Monday, November 9, 2015


I recently received an email from a colleague asking for a help with a patient suffering from chronic fatigue syndrome.  The colleague was asking about the treatment principle to apply.  The patient obviously suffered from a deficiency of Zheng Qi, as all patients with chronic fatigue syndrome do.  But she also had frequent acute invasions of Wind.

The colleague was rightly following the principle that, in the presence of an acute invasion of Wind, one must expel pathogenic factors, in this case expelling Wind, and not tonify Zheng Qi.  In between invasions of Wind, the correct treatment principle is to tonify Zheng Qi, and this what the colleague was doing.

However, the problem was that the patient suffered from very frequent invasions of Wind, so that there was hardly any time to tonify Zheng Qi for a prolonged time.  She was using Yin Qiao San during the acute invasions of Wind and a Qi tonic to tonify Zheng Qi in between the acute attacks.

She wrote to me to ask whether taking a Qi tonic during an acute invasion of Wind could strengthen the pathogen.  She was also wondering whether one can go on taking Yin Qiao San for prolonged periods as the patient had times when she went from one acute illness to the next, so she could be taking Yin Qiao San for weeks, and my colleague was wondering whether this could deplete her Qi or Yin.

Her second question was whether taking a Qi tonic during an acute invasion of Wind could strengthen the pathogen.

I will try and answer here her questions.

1) Can one take a remedy that expels exterior Wind for prolonged periods?

The answer is basically: “no”.  Remedies that expel exterior Wind (such as Yin Qiao San) by definition should be taken only during an acute invasion of Wind for a few days.  After a few days or a week, either the exterior Wind has been expelled or the pathogenic factor has penetrated into the Interior at which time the patient needs a different treatment.

However, chronic fatigue syndrome presents a different situation and one that is not contemplated in Chinese books.  I have never seen a discussion of chronic fatigue syndrome in any Chinese book: indeed, a Chinese journal years ago published a translation of an article I wrote on chronic fatigue syndrome.

In my experience, chronic fatigue syndrome is characterized by a prolonged course of the disease with deficiency of Zheng Qi and frequent invasions of exterior Wind.  However, the exterior pathogen in such patients is “weak” and it is weak precisely because of the prolonged course of the disease and the prolonged deficiency of Zheng Qi.

So, in such cases, the patient may need to take a remedy that expels exterior Wind frequently, e.g. for a week every few weeks or so.  However, because the pathogen is weak, one can use a small dose such as for example only three tablets of Expel Wind-Heat a day.

2) Can tonifying the Zheng Qi also tonify an exterior pathogen?

Again, in theory “yes”.  However, again, chronic fatigue syndrome is an exception.  As the deficiency of Zheng Qi is very prolonged and the pathogen “weak”, during invasions of exterior Wind in chronic fatigue syndrome, I do occasionally combine expelling exterior Wind with Yin Qiao San with a Qi tonic, both in small doses.  For example, I might use 3 tablets of Qi tonic in the morning and 3 tablets of Yin Qiao San in the evening.

For a discussion of Chronic Fatigue Syndrome see chapter 41 of my book The Practice of Chinese Medicine, 2nd Edition.

Monday, October 5, 2015


The Nei Jing, and especially the Ling Shu, contains very many passages with instructions to acupuncturists as to how to needle. All these passages give instructions as to how to engage the Shen, Yi or Zhi (of the practitioner) when needling.

Just as a reminder, Yi is the mental faculty of the Spleen which refers to “focusing”, “attention”, “concentrating”, “idea”. Its character is based on the Heart radical which means that this mental faculty relies on the overlapping natures of Yi and Shen (and therefore Spleen and Heart).

意 Yi
心 Xin (heart)

Zhi of the Kidneys refers to “will power”, “intention”, “resolve”, “commitment” but also “memory”, “will”. Its character is based also on the heart radical together with the character for “Shi” which means scholar, soldier, gentleman, person trained in certain field, general, officer.

志 Zhi
士 Shi (scholar, soldier, gentleman, general, officer)

What is evident from all these passages is that the results one gets depend on the skill and sensitivity of the acupuncturist deriving from his or her Shen, Yi and Zhi. They are therefore very subjective: two acupuncturists may use the same points but the results may vary depending on the subjective application of the mental faculties of Shen, Yi and Zhi.

Ling Shu, chapter 1
“When holding the needle [literally “the Dao of holding the needle”], it should be held straight and not slanting to left or right. The [acupuncturist’s] Shen should be on the tip of the needle and his/her Yi on the disease.” Some translate the last few words as “the acupuncturist should concentrate his/her mind at the needle point and take good notice of the patient”. They therefore interpret the word bing, which means “disease”, as bing ren which means “patient”.1

Another source translates this as “When inserting the needle, the doctor should concentrate his mind on the patient.” Both these translations sound plausible but both miss the clear reference of the original to text to Shen and Yi as two separate mental faculties. Shen zai qiu hao, shu Yi bing zhe.2

Both these translations miss the beautiful idea that the “Shen should be on the needle and the Yi on the disease.” This makes complete sense if we consider that the Shen, besides cognition, is responsible for what we might call “muscle memory”. Shen, Yi and Shi, all three are responsible for memory but the Shen is responsible for “intrinsic” memory, i.e. for example remembering how to sew or ride a bike as opposed to remembering events, numbers, names, etc.

Thus, the Shen being on the tip of the needle refers to the skill, sensitivity and concentration of the acupuncturist. On the other hand, the Yi is responsible also for concentration, but also focusing, cognition, studying. That the Yi should be “on the disease” is a reference to the necessity of a laser-like diagnosis, pathology and treatment of the disease. Our acupuncturist’s skill would be for nothing if our diagnosis and treatment are wrong.

Ling Shu, chapter 9
“Concentrate the Shen on one point and the Zhi on the needle.” Notice the distinction between the Shen and the Zhi, similar to that between Shen and Yi of chapter 1. This distinction is completely lost in a modern Chinese translation: “Concentrate the attention and focus the whole mind on needling.”3

This statement is in the context of the description of the optimum conditions for needling a patient. “Acupuncturists should be in an isolated quite place, carefully observing the mental state [of the patient], close all doors and windows, tranquilize the mind, concentrate the attention.”

What they translate as “tranquilize the mind” is actually “so that Hun and Po are not scattered”; and what they translate as “concentrate the attention” is actually “focusing on Yi and concentrating the Shen”.

Ling Shu, chapter 8
The famous chapter 8 of the Ling Shu (entitled Ben Shen) is frequently quoted, especially its famous opening sentence. I would like to comment briefly on that sentence and propose a different translation of it.

The opening sentence of chapter 8 of the Ling Shu is: Fan ci zhi fa, xian bi ben yu shen 凡 刺 之 法 先 必 本 于 神 and the words mean literally “every needling’s method first must be rooted in Shen”. This sentence is usually translated as: “All treatment must be based on the Spirit”. The implication of this sentence is that all treatment must be based on the Spirit (of the patient), whatever interpretation we give to the word “Spirit”.

I propose an alternative translation with two important differences. Firstly, the text uses the word ci which means “to needle”, not “to treat”. If the text had meant to use the term “to treat”, it would have used the word zhi which does occur a lot in both the Su Wen and the Ling Shu. Thus, the first difference is that the first half of the sentence is “when needling” rather than “when treating”: this is an important difference.

The second difference is that the “Shen” referred to here may be interpreted as the Shen of the practitioner, not of the patient. Therefore, the whole sentence would mean: “When needling, one must first concentrate one’s mind [Shen]”. If that “Shen” is the Shen of the practitioner, then “Mind” would be a better translation here.

This interpretation is consistent with two factors. Firstly, the Ling Shu is very much an acupuncture text and therefore the reference to concentrating when needling makes sense. Secondly, the advice to concentrate and focus when needling is also found in many other places in the Nei Jing. Indeed, the word “shen” is even used occasionally to mean “needling sensation”. Chapter16 of the Su Wen says: “In Autumn needle the skin and the space between skin and muscles: stop when the needling sensation [shen] arrives.”

There are many passages in both the Ling Shu and Su Wen that stress the importance of concentrating one’s mind when needling. Indeed, chapter 25 of the Su Wen contains a sentence that is almost exactly the same as the opening sentence of the famous chapter 8 of the Ling Shu. Chapter 25 of the Su Wen contains this sentence: “fan ci zhi zhen, bi xian zhi shen”. 凡 刺 之 真必 先 治 神]. I would translate this so: “For reliable needling, one must first control one’s mind [shen].” Note the beautiful rhyming of “zhen” with “shen”.

The English translation of the Su Wen by Li Zhao Guo simply translates this sentence as “The key point for acupuncture is to pay full attention.”4 My interpretation is corroborated by the other paragraphs in that chapter which give advice as to how to practice needling. In fact, it says that the acupuncturist should not be distracted by people around or by any noise.

Unschuld, in his new translation of the Su Wen, translates this sentence as “For all piercing to be reliable, one must first regulate the spirit.”5 This translation would contradict mine but a footnote in the same book reports the interpretation of Wang Bing (the editor of the Nei Jing): “One must concentrate one’s mind and be calm without motion. This is the central point of piercing.”6 Notice that Unschuld says “piercing” and not “treating.”

Su Wen, chapter 54
This chapter has similar recommendations about concentrating while needling. It says: “Do not dare to be careless, as if one looked down into a deep abyss. The hand must be strong as if it held a tiger. The spirit [Shen] should not be confused by the multitude of things, that is have a tranquil mind [Zhi] and observe the patient, look neither to the left nor to the right.”7

After this passage, the text says that “one [the acupuncturist] must have a positive mind [Shen] by looking into the patient’s eyes and control his/her mind [Shen] so that Qi flows smoothly.”8

The modern Chinese translation of this passage is “To keep the mind [of the patient] concentrated means to prevent [the patient] from distracting his or her attention so as to make Qi flow smoothly.” The translator here takes the first reference to “shen” as the Shen of the patient while I interpret it as the Shen of the practitioner that must be concentrated.

Note how all meaning is lost when the Chinese medicine terms are translated. The distinction between Shen, Yi and Zhi when concentrating in needling is lost when these are translated as “attention”; or translating “so that Hun and Po are not scattered” as “tranquilizing the mind”; or translating “focusing on Yi and concentrating the Shen” as “concentrating the attention”; or translating the beautiful expression “the Shen on the tip of the needle and the Yi on the disease” as “when inserting the needle the doctor should concentrate his mind on the patient”; or translating “Jing-Shen not focused and Zhi and Yi not logical” as “cannot concentrate mind or make logical analysis”9; or “when the essence spirit is not concentrated and when the mind lack understanding”10.

As for the translation of “Shen” as “spirit” or “mind”, that would require a long dissertation. Suffice to say that in all these passages “Shen” refers to “concentration”, “analysis”, “focusing”. “attention” and therefore “mind” would be a better translation of it.

Acupuncture and shamanism
Shamanism was the form of healing prevalent in China before the Warring States Period (476-221 BC). Disease was caused by invasion of evil spirits (gui) and healing was performed by shamans reciting incantations. Shamans used to do this also fending the air with arrows and spears.

The character for “medicine” (Yi) in use before the Warring States Period is made up of the radicals for “ancient weapon made of bamboo” (shu), “quiver of arrows” (yi) and “shaman” (wu). During the Warring States Period the radical for “shaman” in the pictograph of “medicine” was replaced by the radical for herbal decoction: the shaman had been replaced by the herbalist.

医 quiver of arrows
殳 bamboo weapon
巫 shaman
穴 cave, acupuncture point (xue)

Evil spirits used to reside in “caves” called xue which is the same character as “acupuncture point”. I am of the opinion that shamanism was the origin of acupuncture: I think it is a short step between fending the air with an arrow to drive out evil spirits and actually piercing the body to drive out evil spirits from the “caves” in the body. I stress this is only my intuition and I have never read any corroboration of it.

The early connection between shamanism and acupuncture in my opinion is mirrored in the many Nei Jing passages describing the skill, intuition and sensitivity of the acupuncturist depending on his/her Shen. We are not shamans but there is a “shamanistic” quality to acupuncture, it is an art and it is very subjective.

I have noticed this also when I would get excellent results and the patient would feel very much better: whenever I repeated that same acupuncture treatment, it never yielded the same results because the conditions of the first treatment (influenced by subtle, subjective factors due to my Shen and its interaction with the patient’s Shen) could not be reproduced.

It is interesting that during the Northern Song dynasty (960–1127) there was a strong movement towards establishing medical schools and editing the classics of Chinese medicine (the Nei Jing was edited three times by imperial committees). As part of this “clean-up” of medicine, there was a drive towards eliminating shamans and the shamanism that was prevalent in the South.

During the Northern Song dynasty, southerners’ medical customs and reliance on shamans were considered almost “barbaric” usually in a degree increasing with their distance from the northern centre. Their deities were labelled “demons” (gui), their religious officiants were labelled shamans (wu) and their healing practices were described as noxious.11

Song officials’ concern focused on the southerners’ preference for local shamans over physicians which was seen as the root of their ignorance of medicine. In some prefectures, prefects even forced shamans to change occupation and apply themselves to acupuncture! Their shrines were destroyed.12

If acupuncture has indeed shamanistic qualities (much more than herbal medicine), it may explain the difficulties of conducting acupuncture clinical trials. An acupuncture treatment is subject to very many variables, to the subjective state of the practitioner’s Shen, to the interaction with the patient’s Shen, to the intent, skill and sensitivity of the acupuncturist, all of which may make it difficult to conduct clinical trials, especially if they are based on a standard acupuncture “prescription”. Even in modern China, acupuncture doctors teach about directing the needling sensation simply with the power of Shen. For example, in Nanjing they taught us that, in order to direct the needling sensation downwards along a channel, we should press with the thumb behind the point and visualize with our Shen the downward movement of Qi along the channel.

1. Wu N L, Wu A Q Yellow Emperor’s Canon of Internal Medicine, China Science and Technology Press, Beijing, 1999, p. 495.
2. Li Z G, Liu X R, Yellow Emperor’s Canon of Medicine - Spiritual Pivot, World Publishing Corporation, Xi’an, 2008, p. 9.
3. Ibid., p. 179.
4. Li Zhao Guo (translator) Yellow Emperor’s Canon of Medicine, Library of Chinese Classics, World Publishing Corporation, Xi’an, 2005, p. 335.
5. Unschuld P U and Tessenow H, Huang Di Nei Jing Su Wen – An Annotated Translation of the Huang Di’s Inner Classic – Basic Questions, Vol. I, University of California Press, Berkeley, 2011, p. 428.
6. Ibid., p. 428.
7. Unschuld, p. 19.
8. Li Zhao Guo (translator) Yellow Emperor’s Canon of Medicine, Library of Chinese Classics, World Publishing Corporation, Xi’an, 2005, p. 601.
9. Ibid., p. 1261.
10. Unschuld, p. 681.
11. Hinrichs T J, Barnes L L, Chinese Medicine and Healing, Harvard University Press, Cambridge, Massachusetts, 2013, p. 109.
12. Ibid., p. 109.

Sunday, August 2, 2015


When giving my lectures I am often surprised by the fact that many practitioners do not use the Back-Shu points very much.  In this short article I would like to explain how I use the Back-Shu points in practice.

The Back-Shu points are mentioned in various chapters of the Nei Jing.  Chapter 51 of the "Ling Shu" lists the Back-Shu points of the five Zang.1 

Chapter 59 of the "Su Wen" discusses the Back-Shu points of the Fu; in all, the Nei Jing lists 10 Back-Shu points, leaving out BL-22 Sanjiaoshu, first mentioned in the "ABC of Acupuncture" (Jia Yi Jing, AD 282), and BL-14 Jueyinshu, first mentioned in the "1000 Golden Ducats Prescriptions" (Qian Jin Yao Fang, AD 652).2

The Chinese character (Shu 俞) denoting these points means “to transport” indicating that they transport Qi to the inner organs. Each point takes its name from the corresponding organ, e.g. BL-15 Xinshu is “Heart-Shu”. 

The importance of the Back-Shu points in treatment cannot be over-emphasized. They are particularly important for the treatment of chronic diseases and, indeed, one may go so far as saying that a chronic disease cannot be treated without using these points at some time during the course of treatment.  This is essentially how I use them, i.e. to tonify the organs (Yin or Yang) in chronic conditions. 

The Back-Shu points affect the organs directly and are therefore used in Interior diseases of the Yin or Yang organs.  This is a very important aspect of the clinical effect of these points.  The way in which they act is quite a different from that of other points.  

When treating the Internal Organs, other points work by stimulating the Qi of the channel which then flows along the channel like a wave, eventually reaching the Internal Organs.  For example, if we needle LIV-3 Taichong we initiate a small wave around the point that flows along the channel, eventually reaching the Liver.  If we needle BL-18 Ganshu (Back-Shu point of the Liver) we reach the organ directly without having to go through the channel.  

In my experience, when we needle the Back-Shu points, Qi goes directly to the relevant organ, not through the intermediary of its channel.  For this reason, I usually retain the needle in these points a shorter time than for other body points (usually no longer than 10 minutes when used to tonify).  That is because we do not have to wait for the “wave” in the channel to reach the organ. 

Chapter 67 of the “Nan Jing” says: “Yin diseases move to the Yang [area]; Yang diseases move to the Yin [area]. The Front-Mu points are situated on the Yin surface [and therefore treat Yang diseases]; the Back-Shu points are situated on the Yang surface [and therefore treat Yin diseases].”3  According to this statement, the Back-Shu points would be used to treat “Yin diseases” and the Front-Mu points “Yang diseases”.  “Yin diseases” and “Yang diseases” can be interpreted in different ways. 

One interpretation of “Yin” or “Yang diseases” is that of chronic and acute diseases respectively: in this interpretation, the Back-Shu points would be used for “Yin diseases”, i.e. chronic diseases, and the Front-Mu points for “Yang diseases”, i.e. acute diseases. 

Although this rule should not be interpreted rigidly, it is certainly valid and finds a widespread clinical application, i.e. using the Back-Shu points for chronic and the Front-Mu points for acute diseases. This is how I use them. 

Another characteristic of the Back-Shu points is that they are used to affect the sense organ of the corresponding organ. For example, BL-18 Ganshu is the Back-Shu point of the Liver and can be used for eye diseases.

Although the Back-Shu points are mostly used to tonify the organs, they can also be used in Full patterns. In particular, they can be used to subdue rebellious Qi and clear Heat. For example, the point BL-21 Weishu can be used to subdue rebellious Stomach-Qi in case of belching, nausea or vomiting. The point BL-18 Ganshu can be used to move stagnant Liver-Qi.  BL-15  Xinshu can be used to clear Heart-Fire and BL-13 Feishu to stimulate the diffusing and descending of Lung-Qi and release the Exterior.

I personally use the Back-Shu points after needling points on the front of the body.  I would usually retain the body points approximately 20 minutes (in an adult), withdraw them, ask the patient to turn over, and then use the Back-Shu points.  I generally leave the Back-Shu points in a shorter time, i.e. no longer than 10 minutes (in an adult).  I needle the Back-Shu points obliquely towards the midline.

If I use the Back-Shu points to tonify Qi, Yang or Blood, I often use direct moxa cones (7 moxa cones).

In conclusion, I personally think that using the Back-Shu points is essential to treat chronic diseases. 

1. 1981 Spiritual Axis (Ling Shu Jing). People’s Health Publishing House, Beijing, first published c. 100 BC. p. 100.

2.  1979 The Yellow Emperor’s Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen). People’s Health Publishing House, Beijing, first published c. 100 BC,  pp. 303-312.

3. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi). People’s Health Publishing House, Beijing, first published c. AD 100, p.  146.

Thursday, July 2, 2015


Rebellious Qi of the Chong Mai is a relatively common pathology; it is more common in women than men.  In women, I have seen at all ages, from teenagers to women over 65.  The first mention of Rebellious Qi of the Chong Mai is in chapter 29 of the Nan Jing: “The pathology of the Chong Mai is rebellious Qi with internal urgency [li ji].”

Li Shi Zhen says the same thing: “When Qi rebels upwards, there is internal urgency [li ji] and a feeling of heat: this is rebellious Qi of the Chong Mai.”

Therefore, two symptoms are identified as pertaining to the pathology of rebellious Qi of the Chong Mai:

Li Ji 

Ni Qi 


Li Ji is very difficult to translate.  Li means “internal” while Ji means “urgency, urgent, anxious, impatient, rapid, fast, irritated, annoyed, violent, hot-tempered, hot-headed.”  The pictograph depicts a hand grabbing the heart.

Most modern Chinese doctors agree that “internal urgency” refers to “anxiety” and I agree with this view.  However, some think that “li ji” refers to an uncomfortable, tight sensation from the lower abdomen upwards towards the heart. 

Some translate “li ji” as “tightness” or “abdominal tightness”.  This is also an acceptable interpretation as, with rebellious Qi of the Chong Mai, there may be a tightness of the abdomen and especially one experienced as propagating from the lower abdomen to the heart.  As it often happens with Chinese medical terms, they may have simultaneous translations which may be all valid.

In general, I interpret “Li Ji” as a feeling of vague anxiety and restlessness.  Indeed, anxiety may manifest (in some cases) specifically with rebellious Qi of the Chong Mai.  If it does, it gives important implications for treatment because it means we need to subdue rebellious Qi of the Chong Mai and treat the lower abdomen “stabilizing” the Chong Mai in the lower abdomen.  We can do this very simply with Ren-4 Guayuan and KI-13 Qixue.

I translate the word “ni” as “rebellious” as that is its main meaning in Chinese. Most authors translate it as “counterflow” which accurately describes the pathology, i.e. Qi flowing against its normal direction of flow.

I like to keep the translation as “rebellious” because it is very descriptive of the pathology of Qi going the wrong way and also because the word “rebellious” reflects the Confucian influence on Chinese medicine.

Confucianism had a profound influence on Chinese medicine, as big or even bigger than that of Daoism.  Confucianism is a humanist philosophy that sought the best way to ensure harmony in the family, society and the State.  At the root of this philosophy is the correct behaviour based on ren, yi, li and xiao.  All these terms are extremely difficult to translate but they are roughly “compassion”, proper behaviour, rituals and filial piety.

The “proper” behaviour is based on the six relationships, three in the family and three in society, i.e.

Parents - children
Husband - wife
Elder brother - younger brother
Sovereign - subjects
Teacher - student
Friend- friend. 

Those on the left (in the above list) of these relationships have a duty of care towards those on the right, e.g. parents caring for the children.  Crucially, those on the right have a duty of respect and obedience towards those on the left, e.g. children obeying the parents and subjects obeying the sovereign.  When this respect and obedience is lacking, they are “rebellious”.

It is interesting that the word “ni” occurs very frequently in the Nei Jing.  The opposite of “ni” is “shun” i.e. “following the rules, obeying”.  For example, following the seasons is “shun” and not following them is “ni”.  “Ni” brings disharmony and disease, “shun” brings harmony and health. Thus, in the Confucian perspective, illness is as much an ethical problem as a medical one.  In the context of Qi counterflow, “shun” also means “going in the same direction as”. 

The two pathologies of “Ni Qi”and “Li Ji” cause a feeling of heat in the head and cold feet.  This feeling of heat is neither Full nor Empty Heat: it is simply a Chong Mai disharmony.  The feet feel cold because, as Qi is rebelling upwards, there is less Qi going down to the feet in the descending branch of the Chong Mai.

The schematic diagrams of the Chong Mai on the left illustrate the pathway of the Chong Mai: starting in the Lower Dan Tian in the Uterus area, going down to Ren-1 Huiyin and from here to ST-30 Qichong from where it goes to KI-11 Henggu and follows the Kidney channel up to KI-21 Youmen. It goes to the chest, scatters in the breast and flows up to the throat, chin, around the mouth and into the eyes. A branch descends from ST-30 Qichong on the medial side of the leg to the ankle where it separates: one branch goes to the Kidney channel on the sole of the foot and one to the big toe and the Liver channel.

It should be noted that the rebellious Qi follows the Kidney channel in the abdomen and all the Kidney points from KI-11 Henggu to KI-21 Youmen but its “rebelliousness” depends a lot on the Liver channel which should therefore also be treated.

It is very important to note that, in order to diagnose Rebellious Qi of the Chong Mai it is not enough to have “Li Ji” and “Ni Qi” but it is necessary to have various abdominal, chest or breast symptoms at different levels.

Rebellious Qi of the Chong Mai causes various symptoms at different levels of the abdomen, chest, breast and throat.  It causes primarily fullness, distension or pain in these areas. 

By plotting the pathway of the Chong Mai, we can list the possible symptoms of rebellious Qi of the Chong Mai starting from the bottom. These are illustrated in the Figure below.

 Please note that in order to diagnose Rebellious Qi of the Chong Mai, there should be at least 3-4 symptoms at different levels, for example, painful periods, epigastric fullness, breast distension and feeling of lump of the throat.  If, in addition to these, the patient also has some anxiety, a feeling of heat of the face and cold feet, we can then diagnose Rebellious Qi of the Chong Mai.  If all the symptoms were in the lower abdomen, e.g. painful periods, abdominal fullness and a feeling of masses, then this is not Rebellious Qi of the Chong Mai.

A symptom that would be very distinctive of Rebellious Qi of the Chong Mai is a feeling of energy rising all the way from the lower abdomen to the throat: however, very few patients report such a symptom.

What makes the Qi of the Chong Mai rebel upwards? 

In my experience, this may happen for two reasons:

1)     The Qi of the Chong Mai can rebel upwards by itself due to emotional stress that makes Qi rise or stagnate. This condition is Full and I call it “primary” rebellious Qi.

2)     Qi may also rebel due to a Deficiency in this vessel (of Blood and/or deficiency of Kidney Yin or Yang) in the lower abdomen. In such cases, Qi of the lower Dan Tian is weak and the Qi of the Chong Mai “escapes” upwards. This is a mixed Full/Empty condition and I call this “secondary” rebellious Qi of the Chong Mai. This is more common in women. 

The Lei Jing confirms this second aetiology of Rebellious Qi of the Chong Mai in this passage: The Qi of the Chong Mai rises up to the chest, Qi is not regulated and therefore it rebels in the diaphragm, Blood is deficient and therefore there is internal urgency in the abdomen and chest.”

I think that what I call a secondary Rebellious Qi of the Chong Mai, i.e. the one arising from a deficiency of the Kidneys and of Blood in the lower abdomen is more common.

As for what I call the “primary” Rebellious Qi deriving from emotional stress, this is due to:


Of course emotional stress plays some role also in what I call “secondary” Rebellious Qi of the Chong Mai.

Rebellious Qi of the Chong Mai may be a complicating pathology in various gynaecological conditions, such as premenstrual tension, painful periods and menopausal problems.

For example, if a woman suffered from painful periods with dark and clotted menstrual blood, we would diagnose stasis of Liver-Blood. But if in conjunction with the painful period, she also experienced epigastric and breast distension, nausea and anxiety, then we can diagnose that the Liver-Blood stasis is aggravated by Rebellious Qi of the Chong Mai.

During the menopause, Rebellious Qi of the Chong Mai is also a frequent aggravating pathology. Menopausal symptoms are due to the decline of Kidney-Jing: however, they may be aggravated by Rebellious Qi of the Chong Mai. Indeed, the onset of the menopause itself may trigger off (not cause) Rebellious Qi of the Chong Mai, especially in the presence of the above-mentioned emotional stress.

This is due to the phenomenon by which the onset of the menopause “destabilizes” the Chong and Ren Mai in the lower abdomen: as a result of this, the Qi of the Chong Mai may rebel upwards, especially when it is stirred by emotional stress.

The acupuncture treatment of Rebellious Qi of the Chong Mai is illustrated in the two Figures below.

The numbers in front of the acupuncture points indicate the order of insertion.

As for herbal treatment, it is necessary to nourish the Chong and Ren Mai and subdue Qi.  Li Shi Zhen advocated using animal products to nourish the extraordinary vessel and for the Chong Mai, he used Gui Ban Plastrum Testudinis and Bie Jia Carapax Amydae sinensis. To subdue Qi of the Chong Mai he recommended:

Xiao Hui Xiang Fructus Foeniculi
Yan Hu Suo Rhizoma Corydalis
Xiang Fu Rhizoma Cyperi
He Huan Pi Cortex Albiziae
Ban Xia Rhizoma Pinelliae preparatum
Dan Shen Radix Salviae miltiorrhizae
Hou Po Cortex Magnoliae officinalis
Zi Su Ye Folium Perillae

Monday, June 1, 2015


Empty Heat derives from Yin deficiency and the two pathological conditions (Yin deficiency and Empty Heat) are often considered as one.  All modern Chinese books include Empty Heat clinical manifestations under the patterns of Yin deficiency.  For example, under the pattern of Lung-Yin deficiency they will have dry throat and dry cough (Yin deficiency) and 5-palm heat (Empty Heat).

This is not the case in practice as Yin deficiency may last a long time without symptoms or signs of Empty Heat: thus, Yin deficiency and Empty Heat are two separate pathological conditions, even though, of course, the latter derives from the former.

The symptoms of Yin deficiency vary according to the organ involved but generally they will include night-sweating and symptoms and signs of dryness such as dry throat, dry cough, dry lips, dry eyes, dry mouth, thirst with desire to drink in small sips, tongue without coating possibly with cracks.

The symptoms and signs of Empty Heat will include feeling of heat (that is worse in the evening), 5-palm heat (a feeling of heat of palms, chest and soles of feet), malar flush, low-grade fever, a red tongue without coating and possibly a rapid pulse.

The tongue shows conditions of Yin deficiency and Empty Heat clearly.  It is important to understand that, although Empty Heat derives from Yin deficiency, it takes time for it to develop.  Therefore, a patient may display all the signs of Yin deficiency on the tongue for several years without developing Empty Heat and the tongue shows this clearly by lacking a coating (Yin deficiency) but being of a normal colour (no Empty Heat).

In fact, Yin deficiency manifests on the tongue with a lack of coating; therefore, a tongue without coating but of a normal body colour indicates Yin deficiency without Empty Heat. As Yin deficiency aggravates with time, Empty Heat may develop and this turns the tongue red: therefore Empty Heat on the tongue is manifested by a red body colour together with the absence of coating.  One often hears that “in Yin deficiency the tongue is red” (a statement that is tempting to make since “in Yang deficiency the tongue is pale”). This is not so: in Yin deficiency, the tongue lacks a coating; in Empty Heat, the tongue lacks a coating and it is red.

No coating, cracks, normal colour = Yin deficiency

No coating, deep red = Yin deficiency with Empty Heat

A tongue without coating indicates Yin deficiency first and foremost of the Stomach: in addition, it may also indicate Yin deficiency of the Kidneys, Liver or Heart.

That Yin deficiency can occur without Empty Heat is demonstrated by tongue diagnosis as many patients have a tongue that lacks a coating (indicating Yin deficiency) but is not red.

Yin deficiency and Empty Heat are not formed in a short space of time: it takes years from them to develop (the only exception is the Yin deficiency and Empty Heat that may form in an acute way during an invasion of Wind-Heat with Heat penetrating into the Interior). The tongue shows clearly not only the present condition but also the stage it is at: it therefore also shows where it is developing from and what it may lead to.

The three stages of the formation of Yin deficiency based on the tongue are:

1) Rootless coating (this is the mildest form of Yin deficiency)
2) Coating partially missing
3) Coating missing completely

Rootless coating = early stage of Yin deficiency
Coating partially missing
Coating missing completely

Coating missing completely, slightly red
 Empty Heat may develop at any of these stages but it is more likely to develop at the third when the tongue has no coating and it is red.

That Yin deficiency and Empty Heat are two separate pathological conditions is clear also from herbal medicine.  In fact, the herbs and formulae that nourish Yin are in a separate category than the herbs and formulae that clear Empty Heat.

For example, Mai Men Dong Tuber Ophiopogonis japonicis and Tian Men Dong Tuber Asparagi cochinchinensis nourish Yin but they do not clear Empty Heat.  Qin Jiao Radix Gentianae Qinjiao and Qing Hao Herba Artemisiae annuae clear Empty Heat.  When there is Empty Heat of course one combines herbs that clear Empty Heat with those that nourish Yin.

Thursday, April 30, 2015


The following is a case history sent by Jason Smith in Madrid

A woman aged 43 seeks treatment for painful periods. The periods last three days and are extremely painful. She feels cold in general, but the cold is more intense at period time. 

The period is regular (30 days), lasts 3 days, with little bleeding, and the color is dark red with small clots. The pain is very intense, and is felt around the area of Ren-4/Ren-3. A warm bottle alleviates the pain along with analgesics. The period has always been very painful, especially after the age of 18.

The tongue has a normal color with a thin coating with root. However, the sublingual veins appeared very dark. This patient was a semi professional swimmer, practicing intensely around the age of 13-18.

The main pattern is a very obvious case of Cold in the Uterus (nature of pain, feeling of cold and alleviation of the pain by a warm bottle). The Cold in the Uterus led to Blood Stasis, as evidenced by the clots, the dark blood and the dark purple sublingual veins.

Following the four phases of the menstrual cycle, I decided to center the treatment on phase 4 (pre-menstrual phase), since this is the best time to expel the pathogenic factor, in this case Cold, from the Uterus.

With acupuncture, I used the Chong Mai, with SP-4 and P-6, and a moxa box around the area of Ren-4.

With herbal medicine, the patient was instructed to take four tablets of Wen Jing Tang.

After the first period, the pain was reduced by about 50%. After the second period, the pain was reduced by a further 25%. After the third period, and up to date, the patient only feels a very slight pain.

For prevention, the patient was instructed to use a moxa box before the period every now and then, to prevent a new invasion of Cold.

This is a very clear example of how a pathogenic factor can invade the body (after swimming during her puberty, incidentally a time when Chong, Ren and Du are in a very vulnerable state), and remain for about 30 years. It also shows how, no matter how much time has elapsed, pathogenic factors must be expelled.

It is also interesting to note that this patient reported having many times sexual intercourse without any protection, and despite that, never getting pregnant. This is probably due to the fact that Cold has been blocking the Uterus, and thus preventing fertilization: this is infertility from a Shi (Full) condition.

Friday, April 10, 2015


Menis a common symptom in Chinese medicine.  The Chinese character shows a door and a heart inside itThus, it would seem to indicate a heart constricted by a door closing on it.  I translate this  symptom as “a feeling of oppression of the chest”.  Men is very difficult to translate and my translation is an attempt to convey the meaning of this symptom: it certainly does not claim to be the “correct” translation of men as most Chinese medicine terms have multiple, simultaneous meanings.

Chinese patients will actually use the term men: they might say, for example, “I sleep badly, I have a bitter taste and feel men.” In my experience, when a Chinese patients says that it means they are depressed. 

A feeling of oppression of the chest is purely subjective: there is nothing to be observed or palpated  (as there is in feeling of fullness or distension).  Some patients would describe it as a “feeling of weight” on the chest.  Other patients may use the term “tightness of the chest.” 
Men indicates Phlegm or severe Qi stagnation.  Men occurs in the chest or, less frequently, in the epigastrium; it does not occur in the lower abdomen. 
The term men first appears in chapter 19 of the Su Wen where it is described as a feeling of fullness of the chest with anxiety and blurred vision.

There is another condition characterized by men called “Rising Men Qi” (Men Qi Sheng), a condition that affects newborn babies.  It is characterized by a feeling of men in the umbilical area, the baby is not crying and has difficulty breathing.[i]

Men is rich in meaning and, in my experience, it describes not only a physical sensation in the chest but also a mental-emotional state of anguish associated with it.  A feeling of oppression of the chest reflects emotional stress especially to do with sadness, grief, worry, shame and guilt.  I find this symptom very common in the patients we see.

Chronic anxiety often manifests with the feeling of men in the chest and depression may also be accompanied by this symptom.

The presence of men indicates two things: first, that there is Phlegm; secondly, that the Lungs and/or Heart are involved. 

This Phlegm may be of a non-substantial kind and there may not necessarily be any expectoration of mucus (usually there is not).  Its main manifestation is precisely the feeling of oppression of the chest and possibly a Swollen tongue and a Slippery pulse. 

The main points I would use for a feeling of oppression of the chest are Ren-17 Shanzhong, Ren-15 Jiuwei, P-6 Neiguan, LU-7 Lieque and ST-40 Fenglong.

The main prescriptions that could be used are Ban Xia Hou Po Tang (Pinellia-Magnolia Decoction) or Wen Dan Tang (Warming the Gall-Bladder Decoction).

[i]  1980 Concise Dictionary of Chinese Medicine (Jian Ming Zhong Yi Ci Dian           
). People's Health Publishing House, Beijing, p. 476.

Friday, January 30, 2015


This is the fourth and last part of Sexuality in Chinese Medicine.

Chinese medicine has always stressed the importance of excessive sexual activity as a cause of disease but not insufficient sexual activity.  This has not always been so as, during past dynasties, all sex manuals explicitly say that sexual activity is essential for the health of both men and women.  Indeed, sexual abstinence was viewed with suspicion (as Buddhist nuns were).

The current pruderie of Chinese medicine is clearly a result not so much of the Communist influence but of the Qing dynasty’s Confucian influence.  As we have seen, the Confucianists frowned upon sexual activity and believed that it should be carried out in secret and there should be no public display of affection (as in modern China until recently).

It is important to understand, however, that these rules did by no means imply that sex was a “sin” and woman was the origin of such sin as in the Christian view: nothing could be further from the truth.  The Confucianist abhorrence of sexual philandering was determined mainly by the fear that promiscuity might disrupt the sacred family life, and also by their reverence for the process of human procreation, a solemn process that must not be debased by superfluous amorous play.

Therefore, although the Confucianists considered women as inferior to men, this idea appeared natural to them as that of Earth being inferior to Heaven, thus inferior in a philosophical sense rather than in a concrete sense; it did by no means imply that they hated or despised women, as many medieval Christian thinkers and mystics did.

Moreover, women had their own vested rights, and one of them was the right to satisfaction of their sexual needs.  Although physical contact was strictly limited to the marital bed, there the husband had to give all his women the personal attention he was supposed to deny them as soon as they had left the bed.  The Li Ji (one of the Confucian classics) mentions sexual neglect of one of the women as a grave offence; neither age nor beauty should make the husband deviate from the strict protocol set for sequence and frequency of his sexual intercourse with his wives and concubines.

As we have seen, from the latter part of the Ming dynasty onward, Chinese society became more and more straight-laced and frowning on matters of sex.  We have also seen how Chinese doctors considered lack of sex and sexual frustration as a major cause of emotional stress in women: this is all the more likely to happen as, as we have seen, women’s sexuality is more complex than that of men and they therefore need a man who is expert in the sexual art and foreplay.

Sexual desire depends on the Minister Fire and a healthy sexual appetite indicates that this physiological Fire is abundant.  When sexual desire builds up the Minister Fire blazes up and Yang increases: the orgasm is a release of such accumulated Yang energy and, under normal circumstances, it is a beneficial discharge of Yang-Qi which promotes the free flow of Qi.

When sexual desire builds up, the Minister Fire is stirred: this affects the Mind and, in the terms of organs, specifically the Heat and Pericardium.  The Heart is connected to the Uterus via the Uterus Vessel (Bao Mai) and the orgasmic contractions of the uterus discharge the accumulated Yang energy of the Minister Fire.

When sexual desire is present but does not have an outlet in sexual activity and orgasm, the Minister Fire can accumulate and give rise both to Blood Heat and to stagnation of Qi in the Lower Burner.  This accumulated Heat will stir the Minister Fire further and harass the Mind, while the stagnation of Qi in the Lower Burner can give rise to gynaecological problems such as dysmenorrhoea.

Of course, if sexual desire is absent, then lack of sexual activity will not be a cause of disease.  Conversely, if one abstains from sexual activity but the sexual desire is strong, this will also stir up the Minister Fire but without release.  Thus, the crucial factor is the mental attitude.

With regard to sexual frustration, Qing dynasty’s Chen Jia Yuan wrote very perceptively about some women’s emotional longing and loneliness.  Among the emotional causes of disease he distinguishes “worry and pensiveness” from “depression”.

He basically considers depression, with its ensuing stagnation, due to emotional and sexual frustration and loneliness.  He says: “In women...such as widows, Buddhist nuns, servant girls and concubines, sexual desire agitates [the mind] inside but cannot satisfy the Heart.  The body is restricted on the outside and cannot expand with the mind [i.e. the mind longs for sexual satisfaction but the body is denied it].  This causes stagnation of Qi in the Triple Burner and the chest; after a long time there are strange symptoms such as a feeling of heat and cold as if it were malaria but it is not.  This is depression”.

Although the above thoughts derive from Dr Chen’s clinical experience with servant girls, Buddhist nuns and concubines and should therefore be seen in the social context of the Qing dynasty, they also have relevance to our times as he is essentially talking about sexual frustration and loneliness and his reference to widows confirms this (in old China widows were shunned and seldom remarried).  He perceptively refers to sexual craving agitating the Heart and Mind but not finding a satisfaction in the body: besides sexual frustration, he is also referring to emotional frustration and craving for love.

A constant theme of all this was also SEPARATION: the emotions resulting from separation (sadness and grief) are often at the root of Qi stagnation, not of the Liver, but of the Heart and Lungs and some times development of breast lumps and breast cancer.  It is important to realize that stagnation of Qi comes not only from the Liver but also from Lungs and Heart, especially Lungs.  In fact, even emotions that cause depletion of Qi such as sadness and grief, may cause stagnation of Qi (of the Lungs) because, when Qi is depleted in the chest, it does not circulate well and therefore stagnates.

In the particular case of breast lumps, the stagnation of Qi of the Lungs and Heart is particularly relevant because these two organs and channels are situated in the chest.  Zhu Dan Xi says: “When a woman is worried and depressed, accumulation develops, Spleen-Qi becomes weak, Liver-Qi rebels horizontally, stagnant Qi turns into nodules like turtle eggs, there is no pain or itching.  After 10 years ulcers develop and the disease is called Ru Yan [breast cancer]”.

This statement clearly points out the emotional influence on the development of the disease and also its long term development.  It is important to remember that stagnation of Qi in women is very often secondary and the consequence of a deficiency of the Liver and Kidneys affecting the Ren and Chong Mai.

The “Orthodox Manual of External Diseases” (Wei Ke Zheng Zong) written by Chen Shi Gong in 1617, says: “Depression injures the Liver, pensiveness affects the Spleen, accumulation develops in the Heart, the channel-Qi stagnates and generates [breast] nodules”.

The modern doctor Xia Shao Nong thinks that breast cancer is due to widowhood, breaking of relationships, divorce, death of one’s children, bereavement at a young age from the loss of one’s spouse.  These events, especially if occurring suddenly, upset the mind and lead to Qi stagnation.  It is interesting that all the events this doctor cites have to do with separation.

The Uterus Vessel (Bao Mai) connects the Uterus to the Heart: since the Heart is always affected by emotional problems (because it houses the Shen), this connection explains the profound influence of emotional stress on the menstrual function.  For example, the “Su Wen” in chapter 33 says: “When menstruation does not come, this is due to the Uterus Vessel being blocked.  The Uterus Vessel pertains to the Heart and connects with the Uterus; when Qi rebels upwards towards the Lungs, Heart-Qi cannot flow downwards and the periods do not come”.  “Qi rebelling upwards towards the Lungs” describes in particular the effect of worry, sadness or grief.

Emotional problems are all the more detrimental in women if they occur around the time of puberty.  At this time, a girl’s health is particularly vulnerable and emotional problems will affect her body and mind deeply and with long-lasting effect.  In particular, emotional stress at this time will deeply affect the Ren and Chong Mai creating the imbalances that will cause gynaecological problems later in life.

Emotional stress influences menstruation by affecting the movement of Blood by Qi.  In fact, the first effect of emotional stress is to impair or alter the circulation of Qi by depleting Qi, making Qi stagnant or making Qi rebellious.  Each of these pathologies will affect Blood which follows Qi and becomes deficient, stagnant or rebellious.

The “Golden Mirror of Medicine” says: “Women are frequently affected by worry, pensiveness, anger or depression: these make the Blood move, stop, rebel or conform, which is all due to Qi movement”.

Qing dynasty’s Chen Jia Yuan wrote with regard to worry: “Worry injures the Lungs and pensiveness injures the Spleen, when these two organs are injured Qi and Blood stagnate, there is a feeling of indignation, palpitations, a feeling of oppression of the chest and amenorrhoea”. This passage confirms that stagnation of Qi affects not only the Liver but also that amenorrhoea may occur from stagnation as well as from a deficiency.

Thus, considering the social position of women in ancient China and the frequency of the above-mentioned emotional and sexual frustrations, it is no wonder that Qi stagnation (not always of the Liver) occupies such a central place in women’s pathology, and we can also conclude that emotional stagnation in women was often the result of sexual frustration, separation and loneliness: these are the recurrent “anger” in Chinese medicine books.

This is essentially the clinical meaning and application of Xiao Yao San.  As sexual frustration in women is fairly common in our society (often deriving from men’s sexual inadequacy or inexperience), Dr Chen’s observations on the influence of sexual frustration on stagnation of Qi and depression acquire particular relevance.  This is often a cause of disease somewhat akin to emotional stress.

However, Xiao Yao San may work less well in modern women who have weaker Kidneys than in the past: there is no point in “moving Qi” is there is no Qi to move.  This is, in my opinion, the reason why Xiao Yao San does not work so well in modern women unless it is modified with the addition of some Kidney tonics.


What have we got to learn from Daoist sex? One thing that stands out is how the Daoist sex manuals never mention “love”.  Sex seems to be an exercise in moving Qi, releasing the Minister Fire and exchanging Yin and Yang essences with the partner. Both the Daoists and the Confucianists removed love for different reasons and never mention love (although the old poems do).  The modern Chinese have even removed the “heart” from the “love” ideogram!

Modern character for "love" (ai)

Old character for "love"

Heart (xin)

However, there are some useful lessons for us:

1. Differences between men’s and women’s sexuality: many men could learn from that.
2. Importance of women’s orgasm and sexual frustration as cause of Qi stagnation.
3. Importance of men’s expertise in sexual techniques and foreplay.
4. Blow the myth of simultaneous orgasm and the importance of orgasm in men. If the man is         particularly experienced, the woman could have multiple orgasms before his.
5. Western sexuality fixed on orgasm, hence Western men often unskilled: this causes female frustration.  Modern men can learn from Daoist sex to allow for the difference between Water and Fire and therefore women’s slower response.

1. Chen Jia Yuan 1988 Eight Secret Books on Gynaecology (Fu Ke Mi Shu Ba Zhong).  Ancient Chinese Medical Books Publishing House, Beijing, p.152.  Chen’s book, written during the Qing dynasty (1644-1911) was entitled Secret Gynaecological Prescriptions (Fu Ke Mi Fang), and published in 1729.

2. 1979 The Yellow Emperor’s Classic of Internal Medicine - Simple Questions (Huang Di Nei Jing Su Wen), People’s Health Publishing House, Beijing, first published c. 100 BC, p.197.

3. Golden Mirror of Medicine (Yi Zong Jin Jian), p.9.

4. Eight Secret Books on Gynaecology, p.152.