Nick Dent Symptoms occurring at fixed times. Gong Shi-Cheng Gui Zhi jia Da Huang Tang

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1 VOLUME 14 No.3 VOLUME 14 No.3 September 2017 Lantern The ISSN The joy of No! Nick Dent Symptoms occurring at fixed times Gong Shi-Cheng Gui Zhi jia Da Huang Tang Cao Ying-Fu Swollen red sores not always treated as yang heat Qu Yue-Yun The three currents of external medicine Steve Clavey Three difficult paediatric cases for acupuncture Bing Yang Ghost points, insanity and medical evolution John Welden The naked flame Bruce Bentley Reviews Bettina Brill A journal for practitioners of Chinese medicine

2 The Lantern VISIT US ONLINE Guest editorial Nick Dent thelantern.com.au Editors Steven Clavey Bettina Brill Michael Ellis Editorial Board William Campbell, Andrea Kurtz, Renee Lenti, David McGraw, Chris Flanagan. Contact us website snail mail The Lantern 160 Elgin St, Carlton Australia 3053 Subscriptions Australia: This journal is available by subscription via our website, or us for a subscription form. In Australia, single issues are for sale through China Books. International: Visit us online or us. Advertising We welcome inquiries regarding advertising. Please contact us at the above address. Submissions We welcome submissions of articles or case studies for publication in The Lantern. Please contact us beforehand or check our website for technical and style details. We also welcome letters of feedback, via or snail mail. The joy of No! This publication is produced for Oriental medicine professionals, and treatments described herein are not intended for self-medication by those without training in the field. The Lantern and its editors are not responsible for any injury or damage that may result from the improper application of the information in this publication. 2 Vol:14-3 The Lantern is a journal of Chinese medicine and its related fields with an emphasis on the traditional view and its relevance to clinic. Our aim is to encourage access to the vast resources in this tradition of preserving and restoring health, whether via translations of works of past centuries or observations from our own generation working with these techniques. The techniques are many, but the traditional perspective of the human as an integral part, indeed a reflection, of the social, meteorological and cosmic matrix remains one. We wish to foster that view.

3 editorial A monk said to Nasrudin: I am so detached that I never think of myself, only of others. Nasrudin answered: I am so objective that I can look at myself as if I were another person; so I can afford to think of myself. The Subtleties of the Inimitable Mulla Nasrudin by Idries Shah IT S ALWAYS THE nice ones. You can see it in their eyes, the exhausted look, the attempt to live up to your expectations of them, even if it drains them. And it does. When you ask, they ll tell you that they are always willing to help, and would never think of saying no. In fact, they are unable to say no. They need help. They need weapons to fend off those who would live and prosper from draining their life s blood. You need to learn the Joy of No! I say to them. Then I explain. It takes several steps. Step one The first step, I say, is to be aware. Your ears should prick up in alertness when you hear the words But you are so good at this! or But you are just the right person for the job! or No-one else could do it like you could! and these words are accompanied by others such as it won t be much work or it won t take long or it would be easy for you. This is the trap. In the next few minutes, I tell them, you will learn how to avoid it. Step two The second step is practice. You should pick some small thing, a job or task you are being approached to do that really and truly would not be hard for you, that really would not take very long. And then, you say No. At this point, when the patient is a true sufferer from this condition, they wince. They cringe; and you can see how truly difficult it is for them to voice this simple word. I go on, inexorably: You must be careful, here. Do not make an excuse, do not say because I am too busy or I really can t afford the time. If they ask you Why do you say no? then you must give them the only reply for which there is no argument: I don t want to. Every other excuse has an answer: No, no, it won t take much time. No, no, it is easy! Especially for you, because you are so smart, and clever and good at doing this thing. Step three The next step is to look at their eyes. Suddenly you will see a respect that was never present before. Of course they will try to make it look like disappointment, but suddenly you are not a known quantity: Oh, just ask Mary Sue. She ll do it. She never says no. Subsequent to this, watch how long it takes them to find some other sucker who can t say no to do this job that supposedly only you could do. It won t be long, guaranteed. They are good at this. Step four Now revel in the time you have to do what is important to you, time that is not being spent doing someone else s thing, not wasted in the endless running around tying up someone else s loose ends. It might just be the time that you need to recover and heal after decades of time abuse by those who have learned to prey upon the vulnerable. Step five This step is their first practice. As the patient gets up to go, just as they reach the door, you say casually Say, Mary-Sue, can you give me a hand with something? Ninety out of 100 will automatically reply Sure! What would you like? Then their faces change. This is when it hits them how the whole thing works, how easily they have become trapped again and again. I say I would like you to practise before I see you again. Even if it is just one little thing, say No! to someone. Sometimes, they do. The Lantern 3

4 Symptoms occurring at fixed times Treatment with classical formulas By Gong Shi-Cheng The practice of medicine puts a premium on mental flexibility, and blindly following old rules narrows the pathways of thought so that you have trouble dealing with difficult or complex situations in clinic. Zhang Zhong- Jing offered us a rounded and flexible way by seeking patterns from symptoms while also treating symptoms through patterns. This mental pathway is very broad. The symptoms suitable for the formulas that he designed are those which occur often in clinic, and in fact are not limited to those recorded in the Shang Han Lun (Discussion of Cold Disorders) or Jin Gui Yao Lue (Essentials of the Golden Cabinet). During my many years in clinic and discussion with colleagues regarding disorders that appear or disappear at fixed times, especially when our treatments would fail, we would often play around with the logic and structure of classical formulas, extrapolating, and then find that when we used those formulas they worked. Here are some examples. Insomnia at a fixed time Xiao Chai Hu Tang gets good results Mr Wang, 26, presented on September 5, 1988 with insomnia of two years standing, waking every night and being unable to return to sleep, tossing and turning with restless mind until dawn appeared. The prolonged lack of sleep left him with gritty eyes, dry lips, dizziness, and inability to think clearly. If he stayed up until past midnight, once he woke he sometimes could return to sleep and then could wake up energised and deal with any type of work. The weird thing was that on the 15th of each month by the lunar calendar he slept really well for two nights, while the rest of the time on either side of those dates he would wake up in the middle of the night, not return, and get quite depressed about it. This had become a fixed occurrence. His pulse and tongue had no remarkable signs, so this required some thought. Midnight, the time of zî, is when yang qi begins to sprout and propagate. The interaction of yin and yang in the heavens is linked in principle to human s sleep; 4 Vol:14-3

5 when yin and yang enfold each other, sleep occurs. The present pattern is one in which shaoyang s axis-like function of rise and ascent has failed, and so we used Xiao Chai Hu Tang (Minor Bupleurum Decoction). Chai Hu 10g Bupleuri Radix Ban Xia 10g Pinelliae Rhizoma praeparatum Huang Qin 10g Scutellariae Radix Dang Shen 10g Codonopsis Radix Gan Cao 8g Glycyrrhizae Radix Sheng Jiang 5 sl Zingiberis Rhizoma recens Da Zao 7 pc Jujubae Fructus 4 bags, the first boiling to be taken before bed each night, the second boiling in the morning. Two weeks later the young man appeared in fine spirits, saying I took three bags and could sleep all night. I m cured! The Zhang Shi Yi Tong (Comprehensive Medicine According to Master Zhang) says: For inability to sleep, Heart tonics and calming herbs obviously can be helpful. When the five emotions are constrained, this often generates phlegm and thin mucous, both of which block the spirit from returning to its domicile. This is why the Nei Jing suggests a the use of Ban Xia Shu Mi Tang (Pinellia and Millet Decoction) for insomnia, dredging phlegm and thin mucous so that yin and yang unblock themselves and sleep can return. I used the Chai Hu (Bupleuri Radix) in Xiao Chai Hu Tang (Minor Bupleurum Decoction) for its ability to release constraint, and Ban Xia (Pinelliae Rhizoma praeparatum) for its ability to eliminate phlegm. Of the two herbs, one [Bupleurum] grows in winter, the other [Pinellia] in summer, and so they excel at regulating yin and yang. Huang Qin (Scutellariae Radix) eliminates restless heat internally; Dang Shen (Codonopsis Radix), Gan Cao (Glycyrrhizae Radix), ginger and dates all benefit qi and nourish the normal qi so that nutritive and protective qi do not lose normal flow. b All these rectify the problem of fixed time insomnia. a. In Chapter 71 of the Ling Shu (Divine Pivot). b. Which is important because a major theory of etiology for insomnia proposes failure of the protective qi to move inside and circulate internally as a prime factor in its onset. Asthma at the arrival of summer Ling Gui Zhu Gan Tang brings the patient back in step Ms Zhao, 32, presented on July 29, Since she was six years old, she had suffered from wheezing ( xiào) which was more frequent in the summer months. Gradually the pattern shifted until the wheezing was less but the difficulty breathing ( chuân) was more, and she might also have coughing, and very few days without symptoms. After 10 years of age, each summer she would have difficulty breathing and wheeze with intermittent cough. All day long she tried to be warm, and was somewhat averse to cool winds. But by autumn, all the symptoms would start to get better. Since she married 10 years before at 22, the symptoms had followed this pattern without fail: coming on in summer, disappearing by winter. The Western diagnosis was bronchial asthma, and all the medication she took aimed only at a temporary relief of symptoms. Recently she had cough and a feeling of qi coming up, with a loud throat clearing sound that could be heard in the next room. She had a stuffy chest that felt blocked to the extent that she seemed to have to lift her head to help each breath. In bed at night she had to sit up, preventing her getting a good night s sleep. Fortunately her appetite was still good and the long-term illness had not made her hugely deficient. Her pulse was languid and slippery, the tongue coat had a layer of white underneath a superficial layer of yellow. This is a xiaochuan (wheeze and dyspnoea) pattern, and we used She Gan Tang (Belamcandae Decoction) from the Qian Jin Yao Fang (Priceless and Important Formulas for Emergencies): Zhi She Gan 10g Belamcandae Rhizoma, prepared Zhi Ma Huang 10g Ephedrae Herba, prepared Fa Ban Xia 10g Pinelliae Rhizoma, standard Zhi Zi Wan 10g Asteris Radix, prepared Zi Su Zi 10g Perillae Fructus Xing Ren 10g Armeniacae Semen Bai Qian 10g Cynanchi stauntonii Rhizoma Zhi Gan Cao 8g Glycyrrhizae Radix, prepared Wei Sheng Jiang 5g Zingiberis Rhizoma, baked Big Black Dates 7 pieces After the initial three bags, the phlegmy DRUGS, NEEDLES, feature BLOOD AND QI: A SYMPOSIUM ON CHINESE MEDICINE We invite you to an afternoon of expert discussion of Chinese medicine, with particular reference to the bodily fluids and some historical and clinical perspectives on their role in the human body. Shigehisa Kuriyama Bodily fluids and the history of Chinese medicine Lena Springer Bodily fluids and the anthropology of Chinese drugs Steven Clavey Bodily fluids in the practice of Chinese medicine Date: Sunday, December 17, 2017 Time: 3-5pm Australian Centre on China in the World, Building 188, Fellows Lane, The Australian National University, Canberra. This public lecture is free of charge. Sponsored by the Australian Centre on China in the World and the Australian National University. For more details, please check here: The Lantern 5

6 When she reached the summer solstice and dampness began rising from the earth, the damp inside and the damp outside exacerbated each other and the illness blossomed. qi settled and the difficulty breathing was relieved, but after another three bags all the symptoms had returned. She changed doctors, and the next doctor used a treatment based on Kidney grasping qi that also did not work. She returned to me in the hope of some result. I considered that so many asthma cases grew worse in winter and spring and better in summer and autumn, but this patient was exactly the opposite: worse in summer and all better by winter. It could be conjectured that she had phlegm, thin mucous and watery qi residing in the chest, diaphram and Lung system, and that when she reached the summer solstice and dampness began rising from the earth, the damp inside and the damp outside exacerbated each other and the illness blossomed. I decided to change to the following in order to treat the root by generating yang and driving out damp: Fu Ling Zhi Bai Zhu Gui Zhi Zhi Gan Cao 15g Poria 10g Atractylodis macrocephalae, prep 9g Cinnamomi Ramulus 9g Glycyrrhizae Radix, prepared I added the following to facilitate Lung qi descent and treat the branch: c Zhi She Gan Zhi Ma Huang Hou Po Xing Ren Belamcandae Rhizoma, prepared Ephedrae Herba, prepared Magnoliae officinalis Cortex Armeniacae Semen After five bags, the wheezing and difficulty breathing had stopped and she could lie down to sleep. The cough however was worse, which I took as a good sign that the phlegm was breaking up. I continued with only Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodis and Licorice Decoction), and in six bags she was finally cured. The summer of 1989 passed without a recurrence, right up until autumn and through the winter, also with no problem. Cheng Wu-Ji says in the Shang Han Li ( Shang Han Prolegomenon) to his Zhu Jie Shang Han Lun (Annotation and Explanation of the Discussion of Cold Damage, 1144): Once the winter solstice has passed, yang begins to increase and c. Dr Gong s doses for these four herbs are not specified, but probably similar to his initial formula. yin begins to decrease. After the summer solstice, yin qi begins to increase and yang qi begins to decrease. As above, so below, heaven and man match each other, and should, since both are made of a single qi. After the summer solstice, there is a turn towards the growth of yin damp qi, and this patient s asthma responded by getting worse. By the time of the winter solstice, the yang qi began to ascend and the yin damp phlegmy water hid itself, and so the asthma matched the time and stopped. Phlegm and thin mucus should be harmonised with warming herbs. Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodis and Licorice Decoction) can spread warming and harmonious qi, promoting warm transformation, and thus was totally in step with this problem. Obstructed swallowing premenstrually Treat with Gan Mai Dao Zao Tang Ms Yuan, 24, presented on December 12, Her periods were exactly on time, but four years earlier she had started to notice a strange feeling in her throat in the week leading up to the period, a feeling like a bone was stuck there, blocking the throat and feeling uncomfortable. Although she could swallow food, it felt as if it was hard to go down, and this lasted right up until the period came on, at which point it disappeared. In the two years previous to her presentation at the clinic, the feeling had gotten worse. A gastroscope found nothing unusual in the esophagus, but she reported a sensation of obstructed breathing and a buttoned up feeling in the front of the throat, and these were both worse if she leant her head forward. All this of course made her irritable and moody. Nonetheless, her ability to eat was not impaired. Her pulse was slightly wiry, and the tongue had no unusual manifestations. Treatment in the past for plumstone throat had had little success. So I thought that Liver as the organ for blood storage must itself rely on blood in order to use qi, and that prior to the period the blood was gathering in the Sea of Blood, which left the Liver temporarily blood deficient. This of course meant that Liver qi was also temporarily in the ascendent and this qi was rebelling into the Heart so that the shaoyang channel spasmed. This would be enough to lead to the situation of 6 Vol:14-3

7 premenstrual throat obstruction. The quote says Heart patients should eat wheat d and when Liver suffers acuteness, quickly eat sweetness to mollify it. So I used Gan Mai Da Zao Tang (Licorice, Wheat and Jujube Decoction) with some additions: Sheng Gan Cao 10g Glycyrrhizae Radix Fu Xiao Mai 30g Tritici Fructus levis Big black dates 10 pc Lü E Mei 7g Prunus mume, Flos He Huan Pi 9g Albiziae Cortex Decoct twice, sip any time as tea, and eat the dates. After 25 bags, the period arrived with no sensation of throat obstruction. She continued for another 15 bags and after that had no problems. When the sea of blood is full and floods downward, this is the period; blood is then restored to normality and qi flows smoothly, d. xīn bìng zhě yí shí mài. This quote is from Ling Shu (Divine Pivot) chapter 56 and goes on to add yí shí mài yáng ròu xìng xìe, ie. should eat wheat, mutton, apricots and shallots. the channels and vessels are comfortable, and so the sensation of throat obstruction ceases when the period arrives. Until the next time, when it all happens again. The Jin Gui Yao Lue (Essentials of the Golden Cabinet) describes this symptom: The woman s throat feels as if some roast meat is stuck and this later was called plumstone qi pattern. It also has the restless organ pattern (zàng zào) described as joyful, sad, hurt and wishing to cry, all very much as if possessed. The two are caused by different things, one by knotted qi congealing phlegm, the other by lack of nourishment to the yin of the organs. In this case, though, the plumstone qi symptoms are caused by the latter: lack of yin. And so I used the sweet gentle nourishing of Gan Mai Da Zao Tang (Licorice, Wheat and Jujube Decoction) combined with He Huan Pi (Albiziae Cortex) to relieve stored up anger and harmonise the Heart s emotion. Lü E Mei (Prunus mume, Flos) clears the throat and regulates irritability due to deficiency. It is easy to drink and tasty, and even within its balanced blandness, effective. n Dr Gong Shi-Cheng practises at the Tianzhang County Hospital in Anhui Province. n This article first appeared in the Zhongyi Zazhi (Journal of Chinese Medicine), 1991:12, pp The Lantern 7

8 Gui Zhi jia Da Huang Tang A case from Cao Ying-Fu Dr Huang Huang says this about Cao Ying-Fu: Cao Ying-Fu ( , given name Jia-Da) was a native of Jiangyin in Jiangsu Province and a famous modern expert in classical formulas. At a dangerous turning point for Chinese medicine he dared to speak directly and not follow the herd, advocating in no uncertain terms practical research into Zhang Zhong-Jing s works. With an attitude of avidly searching for factual evidence in therapy, he subjected classical formulas to stringent clinical examination. As a proponent of Chinese medicine s scientific nature, he wrote an important page in the history of modern Chinese medicine s development.the following case history and discussion is from the book Jīng fāng shí yàn lù (Records of Experiments with Classic Formulas) by Cao Ying- Fu and his students. MR QING S GRANDSON presented with an illness that started after sudden exposure to wind-cold, with constipation and pain on the vertex of the head. This is a taiyang yangming concurrent illness. The patient took, on his own, Jiu Ming Dan (Rescue Life Special Pill) a after which his bowels moved and the headache was slightly improved. The surface pattern was not completely resolved and the interior pattern was also unresolved. The pulse was floating and languid, the body sweaty, and the appropriate formula was Gui Zhi jia Da Huang Tang (Cinnamon Decoction with added Da Huang). Gui Zhi Bai Shao Gan Cao Da Huang Sheng Jiang Hong Zao 9g Cinnamomi Ramulus 9g Paeoniae Radix alba 3g Glycyrrhizae Radix 9g Rhei Radix et Rhizoma 3 sl Zingiberis Rhizoma recens 3 pc Jujubae Fructus Comment by Zhang Zuo-Jing [Cao Ying- Fu s student]: In treating an illness, the standard method is to first resolve the exterior and only later attack the interior; b this is reaping the benefit of previous generations experience. In clinic I have found that once the surface is resolved the constipation often resolves of itself without the need for help from added herbs. The reason is that while the exterior is bound up with a pathogen, the patient s yuan qi is concerned only with dealing with the surface pattern and has no time for the interior situation. After the exterior is resolved, however, the yuan qi a.there are a number of Jiu Ming Dan (Rescue Life Special Pill) formulations from different books over the centuries, some of which include purgatives; exactly which is referred to here is unclear. b. Attack the interior ( gōng lî) is commonly used to mean purging the bowels in Shang Han Lun contexts. rallies the troops to attend to the inside. Now while no one can actually see with their own eyes the coming and going, to and fro, of the yuan qi, this is actually the fact of the situation, make no mistake. So when I run into a situation of bound exterior with internal distention (biâo shù lî zhàng ) pattern, if the constipation has not exceeded three days, I always treat it as a given that it will resolve of itself. The formula above which releases the exterior while unblocking the interior is both a formula and a method. Because the release the exterior aspect is 70 per cent and the unblock the interior aspect 30 per cent, we can see that there is a guest and host situation, ie. one aspect is more important than the other. In this case, because the patient has already taken a laxative type prescription with the Jiu Ming Dan (Rescue Life Special Pill), the interior unblocking aspect is the guest. The patient took no exterior releasing herbs, so the exterior releasing is the host. But it works along both lines, the demon illness is driven into nothingness while the yuan qi as supreme commander is sitting pretty. When you look at it, there are such a wide variety of methods in Zhang Zhong-Jing s books, it is up to you to extract them. In fact, if you are looking for a method beyond a method, I recommend investigating Hou Po Qi Wu Tang (Seven Substance Decoction with Magnolia Bark). c c. Hou Po Qi Wu Tang (Seven Substance Decoction with Magnolia Bark) is another of Zhang Zhong-Jing s formulas, but found in the Jin Gui Yao Lue (Golden Cabinet) not the Shang Han Lun. It is also designed for a concurrent taiyang-yangming pattern, but with emphasis on the interior rather than the exterior. Zhang Zuo-Jing is recommending a comparison of the contents and dosages of the two similar methods to foster flexibility and subtlety in clinic. Hou Po Qi Wu Tang can be found in Formulas and Strategies as an adjunct to the discussion of Da Chai Hu Tang (Major Bupleurum Decoction) in the section Formulas that Release the Exterior and Purge the Interior. 8 Vol:14-3

9 Swollen red sores are not always treated as yang heat By Qu Yue-Yun Taken from his book Zhongyi Lilun Bian, Hunan Science and Technology Press, 1990, pp ) External medicine conditions such as abscesses, carbuncles, rooted sores and boils a are generally divided into two broad categories of yin and yang types. Generally, yang types are red, swollen, hot and painful with a pathology involving fire, heat or epidemic toxin along with obstruction, accumulation and clumping; the treatment therefore is most often clearing heat and resolving toxins using cold or cooling materials. However, clinical experience shows that this type of treatment is not inevitably successful, and a few cases of hot red swollen sores should in fact be approached as a cold yin type in regards to treatment, and the prohibitions against warming and tonifying do not in fact apply to these situations. I append some case histories extracted from ancient books and modern journals as evidence for this viewpoint. a. yōng, jū, dìng, and jiē. Case 1 Using warming the centre with Spleen qi tonification to treat a buttock boil A 26-year-old male had had a boil on his left buttock for two years, but since its initial appearance it had been deep, lingering and never resolved. At its smallest it was like a mungbean, at its largest like a peach kernel; it was red and suppurating with fluidy pus coming out. From the beginning he had consulted many external medicine doctors and had taken, over a long time, many types of treatments such as antibiotics, high doses of vitamin C, infrared heat lamps, and Chinese medicine pills and cooling antitoxic herbal decoctions. None had helped. As the boil was eroded and excruciatingly painful, he was able to sit on only a quarter of the right buttock, which of course made life very difficult. Three different urine tests were negative for diabetes. He passed stool twice a day, his appetite was poor, he had lost The Lantern 9

10 Ante Babic s Tips for running a successful clinic When a patient says In an ideal world, I wouldn t have done it, it means I wanted to, so I went ahead and did it. weight, his pulse was wiry and his tongue coat was thin and greasy. Treatment involved warming the centre, tonifying Spleen and benefiting qi while expelling wind and damp. The formula chosen was modified Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction): Huang Qi Dang Shen Chao Bai Zhu Dang Gui Sheng Di Shou Di Gui Zhi Chai Hu Sheng Ma Chuan Xiong Jing Jie Zhi Ke Wu Zhu Yu Zhi Gan Cao 12g Astragali Radix 15g Codonopsis Radix 9g Atractylodis macrocephalae Rhizoma, dry-fried 9g Angelicae Sinensis Radix 9g Rehmanniae Radix 9g Rehmanniae Radix preparata 9g Cinnamomi Ramulus 9g Bupleuri Radix 3g Cimicifugae Rhizoma 3g Chuanxiong Rhizoma 9g Schizonepetae Herba 9g Aurantii Fructus 9g Evodiae Fructus 9g Glycyrrhizae Radix praeparata After seven bags of the above, the suppuration has stopped and the wound closed, the pain disappeared and the tongue coat lost its greasy nature, although the pulse remained wiry. As this approach had yielded results, we continued with seven more bags of Bu Zhong Yi Qi Tang to regulate. After this the boil was completely gone and follow-up over a year later showed no recurrence. The boil in this case was not in fact due to fire or excess, but rather to Spleen deficiency creating damp and the damp becoming constrained and leading to fire. The long term cooling and fire draining herbs the previous doctors had given were not only no use, but actively damaged the Spleen qi, making the deficiency worse and allowing the condition to go on and on. Spleen is the root of the acquired constitution and transforms food and fluid into qi and blood, transporting damp. If its ascending and descending functions are disrupted, toxic damp accumulates insidiously, and therefore the only treatment is to strongly support qi, warm the centre, regulate the middle and assist this by eliminating wind and damp. Zhongyi Zazhi (Chinese Medicine Journal, 1984, 6:36.) Case 2 Lower abdominal carbuncle treated by warming yang and tonifying deficiency to draw out toxins Ms Zhao, 28, was rather fat, and had had quite itchy eczema for many years. Ten days before her initial presentation, she had torn the skin with scratching below the umbilicus, and by the second day there appeared something like a grain of millet that gradually became red, hot and inflamed, feeling painful and numb. Over the next few days it worsened, and she had chills and fever, so she consulted a doctor. She was given injections of penicillin and streptomycin, took big decoctions of cooling antitoxic herbs, and applied San Huang San (Three Yellow Powder) externally. After treatment for a week, the chills, fever and pain had reduced somewhat, but on the other hand she was no longer able to eat, and she collapsed into bed. The sore failed to progress or produce pus. Despite consulting several doctors, her condition continued to worsen. On her initial presentation, the sore could be seen to be scarlet red in colour, but when pressed the colour faded and became red again only very slowly. It was hot to the touch, and the hard swelling was 12 x 10 cm in diameter. She also had chills, fever, generalised body aches, exhaustion, a quavery voice, and occasionally nausea, restlessness that prevented her sleeping, and she had been unable to eat for the previous two days. The tongue was darkish pale, the tongue coat thick, the pulse deep, thready and slightly choppy. I thought to myself that chillblains on the toes and fingers in the winter also looked red, and were hot, sore, itchy and painful, but the root cause was congealed cold leading to qi stagnation and blood stasis; and I remembered Xu Ling-Tai s famous phrase red is not always an abscess, white is not always a carbuncle. a At that point I realised that this case was one of a yang deficient constitution being drained by further attacks from the bitter-cold treatments, so that qi and blood had stagnated and pathogenic toxin had sunk further into the interior, causing this pattern of a sore that would neither progress nor resolve. a. 红亦有非痈, 白亦有非疽者. 10 Vol:14-3

11 The treatment required warming yang, dispersing cold, drawing out toxicity and tonifying deficiency. Zhi Fu Zi 20g Aconiti Radix Lateralis praeparata Rou Gui 6g Cinnamomi Cortex powder, to be washed down with the decoction Xi Xin 6g Asari Herba Sheng Huang Qi 40g Astragali Radix Dang Gui 15g Angelicae Sinensis Radix Ma Huang 10g Ephedrae Herba Chuan Shan Jia 10g Manitis Squama Gan Cao 10g Glycyrrhizae Radix The above was to be slowly decocted, then two-thirds taken cool in small sips, while the remaining third was to be applied as a hot compress on cloth over the carbuncle. By the next day, the symptoms had improved somewhat, and the herbs were therefore continued for two more bags. The carbuncle progressed to form pus and burst, thereby reducing by over half; her appetite returned and the tongue was no longer darkish. The fever, chills and bodily discomfort had gone. We consolidated with Shi Quan Da Bu Tang (All Inclusive Great Tonifying Decoction); follow-up five years later showed no recurrence. Xin Zhong Yi (New Chinese Medicine, 1986, 1:50) Case 3 Swelling on the back of the foot treated with warming yang, tonifying deficiency and drying dampness Mr Wei, 52, had had dysentery and been treated successfully for it at another hospital, but was then transferred to our hospital as he had developed pain in his left foot. On observation, it could be seen to be red, swollen, and difficult for him to use; he was initially treated for arthritis using formulas such as Si Miao Wan (Four Marvel Pill), Du Huo Ji Sheng Tang (Angelica Pubescens and Taxilli Decoction) and various Western anti-arthritic medicines. After over a month of such treatment the symptoms had not abated and in fact the swelling, redness and pain grew daily worse. Multiple x-rays returned findings of left foot 2nd metatarsal periostitis inflammation of the connective tissue around the bone. Subsequently, based on his pale swollen tongue that had a white greasy coat and his deep thready pulses that were especially weak at the chi (proximal) positions, it was decided to treat this as a yin-natured swelling ( yïn jü). Yang He Tang (Yang Heartening Decoction) with modifications was chosen. Lu Jiao Jiao 15g Cervi Cornus Colla, dissolved in the hot decoction Rou Gui 4g Cinnamomi Cortex, powdered and taken with the decoction Gan Jiang 10g Zingiberis Rhizoma Shou Di 30g Rehmanniae Radix preparata Chao Bai Jie Zi 10g Sinapis Semen, dry-fried Ma Huang 5g Ephedrae Herba Cang Zhu 15g Atractylodis Rhizoma Gan Cao 6g Glycyrrhizae Radix After three bags, the problem had neither worsened nor improved. Taking into account that this was by now a long-term condition and was unlikely to see results in a brief period, the formula was continued, taking one bag per day. At the same time, a foot soak of 100g each of Ma Huang (Ephedrae Herba), Gui Zhi (Cinnamomi Ramulus) and Sheng Jiang (Zingiberis Rhizoma recens) was made up for him to first steam the foot then soak it, using one bag every two days. After 25 days of treatment, the redness, swelling, heat and pain had disappeared. Follow-up after two years found him walking normally. Xin Zhong Yi (New Chinese Medicine, 1986, 1:50) Case 4 Sores and boils around the body treated by augmenting qi and eliminating damp Boils of different sizes began to appear at various points on the patient s body, at the end of autumn and early winter. They were red, painful, itchy and inflamed, suppurating with yellow fluid. One doctor called it wind-heat and treated it unsuccessfully with several prescriptions of Fang Feng Tong Sheng San (Ledebouriella Powder that Sagely Spleen is the root of the acquired constitution and transforms food and fluid into qi and blood, transporting damp. If its ascending and descending functions are disrupted, toxic damp accumulates insidiously. The Lantern 11

12 n This deficient patient took a bath while sweating which allowed damp to accumulate and enter the interstices of the tissues, where after a long time erosion due to heat created watery pus. Unblocks); another, referencing the Nei Jing, quoted Pain, sores and ulcers all belong to Heart fire b and used 10 bags of herbs such as Huang Qin (Scutellariae Radix), Huang Lian (Coptidis Rhizoma), Shan Zhi Zi (Gardeniae Fructus) and Sheng Di (Rehmanniae Radix); it just became worse. Meanwhile the patient s appetite decreased, the pulse on superficial pressure was faint and fast, on medium and deep pressure was languid and soft. The master c said: When it is wind-heat, it will usually be a raised rash ( yîn zhên) and will not necessarily have sores and boils ( chuäng jië); as to sores and ulcers ( chuäng yáng) belonging to Heart fire, although the Classic indubitably said this, still this pulse is mainly faint and soft, which means that the yuan qi is insufficient. The languid quality shows damp, while the rapidity shows heat, but faint and rapid cannot purely be attributed to fire. Faced as we are with the symptoms of the present case, the fire is the branch, dampness is the root, but when the origin is considered, even the damp is the branch and the root is the lack of yuan qi. Here what has happened is this deficient patient took a bath while sweating d which allowed damp to accumulate and enter the interstices of the tissues, where after a long time erosion due to heat created watery pus. This then emerged as pain and itching. The ruling herbs used were Cang Zhu (Atractylodis Rhizoma), Yi Yi Ren (Coicis Semen) and Fu Ling (Poria) to dry dampness; the ministerial herbs were Ren Shen (Ginseng Radix), Bai Zhu (Atractylodis macrocephalae Rhizoma), Huang Qi (Astragali Radix) and Gan Cao (Glycyrrhizae Radix) to tonfiy qi; assistants were Lian Qiao (Forsythiae Fructus) and Chan Tui (Cicadae Periostracum) to cool heat; Ge Gen (Puerariae Radix) and Bai Zhi (Angelicae dahuricae Radix) guided the rest b. tòng chuāng yáng jiē shŭ yú xīn, from chapter 74; the doctor himself added the word fire ( ) to the quote, although admittedly that is the general understanding of the meaning. c. The famous Ming dynasty external medicine practitioner Lu Xiao-Yu. d. Note that the patient may have been bathing in cold water. into the yangming flesh level. After two bags the pain and itching suddenly reduced, while the appetite improved slightly. After 10 bags he was cured. Xu Ming Yi Lei An (Continuation of Classified Case Records by Renowned Physicians) by Wei Zhi-Xiu, published 1770, section on sores and boils Case 5 Rooted toxic sores on the fingers treated by warming yang, promoting sweating and facilitating damp removal through urination Mr Zhang was 54. After handling the skin of livestock that had died of a contagious disease, small blisters erupted on the fingertips of his right hand and then burst; the fingertips turned black, intensely itchy and slightly painful, and all around the area felt hard to the touch. Subsequently the afflicted area became intensely painful, the area of the sore suppurating clear fluid rather than pus. His pulse was wiry and tight. This is epidemic toxin invading inwardly with yang deficiency and flooding water unable to be expelled outward; the treatment requires warming yang, promoting sweating, and facilitating urination to clear dampness. The herbs used were: Zhi Fu Zi Bai Zhu Bai Shao Ma Huang Fu Ling 24g Aconiti Radix Lateralis praeparata 15g Atractylodis macrocephalae 15g Paeoniae Radix alba 15g Ephedrae Herba 30g Poria After two bags, the patient began to sweat and the heat decreased, the pain reduced and the mouth of the sore exuded black and yellow toxic fluid. Ma Huang (Ephedrae Herba) was removed from the previous herbs, and 30g of Huang Qi (Astragali Radix) added; the toxic sore was eliminated and he was cured. Shanghai Zhongyiyao Zazhi, :5 Case 6 Mr Lu was 46. Some 21 years previously, in September 1956, he had experienced an unexplained sudden burning hot pain in his left foot. The next day it was red and swollen, 12 Vol:14-3

13 preventing him from walking. The Western medicine diagnosis was inflammation of the reticular lymphatic vessels. Over the next 21 years, every August, September or October the patient would experience a recurrence of the old problem. None of a variety of medical treatments had been successful. After using anti-inflammatories together with an external application of Huang Bai (Phellodendri Cortex) powder for 10 days without result, he decided to try Chinese medicine. When he presented, he was walking with the assistance of a crutch. On examination, the skin of the left foot was red and swollen, but this redness and swelling lacked a clear border. The foot was so painful that he could not place it on the ground. His tongue was slightly red and dark, the tongue coat was thin white, and the pulse deep and forceless. Putting together all the foregoing facts, the pattern appeared to be one of invasion by pathogenic fire with heat at the blood level constrained in the tissues and skin. Thus the treatment should be to clear heat, cool the blood, drain fire and resolve toxicity, coupled with reducing swelling and stopping pain. He was given the following herbs: Huang Lian 12g Coptidis Rhizoma Huang Bai 12g Phellodendri Cortex Shan Zhi Zi 12g Gardeniae Fructus Chi Shao 12g Paeoniae Radix rubra Mu Dan Pi 12g Moutan Cortex Chuan Niu Xi 15g Cyathulae Radix Cang Zhu 15g Atractylodis Rhizoma Yi Yi Ren 30g Coicis Semen Jin Yin Hua 25g Lonicerae Flos Pu Gong Ying 20g Taraxaci Herba Sheng Gan Cao 10g Glycyrrhizae Radix After taking three bags of the above, all the symptoms had become worse. Upon reflection, the herbs matched the symptoms, but when they make the problem worse, there is definitely something else going on. Careful questioning revealed that six months previous to the initial appearance of the problem 21 years before, during the winter in January, the patient s left foot had slipped through into a hole in the ice of a river and become severely chilled; subsequently the illness appeared at the onset of the following winter. Taking everything into consideration, and ruminating on the pulse and symptoms, the decision was taken to use a treat according to the cause approach, and he was given a modification of Yang He Tang (Yang Heartening Decoction) to warm yang, tonify blood, disperse cold and unblock stagnation: Shou Di Gan Jiang Gui Zhi Bai Jie Zi Chi Shao Chuan Xiong Ma Huang Dang Gui Wei Chuan Niu Xi Zhi Gan Cao 20g Rehmanniae Radix preparata 6g Zingiberis Rhizoma 10g Cinnamomi Ramulus 6g Sinapis Semen 10g Paeoniae Radix rubra 10g Chuanxiong Rhizoma 3g Ephedrae Herba 15g Angelicae Sinensis Radix tail 15g Cyathulae Radix 10g Glycyrrhizae Radix praeparata After finishing three bags of these herbs, the pain had significantly reduced, leaving a mild burning sensation, but the swelling had disappeared. His foot and lower leg could move normally, but the pulse was still deep and forceless, and the other symptoms remained the same. Since the approach had yielded results and the situation was improving, he was given 11 bags of the same script and he was cured. Follow-up over four years showed no recurrence. Xin Zhong Yi (New Chinese Medicine, 1986, 3:19) Trying to pick a winning horse by comparing pencilled sketches. àn tú suŏ jùn The Lantern 13

14 The three currents of external medicine By Steve Clavey There are many ways to divide a phenomenon along lines of articulation for the purposes of discussion, but in the case of Chinese external medicine, the lines that make the most sense are those of treatment approach. 1 The three lines, or currents, on that basis were the Zhèng Zōng ( Orthodox Lineage) school, the Quán Shēng ( Total Efficacy) school, and the Xīn Dé Jí ( Collected Experience) school. Although each focused on the treatment of skin lesions, their approaches were often strikingly different. 1. Another set of articulations could be those of allegiance to authors or texts, in which case the division, currents, or schools would be five: the Xuē Ji ( ) school, the Zhèng Zōng ( Orthodox Lineage) school, the Jīn Jiān ( Golden Mirror) school, the Quán Shēng ( Total Efficacy) school, and the Xīn Dé Jí ( Collected Experience) school. THE DIFFERENTIATION OF external medicine into different treatment approaches really began in the Jin and Yuan dynasties, with the advent of different theories explaining the origin of skin lesions. One such was the fire toxin theory, especially promoted by Liú Wán-Sù, who said when nutritive qi does not flow well, it counterflows at the level of the flesh and then generates swollen skin lesions. In his Sù Wèn Xuän Jí Yuán Bìng Shì (Mysterious Mechanism at the Origin of Pathology in Basic Questions, 1152), Liu explains that pathogenic fire and heat can produce congealing and stagnation of blood and nutritive qi, and this establishes the internal factors underlying the formation of sores and boils. Later, Li Dong-Yuan also described how fire toxin blocked qi and blood within the channels and collaterals and created skin lesions. He then elaborated on this idea, stating that a yöng abscess at the level of the flesh and vessels belonged to a yang pattern, while a jü carbuncle at the level of the tendons and bones belonged to a yin pattern. A yáng boil is just inside the skin, while a 疮 chuäng furuncle is outside the skin. He went on to say that if the lesion started off swollen, red, painful, burst easily and healed over easily, this was a yang pattern and easily treated. But if in the beginning the lesion was pale, depressed into the skin or without swelling, hard and not painful, failing to come to a head and burst, or failing to heal over, then this was a yin pattern and was difficult to treat. All of the external pathogens can give rise to skin lesions, but fire toxin is the main problem, says the Yï Zöng Jïn Jiàn (Golden Mirror of the Medical Tradition): Boils and carbuncles are all generated by toxic fire. 14 Vol:14-3

15 GLOSSARY Like any discipline Chinese medicine external medicine ( zhōng yī wài kē) has a wide variety of technical terms; only the most common will be introduced below. External medicine deals with any condition manifesting on the surface of the body, for example dermatology is an example of one of the specialties within external medicine. But another area of central concern has been that of sores, abscesses, ulcerations, boils and so on; to such an extent that external medicine has also been called the department of sores and ulcerations ( chuāng yáng zhī kē) and specialists in this area called yáng yī : ulceration doctors. Li Dong-Yuan s definition stated: chuāng is outside the skin; yáng is inside the skin; yōng is in the flesh, jū is at the depth of the bones. Some more specific definitions of the most common terms in this area follow: EXTERNAL MEDICINE TERMS ( ) chuāng: any sore or wound; or short for chuāng yáng : a general descriptive term for any itchy inflamed shallow skin lesion raised above the surface with clearly visible shape that can burst and ulcerate. An abscess, boil or furuncle. dān dú. This is erysipelas in both ancient and modern medicine. An infection of the skin and underlying tissues (usually by some type of the bacteria Streptococcus). The skin becomes suddenly inflamed and swollen, with raised patches several inches across; the patient is ill, with high temperature. Treatment nowadays is with antibiotics. dìng: a boil which resembles a nail, being small in circumference, but with a very deep root. It usually occurs on the head, hands or feet and comes on rapidly but dissipates slowly, which predisposes its toxins to move internally. Therefore a dìng can be quite dangerous. ( ) jiē: a red hot and painful but shallow swelling, which clears up after pus is expelled. In modern Chinese it refers to a furuncle (boil): a tender inflamed area of the skin containing pus (usually caused by streptococci or Staphylococcus aureus entering through a hair follicle or a break in the skin). This is the least severe of all these examples and the ones we would be most likely to see in clinic at this point, although the various types of yōng (abscess) are also quite common. jū: a carbuncle, a large, deep and more serious chuāng (boil), traditionally separated into headed jū and headless jū.. yoǔ toú jū: The headed jū is the yang type and occurs in the cutaneous level, large, red swollen with a number of whiteheads showing. This is a carbuncle, meaning a collection of boils with multiple drainage channels (mostly caused by Staphylococcus aureus) and usually results in an extensive slough of skin.. wú toú jū: A headless jū, a deep-rooted abscess, is the yin type, occurring in the tendon and bone level, arising slowly and painfully without a visible head. It only with difficulty reaches the stage where it creates pus, and is then hard to heal over. It usually damages tendons and bones in joints. In modern medicine this would be any purulent bone or joint disease (eg, osteomyelitis or even gangrene). ( ) kùi: to perforate, meaning to fill with pus and burst. Literally ulcer(ate) ie a noun or verb. Pus formation ( chéng nóng), pre-bursting and post-bursting ( kùi qián, kùi hòu) all mark different stages in development of the various skin lesions. ( ) yōng: an abscess, a large, broad but shallow chuāng. It occurs in the cutaneous level, about 2-3 inches in circumference, and is red, swollen, hot and painful without a pustular head, but is easily cured. In modern medicine this would be either a boil, an abscess (a localised collection of pus surrounded by damaged and inflamed tissue) or acute lymphangitis (an acute inflammation of the subcutaneous lymphatic channels, usually caused by Streptococcus pyogenes)..an ancient definition stated: When small, it is called jiē (see above), when large it is called yōng, and when yōng (abscess) becomes even larger it is called fā (meaning spread, which is equivalent to the modern cellulitis inflammation of the connective tissue, which can spread into the bloodstream). In modern medical Chinese the word yōng now refers to a carbuncle, which in ancient Chinese was called a headed jū (carbuncle). zǒu huáng nèi xiàn: This is blood poisoning. Going yellow, descending internally occurs when the accumulated toxic influences from a dìng (deep-rooted boil) spread and enter the ying and blood levels, attacking the internal organs. While zŏu huáng is reserved for complications from dìng, nèi xiàn descending internally can be used for any skin lesion toxin moving into the body to attack the internal organs after failing to be controlled by the normal qi at the surface. The popular Western equivalent for both is septicaemia or blood poisoning, although these terms are less-used by professionals. The Lantern 15

16 When a person s disease reaches the stage of swelling and pain, naturally this injures Stomach qi and they will not fancy any food. Wait until after perforation and after the toxic pus comes out however, and the Stomach qi will return. Zhèng Zōng Pài Orthodox Lineage school The Zheng Zong Pai (Orthodox Lineage) school is the major school of Chinese medicine external medicine. Although it was named after the book Wài Kë Zhèng Zöng ( Orthodox Lineage of External Medicine, 1617, by Chén Shí-Göng) during the Ming dynasty, it actually was influenced by a number of earlier works from the Song and Yuan dynasties. The Orthodox Lineage School had the most famous exponents and was the most influential of the three schools of thought in external medicine, thus living up to its name. Main theoretical characteristics a) Emphasising differentiation according to zang-fu and to qi and blood The Orthodox Lineage school stressed the uniformity of theory regardless of application to internal medicine or external medicine. It used internal medicine s pathological theories of zang-fu, channels and collaterals, qi and blood to explain the etiology and development of external conditions, and to guide their diagnosis and treatment. Treatment emphasised protection of the Spleen and Stomach and the regulation of qi and blood, and was thoroughly consistent with the teachings of Li Dong-Yuan and Zhu Dan-Xi. b) Internal treatments emphasising dispersal, expulsion and tonification Based on the three external medicine stages of incipience, pus formation and bursting, different approaches would be used as follows to eliminate the swelling of boils and bring the toxins out, and thus promote the healing-over of the lesion: Incipient stage: cause sweating and cool heat, promote flow of ying and wei, qi and blood. Pus formation: lead pus out ( 排脓 pài nóng) and expel toxins ( tuö dú). Post-perforation: tonify qi and blood, regulate Spleen and Stomach, harmonise Liver and Kidneys. The Orthodox Lineage school doctors were particularly well known for their expelling and subsequent tonification techniques. expelling ( tuö) methods for example included refinements such as supporting the normal qi while expelling toxin ( fú zhèng tuö dú), venting pus while expelling toxin( tòu nóng tuö dú) and leading pus out while expelling toxin ( pài nóng tuö dú). Tonification, on the other hand, emphasised Spleen, Stomach and food nourishment, recognising the source of healing as the qi and blood deriving from food. One of the major exponents of the Orthodox Lineage school, Chen Shi-Gong, discusses this in a way that shows both his clinical expertise and his exemplary use of compassionate common sense: As to food and drink, this is the source of life nourishment, and people must eat the right things at the right time. For example when a person s disease reaches the stage of swelling and pain, naturally this injures Stomach qi and they will not fancy any food. Wait until after perforation and after the toxic pus comes out however, and the Stomach qi will return then they will think about food and want to eat. At that time, whatever they wish can be given to them, as it will tonify Spleen and Stomach. If you do not give them what they want, it is actually going against the Stomach qi and conversely causes them to be unable to eat! Whatever you do, do not be too strict: the only taboo foods are raw and cold which damage Spleen, hard foods difficult to digest, and greasy rich foods which cause loose stool this is why they are forbidden. c) External treatment emphasising surgical treatments Chuäng yáng yï kë, yòng zhën wéi gùi (, was a watchword of this school, and means In the department of sores and boils, the use of the needle is king. But in fact all types of minor surgery were used, including moxa, plasters, soaking, smoking, branding and other external applications of heat. Chen s approach and techniques As noted previously, Chen Shi-Gong ( Chén Shí-Göng, ) is one of the major exponents of the Orthodox Lineage School. Here are some of Chen Shi-Gong s techniques, 16 Vol:14-3

17 using the everyday formulas characteristic of this school. Although tonifying and expelling were his strong points, he was not limited to these techniques. He said: First and last you want to close [a lesion] without knotting, open the flow without draining; obtaining peace for the zang-fu and free movement between surface and interior only then can you use herbs to expel and push out pus and then [later] for internal tonification. Chen says: When qi and blood deficient people have swellings that refuse to produce pus (and through this process allow them to clear), use Shi Quan Da Bu Tang (Great Tonifying Decoction) formula, adding: Chen Pi Xiang Fu Ban Xia Lian Qiao Citri Reticulatae Pericarpium Cyperi Rhizoma Pinelliae Rhizoma Preparatum Forsythiae Fructus Ren Shen Yang Rong Tang (Ginseng Decoction to Nourish Luxuriance) can be used when qi and blood are weak and a lesion fails to heal over. If a large sore has just healed, this can prevent any other complications. Chen used Nei Shu Huang Lian Tang (Internal Dispersing Decoction with Coptis) when patients with swelling sores had fever, thirst for cold drinks, restlessness, strong pulse, and constipation. This is a toxic pathogen in the zang organs, and this cooling anti-toxic formula must be used quickly to eliminate it. Despite the reputation for tonification, there is obviously a time and place for everything. Chen Shi-Gong s remarks on moxibustion of yöng (abscess) and jü (carbuncle): During the early stages of any type of chuäng (boil) excepting on the head I always use moxa. Calculating the number of cones and the size of the lesions, I cut a number of thin slices of garlic. I place one upon the top of the boil, with the moxa cone on top of that, and ignite it. I change garlic slices every three cones. If there is pain when the moxa begins, I moxa until the pain goes and only an itchy feeling is left; if there is no pain, moxa is continued until they feel an itchy pain. If there is absolutely no sensation of pain or itchiness when I start, the garlic is taken away and direct moxa is used. Also for yin-type boils of long standing, where garlicslice moxa is simply not strong enough, I will mash the garlic into a paste which is spread over the lesion, and moxa spread over that, which is then ignited: the pain must be intense for there to be effect. Only in this way can the qi of the fire reach the interior: deep inside where there is still good flesh that can feel pain. All this is using moxa fire to root out pentup toxin and open a boil s orifice to allow communication, giving the internal toxin a route of escape to the outside. Truly this is the number one method in the department of boils! The most important thing is to use moxa early. But there are also several taboo conditions for which moxa is not indicated, which I will describe in detail here. The head is pure yang without yin. Any chuäng (boil) swellings here must have rebelling yang heat in the extreme if you add moxa to this the toxic qi will become a conflagration. This soon afterwards causes a large swelling, easily causing internal phlegm which if it spreads means certain death. The same goes for dìng (deep-rooted boil) on the face. Shenshu (UB-23) is a lumbar point either side of the spine which is linked to the Kidney Root of Life ( mìng gën). Boils developing at this point usually result from excessive sexual activity exhausting the constitution and Kidney water drying up. If you add moxa to this situation, the fire will fry the patient s Source [of life], drying both the interior and the exterior. This usually results in blackening and sinking-in [of the area], emotional depression and death. Also, in patients whose yuan qi is weak and deficient, boils usually are not able to rise above the skin. These people are always tired, with weak energy and depression, the pulse is always floating, dispersed ( sân), empty and weakly rapid without force against the fingers. In these cases there is no true qi to defend against fire qi, so if you moxa them they will certainly become agitated and die. It is often said that moxa never harms people, When patients with swelling sores had fever, thirst for cold drinks, restlessness, strong pulse and constipation this is a toxic pathogen in the zang organs n Steve Clavey practices Chinese medicine in Melbourne, Australia. The Lantern 17

18 Although the techniques used for sores and boils are numerous, the most important words come down to two: internal and external. Likewise, while symptoms are many, most primary are the two words yin and yang. but these words have led to many mistakes it would benefit those who are doctoring to examine the facts. Quán Shēng Pài Total Efficacy school The name of this school comes from Wáng Wéi-Dé ( ), who explained the name for his book as follows: I am now 72 years old, with a history of giving treatment for more than 40 years; and in using medicinal substances I have never made a mistake... this is why I called my book the Patterns and Treatments in External Medicine for Total Efficacy, 1740). a The Total Efficacy school was most influential during and after the Qing dynasty. Main theoretical characteristics a) Using yin and yang as framework for differentiation Although this approach was not completely lacking prior to the advent of the Orthodox Lineage school, it had not been thoroughly fleshed out. In the Ming dynasty, Zhang Jing-Yue in his Wài Kë Qián ( Tactics in External Medicine) had said: Although the techniques used for sores and boils are numerous, the most important words come down to two: internal and external. Likewise, while symptoms are many, most primary are the two words yin and yang. On the basis of this the physicians of the Total Efficacy school developed their style of differentiating jü (carbuncle) and yöng (abscess) into yin and yang by the colours white or red. Wang Wei-De, the leading protagonist of the Total Efficacy school, said: Treating yöng (abscess) and jü (carbuncle) according to their channel location has long been the fashion under Heaven; separating their treatment into two according to yin or yang, this is ours alone. His method is based on the colours red and white: red-coloured lesions are yang, and therefore yöng (abscess); white lesions are yin, and therefore jü (carbuncle). In both the primary pathology is obstruction. Red yöng (abscess) are hot qi and blood with accumulated toxic obstruction, white jü (carbuncle) are cold qi and blood with congealed toxic accumulation in both a. Wài Kē Zhèng Zhì Quán Shēng Jí, cases the most important approach is to open the interstices ( käi còu lî). Once the interstices are open, the red yöng (abscess) toxin is settled and the pain stops, the white jü (carbuncle) cold transforms and blood moves. Another doctor commented, using a style strangely like a modern book review, This differentiation of yin and yang by clarifying white and red really brings out something that the ancient books lacked. The words are simple, the method easy; even the uninitiated in medicine will find understanding when they open this book. b) Using warmth to open the interstices as a main treatment method One of the major differences between the Orthodox Lineage and the Total Efficacy schools is that the former used expelling toxins ( tuö dú) and tonification, while the latter use warming and opening. As Wang Wei-De says: Dispersion is king, expulsion is to be feared. This school feels that the interstices ( còu lî) should be opened and any coldcongealing should be dispersed, so that when qi and blood are able to move the toxic accumulation will follow it and be resolved. The Total Efficacy school doctors opposed the use of cold heat-clearing treatments for yin patterns, and thus they designed the famous Yang He Tang (Yang-Heartening Decoction): Shou Di Lu Jiao Jiao Rou Gui Pao Jiang Bai Jie Zi Ma Huang Gan Cao 30g Rehmanniae Radix Preparata 9g Cervi Cornu Degelatinatum 3g Cinnamomi Cortex 1.5g Zingiberis Rhizoma Preparatum 6g Sinapis Semen 1.5g Ephedrae Herba 3g Glycyrrhizae Radix The warm tonification of Shou Di, Pao Jiang, Rou Gui and Lu Jiao Jiao supports the use of Ma Huang to open the interstices, while the Bai Jie Zi eliminates phlegm between the skin and membranes, and thus in the treatment of yin-patterned jü carbuncles it is like sunlight shining and making cold ice melt. That is why it is called yang harmonising. The creation of this formula was really a breakthrough in external 18 Vol:14-3

19 medicine treatments of yin-patterned carbuncles. Wang Wei-De said: All everybody thinks about is using cooling herbs to resolve toxicity, but what they don t know is that toxicity is actually cold. Resolve the cold and the toxicity will transform of itself, cool heat and the toxin becomes even more congealed. There is nothing surprising about this: the transformation of toxins has to come through pus, for pus to form it requires qi and blood, for qi and blood to transform, it requires warmth. Now of course cooling herbs can be used for red swollen boils or furuncles, but if you run into a yincold carbuncle that is depressed into the skin, you need not worry about using warm tonification. What you must not do however is recklessly use cooling herbs for, contrary to your goal, it will damage the Stomach qi. c) Opposing the indiscriminate use of surgery The Total Efficacy school condemned those guilty of the wanton use of knife or needle as butchers ( guì tú, literally disciples of the executioner ) because they felt that it could lead to ulceration, difficulty in healing over of the wound and the likelihood of severe complications, which was probably not unlikely considering the general lack of antiseptic procedures at that historical period. Part of the reason for this viewpoint was however that the Total Efficacy school concentrated on the treatment of headless jü (carbuncle), which would not easily respond to this sort of treatment. Xīn Dé Jí Collected Experience school The name for this school comes from the title of a book by the influential Qing Dynasty physician Gâo Bïng-Jün, the Yáng Kë Xïn Dé Jí ( Collected Experiences on Treating Sores, 1805). The popularity of the warm disease movement and doctors such as Ye Tian-Shi and Wu Ju-Tong, (especially in the Jiangsu and Zhejiang areas) was rampant at this time; the development of the Collected Experience school was a direct result of the influence of warm disease theory on external medicine. jü Main theoretical characteristics a) Emphasising that the cause of disease in external medicine and warm disease theory were the same. Gao Bing-Jun recognised that external conditions must have a basis in internal pathology. He said How could you have a jü carbuncle, how could it be generated, if the flow of qi and blood through the flesh and muscles is normal and strong, and has not been affected by internal pent-up accumulated heat on the inside of the body or if there has been no invasion into the interior of damp-heat? Viewing the body as a whole is crucial, he states. He also points out: If you are clear about the mechanism forming skin lesions and know that it is simply a failure in the flow of protective and nutritive qi backing up inside the flesh, then you will be clear about the way to treat all the patterns. For examples of those patterns, Gao Bing-Jun felt that summer-heat trapped in the surface tissues caused a number of superficial skin lesions such as summer-heat chuäng (boil) and erysipelas ( dän dú: in which the skin becomes suddenly inflamed and swollen, with raised patches several inches across, and high fever). If the pathogen is trapped within the flesh it causes yöng (abscess) or jü (carbuncle). If the pathogen is trapped in the channels and collaterals it spreads along their pathway ( líu zhù). Skin lesions caused by a lurking pathogen expressing itself internally ( fú xié nèi fá) are yang within yin and very difficult to treat. Another Collected Experience school exemplar, Sha Shi-An (, ), remarked: Pent-up heat in the six channels causes warm disease, toxic accumulation in one spot causes external lesions. Both are heat accumulations, the only difference is whether they are dispersed generally or all concentrated in one spot. So Sha felt that if one can treat warm disease, one can treat external lesions. The followers of the Collected Experience School also liked to use the wei-qi-ying-xue and San Jiao methods of differentiation for external medicine, as well as the six-channel system of determining lurking warm disease pathogens. The Total Efficacy school condemned those guilty of the wanton use of knife or needle as butchers because they felt that it could lead to ulceration, difficulty in healing over of the wound and the likelihood of severe complications. The Lantern 19

20 If the fire has burned unceasingly and completely dried the yin into hardness, this is fatal. b) Opposing warm-dispersal and warmexpulsion in the early stages of skin lesion development, advocating pungent-cool surface-opening The differences in treatment approach between the warm disease and the Shang Han schools to a large extent hinges on the way they start to open the surface: warm disease theory uses Yin Qiao San (Honeysuckle and Forsythia Powder) and Sang Ju Yin (Mulberry Leaf and Chrysanthemum Decoction), Shang Han theory uses Ma Huang Tang (Ephedra Decoction), Gui Zhi Tang (Cinnamon Decoction) and the large and small Qing Long Tangs (Green Dragon Decoctions). All exponents of the Collected Experience School strongly advocate pungent-cooling surface opening, as the warm disease school does. Sha Shi-An says: When skin lesions begin, in every case the body is heated, and this heat dissipates when they sweat. To raise a light sweat the pungent-cooling Yin Qiao San (Honeysuckle and Forsythia Powder) can be used, and that is all they need. He also says: As soon as warm herbs are used, any lurking pathogen is incited to move, turn into fire, rot the flesh and produce pus, and may even cause festering of the tendons and destruction of the bones. c) Paying attention to nourishing yin Pathogenic warmth ( wën) is a yang pathogen, easily damaging yin. Thus as long as warm disease patients still have a portion of undamaged yin, they have a chance of recovery. The Collected Experience school practitioners strongly emphasise the protection of yin in their treatments. Sha Shi-An regards yin fluids as the major factor preventing toxins from descending into the body from skin lesions. He also notes that if yin fluids are sufficient, degenerated flesh can easily be replaced by healthy tissue. Gao Bing-Jun also recommended that once chuäng (boils) had filled with pus and burst ( kùi) the best method of treatment is to nourish the yin fluids. Sha himself had an interesting analogy concerning the importance of yin preservation in regard to external medicine treatments. He said: For example, take a brick. A normal unfired clay brick when dry is hard, but when you wet it, it becomes soft and you could even grow things in it [just like normal earth] this is like boils and carbuncles that can resolve when cooling is used. If on the other hand the brick is made from fired clay it is hard like a rock and you could even soak it in water without it becoming soft: there is no yin in that earth at all, it could never grow anything, and this is equivalent to those rock-like lesions that occur around the body As long as there is even a tiny amount of yin, cooling will soften it the softening showing that the fire has reduced so as long as yin fluids have not been completely eradicated there is a hope of treatment. If the fire has burned unceasingly and completely dried the yin into hardness, this is fatal. d) Treating dìng (deep-rooted boil)-toxin beginning to go internally as heat entering the Pericardium Moving internally ( zôu huáng, literally going yellow ) is septicaemia developing from the deep-rooted dìng. In warm disease theory, heat entering the Pericardium is a serious complication involving delirium, clouded consciousness, fever, restlessness, and a scarlet red tongue. It is normally treated with strong cooling orifice-opening spirit-clearing formula such as An Gong Niu Huang Wan (Calm the Palace Pill with Cattle Gallstone), Zhi Bao Dan (Greatest Treasure Special Pill), Zi Xue Dan (Purple Snow Special Pill) and so on. In external medicine, the Collected Exerience practitioners describe toxic heat attacking the organs ( dú göng wû zàng) as toxicity entering the Heart causes muddled thinking, entering the Liver causes spasms, entering the Spleen causes painful abdominal distention, entering the Kidneys causes eye pain and cold hands and feet. When septicaemia due to deep-rooted boils has entered the Heart and begun to cause delirium or cloud the consciousness, the Collected Experience practitioners are on record as also using these formulae, and in just the same way. 20 Vol:14-3

21 Three difficult pediatric cases By Bing Yang Pediatric diseases can be challenging. Many times Western medicine cannot provide effective treatment even with a clear and accurate diagnosis. Acupuncture and herbs can achieve fabulous results with children. Over the past 10 years, I have seen some great outcomes. Here are three cases. Sequela of trauma Caucasian male, 2, initial visit August 16, Three weeks previously the boy had fallen from a second-floor window, hitting the left side of his head on the driveway pavement below. He was rushed to ER and doctors did plastic surgery on his left orbital roof and skull. The surgery was successful, but subsequently the boy had speech and balance problems, and his right limb functions were affected. His parents were told that the boy would never walk or speak normally. At the time of presentation the boy was in hospital tube-feeding every day, receiving intensive physical therapy, occupational therapy and speech therapy. The boy cried a lot, and slept poorly. His tongue was pale; his pulse was weak and rapid. His parents were, of course, devastated and wanted to try Chinese medicine. Because of credential issues, acupuncture was not permitted in the hospital, therefore only acupressure was applied at the early stage. Points were Neiguan (PC-6), Waiguan (SJ-5), Zusanli (ST-36), Xuanzhong (GB-39), Hegu (LI-4), Taichong (LIV-3), Sanyinjiao (SP-6). The parents were advised to continue with the treatment after the boy was discharged Visit 2, August 24, The boy had been discharged from hospital and his parents sought acupuncture treatment. He had weak legs and a weak right arm, his pupils were uneven, his speech was impaired, and he was not sleeping well. His tongue and pulse had not changed. Pool of acupoints: Waiguan (SJ-5), Quchi (LI- 11), Hegu (LIV-4), Zusanli (ST-36), Xuanzhong (GB-39), Sanyinjiao (SP-6), Taichong (LIV-3), Yanglingquan (GB-34), Lianquan (CV-23), Baihui (GV-20), Sishencong. Ten to 20 points (total, left and right sides) were chosen each time from the above pool. Because the patient was so young and could not co-operate with treatment, his mother brought him during nap time. Needles were retained for 20 minutes. A herb powder (5:1) was prescribed, comprising Gu Sui Bu (Drynariae Rhizoma) and Dang Gui (Angelicae Sinensis Radix) both 1.5 grams, taken daily with water, juice or yogurt. His parents were advised to return once or twice a week. Visit 16, October 26, 2008: The boy s speech had become clear and fluent. When relaxed and rested, his pupils were even. His appetite was good, and sleep much better. The Lantern 21

22 n Bing Yang received her Bachelor and Master degrees of TCM from Beijing University of Chinese Medicine. After teaching as an assistant professor at BUCM for several years she moved to the US and is now associate professor and director of the Chinese Herbal Medicine program at New England School of Acupuncture, MCPHS University. She also maintains a practice in Massachusetts. Both legs were stronger; the right arm was almost normal. Now the boy was very cooperative when he had acupuncture. His parents were advised to come once a week. Herbs were Fu Ling (Poria) and San Qi (Notoginseng Radix), both 1.5 grams. Visit 26, January 20, 2009: Normal speech, normal walking, and complete cooperation during treatment. The pupil of the left eye was still smaller than the right, and there was occasional drooling. Acupoints: Xuehai (SP-10), Zusanli (ST- 36), Yinlingquan (SP-9), Sanyinjiao (SP-6), Taichong (LIV-3), Quchi (LI-11), Waiguan (SJ- 5), Hegu (LIV-4), Yintang, Yuyao, Shenmen (HT-7), Baihui (GV-20), Sishengcong. The herb Yi Zhi Ren (Alpiniae oxyphyllae Fructus) 1.5g was added to the original formula. Parents were advised to come weekly or every other week. Final visit, June 9, 2009: Everything was good; legs and arms were normal; balance was good. The pupils of his eyes were even. No more acupuncture and herbs required. His parents were told it was not necessary to return; they were very happy and thankful. Several years later the boy s mother called me and reported that when boy was in kindergarten, the teacher, unaware of the terrible accident, told her that the boy was the most balanced child in his class, and his speech ability was wonderful. In 2015 the boy came to my clinic to visit; he had grown into an intelligent, healthy and happy child. This was a special case: a two-year-old boy injured due to trauma. Although the surgery was successful, the sequelae were severe. The muscle strength of arms and legs was weak, balance and speech were affected, and the left pupil was smaller than the right. After 40 treatments over 10 months, great results were achieved. A child s body is considered a pure yang body with exuberant growing yang qi, therefore we used acupuncture to stimulate yang qi and help the body recover quickly. Hegu (LI-4) and Taichong (LIV-3) are considered the four gates ; opening these gates helped the qi and blood to circulate; Quchi (LI-11) and Waiguan (SJ-5) helped with arm strength, Waiguan (SJ-5) is also the meeting point of the Yangwei vessel; Sanyinjiao (SP-6) is the meeting point of Liver, Spleen and Kidney, so used to nourish yin, calm the Liver, strengthen Spleen and benefit Kidney. Yanglingquan (GB-34) is the meeting point of tendons, Xuanzhong (GB- 39) is the meeting point of marrow; these two points on the Gallbladder channel calm the soul and spirit. Yuyao is a local point to treat eye problems; Yintang, Baihui (GV-20) and Sishencong calm the spirit. In regards to the herbal medicine, in the beginning due to fracture and surgery, Gu Sui Bu (Drynariae Rhizoma) was used to mend bones and help with recovery, Dang Gui (Angelicae sinensis Radix) to nourish and move blood. In the middle stage Fu Ling (Poria) was added to strengthen Spleen and calm the spirit, and since Spleen is the governor of muscle, to help with muscle strength. San Qi (Notoginseng Radix) was used to move blood and unblock vessels. Later Yi Zhi Ren (Alpiniae oxyphyllae Fructus) was added to tonify Kidney and bind essence, benefiting the brain function. Facial tic Caucasian girl, 9, initial visit September 28, In April 2008, she had fallen, hitting the back of her head; one week later she started to feel eye strain, eye pain, frequent blinking, facial twitch and involuntary mouth movements and shoulder shrugging. These symptoms seemed to become worse during allergy season. A year after the symptoms began she was diagnosed with bilateral neurological facial tic. She took no Western medication. Recently things had become worse, the blinking, eye pain and facial pain becoming severe, giving the girl headaches and causing a lot of stress, since her face twitched at school. She also had involuntarily shrugging of her shoulder which her peers noticed. At the end of day, the frontal headache was worse when tic symptoms were active. Other than that, she had no obsessive-compulsive disorders, and no vocal tic symptoms. She enjoyed sports and was a good student. There was no family history of Tourette syndrome. She had hayfever, took a children s vitamin pill regularly, and ate a healthy diet. Digestion was good, sleep normal. Her tongue was pale red with a thin coating, the pulse was wiry. My diagnosis was blood deficiency with internal Liver wind disturbance. 22 Vol:14-3

23 Pool of acupoints: Baihui (GV-20), Sishencong, Yangbai (GB-14), Dicang (ST-4), Jiache (ST-6), Sizhukong (SJ-23), Taiyang, Fengchi (GB-20), Yifeng (SJ-17), Xuehai (SP-10), Zusanli (ST-36), Sanyinjiao (SP-6), Shenmai (BL-62), Waiguan (SJ-5), Quchi (LI- 11), Taichong (LIV-3), Hegu (LI-4). Fifteen to 20 points were chosen (in total, left and right sides) from the above pool each time, with shallow needling, retaining the needles for 30 minutes. We suggested the girl have treatment once a week. Visit 8, November 11, 2012: Much better, her blinking problem was almost gone. The most obvious residual symptom was that her eyebrows raised involuntarily. Her mouth also twitched a bit sometimes. Her shoulder shrugging had stopped after the fourth visit and never came back. Her tongue was a little red; the pulse showed no change. We continued with the points from the pool, but had the patient come every other week. Visit 18: April 7, 2013: She had been more confident at school, her involuntary mouth movements had stopped, and she was no longer raising her eyebrows; the blinking also resolved. The shoulder shrugging never came back. She was very happy. We continued the treatment as before and suggested the patient come once a month for maintenance. The mouth movements and shoulder shrugging never returned, but her eyes bothered her sometimes so the family decided to continue with monthly treatment. It has now been four years and the symptoms have been stable. She has gained a lot of confidence and grown into an elegant young woman. In spring allergy season the eyes seem to bother her more, so she comes in twice a month in spring. Although acupuncture did not take away all the symptoms completely, the girl and her family were satisfied with the results. Tics sudden, brief movements or sounds are a hallmark sign of Tourette syndrome. They can range from mild to severe. Severe symptoms might significantly interfere with communication, daily functioning and quality of life. Common motor tics seen in Tourette syndrome are eye blinking, shoulder shrugging, head jerking, nose twitching, mouth movements, etc. The cause of Tourette syndrome is unknown. It is a complex disorder likely caused by a combination of inherited and environmental factors. People with Tourette syndrome often lead healthy, active lives. However, it can involve behavioural and social challenges that can harm the patient s self-image. a Medications to help control or reduce symptoms of related conditions include those that block or reduce dopamine, botulinum (Botox) injections, ADHD medications, central adrenergic inhibitors, antidepressants, and anti-seizure medications. b Chinese medicine theory regards tic as due to an imbalance of yin and yang, the yin being unable to contain yang, so abnormal movement results. Children s bodies have immature yin and immature yang ( zhì yïn zhì yáng), they grow and develop fast, but their bodies need the yin essence to nourish and support this development. If yin is insufficient, yang becomes excessive, and symptoms can arise. In addition, Liver wind and phlegm fire can also cause unintended body movements. Liver, Spleen and Kidney are the organs mostly affected. In this case, the girl had brain trauma which might have been a triggering cause affecting the balance of yin and yang. It was recorded in the Huang Di Nei Jing (Yellow Emperor s Inner Classic): All wind symptoms, which include dizziness and movements, can be attributed to the Liver. Wan Quan ( ) in his Ming dynasty book You Ke Fa Hui (, Elaboration of Pediatrics) holds the idea that for children, the Liver organ is always excess, the Spleen organ is always insufficient, which means that, physiologically, children generally have weaker Spleens than adults, and therefore it is easier to arouse internal Liver wind under certain circumstances. Spleen is the post-natal root, Kidney is prenatal root; these two organs are important in children s development. The treatment strategy in this case was to calm Liver wind, and tonify Spleen and Kidney. In addition, to treat wind, one needs to treat the blood; when the blood is moving, the wind will be gone. Therefore, moving qi and blood was also part of the treatment principle. a. 6/5/2017. b. syndrome/diagnosis-treatment/treatment/txc , 6/5/2017. For children, the Liver organ is always a surplus, the Spleen organ is always insufficient. The Lantern 23

24 When Kidney yang was sufficient and qi and blood moved smoothly, the testicles descended normally. For the pool of points, local points are combined with whole body points. Yangbai (GB-14), Dicang (ST-4), Jiache (ST-6), Sizhukong (SJ-23) and Taiyang are points on the face to stimulate local qi and blood circulation. Yifeng (SJ-17) and Fengchi (GB-20) extinguish wind. Baihui (GV-20) and Sishencong calm the spirit, Hegu (LI-4) and Taichong (LIV-3) are the four gates, excellent for qi stagnation and blood stasis. Hegu also treats all problems on the face. Sanyinjiao (SP-6) and Zusanli (ST-36) tonify Spleen and Kidney, and regulate Liver. Shenmai (BL-62) is the confluent point of the Yang Qiao vessel and a Sun Si-Miao ghost point, good for generalised head wind and pacifying interior wind. Waiguan (SJ-5) is the luo-connecting point of the San Jiao channel, also the confluent point of the Yang Wei vessel, helpful for wind and face problems. Undescended testicles Caucasian male, 7, initial visit September 13, During a recent check-up his doctor found that he had undescended testicles on both sides. Surgery was scheduled for December, but his mother wanted to try acupuncture before going ahead with surgery. His mother indicated that during pregnancy she had constant abdominal pain, and the birth was three weeks premature. After birth, his development was well behind his peers, with walking and speech delayed. He caught colds frequently, had a stuffy nose, and complained of headaches and stomach aches. He did not talk much, stuttered sometimes, and had mild autism. Urination and bowel movement were normal, and appetite good. His tongue was red with a sticky yellow coating, pulse was slippery and rapid. Pool of points: Zusanli (ST-36), Sanyinjiao (SP-6), Taichong (LIV-3), Yinlingquan (SP- 9), Ligou (LIV-5), Yinlian (LIV-11), Zuwuli (LIV-10), Qihai (CV-6), Guanyuan (CV-4), Zhongwan (CV-12), Baihui (GV-20), Waiguan (SJ- 5), Quchi (LI-11). We taught the patient s mother how to use moxa, asking her use a moxa stick on Mingmen (GV-4) and Shenshu (BL-23) once every other day, 20 minutes each time. Visit 6, November 1, 2015: The mother reported that the boy had been to see the medical doctor who found the testicle was descended on one side, while the other was still undescended, so the mother was happy with progress. His tongue was less red, its coating no longer sticky yellow. Treatment was as previously, asking the mother to continue with moxa at home. Visit 10, December 6, 2015: They had visited the doctor, checking up before the surgery. Sometimes both testicles were descended, the right side being more stable, but the left moving up and down. The doctor postponed the surgery and asked the family to continue with the acupuncture treatment and observe. The patient s overall condition was good. Treatment was as before, and we advised the patient to come every other week. Final visit, April 24, 2016: Had been to see the doctor on April 21; both testicles were descended and the patient s mother said they had seemed stable for the past two months. From a Western viewpoint, a boy s testicles should descend by nine months of age. Undescended testicles are common in premature infants. An undescended testicle is more likely to develop cancer, even if brought into the scrotum with surgery. Cancer is also more likely in the other testicle. Treatment includes hormone injections (B-HCG or testosterone) or surgery to bring the testicle into the scrotum. Complications may include damage to the testicle from surgery. c Differentiation in this case belongs to Five delays and five softnesses. Prenatal Kidney qi and essence are insufficient, with internal phlegm heat. Treatment principles are tonifying Kidney and strengthening Spleen, clearing heat and transforming phlegm. For channel differentiation, this is stagnation in the Liver channel. Zusanli (ST- 36), Sanyinjiao (SP-6), Yinlingquan (SP-9), Qihai (CV-6), Guanyuan (CV-4) were used to tonify Kidney and Spleen; Taichong (LIV- 3), Ligou (LIV-5), Yinlian (LIV-11), Zuwuli (LIV-10) were used to dredge Liver channel stagnation, Baihui (GV-20) was used to raise yang qi, Waiguan (SJ-5) and Quchi (LI- 11) to clear heat and regulate qi. Moxa on Mingmen (GV-4) and Shenshu (BL-23) was helpful to tonify Kidney yang and unblock local stagnation. When Kidney yang was sufficient and qi and blood moved smoothly, the testicles descended normally. c.medlineplus.gov/ency/article/ htm, 7/25/ Vol:14-3

25 Ghost points, insanity and the evolution of Chinese medicine By John Welden Examining the history of ghost points and the treatment of insanity provides a glimpse into the evolution of Chinese medicine. One insidious myth that has been too often repeated is that Chinese medicine has remained virtually unchanged for thousands of years. In contrast, when one examines the breadth of the extant Chinese medical literature on any subject it reveals a slow but continuous process of normal scientific development. This medical science is the result of thousands of years of observation, hypothesis, experimentation, and publication of findings that were peer reviewed by subsequent generations, who then repeated this process over millennia. As a result, changes were gradually made to this system of medicine in an on-going effort to improve clinical outcomes. Far from this myth of a stagnant intellectual field, the history of Chinese medicine has been unctuously dynamic. GHOST POINTS WERE developed for the treatment of severe psychological disorders. Finding safe and effective strategies has remained challenging, and modern practitioners continue the struggle. The origin of ghost points is rooted in ancient beliefs that spirit possession was the cause of these types of illnesses, and thus treatment required the exorcism of these malevolent ghosts. The earliest record of medical practices deciphered from the jiagu (oracle bones) of the Shang dynasty (c BC) reveals that deities or powers of nature, along with the spirits of ancestors, were believed to be the primary causes of disease, and treatments included animal or even human sacrifices (Keightley, D.C., 2000). Almost 1000 years later, excavated texts from the Mawangdui archaeological site dated to 168 BC reveal the continued belief in supernatural causes of disease, with treatments using rituals, talismans, incantations, and the The Lantern 25

26 Ante Babic s Tips for running a successful clinic Got time to lean? Got time to clean. occasional animal sacrifice alongside herbal remedies, cauterisation and stone lancing (Harper, D., 1998). While not described explicitly for mental illness, the recommended treatments for gu (magic poison, sorcery) and spirit possession are dominated by supernatural remedies. There is no mention of ghost points, and it likely this technique was developed much later. As was Chinese custom, the invention or discovery of ghost points was attributed to a famous historical figure, in this case Bianque (Wandering Magpie, c.500 BC). Bianque was a shamanic figure from the late Zhou dynasty (c bc) who reportedly wandered among the warring states offering his services to various princes and kings. Early depictions suggest he was a half-bird, half-human being, and modern scholars consider him more mythical than historical, with some arguing that Bianque s exploits tell us more about Zhou era statecraft than medicine (Brown, M., 2015). Details are sparse in the early literature where he is mentioned, although he reportedly used a type of zhenlishi (polished stone needle) for treatment (e.g., Shuoyuan, c.100 BC; Hanshi Waizhuan, c.100 BC; Shiji, c.100 BC; Hou Hanshu c.400). The earliest reference to Bianque s use of ghost points is found in a text by the Tang dynasty ( ) physician Sun Simiao ( ) during his discussion of diankuang (deranged madness, insanity). Sun provides the following description of this condition: Sometimes the afflicted [behave as though they] are mute and deaf, and sometimes they return to incessant talking and vulgar speech; sometimes they sing, sometimes they cry, sometimes they laugh, sometimes they groan. Sometimes they will lie down and sleep in ditches and ravines and eat manure and other filth. Sometimes they get drunk and expose their naked bodies. Sometimes they wander around day and night [without resting]. Sometimes they become angry and abusive without restraint. Sometimes [they think] flying bugs are magic spirits, their hands move chaotically and their eyes are intense. All of these cases are classified as people with diankuang (deranged madness). Today one can use acupuncture, moxibustion, and prescribed medicinals together to treat this condition. Qianjin Yifang, 2009 reprint, j. 27, di.4, p.911. In the final sentence, Sun acknowledges that this condition has long been known but suggests there have been recent advances in therapeutics, and thus already we see evidence of change over time. Moreover, given the 1000-year temporal chasm between these two doctors, one needs to be careful in trying to distinguish Sun s strategies from those of Bianque. Most likely, Sun s text represents medical practices of the Tang rather than an accurate historical record of Zhou medicine. Insanity is referenced in the Nanjing (Classic of Difficulties, c ), a text purportedly written by Bianque but with an enigmatic date of composition. In the 20th difficulty, it states that if the yang influences in the pulse reach an extreme of fullness or emptiness, then there is madness and the patient will see ghosts or go blind. Notably, this is the only reference to gui (ghosts) in the entire text. The 59th difficulty asks about the difference between dian and kuang. It concludes that kuang is more yang, with restlessness, a hearty appetite, and incessant and incoherent talking, laughing, and singing; dian is more yin, with sadness, lying still, and staring straight ahead. This description is obviously similar to modern terms like manic-depressive. A controversial subject is the publication date of the purported second half of the Huangdi Neijing (Yellow Emperor s Inner Classic), the Lingshu (Spiritual Pivot). The Song dynasty s Xiaozheng Yishu Ju (Bureau for Revising Medical Texts) first published a reconstruction of this text in 1090 after a fragmentary copy was brought back from Korea, and later republished a corrected edition in Since then, many scholars have challenged the authenticity of the Lingshu as a genuine Han era (c.200) classic (Welden, 2015). Important for this discussion, diankuang is the subject and title of chapter 22 of the Lingshu, wherein it recommends treating with acupuncture, bleeding, and 26 Vol:14-3

27 moxibustion. Techniques include burning 20 moxa cones on Changqiang (long and strong, Du-1) at the base of the coccyx, and needling Shexia (under the tongue). The character gui (ghosts) appears only three times in the Lingshu, and always as part of the more positively phrased binome guishen (ghostly spirits), including once in this chapter. Here, it echoes the Nanjing, stating those with kuang will eat a lot and see ghostly spirits. Moreover, this chapter seeks to correlate psychological symptoms with physical disorders, including musculoskeletal pain, headache, cough, indigestion, vomiting, and dysuria, to identify the best channelorgan for treatment. This chapter avoids supernatural topics and focuses on objective physical symptoms, and the treatment strategies are substantially more moderate than Tang era texts. Therefore, it appears plausible that at least this chapter of the Lingshu was composed sometime after Sun Simiao wrote his medical treatise. For a more accurate picture of medical practices prior to the Tang, one can examine the writings of Ge Hong ( ) from the Jin dynasty ( ). For the treatment of guiji (ghost attack) his recommendations include burning one or more moxa cones on Renzhong (mankind s affliction, Du-26) (Buque Zhouhou Baiyi Fang, 2009 reprint, j.1, di.4, p.445); for sickness caused by the wushi (five corpses), moxa behind the breast near Tianchi (heavenly pond, PC-1), beginning on the left for men and the right for women (ibid., di.6, p.446). This left-man and right-woman designation is repeated frequently in Ge s writings. Ge also wrote an essay specifically on diankuang, wherein the opening statement is: A prescription to treat those afflicted by derangement: burn three moxa cones on top of the shaft of the penis, and after they urinate they will be cured. Buque Zhouhou Baiyi Fang, 2009 reprint, j.3, di.17, p.463. Ge goes on to recommend burning moxa on the nipples, or the big toes, as well as a variety of herbal remedies. Ge also mentions using acupuncture for kuangyan guiyu (incoherent ghost speech) by needling under the nail of the big toe. Although Ge never mentions ghost points, these treatments are preserved by later authors. Influential medical works from the 7th and 8th centuries further discuss diankuang. According to the Zhubing Yuanhou Lun (Treatise on the Origins and Progression of Various Diseases, 610) by Chao Yuanfang ( ), both types of insanity, dian and kuang, can be due to fengxie (wind evils) entering the body, and be further differentiated by yin and yang, excess and deficiency (Zhubing Yuanhou Lun, 2011 reprint, j.2, di.43-48, pp.11-13), echoing the Nanjing. It notes that these external influences are able to damage the hun (ethereal soul), and then proceeds to discuss guixie (ghost evils) as a cause of disease. An essay devoted to diankuang also appears under miscellaneous diseases of women (Zhubing Yuanhou Lun, 2011 reprint, j.37, di.10, p.208). This section also differentiates dian from kuang, reiterating that it is caused by wind evil; when it affects the yin it is dian, and when it affects the yang it is kuang. It adds that if a mother is afflicted with this condition it could be passed on to her child. Waitai Miyao Fang (Secret Essential Prescriptions from an Official, 752) also discusses dian and kuang being caused by wind evil. (2011 reprint, j.15, di.1, p.241) Although it mentions some herbal formulas as potential treatments, it may have been frustration in finding an effective remedy that spurred the development of ghost points. In Sun Simiao s Qianjin Yifang (Supplemental Prescriptions Worth Thousands in Gold, c.680), a diverse set of therapeutic options is presented for diankuang, but he includes the methods of Bianque as the established authority in the treatment of mental illness: Bianque said: There are 13 acupoints to be This section also differentiates dian from kuang, reiterating that it is caused by wind evil; when it affects the yin it is dian, and when it affects the yang it is kuang. The Lantern 27

28 needled for diseases caused by the hundred evils. When needling the body; first begin from guigong (ghost palace), next needle guixin (ghost faith), then arrive at guilei (ghost fortress), and thereupon guixin (ghost heart). It is not necessary to needle [all thirteen acupoints] together; stop at five or six acupoints and you may understand. If [they are possessed by] the spirit of an evil creature, it will reveal itself and explain the reason for its wanderings. This will confirm possession by a spirit. One doesn t need to obliterate its existence; just request that it leave. For men begin needling on the left, for women begin needling on the right. If after [treating] numerous places [the sprit] has not spoken, you may [need to] needle both sides. Pay attention to these methods and abide by them. All of these places for acupuncture and moxibustion have been provided for you to manage [diankuang]. (ibid.) Qianjin Yifang, 2009 reprint, j. 27, di.4, p.911 Following this introductory passage, Sun details Bianque s 13 ghost points and their treatment methods. However, Sun details at least 20 different ghost points in total, as well as several other acupoints used in the treatment of diankuang, xiegui (evil ghosts), fengxie (wind evils), and guimei (ghost demons). From this it can be deduced that while earlier practices may have focused on just 13 acupoints to rid the body of demons, by the time of Sun the possibilities had expanded to a greater diversity of options. Tang doctors were clearly experimenting to find a cure for insanity. Five hundred years later, a physician named Dou Cai (c.1146) of the Southern Song dynasty ( ) produced a book called Bianque Xinshu (Book on the Heart of Bianque), which was amended by subsequent authors during later dynasties making precise dating difficult. This text exemplifies the attributing of contemporary practices to mythical figures, arguing there have been three different Bianques. One lived during the time of the legendary first emperor Huangdi (c.3000 BC) and passed on ancient wisdom in texts no longer extant. The second lived during the Warring States Period (c BC) and was also known as Qin Yueren, and he compiled both the Huangdi Neijing and the Nanjing. The third is Dou Cai himself, and the text suggests another Bianque will appear again in the future when further advances to medicine are achieved (Bianque Xinshu, 2011 reprint, j.1, di.5, p.4). The Bianque Xinshu briefly mentions afflictions from guixie (ghost evils), including as the cause of skin lesions, and states that it is due to a flourishing of yin and a deficiency of yang. The treatment is to tonify the yuan qi (source energy), which will cause the ghost evils to flee. (Bianque Xinshu, 2011 reprint, j.1, di.6, p.5) This text also includes a section on fengkuang (wind madness). This illness is attributed to an insufficiency of Heart blood due to damage from the seven emotions and six desires allowing the fengxie (wind evils) to invade. Treatments include burning moxa cones on Juque (great tower gate, Ren-14), or five cones each on Xinshu (heart acupoint, UB-15), or Sun Simiao s formula Dingzhi Wan (Calm the Emotions Pill) (Bianque Xinshu, 2011 reprint, j.2, di.24, p.30). These passages reveal that the Southern Song dynasty had a substantially different approach to mental illness than the Tang dynasty. The reconceptualising of insanity is further evident in the writings of Liu Wansu (c ). A defining feature of Jin dynasty ( ) medicine is the extensive use of wuxing (five elemental-phase) theory as an explanatory model. In Suwen Xuanji Yuanbing Shi (The Suwen s Profound Theories on the Origins of Disease Patterns, c ), Liu provides the following argument on the origins of kuangyue insanity): (extreme madness, Since Kidney water governs emotions, and water and fire are mutually opposed, therefore Heart fire flourishes and Kidney water declines, and thus one loses [control of one s] emotions and there is kuangyue (extreme madness). Suwen Xuanji Yuanbing Shi, 2006 reprint, j.1, di.4, p.98). Liu goes on to state that although it has been said that kuang is more yang and dian 28 Vol:14-3

29 is more yin, later commentaries disagree, stating that those with dian are happier indicating a disharmony with the Heart, while those with kuang are angrier due to Liver pathology. Moreover, when Heart fire is excessive it restrains Lung metal, which is unable to harmonise Liver wood. Liu consistently emphasises how excessive Heart fire is at the root of many ailments, and in another text recommends using strong heatclearing formulas like Huanglian Jiedu Tang (Coptis Relieve Toxicity Decoction) for this condition (Shanghan Biaoben Xinfa Leicui, 2006 reprint, j.1, di.40, p.182). The Yuan dynasty ( ) medical scholar Zhu Danxi ( ) built upon the work of Jin doctors like Liu Wansu, adding his own interpretation of diankuang (insanity). Zhu states that if the pulse is empty it can be treated, but if full it will lead to death. He adds that when there is an abundance of phlegm in the chest it will suppress the Heart spirit causing insanity. He reiterates that in cases of kuangyan guiyu (incoherent ghost speech), one should needle under the nail of the thumb and big toe. Otherwise, inducing vomiting or downward draining formulas are appropriate treatments. Zhu concludes that if one treats in the spring the patient will recover in the summer, and that dian is due to yang deficiency with yin excess, while kuang is due to yin deficiency with yang excess (Danxi Xiansheng Xinfa, 2006 reprint, j.4, di.60, pp ). A few centuries later, the Zhenjiu Dacheng (Great Compendium of Acupuncture & Moxibustion), compiled by Yang Jizhou ( ) and published in 1601 during the Ming dynasty ( ), included among its collection of essays one entitled: Sun Zhenren s Song of Needling the 13 Ghost Points. Zhenren was Sun Simiao s Daoist title meaning the perfected one, and while there are some obvious consistencies between the texts they also have some important differences. Notably absent is any reference to Bianque in the later essay, as Sun has now replaced him as the authority. Moreover, the information has been transformed into a formal poem composed of paired sets of seven-character verses. This was likely done as a memorisation aid. The song begins: The hundred evils are why we have the disease diankuang (insanity), and there are 13 acupoints for needling that one must know. When needling the body, you must first use guigong (ghost palace), and next needle guixin (ghost faith); none will not respond. One by one, following in sequence, from the beginning onward, and for men [begin from] the left, for women begin from the right. Zhenjiu Dacheng, 2010 reprint, j.9, di.5, p.411) Immediately evident is the different approaches to treatment of Sun and Yang. While Sun recorded that Bianque said it was not necessary to needle all of the ghost points, Yang emphasises that they should all be needled in a specific order. This modifies Sun s strategy of trying a diversity of options, to a specific technique requiring the needling of all 13 acupoints in succession. Yang further omits the other seven named ghost points and supplemental prescriptions, focusing solely on the 13. It is tempting to assume that this change represents a substantive improvement in clinical outcomes. However, given the slow pace of development, it is more likely that different approaches by different physicians continued to yield only modest improvements for this condition. Another important difference between Sun and Yang is found in the identification of acupoint names and locations that correspond to each ghost point. As the Song continues, Yang lists the first four ghost points in the same order as Sun, with similar notes on location and insertion: First needle Renzhong (mankind s affliction, Du-26), stopping by Guigong (ghost palace); insert the needle from the left and have the needle come out from the right. Zhu states that if the pulse is empty it can be treated, but if full it will lead to death. The Lantern 29

30 There is insufficient flesh at the standard location of these jing (well) acupoints to needle that deep, since you would strike bone soon after going deeper than one fen, but it is possible to needle that deep under the nail. For the second one, [insert the needle] under the nail of the thumb; this is called Guixin (ghost faith), and you pierce three fen deep (3/10 of a cun). For the third needle, [pierce] under the nail of the big toe; this is called Guilei (ghost fortress); insert two fen [deep]. The fourth needle [is inserted] above the palm at the acupoint Daling (big mound, PC-7); insert the needle five fen (1/2 cun), which is called Guixin (ghost heart). Zhenjiu Dacheng, 2010 reprint, j.9, di.5, p.411 The use of Du-26 echoes the strategies of Ge Hong, as do some of these other methods. Whether one reads Ge, Sun, Zhu, or Yang on this strategy, the method for the second and third ghost points is to insert the needle under the thumbnail or big toenail. Sun added that after needling Guilei, you may also want to needle each of the five toes, presumably in the same manner; however, Yang omits this detail. While Sun does not indicate any acupoint name equivalencies, Yang later adds in his own amendment to the poem that Guixin (ghost faith) is also known as Shaoshang (few merchants, LU-11), and Guilei (ghost fortress) is also known as Yinbai (hidden white, SP-1). When Sun describes the location of these points, he writes zhaojia xia (under the nails), adding the character zhao to render the binome for the nails with greater clarity. This binome was halved by Yang as he forced the poem into the seven character format, perhaps contributing to the confusion. Nonetheless, this marks an important departure from the earlier text. Modern and ancient patients would certainly agree these acupoints are preferable to a torturous insertion under the nails, but there is no reason to believe that this is the original method. This translation of xia (under, below) is sure to be controversial, so further support is needed. Besides Sun s text, there were primarily two authoritative texts on acupuncture needling locations in the early literature: the Lingshu, and the Zhenjiu Jiayi Jing (Systematic Classic of Acupuncture and Moxibustion) by Huang Fumi ( ). Chapter 2 of the Lingshu provides the only description of the location of both Shaoshang (LU-11) and Yinbai (SP-1), stating simply that they are found duan nei ce (on the inside of the end) of the thumb or big toe. For more specifics, one needs to consult the Zhenjiu Jiayi Jing which repeats this phrase, but then adds for the majority of the most distal acupoints that they are found: Approximately a leek leaf s distance beyond the corner of the nail. Zhenjiu Jiayi Jing, j.3, di.24-35, p Moreover, in Sun s other complilation, Beiji Qianjin Yaofang (Emergency Prescriptions Worth Thousands in Gold), he uses these exact phrases to describe the location of these points (Beiji Qianjin Yaofang, 2009 reprint j.29, di.1, p ) None of these texts uses the term xia to describe their location. Therefore, if Sun had meant to needle LU-11 and SP-1 for these ghost points, why wouldn t he have used this standard description of their location? Making this argument more compelling, the Zhenjiu Jiayi Jing also provides depths of needling for LU-11 and SP-1, which is to insert only one fen, or one tenth of a cun (proportional inch) (Zhenjiu Jiayi Jing, j.3, di.24-35, p ) This depth makes sense if one is needling the locations described above, but Sun specifically instructs that the needle be inserted three fen under the thumbnail for Guixin (ghost faith), and two fen under the toenail for Guilei (ghost fortress). There is insufficient flesh at the standard location of these jing (well) acupoints to needle that deep, since you would strike bone soon after going deeper than one fen, but it is possible to needle that deep under the nail. These terms were meant to be specific. The Beiji Qianjin Yaofang repeats many of the same techniques for the treatment of insanity as found in the Qianjin Yifang, but also adds this: 又灸足大指上聚毛中七壯 Another [prescription]: burn seven moxa cones on top of the big toe in the middle of where the hair gathers. Beiji Qianjin Yaofang, 2009 reprint j.14, di.5, p Vol:14-3

31 Although this is describing LIV-1 based on the reference to hair (as repeated in the Zhenjiu Jiayi Jing), the use of shang (above, on top) clearly distinguishes this location from his description of the ghost points. Sun also details needling the tips of the 10 fingers, known as Guicheng (ghost city) by stating the point is found qu zhao yifen (one fen beyond the nails) (ibid., p.269) highlighting this other term used in reference to the nails. This further supports the argument that Sun purposefully used the different terms under the nails, above the nails, and beyond the nails for specificity of location. Finally, Sun adds this guideline: For those afflicted by madness and ghost speech, needle under the nail of their big toe. Insert a little bit and then stop. (ibid., p.270.) Here Sun adds the greatest specificity on the location by using binomes for both the the big toe (muzhi) and its nail (zhaojia), as well as realising one might not get the needle two fen deep, but leaving little doubt he meant to insert under the big toenail. All of this evidence together supports the argument that the original technique was to needle below the actual body of the nails for these ghost points. Other harsh techniques are described alongside this one. An example is the 13th ghost point, Guifeng (ghost seal), which presumably was used last after all others failed. According to Sun, this treatment requires that the patient stick out their tongue so that the needle can be inserted underneath and pierce through the top. After piercing the tongue, one must wrap some cloth around the head in order to secure the needle in place, then instruct the patient not to move their tongue. Sun does not say for how long the patient needs to remain with their tongue in this state, so one could assume it is until they show signs of being cured. In contrast, Yang s poem instructs the doctor only to insert the needle under the tongue, in the centre, and says nothing about piercing through the top or securing the needle in place. Yang later adds that one can simply prick to bleed this acupoint, and while still instructing the patient not to move their tongue (presumably meaning not to speak), needle Jianshi (the messenger, PC-5) and Houxi (behind the creek, SI-3) together for an outstanding effect. In all of these instances, there is a significant reduction by Yang in the severity of the techniques used by Sun. This latter treatment guideline highlights another difference. In Sun s text, Bianque s ninth ghost point is Jianshi (PC-5), also known as Guilu (ghost road); but Guilu is also Sun s fifth ghost point located below the lateral malleolus, as well as an alternative name of Laogong (palace of labour, PC- 8). In Yang s text, the fifth ghost point is also Guilu, which he identifies as Shenmai (branched vessels, UB-62), but the ninth point is Guiku (ghost den), also called Laogong (PC-8). Thus, there are some clear differences in the names and locations of ghost points between Sun and Yang. Other techniques, such as for the 11th ghost point named Guicang (ghost storehouse), may reveal early attitudes towards sexuality, suggesting a perceived link between madness and sexual desire. According to Sun: [For men] burn three moxa-cones on yinxiafeng (crease below the genitals, perineum) and on women [burn] three moxa cones on yumentou (jade gate head, clitoris), which is known as Guicang (ghost storehouse). Qianjin Yifang, 2009 reprint, j. 27, di.4, p.911 To state that one should be cautious burning three moxa cones on the perineum is an understatement. However, burning moxa cones directly on the genitals is certainly pushing the legal and ethical limits of our scope of practice today. The source text does not make it clear if one was expected to remove the moxa before it caused any physical harm, but other methods described for the treatment of insanity suggest severe burns were often expected. For example, Sun describes a treatment similar to Ge Hong: After piercing the tongue, one must wrap some cloth around the head in order to secure the needle in place, then instruct the patient not to move their tongue. The Lantern 31

32 Moxibustion was used more often than needling, including directly on the genitals in an apparent attempt to curb sexual desire to cure insanity. Burn three moxa cones on the bend of the penis, and after they urinate they will be cured. Right on the urethra is the point. Alternatively, burn three moxa cones on the head of the penis or, again, burn three moxa cones on the nipples. Qianjin Yifang, 2009 reprint, j. 27, di.4, p Sun s suggestion of burning three moxa cones on the head of the penis, as well as on the nipples (presumably of either sex), again raises the question of a perceived link between sexuality and madness by early Chinese doctors. By the 17th century, attitudes had changed. For the 11th ghost point, Yang essentially repeats what Sun wrote, but he omits the specific instruction that one should burn moxa on women s genitals. Instead, he later adds that in men this acupoint is called Huiyin (gathering darkness, Ren-1), in women it is still called yumentou (jade gate head), and that one can just insert a needle three fen. Thus, Yang proposes that this same point has two different names based on gender. These changes again appear to be providing alternative treatments that are potentially less severe, and thus are indicative of changing attitudes about both sexuality and medicine. By the time of the Ming dynasty, doctors had come to realise the harsh techniques of the past did not yield any better clinical outcomes than a gentler approach. The history of the ghost points and the treatment of insanity reveals the slow evolution of Chinese medicine. Three thousand years ago, the ghosts of angry ancestors and nature spirits were thought to cause all sickness. Treatment was aimed at appeasement with human and animal sacrifices accompanied by rituals and incantations. Two thousand years ago, it was believed that not only ghosts and demons caused insanity but also evil winds. This was part of a gradual shift towards a more naturalistic approach to medicine, but supernatural practices continued with animal sacrifices, rituals, incantations, talismans, along with stone lancing, cauterisation, and herbal remedies. Ghost points were likely first created about 1500 years ago, when acupuncture was still in its early development, and for the treatment of insanity a doctor might insert a needle under your toenail or through your tongue and tie it in place. Moxibustion was used more often than needling, including directly on the genitals in an apparent attempt to curb sexual desire to cure insanity. The system of acupuncture known today from the received literature was formalised 1000 years ago by Song dynasty medical officials. During the centuries thereafter, new approaches were developed that focused on natural causes and marginalised the harsh techniques of the past. Four hundred years ago, a revised and more gentle approach to the use of ghost points was promulgated for the treatment of insanity, more closely resembling how acupuncture is practised today. As Chinese medicine continues to evolve into the 21st century, we must recognise that it has changed substantially over the past few millennia, and is certain to change in the future. References Brown, Miranda. (2015). The Art of Medicine in Early China: The Ancient and Medieval Origins of a Modern Archive. New York, NY: Cambridge University Press. Chao, Yuanfang. (610). Zhubing Yuanhou Lun (Treatise on the Origins & Progression of Various Diseases). Beijing, People s Republic of China: Zhongguo Yiyao Keji Chubanshe (China Select Branch of Medicine & Pharmacy Publishing House). Reprint Dou, Cai. (c.1146). Bianque Xinshu (Book on the Heart of Bianque). Beijing, People s Republic of China: Zhongguo Yiyao Keji Chubanshe (China Select Branch of Medicine & Pharmacy Publishing House). Reprint Ge, Hong. ( ). Buque Zhouhou Baiyi Fang (Hundreds of Supplemental Prescriptions to Keep Up the Sleeve). In Sanguo Liangjin Nanbeichao Yixue Zongji (A Complete Collection of Medical Works in the Period of Three Kingdoms, Two Jin, & Southern & Northern Kingdoms), Yan Shiyun (Ed.). People s Republic of China: People s Health Press. Reprinted Hanshi Waizhuan (Biography of Han Poetry). (c.100 BC). Retrieved June 2017 from http.//ctext.org/ pre-qin-and-han. Harper, Donald J. (1998). Early Chinese Medical Literature: The Mawangdui Medical Manuscripts. London, U.K.: Kegan Paul International. Hou Hanshu (History of the Later Han Dynasty). (c.400). Retrieved June 2017 from http.//ctext. org/pre-qin-and-han. Huangdi Neijing Lingshu (Yellow Emperor s Inner Classic, Spiritual Pivot). (c.200). 32 Vol:14-3

33 Retrieved June 2017 from http.//ctext.org/preqin-and-han. Huangfu, Mi. ( ). Zhenjiu Jiayi Jing (Systematic Acu-moxa Classic). Beijing, People s Republic of China: Renmin Junyi Chubanshe (People s Military Medical Press). Reprinted Keightley, D.C. (2000). The Ancestral Landscape: Time Space, and Community in Late Shang China (ca B.C.). Institute of East Asian Studies, University of California, Berkeley. Liu, Wansu. (c.1146). Shanghan Biaoben Xinfa Leicui (Collection of Core Methods Related to the Manifestation & Root of Cold Damage). In Liu Wansu Yixue Quanshu (Complete Collection of Liu Wansu s Medical Studies). Beijing, People s Republic of China: Zhongguo Zhongyiyao Chubanshe (Chinese Medicine Publishing House of China). Reprinted Liu, Wansu. (c ). Suwen Xuanji Yuanbing Shi (The Suwen s Profound Theories on the Origins of Disease Patterns). In Liu Wansu Yixue Quanshu (Complete Collection of Liu Wansu s Medical Studies), Hu Guochen, Song Naiguang et al., Eds. Beijing, People s Republic of China: Zhongguo Zhongyiyao Chubanshe (Chinese Medicine Publishing House of China). Reprinted Nanjing (Classic of Difficulties). (c ). Retrieved June 2017 from ttp.//ctext.org/ pre-qin-and-han. Shuoyuan (Discussions in the Garden). (c.100 BC). Liu Xiang (77-6 BC) ( Ed.) Retrieved June 2017 from http.//ctext.org/preqin-and-han. Sima, Qian. ( BC). Shiji (Historical Records). Retrieved June 2017 from http.//ctext.org/pre-qin-and-han. Sun, Simiao. ( AD). Beiji Qianjin Yaofang (Emergency Prescriptions worth a Thousand Gold). In Sun Simiao Yixue Quanshu (Complete Collection of Sun Simiao s Medical Studies). Beijing, People s Republic of China: Zhongguo Zhongyiyao Chubanshe (Chinese Medicine Publishing House of China). Reprinted Sun, Simiao. ( AD). Qianjin Yifang (More Prescriptions worth a Thousand Gold). In Sun Simiao Yixue Quanshu (Complete Collection of Sun Simiao s Medical Studies). Beijing, People s Republic of China: Zhongguo Zhongyiyao Chubanshe (Chinese Medicine Publishing House of China). Reprint Wang, Tao. ( ). Waitai Miyao Fang (Arcane Essential Prescriptions from an Official). Beijing, People s Republic of China: Zhongguo Yiyao Keji Chubanshe (China Select Branch of Medicine & Pharmacy Publishing House). Reprinted Welden, John. (2015). To Bring Order Out Of Chaos: Literati Medicine of the Jin dynasty ( ). Dissertation completed for a Doctorate in History from the University of Hawai i. UMI Number: Yang, Jizhou. (1601). Zhenjiu Dacheng (Great Compendium of Acu-Moxa). Beijing, People s Republic of China: Renmin Baosheng Chubanshe (People s Hygiene Press). Reprinted Zhu, Danxi. (c.1350). Danxi Xiansheng Xinfa (Core Methods of Master Danxi). In Zhu Danxi Yixue Quanshu (Complete Collection of Zhu Danxi s Medical Studies). Beijing, People s Republic of China: Zhongguo Zhongyiyao Chubanshe (Chinese Medicine Publishing House of China). Reprint Why certified herbs are the answer! There seems to have been a flood of negative accounts about Chinese medicine in the past year, ranging from ABC news, a Greenpeace report and so-called friends of science research claiming that Chinese herbal substances were at worst compromised by pollutants and at best of poor quality and therefore unlikely to work as traditionally indicated. While we dispute much of this material, it is in everybody s interests not only to ensure standards of quality and safety, but also to be able to demonstrate this to the public s satisfaction. For this reason, in the past three years Winner Trading has adopted European pharmacopoeia standards of herbal testing and analysis. We believe that the previous Certificate of Analysis (COA) provided by most manufacturers is now insufficient and therefore invited the world s biggest independent laboratory, Eurofins, to test our herbs according to the higher European standards. Eurofins certification will ensure that raw herbs entering the Australian market are of the highest quality. We must also ensure herbal medicine stays affordable for the public. With this in mind, rather than introducing an expensive organic herbs range, we decided instead to improve our selection of certified herbs. This entails working with large-volume suppliers to improve the affordability of their products. If farmers have greater demand for products that meet certification standards, they have more incentive to produce quality herbs, which will work to eventually bring down the cost. Greater volume is the answer. This is why we need the ongoing support of practitioners in choosing to dispense certified products wherever possible. Together let s eliminate criticism of Chinese herb quality uninformed or otherwise. Guarantee your herbs are pesticide and heavy metal free! We would be grateful for your feedback on how to improve our products and service. We value your contribution to the promotion of the great benefits of Chinese medicine to the Australian community. Shop online today at: Ph: info@chineseherbsonline.com.au The Lantern 33

34 The naked flame And other hot topics 34 Vol:14-3

35 By Bruce Bentley This first of a two-part series explores the element of fire in cupping's ancient past, the ways and means of its transfer, the essential role it plays in cupping's therapeutic effect, and representations of the "fire method" in the Western medical tradition up until the 7th century AD. Neolithic stone lamps at the Thousand Lamp Museum, Qiandeng, Kunshan (Photo: Gisling, 2011, FIRE, BRINGER OF light, warmth and transformation; steeped in wonder and magic. Australopithecus at a campsite in Kenya might have been the first to harness it some two million years ago; and at least 70,000 years ago an oil lamp was created to illuminate the night (Safra and Aguilar- Cauz, 2005: 124). Certainly if we turn the time dial forward to around 30-40,000 years ago, in caves in southern France, Cro-Magnon artists used oil lamps, from the Greek lampas meaning torch, in otherwise pitch-black conditions to light the walls and paint their awe-inspiring masterpieces. 1 The tools they employed actually differ very little from a modern painter s equipment. They fashioned delicate brushes, prepared ochres and chipped stone to become scrapers. The raw natural lamps they used, the size of a human hand and emitting 1-5 times candlepower, have been discovered in their hundreds on the floor of these caves. They are sandstone with a central recess into which they added animal fat that absorbed into lichens or a wick that was draped over the edge and lit. At the Lascaux International Cave Art Centre a remarkably refined Cro-Magnon oil lamp is on display. In China, a stone oil lamp discovered in Kunshan, Jiangsu Province is dated from the Neolithic Period beginning about 10,200 BC. Many of the technologies already mentioned are seemingly more complex than the creation of a rudimentary cupping vessel. It is well within the realm of possibility that early prehistoric humankind discovered vacuum, and the prospect of the cupping vessel, in the course of their everyday activities. This superb lamp, an elegant one-off, is an exhibit at the Lascaux International Cave Art Centre. It still contains traces of combustible material. The charcoal remains were found to be wicks of conifer and juniper saturated by melted fat (photo Bentley, 2017). Primordial cups At least two possible scenarios explain why hollow animal horns are likely to have been the first cupping instruments. When marrow is being sucked out from inside a horn, a vacuum is produced that then adheres it to the lips of an eager diner. Alternatively, emptied animal horns may have been left beside a fire, and the heat build-up inside the horn transformed into negative pressure. It was only a matter of time until one of these horns was picked up and unknowingly applied to the flesh. Either way, imagine the amazement at experiencing a sensation made possible by an object from the natural world yet not duplicated elsewhere in natural circumstances. The opportunity supplied by The Lantern 35

36 a hollow horn would have been perceived as magical and at the same time practical; and subsequently became the principal means for supernaturalistic medical practices to draw out malevolent spirits and influences, and for naturalistic medicine to draw out physical intrusions and natural illness causation factors. In June 2017, I visited the Lascaux and Grotte de Rouffignac Cro-Magnon cave art sites in the south of France. At both places, dated to be 20,000 and 15,000 years old respectively, I asked archaeologists if they thought hollow horns could have been employed as cupping vessels. They were more surprised at never having heard the suggestion before than at the implausibility of the idea. Indeed they were open to the possibility. Far more sophisticated technologies had already been developed and herbs have been found in settlements and graves associated with these sites. These archaeologists spoke to me about how Cro-Magnon would certainly have sucked out and eaten the nutrient rich marrow from inside them. came in a number of forms. During the 3rd millennium BC, the first people to establish a civilization in Europe were the Minoans. They were based in Crete and also occupied some neighboring Aegean islands. When I visited the old capital at Knossos in 2013, my guide said that she had seen thousands of oil lamps housed for safekeeping in archaeological vaults. Candles discovered on site also prove these too were a regular part of life (Safra and Aguilar-Cauz, 2005:798). I purchased a few replica Minoan lamps (below left) at shops nearby, and some originals are on display at the Heraklion Archaeological Museum, not far from Knossos. Vegetable oils such as olive and sesame oil were used as fuel, and some lamps, which probably belonged to the elite and privileged, were elaborately painted, had a special snout or nozzle, a pouring hole, a handle and were enclosed to avoid oil spillage. It is likely that most common folk had simple clay instruments with a pinched lip to take the wick (below). Ancient epochs In the worlds of Sumaria (c BC), Pharaonic Egypt ( BC), the Akkadian Empire ( BC) and Babylonia ( BC), oil lamps were commonplace and Simple clay lamps like this one were used in common households that surrounded the royal palace at Knossos. Replicas of lamps discovered at the palatial residence at Knossos, the centre of Minoan civilisation. Unfortunately, we have only scratched the surface of Minoan culture and social life, and know little about the medical practices they performed, and even less about the instruments they used as a survey of the related literature, including Arnott (2004) and Warren (1970) makes plain. If the Minoans practised cupping, then there is no reason why both these light sources could not have doubled to become the means of a flame for cupping. We can reasonably presume this because oil (or grease) lamps feature alongside cupping in later medieval European artworks, and throughout the world to this day many folk practitioners use a candle and take its flame inside a cupping vessel before application. I suggest 36 Vol:14-3

37 that the presence of these as basic tools, and the simplicity of the procedures, are indicators that they served the same task many centuries, perhaps even thousands of years, earlier. Difficulties in identifying the past To date in prehistory, cupping vessels have been elusive to discover and identify. It could be that archaeologists and historians are simply not recognising them, and overlooking the possibility that the ordinary clay household drinking cup could have a dual purpose as it is often does today in folk medical settings in Greece, China, Poland, Russia and other countries. On July 13, 2014, I spent an afternoon in Athens at the residence of Professor Stefanos Geroulanos, who besides having a glittering medical career is also the President of the International Hippocratic Foundation. We spoke about the possibility of rural people using dried gourds and clay cups back in ancient times. He explained, It would have been the same back then as it is now with people using household cups as therapeutic instruments. All the implements that were used for drinking and other purposes could also be used as cupping vessels they don t need to be made from bronze or glass. Ceramic shards, because of their ubiquity, go unnoticed but they pepper the countryside throughout Greece. My father, who planted thousands of olive trees, said he was constantly digging up old clay pots and cups. Confirming cupping vessels it seems is is not helped by the fact that academic disciplines tend to follow a narrow range of pursuits. Last year, for example, I corresponded with the curator of an internationally famous museum of ancient antiquities in Egypt. He was astounded and grateful for my input concerning an archaeological relic that was clearly a cupping vessel. He agreed with my summation based on the reasons I gave, and said it had never occurred to the specialists working there. In his scholarly work Medicine and Philosophy in Classical Antiquity, Van Der Eijk makes the point that the new era of a wider study of classical medicine requires, almost by definition, an interdisciplinary field (2006:7). On another occasion in 2014, I had a conversation with an archaeologist at an Athens museum who believed that the Minoans probably performed cupping because he too supposed it had a long prehistoric past. He was not comfortable to be identified, however, because he said there could be recriminations from his seniors who did not sanction unauthorised statements. We agreed that, while not on the archeological or historic record, since early humankind there must have been a series of happenings that were logical lead-ups to the first written evidence on cupping penned in classical Greek by the Hippocratic physicians of the mid 5th and 4th centuries BC. The content of these volumes in themselves suggests the likelihood of a much older date of origin as both dry and wet cupping are described numerous times throughout the Hippocratic Collection in sophisticated terms, from the reasons for the shape of the cupping vessel to many treatment recommendations and philosophical/functional speculations. One could imagine that the journey to such detailed knowledge would come only after long experience gained by trial and error. Interpreting modern history can even be problematic, let alone the ancient past. A woman receives cupping after a bath. Bathhouses were popular throughout Europe during the latter Middle Ages and cupping, massage and gymnastics were performed. Note the cupper is holding an oil lamp with a visible flame in the left hand. 15th century German woodcut from Kalendar, 1483, Iconographic Collection, Wellcome Institute for the History of Medicine, London. The Lantern 37

38 Greek oil lamps from the Classical Period (replicas from Bruce s collection, 2017). As the noted historian Richard Miles 2 described during a long lunch a few years ago, the further back we shine the torch on the past, the dimmer the light becomes. For example, debate surrounds the commonality of cupping in China at the time when it was first written about in the Mawangdui medical manuscripts. The following illustrates how two scholars can be at odds when interpreting the same text. As I have previously written (Bentley, 2014:20): There are differing opinions among medical sinologists regarding the likelihood of Chinese common folk performing cupping in ancient times. The first textual record of cupping that we know of is found in the Mawangdui medical manuscripts. These scripts, dated around 168 BC, are a treasure trove of information on treatments and health enhancement (yangsheng) practices. Cupping makes a rather unflattering cameo as a preliminary treatment method for haemorrhoids either large ones like a zao [jujube] and small ones like a zao [jujube] pit The treatment schedule recommends, to apply a small horn to it, for the time it takes to cook two dou (a unit of quantity) of rice. Then bind it with a small cord and cut it open with a knife (Harper, 1998: 271). In his commentary, Donald Harper concludes that, whether using instruments fashioned from animal horns or otherwise, cupping was adopted much less frequently in ancient China than it was in Greco-Roman medical culture around the same era. He argues that the omission of cupping from other early Chinese medical writings, as well as the lack of information given to a cup s construction and its mode of application, only adds further weight to this deduction. On the other hand, the Chinese researcher Ma Jinxing reaches the opposite conclusion from the same evidence. He interprets the lack of details as a sign that cupping was already commonly practised and did not require explanation (Harper, 1998: 271). My research leads me to wholeheartedly side with Ma Jinxing s assessment. In a similar vein, when the 60-odd volumes of the Hippocratic Collection were written, it is unfortunate that there are no explicit descriptions given about how the heating procedure was performed. One can surmise that despite being from a time when writing was well developed and erudite, the early Greek medical literati seem to have thought that explaining how to bring a flame inside a cupping vessel was either too simple or commonplace, and so unnecessary to mention, let alone bother with instructions. The same could be said for Chinese medical literature some centuries later. It should be kept in mind as well that we now have only a small amount of the medical literature available to us that was written during the Greek Classical Period. Much of it has been lost, including the Hippocratic volume On Practice, which disappeared forevermore in a series of fires, the first occurring in 48 BC that destroyed the Greek mega-library at Alexandria. On Practice may have held the key to answering the burning question we otherwise have to reconstruct to offer some less-than-perfect answers. The virtue of heat and design and the law of attraction Cupping was so favoured by Greek physicians that the instrument was adopted to be the symbol of the profession, in the same way the stethoscope identifies the contemporary biomedical doctor. It was performed to balance the exchange between 38 Vol:14-3

39 the four humours, as well as promote the movement of blood. Cupping could be used to bring either humours or blood to a problem of scarcity, or conversely, be applied to a part of the body distal to the site of an ailment and so draw away and reduce an accumulation of superabundance (pain) thereby restoring health by bringing about a state of comparative balance. In relation to heat required for the application of a cupping vessel, in his commentary on the Hippocratic volume Diseases IV, Iain M. Lonie remarks, heat is also implied with the physician s gourd, since these are heated (1981: 281). Lonie also writes, No physician used to handling cupping instruments [either bronze cups or gourds] could disregard the factor of warmth in their action. (1981:26) The principle of heat and vacuum also conformed to the philosophical principles around the laws of attraction as propounded by Plato and Aristotle. Heat attracts coldness, which together with a correctly shaped cup and consequent effective vacuum make all three in tandem a formidable therapeutic trio. Similarly, cupping continues today in Greece as a folk practice employed mostly to remove coldness (kreo) from the body. In the Hippocratic Collection the shape of the cupping vessel replicates the look and function of the hollow organs being the brain, uterus and bladder. It was understood that these organs draw fluids (humours) into their interior, just as the similarly shaped cupping vessel draws unhealthy elements from the body. Each of these organs was perceived to have an entrance, a narrow passageway and a bulbous main section just as the common manufacture of the cupping vessel these days also has a lip, a neck and belly notably therefore, being both descriptions of its design as well as being body metaphors. The Chinese probably borrowed the design of the cupping vessel from the Greeks. Sikia It is fascinating to discover in the Hippocratic writings that cupping is referred to in classical Greek as sikia, which means gourd. So while the learned physicians who could afford expensive instruments were mostly using bronze cups, the word sikia surely indicates that regular people used dried hollow gourds as cupping vessels. These would have been employed especially by rural folk who could grow their own. Following the Greeks, the Romans borrowed the term sikia, but latinised it to become curcurbita, meaning gourd or in the shape of a gourd, as a synonym for cupping (Kravetz, 2004:1418). The medical historian John Stewart Milne (1907:101) notes that in the Indian Vedas, a cupping procedure was to apply a gourd with a fire in it ; and Mukhopadhyaya (1913:150) wrote that cupping was performed using, alibu (Lagenaria vulgaris) or gourd which is made of the bark of the succulent fruit called alabu. It is difficult to make out whether a fire in it means a lit material of some sort thrust into the gourd, or if it was a flame taken inside and removed quickly before the vessel was attached. Testing the proposal I conducted an experiment to see if the flame produced by a replica classical oil lamp that I purchased in Athens was effective in applying a cupping vessel to the skin. I used Greek olive oil as the fuel. It should be kept in mind that the quality of the replica lamp and the wick that came with the purchase is certain not to be of the same type or quality as an original. I found that while I was successful adhering the cup, it did require quickly taking it to the body, and even then the strength of the suction was mild. My assessment is, in order to achieve a stronger suction when required, the lamp wick would need to be thicker and made from a material that effectively absorbed the olive oil to engender a bigger flame. What we should take for certain is that the right lamp does the job, otherwise they would not feature in medieval illustrations and on through into 19th and early 20th century clinical practice. For my second experiment, rather than using a current standard Chinese glass cup, I chose to use a 19th century thin Romanian glass cup from my cupping vessel collection. I decided on this type of cup because when I was doing research at the Department of the History of Medicine in Rome in 1998 I had the opportunity to examine some glass cups from Pompeii. I was amazed not only that they survived the volcanic eruption but how thin and delicate they were. To my great Ceramic cupping vessels from Egypt About 15 years ago, a cupping student of mine kindly gave me these two specimens. His father was a physician, and a doctor friend of his with a passion for medical archeology had been at a dig in progress in Egypt 50 years earlier. The workers discovered these two cups and held them up for all to see. The doctor gestured, and brought his hand to his mouth, to which the workers emphatically disagreed and signed back emphasising that the vessels were to be placed on the skin surface. Their glazed surface dates them at 800 to 1000 years old (photo: Bentley, 2016). The Lantern 39

40 Even with a flame from a replica Greek oil lamp, a fine job of cupping was achieved, using this 19th century Romanian glass cup (photo Bentley, 2017). satisfaction, this cup did indeed fasten to the flesh and draw far more effectively. As it stands, I am inclined to think that when bronze cups were being used, a material impregnated with fuel thrown into the cups probably best served the purpose. However, if clay cups were used, presumably with continuous straight or angled sides, then the flame from a lamp would be a safer and better option. I employed the same Greek lamp to effectively carry out the cupping procedure with my only clay option being an old Egyptian clay vessel. The difference between this and either Minoan or classical Greek vessels would be the glaze. Certainly by the time glass cups were being made, during the Roman era, using a lamp was probably the done thing. The works of Paulus Paulus Aegineta ( AD) was the last of the great physicians of the Byzantine period (Eastern Roman Empire AD), so called because after the Fall of Rome, imperial power shifted east to Constantinople, now Istanbul. His great accomplishment was as a medical encyclopaedist who compiled the writings of many of the scholars and physicians of Greek, Roman and Arabian medicine from the time of Hippocrates and his followers. Together with the inclusion of his own knowledge and practice, he set it all down in fine and thorough detail in his Opus Magnus of seven volumes titled The Medical Works of Paulus Aegineta (Welsh, 2007). Within this massive compilation, besides describing a broad range of treatments based on complex diagnostics and extensive herbal, dietary, exercise and physical therapy, he makes copious inclusions regarding cupping, the ailments it treats and how it should be applied. The following is a selection from the array of references. For our purpose I have listed some of the recommendations for cupping performed with Great Heat, or by heating the cup until it is hot (without burning the patient). In a few cases he describes the best way of heating the cups. I have taken the liberty to capitalise the heat references for easier recognition. Otherwise the capitals are direct from the source: n To treat Earache occasioned by Coldness, and a melancholy Spirit is greatly remedied by applying a cupping instrument, previously heated in hot water and affixed near the ear. Fine glass cups from Pompeii on display at the Department for the History of Medicine, University of Rome (photo Bentley, 1998). Could he be referring to a case of someone suffering earache from being exposed to cold windy conditions? Certainly it is a common for many people to get earache under such climatic circumstances. I do! And especially when wind is loaded with coldness and in my case at least, wind is the critical nasty overlay. Furthermore, many people report that when they are exposed to windy conditions it makes them feel uneasy and mentally on edge. Considering the antiquity of the era and the subtleties of translating the original text, could this be tied with a melancholy spirit? It is such an appropriate interlinking of the 40 Vol:14-3

41 emotions with the physical complaint Does Paulus then refer to an ailment caused by both cold and wind climatic conditions. I think so. Celsus, the noted Greco-Roman encyclopaedist of the 2nd century AD, made the distinction between dry and wet cupping clear in his De Medicina (Of Medicine) by explaining: If the skin upon which the cup is to be stuck is cut beforehand with a scalpel, the cup extracts blood; when the skin is intact, wind (Spencer, 1953: 167). n On vomiting of Bile: A cupping instrument when applied with a Great Heat is of great service. n On Pain: When pain is occasioned by warm air or flatulence, apply cupping with Great Heat. [He cites Aetius, a Greco-Roman physician who also recommends applying cupping instruments with Great Heat to the breast, stomach and back, and in certain cases to treat inflammation of the stomach and neighbouring parts.] n For Lethargy: Aetius says when the disease is protracted, the head must be shaven we may apply dry cupping, with Much Heat. n On Pain when occasioned by warm air or melancholy, cupping should be applied with Great Heat. n For uterine suffocation: Apply a cupping instrument to the groins and hypogastrium, with Great Heat. n For prolapsed uterus: cupping instruments with Much Heat are to be fixed to the navel and the groins on both sides. n For ischiatic disease [an arthritic complaint seated in the hip joint] cupping instruments may be applied to the hip with Much Heat. n Part 2 in the next issue of The Lantern will continue with the Western flame lineage, as well as presenting its history and conduct in the Chinese, Indian, Islamic and various folk medical traditions. Footnotes 1. Interestingly, the toxicologist and environmental health engineer, Albert Donnay ( points out, Such a large number of lamps would have produced enough light to paint by and also reduced the risk of fatal CO poisoning that came with making or carrying larger fires deep in the cave. Few anthropologists have studied these lamps but a French team once tested them in a painted cave, briefly lighting hundreds on the floor. They found that the merged light flicked very quickly so that all the animals on the walls and ceilings appeared to be moving. This moving picture effect cannot be seen when the caves are lit only by flashlight or electric light. 2. Professor Richard Miles is the author of Ancient Worlds (2011. Penguin History) which became a BBC documentary series. His other BBC series is Archaeology: a Secret History. Bibliography Arnott, R. (2004) Minoan and Mycenaean Medicine and Its Near Eastern Contacts in Horstmanshoff, H.F.J. and Stol (eds) Magic and Rationality in Ancient Near Eastern and Greco- Roman Medicine, Vol 27. Leiden. Bentley, Bruce (2014) Cupping s Folk Medical Heritage: people in practice (chapter 2) in Chirali, Ilkay Traditional Chinese Medicine: Cupping Therapy (3rd Ed). Churchill Livingstone. China. Donnay, Albert (2014) Was there a function to the Lascaux cave paintings? www. quora.com Answer June 18, Galen (2011) Method of Medicine. Books 1-4. Edited and translated by Johnson, Ian and Horsley, G.H.R. Harvard University Press. Cambridge. Harper, Donald (1998) Early Chinese Medical Literature: The Mawangdui Medical Manuscripts. Kegan Paul. London. Lonie, Iain M. (1981) The Hippocratic Treatises On Generation On the Nature of the Child Diseases I V. Walter de Gruyter. Berlin. Milne, John Stewart (1907) Surgical Instruments in Greek and Roman Times. Clarendon Press. Oxford. Mukhopadhyaya, Girindranath (1913) The Surgical Instruments of the Hindus (Vol 1). Calcutta University Press, Calcutta. Ruspoli, Mario (1987) The Cave of Lascaux: The Final Photographic Record. Thames and Hudson Ltd. London. Safra, Jacob E. (chairman) and Aguilar-Cauz, Jorge (president) (2005) The New Encyclopaedia Brittanica. 15th Ed, Volume 7. USA. Celsus De Medicina, Vol , Spencer, W.G. (trans 1953), The Loeb Classical Library. William Heinemann, London. Van Der Eijk (2006) Medicine and Philosophy in Classical Antiquity. Cambridge University Press: Cambridge. Warren, C.P.W. (1970) Some Aspects of Medicine in the Greek Bronze Age in Cambridge Journal of Medical History. Oct; 14 (4). Cambridge University Press: Cambridge. Welsh, J. (2007) The Medical Works of Paulus Aegineta.Vol.2. Treuttel, Wurtz, & Co. London. n Bruce Bentley is a Australian registered acupuncturist and Chinese herbalist who presents cupping and gua sha workshops. In 2017 Bruce was employed as an editorial advisor in the WHO division of traditional, complementary and alternative medicine, and accepted the role as president of the World Society for Ethnomedicine. n com.au n Facebook/ Healthtraditions. The Lantern 41

42 review Inspiring Rothenburg 2017 TCM KONGRESS: Shen and emotions; the cardio-vascular system; Bianque and the four diagnostic methods n For information on the next TCM Kongress (May 8-12, 2018) visit: Review: Bettina Brill MORE THAN 1200 participants and 100 presenters from 40 countries met again this year at Rothenburg in May for the biggest TCM conference in the Western world. Over the span of five days there were many lectures and intensive short courses on the agenda. There is always an opportunity to go political, and this year was no exception. The ETCMA (European TCM), World Health Organisation and diverse professional organisations discussed how TCM may be incorporated into general health care. Prof. Dr Benno Brinkhaus, head of the Institute for Social Medicine, Epidemiology and Health Economy at the Charité medicine department, University of Berlin, and head of medicine at the TCM Kongress, presented a talk titled Acupuncture research pioneer for the acceptance of Chinese medicine? He presented research on chronic lower back pain and allergic rhinitis. Brinkhaus s team conducted large-scale studies and a meta-analysis and were able to show that acupuncture had a significant effect that exceeded that of standard therapies. This may open up new discussions about the integration of acupuncture, as has already been done in the US. This year s delegation from Chengdu included Prof. Gao Yongxiang, Prof. Weiqi Ma, Yuning Wu and Luo Zaiqiong, who presented practice-oriented talks ranging from the treatment of brain diseases to diabetic neuropathy and gout, and on classical pulse diagnosis. Spoiled for choice, I spent my time at Barbara Kirschbaum s course on tongue diagnosis and with Stephen Boyanton on the shaoyang and shaoyin chapters of the Shang Han Lun. Great decisions they were both experts delivered inspiring lectures. Other courses, tailored to this year s theme, included a presentation by Tzafrir Nachmani from Israel on post traumatic stress disorder that emphasised the importance of acupuncture for aid projects in crisis areas worldwide as effective, low-cost therapy, and Bob Flaws from the USA, who devoted himself to the spiritual development of the practitioner in order to create beneficial relationships with patients. The practical workshops were in high demand. Bruce Bentley from our own backwaters of Australia instructed on guasha, cupping and tuina which were, not surprisingly, very popular. Not only does the Rothenburg Kongress offer a great variety of courses, but there are also all the extras that make this week a great experience: taichi on the lawn, the legendary Friday night party and a reflective concert with music by Joseph Haydn performed by the Doctors Music Ensemble, part of the TCM Social Forum (proceedings going to the Moxafrica project, 42 Vol:14-3

43 review Can I see your ID? CHINESE MEDICINAL PLANTS, HERBAL DRUGS AND SUBSTITUTES AN IDENTIFICATION GUIDE, by Christine Leon & Prof. Lin Yu-Lin; Kew Publishing, Royal Botanic Gardens: Kew 2017 Review: Bettina Brill THIS EASY TO navigate, comprehensive, first botanically authoritative illustrated guide to identifying Chinese materia medica is well suited for those with or without botanical identification training. The authors emphasise the need for this book in light of the development of a global market for Chinese herbs and the concerns this may entail. With Chinese medicine relying on the use of formulas containing many individual herbs, correct identification is essential for efficacy and safety. Proof of identity is a prerequisite for clinical trials into herbal medicine. Sustainable methods of growing and harvesting plants will lead to more reliable supply and conservation of wild species. The use of unofficial substitutes and adulterants has become a big issue, especially high-value drugs that may be substituted for similar looking but less potent alternatives. An example is Chuan Bei Mu (Fritillariae Cirrhosae Bulbus), which is victim to frequent substitution due to its high market price. The largest bulbs that fetch the best prices have been wild-harvested, with five of the official species used now becoming threatened. This has caused widespread substitution and adulteration using similar looking bulbs of other species in the genus. Over the past 15 years, Christine Leon, a medical botanist specialising in Chinese medicinal plants based at the Royal Botanic Gardens, Kew and Prof. Lin Yu-Lin, a specialist on the identification of Chinese medicinal plants, have been collecting specimens throughout China, using verified species to create typical TCM reference drugs, prepared according to traditional methods. Chinese Medicinal Plants, Herbal Drugs and Substitutes includes 226 herbs (in their crude and processed forms) and the morphological identification of their source plants. It also includes comparative identifications of more than 150 unofficial substitute and adulterant species. The book is beautifully presented with high-resolution photographs. The herbal entries are arranged by colour-coded groups reflecting their plant parts (rhizomes, roots, tubers and bulbs; aerial parts and whole plants; stems and woods; stem barks and root barks; leaves; flowers and flower parts; and fruits, seeds and other fruit parts). Plant descriptions are given for official species and substitutes, with details on the harvesting, source and natural range, conservation status, the number of wild Chinese species, and up-to-date taxonomy and nomenclature for Latin scientific names. Accompanying this is the derivative drug morphology, showing crude and processed forms, along with drug common names, properties and uses, and toxicity rating. Guidance is given on when to use laboratorybased methods to improve identification robustness. I really love this book. It will serve me well to identify potential adulterants in my dispensary, but it may also come in very useful should I be lucky enough one day to wonder around the wild in China. While familiar with the appearance of some plants I manage to grow in the garden I would easily walk right past most of the Chinese materia medica! So a great thank-you to Christine Leon and Prof. Lin Yu-Lin for providing such a great resource, a must for herbal dispensers and practitioners, TCM traders, researchers and those involved in the cultivation and sustainable supply of herbs. The Lantern 43

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