A case history on chronic bronchitis from Jason Smith in Madrid.

A 35 year old woman sought herbal treatment for chronic bronchitis.
The problem started 5 years ago with a flu. For a while, the flu did not seem to go away, since the flu like feeling persisted for some time. After a couple of months, and seemingly recovered from it, she developed a bronchitis.
For the past 5 years she had several cases of bronchitis. They all started the same way. Every winter, after contracting a cold, this cold progressed to bronchitis.
Tired of this situation, she sought treatment specifically with herbal medicine (not acupuncture), although in her own words, "I had little faith in these strange Chinese pills..."
 
Patterns
As for patterns, this is an obvious case of residual pathogenic factor in the Lungs. The first flu she contracted 5 years ago was of course a case of Wind-Heat at the Wei Level according to the Wen Bing School.

However, the pathogenic factor was not completely expelled at that time (accounting for the flu like feeling experienced for some time after), and remained in the body as a residual pathogenic factor, being latter responsible for the recurrent cases of bronchitis over the next winters.
There was also an obvious Lung deficiency, accompanied also by a Spleen deficiency. The Spleen deficiency was diagnosed because of slow digestions, swelling of the abdomen after eating, poor appetite and teeth marks on the sides of the tongue, and the Lung deficiency because of a slight spontaneous sweating, a propensity to catching colds and a weak Lung pulse.
It is also interesting to note that this woman was a yoga teacher and a vegetarian. It was my assumption that her eating habits had led to a Spleen Qi Xu, and that Spleen Xu had, on the other hand, led to a situation where the Earth could not generate (nourish) Metal.
On the other hand, although Yoga is obviously a great exercise, this patient taught Yoga for 6 hours a day, 6 days a week: this would be a form of "overwork" and it would weaken the Spleen and Kidneys.

Treatment
The treatment was aimed at a) expelling the residual pathogenic factor and b) tonifying the Lungs and Spleen. The first issue was addressed with a remedy from the Little Treasures (although specific for children, it is not exclusively used for children), Resolve Phlegm.
This remedy is a variation of Wen Dan Tang and is specific for the treatment of residual Phlegm Heat in the Lungs. Since this remedy is, in the long run, detrimental for the Spleen (because of the cold herbs), she was instructed to take it during only for one month.
On the other hand, a Spleen/Lung tonic was also administered to strengthen the Spleen and the Lungs: Central Mansion, a variation of Shen Ling Bai Zhu San. She was instructed to take this for three months.

Results and prognosis
The patient sought treatment last September, and has not had a single cold or bronchitis for the past 9 months (winter included) as of May.
Although the treatment has been successful, it is my assumption that a further treatment should be undertaken, aimed at tonifying the Kidneys.
Apart from the Lungs, the Kidneys play also a crucial role in the defensive system of Wei Qi, through the 8 Extraordinary Vessels. These vessels are all related in some fashion to the Kidneys, and circulate Jing, and this Jing also contributes to the protection of the body against pathogenic factors, along with the Wei Qi and the Ying Qi.
For this reason, a further treatment might be advisable to tonify the Kidneys: a good option would be the Three Treasures remedy Herbal Sentinel (Yin o Yang), that strengthens Lung-Spleen-Kidney Qi and nourishes Yin or Yang as required by the constitution of the patient.
It is also interesting to note here the Chinese medicine point of view on invasions of Wind Heat/Cold: in western countries, it is customary for people to keep on working and carrying out their daily activities even if they are in the middle of a cold, and not taking time to rest and completely recover, something completely discouraged from the Chinese point of view. This custom is a major cause of formation of residual pathogenic factors, that can give rise to problems at a later stage.

Ganoderma Lucidum reduces obesity in mice by modulating the composition of the gut microbiota

Traditional Chinese Medicine has a long history in Asian countries dating back several thousands of years,  One class of traditional remedies commonly in use consists of medicinal mushrooms such as Ophiocordyceps sinensis, Antrodia cinnamomea and Agaricus blazei Murrill, which contain a wide range of immuno-modulatory and bioactive compounds.  One of the most intriguing medicinal mushrooms is the Basidiomycete fungus Ganoderma Lucidum, which has been used for centuries to promote health and longevity. Previous studies have shown that triterpenes and polysaccharides isolated from Ganoderma Lucidum inhibit adipocyte differentiation and produce hypoglycaemia effects in diabetic mice. In addition, proteoglycans isolated from Ganoderma Lucidum fruiting bodies induce antidiabetic, antihyperlipidemic and antioxidant activities8. However, it remained unknown whether Ganoderma Lucidum produces any effect on body weight and obesity-related disorders.

Obesity is defined as a disease condition associated with numerous health problems and a reduced life expectancy9. Growing evidence indicates that obesity is closely linked with chronic, low-grade inflammation, which can lead to insulin resistance, type 2 diabetes, fatty liver disease, cardiovascular disease, obstructive sleep apnoea and cancer. The high prevalence of obesity is currently a major threat to public health, with 500 million obese people and 1.4 billion overweight individuals worldwide. Prevention of obesity thus represents a major challenge for modern societies.

A recent study indicates that changes in the composition of the gut microbiota are associated with the development of obesity and its associated metabolic disorders. The gut microbiota comprises trillions of bacteria that contribute to nutrient acquisition and energy regulation. An increased ratio of the major phyla Firmicutes/Bacteroidetes and changes in several bacterial species can promote the development of obesity in both dietary and genetic models of obesity in mice. Other studies in obese animals suggest that obesity-induced gut dysbiosis caused by either environmental or genetic factors impairs intestinal integrity. This process leads to the release of the endotoxin lipopolysaccaride (LPS) from intestinal Gram-negative bacteria into the bloodstream, in turn, leading to metabolic inflammation and insulin resistance in obese mice due to stimulation of Toll-like receptor 4 (TLR4)-mediated inflammation. Moreover, chronic injection of LPS in mice leads to mild obesity and insulin resistance21, highlighting a possible role for microbiota-derived LPS in obesity-induced inflammation.

A number of treatments, including antibiotics and prebiotics, are being evaluated for the management of obesity and its related metabolic disorders. For example, antibiotic treatment alters the gut microbiota, reduces blood endotoxemia and improves glucose tolerance in mice lacking the leptin gene (ob/ob mice) or in mice fed with a HFD19. In addition, prebiotics are non-digestible, fermentable carbohydrates and fibres, which reduce body weight and exert anti-inflammatory effects mainly by enhancing the growth of specific beneficial bacteria found in the gut. Prebiotics not only alter the intestinal microbiota but also improve intestinal tight junction integrity and decrease blood endotoxemia caused by LPS18. Prebiotics may, therefore, protect animals against obesity-induced inflammation.

In the present study, we examined whether a water extract of Ganoderma Lucidum mycelium (WEGL) can decrease obesity in HFD-fed mice. Our results indicate that WEGL reduces obesity and inflammation in the treated mice. These effects are transmissible to HFD-fed mice through horizontal faeces transplantation, indicating that the effects of WEGL involve the gut microbiota. Characterization of WEGL showed that polysaccharides of molecular weight >300?kDa exerted similar ameliorative effects as WEGL. These results implied that the high molecular weight polysaccharides may be the active components of WEGL. Our data thus demonstrate that WEGL represents a potential prebiotic agent that may be used for the treatment of obesity and its complications.

in "Nature" 23rd June 2015.

Along with the Eight Principles (Yin and Yang, excess and deficiency, hot and cold, interior and exterior), the various forms of Qi (energy) that course through the meridians or bioelectric pathways, Blood, the Zang and Fu organs — the la theory of the Five Elements forms the basis for the understanding of how acupuncture and Chinese Medicine works. By means of the interconnecting system of the meridians, the Five Elements maintain a relative balance and coordination.

As you know Chinese Medicine has been around for at least 3000 years since the Shang Dynasty when the hieroglyphs of acupuncture and moxibustion first appeared.  The theory of the Five Elements was developed by the same school that developed the theory of Yin and Yang. The chief exponent of this school being Zou Yan (circa 350-270 BC).

The key to diagnosis in Five Element Acupuncture is discerning the root imbalance. Each of the Five Elements has a corresponding emotion, flavor, organ, sense, tissue, season, color, etc. that can be perceived when that element is out of balance.

The Five Elements are comprised of the following:

Fire – Heart – Shen or Mind. Associated with consciousness and relatedness, inspiration, joy, laughing, communication, oneness, compassion. Connected with the blood vessels and the tongue. The Ruler of Spirit. Responsible for nourishing his kingdom.  Anything which disturbs the Shen or the Mind causes memory problems. The season of Summer.

Earth – Spleen – Yi or Thought, the capability to create structures — physically, mentally and emotionally. Understanding, receiving, contemplation on the positive side. Worry or getting into a rut on the negative side. Connected with digestion and the muscles. Indian Summer.

Metal – Lungs – Po or Corporeal Soul, the Storehouse of Vitality. Your “shield” — the immune system. The energy which keeps you protected. The ability to let go. Associated with the emotions of grief and letting go. The season of Fall.

Water – Kidney – Zhi or Will Power. The storehouse of the Will to survive. Connected with the Bones. On a positive note it nourishes the backbone. On the negative side it results in fear. Relates to the season of Winter, hibernation, conservation, preservation, sexual power, the Fountain of Youth, fertility, long term memory, the low back, knees and the ears.

Wood – Liver – Hun or Ethereal Soul. Wood’s function is about maintaining a harmony of flow, a strategizing function.  It gives a sense of one’s ability to wander gracefully through life. Connected with the emotions of depression, frustration and anger: When the spirit is obstructed people “snap”. Connected with “Wind” as manifested in convulsions and tremors. Connected with ligaments, tendons, spasms and vertigo. The season of Spring.

Foods which Nurture based on the Five Elements:
(Eat foods from organic/pasture-raised animals, or wild-caught foods whenever possible. Avoid foods that have been exposed to pesticides or antibiotics.)

Foods which nurture the Heart: Whole wheat, brown rice, oats, mushrooms, barley gruel, cucumber, celery, lettuce, mulberries, lemons, jujube seeds, cow and goat milk, clarified butter (ghee).

Foods which nurture the Spleen: Barley, bean curd, beef, bitter gourd, black soybean, dehydrated unprocessed brown sugar, carp (common, gold and grass), carrot, chestnut, chicken, cinnamon bark, clove, coriander, cucumber, date (red and black), dill seed, eel, eggplant, fig,garlic, ginger (fresh and dried), ginseng, grape, grapefruit peel, green pepper, hawthorn fruit, honey, Job’s tears, licorice, litchi, longan, loquat, lotus fruit and seed, malt, mutton, nutmeg, peanuts, pork, red pepper, rice, squash, star anise, string bean, sweet basil, wheat, yellow soybean.

Foods which nurture the Lungs: Carrot, castor bean, Chinese wax gourd, cinnamon twig, common button mushroom, coriander, crab apple, duck, garlic, ginger, leek, licorice, lily flower, loquat, milk, olive, peanut, pear, peppermint, persimmon, radish, dehydrated unprocessed sugar cane, sweet basil, tangerine, walnut, water chestnut, wine.

Foods which nurture the Kidneys: Black sesame seed, black soybean, caraway, kidney beans, asparagus, chestnut, chicken egg yolk, chive, chive seeds, cinnamon bark, clam (freshwater), clove, cuttlebone, cuttlefish, dill seed, duck, eel, fennel, grape, grapefruit peel, Job’s tears, lotus fruit and seed, mutton, plum, pork, salt, star anise, string bean, tangerine, walnut, wheat, watermelon and other melons, blackberry, mulberry, blueberry, sardine, crab, lamb, seaweed.

Foods which nurture the Liver: Black sesame seed, brown sugar (raw unrefined), celery chicory, chive, chive seed, clam (freshwater, clamshell (river), crab, crab apple, cuttlefish, eel, hawthorn fruits, leek, litchi, loquat, peppermint, plum, saffron, sour plum, star anise, vinegar, wine, kale, collards, spinach, turnip tops, beet tops, dandelion greens, romaine lettuce, endive, radicchio, arugula, turmeric, basil, cardamom, cumin, fennel, ginger, strawberry, peach, cherry.

The essence of Daoist sexuality is the idea that the sexual act is an exchange of Yin and Yang essences, from the woman and man respectively, which is beneficial to each partner: it represents the harmonious interaction and mutual nourishment of Yin and Yang.

Central to Daoist sexuality is the idea that man must conserve its sperm and only ejaculate occasionally: this is because sperm is a direct physical manifestation of Jing and too frequent ejaculation depletes Jing. If sperm is not ejaculated and directed upwards along the Du Mai to the brain, it can be transmuted and then lowered down to the Dan Tian where it nourishes the body and mind.

Since excessive ejaculation weakens the Jing, and since sex without ejaculation can replenish the Jing, it follows that Jing lost through sexual activity can be replaced by sexual energy itself, by practising sex without ejaculation.

Sexual intercourse was considered to have two aims: first to produce sons who would continue the family (and look after the parents' grave). This was a sacred duty to one's ancestors since the well-being of the dead could only be ensured by regular sacrifices made by their descendants, especially the male ones.

The second aim (more relevant to us) was to strengthen a man's vitality by making him absorb the Yin essences of the woman. As a matter of course, these two aims were closely interwoven.

In order to obtain healthy male children the man's Yang essence should be at its apex when he ejaculates, and ancient sex manuals frequently pointed out the optimal conditions the best conditions for a healthy child: at the time of ejaculation and subsequent conception, the man should not be in a state of exhaustion and should not drink alcohol, for example.

To the Daoists, sex was like a process of alchemy, of transformation of the sexual essences into Qi and Jing, through the harmonious intermingling of Yin and Yang. They identified the woman with a crucible and her vital essence with cinnabar (red); they identified the man's white semen with lead; the coitus with the mixing of the elements, and the technique of the coitus with the firing times.

Since men had to restrain themselves by not ejaculating whereas women could reach an orgasm whenever they liked, the onus was very much on men to conduct and prolong sexual intercourse by sexual expertise; in fact, because of this, sexual intercourse is often described by the Daoists as a "battle", as "riding a tiger", or as "walking on the edge of a precipice": i.e. man is easily aroused and easily ejaculates and must learn to control his ejaculation to prolong sexual intercourse (see below).

There were also social reasons for this as the sexual art was essentially for the upper classes whose men had a wife and concubines and they therefore had to restrain themselves in order to satisfy them all.

A constant theme running through Daoist sex manuals is that excessive ejaculation is detrimental to health. This is because too frequent ejaculation leads to a direct loss of Jing and also Minister Fire: thus it depletes both Water and Fire. As we all know, this is very much a theme of modern Chinese medicine books where "excessive sexual activity" features prominently in the aetiology of diseases. As I will explain below, I think that this cause of disease does not apply to women.

The role of the Ming Men (Minister Fire) in human physiology should be discussed. The Fire of Ming Men represents the physiological Fire within the Kidneys, it arises from the area between the two kidneys and is closely related to the Yuan Qi from which the Du, Ren and Chong Mai originate.

Under physiological conditions, the Fire of Ming Men warms the Uterus, the Intestines, the Bladder and the Heart and balances the Yin influences: it makes conception possible and is related to sexual desire. In women, "it is through Kidney-Yang [and therefore the Fire of Ming Men] that the Tian Gui turns red [i.e. it turns into Blood]".1

The Fire of Ming Men is the origin of the "formless" Minister Fire which also generates Water, hence the Kidneys are the source of both Water and Fire. This physiological Fire is unique in that, not only it does not dry up Water, but it can nourish Water..

The Minister Fire is called "formless" because it is a non-substantial Fire which actually generates Water rather than overcoming it. It is a Pre-Natal type of Fire formed at conception on the Du/Ren Mai axis.

In fact, the "Golden Mirror of Medicine" (1742) says: "The Pre-Natal Tian Gui originates from the mother and father, the Post-Natal Jing and Blood are derived from food and water, a girl's Tian Gui matures at 14, when the Ren Mai is open, the Chong Mai is flourishing and the periods arrive".2

The commentary then explains: "At 7 the Motive Force [Dong Qi] is flourishing. At 14 the Tian Gui matures: this is the Motive Force within the Pre-Natal Water of Tian Gui, crystallizing in a girl's uterus".3

"Motive Force" (Dong Qi) is the Yuan Qi. This last passage is interesting as it confirms that the Yuan Qi and the Minister Fire are pre-natal and present before the onset of the periods. It also highlights the close integration of the Minister Fire and the Tian Gui (the Yang and Yin aspects of the Kidneys).

Zhang Jing Yue says: "The Ming Men is the Root of the Yuan Qi and the residence of [both] Water and Fire. The Yin of the 5 Zang cannot nourish without it and their Yang cannot develop without it".4  

This passage clearly shows how the Minister Fire is the Fire within Water, interdependent with Water and inseparable from it. The Emperor Fire (of the Heart) is called "with form", i.e. it is a substantial Fire which overcomes Water, is formed after birth and is therefore post-natal.  

It is important to note again that the Minister Fire cannot be seen in the context of the Five Elements, it is not like the Fire of the Heart and it is a Fire within Water of the Kidneys that actually nourishes Water.

DIFFERENCES BETWEEN WOMEN'S AND MEN'S SEXUALITY

Women pertain to Water and men pertain to Fire and there are important differences in their sexuality. Women are like water, i.e. slow to bring to the boil and slow to cool down; men are like fire, i.e. easy to arouse and quick to cool down.

Ever since very early times, Chinese sexual manuals stressed that women like "slowness" and "duration" and abhor "haste" and "violence". This difference is the crux to understand the different sexual behaviour by men and women necessary or a successful sexual life. For this reason, all Daoist texts stressed very much the importance of expert foreplay by the man to arouse his partner and hence the detailed description of the signs of women's arousal.

From the point of view of Chinese medicine, there are important differences between men's and women's sexuality. In men, the lower Dan Tian contains the "Room of Sperm" and is, so to speak, "empty"; in women, the lower Dan Tian is, so to speak, "full" as it contains the Uterus and Blood. Excessive sexual activity does not affect women as much as men for various reasons.

In men, ejaculation is a direct (but temporary) loss of Jing as sperm is derived directly from the Jing.   Sperm is Tian Gui whereas Tian Gui in women is menstrual blood and ovarian follicles and eggs. As in sexual activity men lose sperm but women do not lose menstrual blood (unless they have sex during the period which they should not do) or follicles.

As there is no comparable loss of Jing in women as there is in men, there is no equivalent depletion after sex. Quite simply, the Kidney-Jing is the origin of sperm in men and of menstrual blood and ova in women: while men lose sperm during sex, women do not lose menstrual blood or ova.

Although some practitioners consider the lubricating fluids secreted by the Bartholin's glands during sexual arousal in a woman to be also a manifestation of Jing comparable to sperm, I tend to disagree because such fluids are secreted by glands in the vagina and not by sex organs (such as the ovaries in women or testicles in men): I would therefore consider these fluids precisely as a form of Body Fluids (jin ye) rather than a direct manifestation of Jing. In fact, the Bartholin's glands in the vagina are homologous to the Cowper's glands in men and their function is purely lubricative.

In other words, sperm is a direct manifestation of Jing, the equivalent of which would be the ova and menstrual Blood in women: the former is lost in men's orgasm, the latter are not lost in women's orgasm.

Furthermore, the Lower Dan Tian in men contains the Room of Sperm which is directly related to Jing, while in women it contains the Uterus which is related to Blood. The Room of Sperm is related to the Kidneys while the Uterus is related also to the Liver and Blood (although also to the Kidneys through the Bao Luo). Because the Lower Dan Tian in women contains the Uterus rather than the Room of Sperm, in women excessive loss of blood after childbirth or excessive loss of blood in menorrhagia would be equivalent to excessive sex for men.

In men, the lower abdomen is occupied by the Room of Sperm and it is therefore "empty", also because sperm is easily discharged while Blood is not.

The book "Elementary Medicine" (1575) says: "The Room of Sperm in men suffers no accumulation or fullness, while the Blood Chamber in women suffers from accumulation and it overflows downwards in the period....[The Lower Dan Tian] in men stores Jing [=sperm] while in women it stores the Uterus and foetus. Men pertain to Qi and when it mixes with the Abysmal [the trigram corresponding to Water], Qi makes Water steam and produces sperm which is white... Women pertain to Blood, when this mixes with the Clinging [the trigram corresponding to Fire], Blood is transformed into the period which is red".5
 

By Giovanni Maciocia


END NOTES
1. Cong Chun Yu 1989 Chinese Medicine Gynaecology (Zhong Yi Fu Ke Xue), Ancient Chinese Medicine Texts Publishing House, Beijing, p.11.
2. Wu Qian 1977 Golden Mirror of Medicine (Yi Zong Jin Jian), People's Health Publishing House, Beijing, vol. 3, p.7.  First published in 1742.
3. Ibid., p. 7.
4. Zhang Jing Yue 1986 The Complete Works of Jing Yue (Jing Yue Quan Shu), Shanghai Science and Technology Press, Shanghai, p.19.  First published in 1624.
5. Elementary Medicine (Yi Xue Ru Men ) 1575 cited in Zhang Qi Wen 1995 Menstrual Diseases (Yue Jing Bing Zheng), People's Hygiene Publishing House, Beijing, p.10.

You lay down at night and you roll from one side of the bed to the other all night long, you can't sleep, what's the matter? The blues has got you. You get up and sit on the side of your bed in the morning and you may have a sister, brother, mother and father around you but you don't want no talk out of them, what's the matter? The blues has got you. You go and put your feet under the table and look down on your plate and you've got everything you want to eat but you shake your head and get up and say "Lord, I can't eat, I can't sleep", what's the matter? The blues has got you.

The purpose of this article is to take an in-depth look at the Three Treasures and Women's Treasure remedies which are applicable in the treatment of mental and emotional disorders ranging from severe depression on the one hand to anxiety, obsessive thinking and worry on the other.

CHINESE VIEW OF DEPRESSION

The Chinese term for depression is yu or yin yu. "Yu" has the double meaning of "depression" or "stagnation".

Yu as stagnation
The "Simple Questions" in chapter 71 talks about Five Stagnations of Wood, Fire, Earth, Metal and Water. It says: "When Wood stagnates it extends, when Fire stagnates it rises, when Earth stagnates it seizes, when Metal stagnates it discharges, when Water stagnates it pours."

The "Essential Method of Dan Xi" (Dan Xi Xin Fa 1347) talks about Six Stagnations of Qi, Blood, Dampness, Phlegm, Heat and Food. It says: "When Qi and Blood are harmonized, no disease arises. If they stagnate diseases arise. Many diseases are due to stagnation...stagnation makes things accumulate so that they cannot flow freely, they would like to rise but cannot, they would like to descend but cannot, they would like to transform but cannot...thus the 6 Stagnations come into being".

The "Complete Book of Jing Yue" (Jing Yue Quan Shu 1624) gives it an emotional interpretation and talks about Six Stagnations of anger, pensiveness, worry, sadness, shock and fear. This confirms that all emotions can lead to stagnation of Qi. He said: "In the Six Stagnations, stagnation is the cause of disease. In emotional stagnation, the disease [i.e. the emotion] is the cause of the stagnation."

Yu as mental depression
"Yu", besides meaning "stagnation" also means mental depression and Chinese books usually ascribe it to Full causes, i.e. Liver-Qi stagnation, Qi stagnation turning to Fire, and Qi-Phlegm, and a heavy emphasis is put on Liver-Qi stagnation at least in the beginning stages. In the later stages, they talk about Qi-Blood-Yin deficiency.

Thus, in Chinese medicine stagnation and depression are almost synonymous implying that all depression is due to stagnation. However, this is not true in practice as there are many types of depression due to Deficiency, and especially Kidney deficiency. It is true, however, that also within the Deficiency types there is an element of stagnation which manifests in the typical resistance to improvement by chronic depressives.

THE MIND (Shen)

Shen is our consciousness which allows us to feel our emotions. For example, when we are angry it is due to the Liver, but it is the Shen of the Heart that feels the anger and knows that we are angry. Therefore one of the functions of the Shen is that it governs our emotional life and by implication it is therefore always involved in mental and emotional conditions.

This explains partly why a Red tip of the tongue is such a common clinical finding. It does not necessarily indicate a problem solely with the Heart, but it could have its root in any emotion affecting any organ, e.g. worry and pensiveness affecting the Spleen, sadness affecting the Lungs, anger affecting the Liver. Such emotions affect various organs but the Heart, housing the Shen, is the organ that "feels" them.

THE ETHEREAL SOUL (Hun)

While the Shen gives us our consciousness as a human, the Hun belongs to a different world - to the world of the spirits. The Hun is Yang in nature and it is imparted to the child three days after birth.

The nature of the Hun is that it is constantly moving, searching and exploring; it is never still. When the Hun wanders a bit at night, we dream - this is normal. However, if there is excessive dreaming, the Hun is searching, moving etc. too much. It is interesting to note that from a Western point of view, the most dreaming occurs during REM phase of sleep when the eyes are flickering and from the Chinese point of view the Liver controls and nourishes the eyes.

So the Hun is an essential complement to the Shen because it gives it this coming and going movement, which manifests as our ability to have plans, vision, inspiration, sense of direction, relationships etc. Without the Hun, the Shen would be like a computer without software.

THE SHEN AND THE HUN IN DEPRESSION

The relationship between Shen and Hun is everything in depression; they cannot function without each other and their relationship must be balanced in order for a person to be mentally and emotionally healthy. The Hun gives the Shen the movement of coming and going - this manifests as being able to cultivate relationships with other people, a relationship with the environment, to have plans, dreams, creativity, inspiration, original thinking and vision. These things all come from the Hun and not from the Shen and the Heart. When a person is undecided and unsure of what to do with their life, it is due to the Hun not having that movement, and coming and going as it is in its nature to do.

On the other hand, the Shen gives the Hun control and integration. If the Shen does not control the Hun, the Hun will be "coming and going" too much. Furthermore, the Shen has to integrate all these things into the consciousness. The Hun is a sea of ideas that bubble up all the time and the Shen can only deal with one at a time so it has to control the Hun and integrate all the material coming from the Hun into the total psyche. We can often witness an "overactive" Hun in children who give life to inanimate objects and have an amazingly developed sense of imagination. After the age of seven, the Shen begins to become stronger and gradually "orders" and "controls" the imaginings of the Hun.

We can therefore see the role that the Shen and the Hun play in bipolar depression. The Hun is being "overactive" and producing endless ideas but the Shen is not able to integrate them: that is why manic depressives are often very creative. So in the manic phase of bipolar depression the Hun is coming and going too much. In extreme cases of mania, it becomes psychotic and causes "madness". However, it exists in many different degrees and is not always as extreme as this. In a milder degree, people have lots of ideas, start lots of courses, become very active at night, restless, confused, spend too much money - nothing ever comes to fruition.

Conversely, when the Hun isn't coming and going enough, the depressive phase of bipolar disease sets in. This manifests in extreme lethargy, fatigue, disinterestedness, despair, apathy and a feeling of hopelessness, lack of vision, lack of plans, etc...

DEPRESSION

SHI CONDITIONS

Liver Qi Stagnation
Depression, moodiness, anxiety, frustration, uptight, tense, pre-menstrual tension. Wiry pulse. Often the subdued and depressed appearance of the patient may belie the true origin of the problem, but the Wiry pulse gives it away.
Three Treasures remedies: Release Constraint, Freeing Constraint .

Liver-Qi Stagnation Turning Into Fire
Anxiety, depression, agitation, short-temper, a feeling of oppression of the chest, tongue Red on the sides with a yellow coating, Rapid-Wiry pulse.
Three Treasures remedy: Freeing the Sun.

Diaphragm Heat
Mental restlessness, depression, anxiety feeling below the heart, insomnia, yellow tongue coating, Rapid pulse.
Three Treasures remedy: Clear the Soul.

Phlegm-Heat Harassing Mind
Mental restlessness, depression, agitation, restless sleep, excessive dreaming, Swollen tongue with a sticky tongue coating, Slippery pulse.
Three Treasures remedy: Clear the Soul.

Stagnation Of Qi With Phlegm
Moodiness, up and down, pre-menstrual tension, also mild symptoms of "Dian" such as apathy, forgetting to eat, slowed thinking, sleep disturbance, tongue coating sticky, Wiry or Slippery pulse.
Three Treasures remedies: Clear the Soul, Open the Heart

MIXED CONDITIONS

Liver-Blood Deficiency Leading To Liver-Qi Stagnation
Pre-menstrual tension, frustration, tension/irritability before the period, crying and tiredness after the period, insomnia, lack of direction, Pale tongue, Wiry-Choppy or Thin pulse.
Three Treasures remedies: Freeing the Moon , Precious Sea, Calm the Shen.

EMPTY CONDITIONS

Worry Injuring The Mind
Depression, absent, anxiety, no desire to do anything, sadness, worry, crying, stretching and yawning, tongue Pale, tongue coating sticky-white, Wiry and Fine pulse.
Three Treasures remedies: Calm the Shen, Breaking Clouds.

Heart And Spleen-Blood Deficiency
Brooding, depression, always thinking, palpitations, timidity, difficulty in falling asleep, poor appetite, Pale tongue, Weak or Choppy pulse.
Three Treasures remedy: Calm the Shen .

Heart Yang Deficiency
Depression, chilliness, curling up, not wanting to do anything, anxiety, palpitations, easily startled, insomnia, Pale tongue, Deep-Weak or Knotted (in severe cases) pulse.
Three Treasures remedy: Breaking Clouds .

Yin Deficiency With Empty-Fire Blazing
Depression, anxiety in the evening, mental restlessness, insomnia, Red tongue, Wiry-Fine or Floating-Empty pulse.
Three Treasures remedy:Root the Spirit .

Kidney-Yang Deficiency
Exhaustion, depression, does not want to do anything or go out, weariness, chilliness, curling up, no will power, no initiative, very Pale tongue, Weak-Deep-Slow pulse.
Three Treasures remedy: Strengthen the Root  , Breaking Clouds.

THE THREE TREASURES FORMULAE FOR TREATING DEPRESSION

Breaking Clouds
Depression can be caused by many patterns and the present formula, a variation of Bu Zhong Yi Qi Tang, addresses depression primarily from Qi deficiency and secondarily from Qi stagnation. Its primary action is that of "lifting" things, both on an emotional and physical level.

This person, on the one hand, may have a mild case of depression manifesting in a chronic low mood, despondency and depression. On the other hand, they may be intensely depressed and suffer from lack of self-esteem and self-confidence. They will find pleasure in nothing and will suffer from intense feelings of guilt. Although they may bravely try to soldier on, they are in a constantly depressed mood and the strain of carrying on may sometimes feel too much for them. They will have a feeling of unreality and will find it difficult to cope socially; they have a tendency to bouts of crying and will often describe their feeling as "if being in a dark tunnel without exit".

Release Constraint
Release Constraint is extremely effective in dealing with emotional strain and depression deriving from stagnation of Liver-Qi especially, though not exclusively, in men. It is indicated when the condition is predominantly a Full one, i.e. not when the stagnation of Liver-Qi derives from an underlying deficiency.

The formula addresses the emotional and mental manifestations of stagnation of Liver-Qi when it causes the Shen to be obstructed: moodiness, mental depression, pre-menstrual tension, irritability, frustration, annoyance and impatience. A typical feature of this condition of Shen obstructed is first of all a certain mental confusion deriving from stagnation, and secondly, a strong resistance to any mental or affective change. This person may have a huge amount of pent-up anger but be unable to use this to help bring about positive change.

A person suffering from severe Liver-Qi stagnation will not always appear angry and raging. In some cases, Liver-Qi stagnation can equally cause someone to appear subdued, quiet, depressed and introverted.

Freeing the Moon
This variation of the classical prescription "Free and Easy Wanderer" (Xiao Yao San), aims at treating pre-menstrual emotional strain occurring against a background of Liver-Qi stagnation and some Liver-Blood deficiency.

The patient will feel tense, wound-up and irritable, but also rather sad and depressed. They may oscillate between crying and flying off the handle. Thus on the one hand Liver-Blood deficiency causes the Hun to be unrooted and on the other hand stagnation of Liver-Qi harasses the Hun giving rise to irritability and depression.

The combined patterns of Liver-Qi stagnation against a background of Liver-Blood deficiency are seen together especially in women, when the Liver-Qi stagnation is especially predominant before the period. The subject around which a woman is depressed pre-menstrually may not cause her any concern for the rest of the month. However, if the same issues cause a woman to be depressed pre-menstrually month after month, it indicates that these issues need to be addressed and are very "real" (even though they may not bother her at other times).

Clear the Soul
This formula, a variation of "Warming the Gall-Bladder Decoction" (Wen Dan Tang) is aimed at treating emotional tension and anxiety occurring against a background of Phlegm obstructing the chest and therefore the Lungs and Heart.

The formula is called Clear the Soul because on the one hand it settles the Hun by resolving Phlegm and clearing Heat and on the other it releases tension of the Corporeal Soul by relaxing the chest and Lungs.

Phlegm-Heat disturbs the Shen in two ways: Phlegm obstructs the Mind's orifices and Heat agitates the Shen. The combination of these two factors will cause mental restlessness and manic behaviour alternated with severe depression, crying or laughing without reason and insomnia. The patient may feel jumpy and talk of a "flustered feeling" in the heart region. This could be seen as a very mild form of dian-kuang (as discussed above). In women, these symptoms may only appear pre-menstrually, in which case the formula need only be taken during the fourth phase of the menstrual cycle.

This pattern is usually caused by pensiveness, jealousy, worry, or obsessive thinking over a long period of time. The more obsessive a person's thinking becomes, the more Heat is created and the more Heat there is, the more the person will be prone to over-thinking: thus a vicious circle is created.

Open the Heart
Open the Heart is a variation of "Pinellia-Magnolia Decoction" (Ban Xia Hou Po Tang). It is aimed at dealing with emotional strain deriving from worry, frustration, or bottled-up anger, manifesting as tightness of the chest or a feeling of obstruction of the throat. The formula is often cited as one to move Liver-Qi when in fact its clinical use is really to deal with stagnation of Qi in the chest deriving not so much from the Liver as from the Lungs and Heart.

This person becomes anxious as well as sad, feels depressed, sighs frequently and has the typical feeling of obstruction in the throat and chest. This is caused by the constriction of the Corporeal Soul in the throat and chest. The chronic stagnation of Heart-Qi obstructs the Shen and causes severe confusion. Therefore this formula is used literally to "get it off one's chest".

Whereas Liver-Qi stagnation derives often from pent-up and unexpressed feelings, stagnation of Heart- and Lung-Qi derives more from chronic worry and sadness. Therefore, where Open the Heart is indicated, the person will have a sense of someone whose soul is not at peace and they may be dealing with very deep issues in their life.

Calm the Shen
Calm The Shen treats the conditions of Spleen- and Heart-Blood deficiency. These patterns are caused by sadness, grief, worry or shock over a long period of time. These emotions deplete Qi of the Spleen, Heart and Lungs and, after some time, this gives rise to Blood deficiency. This patient will be sad, despondent, depressed and weary: he or she is prone to bouts of crying especially at the end of the day or when tired. Since this crying derives from a deficiency rather than from repressed, stagnant Qi, it does not relieve the mental state.

This pattern is commonly seen in students who are doing a lot of mental work and have a poor diet - both factors which weaken the Spleen. They may oscillate between feeling anxious and uptight about their work on the one hand, and sad, depressed and despondent on the other hand.

Root the Spirit
Root the Spirit is a variation of the ancient prescription "Attracting Sleep Decoction" (Yin Mei Tang). It is aimed at treating mental restlessness, anxiety, vexation and insomnia deriving from a deficiency of Liver-Blood and/or Liver-Yin; this leads to the Hun being unrooted and the person feeling restless and aimless.

Frustration, resentment, or old grudges can cause Liver-Blood or Liver-Yin to become deficient. The patient's Liver-Yin has been consumed by repressed anger over many years. He or she feels tense and anxious and sleeps badly, disturbed by unpleasant dreams. Another characteristic sign may be that the person has a peculiar floating sensation accompanied by a vague feeling of anxiety just as they are about to drop off to sleep.

In some cases, sadness depletes Liver-Blood or Liver-Yin. When it does, the person feels depressed and sad and sleeps badly, but does not dream much.

The patient also lacks a sense of direction and finds it difficult to focus on life's personal aims. They may seem "stuck in a rut" and be unable to see anyway out of their current situation. To ease their pain, they may resolve to work even harder which further depletes the Liver-Yin, and the more the Yin is depleted the harder they may find it to "switch off" and take a break; thus a vicious circle is created.

Freeing Constraint
The pre-menstrual tension addressed by this formula, a variation of Yue Ju Wan manifests with outbursts of anger, moodiness, depression, resentment, etc. all symptoms of severe stagnation of Liver-Qi. In this instance, the severe stagnation of Liver-Qi leads not only to unsettling of the Shen, but also a slight obstruction of the Shen. This many manifest with irrational behaviour and shouting at or hitting members of her family.

This formula addresses the emotional and mental manifestations of stagnation of Liver-Qi when it causes the Shen to be obstructed: moodiness, mental depression, pre-menstrual tension, irritability, frustration, annoyance and impatience. A typical feature of this condition of Shen obstructed is first of all a certain mental confusion deriving from stagnation, and secondly, a strong resistance to any mental or affective change.

Penetrating Vessel
This formula is specific to harmonize the Penetrating Vessel. Disharmonies of the Penetrating Vessel with rebellious Qi are very common in women. Rebellious Qi causing the feeling described as li ji in Chinese, is the major pathology of this vessel. This symptom can be interpreted on a mental level as a feeling of anxiety, or on a physical level as a tension of the connective tissues of the abdomen. Both these interpretations are valid.

This patient will feel anxious and agitated, especially pre-menstrually, as well as tired and depressed. They may be easily panicked. They will be pale and lack Shen in their eyes.

Freeing the Sun
This formula clears Liver-Heat deriving from Liver-Qi stagnation. This pattern is more common in men suffering from long-standing Liver-Qi stagnation (deriving from emotional problems) leading to some Liver-Heat. This formula could be described as a men's Freeing the Moon.

Liver-Qi stagnation is typically caused by repressed anger, frustration or resentment. This person may find it difficult to express anger appropriately, i.e. they may avoid expressing it when they have suffered an abuse as they tend to shy away from conflict, or they may "fly off the handle" at the smallest aggravation. They may oscillate between these two responses. Usually when anger is expressed it gives rise to Liver-Yang rising while, when it is repressed, it causes Liver-Qi stagnation. This patient is typically a man who is either irritable and prone to bouts of anger or he will appear depressed and subdued but the Wiry pulse betrays the pattern of Liver-Qi stagnation caused by anger. Long-term stagnation of Liver-Qi may give rise to Heat in the Liver which will cause the person also to become anxious and restless. However, this remedy is often applicable to women too.

COMPARISON OF FORMULAE

Release Constraint  and Freeing the Moon
Release Constraint differs from Freeing the Moon in so far as it is suitable for cases when the stagnation of Liver-Qi predominates and the condition is primarily full. Instead, Freeing the Moon is indicated in conditions of mixed deficiency and excess, with a deficiency of Liver-Blood and Spleen-Qi and with stagnation of Liver-Qi. The pulse and tongue are good discriminating factors between these two formulae: if the pulse is Wiry and the tongue is Red, Release Constraint is indicated; if the pulse is Choppy or Fine overall and Wiry in parts, and the tongue is Pale on the sides, Freeing the Moon is indicated.

Clear the Soul and Open the Heart
Clear the Soul is indicated when there is Phlegm-Heat in the chest, while Open the Heart is indicated when there is stagnation of Qi in the chest. Both these patterns may manifest with depression and a feeling of oppression and tightness in the chest. However, in the case of Phlegm-Heat, the patient will be more restless and may show some signs of manic behaviour, whereas in the case of stagnation of Qi in the chest, these manic signs (such as jumpiness, flustered feeling) will not be present.

As the names imply, when there is Phlegm-Heat in the chest, the spirit needs to be "cleared"; when there is stagnation, the appropriate action is one of "opening" to allow Qi and stuck emotions to "move on".

The most important discriminating factors, however, are the pulse and tongue. When Clear the Soul is indicated, there will be a sticky-thick-yellow coating on the tongue and the pulse will be Slippery-Rapid. When Open the Heart is indicated, the thick tongue coating will not be present and the pulse will be slightly Wiry in the front positions, as opposed to Slippery.

Calm the Shen  and Root the Spirit
Both Calm The Shen and Root the Spirit are indicated when there is Blood deficiency and therefore in both cases there will be anxiety and insomnia. However, Calm The Shen is indicated when the Blood deficiency is primarily of the Spleen and the Heart, where as Root the Spirit nourishes Liver-Blood. In terms of clinical manifestations, Calm The Shen is more suitable for someone suffering from sadness, weariness and crying, together with symptoms of weak Spleen-Qi, whereas Root the Spirit is suitable for someone suffering from anxiety, tension, insomnia and a lack of direction, together with symptoms of Liver-Blood and/or Yin deficiency.

When Spleen- and Heart-Blood deficiency are present, the spirit will be unsettled and anxious and thinking, sleep and the ability to feel joyful will be affected. As the name implies, the spirit needs to be "calmed". However when Liver-Blood and/or Yin are deficient, the Hun does not have a proper resting place and begins to wander. Therefore, it needs to be "rooted" rather than merely calmed.

Freeing the Sun  and Freeing the Moon
Both Freeing the Sun (from the Three Treasures) and Freeing the Moon (from the Women's Treasure) are indicated when there is Liver-Qi stagnation against a background of Liver-Blood deficiency. However, in the case of Freeing the Sun, the chronic Liver-Qi stagnation has lead to some Liver-Heat causing additional symptoms such as a feeling of heat, slight thirst or a slight bitter taste. The sides of the tongue being Red (in the Liver area) is, in itself, enough to confirm the presence of some Heat in the Liver. In cases where Freeing the Moon is indicated, the sides of the tongue would be Pale.

In both cases, the person may oscillate between "flying off the handle" and feeling tired, tearful and lethargic. However, where Freeing the Sun is indicated, there will also be an element of restlessness and anxiety.

Breaking Clouds  and Calm the ShenThe names of these two remedies conjure up an image of the type of depression they are indicated for. A cloudy sky is heavy, oppressive and dark and it obscures one's view. And so with a patient suffering from Spleen-Qi deficient and sinking, they will have a sense of heaviness and oppression, a loss of insight and their mood will be gloomy and dark. "Breaking" the clouds will allow light to seep through, the heaviness and oppressiveness will diminish and the view will become clearer: lifting and strengthening Spleen-Qi can be equated with allowing the sun to begin to peep through the clouds. Its effect is to "lighten" the mood.

Conversely, when Spleen-Blood as opposed to Spleen-Qi is deficient, the person will lack a sense of being grounded and centred. Calm The Shen helps to "root" and "hold" the person's Spirit by calming an overactive mind. So this formula has more of an "earthing" effect as opposed to Breaking the Clouds which has a "lifting" effect.

Researched by Rebecca Avern
Written by Giovanni Maciocia

Understanding Glaucoma

With an Emphasis on Primary Open-Angle Glaucoma

Introduction
Glaucoma is one of the leading causes of irreversible blindness, with nearly 70 million people suffering from this chronic ophthalmologic condition worldwide. Ninety percent of all cases are primary open-angle glaucoma (POAG). POAG is often called ‘the silent thief of sight’, as in the early disease phase, typically no symptoms are experienced. Patients may experience progressive worsening of their vision, initially peripherally (i.e., vision outside the center of gaze), but eventually involving the central vision. (Vandenbroeck et al 2011)

Primary open angle glaucoma is described distinctly as a multifactorial optic neuropathy that is chronic and progressive with a characteristic acquired loss of optic nerve fibers. Such loss develops in the presence of open anterior chamber angles, characteristic visual field abnormalities, and intraocular pressure (IOP) that is too high for the healthy eye. (Kokotas et al 2012)

Glaucoma is considered as a progressive optic neuropathy often caused by elevated intraocular pressure consequent to abnormally high resistance to aqueous humor (AH) drainage via the trabecular meshwork (TM) and Schlemm’s canal. Morphological and biochemical analyses of the TM of patients with POAG revealed the loss of cells, increased accumulation of extracellular matrix proteins (ECM), changes in the cytoskeleton, cellular senescence, and the process of subclinical inflammation. The TM is the target tissue of glaucoma in the anterior chamber, and the development and progression of glaucoma are accompanied by the accumulation of oxidative damage in this tissue. (Babizhayev MA 2012)

Glaucoma is an optic neuropathy, specifically a neurodegenerative disease characterized by loss of retinal ganglion cells (RGCs) and their axons. In the past, glaucoma was viewed as a disease of raised intraocular pressure (IOP); however, it has become increasingly clear that elevated IOP is only one of the risk factors for this disease. Recent evidence indicates that lowering IOP does not prevent progression in all patients and that progression can continue despite effective lowering of IOP. (Vasudevan et all 2011)

Glaucoma filtering surgery may be compromised by cystic blebs which develop more frequently when anti-metabolites are used to arrest wound healing. Matrix metalloproteinases (MMPs) and the naturally occurring tissue inhibitors of metalloproteinases (TIMPs) are essential in connective tissue remodeling and wound healing. Increased MMPs and TIMPs expression is associated with the formation of filtering blebs, suggesting involvement of MMPs in bleb remodeling. MMP-2 and ProMMP-2 levels in tear fluid may be markers for bleb configuration. (Mathalone et al 2011)

The trabecular meshwork (TM) accounts for about 70–90% of total aqueous humor (AH) outflow from the anterior chamber in the adult human eye. Moreover, the TM constitutes an outflow resistance and thereby determines the intraocular pressure (IOP). Increase of outflow resistance and IOP, eventually, is a major risk factor in primary open angle glaucoma (POAG). POAG patients exhibit specific morphological peculiarities as accumulations of extracellular matrix material (ECM) and condensation or clustering of the cytoskeleton. Frequently, signs of subclinical inflammation are reported. Moreover, deregulations on the cellular level affecting signaling pathways regulating apoptosis, cellular senescence and cell cycle control were observed in ocular cells of POAG patients. (Tourtas et al 2012)

Current glaucoma therapy relies on drugs that lower intraocular pressure (IOP), and several glaucoma medications are effective at lowering IOP when administered properly. However, poor adherence is a fundamental problem that increases with the age of the patient, and approximately 20% of patients eventually require surgery to lower IOP. An alternative treatment approach may lie in the use of neuroprotective agents, designed to promote RGC survival independent of IOP. The most common way to reduce IOP is topical administration of eye drops one or more times daily. (Lavik et al 2011)

There are several classes of effective topical glaucoma medications that lower the IOP. They include prostaglandin analogs (eg, latanoprost), beta-blockers (eg, timolol), alpha-adrenergics (eg, brimonidine), carbonic anhydrase inhibitors (eg, dorzolamide), and cholinergics (eg, pilocarpine). (Lavik et al 2011)

Certain yoga exercises in inverted position (like Sirsasana) leads to two- to three-fold IOP rise from baseline for short duration. We documented a three-fold increase in IOP during the inverted position (IOP checked with Tonopen?) in at least three of our progressive POAG patients with good 24-hour IOP control (personal communication with Dr. Rajul S Parikh). Though evidence is not sufficient to prove the role of inverted yoga exercises as a causal risk factor for glaucoma progression, it is imperative to inform glaucoma patients about IOP elevations associated with inverted posture. (Parikh R & Parikh S)

Blood Tests in Glaucoma
Glucose & insulin – Glaucoma has been positively linked to diabetes mellitus. Glaucoma is more often present in the elderly. Important prognostic factors of glaucoma may be oxidative stress resulting from the toxic effects of glucose, and diabetes-associated vascular complications. Our observations suggest that the generation of reactive oxygen species may promote localized DNA damage in glaucoma-iris tissues of elderly patients vulnerable to diabetic injury. (Szaflik et al 2010)

Homocysteine (Hcy) and hydroxyproline (Hyp) – Increased levels of aqueous humor Hcy and Hyp may be associated with primary open angle glaucoma (POAG). In addition, Hcy and Hyp may be useful protein levels in aqueous humor of POAG patients as a consequence of glaucomatous damage. (Ghanem et al 2012)

hs-C-reactive Protein (CRP) – Measurement of hs-CRP, an inflammatory biomarker, independently predicts future vascular events and improves global classification of risk of cardiovascular diseases. (Shen et al 2012)

Lipid Panel – Serum lipid values could be one of predictable factors in primary open-angle glaucoma diagnosis. Due to the patient age, cholesterol values, as common factors in primary open-angle glaucoma and atherosclerosis genesis, could be concern in the same aetiology based on dyslipidaemia as well. (Pavljasevic & Asceric 2009)

Lipid Panel – The lipid profile exhibited a mild elevation in the patients with POAG. (Su et al 2007)

IL-6 - In glaucoma, the optic nerve head (ONH) is the principal site of initial axonal injury, and elevated intraocular pressure (IOP) is the predominant risk factor. Cell proliferation and IL-6-type cytokine gene expression, rather than astrocyte hypertrophy, characterize early pressure-induced ONH injury. (Johnson et al 2011).

TCM formulas for Glaucoma:

Qi Ju Di Huang Wan
Long Dan Xie Gan Tang
Ming Mu Di Huang Wan

Natural Compounds Helpful in Glaucoma
Anti-oxidants –  One factor in the focus of investigative glaucoma research is oxidative stress, as one of the main problems in glaucoma is an imbalance of reactive oxygen species (ROS) formation and decomposition resulting in ROS accumulation, as well as general reduction of anti-oxidant capacities. trabecular meshwork cells were shown to be especially sensitive to oxidative stress, and typical responses affect ECM synthesis, and basic cellular processes, like cell cycle control, proliferation, apoptosis and cellular metabolism. In this respect, prophylactic intake of dietary supplements with alleged antioxidant capacities is recommended for protection from deleterious effects of oxidative stress and prevention of glaucoma thereby. (Tourtas et al 2012). 

Ginkgo Biloba extract administration appears to improve preexisting visual field damage in some patients with normal tension glaucoma. (Quaranta et al 2003)

Hyaluronic acid (HA) – is one of the major components of the ECM and may attribute to the filtration function of the trabecular meshwork. The depletion of HA may increase aqueous outflow resistance in the trabecular meshwork of primary open angle glaucoma (POAG) patients. In POAG trabecular meshwork cells, the level of HA concentration increases the activities of MMP-2 and MMP-9. The lack of HA in aqueous humor can result in a reduction in activities of MMPs and therefore may be involved in the pathogenesis of POAG. (Guo & Liang 2012)

Omega-3 Fatty Acids - The stimulation of IL-6, a key pro-inflammatory interleukin and circumscribed oxidative stress marker, was repressed by ?-3 and ?-6, for the former even to a significant extent. Based on the observed side effects of omega-6, omega-3 appears to be the more beneficial fatty acid in respect of prophylactic intake for prevention of a glaucomatous disease. (Tourtas et al 2012)

Vitamin E - The importance of oxidative stress in both the formation and the course of glaucoma has been known. Neuroprotective effects of vitamin E compounds in retinal diseases and glaucoma have been clincally demonstrated. (Engin et al 2010)

WESTERN MEDICAL PERSPECTIVE

Definition
Endometriosis is a condition resulting from the presence of actively growing and functioning endometrial tissue in locations outside the uterus. The areas where endometriosis may occur are widespread and usually multiple. They include:

•       the ovaries          
•       sigmoid colon
•       uterine wall          
•       rectum
•       Fallopian tubes          
•       ureters
•       abdominal scars          
•       bladder
•       umbilicus              
•       vagina

Occurrence
The incidence of endometriosis is currently on the increase. The following groups may be affected by it:

•       women between the ages of 25-40 who have not had children
•       teenagers (previously not thought to be commonly affected)
•       women who have undergone elective tubal sterilization
•       familial incidence (7% relative risk of developing it if a first-degree female relative has it)
•       there seems to be a correlation between endometriosis and the use of tampons, intercourse during menstruation and the use of the intrauterine contraceptive device (the coil)

Aetiology
Although many theories exist, the pathogenesis of endometriosis is still not fully understood in the Western medical world. The following are some of the most common theories:

•       retrograde menstruation and tubal reflux: proposed by Samson who believed that menstrual blood was forced out along the fallopian tubes into the peritoneal cavity. He suggested that menstrual blood contains fragments of endometrium which may implant on pelvic structures and grow. Excessive uterine contractions characteristic of primary dysmenorrhoea (often present in women with endometriosis) may contribute to a bidirectional menstrual flow from the uterus.
•       celomic metaplasia: proposed by Meyer and Ivanoff who suggested that all tissues in which endometriosis arises are embryologically derived from celomic epithelium, i.e. peritoneal cells change into endometrial tissue. Chronic irritation of the peritoneum by menstrual blood may cause celomic metaplasia, which can subsequently result in endometriosis.
•       direct implantation: according to this theory, endometrial tissues are displaced into an implant in the new sites. This explains why endometriosis may be found in surgical scars.
•       genetic and immunologic factors: there is a 5.8 percent familial incidence among immediate female siblings, an 8.1 percent risk if the mother had endometriosis and a 7 percent risk if a female sibling has endometriosis. These figures suggest a polygenic and multifactorial inheritance for endometriosis.
•       lymphatic dissemination: Halban suggested that normal endometrium might "metastasize" via lymphatic channels and thus spread to extrauterine sites where implantation and growth would produce the characteristic lesions of endometriosis.
•       vascular theory: this theory was proposed by Navratil who suggested that normal endometrium was deported via the veins to remote areas of the body.

Pathology
There are three diagnostic histologic features of endometriosis. They are:

•       endometrial glands
•       endometrial stroma
•       evidence of haemorrhage

The typical lesion will show an abundance of inflammatory cells and fibrous connective tissue.

Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the ovary or as larger cysts which may be up to 10cm in size (known as endometriomas or "chocolate cysts" and which may rupture. In the ovary, the process is almost always bilateral. There is usually considerable fibrosis and puckering of the ovarian surface in the region of the cyst as well as adherence to neighbouring structures.

In the other most frequently involved areas, i.e., throughout the pelvic peritoneum, the lesions are normally smaller and more numerous and are surrounded by dense, fibrous scar tissue.

Clinical manifestations
The most commonly seen symptoms and signs of endometriosis are as follows:

I.    dysmenorrhoea (severe pain beginning before menstruation and continuing almost to the end)
II.    pelvic pain
III.    lower backache radiating to the anterior thigh
IV.    heavy periods
V.    irregular bleeding
VI.    infertility (since inflammation, scar tissue and adhesions in the pelvis may obstruct the passage of an egg along the fallopian tube)
VII.    dyspareunia
VIII.      pain sometimes accompanied by nausea and vomiting or diarrhoea
IX.    pain on defecation
X.    rectal pressure
XI.    tender and enlarged ovaries
XII.    pelvic nodularities and thickenings

It is important to note, however, that 30-35% of patients with endometriosis do not suffer any pain or discomfort, though they may suffer from other manifestations such as infertility or pelvic masses. Also, there is no direct correlation between the severity of the pain and the extent of endometriosis: thus, a woman with advanced endometriosis may suffer less pain than a woman with the beginning stages of the disease.

Diagnosis
Diagnosis of endometriosis is made principally by taking a clinical history. If it is suspected, confirmation is usually obtained by laparoscopy which shows endometriotic cysts and deposits. Definitive diagnosis can be made by microscopic examination of excised tissue that demonstrates both glands and stroma.

Diagnosis is, however, fraught with difficulties and is affected by subjectivity. Laparoscopy relies entirely on the visual and very subjective assessment of the pelvis by the operator and consequently is prone to misinterpretation and subjectivity. Another difficulty is that the symptoms of endometriosis are very similar to those of other diseases, e.g. pelvic inflammatory disease, ovarian tumours and irritable bowel syndrome making differential diagnosis problematic.

CHINESE MEDICINE PERSPECTIVE

Aetiology

Intercourse during menstruation
When a woman becomes sexually aroused, the Minister Fire goes upwards. If this happens when menstrual blood is flowing downwards, the two will "meet", blocking each other and therefore leading to stagnation of Qi and Blood in the Uterus.

Excessive physical work or exercise
Excessive physical work or exercise can weaken the Spleen, Liver and the Kidneys and adversely affect the Chong and Ren Mai. This is especially the case during puberty when the Chong and Ren Mai are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation.

Excessive exercise, especially at puberty, during the period or when pregnant, will weaken the Spleen and Kidneys possibly leading to a whole host of problems including a deficiency of Yin, Yang, Qi or Blood and stagnation of Qi and Blood.

External Cold
Women are particularly prone to invasion of Cold just before, during and just after the period, as well as just after childbirth. When Cold invades the Uterus, it contracts causing Blood to stagnate.

Tampons
Tampons block the normal downward flow of menstrual blood thereby leading to stagnation of Blood.

Too early sexual activity
Too early sexual activity (i.e. during puberty) damages the Chong and Ren Mai and renders the Uterus more vulnerable to Blood stasis later in life.

Pathology
The Western disease entity of "endometriosis" broadly corresponds to the Chinese disease-symptom of "Painful Periods": in other words, the pathology, patterns and treatment for Painful Periods is applicable to endometriosis. However, there is an important difference. It is generally agreed by all Chinese gynaecologists that in endometriosis there is always Blood stasis and that endometriosis should be treated as "Abdominal Masses" in Chinese gynaecology. In other words, the endometrial lesions should be considered a form of abdominal masses even though they are not palpable. The important implication of this is that, in the herbal treatment, herbs that "break Blood" and dissolve masses should be chosen.

I.    In endometriosis there is always Blood stasis, but in infertility due to endometriosis there are other factors at play and especially Kidney-Yang deficiency causing a luteal insufficiency. In treatment, place the emphasis on Biao, i.e. Blood stasis only if the period is very painful.
II.    There is always a Kidney deficiency and disharmony of Liver and Spleen
III.    Retention of menses is an important factor, often occurring after childbirth. "Retention of menses" refers to an insufficient discharge of blood during menstruation.
IV.    The temperature chart is flat in endometriosis for two reasons, one due to Biao, the other to Ben. The temperature does not decrease enough during the period because of Blood stasis (Biao) and it does not increase enough after ovulation due to Kidney-Yang deficiency (Ben).
V.    Yang not growing enough during phase 4 so that Yin pathogenic factors are not expelled (see Winter 2002 Newsletter).
VI.      As modern women have a much higher number of menstrual cycle throughout their lifetime, it means they will have all the more "retention of menses". This is due to earlier menarche, later menopause, fewer children, shorter breastfeeding.

Treatment Principle

The main patterns appearing in endometriosis and the relevant remedies are as follows:

I.    Liver-Blood stasis (Stir Field of Elixir Harmonizing the Moon, Invigorate Blood & Stem the Flow)
II.   Stagnation of Cold in the Uterus (Warm the Menses)
III.  Damp-Heat in the Uterus (Drain Redness)
IV.   Damp-Phlegm in the Uterus (Clear the Palace)
V.    Kidney-Yang deficiency (Unicorn Pearl)
VI.   Kidney-Yin deficiency (Growing Jade)
VII.  Blood deficiency (Precious Sea)

Combinations Of Patterns

1) KIDNEY-YANG DEFICIENCY WITH BLOOD STASIS AND DAMPNESS
Clinical manifestations
Painful periods, abdominal pain which is relieved by warmth, mid-cycle hypogastric pain, possibly abdominal masses, lower backache, scanty or heavy periods, dark blood with clots, vaginal discharge, feeling cold.
Tongue: Swollen, Pale with Purple sides.
Pulse: Deep-Weak-Slippery-Wiry.

Treatment Principle
1. Menstrual phase: invigorate Blood, eliminate stasis. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness. Clear the Palace or Drain Redness if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): Invigorate Blood, eliminate stasis, resolve Dampness. Harmonizing the Moon.

2) KIDNEY-YANG DEFICIENCY WITH COLD IN THE UTERUS AND DAMPNESS
Clinical manifestations
Severe abdominal period pain, pain central, pain relieved by the application of heat, menstrual blood scanty with small, dark clots, feeling cold, white vaginal discharge, lower backache, feeling of fullness and heaviness.
Tongue: Pale-Bluish or Bluish-Purple with sticky-white coating.
Pulse: Deep-Weak-Tight.

Treatment principles
1. Menstrual phase (about 5 days): invigorate Blood, eliminate stasis, scatter Cold, warm Yang. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi, resolve Dampness. Clear the Palace or Drain Redness if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, scatter Cold, resolve Dampness. Harmonizing the Moon.

3) KIDNEY-YIN DEFICIENCY WITH BLOOD STASIS AND DAMPNESS
Clinical manifestations
Painful periods, stabbing or heavy abdominal pain, mid-cycle hypogastric pain, possibly abdominal masses, sore back, scanty or heavy periods, vaginal discharge, dizziness, tinnitus.
Tongue: without coating.
Pulse: Floating-Empty and Slippery-Wiry.

Treatment Principle
1. Menstrual phase (about 5 days): Invigorate Blood, eliminate stasis. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): nourish Kidney-Yin, tonify Spleen-Qi. Growing Jade
3. Mid-cycle phase (about 7 days): Nourish Kidney-Yin, tonify Spleen-Qi, resolve Dampness. Clear the Palace or Drain Redness if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, resolve Dampness. Harmonizing the Moon.

4) BLOOD STASIS WITH KIDNEY-YANG DEFICIENCY WITH DAMP-PHLEGM IN THE UTERUS
Clinical manifestations
Painful periods, abdominal pain which is relieved by warmth, mid-cycle hypogastric pain, soft and moveable abdominal masses, tingling limbs, dizziness, lower backache, scanty or heavy periods, dark blood with clots, excessive vaginal discharge, feeling cold.
Tongue: Swollen, Pale with Purple sides.
Pulse: Deep-Weak-Slippery-Wiry.

Treatment Principle
1. Menstrual phase: invigorate Blood, eliminate stasis. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): warm and tonify Kidney-Yang, tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness and Phlegm. Clear the Palace.
4. Pre-menstrual phase (about 7 days): Invigorate Blood, eliminate stasis, resolve Dampness and Phlegm. Harmonizing the Moon.

By Giovanni Maciocia

DESCRIPTION

Originally described by Stein and Leventhal, Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age. According to the initial description by Stein and Leventhal in 1935, the diagnosis of PCOS was based on the clinical symptoms (oligo/amenorrhoea, infertility, hirsutism, and obesity) in the presence of histologically verified polycystic ovaries. Presently, ovarian morphology can easily be identified by ultrasound, which has revealed that PCOS is not only linked to the "classic Stein-Leventhal syndrome", but women with polycystic ovaries exhibit a wide spectrum of clinical presentations.

PCOS account for 75% of women with anovulatory infertility, 30% to 49% of secondary amenorrhea, and 85% to 90% of women with oligomenorrhea. The majority of patients with PCOS are hirsute. Obesity is also a frequent finding among women with PCOS. 30 to 60% of PCOS patients are overweight.

PCOS often comes to light during puberty due to period problems, which affect around 75% of those with the disease. Infrequent, irregular or absent periods are all common variations, many finding their periods particularly heavy when they do arrive. The period disturbance is a sign that there is a problem with regular monthly ovulation. Many teenagers use the contraceptive pill to control their periods as irregularity or heaviness is a common complaint at this time, even in the absence of PCOS. This often leads to a delay in the diagnosis of PCOS, many not presenting until the pill is stopped and finding periods cease or become irregular.

Endocrinology
Endocrinologically PCOS is also heterogenous; classically it is characterized by hyperandrogenism, inappropriate pituitary gonadotropin secretion, which causes an elevated LH to FSH ratio, and hyperinsulinism.

DIAGNOSIS

Ultrasound scan
This is usually done as an internal scan, meaning a small ultrasound probe is placed just inside the vagina, giving the best views of the ovaries and pelvic organs. In PCOS, the ovaries are found to have multiple, small cysts around the edge of the ovary. These cysts are only a few millimetres in size, do not in themselves cause problems and are partially developed eggs that were not released.

Blood tests
A couple of blood tests will assist in making the diagnosis - one to check the level of androgens, such as testosterone. Another test will measure the hormones involved in egg development - in PCOS there is a characteristic rise in lutenising hormone (LH). A progesterone blood test 7 days before the expected menstrual period can check if the woman is ovulating.

Although 60 years have passed since the first description of the syndrome, its definition and diagnostic criteria are still controversial. Several hormonal assays have been widely used to support the diagnosis, and are essential for exclusion of specific disorders which can cause polycystic ovaries. Accurate endocrine characterization of patients enables the recognition of biochemically more homogeneous subgroups of PCOS, which further provides facilities to better evaluate the pathogenesis of each of these subsets, and provide data necessary for formulating specific therapy.

CLINICAL MANIFESTATIONS

I.    Obesity
II.    Amenorrhoea or oligomenorrhoea
III.    Infertility. Given that the period disruption with PCOS is due to irregular or absent ovulation it is not surprising that it is a common cause of infertility. It is not usually 100% absolute, and some women with PCOS will ovulate normally, some will ovulate less frequently (leading to a delay to pregnancy) and some will not ovulate at all.
IV.    ïHirsutism
V.    Ovaries are enlarged and smooth. The tunica albuginea is thickened and beneath it are numerous small cystic follicles, varying in size but seldom exceeding .5 cm in diameter.
VI.    Failure of the ovarian enzyme system which are necessary for the production of oestrogen.
VII.    Reduced oestrogen
VIII.    Raised testosterone
IX.    Raised ratio LH:FSH

TREATMENT

Periods may be controlled by the use of the contraceptive pill, which is most suitable for women under the age of 35 who also require a good form of contraception. The other type of drug used is a progesterone-like hormone. Progesterone is the main hormone of the second half of the menstrual cycle, maintaining its length and helping reduce the heaviness. Progestagens are taken as tablets in a cyclical way, for example between days 12-26, the exact type and timing depending upon the woman's individual cycle problem.

Some women have no periods at all, and either the contraceptive pill or cyclical progestagens are advisable to avoid the risk of endometrial cancer. Around 6 periods per year is adequate to protect against this.
CHINESE MEDICINE PERSPECTIVE

In Chinese medicine, POS may correspond to several different gynaecological diseases:

I.    Scanty periods
II.    Amenorrhoea
III.    Infertility
IV.    Flooding and Trickling (Beng Lou)
V.    Irregular periods

CLINICAL MANIFESTATIONS

From a purely Chinese medicine perspective, i.e. ignoring hormonal changes and histological changes in the ovaries, the clinical manifestations are:

I.    Amenorrhoea or scanty periods
II.    Irregular periods
III.    Hirsutism
IV.    Obesity
V.    Infertility

Interpretation of clinical manifestations

I.    Amenorrhoea or scanty periods: deficiency of Blood of the Chong Mai; also Blood stasis within the Chong Mai. Menstrual blood is a manifestation of Tian Gui and therefore there is always a Kidney deficiency which may be Yin or Yang
II.    Hirsutism: dysfunction of the Chong Mai with imbalance between Qi and Blood. A deficiency of Blood in the Uterus leads to amenorrhoea, but this would mean that there is more Blood available at the skin level to promote the growth of hair
III.    Obesity: Damp-Phlegm affecting both the Chong Mai and the Ren Mai
IV.      Ovarian cysts: Damp-Phlegm in the Chong and Ren
V.    Hormonal imbalance, raised testosterone: dysfunction of the Du Mai, the Yang aspect of the menstrual cycle
VI.    Hormonal imbalance, raised LH: an increase in Yang (but only relative to Yin, oestrogen) and therefore a condition of Heat in the Liver and Chong Mai.

PATTERNS

Explanation of clinical manifestations according to patterns

I.    Damp-Phlegm: there is nearly always Damp-Phlegm. The ovarian cysts are due to Damp-Phlegm
II.    Kidney deficiency: there is always a Kidney deficiency in POS causing the hormonal imbalance. This can be Yin or Yang, more often Yang
III.    Blood stasis: there may be Blood stasis especially if the ovarian cysts are palpable and the periods painful
IV.    Liver-Fire: there may be Liver-Fire or Damp-Heat in the Liver channel
V.    Blood deficiency: there may be Blood deficiency which causes scanty periods or amenorrhoea.

DAMP-PHLEGM IN THE UTERUS

Damp-Phlegm in the uterus is the main pathogenic factor in polycystic ovary syndrome. Damp-Phlegm in the uterus manifests with the following symptoms and signs:

I.    Leucorrhoea
II.    Tongue swollen with sticky coating at the root
III.    Tendency towards obesity
IV.    Fullness and heaviness of the abdomen
V.    Slippery pulse
VI.    Mid-cycle problems (slight pain, discomfort, heaviness, bleeding)

In addition, there may be some general symptoms of Phlegm such as expectoration of phlegm and a feeling of oppression of the chest.*

Clear the Palace

The remedy to resolve Damp-Phlegm from the uterus is Clear the Palace. This remedy is a variation of the formula Qi Gong Wan which is specific to resolve Damp-Phlegm in the uterus in infertility.

Although it contains one Kidney tonic (Tu Si Zi), Clear the Palace is primarily to resolve Damp-Phlegm and treat infertility resulting from obstruction of the uterus by Damp-Phlegm.

PATTERNS AND TREATMENT

Rather than discuss individual patterns, I will discuss common combinations of patterns.

1) Damp-Phlegm, Kidney-Yang Xu

Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, low spirits, Pale and Swollen tongue with sticky coating, Weak and slightly Slippery pulse.

Treatment principle and prescriptions
1) Phase 2: tonify Kidney-Yang. Unicorn Pearl.
2) Phases 3 and 4: resolve Damp-Phlegm. Clear the Palace.

2) Damp-Phlegm, Kidney-Yang Xu, Blood Statis

Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark-clotted blood, abdominal pain, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, low spirits, Pale, Bluish-Purple and Swollen tongue with sticky coating, Weak and slightly Slippery or Firm pulse.

Treatment principle and prescriptions
2) Phase 1: invigorate Blood. Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy)
3) Phase 2: tonify Kidney-Yang. Unicorn Pearl.
4) Phases 3 and 4: resolve Damp-Phlegm. Clear the Palace.

3) Damp-Phlegm, Kidney-Yin Xu, Blood Statis

Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark-clotted blood, abdominal pain, backache, dizziness, tinnitus, night-sweating, feeling of heat in the evening, tiredness, low spirits, Swollen tongue with sticky-rootless coating or without coating, slightly Purple on the sides, Weak and slightly Slippery or Firm pulse.

Treatment principle and prescriptions
3) Phase 1: invigorate Blood.Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy)
4) Phase 2: nourish Kidney-Yin. Growing Jade.
5) Phases 3 and 4: resolve Damp-Phlegm. Clear the Palace.

4) Damp-Phlegm, Damp-Heat, Kidney-Yang Xu

Clinical manifestations
Feeling of fullness and heaviness of the abdomen, excessive vaginal discharge, acne, hirsutism, feeling of heat, dark urine, scanty periods, amenorrhoea, mid-cycle bleeding and/or pain, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, low spirits, Pale and Swollen tongue with sticky-yellow coating on the root, Weak and slightly Slippery pulse.

Treatment principle and prescriptions
3) Phase 2: tonify Kidney-Yang. Unicorn Pearl.
4) Phase 3: resolve Dampness, clear Heat. Drain the Jade Valley.
5) Phase 4: resolve Damp-Phlegm. Clear the Palace.

EXTRAORDINARY VESSELS TREATMENT

Ren Mai: LU-7 Lieque (on the right) and KI-6 Zhaohai (left), Ren-4 Guanyuan, ST-28 Shuidao, Zigong.
Chong Mai: SP-4 Gongsun (right) and P-6 Neiguan (left), KI-14 Siman, SP-10 Xuehai, LIV-3 Taichong.
Du Mai: SI-3 Houxi (right) and BL-62 Shenmai (left), Ren-4 Guanyuan, Du-3 (Yaoyangguan).
Du Mai and Ren Mai: SI-3 Houxi (right), BL-62 Shenmai (left), LU-7 Lieque (left), KI-6 Zhaohai (right), Ren-4 Guanyuan, Du-20 Baihui, Du-3 Yaoyangguan.Journal of Chinese Medicine, no. 51, Cao Wen Zhong and Xu Hui Qing "Some Difficult Cases Treated by Acupuncture", p. 9.

LU-7 Lieque (to activate Ren Mai)
BL-32 Ciliao to invigorate Blood
ST-25 Tianshu to move Qi and invigorate Blood
Du-1 Changqiang to invigorate Blood
ST-40 Fenglong to resolve Phlegm and Dampness
SP-6 Sanyinjiao "for a moderating effect to avoid injury to Qi"
L.I.-4 Hegu and LIV-3 Taichong to tonify and regulate Qi and Blood and to balance Yin and Yang
BL-31 Shangliao, BL-32 Ciliao, BL-33 Zhongliao, BL-34 Xialiao every 3rd treatment with Fire needle.

Journal of Chinese Acupuncture Zhong Guo Zhen Jiu, no. 4, 1999, p. 199.
-Ovarian failure: Ren-4 Guanyuan, Ren-3 Zhongji, KI-12 Dahe, BL-23 Shenshu.

Journal of Chinese Acupuncture Zhong Guo Zhen Jiu, no. 7, 2000, p. 399.
-Ovarian failure by treating the Du Mai: Du-14 Dazhui, Du-13 Taodao, Du-12 Shenzhu, Du-10 Lingtai, Du-9 Zhiyang, KI-1 Yongquan. (Explanation: Du Mai, together with Chong and Ren Mai, connects with the Heart and Kidneys).

Journal of Chinese Acupuncture Zhong Guo Zhen Jiu, no. 12, 1999, p. 727.
-Ovarian failure treated with moxibustion: Ren-4 Guanuan, Zigong, SP-6 Sanyinjiao.

By Giovanni Maciocia

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.

By Giovanni Maciocia

This article is dedicated to the discussion of the remedy Chemo-Support which is intended to minimize the side effects of chemotherapy. This remedy was formulated 15 years ago and it has been used by many patients undergoing chemotherapy.

CHEMOTHERAPY SIDE-EFFECTS FROM THE POINT OF VIEW  OF CHINESE MEDICINE

If we analyze the side-effects or chemotherapy, there are important differences between various cytotoxic drugs and one could conceivably formulate an individual Chinese herbal formula for each.  However, one can identify common characteristics among the above side-effects.  We can attempt to group the side-effects according to the Chinese pathological pattern induced by the various cytotoxic drugs.  Looking at the side-effects of each drug, four patterns in particular stand out:

1.    DEFICIENCY OF QI, BLOOD AND YIN
Hair loss, diarrhoea, nail ridging, bone-marrow suppression, malaise, fatigue, depression, loss of appetite, neurological damage, dizziness, constipation, numbness, tingling, paraesthesia of hands and feet.

2.    ST-QI REBELLING UPWARDS
Nausea, vomiting.

3.    STOMACH HEAT
Mouth ulcers, stomatitis, stomach ulcers.

4.    BLOOD HEAT
Haematuria, fever, skin reactions, cystitis.

Thus, we can deduce from the analysis of the above patterns that cytotoxic drugs cause the following:

1.    Qi, Blood and Yin deficiency (of Stomach, Lungs, Liver and Kidneys)
2.    Stomach-Qi rebelling upwards
3.    Stomach Heat
4.    Blood Heat.

The treatment principles to adopt are therefore (the herbs used are indicated in brackets):

Tonify Qi, Blood and Yin (Huang Qi Radix Astragali, Ren Shen Radix Ginseng, Ling Zhi Ganodermae, Mai Men Dong Radix Ophiopogonis, Dang Gui Radix Angelicae  sinensis, Nu Zhen Zi Fructus Ligustri lucidi, Huang Jing Rhizoma Polygonati)

Subdue rebellious Stomach-Qi (Lu Gen Rhizoma Phragmitis, Ban Xia Rhizoma Pinelliae preparatum, Sha Ren Fructus Amomi)

Clear Stomach Heat (Lu Gen Rhizoma Phragmitis, Zhi Mu Radix Anemarrhenae)

Cool Blood (Mu Dan Pi Cortex Moutan)

ANALYSIS OF INDIVIDUAL HERBS  IN CHEMO-SUPPORT
-      Huang Qi Radix Astragali: tonify Qi and raise immune response.
-      Ren Shen Radix Ginseng: tonify Qi.
-      Ling Zhi Ganodermae: tonify Qi and Blood and raise the immune response.
-      Mu Dan Pi Cortex Moutan: cool Blood.
-      Zhi Mu Radix Anemarrhenae: clear Heat.
-      Fu Ling Poria: resolve Dampness.
-      Chen Pi Pericarpium Citri reticulatae: resolve Dampness, stop nausea.
-      Mai Men Dong Radix Ophiopogonis : nourish Yin.
-      Dang Gui Radix Angelicae sinensis: nourish Blood
-      Ban Xia Rhizoma Pinelliae preparatum: resolve Phlegm, subdue rebellious Stomach-Qi, stop nausea and vomiting.
-      Lu Gen Rhizoma Phragmitis: clear Stomach-Heat, stop vomiting.
-      Nu Zhen Zi Fructus Ligustri lucidi
-      Sha Ren Fructus Amomi: move Qi, resolve Dampness, stop nausea.
-      Huang Jing Rhizoma Polygonati: tonify Qi, nourish Yin and Jing.
-      Gan Cao Radix Glycyrrhizae uralensis: harmonize.



DOSAGE AND PROTOCOL
Chemo-Support works better if it is started some time before the beginning of chemotherapy and continued for about two weeks after the end. It is important to note that “during the treatment” means during the course of treatment, i.e. also in the days of break from the treatment.  The dosage is as follows:

-       Two weeks before start of treatment: 2 tablets a day
-       Four days before the start of treatment: 2 tablets twice a day
-       During the treatment: 3  tablets three times a day
-       After the end of the treatment for about 4 weeks: 2 tablets twice a day

It is best to take the tablets away from meals, i.e. about 1 hour before or after a meal, swallowed with hot water.  The tablets should also be taken separately from other medication, at least 1 hour away.  If the patient feels very nauseous and finds it difficult to swallow the tablets, these could be crushed and powdered, immersed in a small amount of hot water with three slices of fresh ginger and the water sipped slowly.

The dosage during treatment indicated above should be adjusted according to the severity of the side-effects and the above dosage could be reduced or increased.

If the patient is receiving both chemo- and radio-therapy and is taking both Chemo-Support and Radio-Support, the dosage of each should be reduced.  Adjustments can be made according to the patient’s side-effects and timing of therapies in this situation by using a higher ratio of Chemo-Support during the days surrounding chemotherapy or when its side-effects are heightened.  Similarly, the dosage of Radio-Support can be increased if the side-effects experienced from radiotherapy are more severe, or during the days surrounding the administration of radiotherapy.

Chemo-Support should be discontinued approximately four weeks after the end of the treatment when the condition should be reassessed and a different formula given.  By contrast, Radio-Support should be continued for at least 6 weeks after the end of radiotherapy.

ACUPUNCTURE TREATMENT OF CHEMOTHERAPY SIDE EFFECTS

Acupuncture can be used to great effect, in conjunction with Chemo-Support  to reduce the side-effects of chemotherapy.  Indeed, acupuncture can complement the use of Chemo-Support by tailoring the treatment to the specific side-effects suffered by the patient. The following are suggested point combinations for specific symptoms and signs.

Fatigue
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-21 Weishu.

Nausea, vomiting
Ren-13 Shangwan, P-6 Neiguan, ST-34 Liangqiu, ST-36 Zusanli.  In addition to acupuncture, the following massage technique is very effective to combat nausea and vomiting: apply a massage oil liberally to the lower legs, make a loose fist with your hands, starting from ST-36, massage downwards along the Stomach channel using the knuckles of the index fingers all the way down to the ankle and then massage upwards along the Spleen channel using your thumbs.  This technique harmonizes the ascending and descending of Stomach- and Spleen-Qi, stimulating Stomach-Qi to descend and Spleen-Qi to ascend.

Alopecia
BL-17 Geshu (with direct moxa cones), ST-36 Zusanli, SP-6 Sanyinjiao, LIV-8 Ququan, BL-20 Pishu, BL-23 Shenshu.  Add Shou Wu Pian or Glorious Sea to Chemo-Support.

Myelo-suppression
BL-17 Geshu (with direct moxa cones), BL-11 Dashu (with direct moxa cones), BL-20 Pishu, BL-23 Shenshu.

Stomatitis, mouth ulcers
ST-44 Neiting, L.I.-4 Hegu, L.I.-11 Quchi.

Cystitis
Ren-3 Zhongji, BL-63 Jinmen, BL-28 Pangguangshu, BL-32 Ciliao, SP-9 Yinlingquan.

Fever
L.I.-11 Quchi, KI-2 Rangu, Du-14 Dazhui.

Skin rash
L.I.-11 Quchi, SP-10 Xuehai.

Diarrhoea
ST-25 Tianshu, ST-37 Shangjuxu.

BIBLIOGRAPHY
1)    Perry M, Anderson C, Dorr V, Wilkes J, The Chemotherapy Sourcebook, Williams & Wilkins, Baltimore, Maryland, 1999.
2)    Skeel R, Handbook of Cancer Chemotherapy, Williams & Wilkins, Baltimore, Maryland, 1999.
3)    Zhu YP, Chinese Materia Medica, Harwood Academic Publishers, Amsterdam, 1998.
4)    Bensky D and Gamble A, Chinese Herbal Medicine Materia Medica, Eastland Press, Seattle, 1993.
5)    Chang H.M. and But P.P.Hay, Pharmacology and Applications of Chinese Materia Medica, World Scientific, Hong Kong, Vol. I, 1986.
6)    Chen J K, Chen T T, Chinese Medical Herbology, Art of Medicine Press, City of Industry,         CA, USA 2004.

By Giovanni Maciocia

STOMACH-YIN DEFICIENCY

Aetiology
The Stomach is a Yang organ but it frequently suffers from Yin deficiency.  Indeed, I would say that Stomach-Yin deficiency is very common in the patients we see.  The cause of Stomach-Yin deficiency is irregular eating habits.  That includes eating late at night, eating in a hurry, eating while working, eating standing up, etc. all very common habits in the patients we see. 

Another less common cause of Stomach-Yin deficiency is eating too drying foods.  The Stomach likes warm but moist foods such as soups, porridge or rice congee.  “Drying” foods includes broiled or baked foods which would include bread. Broiling and baking makes foods dry and causes dryness when eaten in excess.  That dryness can eventually lead to Stomach-Yin deficiency.  Interestingly, there is very little broiling and baking in Chinese cooking and even bread is steamed (man tou) rather than baked.

Diagnosis
How do we know there is Stomach-Yin deficiency?  Primarily from lack of coating on the tongue. The normal tongue coating derives from the Stomach rotting and ripening and it indicates a normal functioning of the Stomach.  When Stomach-Yin is deficient, there is no coating on the tongue.

However, there are some intermediate stages before reaching a full-blown Stomach-Yin deficiency and no coating on the tongue.  The very beginning of Stomach-Yin deficiency will manifest with a coating without root. A coating without root looks likes it is resting on the tongue rather than growing out of the tongue body the same way grass grows out of the soil.

The next stage of Stomach-Yin deficiency is manifested with a tongue that lacks a coating in patches, wherever the patches may be: they may not necessarily be in the Stomach area in the centre of the tongue. 

Please note that when the tongue lacks a coating but has a normal colour, it indicates Stomach-Yin deficiency without Empty Heat: it is only when the tongue lacks a coating and it is red, that it indicates Empty Heat deriving from Stomach-Yin deficiency.

Another sign of Stomach-Yin deficiency is a Stomach crack (or cracks) on the tongue.  However, Stomach cracks may indicate a constitutional tendency to Stomach-Yin deficiency rather than the actual pathology.  In any case, when I see such cracks I nourish Stomach-Yin.

Treatment
The treatment depends a lot on the tongue: if there is coating but it is either rootless or in patches, I use Central Mansion, a variation of Shen Ling Bai Zhu San Ginseng-Poria-Atractylodes Powder.

If the coating is missing entirely, I use Jade Spring, a variation of Sha Shen Mai Dong Tang Glehnia-Ophiopogon Decoction.

With acupuncture, the points to nourish Stomach-Yin are very simple: Ren-12 Zhongwan, ST-36 Zusanli and SP-6 Sanyinjiao.

Obviously treatment must include also a change in eating habits

By Giovanni Maciocia

It always seems strange that joy should be listed among the emotional causes of disease in Chinese medicine. And yet, it has always been mentioned as an emotional cause of disease since ancient times. Strangely, the Chinese character for “joy” [xi ?] is the only one of the emotions that is not based on the ‘heart” radical. The character Xi is based on the radical for “drum” plus “mouth”, i.e. beating a drum and singing in happiness. Incidentally, two xi characters next to each other are called “double happiness” and are a symbol of a wedding.

It is interesting that, in the list of emotions as causes of disease, “joy” is always top of the list, followed by anger. For example, these are the emotions listed by Confucius: joy, anger, grief, fear, love, hatred, desire. These are the emotions listed by Lao Zi: joy, anger, worry, sadness, love, hatred, desire. It is interesting that both lists include “love” as an emotional cause of disease! Chen Wu Ze (1174) lists: joy, anger, pensiveness, worry, sadness, fear, shock. These became the widely accepted “7 emotions” of Chinese medicine. Zhang Jie Bin (1624) lists eight emotions: joy, anger, pensiveness, worry, sadness, fright, fear, shock.1

A normal state of joy is obviously not in itself a cause of disease; on the contrary, it is a beneficial mental state which promotes a smooth functioning of the Internal Organs and their mental faculties. The “Simple Questions” in chapter 39 says: “Joy makes the Shen peaceful and relaxed, it benefits the Ying and Wei Qi and it makes Qi relax and slow down.”2 On the other hand, in chapter 2 the “Simple Questions” says: “The Heart … controls joy, joy injures the Heart, fear counteracts joy.”3 Other passages in the Nei Jing clearly refer to joy as a cause of disease. For example, chapter 5 of the “Simple Questions” says: “Joy injures the Heart.”4 Chapter 8 of the “Spiritual Axis” says: “Joy scatters the Heart and deprives it of its residence.”5

Fei Bo Xiong (1800–1879) in “Medical Collection of Four Doctors from the Meng He Tradition” says: “Joy injures the Heart … [it causes] Yang Qi to float and the blood vessels to become too open and dilated …”6

I think that the best (and probably only) way to understand “joy” as an emotional cause of disease is in the light of the three main philosophies of China, i.e. Daoism, Confucianism and Buddhism. I think that “joy” is akin to “desire” and “craving” from the point of view of these three philosophies. Of the three philosophies, Daoism and Confucianism are the main ones because Buddhism was not widespread in China at the time when joy was already considered as a cause of disease, i.e. during the Warring States Period (476-221 BC).

All these three religions (or rather philosophies), for different reasons, advocated emotional restraint and avoidance of “craving” and “desire”. For example, the Daoists shunned social relations and advocated “following the Dao”, “absence of desire” (wu yu) and “non-action” (wu wei). They felt that joy would stop us from following the Dao as much as other emotions such as anger. The great Daoist Zhuang Zi (370-301 BC?) talks about wu qing, i.e. absence of feelings: “What I mean when I say that they [sages] are wu qing (without feelings) is that they do not injure their own persons with likes and dislikes and are always responsive to what is natural without trying to increase life.”7

The ancient Daoist text Nei Ye (Inner Training), older than the Dao De Jing, has this interesting passage on emotions:

The vitality of all people
Inevitably comes from their peace of mind
When anxious, you lose this guiding thread
When angry, you lose this basic point
When you are anxious or sad, pleased or angry,
The Dao has no place within you to settle
Love and desire: still them!
If you are tranquil, you will attain it (the Dao)
If you agitated, you will lose it.8

Indeed, to the Daoists, stimulation has a negative connotation. Zhuang Zi says concisely: “When desire is profound, the force of Heaven is superficial.” This means that desire turns us away from the vitality of Heaven stirring emotions within us that make us stray from the path of the Dao.

Confucianists believed that the true “gentleman” (a mistranslation of the term jun zi that actually applies to both men and women) is not stirred by emotions because these cloud his or her true nature. They used the image of a pond with a muddy bottom. If the water is very still, it becomes clear: if we stir the bottom, the water becomes turbid. The pond is our human nature which is naturally “clear”; if we are stirred by emotions, these will cloud our human nature. Consider this passage from Xun Zi (a Confucianist philosopher, 312-230 BC): “It is ever so that the Heart-Mind [Xin] is naturally full, naturally born and naturally perfected. Should its function be impaired, it is certain to be due to sorrow and happiness, joy and anger, desire and profit-seeking. If we can rid ourselves of sorrow and happiness, joy and anger, desire and profit-seeking, the Heart-Mind [Xin] will revert to its flawless state.”9

The Buddhists considered desire and craving as the very root of human suffering. Greed (excessive desire), hatred and ignorance are at the centre of the Wheel of Life and greed is strangely symbolized by a rooster. According to them, our very existence begins out of the desire and craving of a mind in the Bardo state (the period after death and before the next reincarnation): the mind desires the warmth of a womb and it reincarnates. Later on in life, desire causes our mind to try to grasp objects like a monkey sways from tree to tree (that is why the Buddhist Wheel of Life has, among others, the image of a monkey on a tree).

So, what relevance has this view of “joy”, “desire” and “craving” to us in the 21st century? I think that these emotions are indeed causes of disease and I would call the modern equivalent of these emotions “overstimulation”. I think that this, rather than “joy”, would probably be the best translation of xi. Our society indeed bombards us with objects of craving and it artificially creates “desire” and “craving” through advertising; on the other hand, it provides and fosters substances that overstimulate us.

We are all “overstimulated” by entertainment, frenetic lifestyle, consumerism, coffee, tea, tobacco, alcohol, TV, video games, “recreational drugs”, medicinal drugs, and sexual stimulation.

The main stimulant drugs are:
• Caffeine
• Nicotine
• Cocaine
• Amphetamines
• Prescription drugs e.g. Ritalin® (Methylphenidate), Adderall® (amphetamine and dextroamphetamine), Dexedrine® (dextroamphetamine), Strattera® (atomoxetine), Focalin® (Dexmethylphenidate) etc.

Interestingly, antidepressants are not actually stimulants and do not usually lead to “joy”. My experience with depressed patients on anti-depressants is that these drugs “blunt” all emotions; they do somehow lift depression but at the expense of alertness and enthusiasm. Indeed, some anti-depressants are used for anxiety with some effect.

I think that the ‘blunting” effect of anti-depressants is reflected in the resulting pulse, i.e. a pulse that feels “stagnant” and does not have the healthy “wave” of the normal pulse. It is not Wiry, not Tight but I describe it as “stagnant” and “reluctant”. While most authors see anti-depressants as mood-elevating and stimulants, I do not share that view and the pulse qualities described above seem to confirm this.

Overstimulation, in the broad sense indicated above, makes the Heart larger. This leads to excessive stimulation of the Heart, which in time, may lead to Heart-related symptoms and signs. These may deviate somewhat from the classical Heart patterns. The main manifestations would be palpitations, over-excitability, insomnia, restlessness, talking a lot and a red tip of the tongue. The pulse would typically be slow, slightly Overflowing but Empty on the left Front position. It may seem strange that “joy” or overstimulation makes the pulse slow. This is because overstimulation makes the heart larger and therefore slows down circulation (shock, by contrast, makes the heart smaller).

Giovanni Maciocia

The points I use for overstimulation are HE-7 Shenmen, P-7 Daling, Du-19 Houding, Ren-15 Jiuwei.

1. Zhang Jie Bin (also called Zhang Jing Yue) 1982 Classic of Categories (Lei Jing), People’s Health Publishing House, Beijing, p. 424. First published in 1624.

2. 1979 The Yellow Emperor’s Classic of Internal Medicine-Simple Questions, p. 221.

3. Tian Dai Hua 2005 The Yellow Emperor’s Classic of Internal Medicine - Simple Questions p. 38.

4. Ibid., p. 38.

5. Spiritual Axis, p. 25.

6. Medical Collection of Four Doctors from the Meng He Tradition, p. 40.

7. Ames RT and Hall DL A Philosophical Translation of the Dao De Jing, Ballantine Books, New York, 2003, p. 47.

8. Roth H Original Tao, Columbia University Press, New York, 1999, p. 94.

9. Lee J Xunzi and Early Chinese Naturalism, State University of New York Press, Albany, 2004, p. 35.