So The Illumined Spirit Can Ascend
Treating Ear Diseases, Part 2
Last week I posted a couple of excerpts from Zhēn Jiǔ Féng Yuán (針灸逢源, Encountering the Origins of Acumoxa) regarding the treatment of ear diseases. I mentioned a followup post, so here it is.
Ear Pathomechanisms and Treatments from Yè Tiānshì’s Lín Zhèng Zhǐ Nán Yī Àn
In my text-mining I ran across a short summation of ear disease patterns and treatments in Yè Tiānshì’s Lín Zhèng Zhǐ Nán Yī Àn (臨證指南醫案, Clinical Guidelines and Medical Cases, 1746). The passage is appended to one of Yè’s cases and is signed by his student Zōu Shíchéng (鄒時乘, also known as 鄒滋九 Zōu Zījiǔ).
Here’s my working version:
腎開竅於耳。心亦寄竅於耳。膽絡脈附於耳。體虛失聰，治在心腎，邪乾竅閉，治在膽經，蓋耳為清空之竅，清陽交會流行之所，一受風熱火鬱之邪，與水衰火實，腎虛氣厥者，皆能失聰，故先生治法，不越乎通陽鎮陰，益腎補心清膽等法，使清靜靈明之氣，上走空竅，而聽斯聰矣，
The kidney opens into the orifice of the ears. The heart is also dependent on the orifice of the ears. The gallbladder network vessel attaches to the ears. In hearing loss with whole body vacuity, treat at the heart and kidney. In evil disturbing and blocking the orifices, treat at the gallbladder channel. In fact the ear is the clear and empty orifice, the place where the clear yáng meets, flows and moves. Once it receives wind heat or fire depression evil, water is weakened and fire is replete, [there is] kidney vacuity qì reversal, all this can [cause] hearing loss. Thus the master’s treatment method, [which is] not to stray from freeing the yáng and settling the yīn, boosting the kidney, supplementing the heart, clearing the gallbladder, and so on, so that the clear and tranquil qì of the illumined spirit can ascend and travel to the empty orifices, thus sharpening the hearing.
如溫邪暑熱火風侵竅而為耳聾痛脹者，用連翹山梔薄荷竹葉滑石銀花，輕可去實之法，輕清泄降為主，
In cases where warm evil, summerheat, heat, fire, or wind invade the orifice causing deafness, or pain and distension, use Lián Qiáo [Fr Forsythiae], Shān Zhī [Fr Gardeniae], Bò Hé [Hb Menthae], Zhú Yè [Fm Bambusae], Huá Shí [Talcum], Yín Huā [Fl Lonicerae], the method of employing light medicinals to eliminate repletion, rely mainly on light clearing, discharging and downbearing.
如少陽相火上郁，耳聾 脹者，用鮮荷葉苦丁茶青菊葉夏枯草蔓荊子黑山梔羚羊角丹皮，辛涼味薄之藥，清少陽鬱熱，兼清氣熱為主，
In cases where shǎoyáng ministerial fire depresses upward with deafness and distension, use Xiān Hé Yè [Fm Nelumbinis Cruda], Kǔ Dīng Chá [Fm Ilicis], Qīng Jú Yè [Fm Chrysanthemi], Xià Kū Cǎo [Spica Prunellae], Màn Jīng Zi [Fr Viticis], Hēi Shān Zhī [Fr Gardeniae Carbonisatus], Líng Yáng Jiǎo [Cornus Saigae Tataricae], Dān Pí [Cx Moutan]; acrid cool thin-flavored medicinals to clear shǎoyáng depressive heat, focusing on simultaneous clearing of qì and heat.
如心腎兩虧，肝陽亢逆，與內風上旋蒙竅而為耳鳴暴聾者，用熟地磁石龜甲沉香二冬牛膝鎖陽秋石山萸白芍，味濃質重之藥，壯水製陽，填陰鎮逆，佐以酸味入陰，鹹以和陽為主，因症施治，從虛從實，直如庖丁之導 矣。（鄒時乘）
In cases such as dual depletion of heart and kidney, with hyperactive counterflow of liver yáng together with internal wind swirling upward and clouding the orifices, causing ringing in the ears or sudden deafness, use Shú Dì [Rx Rehmanniae Praeparata], Cí Shí [Magnetite], Guī Jiǎ [Plastrum Testudinis], Chén Xiāng [Lignum Aquilariae], Èr Dōng [Tuber Ophiopogonis and Rx Asparagi], Niú Xī [Rx Achyranthis Bidentatae], Suǒ Yáng [Hb Cynomorii], Qiū Shí [Depositum Hominis Urinae Praeparatum], Shān Yú [Fr Corni], Bái Sháo [Rx Paeoniae Alba]; dense flavored, heavy, substantial medicinals to invigorate water and restrain yáng, replenish yīn and settle counterflow. The assistant [medicinals] should mainly be sour flavors that enter the yīn and salty [flavors] to harmonize yáng. Treat according to the cause of disease, following vacuity and repletion, as if under the guidance of a chef. (Zōu Shíchéng)
Applying Yè’s Treatments to Acupuncture
I was recently looking back through the mulch archives and was reminded of why I started this publication in the first place. At the time, I was finishing up the doctoral program at the now-defunct American College of Traditional Chinese Medicine (ACTCM), in which I did quite a bit of writing, and I thought I would find a space to showcase some of my doctoral work. Much of my work revolved around the idea of developing a methodology for constructing point prescriptions for wēn bìng (warm diseases), which meant applying the treatment strategies of Yè Tiānshì, among others, to acupuncture practice. Starting with my stylistic home base of Japanese keiraku chiryō, and its basis in the rigorous five-phase approach of Classic of Difficulties (Nán Jīng), I engineered a framework to fit the four levels, three burners, and so forth. The process fundamentally changed the way I practice.
If you want more background, have a look at the lurking pathogens series. I thought I would go through the process in taking apart Zōu’s passage above, and demonstrate how I would approach putting acupuncture treatments to it.
Invasion of the Defensive Exterior
“In cases where warm evil, summerheat, heat, fire, or wind invade the orifice causing deafness.” The description as well as the medicinals listed primarily indicate pathogenic penetration into the wèi level, or at most, early invasion of the qì level. Medicinals like Lián Qiáo, Yín Huā, and Bò Hé are cool acrid surface-venting herbs, while Shān Zhī, and Zhú Yè clear heat from the chest; these are “light medicinals to eliminate repletion, [that] rely mainly on light clearing, discharging and downbearing."
When we look at the acupuncture points typically used in treating these types of maladies, many of which we saw in last week’s Zhēn Jiǔ Féng Yuán excerpt, they are generally symptomatic for tinnitus or deafness, and rarely include yīn channel points, or even points related to the underlying pathomechanism or disease level. In using medicinals, on the other hand, we are focused on the disease mechanism (Lián Qiáo and Yín Huā are not specifically indicated for ear problems, for example) rather than the symptom. But with acupuncture, we can include both. The points to treat the pattern do not necessarily have to be indicated for ear problems – though it might strengthen our case for selection if any of them are – they need to address the mechanism and the disease level. We can always include local and adjacent points to affect the ears directly.
That having been said, wèi level points which may be selected include:
LU7 - regulates surface, diffuses and downbears the lung
LU1 - clears and diffuses upper burner
LU6 - clears heat and resolves exterior
SP5 – clears wèi level, especially summerheat or damp-heat invading
TB5 – dissipates wind and resolves exterior, clears heat, resolves toxicity
LI4 – frequently used to release exterior with LU7
Shǎoyáng Fire Depresses Upward
In cases where "shǎoyáng ministerial fire depresses upward with deafness and distension” one should use “acrid cool thin-flavored medicinals to clear shǎoyáng depressive heat, focusing on simultaneous clearing of qì and heat." This puts the disease at the qì level, specifically what would be shǎoyáng stage or its wēn bìng analog, heat in the triple burner. In our scheme of application, the qì level applies to the spleen pattern, with pericardium and triple burner both likely involved as well. Though the medicinals written of in Zōu’s explanation largely enter the liver, in our model the liver appears in the yíng and xuè levels; if the presentation includes significant shén disturbance and a deep red or purplish tongue then we would opt to treat the yíng level.
As a side note, one of the few sources I have seen for points related to warm disease patterns is Feit & Zmiewski (1990). For the pattern of “Heat Lodging in the Triple Burner”, essentially a depressed shǎoyáng fire presentation, they give SP3 and PC6, which for our purposes is a five-phase spleen pattern.
Qì level point selection for this case could thus include:
SP3 - Regulates qì dynamic
SP4 - Rectifies qì dynamic
PC6 – opens depression
PC3 – clears yíng level heat
PC7 – clears yíng level heat
Virtually any of the most distal points on the shǎoyáng channels can be selected alongside the pattern, since they are generally indicated for deafness and tinnitus: TB1, TB2, TB3, TB5, GB41, GB42, GB43, GB44. My pairings usually lean toward using TB5-GB41 for their extraordinary vessel associations, or TB2-GB43 if there is lots of heat.
Depleted Heart-Kidney Axis with Ascending Liver Yáng
In cases of “dual depletion of heart and kidney, with hyperactive counterflow of liver yáng together with internal wind” we have more of a xuè level issue; this involves for our purposes liver and kidney (meaning a five-phase liver pattern) and/or a shǎoyīn pattern (which Maclean et al 2018 include among their analysis of disease levels, and which I sometimes will treat along with the more conventional five-phase pairings). Substances used in Zōu’s discussion are “dense flavored, heavy, substantial medicinals to invigorate water and restrain yáng, replenish yīn and settle counterflow.”
Possibilities here include:
LR2 - extinguishes wind
LR8 - nourishes blood and yīn, pacifies wind
KD6 - benefits yīn
KD3 – supplements yīn, indicated for tinnitus
SI4 - indicated for tinnitus and deafness
HT5 could be a candidate: along with SI4 is a host-guest combination, and is also indicated for interior wind symptoms
UB62 pacifies wind, indicated for tinnitus
Branch Treatment
For branch or symptomatic treatment, points listed in last week’s excerpt from Zhēn Jiǔ Féng Yuán, such as SI19, TB21, GB2, TB17, may be used as appropriate. In these types of cases, I often find needling the gallbladder channel behind the ear, say GB10-11-12, along the mastoid area, along with GB20 to be particularly helpful. This is usually done these days with the patient lying prone, offering additionally the opportunity to target local needling on any tension in the trapezius, interscapular and upper back areas as well. This facilitates the descent of the turbid yīn from the orifices in order to promote the ascent of the clear yáng.
Conclusion
Ear problems can certainly be challenging to treat. I’ve had mixed results in the past and that drives me to keep searching the old texts for some insights I can apply. So far the cases I have treated with the approach I described here have reported encouraging results.
As always, thanks for reading.
Note: this publication 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
Deadman, P., Al-Khafaji, M., & Baker, K. (2007). A manual of acupuncture, 2nd ed. Journal of Chinese Medicine Publications.
Ellis, A., Wiseman, N., Boss, K., & Cleaver, J. (2004). Fundamentals of Chinese acupuncture (Revised ed). Paradigm Publications.
Feit, R., & Zmiewski, P. (1990). Acumoxa therapy, volume 2: Treatment of disease. Paradigm Publications.
Maclean, W., Lyttleton, J., Bayley, M., & Taylor, K. (2018). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine. Eastland Press.
Yè, T. (1746). Lín zhèng zhǐ nán yī àn. https://jicheng.tw/tcm/book/%E8%87%A8%E8%AD%89%E6%8C%87%E5%8D%97%E9%86%AB%E6%A1%88/index.html