History and background of traditional Chinese medicine in neurological conditions

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1 History and background of traditional Chinese medicine in neurological conditions

CHAPTER CONTENTS

Historical development 4
Zang Fu, the origins of physiology 5

Heart (Xin) 6
Lungs (Fei) 7
Liver (Gan) 8
Spleen (Pi) 9
Kidney (Shen) 10
Pericardium (Xin Bao) 12
Fu organs 12

Small Intestine (Xiao Chang) 12
Large Intestine (Da Chang) 12
Gall Bladder (Dan) 13
Stomach (Wei) 13
Urinary Bladder (Pang Guan) 14
Sanjiao 14
Zang Fu in neurology 15

The Brain (Nao) 15
Introducing the important syndromes 15

Bi syndrome 15

Wind invasion 16
Wind Bi suggested points 17
Cold invasion 17
Cold Bi suggested points 17
Damp invasion 17
Damp Bi suggested points 17
Heat Bi 17
Heat Bi suggested points 17
Bony Bi 18
Bi syndrome associated with Zang Fu organs 18

Tendon/Liver Bi 18
Vascular/Heart Bi 19
Muscle/Spleen Bi 19
Skin/Lung Bi 19
Bone/Kidney Bi 20
Wei Bi or atrophy syndrome 20

Common TCM syndromes associated with Wei Bi 20
Feng syndromes 22
Summary 22

KEY POINTS

• The concept of ‘neurology’ is a relatively modern one, with no real place in traditional Chinese medicine (TCM). This is only partly because there is no historical concept of the ‘brain’ in TCM physiology.
• There have been many schools of Chinese medicine: some included ideas that we would recognize as ‘neurology’, whereas others did not.
• The ideas informing the Zang Fu consider different emotions, understanding that they may have a pathogenic influence, and consequently attribute them to appropriate organs.
• There are three syndrome groups that are particularly concerned with neurological symptoms: Bi, Wei and Feng.
• The Bi subgroups are usually defined by the type of Pathogenic invasion but also by the tissue most affected.
• Wei or atrophy syndromes are characterized by limb weakness.
• Feng syndromes are associated with muscle tremor or spasm.
• Acupuncture can often be effective in treating Wei syndromes in their early and middle stages.

Historical development

The combination of the ancient art of acupuncture, part of the equally venerable tradition of Chinese medicine, and what is perceived by Western medicine at least as the most modern of sciences, neurology, seems at first to be quite a challenge. On the one hand we have a tradition of consensus medicine where ideas and theories were handed down from father to son or from master to apprentice and, while there was a great deal of documented debate, no reductionist analysis has been recorded.

On the other hand, the type of evidence required for general acceptance of any medical intervention in our current society, the controlled clinical trial, is relatively new in the world of acupuncture and, while there is an explosion of work in the field of acupuncture for pain control, neurological problems have, thus far, been mostly ignored.

One reason for this lies within the relatively alien ideology and structure of Chinese medicine, but equal blame lies within the fundamental ideologies of Western medicine. Neurology is a complex branch of medicine but tends to be described in two dimensions, being either ‘on’ or ‘off’, like an electrical circuit.

Another very good reason for the relative lack of research into acupuncture and neurological conditions is the complexity of the symptomatology and sheer difficulty of isolating a homogeneous patient group of sufficient numbers to be accepted as a definitive randomized controlled clinical trial.

The history of acupuncture is a long and complex one. It is not necessary, perhaps, to understand every detail but it is very useful to understand how the thoughts of the ancient sages can inform the modern practice of acupuncture. There is an inherent difficulty even in the preceding statement in that actually knowing what is meant by some of the terms is very difficult. Terms gain their meaning through context and the historical contextual background is further complicated by influential modern schools of thought. For instance, the teachings of Worsley, an originator of much of the modern Five-Element theory, lay great emphasis on the ‘Spirit’ of the acupuncture point, even though there is little agreement among Chinese scholars as to what is meant by the term ‘Spirit’ or even what exactly was meant by the names of the points. The possibility for confusion is built in from the start of recorded ideas.

While many Chinese characters can have more than one English equivalent, a majority are well suited by one term. Most sources translate Shen as Spirit, so the question is, what do we really mean by this term? The Chinese context of Spirit is an integral part of the paradigm and, as difficult as it may be to understand, we must make the effort. Otherwise, we only superimpose our own cultural attitudes and beliefs on Chinese medicine.

The seminal written accounts of Chinese medicine theories are over 1000 years old and even in our own culture we are aware of the subtle changes in meaning of seemingly simple words and concepts. The word ‘gay’ would be a good example; it raises no eyebrows when it occurs in the writings of Jane Austen, for example, but when included in today’s prose it would be interpreted rather differently.

Chinese medicine has been used over many hundreds of years. It has a long recorded history: the first written records, the Huang Di Nei Jing, date from about 200 bc. It has evolved as part of the traditional Chinese medical paradigm, together with Chinese herbal medicine. The origins of traditional Chinese medicine (TCM) are closely associated with demonology and ancestor worship, this being usefully defined as a ritualized propitiation and, possibly, invocation of dead relatives. Ancestor worship is firmly based on the belief that the spirits of the dead continue to dwell in the natural world, and have the power to influence the fortune and fate of the living.

Although mysterious forces such as gods, demons or ancestors were originally called on to provide explanations for the phenomena of the perceptible world, a great deal of the original Chinese philosophy underpinning TCM was the attempt to explain these phenomena as natural occurrences. Medicine and religion were closely linked in the early history of the area now known as China and cultural changes were reflected in the accounts we have of medical practices.

In the sense that what you think and believe about what is happening to you will affect how you respond psychologically to any illness, the original shamanistic ideas must have had a huge effect on the recovery of patients treated in the Shang and early Zhou dynasties. Nowadays this might well be defined as merely a placebo response but nobody will deny that a placebo response can nonetheless be powerful. A white-coated doctor in an NHS surgery with a stethoscope is still a powerful placebo!

The history of acupuncture cannot be divorced from the history of Chinese culture. The Middle and Late Zhou dynasties were particularly important and much of the theory accepted today was first recorded then. Various theories were widely discussed and some gained temporary dominance.

It would be fair to say that the origins of Chinese medicine are obscure. Some of the great heroes, Fu Xi, Shen Nong and Huang Di, were said to have lived in the Shang dynasty but were not actually written about until much later.

The recorded history of acupuncture starts from about 1520 bc and comes nearly to an end in 1911. It is useful to remind ourselves of this long history and vast wealth of empirical evidence. It is also interesting to see where theories relating to what we now understand as neurological problems fit in to the overall picture of Zang Fu physiology.

Zang Fu, the origins of physiology

The Zang Fu organs are perhaps the most fascinating aspect of TCM theory. The ancient Chinese medical practitioners did not have the advantage of meticulous dissection and careful histological studies to help them understand the body. Gross functions could be undderstood but the complexity and subtlety of human physiology could only be guessed at by observation and trial and error when administering herbs or acupuncture. Nonetheless, when used to define treatment protocols the observations made in the past still appear quite valid.

Many of these ideas originated in a martial society and the metaphors for function and control tend to sound like elements of military campaign. It will be useful to describe each organ in turn and discuss the links to the others. Disease patterns generally involve more than one organ at a time, and sometimes these indicate where there may be relevance to neurological conditions. The primary focus may be identifiable from the associated symptoms, but unless the practitioner has a good working knowledge of all the Zang Fu characteristics and connections, the secondary foci and possibly the origins of the problem may be hard to decide. Chinese medicine defines disease as disorders within these Zang Fu relationships rather than as a single failing organ. It is difficult to separate Western ideas of organ function from the Chinese concepts but it is important to do so before it is possible to see the patterns. Many of the functions seem arbitrary to a Western eye but the fundamental theories informing them are often very logical.

Firstly we will give a quick explanation of the major functions of the Zang Fu organs. These functions are seen as inextricably linked and interdependent and lead to TCM diagnoses of some complexity. We are indebted to Worsley, an influential Western teacher and practitioner (and also originally a physiotherapist) for some useful ideas about the Zang Fu organs in general [1]. Most texts offer two lists of six pairs of organs, some functions of which correspond to those understood by Western medicine and some which plainly do not (Table 1.1).

Table 1.1 Zang Fu organs

Zang organs (Yin) Fu organs (Yang)
Heart (Xin) Small Intestine (Xiao Chang)
Lungs (Fei) Large Intestine (Da Chang)
Liver (Gan) Gall Bladder (Dan)
Spleen (Pi) Stomach (Wei)
Kidney (Shen) Urinary Bladder (Pang Guan)
Pericardium (Xin Bao) Sanjiao
(Extra Uterus) (Extra Brain)

However, Worsley suggested that the Zang Fu should be considered as 10 organs and two functions. That is very helpful to those of us working with neurological conditions. The two he selects as functions, the Sanjiao and the Pericardium, have extended influence throughout the body physiology. The Sanjiao, or, as it is often known, the Triple Heater, has a wide-ranging function particularly concerned with the circulation of fluid throughout the body and described as being responsible for the opening-up of passages and general irrigation. The fluid thus regulated is associated with both the interstitial spaces and the major organs.

The Pericardium is clearly defined in orthodox modern Chinese texts as the Heart Protector and little more. However, since it is so intimately connected to the Heart it takes on some of the characteristics of that organ.

Heart (Xin)

The Heart is the ‘emperor’ within the body and as such has control over everything. It is said to govern all the other organs and is pictured as a benevolent and enlightened ruler. It regulates the flow of Blood and Qi and governs the Blood in two ways. TCM sources see it as a pump which is responsible for the circulation of blood in the vessels, as understood in Western medicine. This makes it responsible for the innate health of the vessels too. The Heart propels the Blood through the tissues, communicating with every part and suffusing the body with consciousness and feeling.

The relationship between the Heart and the Blood is important and determines the strength of the constitution of an individual. Tongue diagnosis can give an indication of the relative strength of the constitution. The presence of a clear crack down the centre of the tongue would alert a TCM practitioner to the possibility of a deficiency of Heart Qi or energy. The state of the blood vessels and general circulation reflects the strength of the Heart Qi, as does the condition of the Heart pulse. Since the Heart controls the blood vessels and circulation, deficient Heart energy leads to a very noticeable bright, white complexion, often seen in Parkinson’s disease patients.

Since Blood and Body Fluids are thought to have a common origin, sweat is considered to be controlled by the Heart and to be found in the spaces just under the skin. If there is a lack of fluid within the circulation it can be replenished from this source. If there is too much heat within the body it is ‘steamed off’ and discharged through the pores. Whatever the true physiology, Heart points appear to have a clinical influence on otherwise unexplained hyperhydrosis problems.

In addition to the clear links with the mechanism of circulation, the Heart also houses the Mind or Shen. This is where the psychological influences become apparent, affecting five functions, all of which are involved in our response to any neurological illness:

1. mental activity
2. consciousness
3. memory
4. thinking
5. sleep.

The term ‘Shen’ is also sometimes used to indicate vitality. The involvement of the Heart with all of the above means that it must be considered when treating mental illness and, indeed, Heart 7, Shenmen, is a useful point to calm and relax a patient, or to treat insomnia or depression. ‘Shenmen’ translates as ‘Gateway to the Spirit’. The Heart has a strong influence over sleep patterns. If the Heart is deficient in energy the mind is said to have no residence and it will float at night, causing disturbed sleep or excessive dreaming, should sleep come at all.

The connection between the Heart and the emotions is well understood in folk legend in most countries but there is little scientific proof that this could have any foundation. However there are some interesting ideas in a paper by Rosen [2], where the internal memory of the heart cells with regard to physiological process is recognized and discussed. It is suggested that the heart does remember, ‘making use of mechanisms similar to those in other systems that manifest memory, the brain, the gastrointestinal tract and the immune system’.

The emotion of joy is most closely associated with the Heart. Joy is said to slow down the Qi and affects the Heart in this way. Since the Heart controls the Mind or Spirit and hence the emotions, it follows that an excess, i.e. over-joy or extreme anxiety, will damage the balance of Qi in this Zang Fu organ. Excess joy is said to disturb the Xin Qi so much that the Shen becomes confused and scattered. Over-joy is quite a violent emotion and in TCM a sudden laughing fit is thought to be able to trigger a heart attack. The effect of emotional lability, often found in multiple sclerosis (MS), mimics this imbalance.

The concept of a ‘broken heart’ is far from alien to TCM. When the Heart is overwhelmed by strong emotion, usually in this case shock or sorrow, the Shen will be able to break free, thinking becomes disordered and confused and the resulting anxiety will be evident in the abnormal circulation. The impaired circulation will lead to stagnation of the Blood, blood pressure decreases and the patient will show signs of heart disease, angina or chest pain. Shock and fright have an opposite effect on the Heart and are said to cause the Shen to contract.

The most extreme disharmonies of the emotions arise from imbalances within Xin (Heart) and Gan (Liver) and it is sometimes difficult to differentiate between a lack of joie de vivre caused by Xin deficiency and the sorrow and melancholy caused by depression of Gan Qi.

A further disharmony that will give rise to confusing symptoms is that between the Heart and the Kidney. This is often considered in terms of Yin and Yang or Fire and Water. The water aspect of the Kidneys must control the Fire aspect of the Heart, but if the Yin aspect of the Kidney energy is deficient then it will not control and cool the Heart Fire, which then flares up, causing symptoms like insomnia and irritability.

The Heart is said to be the most important Zang Fu organ but, although it is intimately concerned with feelings and emotions, it has little or no influence on the movements and physical activities that we understand to be controlled by the brain. The Governing Vessel, or Du meridian, in its anterior pathway passes through the Heart and is said to penetrate the brain posteriorly at GV 16 Fengfu.

Since the Du meridian is also closely associated with the Kidneys at Du 4 or Mingmen, both these points can be used to influence Heart function (Figure 1.1).

image

Figure 1.1 • Du meridian: Marrow and Heart linked.

A useful comparison with the TCM function of the Heart is with that of the cerebral cortex, an integrative function, giving rise to the capacity for individual thought and memory. This is further expressed through speech, the voice and facial expression. The intimate link with the Pericardium means that some of the Heart functions can be influenced by treating points on the Pericardium meridian. It is commonly held that this is a ‘gentler’ form of treatment.

Lungs (Fei)

The Lung is characterized as a diplomatic foreign minister, conducting affairs of state and determining foreign boundaries, thus effectively governing the relationship between the inside and outside of the body. The Lungs are the most external of all the organs, having direct contact with the outer air. Because the Lung is so susceptible to Pathogenic invasion it is sometimes referred to as the ‘tender organ’.

The Lungs control respiration and are responsible for the intake of clean air, which they convert into ‘Clear Qi’. Together with the Qi produced from substances that are eaten and drunk, this goes to make up the Post Heaven or renewable Qi within the body. The rhythm of the Lungs sets the rate for all other body functions, starting with the first breath taken by the newborn baby. The clean air or Qi from the Lungs condenses into fluid and passes down through the Sanjiao to the Kidneys, where it is heated, vaporizes and ascends to the Lungs again, forming a sort of energy cycle effectively controlling water circulation within the body (Figure 1.2).

image

Figure 1.2 • Jin Ye circulation.

(Reproduced with permission from Hopwood V. Acupuncture in Physiotherapy. Oxford: Butterworth Heinemann: 2004.)

The emptying of the Lungs, expiration, slows the movement of Qi whereas the act of filling them, inspiration, speeds it up.

Some teachers compare the activity of the lungs to that of the parasympathetic system, an inhibitory action, but it could be argued that they are just as likely to be involved in a sympathetic mode. Either way, they may be peripherally affected when central nervous system control is damaged in any neurological condition.

The Lung controls the condition of the hair and also the state of the pores. The skin is sometimes referred to as the ‘third lung’. If the skin is in poor condition the pores may remain more open than usual, allowing the invasion of exogenous pathogens. The Lung is also said to produce and control the Wei Qi, or Defensive Qi. This is the first line of defence against Pathogenic invasion of the body and circulates in the spaces just underneath the skin. The link with the Kidneys and water circulation coupled with the control of the pore size means that it also has an effect on sweating, along with the Heart.

The Lung opens into the nose, and is vulnerable to the External Pathogens Wind and Cold. The common cold is said to be an invasion of a combination of Wind and Cold. The sense of smell and the loudness of the voice are dependent on Lung health. A husky voice and a runny or blocked nose are therefore not surprising as common cold symptoms.

The Lung houses the Corporeal Soul or Hun. It is particularly sensitive to grief or sadness, and often affected by bereavement. It is associated with the pain of loss, of letting go, sorrow, loneliness, anxiety and melancholy. The effect of sorrow on the Lung can result in a lack of desire to face the world. Sadness of this kind tends to produce stagnation of Qi in the chest and this in turns inhibits the function of both the Lungs and the Heart. This could result in the subsequent stagnation of Blood throughout the body.

Treatment of LU 7 or Lieque can have a powerful release effect in constrained emotional conditions. The link between sorrow and the function of the Lung has been suggested as the reason for many recently bereaved elderly patients contracting fatal chest infections while still grieving.

Liver (Gan)

The Liver is often characterized as a General, directing his troops; this is a useful analogy because it allows us to think of this organ as concerned in the balance of energies. The Liver has a controlling action on the circulation of blood but this activity depends on whether the body is at rest or active. The Liver sends blood through the vessels when the body is in movement but gathers it back into itself and stores it when at rest.

Some authorities describe this as a rhythm, similar to that of the Lungs, but differing in that it is a voluntary rhythm depending on the circumstances [3]. Ideas of fight and flight, as understood in Western neurology, are clearly appropriate here.

The Liver is responsible for the smooth movement of Qi and body fluids throughout the body. The Liver is involved in the process of digestion, providing energy for the transportation of the Gu Qi produced by the Stomach and Spleen. The Qi from each organ has a characteristic direction of flow, actually controlled by the Liver, ensuring the TCM physiological pathways. The Liver is the source of endurance in times of mental stress or physical exertion. If the Liver Qi is weak, one is easily exhausted, finding it difficult to get out of bed in the morning. Diseases such as MS are thought to attack and weaken Liver Qi.

Liver Qi should flow freely in all directions. If it is constrained it is said to invade the Stomach, Spleen or Lung. ‘Liver invading Spleen’ is fast becoming a common modern syndrome, perhaps because of the combined effect of unsuitable diet and stress on the liver triggering a chain reaction throughout the Zang Fu [4]. The Liver functions as a gentle regulator of the Spleen and Stomach and is thus a regulator of digestion. In addition, bile, under the control of the Liver, aids in the digestive process.

Storage of Blood is seen as integral to Liver function. The Liver releases blood for the start of menstruation and continues to do this regularly, in appropriate quantity, throughout the fertile life of the female. Menstrual problems, such as amenorrhoea and dysmenorrhoea, are primarily treated by restoring Liver function. The Liver has an influence on the even movement of Blood around the body in both sexes. Stagnation is often seen as a result of poor Liver function since Blood and Qi flow together and Qi is said to clear and smooth the channels to allow the accompanying Blood flow.

The Liver controls normal muscle tone in the body. Disturbance of this function leads to muscle tremor, twitching, spasm or even convulsions. This would be said to be the result of an ‘insufficiency of the Yin and Blood in the Liver’, resulting in malnutrition of the tissues. Many of the muscle impairments present in neurological disorders, such as tremor in Parkinson’s disease and progressive paralysis in MS, are associated with Liver Qi imbalance. The Liver is also said to influence the muscle tendons. The fingernails are considered by TCM to be extensions of the tendons; thus, dry, flaky and ridged nails are indicative of an energy deficiency in the Liver.

A link with the eye means that the condition of the Liver can also be detected through examination of the ‘white of the eye’. Conversely, it also means that Liver points can be used to treat eye problems, particularly LR 2 for problems of an inflammatory nature. The fluids most closely associated with the Liver, apart from Blood, are the tears. The syndrome ‘stirring of the inner Wind of the Liver’ can cause poor vision, night blindness and abnormal movements of the eye.

Failure of the free-flowing function of the Liver may be associated with both frustration and depression and outbursts of uncontrolled anger. The Liver requires a calm internal environment, with an even disposition. It is very sensitive to being obstructed in any way. It is interesting that the English language equates being ‘liverish’ with being irritable. The Hun or ethereal soul is housed in the Liver; it is injury to the Hun which causes insomnia, so Liver Qi stagnation in neurological diseases such as MS needs to be addressed to relieve insomnia.

Blazing Gan Fire is linked with severe and violent outbursts of rage. Feelings of irritation and moderate anger are also associated with Liver imbalance and often ascribed to deficient Liver Yin or hyperactive Liver Yang, both of which cause the even tenor of life to become a little more bumpy. Stagnation of the Liver Qi, often produced by anger, can also have a profound effect on the Stomach and Spleen Qi and disturb digestion.

Spleen (Pi)

The Spleen is an interesting organ from a TCM point of view but has never excited much enthusiasm in Western medicine. It occupies the very last pages in Gray’s Anatomy and has always been regarded as generally superfluous to requirements. Splenectomy is not regarded as a life-threatening situation, although antibiotics are required to maintain health afterwards.

The spleen is said to store blood and to have some blood-manufacturing properties but the important part played in the digestive process is not recognized in the West. Interestingly, it has been observed to increase in size during digestion, although no conclusions appear to have been drawn from this.

In TCM the Spleen is regarded as the minister of agriculture, able to control and regulate the production and distribution of essential nourishment. The Spleen is said to govern transformation and transportation. It is the main digestive organ in TCM and responsible, along with the Stomach, for the breaking down or transformation of ingested food and drink and its subsequent transportation to the other sites in the body where it will be utilized. The Spleen is said to incorporate and then distribute Nutritive Essence in order to diminish or augment body mass [5]. It is responsible for forming and reconstituting the internal milieu, gathering and holding together the substance of the body.

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