Clinical Point Selection, Week 1 CAM: 373-397 Page 2 of Handouts

Lorraine Wilcox L.Ac. zhenjiu@gmail.com

Before we turn to CAM, a little review...

What causes illness?

External factors: evils - wind, cold, fire (heat), dampness, dryness, and summerheat. If not expelled, they can cause internal damage, or sometimes they directly hit the internal organs.
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What causes illness?

Internal factors: emotions such as anger, joy, thinking too much, anxiety, sadness, fear, and fright. These directly affect the organs and movement of qi (the qi mechanism).

The Qi Mechanism ( qi ji)

What causes illness?

Neither-external-norinternal factors: diet, exercise/activity/work, rest, sex, trauma, etc. These easily affect the organs.

What causes illness?

Pathologically formed evils are produced when there is imbalance, and they cause further pathology: blood stasis, qi stagnation, food stagnation, phlegm, turbid fluids (rheum), internally generated wind, heat, cold, dampness, etc. Constitutional issues.

 Pattern Identification

Pattern Identification
Pattern identification is identifying the basic disharmony behind a set of clinical manifestations. The four examinations are used. Then the diagnostic information is classified. All signs and symptoms must be taken into account. Looking for relationships is more important than looking for causes.
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Pattern Identification
Pattern ( or zheng4): This refers to the whole pattern of the symptoms or signs that manifest at one point in time. It is the complete picture. In some cases, the pattern is the cause of disease (for example, exterior invasion of wind-cold) but not necessarily: kidney yin vacuity may be caused by aging or lifestyle.
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The pattern itself lets us understand the cause or the root, the location and nature of the disease, and the circumstances of the evil and the right qi. It also implies the treatment principle. location spleen substance right qi evil qi qi vacuity with dampness

Treatment principle: Supplement spleen qi, transform dampness.

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Pattern Identification
Symptom/sign ( zheng4): any manifestation, symptom, or sign, such as fever, cough, shortness or breath, abdominal pain, or diarrhea.
A symptom has little diagnostic value on its own. Diarrhea could be due to damp-heat, cold-damp, spleen qi vacuity, spleen yang vacuity, or spleen and kidney yang vacuity. The symptom of diarrhea cannot be treated without understanding it within its context or pattern.
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 versus (both pronounced zheng4)

In many cases in Chinese language, (here, symptom/sign) and (here, pattern) are interchangeable, but in medicine, there is a difference.

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Pattern Identification
Disease ( bing4): There are two types of disease.
A Western disease is something like hypertension, multiple sclerosis, or hepatitis B. Chinese medicine also has the concept of disease. There are traditional names of diseases, for example, painful periods, cough, headache, constipation. Perhaps you could generally think of this as the chief complaint, but sometimes it is not. A patient may come in complaining of infertility (a Chinese disease), but you may find that they also suffer from painful periods and constipation (which are also Chinese diseases). Chinese diseases are often considered symptoms by Western medicine.
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Pattern Identification
Different individuals may have different patterns for the same Chinese disease, or one individual may have different patterns over the course of the same disease.
The same disease has different treatments. liver blood stasis Painful cold in the uterus periods kidney vacuity Different diseases have the same treatment. pre-menstrual irritability Liver qi painful periods depression indigestion
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Pattern Identification
Only certain patterns are possible for each Chinese disease. Therefore, whether or not you know the name of the Western disease, take the main clinical symptoms and find the corresponding Chinese disease or diseases. Then check which patterns are possible and focus your questioning on confirming or denying these patterns. If more than one disease manifests, look first for one pattern that covers more than one of these diseases. 16

Pattern Identification
We can combine disease differentiation and pattern differentiation for precise assessment of disease.
A disease name summarizes the characteristics or symptoms of a disease. A pattern name integrates the nature, cause, and location of the disease.

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Pattern Identification
The most common type of pattern identification in the style called TCM is organ pattern identification. This combines:
qi, blood, and body fluid patterns pathogenic factor (evil) patterns eight principles patterns the physiological and pathological workings of the five viscera and six bowels
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organ pattern identification

qi, blood, zang-fu fluid patterns patterns spleen qi eight principles patterns vacuity pathogenic factor (evil) patterns with dampness

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Pattern Identification
Because it focuses on the organs, it is most useful for interior patterns, although a few exterior patterns are included, especially for the lungs. Pattern identification for exterior conditions is more detailed in:
pathogenic factor (evil) patterns six channel patterns (cold damage) four levels patterns (warm disease) triple burner patterns channel patterns
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Pattern Identification
Here are some important points regarding organ pattern identification:
It is important to understand the mechanisms of disease and the relationships of the organs. You cannot simply memorize a list of signs and symptoms. Not all signs or symptoms are necessary to receive a diagnosis. A mild case will have fewer signs and symptoms. Many times patients have a combination of more than one pattern, but look for relationships between the various patterns a patient has. Look for the traditional combination patterns, such as vacuity of heart and kidneys. The points listed to treat a pattern are only examples. There are many other possibilities.
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Chinese medicine is philosophical

Dont forget Holism: Be aware of the interaction of a person with their environment (right versus evil, for example), and internal interactions (between organs and other aspects) within a person.
The unity of heaven and man: Heaven and earth are a big Tai Ji; the human body is a small Tai Ji. The relationship of the patient with time (day/night, four seasons, phase of the month) and space (geography, climate, weather, environment)
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Chinese medicine is philosophical

Dont forget The inseparability of body and spirit You can examine the exterior to know the state of the interior. The dynamics of change: Everything in the universe and in the body is continuously moving and changing. Dynamic balance.
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General principles of treatment CAM: 373-397

1. Regulation of yin and yang

Disease means yin and yang are not balanced. Ling Shu, Chapter 5 says: How to regulate yin and yang is most important in acupuncture treatment.

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Yin-Yang Balance is Health

yang

yin

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Imbalance: yang repletion (hot)

Excessive yang will eventually damage yin. yin

excessive yang: drain it yang

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Excessive yang damages yin

excessive yang: drain it yang insufficient yin: nourish it yin

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Imbalance: yin repletion (cold)

Excessive yin will eventually damage yang. yang yin

excessive yin: drain it

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Excessive yin damages yang

excessive yin: insufficient yang: fortify it yang

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drain it

Imbalance: yin vacuity (hot)

yang

insufficient yin: nourish it yin

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Imbalance: yang vacuity (cold)

insufficient yang: fortify it yang

yin

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Su Wen, Chapter 5: Treat yin for problems in yang; treat yang for problems in yin. For example:
back shu points (yang) are more frequently used to treat the viscera (zang yin organs). mu alarm points (yin) are more frequently used to treat the bowels (fu yang organs).

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2. Strengthening right qi and eliminating evils

Right qi (or righteous or upright qi): [ zheng4 qi4] the sum of all healthy qi and other health-promoting substances in the body: antipathogenic factor. Supplement it. It will prevent evils from taking hold. Evil qi [ xie2 qi4]: Qi, mostly from the weather, that can cause disease: pathogenic factors. Evils can also arise internally. Drain it. It will allow right qi to regain strength.
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Right Versus Evil

Disease is a struggle between right versus evils

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2. Strengthening right qi and eliminating evils

Should we strengthen the right? (In chronic conditions, treat the root. In this case, root usually means the bodys right qi.) Should we drain the evil? (In acute conditions, treat the branch. In this case, branch usually means the evil qi.) Should we do both simultaneously? (In most cases we can, but be aware of which points are strengthening the right and which are draining the evil, and use the correct technique on each point.)
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2. Strengthening right qi and eliminating evils

If a very weak patient has an evil, sometimes you cannot attack the evil without killing the patient. In that case supplement first and attack the evils when the patient is stronger.

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3. Distinguishing root and branch

To treat disease, seek its root. Elementary Questions, Chapter 5 (Warring States Period) CAM calls this primary ( ben root) and secondary ( biao branch).
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Root and Branch

Examples: If insufficient spleen qi leads to bleeding, spleen qi vacuity is the root and bleeding is the branch. Liver yin vacuity (root) can lead to liver yang rising (branch). Liver yang rising (root) can lead to liver wind (branch).

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If you treat the root, all the symptoms will resolve. The symptoms are like bowling pins. You dont want to knock them down one by one. If you hit the kingpin just right, you will knock down all the pins with one ball. This is treating the root.

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Root and Branch

Usually translated as, In acute conditions, treat the branch. Usually translated as, In chronic conditions, treat the root.
(ji2): acute, urgent, tense, quick, (huan3): chronic, slack, slow, gradual, moderate, mild.

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4. Treatment of disease according to climate, season, location, and individual

Treat according to the season and weather: In the summer, you are likely to use less moxibustion and will use fewer warming herbs. Also the qi flows differently through the seasons, for example, in the summer qi flows more superficially. Diet and lifestyle should vary with climate and season.

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Treatment of disease according to climate, season, location, and individual

Treat according to the place: here in Los Angeles there is less cold and dampness, and more dryness and heat.

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Treatment of disease according to climate, season, location, and individual Treat according to the individual (age, sex, constitution): Herb formulas and point formulas can be adjusted for the condition of the patient. This gives better results than using an unmodified formula.

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 Therapeutic methods
There is a logic to acupuncture treatment: principle/theory, method, formula, and points 1. Supplementing 2. Draining 3. Warming 4. Clearing 5. Ascending 6. Descending
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1. Supplementing
Treats vacuity patterns Example acupuncture techniques: emphasis on clockwise or thrust. Close the point. Supplement kidney qi or yang: Shen Shu (UB 23), Guan Yuan (Ren 4), Tai Xi (KI 3) using supplementing hand technique or moxibustion. Nourish kidney yin: Tai Xi (KI 3), Zhao Hai (KI 6), Zhi Shi (UB 52) using supplementing hand technique.
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1. Supplementing
Supplement spleen-stomach qi: Zhong Wan (Ren 12), Qi Hai (Ren 6), Zu San Li (ST 36) using supplementing hand technique or moxibustion. Replenish qi-blood: Pi Shu (UB 20), Ge Shu (UB 17), Zu San Li (ST 36), San Yin Jiao (SP 6) using supplementing hand technique or moxibustion. Do not supplement if evils are strong, or if external evils are not yet eliminated.
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2. Draining
Treats patterns with evils and accumulations Example acupuncture techniques: emphasis on counterclockwise or lift. Leave the point open. Dispel wind, release the exterior: Drain Feng Chi (GB 20), He Gu (LI 4). Induce a bowel movement to drain heat: drain Qu Chi (LI 11), Tian Shu (ST 25), Feng Long (ST 40). Bleed related points to resolve blood stasis. Do not drain vacuity.
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3. Warming
Treats cold patterns, warms the channels, removes blockage, fortifies yang. Use moxibustion or long needle retention. Warm the middle jiao: moxibustion or long retention on Zhong Wan (Ren 12) and Zu San Li (ST 36). Collapse of yang: moxibustion on Guan Yuan (Ren 4) and She Que (Ren 8). Do not use for heat conditions; caution in yin vacuity.
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4. Clearing
For heat patterns. Always implies clearing heat. Use draining technique or let blood. Short needle retention. Heat evils: Drain Da Zhui (Du 14), Qu Chi (LI 11), He Gu (LI 4). Heat in the organs: drain related well points or spring points. Resuscitation due to heat: drain or let blood at the hand well points or Ren Zhong (Du 26).
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5. Ascending
Raises yang and lifts what has sunken: for prolapse, chronic loose stool, lack of nourishment to the head and sense organs. Supplement and use moxibustion on points such as Bai Hui (Du 20), Qi Hai (Ren 6), Guan Yuan (Ren 4), Zu San Li (ST 36). Do not use with yin vacuity and hyperactive yang.

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6. Descending
Subdues yang, wind, fire, or counterflow. Descend stomach qi: even technique on Tan Zhong (Ren 17), Zhong Wan (Ren 12), Nei Guan (PC 6), Zu San Li (ST 36). Subdue the liver: drain Feng Chi (GB 20), Tai Chong (LV 3), Yong Quan (KI 1).

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Basic principles for prescription and selection of points

Basic principles for prescription and selection of points

1. Acupuncture Prescriptions: Treatment plan (different than treatment principle): point selection, hand technique, number of points, etc. 2. Principles for point selection: local, adjacent, and distal points, symptomatic points

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For acupuncture-moxibustion, choose:

Local points: the address on the envelope. If you do not also use distal points, this is like sending an empty envelope. It will get there, but there is no message inside. Local points often treat the branch. These are like the guiding herb in a formula; they take the effect of the point formula to the affected site. Distal points: the message in the envelope. These are often points to treat the root, or related to the affected site by channel pathway.
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Local points: the address on the envelope Distal points: the message in the envelope

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For acupuncture-moxibustion, choose:

Modality: Acupuncture, moxibustion, cupping, bleeding, etc. Each one gives a different message. Which modality will you use on each point? Technique: Drain or supplement? Direct or indirect moxibustion? etc. Each one gives a different message. Which technique will you use on each point? Some points may need to be supplemented and others drained within the same treatment. Balance: Look at the overall treatment. Is it balanced for this patient? Is it balanced overall?
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Local, Adjacent, and Distal Points (examples)

Region Forehead Temples Nape Eye Nose Mouth, cheek Ear Distal LI 4, ST 44 SJ 5, GB 41 SI 3, UB 60 SI 6, LV 3 LU 7, ST 45 LI 4, ST 41 SJ 3, GB 43 Adjacent Du 20 GB 20 Du 14 GB 16 Du 23 SI 18 GB 20 Local GB 14 Tai Yang , GB 8 UB 10 UB 1 LI 20 ST 4, ST 6 GB 2, SJ 17
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Local, Adjacent, and Distal Points (examples)

Region Throat Chest Rib-sides Upper abdomen Lower abdomen Low back Rectum Distal LU 10, KI 6 PC 6, ST 40 SJ 6, GB 34 PC 6, ST 36 SP 6, LV 8 UB 40, SI 3 UB 57 Adjacent UB 10 LU 1 LV 13 ST 21 ST 25 UB 32 UB 30 Local Ren 23, SI 17 Ren 17 LV 14 Ren 12 Ren 4 UB 23, UB 25 Du 1
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Point Formulas for Symptoms (examples)

Symptom Fever Coma Night sweating Clenched jaws Cough, asthma Sensation of suffocation in the chest Formula Du 14, LI 4, LI 11 Du 26, Shi Xuan SI 3, HT 6 ST 7, ST 6, LI 4 Ren 22, Ding Chuan Ren 17, PC 6

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Point Formulas for Symptoms (examples)

Symptom Cardiac pain Rib-side pain Abdominal distention Constipation Convulsions Epistaxis Digestive problems in children Bleeding hemorrhoids Formula PC 6, PC 4 SJ 6, GB 34 Qi Hai, ST 36 SJ 6, KI 6 LI 4, LV 3 Du 23, LI 4 Si Feng (prick) Er Bai (moxibustion)

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The Five Shu (Transport) Points

Point Jing well (yin wood, yang metal) Ying spring (yin fire, yang water) Shu Stream (yin earth, yang wood) Jing River (yin metal, yang fire) He Sea (yin water, yang earth) Nanjing 68 fullness below the heart (treats the chest in general) heat in the body heaviness in the body, painful joints cough, dyspnea, chills and fever counterflow qi, diarrhea (mostly related to the yang organs) Lingshu 44 disease in the viscera (yin organs) changes in color (complexion) intermittent or prolonged disease (eight treat malaria) changes in the voice disease in the stomach from irregular eating diseases of the bowels (use lower he sea), bleeding
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Other clear heat, open orifices, other end of channel, spirit disorders

The Five Shu Points and their Corresponding Element

Category Jing well Ying spring Shu Stream Jing River He Sea Element on Yin Channels Wood Fire Earth Metal Water Element on Yang Channels Metal Water Wood Fire Earth
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Application of specific points (point categories)

The Five Shu Points of the Yin Channels Point Jing Well Ying Spring Shu Stream Jing River He Sea Element Wood Fire Earth Metal Water Liver Heart Spleen Lungs Kidneys Pericardium LV1 HT9+ SP1 LU11 KI1PC9+ LV2HT8 SP2+ LU10 KI2 PC8 LV3 HT7SP3 LU9+ KI3 PC7LV4 HT4 SP5LU8 KI7+ PC5 LV8+ HT3 SP9 LU5KI10 PC3
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 The Five Shu Points of the Yang Channels

Point Element Gallbladder Small Intestine Stomach Large Intestine Jing Well Metal GB44 SI1 ST45LI1 Ying Spring Water GB43+ SI2 ST44 LI2UB66 SJ2 Shu Stream Wood GB41 SI3+ ST43 LI3 UB65SJ3+ Jing River Fire GB38SI5 ST41+ LI5 UB60 SJ6 He Lower Sea He Earth Sea GB34 SI8ST36 LI11+ UB40 SJ10GB34 ST39 ST36 ST37 UB40 UB39
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Bladder UB67+ San Jiao SJ1

Nan Jing 69 says:

In vacuity, supplement the mother point or channel. In repletion, disperse the child point or channel.

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 Yuan and Luo Points

Yin Channels Channel Liver Heart Spleen Lungs Kidneys Pericardium Ren Great luo of spleen Yuan LV3 HT7 SP3 LU9 KI3 PC7 Luo LV5 HT5 SP4 LU7 KI4 PC6 Ren15 SP21 Yang Channels Channel Small Intestine Large Intestine San Jiao Du Great luo of stomach Yuan SI4 LI4 SJ4 Luo GB37 SI7 ST40 LI6 UB58 SJ5 Du1 xuli
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Gallbladder GB40 Stomach ST42 Bladder UB64

Application of specific points

Xi Cleft Points Channel Point Back Shu and Mu Alarm Points Organ Shu Point Mu Point

Lung Large Intestine Stomach Spleen Heart Small Intestine Kidney Pericardium San Jiao Liver

LU6 LI7 ST34 SP8 HT6 SI6 KI5 PC4 SJ7 LV6

Lungs Pericardium Heart Liver Gall Bladder Spleen Stomach San Jiao Kidneys Large Intestine Small Intestine Urinary Bladder

UB13 UB14 UB15 UB18 UB19 UB20 UB21 UB22 UB23 UB25 UB27 UB28

LU1 Ren17 Ren14 LV14 GB24 LV13 Ren12 Ren5 GB25 ST25 Ren4 Ren3
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Urinary Bladder UB63

Gall Bladder GB36

Xi Cleft Points of the Eight Extraordinary Vessels

Yang qiao UB59 Yin qiao KI8 Yang wei GB35 Yin wei KI9

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 Eight Extraordinary Vessels Confluence Point Combinations

Combine Du SI3 Ren LU7 Dai GB41 Chong SP4 Yin qiao KI6 Yang wei SJ5 Yin wei PC6 To treat diseases of lung system, throat, chest, diaphragm outer canthus, behind the ear, cheek, neck, shoulder, diaphragm chest, heart, stomach Yang qiao UB62 inner canthus, nape, ear, shoulder, back

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 Eight Meeting (Influential) Points

Zang (viscera, yin organs) LV13 (also spleens mu point) Fu (bowels, yang organs) Ren12 (also stomachs mu point) Qi Ren17 Blood UB17 Sinews GB34 Vessels/Pulse LU9 Bone UB11 Marrow GB39

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 Crossing Points
Too many to make a table here. See CAM, 3rd edition, page 393-7

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