GOOD NEWS FOR HERBAL MEDICINE IN THE UK

There are good news from England in the fight to preserve the freedom to prescribe herbal remedies. As a background, herbal practitioners have been fighting to obtain a derogation from the upcoming European Directive so that they would be able to prescribe unlicensed remedies. This derogation revolved around them being statutorily registered: we have now obtained this.

The UK Secretary of State for Health has made an announcement today about regulation of herbal medicine practitioners. The issue of whether or not practitioners of acupuncture, herbal medicine and traditional Chinese medicine should be statutorily regulated has been debated since the House of Lords Select Committee report on Complementary and Alternative Medicine in 2000.

The Health Professions Council (HPC) has now been asked to establish a statutory register for practitioners supplying unlicensed herbal medicines. The proposal is, following creation of this register, to make use of a derogation in European medicines legislation (Article 5 (1) of Directive 2001/83/EC) that allows national arrangements to permit those designated as "authorized healthcare professionals" to commission unlicensed medicines to meet the special needs of their patients.

Accordingly, a scheme would be created enabling registered practitioners to commission unlicensed herbal medicines to meet the special needs of their individual patients. Safeguards for the public would be provided by a combination of professional regulation and linked medicines regulation, for example, to safeguard manufacturing standards.

If practitioner regulation is in place for the purposes of creating an Article 5(1) scheme this also opens the way to reform Section 12 (1) of the Medicines Act 1968. Under Section 12 (1), practitioners may prepare unlicensed herbal medicines on their own premises for use following consultation with individual patients. It is intended to move to the position that only registered practitioners would be able to operate under Section 12 (1) after regulation of practitioners is in place.

A formal consultation exercise will take place on specific legislative proposals for establishing the register and proposed reforms of medicines legislation later in 2001.

I think we all owe the European Herbal Practitioners Alliance (EHPA) and its chairman Michael McIntyre a huge debt of gratitude. In particular, Michael McIntyre has been fighting tirelessly for the past 10 years in defence of herbal medicine in England and Europe.

MORE ON P-6 NEIGUAN

I would like to expand on what I said about P-6 Neiguan last month. P-6 Neiguan is a complex point, rich in clinical applications.

Descend Stomach-Qi
P-6 is closely connected to the Stomach channel and, for this reason, it is a major point to make Stomach-Qi descend. For this reason, it treats vomiting, nausea, belching and acid reflux. In order to make Stomach-Qi descend, P-6 combines very well with Ren-13 Shangwan and ST-21 Liangmen. Notice that Ren-13 is better than Ren-12 at making Stomach-Qi descend because it treats specifically the upper part of the stomach.


Descend Heart-Qi
Besides making Stomach-Qi descend, P-6 also makes Heart-Qi descend. Interestingly, Heart-Qi not descending also causes nausea and vomiting; therefore, when we use P-6 for nausea and vomiting we are acting both on the Stomach and the Heart channel. How do we know whether nausea in a patient is due to rebellious Stomach-Qi or rebellious Heart-Qi? In two ways. Firstly, from the pulse: in case of rebellious Stomach-Qi, we will feel that on the right-Guan position (feeling Tight or very slightly Overflowing). In case of rebellious Heart-Qi, the left-Cun position will be slightly Overflowing. Secondly, when nausea and vomiting are strongly associated with the emotional state (i.e. the patient feels nausea when depressed, anxious, worried or guilty), then they are due to Heart-Qi not descending.

Relationship between Stomach and Heart
There is a close relationship between the Stomach and the Heart that has many clinical applications and repercussions. Indeed, in some of the old classics, epigastric pain, i.e. pain below the xyphoid process was called xin tong i.e. Aheart pain@. Modern Chinese books say that the old doctors somehow Aconfused@ stomach with heart pain. I do not agree with this view. I think that the old doctors knew perfectly well the difference between a stomach and a heart pain.
The fact is that there is a broad overlap between the Heart and Stomach both from the point of view of organs and that of channels. One way in which the channels of the Heart and Stomach overlap is through the Divergent Stomach channel and the Great Luo of the Stomach. In fact, the Stomach Divergent channel ascends in the abdomen and then enters the stomach, spleen and heart.



On the other hand, the Great Luo of the Stomach starts in the chest, penetrates the diaphragm, connects with the lungs and exits below the left breast. The pulsation of the left ventricle felt in the fifth intercostal space is called the pulsation of Xu Li and Xu Li is another name for the Great Luo of the Stomach. Therefore, while what we feel in the fifth intercostal space is obviously the heart, from a Chinese perspective, it is also the beating of the Xu Li and of the Zong Qi (the Qi of Heart and Lungs in the chest).


What this means in clinical practice, is that treatment of the Stomach channel is important to regulate the Heart both on a physical and a mental-emotional level. On a physical level, treatment of ST-36 and ST-40 is important to regulate the rhythm of the heart when it is irregular or fast and to make Heart-Qi descend when there is nausea. On an emotional level, treatment of ST-40 calms the Mind and makes Heart-Qi descend, allaying anxiety and worry.
Not by chance, some of the symptoms of myocardial infarction are often digestive such as belching, acid reflux, nausea and vomiting.


HAPPY NEW YEAR OF THE RABBIT!

ON P-6 NEIGUAN

P-6 Neiguan is one of the most important and most widely used acupuncture points. First of all, let us analyse the name “Nei Guan”. “Nei” means “inner” and there is no disagreement about this. However, the second half of the name “Guan” can have different interpretations. In ordinary, every-day language, “guan” means to “shut”, “close”, “turn off”, “lock up”. If we go to a shop and we find it closed, one would say that the shop “guan le”, i.e. it is shut or “it shut” (in the past). If we interpret “guan” in this sense, then P-6 is an “inner closure”, an “inner stop cock” or something similar. Could it be interpreted in this way? Yes, it could, and in this sense, P-6 would be the point that closes the Yin in the Interior and this should be seen in relation and analogous to T.B.-5 Waiguan, the “outer closure”, i.e. the point that closes the Yang on the outside.

However, the nature of P-6 is such that it is a very dynamic point and this does not fit in with its translation as “inner closure” because “closure” implies to stop something, as for example, when one closes a tap (faucet) to stop the flow of water.
If we look up the other meanings of “guan” (as in Chinese one word can have multiple meanings), we find that it also means “mountain pass”, “critical juncture”, “customs house” or “barrier” (of a customs house). According to G. D. Wilder and J. H. Ingram, Analysis of Chinese Characters, 1922, “guan” is a cross bar of a gate, to shut or bar the gate, a custom-house barrier. The character is composed of the radical “Men” (door). Inside the “door” there is “guan”, which means to pass threads through a web with a shuttle. The script represents the warp of a textile. The down strokes in the lower part represent a shuttle carrying the thread through to form a woof. By extension, it means to fix transversely. The cross bar of the gate passes through the slots and iron loops like a shuttle passing through the warp.

Translating “guan” in this way, would change the meaning of “Nei Guan” entirely. The point would then be an “inner critical juncture” or an “inner barrier” (of a customs house). Notice that it is the barrier of a customs house that is open to let goods through. This would change the nature of the point entirely, making it a dynamic point that is a critical juncture and that lets things through. In my opinion, this reflects the nature and functions of P-6 more accurately. The reference to “fixing transversely” is also interesting as it would be an allusion to the flow of the Luo channels flowing “transversely” in relation to the Main channels that flow “vertically” (P-6 is of course the Luo point of the Pericardium channel).

The “Su Wen” in chapter 8 says: “The Pericardium is the ambassador and from it joy and happiness derive”. The Pericardium is closely related to the Heart and, indeed, the Nei Jing and the Nan Jing constantly refer to the “5 Zang and 6 Fu”, the 5 Zang being the Heart, Liver, Spleen, Lungs and Kidneys, i.e. the Pericardium was assimilated to the Heart: the two could not be separated being so close anatomically. However, chapter 8 of the Su Wen does mention the 12 Organs and it lists their functions including those of the Pericardium. The Su Wen’s reference to “joy” and “happiness” also makes it sound like the Pericardium has similar functions to those of the Heart. Notice however that in this chapter, the Pericardium is called ”Shan Zhong”, i.e. the “centre of the chest” (where Ren-17 is), not the usual “xin bao luo”, i.e. the “luo of the heart’s envelope”. As we shall see, this is because the Pericardium has several different functions corresponding to its multi-faceted nature.

So, the first aspect of the Pericardium’s nature is that it is closely connected to the Heart and that it is in the centre of the chest; the reference to “joy” and “happiness” implies that it somehow houses the Shen in the same way as the Heart does. This is the first clinical use of the Pericardium channel and of P-6, to affect the Shen. Like the Heart, the Pericardium houses the Shen and it therefore influences our mental-emotional state deeply. For example, a deficiency of Blood will affect the Pericardium as well as the Heart, making the person depressed and slightly anxious. Heat in the Blood will agitate the Pericardium and make the person agitated and restless. Phlegm obstructing the Pericardium will also obstruct the Shen causing mental confusion.

Emotions “stir” both the Heart and the Pericardium by agitating the Minister Fire and making it flow upwards to these two organs. Li Dong Yuan said: “Not a day goes by in people’s lives that the Minister Fire is not stirred”. In Chinese medicine, there is this idea that the Minister Fire should be “concealed” in the Lower Burner: it performs its function of warming the organs in the background and it should not be seen. Emotions stir up the Minister Fire and cause it to leave its “place of concealment” in the Lower Burner: that is when the patient suffers from “Heat” and there are symptoms of Heat such as a red face, a feeling of heat, thirst, etc. Notice that emotional stress usually leads to Heat, it never leads to Cold.

The Pericardium houses the Shen (with the Heart)
•Blood deficiency of the Pericardium will cause depression and slight anxiety
•Blood Heat of the Pericardium will cause anxiety, insomnia and agitation
•Phlegm in the Pericardium will cause mental confusion and, in severe cases, mental illness
•The Pericardium affects emotional problems from relationship problems
Although assimilated to the Heart, the Pericardium has an important difference from the Heart channel. The Pericardium channel controls the Qi of the chest and it moves Qi and Blood, more than the Heart channel does. For example, P-6 has an important influence on the movement of Qi in the chest (hence its use for chest pain); the Heart channel does not have such a function. In other words, I use HE-7, for example, to nourish Heart-Blood and settle the Shen while I would use P-6 more to move Qi and Blood in the chest causing physical symptoms such as chest pain and mental-emotional symptoms such as depression (from Qi stagnation).

The second aspect and function of the Pericardium is its relationship with the Liver within the Jue Yin channels: Liver and Pericardium are the Jue Yin channels which are the “hinge” of the Yin channels. Thus, when we use the Pericardium channel, we indirectly use the Liver channel too. In my clinical experience, I use P-6 exactly in this way: besides its other functions, it moves Liver-Qi and stimulates the movement of the Hun (see below).

The Pericardium function on the mental-emotional plane is the psychic equivalent of the Pericardium’s moving of Qi and Blood of the Heart and Lungs in the chest: just as it does that on a physical level, on a mental-emotional level, the Pericardium is responsible for “movement” towards others, i.e. in relationships. Given that the Pericardium is related to the Liver within the Terminal-Yin channels, this “movement” is also related to the “movement” of the Hun from the ego towards others in social, relationships and familial interactions. For this reason, on a mental-emotional level, the Pericardium is particularly responsible for a healthy interaction with other people in social, love and family relationships.

Moreover, the “moving” nature of the Pericardium is also enhanced by its relationship with the Triple Burner as a channel (within the “Minister Fire” channels). As the Triple Burner is responsible for the free flow of Qi (together with the Liver), the Pericardium’s relationship with the Triple Burner accounts for its action in moving Qi and Blood and its mental-emotional function of “movement” towards others.

Thus the Pericardium is a unique organ in that it has three sets of relationships: with the Heart, with the Liver (Jue Yin channels) and with the Triple Burner (within the Minister Fire channels). Notice also how the Pericardium is related to the Jue Yin (the hinge of the Yin) through the Liver and to the Shao Yang (the hinge of the Yang) through the Triple Burner. Thus the Pericardium is doubly the “hinge”: I believe this contributes to its dynamic nature. This makes it such a complex and rich channel with so many interactions and different functions.

The book “An Explanation of Acupuncture Points” (Jing Xue Jie, 1654) confirms this dual nature of the Pericardium by listing the actions of P-6 under the two heading of Heart and Liver. In other words, it lists the Heart-related and Liver-related actions of P-6. Under the Heart-related indications it lists poor memory, chest pain and (when Empty) head and neck ache. Under the Liver-related indications, it lists red eyes, elbow pain and hot palms.

The symptom of head and neck ache is interesting for me as it is something I have noticed frequently in practice, i.e. that P-6 is effective in treating headache, especially occipital and temporal. I believe this is due to the connection between the Luo point of the Pericardium and the Triple Burner channel.

RELATIONSHIP BETWEEN PERICARDIUM AND MINISTER FIRE
The “Minister Fire” (Xiang Huo) is the Fire of the Gate of Life (Ming Men). This Fire is essential to the healthy functioning of the body.
Although many doctors such as Zhu Zhen Heng (1281–1358) identified “Minister Fire” with the Fire of the Ming Men (and therefore the Kidneys), others, such as Zhang Jie Bin (1563–1640), identified the “Minister Fire” with such internal organs as the Kidney, Liver, Triple Burner, Gall Bladder and Pericardium. In fact, the Minister Fire is said to go upwards to the Liver, Gall-Bladder and Pericardium (in so doing it is compared to the “Fire Dragon flying to the top of a high mountain”) and downwards to the Kidneys (in so doing it is compared to the “Fire Dragon immersing in the deep sea”).

Thus, purely from a 5-Element perspective, the Minister Fire pertains to the Pericardium and the Triple Burner (as opposed to the Emperor Fire of the Heart), while from the perspective of the Internal Organs, the Minister Fire is the Fire of the Ming Men pertaining to the Kidneys. However, there is a connection between the two views as the Minister Fire does flow up to the Liver, Gall-Bladder and Pericardium. In pathology, this has an even greater relevance as the pathological Minister Fire (driven by emotional stress) flares upwards to harass the Pericardium causing mental restlessness, agitation, anxiety and insomnia.

NATURE AND FUNCTIONS OF P-6
1) HEART
The Pericardium is closely related to the Heart and P-6 therefore acts on the Heart. I use it primarily to move Qi and Blood, not so much to nourish Blood and the Shen. I use P-6 to move Qi and Blood and P-7 Daling to subdue Qi and calm the Shen.

2) MOVING QI IN THE CHEST
P-6 is an important point to move Qi and Blood in the chest: this is one of the main functions that distinguish it from Heart points. On a physical level, it moves Qi in the chest when Qi stagnation is causing chest pain; it is also very effective for traumas of the chest causing stagnation of Qi and/or Blood. To treat the chest, P-6 combines very well with ST-40 (I usually needle them contralaterally, i.e. one on the right and the other on the left).

3) MOVING LIVER-QI
The Pericardium is coupled with the Liver within the Jue Yin channels (the “hinge” of the Yin). P-6 therefore moves Liver-Qi. When would one want to use the Pericardium rather than the Liver to move Liver-Qi? I would use P-6 especially for mental-emotional problems deriving from relationship problems and causing Liver-Qi stagnation. Using P-6 will treat both the Liver and the Heart simultaneously, which makes it so useful in mental-emotional problems. Another reason for using P-6 to move Liver-Qi is when the symptoms are located in the Upper Burner, for example pre-menstrual breast distension. In this context, P-6 combines very well with LIV-3 (usually contralaterally, i.e. one on the right, the other on the left).

4) THE PERICARDIUM AND THE HUN
As we have seen above, the Pericardium is associated to the Liver within the Jue Yin. The Liver houses the Hun which provides “movement” to the Shen: this “movement” provides creativity, inspiration, planning, sense of direction in life to the Shen. Without these, the Shen would suffer and the person would be depressed. P-6 is excellent to stimulate the movement of the Hun and I therefore use it very frequently in depression (and not only that deriving from Liver-Qi stagnation). When used for depression, I frequently combine it with Du-20 Baihui.

5) P-6 AS LUO POINT
P-6 is the Luo point of the Pericardium channel. As a Luo point, it has a dynamic nature and I use it primarily to move rather than to tonify. I see P-6 as having a “centrifugal” effect. Contrary to it being a point that “closes” (if we interpret “guan” in its name as ‘closing”), I actually see it as a point that opens and moves. In mental-emotional problems, it moves Qi, relieves stagnation and “opens” the patient to a new emotional awareness.

6) P-6 SYNERGISTIC EFFECT
P-6 has a synergistic effect on acupuncture points prescriptions. The addition of P-6 to any prescription increases the therapeutic effect. Just as P-6 has this effect on a physical level, it has one on a mental-emotional level, i.e. it can bolster the effect of a point combination for mental-emotional problems. The Pericardium is the hinge of the Yin channels, and, being the Luo point, P-6 is the “hinge” of the Hinge: in its capacity as “hinge” it connects things.

GERIATRICS IN CHINESE MEDICINE

The thinking about geriatrics in Chinese medicine has been dominated by Kidney deficiency for centuries. As Kidney-Jing declines as we age, the clinical approach to the treatment of the elderly has been based largely on tonifying the Kidneys.

However, modern diseases of the elderly that account for 90% of mortality (cancer, heart disease and stroke) are characterized by Fullness. Quite simply, we do not die of Kidney deficiency but of Phlegm, Blood stasis and Internal Wind.

The most common pathogenic factors (and those leading to serious diseases) are:
Phlegm
Blood stasis
Internal Wind

Apart from the major diseases of the elderly such as cancer, stroke and heart disease, very many symptoms and signs that occur in old age are caused by Phlegm and/or Blood stasis. The following is a partial list.

GERIATRIC SYMPTOMS/SIGNS
•Otosclerosis: Phlegm/Blood stasis
•Cataract: Phlegm
•Macular degeneration (vascular, lack of blood nourishment): Blood stasis
•Dry eyes: may be due to Blood stasis
•Alzheimer: Phlegm (the neurofibrillary tangles and plaques in the brain are a form of
Phlegm)
•Parkinson: Wind
•Poor memory: is often due to Phlegm
•Brain muzziness: Phlegm
•Dizziness: Phlegm
•Epiretinal membrane: Phlegm
•Macules: Blood stasis
•Dry skin: in the elderly may be due to Blood stasis
•Itching: Phlegm/Wind
•Numbness: Phlegm/Wind
•Hair loss: may be due to Blood stasis

The following three Tables list the major diseases of the elderly with the pathology they are due to:

Many of the symptoms of the elderly are due to Phlegm:
Heart: mental confusion, feeling of oppression in the chest
Gall-Bladder: stones, nausea, inability to digest fats
Joints: bone deformities, pain, rigidity
Lungs: cough with mucus, feeling of oppression of the chest, asthma, breathlessness
Stomach: lack of appetite, digestive problems, hiatus hernia, acid reflux.
Skin: greasy skin, sweating, yellow moles.

TONGUE DIAGNOSIS IN THE ELDERLY
This has already been discussed in a previous blog (April 2010). The major pathogenic factors of the elderly manifest on the tongue with the following signs:

Phlegm: swollen tongue body, sticky coating
Blood stasis: purple, stiff body
Internal Wind: stiff, moving deviated.

For example, if we see a tongue that is swollen, purple and stiff, it indicates all three pathogenic factors of Phlegm, Blood stasis and internal Wind. When I see a tongue like that in an elderly patient, I actively invigorate Blood and resolve Phlegm for prevention.

Purple (especially on sides) = Blood stasis
Stiff = internal Wind

Purple = Blood stasis
Swollen = Phlegm
Slightly Deviated = internal Wind

PULSE DIAGNOSIS IN THE ELDERLY

Pulse diagnosis in the elderly also reflects the fact that their clinical picture is dominated by Full conditions. In fact, in the elderly, the pulse is very often Full and Wiry and/or Slippery, not Weak.

TREATMENT PRINCIPLES IN DISEASES OF THE ELDERLY
Considering the above, I believe the most important treatment principles in the elderly are:
1) Invigorate Blood and eliminate stasis
2) Resolve Phlegm
3) Extinguish (internal) Wind

Some people think that eliminating pathogenic factors (with herbal medicine or acupuncture but especially with herbal medicine) may “weaken” the elderly. I have never found that to be true in practice: if an elderly person has Phlegm and Blood stasis, they will not be “weakened” by resolving Phlegm and invigorating Blood. Of course, one does need to adapt one’s doses to age so that dosages of herbs for the elderly should be lower than those for young people.

Invigorating Blood remedies: Red Stirring (Upper Burner), Stir Field of Elixir (Lower Burner), Harmonizing the Moon (Blood stasis in Uterus)
Resolving Phlegm remedies: Clear the Soul, Limpid Sea
Extinguishing Wind remedy: Clear Yang

Red Stirring = Xue Fu Zhu Yu Tang

Stir Field of Elixir = Ge Xia Zhu Yu Tang

Harmonizing the Moon = Gui Zhi Fu Ling Wan

Clear the Soul = Wen Dan Tang

Limpid Sea = Er Chen Tang

Clear Yang = Ban Xia Bai Zhu Tian Ma Tang

APPEAL TO EUROPEAN HERBAL PRACTITIONERS

I would like to remind all European herbal practitioners of the looming dangers of the European Union (EU) “Directive” called “Directive on Traditional Herbal Medicinal Products” (THMPD) coming into force in April 2011. This “directive” (note the Soviet-style sound of this word) is the greatest threat to herbal medicine. The EU Directive (formulated and enforced by the unelected and unaccountable European Commission) sets new over-the-counter (OTC) standards adopted in April 2004 with requirement for full implementation by April 2011. In the UK this will replace S12(2) of 1968 Medicines Act for OTC products (see below).

The Traditional Herbal Medicinal Products Directive (THMPD) comes fully into force in April 2011. After this time, only herbal medicines that have been registered under the scheme will be available EU-wide. For a wide range of herbal products, especially those from non-European traditions such as Ayurveda and traditional Chinese medicine, the requirements of the scheme are either impossible to meet or are prohibitively expensive. In many cases, both constraints apply so the result is that virtually no herbal medicines from these traditions have been registered. These products will effectively be banned after April 2011. The ban will also effect medicinal herbs in food supplements, which are used by many thousands of people across Europe to help maintain their health.

The Directive has the following aims:
- Aims to ensure correct identification of medicinal plants and adoption of Good Manufacturing Practice (GMP) by suppliers and manufacturers.
- Requires that OTC herbals demonstrate 30 years safe use for registration, 15 years of which within the EU.
- Monographing herbal safety and efficacy by the European Medicines Evaluation Agency Committee on Herbals.
- Permits limited medicinal claims on THMPD products

Problems with THMPD:
- Cost of licensing high.
- Cost of quality assurance also high.
- Quality control guidelines not workable for multi-herb complexes. This now has been recognised but now no applications for multi-herb complexes will be accepted until this is sorted out. The time for all this is running out as Section 12(2) products must be withdrawn from the market from April 2011 when the THMPD is fully implemented.

In the UK, herbal practitioners have been free to practise their art since the times of Henry VIII:
“Be it ordained established and enacted by authority of this present parliament, that at all time from henceforth, it shall be lawful to every person being the King’s subject, having knowledge and experience of the nature of Herbs, Roots and Waters… to practise, use and minister in, and to any outward swelling or Disease, any Herbs, Ointments, Baths, Pulters and Emplaisters, according to their Cunning, Experience and Knowledge … without suit, vexation, trouble, penalty or loss of their goods.”
The Herbalists’ Charter ordained by Henry VIII, 1543.

In 1968 the UK Medicines Act was enacted:
- Provides legal basis for the supply and sale of herbal medicines.
- Herbal medicines exempt from licensing.
- SI 2130 specifically allows powerful herbal medicines to be prescribed by herbalists.
- The term “herbalist” not defined.

The implementation of the EU THMPD would supercede this Act and would have particularly dire consequences from a medical, social, economic and political point of view as it would at a stroke abolish a freedom that has existed in England since 1543.

I therefore urge European herbal practitioners to support the organizations that are working very hard to oppose or at least mitigate the THMPD before April 2011.

European Herbal and Traditional Medicine Practitioners Association (EHPA): http://www.ehtpa.eu/

Association for Natural Health (ANH): http://www.anh-europe.org/

European Benefyt Foundation: http://www.benefyt.eu/

DAO DE JING
Chapter 30 (partial)
Whoever relies on the Tao in governing men
does not try to force issues
or defeat enemies by force of arms.
For every force there is a counterforce.
Violence, even well intentioned,
always rebounds upon oneself.

Chapter 60 (partial)
Governing a large country
is like frying a small fish.
You spoil it with too much poking.
Center your country in the Dao
and evil will have no power.

Chapter 75
When taxes are too high,
people go hungry.
When the government is too intrusive,
people lose their spirit.
Act for the people's benefit.
Trust them; leave them alone.

Translation by S Mitchell

Ear infections and antibiotics

A recent issue of the Journal of the American Medical Association carried an interesting article on the use of antibiotics for acute otitis media (AOM) or middle-ear infection. The reference is:
Tumaini R. Coker et al “Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children” - A Systematic Review, in Journal of the American Medical Association, Vol. 304, No. 19, November 17, 2010, pp. 2161-2169.

The objective of the study was to perform a systematic review on AOM diagnosis and treatment with antibiotics. The study selected studies with a criterion standard, observational studies, randomized controlled trials on AOM microbiology and randomized controlled trials assessing antibiotic treatment.

The conclusion of the study was that antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. Therefore, giving children antibiotics for ear infections does little to speed their recovery while raising the risk of some side effects.
The study found that 80 out of 100 otherwise healthy children would recover from an acute ear infection within a few days if given medication only to relieve pain or fever.

The study found that it does not matter which antibiotic is used to treat an ear infection when antibiotics are warranted. It found older types such as amoxicillin work as well as newer and more expensive antibiotics: indeed, newer antibiotics seem to cause more side-effects.

The study was designed to review existing research on the topic for the American Academy of Pediatrics, which is in the process of revising its guidelines for treating uncomplicated acute otitis media. The pediatricians’ group and the American Academy of Family Physicians have suggested that “observation” (i.e. avoiding antibiotics) is an option for treating ear infections in otherwise healthy children between the ages of 2 and 12. See http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1451.

Of the three basic types of ear infections, acute otitis media may benefit from antibiotics because it is often caused by a bacteria. However, it can also be caused by a virus, which will not respond to antibiotics. Another type of ear infection, otitis media with effusion, causes a buildup of fluid in the middle ear. That is also caused by a viral infection, against which antibiotics are ineffective.

This is interesting from the perspective of Chinese medicine. I have observed over and over again in practice that antibiotic treatment seems to have little effect on ear infections (whilst, by contrast, they have some effect on chest infections). One obvious reason for this is that, as mentioned above, some ear infections may be viral. There may be another interesting reason. The ears are on the Shao Yang area of the body; indeed the Triple Burner and Gall-Bladder channels (Shao Yang channels) course around the ears. In the context of exterior diseases, i.e. diseases caused by external Wind, the Shao Yang stage behaves quite differently than the Tai Yang or Yang Ming stages. The Tai Yang stage is a purely exterior stage when Wind is located on the Exterior of the body, i.e. in the Wei portion. The Yang Ming stage, on the other hand, is an interior stage that occurs when the pathogenic factor has penetrated into the Interior and it has transformed into Heat.

The Shao Yang stage is quite different: it is the stage that is the “hinge” between the Exterior and the Interior. Because of this nature, pathogenic factors can get “stuck” in the Shao Yang stage, bouncing between the Exterior (Tai Yang) and the Interior (Yang Ming). When it is on the Exterior, the patient feels cold; when in the Interior, the patient feels hot: hence the famous “alternation of chills and fever” of the Shao Yang stage.

Another characteristic of the Shao Yang stage, and one that is related to its being the “hinge”, is that pathogenic factors can get “stuck” there and remain in the body for a long time. This cannot happen at the Tai Yang stage because, at this stage, either the Wind is expelled or it changes into Heat and penetrates in the Interior. At the Yang Ming stage too, the pathogenic factor is either cleared or it will injure Yin and it will penetrate into the Yin.

Because of the tendency of pathogenic factors to linger in the Shao Yang, this may be a cause for antibiotics not working and for middle-ear infections becoming chronic which, in children, they very frequently do. Moreover, the use of antibiotics may tend to injure the Stomach and lead to the formation of a residual pathogenic factor in the ears that is usually Damp-Heat. A residual pathogenic factor in the ear from the improper use of antibiotics is the most common cause of chronic ear pathology in children.

The remedy Ear Release in The Little Treasures was designed to treat chronic retention of Damp-Heat in the ears in children. See http://www.three-treasures.com/littletreasures/default.html

BL-22 SANJIAOSHU

Since the previous Clinical Tips were about the Swollen tongue and Phlegm, the use of acupuncture to resolve Dampness and Phlegm and the use of ST-40 to resolve Phlegm, I would like to stay with the subject of fluids pathology and discuss the use of the point BL-22 Sanjiaoshu.
I have mentioned this point in a previous entry as one of the points to resolve Dampness and/or Phlegm. BL-22 is called Sanjiaoshu, i.e. "Shu [point] of the San Jiao" and it is obviously situated just above BL-23 Shenshu, the Back-Shu point of the Kidneys: as we shall see below, this is very significant.
Given that the Triple Burner is an Arm channel, i.e. Arm Shao Yang, and therefore a channel of the upper limbs, why should the Back-Shu point of the Triple Burner be in the lower back near the kidneys and not in the upper back?
The book "An Explanation of Acupuncture Points" (1654) has a very interesting observation. It says that the Pericardium (Arm Jue Yin) has a Back-Shu point at BL-14 Jueyinshu (in the upper back) and the Triple Burner has a Back-Shu point at BL-22 Sanjiaoshu. Notice how the Pericardium has a Back-Shu point in the upper back (not by chance just above the Heart Back-Shu point BL-15 Xinshu) and the Triple Burner has its Back-Shu point at BL-22 Sanjiaoshu in the lower back, just above the Kidney's Back-Shu point BL-23 Shenshu (Fig. 1). "Logically" as the Triple Burner channels is associated with the Pericardium channel, the Triple Burner's Back-Shu point should be in the upper back also because the Triple Burner is an Arm channel (Arm Shao Yang). We shall soon see why it is in the lower back, just above the Kidney's Back-Shu point.







To explain why the Triple Burner Back-Shu point is next to the Kidney's we need to explore the nature of the Triple Burner. The Triple Burner's nature has occupied Chinese doctors for centuries and there are different views of it; as usual in Chinese medicine, different view are contrasting but not necessarily mutually-exclusive ones. For centuries, Chinese doctors have been discussing whether the Triple Burner "has a form" (you xing) or not. The Chinese expression "has a form" means that the Triple Burner is an actual Fu organ; if the Triple Burner "has no form", then it is not like the other Fu but just a complex of functions "without form". Both these views are correct!
Chapter 38 of the Nan Jing has the famous statement that the Triple Burner "you ming er wu you xing", i.e. it "has a name but not a form". The Chinese expression is very elegant in that it contrasts you (it has) with wu you (has no, it does not have) and also rhymes ming (name) with xing (form). Therefore according to the Nan Jing, the Triple Burner has no physical entity like the other Fu organs but it is a set of functions.
What are the main functions of the Triple Burner in the Nan Jing? Chapter 8 discusses the function of the Triple Burner: "This Yuan Qi is the root of the 12 channels, it is the Motive Force (Dong Qi 动 气) between the Kidneys, the root of the 5 Zang and 6 Fu and of the 12 channels, the gate of breathing and the origin of the Triple Burner."
Chapter 66 of the Nan Jing further explains the function of the Triple Burner and it is the origin of the famous view of the Triple Burner as the "envoy" of the Yuan Qi. It says: "Below the umbilicus and between the kidneys there is a Throbbing Qi [Dong Qi 动 气] which constitutes a person’s life [sheng ming 生 命]. This [Throbbing Qi] is the root of the 12 channels, also called Yuan Qi [原 气]. The Triple Burner is the envoy of the Yuan Qi [or it allows the Yuan Qi to separate into its different functions]." Figure 2 illustrates this passage.

This is a very important statement that links the Triple Burner not only with the Yuan Qi but also with the Ming Men which is called also the "Minister Fire". It may be because of this that the Triple Burner is said to belong to the “Minister Fire”. The Minister Fire is the physiological Fire of the Kidneys that is essential to all the Zangfu and all physiological processes. It is in the Kidneys but it comes out of the Kidneys through the intermediary of the Triple Burner and that is why the Triple Burner's Back-Shu point is not by chance above BL-23 Shenshu, the Back-Shu point of the Kidneys (Fig. 3).

Notice that I have two different translations of a crucial few words above, i.e. either "the Triple Burner is the envoy of the Yuan Qi" or "it allows the Yuan Qi to separate into its different functions". This second translation was proposed by Steve Clavey and it is one that has great merit. This interpretation means that the Triple Burner allows the Yuan Qi to separate into its different forms in different parts of the body to perform is various functions. The places where the Qi of the Yuan Qi "comes to a halt" are the Yuan points on each channel.
There is another interesting significant symmetry in the location of points and that is the one between BL-22 Sanjiaoshu and Ren-5 Shimen. BL-22 is the Back-Shu point of the Triple Burner and is above BL-23 Shenshu (Kidney’s Back-Shu); Ren-5 is the Front-Mu point of the Triple Burner and is above Ren-4 Guanyuan (a point closely related to the Kidneys). Note that Ren-5 also tonifies the Yuan Qi.
Thus, the location of BL-22 just above BL-23 and of Ren-5 just above Ren-4 (a point that tonifies the Kidneys and is related to Jing) confirms the above view of the Triple Burner as the agent allowing the Original Qi to emerge from between the Kidneys and be activated all over the body to perform its various functions. In practice, I often do use both these points (BL-22 and Ren-5) to stimulate the Triple Burner’s metabolism of fluids.
But going back to the point BL-22 what are its functions? I had the rather lengthy introduction above because some of its functions are related to the Triple Burner's being the "envoy" of the Yuan Qi. We could also call it the “agent” of the Yuan Qi.
The ancient book "An Explanation of the Acupuncture Points" mentioned above breaks down the actions of the point BL-22 according to Upper, Middle and Lower Burner.
- Upper Burner: headache from invasion of Wind-Cold, vomiting and rebellious Qi with digestive symptoms and dizziness.
- Middle Burner: (substantial) masses of the internal organs, a feeling of distension and fullness with emaciation, no appetite, shoulder pain, backache with rigidity.
- Lower Burner: turbidity, diarrhoea, abdominal distension, borborygmi.
Modern books lists more symptoms and these can be found in Deadman and Al Khafaji's "Manual of Acupuncture" (p. 282) and my own "The Channels of Acupuncture" (p. 984-5). Among the indications, modern books mention also the Shao Yang Syndrome, i.e. alternation of chills and fever, bitter taste, dry throat, etc.
From what I can see the old texts do not mention these indications under BL-22; for example, the Compendium of Acupuncture (Zhen Jiu Da Cheng) and the ABC of Acupuncture (Jia Yi Jing) do not mention it. I suspect this is a modern addition inspired by BL-22 being the Back-Shu point of the Triple Burner. However, and this is an important point, the "Triple Burner" that is the "agent" of the Yuan Qi and the Triple Burner as Water passages have nothing to do with the Triple Burner as the Shao Yang channel! In other words, there is an apparent dichotomy between the Triple Burner as the agent of the Yuan Qi and the Triple Burner as the Shao Yang channel. Thus, to treat the Shao Yang Syndrome I would definitely use points from Triple Burner channel and particularly T.B.-5 Waiguan and not BL-22.
Modern books list also oedema, difficult urination, turbid urine, blood in the urine and these indications are indeed also in the old texts. I personally use this point almost exclusively for the Lower Burner and especially to promote the transformation, transportation and excretion of fluids in the Lower Burner, hence the symptoms of oedema, difficult urination and turbid urine. I use this point in all cases of Dampness or Phlegm in the Lower Burner in combinations that I posted on an earlier blog and a previous Clinical Tip.
But another reason why this point would act on the fluids of the Lower Burner is to do with its function with regard to the Minister Fire of the Kidneys. Just like it is the "envoy" of the Yuan Qi, it is also the envoy of the Minister Fire. The Minister Fire heats the fluids in the Lower Burner and this (physiological) heat is essential to the transformation, transportation and excretion of fluids.
Thus, the point BL-22 acts on the fluids metabolism in the Lower Burner for two reasons. Firstly, the point transforms fluids and therefore resolves Dampness because the Triple Burner is a system of waterways for the transformation, transportation and excretion of fluids. The famous chapter 8 that compares the Zangfu to “officials” says that the Triple Burner is the official in charge “of irrigation and controls the Water passages”. Secondly, the point transforms fluids through its activation of the Yuan Qi and of the Minister Fire.
Thus, as the Triple Burner’s Back-Shu point is on the Bladder channel, there is a connection between these two channels. Interestingly, there is another connection between the Triple Burner and the Bladder channels that is highlighted in the “ABC of Acupuncture” (Jia Yi Jing) by Huang Fu Mi. This connection occurs via the point BL-39 Weiyang which is the Lower He point of the Triple Burner. The He points of the Triple Burner, Small Intestine and Large Intestines (all Arm channels) are T.B.-10 Tianjing, S.I.-8 and L.I.-11 Quchi respectively. However, since the organs of these three channels are located in the Lower Burner, these three channels also have three so-called “Lower He” points which are BL-39 Weiyang for the Triple Burner, ST-37 Shangjuxu for the Large Intestine and ST-39 Xiajuxu for the Small Intestine.
The “ABC of Acupuncture” says that the point BL-39 Weiyang, Lower He point of the Triple Burner, is used for abdominal distension and pain with retention of urine. The text specifically says that this is a “Triple Burner disease” and this confirms the nature of the Triple Burner as a system of waterways for the transformation, transportation and excretion of fluids.
In conclusion, there are at least four aspects to the Triple Burner:
1) It is a system of waterways that transport and excrete fluids
2) It is the “envoy” of the Yuan Qi and Minister Fire
3) It is a system of “cavities” (not discussed here)
4) It is a Shao Yang channel that treats mostly problems of the Shao Yang area in the shoulder and head (especially ears) and also the Shao Yang Syndrome from the Shang Han Lun.