Acupuncture and Classical Chinese Medicine

Acupuncture is a vast and ancient medicine. This blog seeks to help make the bridge between ancient and contemporary practice.

Sunday, November 20, 2005

Abdominal Acupuncture Article

ABDOMINAL ACUPUNCTURE:

A Contemporary Microsystem

Using Classical Chinese Inspiration

Roger Lore, DAOM, LAc.

ABSTRACT – A widely-used microsystem in contemporary acupuncture is widely used in clinics throughout Nanjing China. It represents an evolution towards gentler yet paradoxically more powerful approaches to acupuncture in the PRC. This article describes its practice so that more acupuncturists may begin conducting their own investigations into this unique method.

Keywords: Abdominal Acupuncture; pain; microsystems; ba gua; abdominal diagnosis.

INTRODUCTION –

History- Abdominal Acupuncture or Fu Zhen is only 20 years old, but is based on ancient and uniquely Chinese cultural experience. Its simplicity with profound effects led to widespread use throughout China: Most of the acupuncture clinics in Nanjing China during this authors’ internship in May-June of 2005 used it extensively. The lead teacher in a doctoral program in the US declared it to be “the most powerful of any microsystem in acupuncture,” superior to that of the ear or scalp.[1] Its novelty has led to only about ten years of widespread use and only 3 years of independent research,[2] making this a difficult claim to substantiate. However significant clinical results are widely shared using this approach in both China and internationally.

It represents an important step in Chinese acupuncture that occurred with its privatization there in the mid-1980s. This change encouraged acupuncturists to find gentler yet effective methods that allowed patients to continue their intensive and long-term treatments that are still the norm there. Many prior acupuncture techniques –still the mainstay of much of the literature on acupuncture—developed in the 1970s when patients had little choice as to treatment options for acupuncture. The notion that Chinese acupuncture is still heavy-handed or painful is still common among English-language students of acupuncture: This may be outdated. Abdominal acupuncture is a prime example of this gentler movement within Chinese acupuncture –that paradoxically can be more powerful in its effects.

This approach is credited to Bo, Zhi-Yun.[3] There are few known articles in English on this topic.[4] This one will make the practice of the method accessible to English-speaking practitioners so that they may begin to use it. Other articles for example do not specify point locations for the microsystem. This will prepare the way for Bo’s book, now being translated into English.

Application – Abdominal Acupuncture is considered a gentle approach, and so is especially useful in pediatrics and geriatrics. Any sensitive patient may prefer it. Its gentleness does not reduce its effectiveness. On the contrary, many students find it to be more effective in some instances than what they used before.

While its ideal applications are still being sorted out, one common effect is its ability to regenerate function. It is thus used to treat post-stroke sequelae. It is surprising that most all stroke rehabilitation treatments this author witnessed in Nanjing China used this type of acupuncture alone --without any scalp acupuncture.

As with any microsystem, certain practitioners develop skill with it to apply it broadly. Since many acupuncture treatments involve points on the abdomen, this microsystem can enhance their effectiveness, both for diagnosis and treatment.

PROCESS

The Three Levels- Traditional Chinese Medicine often uses three realms to describe the relationship between Heaven, Humanity and the Earth. Abdominal Acupuncture focuses on 3 depths of needling:

  1. Superficial - the body as a microsystem imaged as a turtle, centered on the navel. This level is used to treat pain, for example, on the corresponding body part. To some, this level contains the circulation of the Chong mai/Penetrating vessel[5] and perhaps the other Extraordinary Channels,[A] which relate more to congenital or pre-natal qi. As such, it relates to Heaven or the Sky. It also is where pathogens lie: we are advised not to push them further in by careless needling (a common idea in the Nei Jing/Inner Classic). This layer is just under the skin, and sometimes superficial enough that the needle may fall over.
  2. Middle – the conventional Jing-Luo channel system of acupuncture, which serves as a bridge between these other two layers. These include both primary and extraordinary channels. It is anatomically in the fat layer. It symbolizes humanity’s position between heaven and earth.
  3. Deep – this level relates to the organs. They are arrayed as the post-natal Ba Gua or 8 Trigrams of the Yi Jing or Book of Changes/Symbols. This level relates to the acquired or post-natal qi, since it is the deepest and hence the Earth level. It accordingly uses the ‘post-creation’ arrangement of the trigrams:[B] South is above the navel and is symbolized by the Fire trigram, North is below with Water, Thunder or the East is on the right, and Lake or the West is on the Left. Its anatomy is in the muscle layer, but never penetrates the peritoneum and into the abdomen (as conventional TCM needling does). This Ba Gua is as wide as SP-15 Daheng.

In clinical practice, the superficial level with its turtle microsystem is the hallmark of this type of acupuncture. Conventional acupoints are of course used appropriately and usually combined with it. The 8 Gua were observed to be applied indirectly.

The Turtle[C] Microsystem –

Chinese medicine since at least the Nei Jing or Inner Classic recognized that each part reflects the whole. This is also a tenet of the Dao De Jing and many spiritual writings. Another aspect of microsystem philosophy is that the outer reflects the inner, as expressed by the deep philosophy of the Ling Shu / Spiritual Pivot in its chapter 45.[6] Ancients relied on this miniaturization to diagnose more than treat. In contrast, contemporary acupuncture often uses microsystems more to treat than diagnose. An example of this is facial diagnosis in the Ling Shu[7] that became Face Acupuncture in contemporary Chinese texts.[8] Similarly, classical texts such as the Nan Jing covered abdominal diagnosis extensively, yet only recently invented Abdominal Acupuncture makes systematic treatment from needling the abdomen.

Additionally, modern capabilities to widely share detailed graphics may contribute to a flowering of microsystems, where precise point location speeds results.

As with all microsystems except the scalp, points are ipsilateral (instead of contralateral). As a two-dimensional system, the correspondences are as follows: The head is from REN-12 to 11; the neck is from REN 11 to 10; REN 6 relates to L-1 (below first lumbar vertebrae on the Governing vessel), and REN 4 to L-4. The central line thus treats both Conception and Governing channels.

The shoulders are represented at ST-24 Huaroumen and the hips at ST-26 Wailing. Needled bilaterally, these four points are known as the ‘Four Gates’ of this system: they can open up the flow of qi throughout the entire body. They are also always used individually for the same purpose to treat an afflicted limb. So for example with right wrist pain, the right shoulder point is first treated to marshal the qi into the affected area.

The treatment of the limbs in this system is unique, precise and effective. The elbow point is exactly one half cun lateral and superior from those of the shoulders (ST-24). The wrist point lies another 0.5 cun lateral but also inferior to that of the elbow. (The upper limb thus forms an inverted ‘V’.) The hand is envisioned as just beyond the wrist. For the lower limb, the knee is precisely one half cun lateral and inferior to the hip, and the ankle continues on the same line another half cun infero-laterally. The foot is just beyond that. This peculiar layout follows the anatomy found in turtles.

For the limbs, remember to go superficially for best results: Deeper needling produces both discomfort and reduced effects with this system. The needle is inserted perpendicularly just until the tip reaches a layer of ‘gummy’ tissue, usually within a half cun depth. The needle can be seen to pulse after insertion into the appropriate depth. Multiple needles may be used.

The points for the elbow, wrist, knee and ankle are collectively referred to as the Feng Shi Dian, or Wind-Damp points. These are traditional pathogens involved in Bi / Obstruction Syndrome, a classical theory of pain. (The term ‘Dian‘ suggests their precise and small nature, as opposed to the term Xue or cave that refers to the larger, more spacious conventional acupoints.)

Diagnosis –

First the abdomen is gazed at:

·Creases, moles, colors, depressions and swellings are all very significant. Their locations have strong correspondences to the points described above. Collections of moles seem to form constellations and patterns.

·The hair on the abdomen is also meaningful. A manifestation of yin and blood, it should form a straight line down the Ren mai. If the hair deviates to the left, for example, it is caused by the underlying channel imbalance.

·An irregularly shaped navel can denote where underlying pressures exist. A navel squeezed into a vertical line can be treated by needling right next to it at a 45-degree angle deeply into the swelling at KID-16 Huangshu. If done correctly, the shape will instantly change.

The abdomen is then gently palpated. A hand can gently push the belly from side to side. Assumedly the PC-8 Laogong point of the hand can be trained to ‘read’ the dynamics. One can usually feel noteworthy differences in the firmness or temperature between the 4 [or more] directions around the navel. Or sometimes soft nodules the size of marbles can be felt on the Chong mai. The navel itself is palpated to assess the Center or Earth. Abdominal palpation was advocated in the Nan Jing chapter 66 as superior to pulse reading[9].

Treatment-

One usually begins with REN-12 Zhongwan. This central point (as the name implies) the richness of the levels within this system. Superficially it treats the head per the turtle microsystem. At a middle level, from our prior discussion it treats the channel network: Positioned at the middle of the Conception vessel, it conceivably treats all yin meridians. At a deeper level, one may connect with the internal pathways of both the Lung and Heart. Previously we saw how the deep level addresses the organs, and in this case deeper treatment obviously affects the Stomach and thereby it’s paired organ, the Spleen.

Suffice to say, this single point treats both the head and –per the Ba Gua correspondence discussed above—represents the South or Heaven.

REN-10 Xiawan is then often needled. One practitioner was more prone to use REN-9 Shuifen instead, due to an interest in treating Dampness.[10]

REN-6 Qihai and REN-4 Guanyuan are needled more deeply. This reflects their relationship to the depths of Water and the North.

The above 4 points are though to “bring the Turtle home.” They activate the system. Two points can be used instead on more sensitive patients, such as REN-12 and 4. This is to establish the all-important North-South axis.

The relationship of these points to sites on the Governing vessel was outlined above. The Kidney channel is commonly used: It easily treats the Bladder channel on the back. So for example pain at UB-25 Dachangshu can be treated by KID-13 Qixue, next to REN-4 Guanyuan.

The abdominal branch of the Penetrating vessel / Chong mai runs along this axis on the Kidney vessel’s points. [Note that the Nan Jing or Classic of Difficulties locates it on that of the Stomach.[11]] Blockages along this important channel are palpable. Dr. Tran, Viet-Dzung finds that when the Chong vessel is needled, there is a warm, spreading sensation of the Jing Qi, since it is pure and hot in nature. If one needles too deeply, a different sensation is reported since one is then working with the primary channels.[12]

The East and West can then be addressed. ST-25 Tianshu is the most common point used along it. As the front-Mu point of the Large Intestine, it is capable of regulating all three levels as Jiaos:

1. The upper jiao via the Lungs, its paired organ;

2. the middle jiao through the Stomach, its paired channel;

3. the lower jiao by virtue of its anatomical location and function.

SP-15 Daheng could just as easily be used on this axis. It depends upon the practitioner’s sense regarding both visual and palpatory cues from the points involved. The Dai mai / Belt channel circles the body from GB-26, the Daimai point, directly through the navel. [GB 27 & 28, Wushu and Weidai, may reflect this channel but are perceived not to be on it by several sources in Nanjing.]

Once the North-South and East-West axes are balanced, specific points can be applied for pain, such as those corresponding to the limbs. One or more needles can be used to affect one area to form lines, diamonds or triangles.

The treatment is guided by what the practitioner senses more than that of the patient. Great concentration is advised, such as while investigating the depth of needling. Patients feel a unique type of relaxation with these treatments that can be described as centering yet energizing.

Needle retention is comparable to conventional acupuncture. Though not necessary, a moxa pole or TDP infared lamp can be placed over the navel for the duration of the session. Treatments using abdominal acupuncture are usually either combined or alternated with standard acupuncture. For example, on Monday a patient may receive abdominal acupuncture to return Wednesday for TCM acupuncture on the limbs or back. Or an abdominal acupuncture treatment may be combined simultaneously with GB-20 Fengchi [angled inferiorly towards the feet[13]] to treat either anxiety or headache, or ST-33 Yinshi for leg pain.

DISCUSSION

Relationship to Other Abdominal Microsystems-

Several hundred years old, Shiatsu is a Japanese form of bodywork that usually begins with an assessment of the abdomen. One ‘map’ of the abdomen shows interesting correlations to Abdominal Acupuncture. It was said that the latter’s development was influenced by traditional Japanese abdominal diagnosis, which in turn took much literary inspiration from the Nan Jing. There are of course many schools of abdominal diagnosis within Shiatsu. In the subtle approach taught by Pauline Sasaki –and many others—the emphasis is on finding the exact level to perceive the relevant qi. Note that the pressure of palpation is “very light... [to] barely indent the surface of the receiver’s body.”[14] This may be accessing the Turtle microsystem level described above. The following chart begins to find correlations between the two approaches, both of which are centered on the Earth / Spleen:

Abdominal Acupuncture

Turtle Microsystem

Zen Shiatsu

Hara Diagnostic Zones

Head

Pericardium

Arms (inverted ‘V’)

Upper border of Kidney zone (KI)

Legs (dangling out at 45-degrees):

Small Intestine (SI)

-Hip

SI / KI (overlapped)

-Knee

SI / UB (Bladder)

-Ankle

SI / LI (Large Intestine)

Chi Nei Tsang[D] is a Daoist system of abdominal massage. Part of it posits a Ba Gua centered on the navel, similar to the deeper level of Abdominal Acupuncture. Chi Nei Tsang practitioners press on ‘Wind Gates’ at the outer edge of the navel. This is viewed as releasing toxins from the organs. A TaiJi symbol is placed directly on the navel.[15] The following table shows an 8-direction layout placed on the navel, with corresponding directions, Chinese organ systems, and Gua or trigrams from the Yi Jing:

SE

Liver

Wind

South

Heart

Fire

SW

Spleen

Earth

East

Rt. Kidney (Yang)

Thunder

Navel

Center

TaiJi

West

Left Kidney (Yin)

Lake

NE

Intestines

Mountain

North

Urogenital

Water

NW

Intestines

Sky

The organs are placed according to anatomical locations. For example, the liver is closest to the NE quadrant. Organ associations with Gua vary in different sources are not set in stone, but instead are rather fluid as a concept that allows wide application. This is due to their functional representation, not a mathematical one. The Sky trigram is the yang of metal, normally associated with the Large Intestine. The North-East is the Mountain, which is loosely allied here with the intestines[16] (and normally represents Earth and Stomach).[17] This literature helps to clarify the correspondences between the directions and the organ systems used in the deeper layer of Abdominal Acupuncture as well.

The representation of the Ba Gua above matches what is given in an entire chapter of the Ling Shu.[18] As is typical from this original source, the teaching is profound and adds poignant details to consider. It clearly forms the theoretical underpinnings of the deepest level of Abdominal Acupuncture and the highest level practice of Chi Nei Tsang. Below is a table of only some of the intriguing aspects in this chapter:

SE

Wind gua

Obesity

Muscles

‘Weak wind’

S

Fire gua

Heart

Channels (all)

Summer solstice

SW

Earth gua

Spleen

Debility

E

Thunder gua

Joints, tendons

Damp

Spring Equinox

C

Centrality

W

Lake gua

Lung, skin

Dryness

Fall Equinox

NE

Mountain gua

Large Intestine

Ribs

‘Fierce wind’

N

Water gua

Bones

Cold

‘Great Firm wind’

Winter solstice

NW

Sky gua

Small Intestine

Some of these correspondences relate more to the gua than to the organs there are proximal to, as in the prior table of Chi Nei Tsang. The characteristics of the winds, such as ‘fierceness’, are another possibility to palpate for. The seasons may relate to the time of onset of a disease, a major focus in the Nei Jing. Each position of course had correlating constellations (which have since shifted since that time). An intriguing possibility from Abdominal Acupuncture is that this sweeping worldview has at some level its concrete correlates in our bellies, and that it could be leveraged for change.

Inspiration and Clarification from the Nan Jing-

This classic is a source of advocates for abdominal palpation in diagnosis. A famous claim was made in Chapter 8 that a patient could have perfect radial pulses, only to die the next day. The cause is traced to something that sensitive abdominal diagnosis alone might have revealed: the origin of the problem as it emerges in the roots of our being, the abdomen. This text makes repeated reference to the similarity of humans to trees. As any gardener knows, a disease on the leaf –or in this case, the wrist pulse—is caused by what occurs hidden below the soil. This text refers to the “moving qi between the kidneys” (perhaps expressed by the tables above). Definitely centered in the abdomen, this is the site of the:

  • “origin of vital [qi]…
  • [and of] the Triple Burner… which distributes all Ying and Wei,
  • foundation of all 12 [channels]…
  • [and] of the [zang-fu]…
  • gate of [the breath]…
  • ‘spirit guarding against evil,’
  • a person’s root and foundation.”[19]

There is clearly much to investigate here, through either careful palpation and/or meditative awareness. Practices such as Abdominal Acupuncture may lead practitioners into connecting with these aspects. This surely takes time to develop: As one teacher on this practice said, “Practice for three years, then we’ll talk.”

An intriguing commentary from the same classic adds another layer to our discussion. It was written by a Dr Yang sometime between the 8th and 11th century of our era, and is a vital description of a meditative awareness of the lower dan tian or ‘cinnabar field’ below the navel. It notes it as the focus of both Buddhist and Daoist meditation in China.[20]

It helps explain why the turtle symbol is used in Abdominal Acupuncture. This commentator described the dan tian by its other name, the great sea or Da Hai. In it lay a “spirit-turtle [that] exhales and inhales the original [qi]” which “penetrate the four extremities as wind and rain; they reach everywhere.”

This same passage adds a layer of complexity that may bring our orientation within the abdomen to a deeper and more comprehensive state. Readers familiar with classical sources may be puzzled by the orientation given above that associates the Wood with the right and Metal with the left. For in both the Nei and Nan Jing, this laterality is reversed. The radial pulse of the Liver is on the left, while the Lungs are on the right, for example. The Nei Jing observed changes with the Liver on the left cheek, and the Lungs on the right.[21] And the Nan Jing proposed that Liver disease manifests with “firmness and pain” if pressed upon to the left of the navel; the Lungs on the right.[22] The South and Fire being represented by upper regions with North/Water below is consistent among all systems under discussion. An apparent contradiction remains with laterality.

This may be solved by considering Dr Yang’s report of common experiences of the dan tian of his time: “…three inches below the navel; its circumference measures four inches. It is attached to the vessels of the spine and to the root of the kidneys. It has a yellow color at its center, [blue-green] to the left, white on the right, red on top and black on its base.”[23] TCM Students will recognize these as standard 5-Step / Wu Xing correspondences, with wood on the left and metal on the right.

This suggests a deeper, fourth layer beyond the first three described in Abdominal Acupuncture. It might be accessed through meditative awareness, collaborated upon through sharing collective subjective experiences,[24] and perhaps best treated through the channels of the limbs which may provide sufficient leverage to access this depth.

The sometimes bewildering complexity of Chinese medical thought may come from wisdom. For example Nan Jing recommends to not rely on a single doctrine.[25] This allows for flexibility and the application of multiple theories to the same reality. The view of differing levels begun in Abdominal Acupuncture helps to harmonize different views, --and open up others beyond is system.

The Nei Jing is fascinated with the Stomach, while centuries later the Nan Jing focused on the Kidneys and lower dan tian. In between these two interests lies the navel, the center of Abdominal Acupuncture. It thus is well-situated to address both concerns as needed.

One could ultimately investigate other maps on the abdomen, such as the circle of Twelve Earth Branches that relate the seasons to 12 Chinese zodiac positions, related Yi Jing Hexagrams,[26] and channels.[27] This could in the right hands form a ‘Fifth level’ of abdominal diagnosis.

RECOMMENDATIONS

There is clearly much potential to explore in Abdominal Acupuncture through years of practice. Acupuncturists may begin by simply:

  • looking at irregularities on the skin of the abdomen,
  • palpating for subtle irregularities within it, and
  • applying a few choice points from the turtle microsystem to assist their existing treatments. The points for the limbs for example are easy to locate and useful to many.

Modern outcomes research was proposed to compare this microsystem with others, such as auricular or scalp. However it was considered too difficult: trying to get equally matched patients for this type of project is not practical. It is up to practitioners to explore this with and open but unbiased mind to weigh the results.

REFERENCES:



[A] This is confirmed by a DeQi sensation that feels warm and spreading to the patient, often traveling along the known pathways of these channels. Dr Tran pointed this out, and is confirmable by experience. Needling must be kept in the first half inch, and often requires some lifting and thrusting for the channel to release. For example a superficial lump at ST-21 if needled this way will shoot upwards along the Chong mai; deeper needling will affect the primary channel which usually directs the qi down along its path. The sensation of warmth from the Extraordinary channels is due to their carrying Jing qi or Essence (as do the Extraordinary Points), which is pure and hot.

[B] Although unstated, it is logical for the superficial/Heaven layer described above to have the pre-natal / pre-creation Ba Gua representation (where Sky and Earth form the dominant polarity).

[C] The Chinese term Gui refers to both turtles and tortoises.

[D] This is a Wade-Giles of what in Pinyin may be Qi Nei Zang.



[1] Dr. Li, Yu-Tang of the Nanjing University of Traditional Chinese Medicine, during lecture at Oregon College of Oriental Medicine’s (OCOM) Doctor of Acupuncture and Oriental Medicine (DAOM) program in Portland, Oregon in September of 2003.

[2] Dr Han, Yan of Jiangsu Provincial Hospital, Nanjing PRC, during lecture to OCOM DAOM class in that city, July 18, 2005.

[3] Bo Z, Fu Zhen Liao Fa, Beijing: Science & Technology Publishing Press,1999. Chinese language. ISBN 7-5046-2771-2.

[4] Acupuncture Today, An Interview with Zhiyun Bo, Inventor of Abdominal Acupuncture (Fu Zhen). D’Alberto A, Kim E. August 2005. Vol. 6, Issue 8. http://www.acupuncturetoday.com/archives2005/aug/08dalbertokim.html --last accessed November 5, 2005.

[5] Dr Tran, Viet Dzung, inaugural lecture of OCOM’s DAOM Program, July 2003, Portland Oregon.

[6] Wu & Wu [trans.], Yellow Emperor’s Canon of Internal Medicine, Wang Bing version. Beijing: China Science & Technology Press. 1997. Ling Shu/Spiritual Pivot, Chapter 45, p.683.

[7] Wu & Wu, Ling Shu Chapters 29 & 49, Shi Chuan & Wu Se, pp. 641 & 701.

[8] Bensky D et al [translator]. Acupuncture: A Comprehensive Text, Shanghai College of Traditional Medicine, Seattle: Eastland Press, 1984, p.492.

[9] Unschuld, P [translator], Nan-Ching: The Classic of Difficult Issues. Berkeley: University of California Press, 1986. Chapter 66, p.567.

[10] Dr. Ou, Jian-Wen of Nanjing Municipal TCM Hospital. Clinical internship: May 2005.

[11] Unschuld, Nan-Ching Chapter 28, p.327.

[12] Dr. Tran, Viet-Dzung at the inaugural lecture of OCOM’s DAOM Program, July 2003, Portland, Oregon

[13] Bensky, p.168.

[14] Beresford-Cooke C, Shiatsu Theory and Practice. Churchill-Livingstone, 2nd ed., 2003. p.238.

[15] Chia M & M, Chi Nei Tsang: Internal Organs Chi Massage. NY: Healing Tao Books, 1990, p.140

[16] Marin G, Healing from Within with Chi Nei Tsang. Berkeley: North Atlantic Books, 1999, p.210

[17] Shima M, The Medical I Ching. Boulder CO: Blue Poppy Press, p.13.

[18] Wu & Wu, Ling Shu Chapter 77, Jiu Gong Ba Feng, pp.804-7.

[19] Unschuld, Nan Jing Chapter 8, pp.130-138.

[20] Ibid., pp.597-8.

[21] Wu & Wu, Ling Shu Chapters 29, 37, 49, pp. 641, 660, 701.

[22] Unschuld, Nan Jing Chapter 16, p.219

[23] Ibid., p.567.

[24] Wilber K, A Theory of Everything

[25] Ibid., Commentary on Nan Jing Chapter 68, written in 1727 CE.

[26] Ibid., p.267

[27] Fruehauf H, The Science of Symbols, JCM Feb 2002, #68, p.33; Part II: June 2002 #69 p.20.