8 Functions of Qi & Clinical Practice Liver Qi Disharmonies 1. What is the Qi mechanism around the diagnosis of Liver Qi Rising? Already, our diagnosis, the diagnosis any practitioner might make, uses one of the functions of the 8 Functions of Qi. The Qi we are attributing to the Liver is a Qi that must move and wants to move, but because it has more vitality or pressure, the up nature is easily in excess and the down nature is easily in deficiency. When too agitated, the Yang or Up nature of the Liver Qi rises into the head, creating a problem of too much Raising. With too much Raising into the head, there is now an Excess of Gathered Qi as a result of the Raising, not as the source problem itself. The moment there is too much Raising and Gathering in the top of the body, we must immediately look to the bottom of the body to see if there are opposite symptoms of not Enough Lowering or Qi unable to Gather. This will help us understand whether it is a Yang-Yang problem or a Yang-Yin problem. Aside from the ringing in the ears, red eyes, irritability, and insomnia, do we have: 1. swollen and red hands and feet, distaste for socks or pants, constipation and manic behavior; or 2. poor circulation to the feet, wants pants and socks but dislikes sleeves or coat, diarrhea, exhaustion but unable to sleep. In the first circumstance of Yang manifesting in a Yang way, our treatment cannot first do channel movement or balancing, as the Qi is in Excess everywhere. Why would we want to pull down the Excess in the head into the feet that are already Replete with Qi, red and full, possibly cracked and dry from the heat? We would want to first Disperse the Gathered, give an Exit to the Excess, then counteract the over- Raising with Lowering. But we are not finished yet--this is internal medicine and we must look at not just at the Liver Qi itself, but the repercussions of the Liver Qi elsewhere in our cycle of disharmony. We must treat the Spleen's diarrhea or Stomach's constipation because the Liver controls the Spleen/Stomach; we must treat the Heart's insomnia due to being harrassed by its mother the Liver. Thus our point protocol for this issue called too much Raising creating attendant Gathering might be: 1. LI11 to first directly Disperse heat and vent the body; 2. Once that is accomplished and they seem less reactive, possibly GB41 to drain further by first agitating and then Exiting the Qi--we watch the breath fill and possibly hold as we stimulate, then look ats@traditionalstudies.org page 1 of 8 www.traditionalstudies.org
for a big exhale and dropping of body weight on the table as we italics the needle out of the point. This choice is a risk and may not be appropriate! However, it can be very effective in taking out the temple manifestations of the Raised and Gathered Qi, such as one sided headache, loud tinnitus, constant moving of the head back and forth...; 3. Use LR03 to Lower down the channel, ridding the head of the stuck Raising, focused on channel work to connect with the excess above and then balance it down but always with an eye to Drain or Exit Qi--we want to not just see a body readjustment or weight shift on the table, but a feeling of calmness or even cool sensation on the surface of the body; 4. For Stomach Qi unable to Lower, Daoist Zangfu Bodywork or needling at REN14, REN13, ST20, ST21, but I only use these if there was already an acute attack on the Stomach causing burping, acid regurgitation, foul breath, etc. Otherwise I address the constipation with SP15 and the lowering of the Qi with ST44. 5. Addressing the Heart involves making a decision based not on theory but on what has happened tangibly on the table so far: we have to choose between needling directly at the head but risking reagitating any Qi still Gathered there (Qi work at DU20, Qi or heavy italics needle at DU24, thumb or retained needle while rocking the body at EP), or work from the Heart points at the wrist (I needle where it is tender to stimulate or non-tender to anchor and not by location though they often match) or LR03 through to KD01 then press on KD01 to the needle tip or Four Gates with retention (if there is an obvious emotional component then this comes to forefront). 6. Finish with Rocking the body or leg traction to accentuate the overall Lowering of the Treatment. In the second instance where we have a Yang illness creating a Yin Imbalance below, we diagnose as the Liver Qi is too Raised, and this is not letting the Yin within the channels Descend properly. We thus have the cold or lack of heat below, diarrhea, and insomnia marked with feeling exhausted in the day. At this point, simply Dispersing the Qi first would also disperse the lack of Qi below because it is all up in the head, and our patient is agitated but Yin weak underneath the veneer of Yang symptoms. So our protocol has to first balance out the channel, creating an Exit or Lower what is Too Raised, then Disperse any Excess, then address the deficiency of Spleen (which is manifesting as unable to Raise and unable to Gather), then address the deficiency of the Heart (which is the Shen being too Dispersed ats@traditionalstudies.org page 2 of 8 www.traditionalstudies.org
and unable to Gather). This might be: 1. GB41 if there is an intense headache at the moment, otherwise LR03 is the most important point and could theoretically be manipulated for its channel, then point, then to KD01 to do everything we need to balance the channel, disperse the excess, Lift the Spleen, and Gather the Shen all at one spot. 2. Add LR03 or leave it retained from step #01, then manipulate its point function or Disperse LI11 depending on the intensity of the heat. 3. Slowly Italics Raise the Qi from LR03 to the lower abdomen with the leg pulled out to the side to encourage it to not move past the lower abdomen. However, for Spleen Qi unable to Rise leading to diarrhea, I use ST25 locally, ST37 for the channel, finishing this sequence with ST36 for the point function to warm the lower abdomen. 4. To nourish the Heart, direct work on the head as before is excellent, but I tend to use the wrist primarily in this exhausted condition as I will finish with Qi work on the head and then body rocking. In these two situations, we addressed the mechanical body but did not factor in if there are External Qi's or Internal Emotions spiking the flow of Qi. Is there damp creating vertigo and dizziness? Is the tongue a thick greasy coating? Is there Fire that is cracking the lips as well as creating problems of the gums or the eyes or the Shen? Are they belligerent on our table meaning the first needles need to be chosen that they will not further anger our patient? Or simply impatient and wanting us to 'get on with it' instead of all this question asking? These two individual situations can also be combined together for a synergistic effect on the Raising that will ignore or be aggravated by a Fixed Protocol Treatment if we do not adapt to it. We adapt by perhaps adding or removing points from our previous Best Choices, but usually it means we vary our order of treatment and/or bodywork first acupuncture second or versa vice. At this point, to be completely effective, we need to look at who they are as a person constitutionally and at this moment on the table, as well as factor in if it is Spring (more agitated Qi), Summer (possibly more exhausted Yin Heart from heat and sweating), Long Summer (damp in the spleen due to the weather or the constant imbibing of cold fluids...). However, if we lay this all out ahead of time in neat protocols, we will find that we are always ats@traditionalstudies.org page 3 of 8 www.traditionalstudies.org
less than 50% tangibly effective as we are no longer looking at the situation and person in front of us at this moment and making changes and choices based on reality instead of theory. As an aside before we move on from Liver Yang Rising, if it is so extreme that all Qi is pulled upwards (all being a completely incorrect term, as it is a 'relative all' not definitive all), then we end up with or Sudden Reversal in which the limbs all go cold not due to lack of Yang but due to constrained liver Qi. If a person with Liver Yang Rising as a constant state is hit by a sudden Excess of Anger or Pernicious Wind (like the Santa Ana's or Mistral Winds), they are in a prime position to have what western medicine calls a CVA, or what we call Struck by Wind. The skill of diagnosis is to Factor In and then Rule Out. 2. What is the Qi mechanism behind Liver Yin not nourishing the tendons? By nature it does imply a primary imbalance of Raising and Lowering, as that is the nature of Liver Qi within its Qi moving all directions at all times. This time, the classic diagnosis does not already give us an answer on direction, but the classic symptom does. By saying Liver Yin is not nourishing the tendons, we are saying that the tendons are tight, pulling at the joints and suffering cramps in the belly of the muscles. The place of cramps is the lower limbs, most often the calves or feet. Thus, as we know Liver Qi naturally rises and they are experiencing cramps in the middle of the night, we can understand that it is an issue of the Liver Yin Qi not Lowering in a sufficient force/quantity to nourish the tendons and muscles, leading them to first be starved and then spasm in response to the poor flow. We also know that Not Nourishing the Tendons is a progressed symptom from Liver Blood Deficiency, which is not that they are necessarily Blood Deficient overall, but that the agitation of the Liver Qi does not allow the Blood to be housed or Stored in the Liver. This automatically tells us the Qi disharmony is keeping the Gathering mechanism of the liver from taking in and holding onto the Blood as it should. But again, we must decide if this is a Yin-Yang problem or a Yin-Yin problem. Aside from the cramping in the middle of the night, do we have: 1. eyes wide open at night, but is constantly nodding off during the day; mouth and tongue ulcers; heat at night that the legs wish to be stuck out and possibly night sweats; or 2. insomnia with exhaustion day and night but unable to enter into the sleep state or sleep but waking unrefreshed; no ulcers but perhaps gums that bleed or other signs of mild heat above; obvious cold from ats@traditionalstudies.org page 4 of 8 www.traditionalstudies.org
the knees down, particularly in the feet. In the first circumstance of Yin manifesting in a Yang way, our treatment has to factor where they are at the moment of treatment. Often times these people have Raising Qi issues, but not in the way we think of as Up and Down. If there is a central point of gravity to Qi, like that point in the inflated balloon from which force is going in all directions, from the center of the universe from which all is eminating away from, the problem for these patients is the Liver Qi has Raised away from that gravitational center, not as a continual push but as a separation or loss of harmony. In the Shanghanlun, Zhang Zhongjing describes a similar phenomenon of Yin and Yang as, or the Ying Qi and Wei Qi have lost their harmony. This is not exclusive or limited to Ying and Wei Qi, but can be a reality for the Yin and Yang of any Qi--in this case the Liver Yin and Yang Qis. With this separation and Raised or Floating Liver Qi, the patient is often very reactive, senstitive to our words, our needles, any stimulation of any kind. Not recognizing this, we can end up with a crying or overwhelmed patient. Thus, our entry into the treatment with a Liver Yin-Yang pattern must be carefully chosen and non-disruptive if we see this in the Shen via the eyes and their demeanor. Combing, Tracing, physical touch regrounding the Qi and purposely choosing a first needle in an area with little sensitivity or with an anchoring function, barely manipulated and retained with no obvious sensation to the patient is often the best first step in. However, the patient might just want a treatment to get better, and losing precious time like this is wasting time for our patient. Everything must be decided by what we are looking at. And if we are looking at a body free of emotion, Pernicious Influence and Celestial Effect with this type of Qi Disharmony, then we know we will address the Liver Qi, the Heart Qi and the Kidney Qi instead of the Spleen Qi unless there is an obvious need to treat it. And thus a potential protocol might be: 1. Comb down the body, noting the tightness around the eyes, intercostal tightness, then tenderness down the Yin channels of the legs; 2. LI11 gently needled with italics out of the body, needle retained, followed by LR05 gently needled with italics into the body and retained. I am using these points to Open and Disperse the Yang with the upper points and Lower and Gather the Yin with Lower Points. Note this is a variation of the Four Gates, in which we are accessing Gates closer to the body but on the same channels. It also allows us to accomplish a calming and cooling of the Qi with less possibility of an emotional response due to the stronger sensations created by the more distal classic points. In short, ats@traditionalstudies.org page 5 of 8 www.traditionalstudies.org
we have more physical depth to work with, meaning more latitude for manipulation without a sudden spiking of sensation. We are only human! 3. Needle or use thumb pressure (I use thumb pressure with a slow but steady increase of pressure followed by a much slower release to create an Opening Response throughout the chest cavity) first at LR14 then LR13. I often repeat LR14 a few times. The hope is that by first Opening the Four Gates alternative, then Opening the Chest, the liver Qi gently spreads with more fullness to the extremities. 4. Remove needles, re-rub down body, then gently needle LR03 so it is full and awake but not overwhelming, then needle a Heart point at the wrist-- HT05 liberally located is my favorite. I use a pattern of In-In-In then a steady Out, which means I am Gathering Gathering Gathering the Yin, then Lowering any Excess trapped in the channel above to balance out the Qi of the channel. 5. In complete honesty, this person would leave my clinic with herbs to clear Kidney Heat and Heart Heat to clear the mouth ulcers and the night heat, giving me more time to finish on putting them into a deep place by rocking the abdomen and working down the legs to fill the feet, finishing with leg traction to pull Qi out of the head. However, as I have already needled LR03 and retained, I would certainly be sure to work KD01 to the needle tip. If I had time and/or did not have the luxury of herbs, I would needle KDO3 and a liberally located KD07/ SP06 to benefit the Yin. Please note the location of BL60 on the other side of KDO3 and its attending functions. 6. As just mentioned, I end with Rocking and leg traction to really cement my Exiting of the Liver Qi, Gathering the Shen via the Heart, and balancing of the Raising and Lowering of the Kidney Qi. This last point bears a final comment. Throughout the final portion of the treatment when we are 'working on Kidney Qi', we are simply balancing Fire and Water. I say simply, but this sounds very esoteric. It means we are Lowering the Yin Fire down through the channel so it is Dispersed comparatively, and we are Raising up the Yang Water through the channel. Yang Water means warming the Kidney Qi (and thus Mingmen fire) so the water can move throughout the system. In the second instance of a Liver Qi Yin-Yin problem, we need to look at the emotionality again. ats@traditionalstudies.org page 6 of 8 www.traditionalstudies.org
Sensitive to the point of being overwhelmed? Or so tired that there is little Qi overall to work with that results may not be very effective even though they will thank us for our treatment and assure us they feel better? We do know that there is severe leg cramping at night, milder cramping happening during the day, insomnia with utter exhaustion, and cold in the limbs, but especially the lower limbs. The Yin channels down the shins are painful to the touch, the feet cramp easily upon manipulation. Thus we need to reprioritize our treatment. The actual 'Liver' part of the treatment is last, not first. 1. Using Pushing techniques to Push the Blood down the Legs, Lowering the Blood and thus the Qi down back to the feet; 2. GB34 is then needled bilaterally, each to elicit a sensation of Qi Entering the foot, felt as electricity to the patient; 3. ST36 is then needled first for the channel to also create Qi Entering the feet, then for the point function to Gather Qi in the lower abdomen, warming the area. 4. Patient turns prone, Deep Qi is done on the Upper Jiao, focusing first on the region of Heart Shu point (we stand at head of patient); then moving to the side so we can continue this region while one hand now does Deep Qi at Liver Shu point. Pattern is first Gathering, then Dispersing, then Gathering. 5. Hands come down to DU04 and the Kidney Shu Points, Rocking and Gathering Qi to the area, then having one hand work down the leg with the Rocking motion before returning to Mingmen for a committed Gathering Effort; 6. Patient returns to Supine, a gentle alternative Four Gates is used, needling HT05 above and LR03 below. Once in and awake without being too much, we Rock the navel and lower jiao to warm and Gather. 7. Needles are removed, and either finish with DU20 and the navel; or leg traction to anchor downwards; or first one then the other if there is time. ats@traditionalstudies.org page 7 of 8 www.traditionalstudies.org
Note that we have not factored in the issue at all of our patient being male or female. A female patient with Liver not Nourishing the Tendons, which is a step beyond Liver Blood Deficiency is going to have a disharmony of the menses. Whether their menses is cold, crampy, clotty and painful accompanied by constipation then diarrhea; or they experience breast tenderness, are irritable and moody, have spotty and/or clotty flow and experience 5 centers heat or flashes will help diagnose Yin-Yin or Yin-Yang and affect point choices based on whether the patient is male or female. Finding the right protocol is a bit of a moving target because of all the influences that exist, BUT if we can view them from within the classical paradigm of Qi, then we are atleast 'inside the car' and thus in balance with what is happening. As before, is there External Pathogenic Influence hindering or exacerbating the negative flow of Qi? Did we disregard that it is winter and in our desire to nourish the water and build their mingmen by working on the feet and left them with no socks and getting physically colder and colder from the knee down because of the temperature of the room? What is happening emotionally? Frustration, insomnia, and frustration due to not being able to sleep on top of the Frustration and insomnia are powerful forces constraining the Liver Qi from spreading through the extremities and thus being balanced. All of these things must be considered and factored in, but only after our Task Saturation Level has reached a place where we are able to see their influences without becoming overwhelmed or forgetting our person on the table. ats@traditionalstudies.org page 8 of 8 www.traditionalstudies.org