Brain Heat and Nasal Abyss, part 2
Putting points to Yè’s prescription
Last week we translated some cases from Yè Tiānshì. I thought this week we would follow up by examining one of those cases, looking at the formula, and coming up with a point prescription to accompany it. C’mon, it’ll be fun!
What’s the case?
Let’s take the case of patient Chén. The original case was posted here.
A quick summary:
· Phlegm fire and qì counterflow pre-existing.
· Wood and fire produce wind which rises and pulls at the vertex of the head.
· Brain heat causes excessive discharge from the clear orifices.
· Ringing in the ears and nasal abyss, more on the left.
· Treatment principles are to clear heat and disperse stagnation; use acrid and cool [medicinals] to reach the head.
· Prescription: Líng Yáng Jiǎo (Cornu Saigae Tataricae), Hēi Shān Zhī (Fr Gardeniae Carbonisatus), Kǔ Dīng Chá (Fm Ilicis), Qīng Jú Yè (Fm Chrysanthemi Viride), Fēi Huá Shí (Talcum), Xià Kū Cǎo Huā (Flos et Spica Prunellae).
What’s the disease entity?
First of all, let’s take a look at the pathology. From Wiseman’s Practical Dictionary, in the entry for 鼻淵, bí yuān “deep-source nasal congestion,” or to put it another way, “nasal abyss”:
“Gallbladder heat (胆热dǎn rè) spreading to the brain usually causes a more severe form of deep-source nasal congestion called brain leak (脑漏 nǎo lòu), characterized by sourness in the nose and persistent nasal discharge like marrow or pus that has a foul or fishy smell and accompanied by dizziness, headache, and forgetfulness.”
So the pathomechanism is heat in the gallbladder, and by implication, the liver. This is important to keep in mind as it is the basis for our choices in selecting points.
What was prescribed?
Let’s look at the medicinal formula, with an emphasis on the taste, nature, and actions of the formula constituents. Materia medica entries from Wiseman & Brand (2020):
· Líng Yáng Jiǎo: salty, cold. LR/HT; Calms liver, extinguishes wind; subdues liver yang; clears liver and brightens eyes; clears heat, resolves toxin
· Hēi Shān Zhī: bitter, cold; HT/LU/ST/TB (Bensky includes LR); drains fire, eliminates vexation; clears heat, disinhibits damp; cools blood, resolves toxin; disperses swelling, relieves pain
· Kǔ Dīng Chá: sweet, bitter, cold; LR/LU/ST; Disperses wind-heat; clears head and eyes; eliminates vexation and thirst
· Qīng Jú Yè: acrid, swt; neutral; LR/LU; disperses wind-heat; clears liver, drains fire, brightens eyes, calms liver yáng; clears heat, resolves toxin
· Fēi Huá Shí: sweet, bland, cold; ST/BL; disinhibits urination, frees strangury; clears heat & summerheat
· Xià Kū Cǎo Huā: bitter, acrid, cold; LR-GB; clears liver fire; disperses binds; resolves toxin
How do we translate that into points?
So between the treatment principles given and the materia medica actions, we have an idea of the kinds of point actions we are looking for. We are not so much trying to find points that match all of the actions of each herb. We are just looking to cover as much of the formula actions as possible with roughly the same number of points as ingredients in the prescription, say 6 points.
Aggregate of treatment principles and formula actions
· Clear heat from LR/GB
· Clear heat from the brain
· Extinguish internal wind
· Use acrid and cool to reach the head
· Disperse stagnation (of phlegm and qì)
We have a few different sources available to check.
First up, let’s run some search terms in the Chinese Medicine Database [http://cm-db.com/], which is an online resource I use to help me translate as well as look up points and medicinals and so forth. We’ll enter some terms in the actions field of the database.
The first search is for “LV fire,” and yields one result: LR2 (xíng jiān). A search for “GB fire” similarly gives only one point: GB39 (xuán zhōng).
Actions:
· LR2: calms liver wind, clears liver fire, spreads liver qì
· GB39: Clears gallbladder fire; huì point for marrow (and thus related to the brain)
To give some of the flavor of the formula, we also might consider the phrase “acrid and cool to reach the head.” Acrid is the taste of the metal phase, and its functions are to disperse and scatter; it is a yáng flavor with a rising and effusing tendency so it naturally goes to the surface and upper burner. There are various possibilities here: we could pick a lung channel or large intestine channel point; we could pick a metal point on a relevant channel; we could pick a point with a tropism for the surface and upper body.
Of course, since this is a case in Yè’s nose chapter, and there is excessive nasal discharge, it would be fairly obvious to pick a point like LU7 (liè quē) or LI4 (hé gǔ). But, looking at the formula, Yè is not treating the nasal discharge directly – as I said last week, the usual suspects one would expect to find in a stuffy nose remedy are absent. Instead, he is focused on draining the fire, eliminating the wind, and clearing the head. Also present among the clinical manifestations is tinnitus. So to keep to the spirit of Yè’s prescription, and to balance some of the lower body points with something on the upper body, I would look to the triple burner channel of hand shàoyáng. TB3 (zhōng zhǔ) and TB5 (wài guān) are both possible choices. TB3 is most closely identified with treating ear disorders, where TB5 releases the exterior (an action associated with the acrid flavor), benefits the head and is indicated for both tinnitus and nosebleed (even though the discharge in Yè’s case is not blood, in both cases the underlying mechanism is heat forcing out the fluids – it is important to think about the pathology rather than just following indications). So I prefer TB5 in this case.
How are we doing?
Let’s check back with our list:
· Clear heat from LR/GB: LR2, GB39
· Clear heat from the brain: GB39
· Extinguish internal wind: LR2
· Use acrid and cool to reach the head: TB5
· Disperse stagnation (of phlegm and qì): ?
While we could say that, for example, the points we already have are sufficient to disperse stagnation of qì, we are lacking something like a Xià Kū Cǎo to dissipate binding phlegm as well as clear heat.
A database search for “phlegm” in the actions field gives 27 choices, which we will need to narrow down a bit. If we are looking at Xià Kū Cǎo, we are specifically looking for the clumping action of phlegm rather than just the phlegm itself. So let’s switch the term to “nodule” and see what we get.
5 results: GB21 (jiān jǐng), LI15 (jiān yú), LI16 (jù gǔ), TB10 (tiān jǐng), GB41(zú lín qì). An interesting list. GB21 is likely more for nodulation in the breast, and LI15-16 more for phlegm in the channels. This leaves TB10 and GB41. Of the two, GB41 clears the head, benefits the eyes and spreads liver qì, making it a better analog to Xià Kū Cǎo. It also pairs synergistically with TB5 as a master-coupled point pair for yángwéi and dài mài.
Are we done yet?
Looking back at the formula, it seems like we have most of the constituents’ actions pretty well covered, except one. Fēi Huá Shí, which is a refined version of talcum, is also in the formula. There is no explanation given, but as we have seen it is sweet, bland and cold, and is usually found in formulas to disinhibit and clear heat through urination. In other words, it provides a route out of the body for the pathogenic fire and turbidity. The other action of Huá Shí, which may or may not be a consideration here, is its ability to clear summerheat. A search in the action field for “resolves damp” gives 17 results, while “urination” gives 13 results, and “summerheat” gives 3. The closest thing to a crossover is BL40 (wěi zhōng).
So this gives us
· LR2, GB39, TB5, GB41, BL40
We can stop there, or we can put in another point or two… maybe something local. But, again, in the spirit of Yè Tiānshì’s example, we’re aiming at treating the pathomechanism of gallbladder heat in the brain producing turbid nasal discharge, rather than just using something to clear the nose (like LI20, yíng xiāng).
Searches for “nose” and “nasal” are producing too many hits; limiting our searches to the GB channel still gives a lot of points. Time to go looking for another source.
Fortunately, we have a very good translation of an important work from the late imperial period, Yuè Hánzhèn’s Explanation of Channels and Points, translated by Michael Brown (2021). Since we are looking at a case history and prescription from roughly the same era, we can get some idea how acupuncture points were conceptualized at that time. Looking in the index of volume 2 (which includes the gallbladder and liver channels), “gallbladder” and “heat” are too broad, and “brain” doesn’t appear. A look at “nasal congestion” shows a manageable number. As we go through the entries we come upon xuán lú, Suspended Skull, GB5. In the entry, there is a passage that mentions “incessant deep-source nasal congestion with turbid discharges” the cause of which is cited as “the fire of shàoyáng affecting the liver.” Bingo. We have a head point.
With that, we have our six points to go with Yè’s six-ingredient formula:
· LR2, GB39, GB41, TB5, BL40, GB5
How did we compare?
Going back to the Practical Dictionary entry, Wiseman does have a point prescription included.
Wiseman’s basic points for bí yuān are LU7, LI4, LI20, yìn táng, GV23 (shàng xīng), GB20 (fēng chí). In case of gallbladder heat, he adds to the main prescription: GB34 (yáng líng quán), LR2, GB39, GB19 (nǎo kōng). So, there are some similarities - and some differences - to our prescription.
A few thoughts here:
· GB19’s name, nǎo kōng, means “brain hollow,” and it is indicated for nasal congestion and heat in the body; the name and indications make it worth considering inclusion in our point prescription.
· GB34 is the hé-sea point of the gallbladder channel, and among other actions it spreads liver qì and clears gallbladder heat as well as liver-gallbladder damp-heat, but the locus of its actions and indications don’t seem particularly targeted to the head, so it is doubtful that it would prove a more effective point choice than what we have come up with.
· To reiterate: including LU7 and LI4, both metal-channel points, would be one way of “using acrid and cool to reach the head.” But Yè kept his treatment pretty tightly focused on wood and fire, so we looked for a way to employ this treatment principle while sticking to the shàoyáng channels.
And we’re done!
So there we are, we have a point prescription that hopefully captures some of the spirit of Yè Tiānshì’s formula in this case, and which is pretty easy to administer (it could be done in a community acupuncture clinic, for instance). This is, frankly speaking, a lot of what I do these days; when reading through these late imperial medical texts, 90% of which are about herbal medicine, I am always looking for ways to translate them into acupuncture treatments and adapt them to the way I practice. As I worked on this article, for example, I treated a case similar to this, though with a different underlying root (lung and spleen vacuity with heat in the gallbladder channel going to the brain and causing purulent discharge and nodulation), and used the basic principles I had just translated and worked through. Doing this kind of research not only augments my treatment options, but it helps me better comprehend the pathomechanisms in a way that is (I hope) closer to the understanding of the great physicians of the past.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
The Chinese Medicine Database. http://cm-db.com/
Wiseman, N. (1998). A practical dictionary of Chinese medicine. Paradigm Publications.
Wiseman, N., & Brand, E. (2020). Comprehensive Chinese materia medica. Paradigm Publications.
Yue, H. (2021). Explanations of the channels and points, vol. 2 (M. Brown, Trans.). Purple Cloud Press.
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