions it is possible to bleed these points with the triangular needle, but it should not be done too often, as it might damage both Qi and Blood.

The functions of Xuehai are very similar, in many aspects, to those of Radix Rehmainia Glutinosa (Sheng Di Huang).

This herb has properties, such as:

1. Clears Heat and cools the blood.

2. Indicated for cases of hemorrhage, where heat has penetrated the blood level (in cases like excessive menstruation, and premature menstruation, for which Xuehal Is also indicated).

3. Nourishes the Yin and the Blood.

The whole points-combination may be compared to a classical herbal prescription, that has about the same properties. it includes:

1. Periostracum Cicade - (Chan Tui)

2. Herba Mentha - (Bo He)

3. Radix Rehmania Glutinose - (Sheng Di Huang)

Chan Tui and Bo He belong to the Cool herbs that release exterior conditions. Therefore their main activity is to disperse Wind and clear Heat.

Both of them are also used to speed recovery in measles, as they are said to encourage rashes to rise to the surface.

Sheng Di Huang, as mentioned above, acts on the blood level. By tonifying the blood it assists in dispersing Wind conditions, and by cooling the blood, it removes the basis for skin Hot conditions.

Miss O.S., age 9, has suffered for one month from a pruritic rash on her right costal surface, anteriorly and posteriorly.

Various allergic examinations did not reveal any special sensitivity, and local application of ointments had not improved her condition.

Questioning revealed that the rash had appeared suddenly, and that it was very itchy.

Observation showed that the rash consisted of tiny red points, giving the impression of Sand on the skin. It also showed a red rimmed tongue with a very thin white moss.

The diagnosis was an externally contracted Wind Heat, affecting the Liver/Gall Bladder meridians. (Wind Rash, in Chinese).

The fact that the rash appeared only on the surface of the right rib-cage, along with the red-rimmed tongue, pointed to the involvement of the Liver and Gall meridians. The sudden appearance of the disease, together with its red color, plus the thin white coating of the tongue, indicated an externally contracted Wind Heat.

The formula chosen for treatment was: Quchi (LI-11), Xuehai (SP-10), Waignau (T-5), Talchong (LIV-3), Sanyinjiao (SP-6).

Taichong and Sanyinjiao were added to the prescription in order to resolve stagnation of the Liver, and hasten the recovery. This is another well-known points-combination, used to promote the function of the liver, and spread Liver Q1.

After two treatments which were carried out on two consecutive days, there was no itchiness at all, and the rash had significantly diminished.

After the fifth treatment the problem was entirely resolved.

6. NEIGUAN (P-6), TALING (P-7), LIEHCHUEH (L-7)

This points-cluster helps facilitate the flow of Qi and blood to the palm and fingers. It is used in cases of Metacarpal Tunnel Syndrome, where Qi and Blood are blocked in the matacorpal joint vicinity, and the symptoms exhibit numbness and weakness of the fingers.

Neiguan is the most important point on the pericardium channel. It is mainly used to treat chest or abdominal problems, and its functions spread from regulating the stomach activities, to improving blood circulation in the heart.

One of its manifold characteristics is to regulate the Qi. The fact that it belongs to the Pericardium-Liver system, the Chueh-Yin, suggests that it is also closely linked with blood circulation problems. (In fact some authors call the Pericardium meridian "Circulation-Sex meridian" (49).

As a tribute to its anatomical location near the metacarpal tunnel, it influences Qi and Blood circulation in this area. Due to its major role in improving blood circulation in general, Neiguan has a double effect on this area: one merely as a local effect, and the second as an influence on systemic circulation in the whole body.

Another characteristic of Neiguan is that due to its anatomical location on the medial nerve of the arm, it is very easy to propagate the needle sensation as far as the finger tips. As Metacarpal Tunnel Syndrome usually exhibits numbness of the middle finger, or even the other fingers too, we can manipulate Neiguan to transmit a clear sensation to those fingers, thus facilitating the flow of Qi and Blood up to the desired foremost target.

Taling has much the same characteristics as Neiguan, with one advantage over the latter. Its location is exactly above the metacarpal bones, and joint, a fact which makes Taling a barrier point for this area.

Its needle senation is also most often felt through to the finger tips, and puncturing this point has a direct effect on the joint tunnel itself.

Taling has a more cooling ability than Neiguan. It is a point often used to clear Heart-Fire, and resolve Heat in the meridian, or the organ. In many cases Metacarpal Tunnel Syndrome also exhibits Heat symptoms, due to the pressure of the stagnation there, and the use of Taling is very beneficial for such a condition.

Liehchueh is the Luo point, or connecting point of the Lung meridian. The connecting channel of the Lung, after leaving the main Lung channel at point Liehchueh, travels to the Large Intestine meridian and connects with it at point Pianli (LI-6). Another branch follows the Lung meridian into the palm, and spreads there through the thenar eminence.

Due to its course Liehchueh is also used for wrist joint problems, or abnormalities of the palm, such as: pain, hot palms, eczematous or numb palms.

Liehchueh has to be punctured with the tip of the needle pointed toward the thumb, for maladies of the palm. The needle sensation must follow the route of the Lung meridian, or to spread into the palm.

In this points-combination we can see that besides its quality as a points-cluster, there is a combination of two points, Taling and Neiguan, whereby each enhances the action of the other. Thus, there is the principle of mutual-assistance, as well as the facilitation of the normal flow of Qi and Blood that any points-cluster would achieve.

The order of needling these points is from Neiguan to Taling, so as to follow the ordinary flow of Qi in this meridian. These are also the more important points of the trio, and the pericardium meridian is more important that the Lung meridian, for this prescription's purpose. Liehchueh is punctured last.

As was hinted above, after Deqi has been obtained, needles must be pointed towards the palm, and manipulated in dispersion so as to cause needle sensation to travel downwards - toward the fingers.

In Metacarpal Tunnel Syndrome, where definite Heat signs are absent, it is recommended to apply moxa stimulation on the points, after needling.

In severe cases, direct moxibustion is usually applied and scars are formed. In less severe conditions it is possible to lay the moxa cones, the size of beans, on a thin layer of fresh ginger (Sheng Jiang). The layer is punctured through, in order to allow the heat to penetrate easily, and the cones are placed one after the other, until the whole area becomes red.

Another technique advocates the use of white pepper mixed with flour to make a paste, and spread over the point. The thickness of the layer should be 0.1 inch, and a hole is made in the center.

A moxa cone is set upon i and ignited. This method is Indicated usually for numbness and stiffnss, and is most suitable for the Metacarpal Tunnel Syndrome (50).

Case history

Mrs. O.T., age 35, is the owner of a goat farm, and she is also the mother of case-history number 5 ( see above).

A year and a half prior to her first visit to my clinic, she began experiencing numbness along the anterior-medial aspect of her right arm, extending towards her fingers. It was more pronounced at night, while sleeping. Later, she began feeling pain when numbness reached its climax. In the last few weeks she began experiencing the same phenomena, though to a much milder extent, in her left hand too.

Routine checks at Nahariya Hospital revealed no signs on her cervical vertebrae, where they had projected their concern. The diagnosis given was of a Metacarpal Tunnel Syndrome, and she was advised to undergo an operation.

On questioning, Mrs. O.T. revealed that sometimes when she awakens in the morning, she senses a sharp prick in her heart region, experiencing difficulty in breathing deeply, for a while. The sensation then disappears.

Questioning also revealed that she is in the habit of milking her goats for many hours, and that she rides a motorcycle in the fields.

Observation revealed a red tipped tongue with red points, and red rims. She also had peeled areas. Her right palm was dry and eczematous, she said that she had been told that it was a fungal infection, but it did not

respond to medications. I diagnosed her condition as follows:

1. A pre-existing state of slight Heat-stagnation of the pericardium, which gave rise to the shape of the tongue, to the stabbing pain in the chest, and to disturbances of the Pericardium meridian.

2. Hard labour of milking had strained the brachial muscles, especially the flexor group. This strain had impeded the flow of Qi and Blood to the palm, and had laid an extra burden on the Pericardium channel.

3. Due to impeded flow of Qi and Blood to the palm, the palm became dry, undernourished and had developed the eczema.

The reason for aggravated numbness at night, was that rest hindered the flow of Qi and Blood even more, due to lack of movement, or activity, thus making the numb sensation more pronounced.

The treatment was constructed from the three cluster points, plus Tanzhong (CU-17). Tanzhong was utilized to build the formula, due to its task as the Mu point for the Pericardium. It has a strong influence on blood circulation, and is said to propel Qi in the Upper-Burner, thus enhancing blood formation, and Qi and Blood circulation (51).

By choosing Tanzhang, I thus dealt with the local carpal stagnation, as well as assisting from afar by viewing the local problem in its holistic background.

After needling Neiguan I applied seven moxa cones on the point, using a layer of a paste made from flour and white pepper, underneath.

After seven treatments during two weeks, Mrs. O.T. improved by 90% - as she proclaimed.

About one year later she came to me again, saying she was afraid that her previous symptoms were returning. She was then given four more treatments, after which she felt better again.

7. JIANYU (LI-15), OUCHI (LI-11), HEGU (LI-4)

Main effect and clinical purpose

This very much used points-combination has been initiated in accord with the principle of choosing points on the same meridian, for mutual assistance.

It is used in many different problems of the arm, involving the shoulder, arm, hand and fingers.

Its main use, however, is to invigorate the flow of Qi and Blood in the upper limb, for problems such as Painful-Bi of different etiologies, or paralysis.

The fact that all these points are situated only on the Large-Intestine meridian, and not on one or more of the other five meridians of the arm, is because this meridian is known to have the richest supply of Qi and Blood (together with its counterpart, the Stomach meridian).

The Nei Jing states: "When treating flaccidity of the limbs (Wei syndrome), use points only from Yangming" (52).

Points discussion

As stated above, all the three points are situated on the Large Intestine meridian, and are considered important points. The title of important points is usually given to those points which have a broad spectrum of activity, and that play a major role in many formulae.

All three have in their indications qualities such as: invigorating Qi and Blood circulation, removing obstruction from the Jing-Luo, relieving pain, scatter Bi, and the like.

By choosing these three points, we thus combine their efforts to assist each other, and to have a mutual impact on the disease, which is far better than any one of them alone.

The fact that all the three are members of the same meridian, enables each point's sensation to travel to the next station, i.e. the next point, and thus propagate the needle sensation along the whole limb. When needle sensation is propagated, so is Qi, and thereafter - Blood.

There is a saying in T.C.M. that "Acupuncture is only effective when the Qi reaches the affected area". Many contemporary researchers have verified this idiom. They also found a significant correlation between the degree of induced propagated needle sensation, and therapeutic success (53).

As we have mentioned above, the Nei Jing has recommended the use of the Yangming system for diseases characterized by flaccidity, numbness, and hypertrophical features. The fact that the Yangming has been appointed for such tasks, is due to its abundance of Qi, and especially Blood.

Recent researchers in China have verified, for instance, that the use of these points in a C.V.A. sequelae, like hemiplegia, has no substitute. The reasons are those mentioned above.

Hemiplegia, as an example, is a paralysis of half of the body, caused by blood stagnation in the brain. This stagnation has induced Qi and Blood circulation impediment and in fact a real blockage, in half of the body, usually longitudally.

Thus, those three points (among other points), are manipulated to invigorate the blocked circulation and return the limb to its normal function.

By the same token, these points help eliminate pain either caused by a Xu condition, like paralysis, or a Shi condition such as paintful obstruction of the joints. The only difference is in the technique of stimulation, and in the combination of other points within the formula.

The needling sequence in this combination is usually performed in accordance with the nature of the disease. In Xu conditions, when paralysis of the arm and fingers exists, or numbness, or weakness of muscles, the needling sequence is applied from Jianyu to Hegu. This is done in order to drive the Qi sensation toward the fingers, which, in most cases, are in a worse condition.

In painful Shi conditions Hegu is most often punctured first, due to its generalized analgesic effect, followed by the rest of the points. It is, nevertheless, possible to start with Jianyu, especially if there is a marked stagnation there.

In the conditions of paralysis, or atrophied muscles, the stimulation is, necessarily, by tonification. The method of tonification varies, but in most cases it is a strong tonification for two reasons:

A. The paralytic state of the limb does not allow a satisfactory Qi sensation, in many cases, if the manipulation is too weak.

B. This is a severe condition which generally will not respond satisfactorily to a mild stimulation. In this context we may compare the amount of stimulation, or degree of needle manipulation, to a measured dose in medication, or a herbal formula. In servere conditions the dose will generally be increased. The difference, however, between acupuncture and other remedies, is that only a well-experienced practitioner is able to develop the "touch" or sensitivity for the right amount of manual stimulation. In orally taken remedies the dosage is measurable, and recommended in the formula.

In many cases of Xu conditions, especially the most severe, or those in which Cold is a part of the condition, the preferred type of tonification is "Burning the Mountain" (54) technique, which was mntioned under case number 1, in this chapter.

Xu conditions of the upper limb are very often treated with moxa too. The warm needle techcnique is highly recommended, as it warms the channel, tonifies the Qi, and accelerates its flow.

Massage techniques, Tui Na, with warming and activating oils and ointments, are also very popular and widely used. The massage is carried along the limb meridians, with rubbing and pinching, and scraping movements, pressing on the acupressure points, and activating Qi and Blood.

For such conditions also the plum-blossom, seven-star hammer-needle is applied, by tapping it along the meridians, until the whole route is reddened.

In Shi conditions, such as painful Bi of the shouder, elbow, carpal and phallangeal joints, the needle technique is sedation and dispersion. The needle is inserted against the energy stream of the channel, or manipulated in sedating procedures, or in the HuiCi pattern, which was described earlier In this work.

Cupping is also applicable, as it drains excess, and disperses stagnation. Also electroacupuncture is possible, usually combining two points from the trio in a disperse-wave.

Mr. G., age 63, a barber by profession, left handed, had, a month before he came to see me, a marked decrease in the power of his left hand, fingers and leg.

He had a sudden decrease of mental acuity, of his usual sense of humor, as well as physical abilities of hand and leg. Mr. G. had to cease working in his barber-shop, since he was left handed.

A week before coming to me, he suddenly felt very unwell, and almost lost consciousness. He could not speak properly, and suffered a staggering headache. He was taken to Nahariya hospital where he underwent a C.T. scan of the head. The diagnosis was a cerebro-vascular infarct in his right brain lobe.

Upon examination it was obvious that he had significant difficulty in moving his left fingers freely, and his gait was a little clumsy. His tongue was big, red and peeled. The pulse was moderate, and big at Cun and Guan positions.

Mr. G. confessed to a long history of moderate hypertension.

My diagnosis was a basic Shi condition of Liver Yang, complicated by a Xu condition, after the brain damage had occurred.

The treatment principle was, therefore, to invigorate the flow of Qi and Blood in his left hand and leg, subdue Liver Yang, and invigorate the blood circulation in general.

The points chosen for these purposes, were:

Jianyu (LI-15), Ouchi (LI-11, Hegu (LI-4), Baxie (extra), Biguan (ST-31), Zusanli (ST-36) - all in the left side only, and, Taichong (LIV-3), Sanyinjiao (SP-6), Xuehai (SP-10) bilaterally.

Jianyu, Ouchi and Hegu were manipulated in a strong tonification. Baxie, are eight points situated between the knuckles of the fingers. These were stimulated in order to facilitate the flow of Qi and Blood in the fingers.

Biguan and Zusanli are a combination of two points on the leg Yangming channel, and the principle of their choice and use is exactly the same as for the three Yangming points of the arm.

Taichong and Xuehai act on the blood level, in general. Taichong reduces Liver-Yang and improves blood circulation by facilitating Liver-Gi, and Xuehails role in the blood has already been discussed in case Number 5 of this chapter.

Mr. G. felt mental improvement after the first treatment. Following this treatment he never again experienced any episode of losing consciousness, or difficulty in speaking. After the third treatment, which took place during the same week, his leg returned to normal, and he had lost his clumsy gait.

After the seventh treatment, his hand and fingers regained their normal flexibility and strength.

Mr. G. was advised to come once a month for a check-up for his Liver Yang, and was consulted about his way-of-life for the same purpose.

8. SHAOZE (SI-1), TANZHONG (CV-17), RUGEN (ST-18)

This points-combination was mentioned in the "Great Compendium of Acupuncture and Moxibustian" (Zhenjiu Dacheng) written in 1601 in China during the Ming Dynasty, by Yang Jizhow (55).

Since those ancient times the relevance of the combination has not changed a bit, and its validity serves us today equally well.

The combination is suitable for all breast diseases, especially those of a Shi nature. It is used with great efficacy in cases of breast-abscess, mastitis, benign tumors of the breast, and the like. This same formula is also utilized in mastosis, or agalactia (insufficient lactation) which are primarily Xu conditions.

Points discussion

Shaoze is the Well point of the Samll Intestine meridian, and its main indications show:

1. Disperses Wind and Heat.

2. Facilitates the flow of milk in the breast.

Its first indication, which is in accord with its role as a Well point, makes it useful in acute conditions of febrile diseases, coma etc.

Its second indication points to its soothing effect on the breast.

The breast is where milk is originated and produced in the female body. It is anatomically located in the Upper Burner, where blood is also produced. Milk, according to Chinese medical theory, is made of seven parts Blood and one part Qi (56). The mechanism of milk production in the female body, is closely related to the functioning of the Chong Mai (the extra meridian which is also called the Sea of Blood), and which traverses the breasts (57).

The Stomach meridian also traverses the breasts, and this meridian too, as we know, is very rich in blood, thus both meridians nourish the breasts.

The close location of the breasts to the Lungs, and Lung meridian, permit the access of Qi from the air, to the blood of the breasts. Thus the intermingling of Qi and Blood, in the proper amounts, make the formation of milk possible.

Still, in order not to accumulate and become stagnant, milk needs a harmonizer, which will activate and supervise its flow. For this purpose, Liver Qi is responsible for two reasons:

1. This is the main task of Liver Qi in the whole body, as the Liver is responsible for the free-flow of Qi anywhere in the body.
2. The Liver meridian itself also traverses the breasts.

Milk flow, therefore, is very dependent on the free-flowing of Liver Qi, in the same manner as blood flow (like menstrual flow), is also dependent on Liver Qi. (Nei Jing: Qi is the ruler of Blood").

When Liver Qi stagnates, due to emotional problems, then blood and/or milk tends to stagnate too. In milk-giving mothers, this stagnation causes Heat (due to the pressure), and then mastitis, breast abscesses, etc.

Shaoze, both due to its milk-flow facilitating quality, as well as its Heat dispersing quality, is a first choice point for such problems.

Tanzhong was partially discussed in this paper under case history Number 6. It is the master point of the Upper-Burner, and the Mu point of the Pericardium. Its stimulation sets in motion the Upper-Burner Qi, in order to eliminate stagnation in the Upper-Burner. It thus helps facilitate the function of the lungs, aids in dispersion of phlegm in the chest in cases of asthma, facilitates the flow of Heart-0i and resolves anginapectoris, circulates the Qi of the breasts, and eliminates stagnation there.

In accord with these qualities, Tanzhong was selected to this combination.

In cases of agalactia due to a Xu pattern, Tanzhong is stimulated with moxa, to tonify the activities of the Upper Burner for milk production.

Rugen is situated in the fifth intercostal space, directly below the nipple. Due to its location, in the vicinity of the breast, and to its belonging to the Stomach meridian, its function is to regulate the breast. Rugen, therefore, assists either by tonification in Xu conditions, or by sedation in Shi conditions of the breast.

The combination, as we can see, was based on the principle of joining points which can assist each other by influencing the same organ. Shaoze and Rugen are specific points fox breast problems, while Tanzhong is the most powerful point in the vicinity of the breast. Tanzhong has in addition some systemic

influences, as we have seen above, influences that help regulate breast functioning through general physiologic functioning.

Usually Shaoze is first punctured so as to direct the influence of the treatment to the breast. Then Tanzhong is stimulated due to its prime importance, and then Rugen.

Shaoze is punctured 1-2 fen deep, slantingly, in direction of the wrist.

Tanzhong is punctured either pointed upward or downward, until Deqi is obtained. When this is done, the needle is lifted to the skin surface, and redirected towards the diseased breast. Manipulation of the needle is then performed by twirling and lift-thrust movements, allowing the sensation to project to the breast. In cases of abscesses, or mastitis, it is imperative that needle sensation should project inside the diseased breast.

If both breasts are diseased, the same procedure is applied to the other breast too.

In Xu conditions of the Upper Burner, leading to agalactia, the use of moxa is very beneficial. It is possible to apply direct moxibustion, taking proper care not to cause too strong a burn. It is possible to warm the point with a moxa stick, or by indirect moxibustion on a ginger layer.

It is forbidden to stimulate Tanzhong with electricity, or cupping, as it may have an adverse effect upon the heart. Actually there are some texts that forbid the stimulation of this point even by acupuncture, and recommend only the use of moxa (Points of Chinese Acupuncture by Dr. J. Lavier, or CHINESE ACUPUNCTURE by Dr. Wu Wei Ping). In any case, contemporary experience in China strongly advocates acupuncture in this point, plus moxibustion.

With Rugen, the procedure of needling is the same as with Tanzhong, only after obtaining the Qi, the needle is directed proximally toward the breast, and then manipulated.

This points-combination, especially when performed in order to soothe Shi patterns, resembles a herbal prescription generally used to treat the same disorders.

1. Pericarpium Citri Reticulata (Qing Pi)

2. Semen Vaccaria (Wang Bu Liu Xing)

3. Radix Salvia Miltihorriza (Dan Shen)

This herbal prescription is used to treat pain and swelling of the breasts, palpable masses or lumps in the breasts, due to congealed Blood, or constrained Qi.

It is also used to promote lactation. Just as the points-combination, it is a basic prescription, on which other herbs are usually added according to the various necessities of any specific case.

Qing Pi is a major herb to regulate the free-flow of Liver Qi. It reduces Qi accumulations due to constrained Liver-Qi in the breasts, and therefore alleviates pain and distension.

Dan Shen invigorates blood flow, and breaks up congealed blood. It may be used also for palpable masses in the chest, cysts and lumps. Dan Shen also clears Heat and may be used therefore to treat breast abscess due to Heat stagnation.

Wang Bu Liu Xing with its qualities regarding the breasts, may be adequately compared to point Shaoze. It also promotes lactation and treats breast abscesses and swellings. The meridians it enters are those of the Stomach and Liver, exactly the same meridians that play such a large role in breast physiology.

This formula, when tonifying herbs such as radix Astragali (Huang Qi) are added, may be used to treat agalactia due to Qi Xu conditions which have led to constrained Qi.

On the other hand, when herbs like Taraxacum (Pu Gong Ying) are added, it may treat breast abscesses, due to Fire and Poison origin, and constrained Liver-Oi.

Miss K., age 27, a stage actress by profession, complained of a large abscess on her left breast. A month prior to that, she had another abscess on her right thigh, on the path of the Liver meridian, near Yinlian (LIV-11).

She was treated at that time with antibiotics, which caused the former abscess to disappear, and the new one to appear on her left breast. The antibiotics, she proclaimed, had made her very weak, lethargic, and depressed.

On arrival at my clinic she had fever, and suffered great pain in her left breast, a pain that radiated along the Pericardium channel of her left arm.

The abscess was large, situated under her left nipple, inflamed, and resembled a second red, big nipple.

Miss K.'s pulse was moderate and choppy, deep and weak. The Cun position, on both sides, was very choppy.

Her tongue was red-purple, with even redder rims. The inside of her eyelids showed a red shaded line on the upper part of the lids - a Blood-Stagnation indication.

In reply to my question as to whether she had had any problems with her liver, she said that she had suffered a severe jaundice five years earlier.

Thus, in accordance with all the symptoms and signs, I diagnosed Miss K. as suffering of Liver-Heat stagnation, affecting the meridian. The abscess on her left breast was of the Fire-Poison category, and also involved Blood-Stagnation. This Blood involvement had caused the fever, and involvement of the Pericardium channel. The pericardium channel is in continuum with the Liver channel, as a partner in the Chueh-Yin system.

The formula for treatment was as follows:

Left side: Shaoze (SI-1), Tanzhong (CV-17), Rugen (ST-18), Zulinqi (G-41), Waiguan (T-5)

Both sides:Quchi (LI-11), Zusanli (ST-36).

This formula was actually constructed from three well known points-combinations.

on the first combination there is no need to elaborate, it is sufficient to say that in this case all the criteria existed in order to utilize this combination.

Zulinqi and Waiguan are the Master and Coupled points of Dai Mai - the Girdle Vessel. This extra meridian harmonizes Liver and Gall-Bladder activities, and its area of influence is the waist, ribs and chest, and the head. Dai Mai, as an extrameridian, absorbs excess energy from the Liver and Gall channels, and adjusts their functioning. Moreover, Zulinqi is indicated for Liver-Qi stagnation affecting the breast, and that includes mastitis and abscess.

Waiguan, in addition to its role as the coupled point of the Dai Mai, is the Luo point of the hand Triple-Burner (San Jiao) meridian. Its coupled meridian is the Pericardium meridian. Puncturing Waiguan may be thus used to divert excess from the Pericardium, and to adjust its functioning. All this is due to the Luo points' role as a "tap", that may be used to balance two coupled (Yin-Yang) meridians.

Quchi and Zusanli, both on the Yangming segment of channels, drain excess Heat, relieve fever and invigorate and regulate the Blood. They are therefore widely used in hypertension due to excess Heat - a fact which has already been discussed in this paper.

The first sesion lasted 30 minutes, in which Tanzhong and Zulinqi were manipulated every 10 minutes. The patient experienced a "sucking" sensation, travelling from Tanzhang to the abscess. Following the treatment, she experienced the same "sucking" sensation plus pain along her left arm, for about six hours.

After six hours the abscess burst open, and a great deal of pus and blood was discharged. Afterwards, she experienced a sudden relief. The pain subsided almost completely, as did the fever and the depression.

Miss K. came thereafter for six consecutive treatments, following which her breast healed completely.

Miss K. came to me a year later for a different problem, and while examining her I noticed that her breast did not bear even the slightest mark of the episode she had undergone.

The points-combination above is mainly used to treat conditions in which phlegm has accumulated in the throat region, giving rise to problems such as: hoarse voice, asthma with a sensation of blocked throat, lumps in the throat, goiter etc.

Hegu is a point which possesses many qualities, some of which have been discussed in various parts of this work, and especially under cases numbers 2 and 7.

Hegu was placed in this points-combination due to its key role in the Large Intestine meridian, which makes its route through the neck and throat.

We have already discussed the invigorating quality of Hegu, which, when stimulated, sets in motion and invigorates the flow of Qi in this channel, thus clearning any blockages along its route. In case number 2, for example, the point was utilized to unblock stagnation in the nasal sinuses area. Here, the point serves to resolve Phlegm, or Phlegm Fire, or Damp-Phlegm in the throat region, all conditions that may cause, if untreated, grave problems in that area.

Due to Hegu's other qualities, it may be used just as well for externally contracted Dampness that has aggravated into Phlegm, or internally originated Phlegm.

We already know that Hegu is a first choice point for externally contracted situations. That may include, in fact, all the patterns. Wind, Heat, Cold, Damp, plus combinations of them. Internally, Hegu Is the Yuan point of the Large Intestine, thus in close relation with the organ itself. The Large bowel is responsible for eliminating toxins and waste through the lower orifice, and thereby Hegu plays an important role. Moreover, Hegu also belongs to the Yang-Ming system, and thereby exerts an influence over the stomach too. As we know that the Stomach/Spleen malfunctioning is responsible for phlegm creation, we can imagine how Hegu may have an influence on the internal origins of Phlegm.

Tiantu is probably the most important symptomatic point in the case of asthma. It is located in the base of the throat, and forms the barrier between the trunk and the head region.

In this area, people often feel a sensation as if "something" is stuck in their throat, a sensation metaphorically related to as "plum seed" in Chinese. This sensation is typical of the formation of phlegm accumulations in the throat.

Since phlegm has a dense energy, or "dirty" energy, it is stuck in the narrow passages of the throat, and blocks Liver-Qi, or the "Clear Yang" of Stomach Qi from ascending to nourish the brain (58).

Stimulation of Tiantu disperses the phlegm in this area and facilitates both ascent of Qi to the head, and absorption of air Qi, in the lungs.

Tiantu is also indicated when Fire exists in the throat. Fire may present on its own, but in the throat region, it is usually combined with Phlegm, thus creating the phenomena of Phlegm-Fire. Phlegm-Fire exists in cases of throat-cancer, or abscess, acute goiter, etc.

Futu is also a point on the Large Intestine meridian, and is located on both sides of the neck. It is combined with Hegu, which is on the other end of the meridian, forming the bond of one point in the vicinity of the diseased organ, and one point distant.

Futu's traditional indications are:

Coughing and wheezing, excessive mucous, difficulty in swallowing, hoarse voice, and "duck-like" sounds in the throat.

It is therefore in mutual assistance with Hegu on the same meridian, and with Tiantu - in the vicinity of the focus of the disease.

As with other conditions which are basically Shi, needling is initiated with distant points, and continued with close points (59).

Hegu is stimulated in sedation in order to invigorate the flow of Qi In the meridian, and to disperse Phlegm in the throat. Then Futu is preferably punctured, to make a continuum with Hegu, and take advantage of the propagated Qi that Hegu has transmitted upward.

Tiantu is lastly utilized to produce its effect on the whole area.

In Taiwan I have watched practitioners using the "warm needle" technique on Hegu in this context, when Heat signs were absent. The idea behind this is that the Nei Jing states that in cases of abundant Dampness "warm needle" technique is superior (60).

The logic is that the heated needle conveys warmth through the point to the meridian. This warmth helps dissipate the phlegm by drying it.

I have therefore occasionally used this technique myself with very good results.

Futu, in cases of goiter, or neck lumps, is sometimes stimulated with indirect moxibustian over a layer of ginger. This is applied after the point has been needled, and the needle is withdrawn right afterwards.

In cases of lumps in the vicinity of Futu, it is often seen that the lump itself is pierced rather deeply, to follow right afterwards with the indirect moxibustion procedure.

Regarding Tiantu there are two main possibilities. The first is to insert the needle parallel to the sternum posteriorly, until Deqi is obtained, and then to withdraw it. The second is to do likewise, but suspend the needle until the whole treatment is terminated.

A herbal formula consisted of the following herbs:

1. Thallus Algae (Kun Bu)

2. Herba Saragassi (Hai Zao)

3. Radix Cynanchi Stautoni (Bai Qian),

is very similar in action to the above-mentioned points combination.

Kun Bu and Hai Zao assist each other in dissipating Phlegm nodules in the neck region, or they are used together to treat goiter. Their nature is cold and salty, and they clear Heat and reduce Phlegm.

Bai Qian is very similar in action to point Futu, and probably Tiantu as well. It is used to treat Phlegm conditions in the throat, and to redirect rebellious Lung Qi, which means asthmatic conditions.

Its traditional indications also mention that Bai Qian is effective in treating "gurgling sounds In the throat", which is a sign of accumulation of Damp Phlegm,.

This indication in particular reminds us of the classical indication of the point Futu, which we have mentioned above, that it treats: "sounds in throat - like duck".

Miss S., age 26, also a stage actress, and a close friend of Miss K. from case history Number 9, was diagnosed five years before as having a benign tumor on her vocal cords.

She exhibited symptoms of hoarse voice, a fact that was not at all unwelcome In her profession, and a constant sense of mucous in her throat.

She had an odorless vaginal discharge, occasional stomachache, and not very frequently, nausea.

All four methods of Chinese diagnosis revealed a state of Lung and Spleen Qi Xu, as a basis for formation of Phlegm, and obstruction of the throat by Phlegm.

Her pulse was thin, soggy and weak, especially on right Cun and Guan positions.

Her tongue body was slightly flabby, and covered with a thick, white, transparent and slippery coating.

Changmen (LIV-13) on the left side was tender but very ticklish, and Zhongwan (CV-12) was very tender too.

Miss S. was a ten-year smoker, and used to smoke at least 20 cigarettes a day.

The treatment principle was to eliminate Phlegm in the throat, and to tonify Spleen and Lung Qi.

I therefore chose the following points for treatment:

Hegu (LI-4), Futu (LI-18), Tiantu (CV-22), Panglianquan (extra), Liehchueh (L-7), Fenglong (ST-40)

Since there were no Heat signs, despite the fact that Miss S. was quite a heavy smoker, Hegu was acted on by the warm needle technique.

Panglianquan are two points located 0.5 cun on both sides of Lianquan (CV-23). These are special points for diseases of the vocal cords. One should insert the needle there transversely, along the skin, in an upward proximal direction, until the patient feels as if he or she "had swallowed fish bones".

Liehchueh and Fenglong make a very effective points-combination to treat Phlegm in the upper respiratory tract. Liehchueh is the Luo point of the Lung meridian, and is very useful in resolving Damp conditions of the Lungs, as well as redirecting rebellious Lung Qi. It is also the master point of the Jen Mai, the extra meridian which passes through and nourishes the throat, and which is very prone to Damp-Phlegmatic diseases. Liehchueh was also chosen because of the leukorrhea of the patient, a problem which is also subject to the functioning of the Jen Mai.

Fenlong is the point to treat any Phlegm condition in the body, as it adjusts the functioning of the Spleen and Stomach meridians.

The last points-combination in this formula is Hegu and Liehchueh which follow the "Host-Guest" principle, and have a renowned ability to harmonize the Lungs, dissipate Phlegm, and redirect Lung Qi.

The patient was instructed to cut-off her cigarette consumption, as well as coffee and milk products.

She made efforts to eat more regularly and to avoid junkfood and too much salt.

Miss S. received seventeen treatments, after which all her symptoms had practically disappeared. She would not agree to undergo another examination of her vocal cords, in order to check upon the tumor there. She was completely satisfied with the way she felt, and said she could not care less whether or not the tumor was still there.

10. SHENSHU (B-23), WEIZHONG (B-54), KUNLUN (B-60)

Main effect and clinical purpose

This is another points-combination in existence for at least 400 years. This combination was first mentioned in the "Great Compendium of Acupuncture and Moxibustion", written by Yang Jizhow in 1601, as was combination number 8, above (61).

It is structured on the principle "one point above - two points below, on the same meridian" (see chapter B, number 6).

It is perhaps the most popular combination to treat low back pain, of any etiology. it may definitely be of great value even in cases of middle and upper back pain, with the addition of some other local points.

Points discussion

Shenshu is the Back-Shu point of the kidneys. It is a very strong point, and one of the most frequently used in clinical practice.

Shenshu's traditional functions include:

• Regulates Kidney-Qi.
• Strengthens the lumbar vertebrae, and knees.
• Benefits the ears and eyes.
• Eliminates Damp.

It thus reinforces Kidney Qi in all Kidney syndromes:

Kidney-Qi-Xu, or not firm, Kidney-Yin Xu and Kidney-Yang Xu.

It is a well-known fact in T.C.M that Kidney-Qi is the actual source of all the energetic activities of the body. Kidney-Qi is the Prenatal Qi, as well as the storage of all reserves of Postnatal, acquired-Qi.

It is also the source of Yang-Qi, as the Fire of Ming-Men resides between the two Kidneys.

Shenshu, as the Shu point of the kidneys, is in close contact with the organ itself. It has probably the best Influence over the kidney function, and is therefore utilized in any disease involving the organ itself.

But, besides diseases such as: nephritis, renal calculi, nephroptosis, or bladder diseases, the physiologic spectrum of kidney function is so broad, that Shenshu is also applied in many other pathologies. This may include: skeletal problems, sexual problems, haematogenesis (since the kidneys are very much involved in this, too), aging diseases, gastrointestinal, hormonal, and other problems.

In this points-combination context, Shenshu is applied due to two of its manifold qualities:

A. As a local strong point in the lower back, which, like any local point, helps regulate local functioning and resolve local Qi stagnation. This is especially so when its indications do demonstrate low-back pain.

B. Many etiologies of low-back pain stem from Kidney-Xu, leading to either skeletal deformations, or muscular impairment in the lower back.

Thus, these qualities make Shenshu the first choice local point for low-back pain.

Weizhong, according to chapter four of the "Spiritual Axis" (Ling Shu), connects behind the knee with its Bladder meridian, as its "Lower Uniting Point". The Bladder channel connects with the Kidney meridian via the Yin-Yang coupled meridians law.

The course of the Bladder meridian passes through the lower back, and influences it.

Moreover, in the classics, Weizhong is regarded as one of the Six Main Points classification, recorded as follows: "Take Sanli for the belly and abdomen, Weizhong for the waist and back, Liehchueh for the head and neck, Hegu for the face and mouth, Neiguan for the heart and thorax, and Sanyinjiao for the lower abdomen".

Therefore, two indications of this point show:

• Relaxes tendons and invigorates collaterals.
• Benefits the lower back and knees, and strengthens the waist.

The other two indications may well be listed here, being:

• Clears Heat from the blood.
• Dispels Summex-Heat Evil (Pathogen).

From the above data we can see that even 3000 years ago, Weizhong was the first-choice distal point, as often as Shenshu the local point, to treat low-back pain.

It is used therefore to treat acute back sprains, or inflammations of lower back tendons and muscles, or, just as often, Xu conditions of chronic low-back pain, or weakness, etc. Weizhong is also a very important point in the treatment of sciatica. It is located upon the trunk of the sciatic nerve behind the knee, and its stimulation may cause an electric shock sensation all along the sciatic nerve - up tp the toes. As we have mentioned in the case of Neiguan (P-6) (see under case Number 6), this electric-like sensation helps propagate the Qi along the channel, and to resolve various stagnant focuses, along it. The very distinct sensation that Weizhong produces, is thus considered the cause for its great efficacy in the treatment of low-back pain and sciatica.

Kunlun is another point on the Bladder channel, whose indications also say: "To relax the sinews and muscles and benefit the lower back".

It is very much used in the treatment of low-back pain and sciatica, as much as stiff neck, and head problems related to Wind.

Since "Dispersing the Wind and clearing the channels" is its other indication, Kunlun is mainly used in low-back pain related to Wind-Bi. Wind-Bi is a form of wandering rheumatism, which may affect various parts of the body consequently. In the posterior part of the body, it is most often seen in people suffering alternately from stiff neck, or stiff back, or buttocks, etc. In such cases the addition of Kunlun to the formula is very rewarding.

The law of "One point above, two points below" is very pertinent in the case of low-back pain. The Bladder meridian energy flows in a distal direction from the back. Shenshu serves as the local point that activates and invigorates the flow of Qi in the lower back, while the other two points attract the Bladder energy downward, enhancing and accelerating its flow.

Beside this principle, all the three points serve in mutual assistance to benefit the lower back, and relax muscles and tendons there, as their indications imply.

In addition, Shenshu has a more fundamental task, which is to act directly on the kidneys, which are the organ responsible for the lower back.

In very acute cases that involve pain, it is advisable to start with the most powerful distant point. Thus, Weizhong is usually the first point, then Shenshu and lastly Kunlun.

In acute sprain of the lower back, Weizhong is utilized while the patient is standing. It is manipulated in sedation, as much as the patient can tolerate, while he, or she, is asked to gently rotate the waist. This type of procedure is often performed in acute, painful conditions of various parts of the body. A point is strongly manipulated while the patient is asked to rotate and manoeuver his painful joint (62).

In acute hot conditions Weizhong is frequently bled with the pyramid needle. This is done especially if congested veins are visible in the vicinity of Weizhong.

Another popular method is to apply cups on Shenshu, with or without needles. Also recommended is the application of cupping on Weizhong in the case of painful knee, related to lowback pain. This is usually done after the needles have been withdrawn (63).

Electrical stimulation of the points is also possible and often seen in the clinic, in cases of low-back pain. Usually the right side is stimulated by one line and the left side by another line. It is performed by a dispersion wave.

Radix Duhuo (Angelica pubescens) has very similar qualities to point Kunlun. It is in the category of Wind-Damp expelling herbs, and its indications are:

• Expels Wind-Damp that causes painful obstruction.

• Alleviates pain caused by the former indication.

• Channels entered are Kidney and Bladder.

• Used to treat low-back pain, and leg pain.

• Also treats headache and toothache because of Wind-Cold-Damp.

With the addition of Herba Assri cum radice (Xi Xin), and Radix Gentiana Macophylla (Qin Jiao), it constitutes a classic formula to treat soreness, pain and numbness in the neck and back, and lower extremities due to Wind-Damp-Bi.

With the addition of Radix Dispaci (Xu Duan) this formula imitates our points-combination very closely, as Xu Duan plays the role of point Shenshu. Xu Duan tonifies Kidney-Qi and Yang, and it strengthens the sinews and bones.

Xu Duan also promotes and invigorates blood circulation and is therefore useful even in cases of low-back pain due to trauma, and blood stagnation. In this, Xu Duan imitates the mutual effect of both Shenshu and Weizhong.

Mrs. D., 40 years old, married plus two children, has suffered from chronic low-back pain, for years. Every weather change, especially cooler, or more damp weather, had affected her body. She could not tolerate cold weather in general, apart from its effect on her lower back condition.

During the last seven years Mrs. D. has not used any contraceptives, because she was certain she could no longer conceive.

Her tongue was pale, flabby with "tooth-marks", and covered with a thin layer of white, damp moss.

Mrs. D.'s pulse was sunken, and weak, even more so in both Chi positions.

It was apparent that her case was a Kidney-Yang deficiency, with Damp-Cold-Bi in her lower back.

Treatment was administered three times a week, based on the points-combination discussed above. In addition to these points, I applied direct moxibustion on her Mingmen (GV-4), every second visit.

Following the first session her lower back improved radically, and after three more treatments it did not bother her at all. The frequency of treatments was then reduced to once a week, for four more treatments.

Two months later, to Mrs. D.'s great astonishment and delight, she became pregnant.

Now Mrs. and Mr. D. have a three year old daughter, in addition to their two former sons, and she very seldom complains about her lower back.

Main effect and clinical purpose

The goal of this much used points-combination is to relieve wheezing, and to abate Phlegm from the chest and respiratory tract.

It is therefore used in cases of asthma with excessive phlegm, or bronchitis, or any other lung disease, characterized by much Phlegm, and difficult breathing.

Points disscussion

Dingchuan is an extra point, located 0.5 cun lateral to the lower end of the spinous process of the 7th cervical vertebra. It is mainly used to stop wheezing and dyspnea, and indeed its effect is, in most cases, very dramatic.

Dingchuan belongs to the Hua Tuo Jiaji points, named after the great Chinese physician who discovered them. Hua Tuo lived in the Han period, during the reign of Emperors Shun (136-141 AD), and Huin Di (208 AD).

The Jiaji points are located 0.5 cun, on both sides of each vertebra. The Ding Chuan point, being so effective in treating difficult breathing, has thus won a special name of its own.

Dingchuan is also effective in treating urticaria, which is an allergic skin disease, often related to lung diseases.

Dingchuan has a remarkable effect on bronchodilation, and relieving spasm of the bronchial branches. It is less effective in clearing the Phlegm from the respiratory tract, and therefore it makes a first choice point in the case of acute ashtmatic attack.

Tiantu was discussed broadly under case number 9. Its indications are:

• To disperse the Lung.

• To resolve and lower Phlegm.

• To regulate Qi.

• To clear and reduce Fire in the throat.

• To stop cough.

• To soothe asthma.

We can see that it is a very appropriate point in all cases involving cough, asthma, excessive phlegm, etc.

Tiantu is an important point on Jen Mai, the vessel of conception. This vessel is the "reservoir" of all Yin energy in the body, and thus one of its chief concerns is to regulate body fluids. Sedation of point Tiantu, would then, disperse accumulations of fluids, of which Phlegm is one phenomenon. In order to perform this adequately, via the Jen Mai, it is appropriate to "open" the Jen Mai by stimulating Liehchueh (L7), which serves as its Master point, at the same time.

Tanzhong, another point of Jen Mai, was also discussed in this paper, under case number 8.

Besides playing a role in Jen Mai functioning, as described above, Tanzhong serves as the master point of all activities taking place in the chest, and upper Jiao.

Because of this, its major indication is to "regulate Qi in the chest,," and to "relax, expand and dispel fullness from the chest". Another indication, Just like the former point Tiantu, is: "To clear the lungs, and resolve Phlegm."

Tanzhong is also considered the Mu (alarm) point of the upper Burner, as much as Zhongwan (CV-12) is of the middle Burner, and Yinjiao (CV-7) of the Lower Burner.

Because of this role, Tanzhong is responsible for regulating Qi and Blood in the upper-Burner, and resolving any forms of stagnation there.

The Qi collected in the chest is Zong Qi, and is the refined Gu Qi ("grain"-Qi), which ascends as the essence of food, by the Spleen. This Qi is responsible for the functioning of the Heart and Lung, including the Qi dominance over the Blood. This Qi also dominates the voice, and enhances blood circulation to the extremities. The place where Zong-Qi gathers and acts in the chest is called "Sea of Qi", and Tanzhong is the point responsible for activating it (64).

One of the commonest stagnations in the body, and especially in the chest, is Phlegm. By utilizing Tanzhong we activate Zong-Qi, enhance its flow in a circular fashion in the chest, and thus disperse Phlegm.

Neiguan has also been discussed in this work. (See case Number 6.) It is considered the most powerful point of the Pericardium meridian, and is also its Luo point.

Neiguan's functioning is closely related to the chest and diaphragm, mainly because of the route of the Pericardium channel, which traverses the chest, along with its Luo channel that connects with the heart.

The function of Neiguan, which relates to the chest says: "It expands the chest, regulates Qi circulation and stops pain." In this regard Neiguan's function is very similar to that of Tanzhong, as it improves Qi circulation in the chest, an activity which necessarily disperses phlegm.

Fenglong is the connecting Luo point of the Stomach meridian. The point connects with the Spleen meridian, which is the coupled meridian of the Stomach, in the Yin-Yang relationship.

The Spleen, when malfunctioning, is considered the source of Phlegm in the body. By stimulating Fenglong one restores harmony between Stomach and Spleen, readjusts their functioning, and in this way, eliminates Phlegm.

Fenglong's qualities are therefore:

• It resolves Phlegm, Damp and Phlegm-Heat.

• It calms and clears the mind.

• It eliminates Phlegm-Fire in the stomach.

Due to these qualities Fenglong is a very important point in any case where Phlegm is abundant, and that, of course, includes asthmatic conditions.

These five points are combined, as we can see, in order to have a strong effect on Phlegm accumulation in the respiratory tract.

The points which were chosen share a mutual quality of Phlegm abatement, and regulating the Qi of the respiratory organs.

The power and great efficacy of this combination is due to the fact that the points which were combined here, belong to different sytems, thus dealing with the problem from different angles.

Dingchuan, for example, exerts its influence through the nervous system, directly on the trachea and the bronchus, and relieves their spasm.

Tiantu, achieves its main effect by eliminating Phlegm from the trachea.

Tanzhong affects the lungs and the bronchioles by eliminating Phlegm, and adjusting their function.

Neiguan plays its role as a distant point that regulates, from afar, the whole chest-organ's functioning, and last, but not least, Fenglong deals with the very source of Phlegm, and abates it systemically.

In this points-combination the needling procedure generally starts with Dingchuan, in a sitting position. The patient bends forward with his arms crossed beneath his forehead, and then Dingchuan is punctured 0.5 cun laterally, slightly below both sides of the prominence of seventh cervical vertebra.

After needling, the point is manipulated in dispersion for 2-3 minutes. Usually the patient experiences an immediate relief from wheezing and dyspnea.

After 5-15 minutes, the patient's position is changed to supine, and the rest of the points are needled, in this order: Neiguan, Tiantu, Tanzhong and Fenglong.

All the points are needled to sedate, and disperse Phlegm. When it is desired to accentuate the needle sensation, the technique of "wagging the tail" is utilized (65). By this technique, after obtaining Qi, the needle handle is "wagged" back and forth, until the patient senses a strong reaction along the meridian. This procedure is said to move the Yang- Qi, and by so doing to disperse Phlegm stagnation.

In the case of children, Tinatu is usually removed after Deqi, whereas with adults the needle is left in situ during the whole treatment.

The proceudre of "wagging the tail", may be performed on Neiguan, if the patient is robust enough to tolerate it, and on Fenglong as well. However, attention must be paid to avoid a strong reaction which might occur after the treatment. In some patients, Fenglong has a strong impact on Phlegm movements in the body, and this may aggravate their condition at the beginning of the treatment. It is advisable in such cases, to instruct these patients to keep using their "Western medicine" broncho-dilators until their basic condition has been significantly improved.

It has been observed that scarring moxibustion is also very effective in stubborn asthma. The points suitable for this technique, from among this combination's points, are Neiguan, Tanzhong and Fenglong.

In order to perform this correctly, a tiny cone of white moxa is placed over the point, preferably after needling it, and burned to its end. Immediately afterwards the procedure is repeated, with slightly larger cones, on the same spot, three to seven more times. There are some specific ointments which may be utilized to heal the wound, after pus has emerged. One of them, and a very good one too, is "Red Jade Ointment" (66), in the case of a serious wound, or simply egg's white, for a relatively mild wound.

This points-combination may be compared to the following herbal formula:

• Semen Pruni Armeniaca (Xing Ren)

• Fructus Perilla Frutescentis (Su Zi)

• Bulbus Fritillaria Thunbergi (Zhe Bei Mu)

• Rhizoma Pinellia Teranta (Ban Xia)

• Radix Cynanchi Stautoni (Bai Gian)

• Stalactitum (E Guan Shi)

This herbal prescription is a combination of herbs that have an effect on cough due to rebellious Lung-Qi, and accumulation of Phlegm.

One component, though, is E-Guan-Shi, which is a mineral, and has a general effect on strenghtening Yang, and transforming Phlegm. It may be compared to point Fenglong, even though it does not affect the Spleen directly.

In order to achieve a more straightforward effect on strengthening the Spleen, and thereby resolving Phlegm, it is suitable to add to the formula herbs such as Codonopsis Pilosula (Dang Shen), or Radix Glycyrrhiza (Gan Cao), both of which tonify the Qi via the Spleen, and also have the effect of reducing Phlegm.

Xing Ren may be compared to both Dingchuan and Tiantu, in its ability to stop wheezing and redirect Lung-Qi downward.

Su Zi is used to stop wheezing and dissove Phlegm. It is mainly used when copious Phlegm obstructs the air passages.

Zhe Bei Mu is also suitable for the same indications, only it is more appropriate for dealing with Heat in the Lungs, as well.

Ban Xia and Bai Qian are both used to treat wheezing and cough due to rebellious Qi and Phlegm.

Mrs. M., age 36, suffered since childhood from severe hay fever and urticaria on her upper back and shins.

Two years prior to her visit in my clinic, she began to experience occasional asthmatic attacks, until this condition became permanent.

Mrs. M. had a "barking" cough and wheezing, and congested chest, with a sensation of lodged phlegm which could not be expectorated.

Her pulse was very Soggy and Slippery. Chi position was not palpable at all, and the pulse of her Lungs was small and hard.

Her tongue was pink-pale, wet and scalloped; the coating was white and damp.

On evaluating the different aspects of this information, I came to the conclusion that Mrs. M. was on the verge of an externally inflicted disease turning into an internal disharmony.

The history of many years of stubborn hay-fever, along with the wet and white-coated tongue, pointed to an external Damp, and probably Cold, origin of the problem.

The Slippery and Soggy pulse, with the scalloped tongue, suggested a weak Spleen, and accumulation of Damp and Phlegm.

The congested pulse on the right cun position, with chest stuffiness and wheezing, demonstrated a concentration of phlegm in her chest, probably phlegm which had become too viscose to allow itself to be expectorated.

The points-combination above was, therefore, utilized, in order to act directly on the phlegm, disperse and eliminate it. Point Neiguan was intermittently switched with the couple Hegu (LI-4) and Liehchueh (L-7). This couple has already been discussed several times in this work. (See Chapter B, paragraph III, case history Number 9.) Here it was chosen for its marked effect on redirecting rebellious Lung-Qi, and eliminating stagnation in the upper respiratory tract.

It is interesting to note here that whenever Mrs. M. had come to the treatment demonstrating dyspnea and wheezing, point Dingchuan, manipulated in the fashion described above, had, in five minutes, relieved her symptoms completely.

After five sessions only, the urticaria and the itchy skin have both disappeared. Her asthmatic condition improved gradually, and after ten treatments Mrs. M. reported that she had no further dyspnea and wheezing.

I then changed her prescription in order to place an emphasis on the "BIAO" - the root - of her body condition. The principle was to tonify both Lung and Spleen Qi, strengthen Wei Qi, while still occasionally using points that release exterior conditions, such as: Fengmen (B-12), Fengfu (GV-16) etc.

Today, after one and a half years, Mrs. M. suffers no more from either asthma or urticaria. She nevertheless has, even though to a much lesser extent, occasional hay-fever attacks.

It is very important, during the course of such treatment, to emphasize to the patient the importance of avoiding Phlegm, or Damp producing foods. These would be especially milk products, sweets and very sweet food, overly greasy food, fried food with much oil, and salt.

It is no less important to stress the essential role of physical exercise, and breathing techniques.

Main effect and clinical purpose

This points-combination is the basic, and most fundamental prescription for all stomach complaints. Its action is to regulate and harmonize Stomach-Qi, resolve gastric stagnation of any kind and redirect the rebellious Qi of the Stomach.

It is therefore mainly used for gastric pain of different etiologies, nausea and vomiting, such as in the morning sickness syndrome.

Points discussion

Neiguan is one of the most popular points in clinical practice. It is very often encountered in treatments, and it has a broad spectrum of indications. It is the third points-combination in this work, in which Neiguan takes part.

Under points-combination number 10, we have already mentioned that Neiguan is one of six points considered "Main Points" in the classics. There, its indications say: "Take Neiguan for the heart and thorax."

Actually the two main organs Neiguan is very effective for, are the heart and the stomach. The influence that Neiguan exerts upon the stomach, is reflected in its indications list:

"To promote the function of the stomach, and regulate the Middle Jiao."

Neiguan is also used as an important point to regulate the heart, and calm the mind. It is therefore used extensively in cases of anxiety and palpitations, etc.

The fact that Neiguan is so helpful in these conditions, is probably due to its role as the Master point of the extra vessel Yin Wei Mai.

This extra vessel is used primarily to treat emotional problems related to deficiency of Yin Qi, and Blood. It is a vessel that binds all the Yin meridians, and controls the heart functioning, related to Blood (67).

Neiguan, as its Master point, is situated on the Chuehyin segment, which is the hinge of the Yin, and thus controls the Yin.

In order to have an effect on Blood production, so as to tonify the heart functioning, Neiguan must regulate Somach-Qi, in order to permit the Stomach and Spleen to produce Blood. Its coupled point in the Yin Wei Mai meridian, Gongsun (SP-4), actually complements Neiguan's influence upon the stomach due to its role as the connecting Luo point between the Stomach and the Spleen. Thus, Gongsun has a tonifying effect on the Spleen, it pacifies the Stomach and it regulates the Chong Mai, of which it is its Master point.

In summary, Neiguan has a regulating and tonifying effect over the Stomach, due to its manifold connections with other vessels in the body.

Zusanli is the lower He-Sea point of the stomach. It is also called the Fissural-point and its action is described in the Ling Shu as follows: "They (Fissural points) refer to the deep regions where the energy of the meridians gathers together, and they are more effective in relieving acute pain in the travelling regions of the related meridian, and also in the internal organ to which the meridian in question belongs."

Zusanli is also one of the "Six Main Points" of the classics described before, and is indicated there for all diseases located in the abdomen and belly.

As the lower He-Sea point of the stomach, Zusanli adjusts the function of the Stomach and Spleen, and is used as the major point to tonify the Spleen. It is often used in conjunction with point Taiyuan (L-9) to tonify the Qi of the whole body, as the source of post-natal Qi are the Lungs and Spleen.

Zusanli also regulates circulation of Qi and Blood, and tonifies anti-pathogenic Qi In the body.

In all Stomach diseases it plays the most important role, and is used to strengthen deficiency conditions, as much as to sedate excess.

Zhongwan is the Alarm-Mu point of the Stomach. It is also used in all Stomach syndromes, both Xu and Shi. It regulates Stomach-Qi and is therefore used in painful syndromes, or nausea and vomiting. It relieves Food stagnation and treats indigestion, abdominal distension and the like. It is also used to tonify stomach and Spleen, and therefore treats anorexia, anemia, chronic diarrhea, and the like. Zhongwan relieves abdominal pain, and is used to treat gastric ulcers and gastrodynia of various etiologies.

Zhongwan is also a confluent point of all the Fu organs, and so exerts its influence on all their activities. It is known, for instance, that the intestinal rhythm, or peristalsis, affects the stomach function, and vice versa. Zhonwan, as the meeting point of all the Fu organs, is thus used to harmonize and regulate peristalsis of stomach and intestines.

After analyzing the three points' functions, it is obvious now how these three points have a regulating effect over the Stomach. It is important to bear in mind, however, that this is, a very fundamental combination, despite its great efficacy. It is necessary, as a rule, to add other points to this trio, according to the various manifestations of gastric stagnation.

In order to further elaborate on this, let us take a few examples:

1. If we have diagnosed a gastric stagnation due to Food and Heat accumulation, it would be appropriate to add: Neiting (ST-44) and Weishsu (B-21).

2. If the stagnation is due to Liver Qi invading the Spleen, we may add: Taichong (LIV-3) and Changmen (LIV-13).

3. Or, in the case of Phlegm accumulation: Fenglong (ST-40) and Yinlingchuan (SP-9). And so on.

Neiguan, as the Master point of Yin Wei Mai, and a distant upper point, opens the treatment by its regulating effect over the chest and abdomen. It is mostly proper to do so when nausea and/or vomiting exist, due to Neiguan's calming effect, and ability to diminish nausea.

In Shi syndromes it is manipulated with lift-thrust and twirling movements. In case number 6 we have stressed the very distinct Qi sensation of this point, and it is of importance to direct this sensation in proximal direction. (In contrast with case number 6 which was a distal direction).

This may be done by pointing the needle tip in a proximal direction, and gently massaging the route of the Pericardium channel, from the needle upward (68). Zhongwan is then needled to produce a sore, or tight sensation, usually in waves encircling the point. It is manipulated in the same way as Neiguan, with one difference. This is a point which "loves" Heat stimulation, and reacts extremely well to it. Thus, in cases where Cold is the cause of disease, or one of its manifestations, this point may be stimulated by all forms of moxa applications (which were discussed earlier In this work), or, even better, a moxa-box. This is a perforated metal box with a handle, in which moxa is lit until it gets hot. Then it is placed over the point, after a piece of gauze has been placed between the body surface and the instrument (69).

In cases of nausea or heartburn, the needle tip at Zongwan may be pointed downward, so as to redirect Somach-Qi. In cases of prolapsed stomach, due to Yang deficiency, the needle tip should be pointed upward, and Zhongwan stimulated by heat.

Zusanly is also manipulated in the same fashion as Neiguan, only it is more difficult to cause its sensation to travel proximally. It is also unnecessary as it may sometimes aggravate the patient's condition. Quite often, Zusanli is also stimulated with moxa, reacting extremely well to it, too.

Herbal equivalent

A proper herbal equivalent for this points-combination is probably the following prescription:

• Pericarpium Citri Reticulata - Chen Pi

• Cortex Magnolia Officinalis - Hou Po

• Rhizome Atractylodis - Cang Zhu

• Fructus Citri seu Ponciri - Zhi Shi

This, too, is a basic prescription to regulate Stomach, and Spleen-Qi. It is used for epigastric and abdominal fullness, distension and pain from stagnant Qi, and it treats nausea and vomiting due to rebellious Stomach-Qi.

Chen Pi moves stagnant Stomach-Qi, and tonifies Spleen-Qi. It also redirects rebellious Stomach-Qi and is used for any type of nausea and vomiting. In addition, it is an important herb to treat coughing due to excessive Damp and Phlegm originated by the Spleen.

Hou Po also moves the Stomach stagnant Qi, redirects rebellious Qi with symptoms of nausea and vomiting, and much as Chen Pi, it dries Dampness, and transforms Phlegm. It, thus, complements Chen Pi, and accentuates its action.

Cang Zhu too has more or less the same qualities, with the addition of tonifying the Spleen. It is therefore used also for anorexia and diarrhea caused by weak Spleen.

Zhi Shi breaks up stagnant Qi and reduces accumulations, and it deals therefore more adequately with the painful symptoms of stagnant Stomach Qi.

Miss K. was ten years old when her parents brought her to see me, on emergency call. Prior to her visit she had been hospitalized for one month in the Paediatric in-patient department of Rambam hospital, Haifa, but her condition did not improve.

Miss K. suffered acute gastrodynia with occasional nausea. Her epigastric region was very tender, her face very pale, and she appeared very emaciated and under severe pain.

Her pulse was fast, and her tongue had red points on tip and both sides.

I diagnosed her condition as a stagnation of Stomach-Qi due to irregular eating habits, and emotional problems.

This conclusion was reached after an interrogation, during which her parents admitted the facts. She did not have the Food stagnation signs, neither Phlegm, nor Blood stagnation.

I applied the points-combination with the addition of Liangqin (ST-34). Liangqin is the Xi-Cleft point of the stomach. It is applied in cases of acute pain in the organ to which it is connected.

All the points were manipulated in the regular sedation technique.

During the first few treatments, Miss K. experienced pain relief which sometimes lasted for a few hours after the treatment. After nine treatments, which were carried out during eleven days, her problem resolved completely. one year after the termination of the treatment there has been no recurrence of symptoms.

Mrs. G., age 37, married plus four children, was in her seventh month of pregnancy, when she came to see me. Since the beginning of her contemporary pregnancy she had suffered severe nausea and vomiting. Since her fifth month she had been experiencing lassitude, anorexia, heartburn, vomiting and nausea.

Furthermore, Mrs. G. complained of dry mouth, especially at night, constant thirst and craving for fruit. In addition she felt abundant phlegm in her throat.

Her pulse was very Slippery and her tongue was scalloped.

In Mrs. G.'s case a stagnation of Stomach-0i was also present, but the pattern was more complex.

In the first place it was obvious that her Spleen and Stomach were not in harmony. There were symptoms such as lassitude, anorexia and phlegm, along with a scalloped tongue, suggestive of Spleen-Oi deficiency. On the other hand, her Stomach-Qi was rebellious, she had heartburn, vomiting and thirst, all of which indicated a Shi/Hot Stomach.

The deficient condition of the Spleen, gave rise to abundant phlegm, a Shi pattern, which aggravated the situation of the patient. Thus, we could see that she was constantly thirsty, and craved for fruit (a very Yin food), but, at the same time, she was anorectic and nauseous because of Phlegm stagnation at her stomach.

It is very common, of course, to see nausea and vomiting in pregnant women. The T.C.M. explanation for this phenomenon is the heavy burden that pregnancy exerts upon the Spleen and Kidney. Both organs play a major role in production of Blood and Yin, essential substances for conception and maturation of the foetus. This burden weakens both the Spleen and Kidney, giving rise to abundant Phlegm, and weakening of Stomach-Qi (70).

The prescription for Mrs. G. included, of course, the points-combination, with the addition of the following points: Tiantu (CV-22) and Fenglong (ST-40) to reduce Phlegm in the throat, and generally in the body. The mutual functioning of these two points was already explained in the previous case, number 11. In addition, two other points were also added: Neiting (ST-44), and Gongsun (SP-4).

Neiting - in order to decrease Stomach-Heat and stagnation, and Gongsun, as the Luo-connecting point of the Spleen, to shift excess energy from the Stomach to the Spleen.

symptomatically, Gongsun is capable of relieving nausea and it thus aids the overall action of the points-combination.

It is important to note here that Zusanli was manipulated in tonificaiton, gently, whereas the other points were all manipulated in sedation. As Mrs. G. was somewhat frightened and sensitive to the treatment, the manipulation of the needles, even in sedation, was carried out rather gently.

Mrs. G. felt much better immediately after the first session. After the third session, she had significantly less phlegm, her nausea and vomiting subsided, and she felt much stronger.

The whole treatment lasted three weeks after which Mrs. G. felt that she had regained full strength. she gave birth in due time, without any complications, and in good health.

Main effect and clinical purpose

This points-combination has indeed a long history. The first two points, Changqiang and Chengshan, were already mentioned as a combination 500 years ago, in 1529, by the Physician Gao Wu, in his Bai Zheng Fu (ode of a Hundred syndromes) (71).

This is the basic formula to treat hemorrhoids of any aetiology. This combination treats haemorrhoids symptomatically, including bleeding and prolapse, but it may need addition of points in order to effectively treat the underlying cause of the haemorrhoids.

Changqiang is the first point of the Du Mai channel, and is also the connecting-Luo point of Du Mai and Jen Mai.

On its route, the Du Mai encircles the anus and then climbs up the spine, to the brain, and emerges at the vertex, at point Paihui. Due to its course, this channel is also associated with diseases of the anus, such as haemorrhoids.

Haemorrhoids, in most cases, is a Shi phenomenon, associated with inflammation and bleeding of the rectal area, causing veins there to bulge out and cause sharp pain. In most cases the disease involves Heat symptoms such as redness, acute pain, bleeding and a burning sensation. In some cases Damp also exists when there is pus involved, diarrhea, and a heavy sinking sensation.

In some other cases the most salient etiology is a Spleen Qi deficiency, an etiology that may also cause bleeding, prolapse and diarrhea, but then the symptoms will not be so acute, rather more chronic. In any case, even on the basis of a Spleen-Qi-Xu condition, a Shi condition may arise, of the previously described symptoms and signs, a condition which is both severe and acute at the same time.

In order to drain excess from the rectal area, and from the Du Mai, there are three main techniques:

1. Puncture in sedation the point Changqiang, which is the Luo point with the Ren Mai, and thereby to transfer excess from Du Mai to Ren Mai, and disperse the stagnation in the rectal area. By doing so we also take advantage of the fact that Changqiang, too, is a local point, situated in the rectal area, and affecting this place symptomatically.

2. Any extra meridian, including the Du Mai, may be "opened" and drained, by simultaneously puncturing two points, one at each end. Thus, puncturing Changqiang and Palhui simultaneously, would drain the excess and harmonize the Governing Vessel.

3. It is also possible to drain excess energy from an extra meridian, by puncturing its master and coupled points.

In this points-combination, both techniques No.1 and No. 2 are utilized, making use of two possible methods to drain the excess from the Du Mai, and to resolve the haemorrhoids problem.

Taking into consideration the facts mentioned above, it is no wonder that one of the main indications of Changqiang, is to treat haemorrhoids and prolapsed anus. Its traditional functions quote:

"To regulate and remove obstruction from the Du Mai and Jen Mai, to promote the functions of the intestines, to treat haemorrhoids and rectal prolapse".

Chengshan is a point located on the Bladder meridian, and is