Chinese Dietetics – Diarrhoea

Jimi Windmills

"Medicaments are ferocious like soldiers of the high guard, and hence should not be thoughtlessly applied in minor cases. [Whereas,] Food can dispel harmful influences, bequeath the internal organs, refresh the spirit and replenish the qi and blood."

- Sun Simiao (?-682)

Western Medicine

According to the World Health Organisation (WHO), "diarrhoea is three or more liquid stools per day, or more frequently than is normal for the individual" (WHO). Boon et al. suggests that normal frequency of bowel movements for the population in general is between three times a day and one movement every three days (2006: 869). As Boon et al. correctly points out, diarrhoea means different things to different people, but that it is generally assumed to mean loose or watery stool, with increased frequency. The most common symptom of diarrhoea is urgency of defecation, and faecal incontinence is not uncommon (2006: 869).

The WHO recognises three clinical presentations of diarrhoea

• Acute watery diarrhoea – lasts several hours or days, and includes cholera;
• Acute bloody diarrhoea – also called dysentery; and
• Persistent diarrhoea – lasts 14 days or longer.

Acute diarrhoea is often a symptom of gastrointestinal infection, usually caused by bacterial, viral or parasitic organisms. Infection is spread either from person to person or through contaminated food or water, or unhygienic environments (WHO). Diarrhoea from infections are usually short lived, patients with symptoms lasting longer than 10 days rarely have an infective cause. Acute diarrhoea can also be cause by certain drugs including cytotoxic drugs, antibiotics, NSAIDs and proton pump inhibitors (Boon et al 2006: 869).

Diarrhoea may be life-threatening as it can lead to severe dehydration, especially in young children, and those who are malnourished or have weak immune systems. Diarrhoeal diseases kills on average 760 000 children every year, it is the leading cause of sickness and death in children under 5 especially in developing nations. Most of these deaths are from severe dehydration, and are both preventable and treatable. Prevention of diarrhoea includes clean water, good sanitation and hygiene. Treatment is usually clean water with sugar, salt and zinc tablets (WHO).

Cholera, caused by the Vibrio Cholerae bacteria has been sweeping the world with a diarrhoeal pandemic that has lasted for over 50 years. In reality, cholera has likely been plaguing human societies for thousands of years. According to Boon et al. it originated in the Ganges valley, and the current '7th pandemic' (the E1 Tor biotype), started in 1961 and spread through the Middle East to Africa. It reached Peru in 1990 and spread through Central and South America Since 2000 there has been a massive outbreak in South Africa. A new strain (serotype 0139) took hold in Bangladesh in 1992 and began a new pandemic (2006: 330). Cholera typically presents with sudden onset severe diarrhoea without pain, and is then followed by vomiting. After the usual contents of the gastrointestinal tract have been emptied, the patient will continue to pass clear fluids with flecks of mucous. This results in an enormous loss of fluids and electrolytes, and in severe cases leads to intense dehydration and muscle cramps, shock, oliguria and eventually acute circulatory failure and death. The majority of cases however, cause only minor illness, with less severe diarrhoea (2006: 330). Treating cholera requires the replacement of fluids and electrolytes. In most cases this is done with an oral rehydration solution, which sometimes has the addition of starch. Sometimes it is necessary to rehydrate a patient via intravenous fluids, and vomiting normally stops once the patient is rehydrated. The amount of fluids replaced is calculated (if possible) from the volume lost in urine, stool and vomit, and is usually around 500ml/hour. Over a course of 2-5 days this may exceed a total of 50 litres. Cholera is also treated with antibiotics, which kill the bacteria, and shorten the course of the disease (Boon et al. 2006 330).

Dysentery can be caused by a number of things, but is most commonly either bacillary or amoebic dysentery. Since bacillary dysentery is most common we will not discus amoebic dysentery here. Bacillary Dysentery is generally caused by one of four Shigellae virii, a close relative of E. Coli. These are Sh. dysenteriae, flexneri, boydii and sonnei. Shigellae are highly resistant to antibiotics, and have caused epidemics of dysentery in Bangladesh and other tropical countries. The virus only attacks humans, and spreads by contaminated food or flies, but is most commonly transmitted by unwashed hands after defecation. It is highly contagious since it requires a dose as small as 10 individual organisms to infect a new host. It is most commonly seen in closed institutions such as schools and mental hospitals and outbreaks often occur after natural catastrophes and during wars, which cause crowding and poor hygiene (Boon et al. 2006 330-1). Sh. Sonnei infections are usually mild and may escape diagnosis, while Sh. Flexneri may cause more severe symptoms. Sh. Dysenteriae can develop very quickly into a life threatening disease, and can cause death within 48 hours (Boon et al. 2006 331).

A moderately severe case of dysentery presents as diarrhoea with colicky abdominal pain and tenesmus (the constant feeling of needing to defecate, even if the bowel is empty). Fever, weakness and dehydration accompany tenderness over the colon. There is only a small amount of stool, and after a couple of bowl movements, blood and purulent exudate are passed with less faecal matter. Dysentery is treated with oral rehydration therapy, or if diarrhoea is severe, with intravenous fluids and electrolytes. Treatment with antibiotics (ciprofloxacin 500mg) every 12 hours for 3 days is effective. The most important method to manage dysentery is prevention. Ensuring food and water are uncontaminated and maintaining high standards of sanitation and hygiene, especially handwashing, is crucial.

There are other causes of acute diarrhoea that should be mentioned briefly. Food poisoning (usually bacterial or bacterial toxins) accounts for a large number of cases of acute diarrhoea, as does diarrhoea as a symptom of the common cold or influenza.

Chronic or relapsing diarrhoea is often associated with irritable bowel syndrome (IBS), has increased frequency of loose, watery, or pellety stool, and is usually most severe before and after breakfast, and rarely occurs in the evenings. These patients also tend to experience constipation at other times, as well as other symptoms associated with IBS. There is often mucous in the stool, but never blood (Boon et al. 2006: 869). We will not consider all the various causes of chronic diarrhoea due to a lack of space.

Chinese Medicine

In Chinese medicine we have several patterns of diarrhoea. However, three of these patterns tend to predominate. These patterns coincide very closely with the three clinical presentations described by the WHO. Two of these patterns are of an external nature, and present as full conditions; Cold-Damp pattern diarrhoea and Damp-Heat pattern diarrhoea. These patters align with the WHOs acute watery diarrhoea and acute bloody diarrhoea, including cholera and dysentery respectively. Chronic presentations of diarrhoea in Chinese medicine stem from deficiencies of the Spleen and/or Kidneys

According to Anshen Shi, the pathophysiology of diarrhoea involves an excess of dampness, dysfunction of the spleen and stomach, and an inability of the large intestine to transport, and separate clear from turbid substances (Shi 2003:91). These disharmonies may arise from a number of causes

• Invasion of external pathogens, particularly cold, dampness, summer heat and fire. The spleen is especially susceptible to external invasions of damp, which then disturbs the functions in the middle jiao (Shi 2003:91).
• Improper diet – overeating may impair the stomachs ability to receive and ripen food, which then affects digestion and absorption. Consumption of cold raw food or contaminated food may damage the spleen and stomach, and impact on their ability to transform and transport, and cause qi to flow in the wrong direction (Shi 2003:91).
• Liver qi stagnation from long-term anger and frustration may invade the spleen causing it to become deficient. This in turn impacts on the spleens ability to transform and transport (Shi 2003:91).
• Overexertion, chronic illness, or an irregular diet can lead to spleen and stomach deficiencies. When the stomach can not rot and ripen, and the spleen can not transform and transport the food, the pure and turbid combine and empty out as diarrhoea (Shi 2003:91).
• Yang Deficiency of the kidney may develop as one ages, from chronic illness, or from a constitutional weakness. When kidney yang is insufficient, it will fail to warm the spleen yang. This leads to an inability of the spleen to transform and transport, and also impairs the kidneys function of controlling bowel movements (Shi 2003:91).

Differentiation of Patterns

• Damp-heat – Sticky or pasty yellow coloured stool, with a strong odour and burning sensation of the anus.
• Cold-damp – Bluish grey or bluish black in colour. Clear thin, or watery stool without much odour.
• Liver overacting on the spleen – onset of loose stools with emotional stress.
• Spleen deficiency – unformed stool alternating with watery diarrhoea, with tends to be worse with fatigue or after meals.
• Kidney deficiency – Watery stool with undigested food present, or abdominal pain with diarrhoea that happens at dawn.

Treating Diarrhoea with Diet

There are certain foods that should be avoided for people with acute or chronic diarrhoea. In cases of chronic spleen and stomach deficiency, the patient should avoid raw and cold foods, especially fruit and fruit juice, dairy products, canned food, frozen foods and denatured foods. (Kastner 2009: 184). These deficient type patients should try to eat boiled or steamed foods which are warming in nature and nourish the spleen and stomach, combined with acrid spices. Beef and poultry, pureed carrots, mushrooms, honey and brown sugar are good. Rolled oats, millet and rice dishes, are also beneficial. Fennel tea to drink and maybe steamed apples and blueberries for desert (Kastner 2009: 184).

Cold-damp acute type diarrhoea patients should avoid raw, cool and cold natured foods, as well as foods that tend to be damp forming such as dairy products and greasy food. These patients would benefit from food that is warming to hot in nature, which support the spleen and stomach, with sweet-warm or bitter-warm flavour. Steaming and boiling are appropriate cooking methods, and warming spices are also indicated. Sweet potato, carrots and fennel are good vegetables, and oats, millet and rice are good grains especially when combined with aniseed, chilli, pepper, ginger and cinnamon. Fennel or spiced tea, or coffee with cardamom is good to drink (Kastner 2009: 185).

Damp-heat diarrhoea patients should avoid acrid, warm and hot foods. For this condition, foods that are cold, cool or neutral are best. Sweet and bitter flavoured foods, and raw, boiled or steamed foods are also indicated. Eggplant, bamboo, cranberries, mung beans, cucumber, spinach and yoghurt are all good examples.

Sweet Potato Dal – A Recipe for Cold-Damp Diarrhoea.

Ingredients

1 cup split mung beans

7 cups water

1 cup (1 tin) chopped tomato

1 zucchini diced

1 large sweet potato, diced

5 tbsp. ghee
1/4 tsp. hing (asafoetida, or asafetida)

1/2 tbsp. grated or minced ginger

1 1/2 tbsp. cumin seeds

1 tbsp. black mustard seeds

1 green chilli (minced or finely chopped)

1 1/2 tsp. turmeric

1 tbsp. salt

Fresh coriander to garnish

Add 3 tbsp. ghee to a pot, when melted add turmeric, hing and beans. Stir and fry for 30 seconds over moderate heat. Add tomato, zucchini, and sweet potato and fry for 1 minute. Add water, salt, chilli, and ginger. Bring to boil, cover, reduce to low heat and let it simmer for an hour, or until the beans have dissolved.

In a small frying pan, add 2 tbsp. ghee. When hot add cumin seeds and black mustard seeds. When the seeds crackle, 30 seconds to a minute, add the mixture to the dal. Stir and garnish with fresh coriander.

Serve by itself or on a bed of brown rice.

Breakdown of Ingredients

• Mung beans are very sweet in flavour, cooling in nature and drain damp (Wilson 127). On their own they nourish the spleen, and their cooling nature makes them well suited to treat heat pattern diarrhoea.
• Tomato is cooling to cold in nature, and sweet and sour in flavour. It has a downbearing direction, and is aligned with wood and earth. Tomatoes Clear heat, enrich yin, and produce fluids (great when diarrhoea causes fluid loss). They also strengthen the stomach and move liver qi (Kastner 2009: 111).
• Zucchini is cooling, sweet and bitter. It cools stomach and liver heat (Kastner 2009: 264).
• Sweet potato is neutral to slightly warm in flavour. They are warm in flavour, and benefit the spleen, stomach and kidney. They have an upbearing direction, and align with the earth phase. Sweet potato benefits the middle jiao, supports qi and blood formation, moves qi stagnation and produces fluids (Kastner 2009: 111).
• Ghee is neutral in temperature, and sweet and fatty in flavour. It supports blood and qi, and moistens (Kastner 2009: 256).
• Ginger is warm in nature and has an acrid flavour, it benefits the lungs, stomach and spleen. It has an upbearing direction and is aligned with the metal phase. Ginger strengthens the middle jiao, and controls nausea. It also clears wind-cold from the tai-yang level (Kastner 2009: 122).
• Cumin is warming, and has a bitter and acrid flavour. Cumin dries phlegm-cold (Kastner 2009: 250).
• Black mustard seeds are warming and acrid. They expel cold-damp (Kastner 2009: 259).
• Chilli is hot in nature, and has an acrid flavour. It benefits the stomach spleen and heart, and has an upbearing direction. It is aligned with the fire phase. Chilli disperses cold and warms the middle jiao, it dissolves food stagnation and dries damp (Kastner 2009: 121).
• Turmeric is warming and has bitter and acrid flavours. It dries phlegm-cold (Kastner 2009: 163).
• Salt is cold in nature and salty in flavour. It benefits the stomach, kidney, small intestine and large intestine. It was a downbearing nature and is aligned with the water phase. Salt clears heat, moistens dryness, and strengthens kidneys (Kastner 2009: 125).
• Coriander is warm in nature, and had an acrid flavour. It benefits the lung and spleen, has an upbearing direction, and is aligned with the metal phase. It is used to warm foods, disperse cold, balance qi and reverse counterflow qi (Kastner 2009: 121).

This recipe is more specific to treating cold-damp rather then damp-heat presentations of diarrhoea. Having a lot of water in the recipe helps to replace some of the fluids lost due to diarrhoea, this is aided by ingredients such as tomato and sweet potato which produce fluids. The mung beans as the primary ingredient although cooling in nature, drain dampness and nourish the spleen and stomach. The recipe itself is simple, and with a combination of short frying time to warm some of the ingredients, and a long time simmering (a neutral cooking method) this would tend to balance and integrate the effects of the various ingredients. With a predominance of warming and acrid ingredients I believe this recipe would have an overall warm nature, and would treat cold-damp diarrhoea very effectively. The recipe could be tailored to treat a damp-heat pattern of diarrhoea with a few modifications. If the recipe was altered to decrease the heating and acrid elements and possibly remove the chilli altogether. Add extra zucchini and tomato, and perhaps a half cup each of amaranth and corn as extra cooling elements, it could be served along with a cucumber and baby spinach raita to treat a damp-heat pattern of diarrhoea.

Bibliography

Boon N, Colledge N, Walker B, Hunter J 2006. Davidson's Principles and Practise of Medicine, Churchill Livingstone Elsevier, India.

Kastner J 2009. Chinese Nutrition Therapy: Dietetics in Traditional Chinese Medicine, Thieme, Calbe.

Maciocia G 2006. The Foundations of Chinese Medicine: A Comprehensive Text For Acupuncturists and Herbalists, Churchill Livingstone Elsevier, China.

Wang Y, Sheir W, Ono M 2010. Ancient Wisdom, Modern Kitchen: Recipes from the East for Health, Healing and Long Life, Da Capo Press, Philadelphia.

WHO 2013. World Health Organisation, Media Centre: Diarrhoeal Disease, Viewed 2 May 2013, http://www.who.int/mediacentre/factsheets/fs330/en/index.html

Wilson G 2006. The Tao Diet Cookbook, Art of Health Publications, Australia.

Wong L, Knapsey K 2002. Food for the Seasons: Eat Well and Stay Healthy the Traditional Chinese Way, Red Dog, Fitzroy

Shi A 2003. Essentials of Chinese Medicine: Internal Medicine, Bridge Publishing Group, Hong Kong.

The Development of Channel and Point Theory

A Brief Look Into the History of Acupuncture

Jimi Windmills

Throughout the history of Chinese medicine, the theories of the channels and points have been developed, studied, summarised and documented. Through observation and clinical experience, these theories have been changed and moulded, to fit the phenomena of healing associated with the various techniques unique to Chinese medicine. These ever shifting theories, although

transmutable, provide a solid framework for clinical practise. A platform of understanding that, for three thousand years, acupuncturists have been able to rely on, to perform efficacious treatments, and to leap from, with the developments of new theories.

Channel Groups and Pathways

The various channels are divided into groups, and not all were originally present. In the Mawangdui Scrolls (475 – 221 BCE), there were only eleven channels in total. Six channels ran from the feet to the head, and five channels from hands to the chest and head. Only four of these channels were associated with internal organs (McDonald 2006). There were no references to specific points on the channels in the Mawangdui Scrolls (Deadman et al. 2007: 11). By the time of the Huang Di Nei Jing, there were twelve channels, in which Qi and Blood flowed, which were described as flowing in an enclosed 'hydraulic' circuit (Unschuld 1985: 76). Along with the twelve main channels described, the Ling Shu and the Su Wen describe, fifteen Luo Mai, twelve Jing Bie, twelve Jing Jin, and the skin zones. The Nei Jing describes the pathways of the six arm channel that run between the hands and the head, the Hand-yin and Hand-yang. It also defines the three Foot-yin channels from the feet to the chest, and the three Foot-yang channels from the feet to the head (Unschuld 1985: 77). The pathways of these channels have not changed since their original description in the Huang Di Nei Jing. The Beginning and ending locations of the channels are in place, and there are detailed anatomical descriptions that mark the pathways, which can still be used today (Lu & Needham 1980: 92). While the eight extraordinary vessels are mentioned in the Huang Di Nei Jing, it is not until the Nan Jing that the pathways for the eight extraordinary vessels are defined (McDonald 2006). There are two competing theories on the discovery of the channels. It is the age-old argument

of which came first, the channels or the points. Obviously one school of though suggests that the channels came first, and the other school believes the opposite, that the channels developed from playing anatomical joint-the-dots. The points first school advocates the belief that points were discovered through the observation of tender spots that occurred during the course of a disease, and the reduction of symptoms associated with stimulating these points with pressure or heat. With enough points known, they were grouped together with other points that has similar effects, and with the experience of propagated sensation from stimulating the points, came to understand that there were underlying channels (Deadman et al. 2007:11). The channels first school, believes that with the experience of propagated sensation, particularly during massage, and exploration of the body through meditation and qigong, knowledge of the channels developed first, and specific knowledge about individual points came afterward. This channels first theory is supported by the fact that the earliest extant piece of literature dealing with the topic, the Mawangdui Scrolls, tells us about channels, but there is no mention at all of individual points (Deadman et al. 2007: 11).

Channel Pathology

In the Mawangdui Scrolls we find specific symptoms and pathologies associated with the channels, which were considered to be the consequence of either too little of to much Qi in the vessels (Unschuld 1985: 74). In the Nei Jing we see specific channels associated with certain conditions, indicating the use of points to treat pathology of those channels (Lu & Needham 1980: 96). By 300 CE the system of channels as we know them today was completely in place. The Ling Shu describes in chapter 10, the syndromes associated with pathology of the 12 primary channels, caused by external, internal, excess, deficiency, and Qi severance. However, these descriptions are only for the five zang (McDonald 2006). The Ling Shu also describes the course, and signs and symptoms of pathology of the 15 Luo Mai, the 12 Jing Bie and the 12 Jing Jin. McDonald also importantly points out, that while the course of the Jing Bie is described, there are no pathologies, and thus, no treatments associated with these channels (McDonald 2006). Zhang Zhong Jing in the Shang Han Lun, identifies that external pathogens can attack the exterior, and penetrate the channels, and that there were specific syndromes associated with a pathogens attack on specific channels (Lu and Needham 1980: 42). The eight extraordinary channels, for the first time fully laid out in the Nan Jing, receive a full complement of functions, courses, and signs and symptoms of disharmony.

Point Origins

It is obvious that from very early on, points were grouped together, based on proximity, and similarity of function. While the Nei Jing mentions more than 300 places suitable for needling, not all of these are named or precisely located (Unschuld 1985: 97). In the Su Wen, Ling Shu and the Nan Jing we have 160 points named and located. These points are also categorised into some of the historical point categories that we still use. These three books gave us the Back-Shu points for the five Zang, the five Transport points on the distal ends of each channel, the Yuan-Source points, 15 Luo-Connecting points, and Ba Hui (the Eight Meeting/Influential points). This collection expanded in the Zhen Jiu Jia Yi Jing to 349 points, when Huang Fu Mi described the anatomical locations of more points (Lu and Needham 1980:15). He also added new points to old categories, and gave us some new categories altogether. These were six Back-Shu points added for the Fu, Front-Mu points for the Zang (not including Ren17 for the Pericardium), and 16 Xi-Cleft points (McDonald 2006).

Point Categories

Back Shu

The first time we see the Back-Shu points is in the Huang Di Nei Jing. Chapter 24 of the Su Wen lists five pairs of points on the bladder channel of the back that correspond to each of the five Yin organs (Zang). It also says that these points can be treated either by needling or with moxibustion. As McDonald points out, The Ling Shu says in chapter 51 that Back-Shu points can be treated with moxibustion for both excess and deficient conditions, but needling them is forbidden (McDonald 2000: 9). Book 3 of the Zheng Jiu Jia Yi Jing, fills in most of the blanks and gives us Back-Shu points for the Diaphragm, Gallbladder, Stomach, Sanjiao, Large Intestine, Small Intestine and Bladder (McDonald 2000: 9). The final addition to this category was BL14 Pericardium Back-Shu, added by Sun Simioa in 682 CE, in his work, Qian Jin Yi Fang (Supplement to Prescriptions Worth a Thousand Gold Pieces). As an aside, Sun Simiao is also credited with the development of needling Ahshi (painful) points, specifically on the back, which were not specific acupuncture points (Lu and Needham 1980: 127).

Front Mu

While the Nan Jing mentions the existence of the Front-Mu points, it does not give any names, locations or indications for their use. The details of the Front-Mu points were not fully elucidated until the Zhang Jiu Jia Yi Jing provided descriptions of each, with the exception of the Front-Mu of the Pericardium given in book 3 chapter 19. Again, it was Sun Simiao that eventually gave the Pericardium a Mu point in the same work just mentioned (McDonald 2000: 9).

Transport Points (Wu Shu)

The transport points were some of the first points to be grouped into a category, based on having common actions. These points had already been allocated by the time of the Nei Jing since they are described and named in the Ling Shu. Wu, in his translation of the Nei Jing tells us:

"the five viscera have five shu acupuncture points each. Five times five is twenty-five points... those points of exit make the jing well points. Those in which there is a flow make the ying spring points. Those in which there is a large flow are the shu stream points. Those in which there is flow make jing river points. Those in which there is entrance in relation to other channels make the he confluence or sea points” (Wu 1993: 4).

It is interesting that there are significant differences in the indications listed in the Nei Jing, and the Nan Jing, for a lot of these points. For instance, the Ling Shu tells us that Jing-Well points are used for diseases of the Zang, while in the Nan Jing they are indicated for fullness below the heart. In the Ling Shu Ying-Spring points are used for diseases that change the colour of the complexion, while the Nan Jing gives us, the perhaps more clinically valuable use, for clearing body heat. Shu-Stream points are used for chronic diseases or intermittent diseases in the Ling Shu, while in the Nan Jing they are used for body heavy, joint pain. The same goes for Jing-River, and He-Sea points (McDonald 2000: 4-6).

Yuan-Source Points

The Yuan-Source points were first identified in chapter 1 of the Ling Shu, where they are indicated for treating diseases of the Five Zang. On the Yin channels, these are the same as the Shu-Stream points, and their use has remained consistent right through the long history of

acupuncture practise, through to modern times (McDonald 2000: 8). Deadman et al. Notes that in this first chapter of the Ling Shu, the Source point for the Heart is given as Daling PC-7, and that it was not until the Zhen Jiu Jia Yi Jing, that the Pericardium and Heart got their own Source points, Daling PC-7, and Shenmen HT-7. The Source points for the Six Fu are given in chapter 2 of the Ling Shu. These are discrete points that are located on the Yang channels between the Shu-Stream and the Jing-River points. The Yuan-Source points on the Yang channels have little ability to regulate or tonify their respective organs, and despite the fact that the Nan Jing says they treat disorders of the Fu, they are better used to expel pathogenic factors and treat channel pathology and pain (Deadman et al. 2007: 39-40).

Luo Connecting Points.

The fist mention of the Luo Connecting points is chapter 10 of the Ling Shu, which describes the location of the Luo channels and the Luo points, where the channels diverge from the primary channels. The points are used in the Ling Shu to treat deficient and excess conditions of their channels (Luomai). In the Zhen Jiu Jia Yi Jing We get another glimpse into the use of the Luo Connecting points. Each Luo point is named, located, its associated with its principle channel. The needling depth, duration, and amount of moxa (in the measurement zhuang) is also given (McDonald 2000: 8). As well as treating the area that the Luomai actaully traverses, Deadman et al. tells us that they also treat conditions of their interior-exterior related channels and Zangfu (2007: 40). This idea is first recorded in the Jin-Yuan Dynasty (1241CE) book by Dou Han Qing named, Zhen Jing Zhi Nan (Guide to the Classic of Acupuncture). The third use ascribed to this category of points by Deadman et al. is treating psycho-emotional complaints (2007:40). I have so far not been able to reconcile this with any classical source. I assume that this is an (perhaps valid) observation made by Deadman et al., based on the individual indications of a number of the Luo points, which do seem to have actions that could be described this way, that the category in general is apt of this description (2007:40).

Xi-Cleft Points

There are 16 Xi-Cleft points all of which are located near the elbows and knees. Each of the 12 primary channels has a Xi point, as do the Yinqiao, Yangqiao, Yinwei and Yangwei channels (Li 1992: 58). The Xi points did not exist at the time of the Ling Shu, Su Wen and Nan Jing, and thus none of the points are listed in these texts. These points came into usage some time between the writing of the Nan Jing, and the Zhen Jiu Jia Yi Jing (282 CE), where for the first time they are named, and categorised as Xi-Cleft points (McDonald 2000: 8). The Zhen Jiu Jia Yi Jing, however, does not provide us with any theoretical understanding of the indications or actions of these points. The idea of using Xi points to treat acute conditions of their channel or organ comes into practise at a later date, however I could not find a classical source from which this theory might be derived.

Confluent Points for the Eight Extraordinary Vessels

It is interesting that the category of confluent points for the eight extraordinary vessels was not created for a long time after the other categories so far discussed. There is no mention of this category in any of the older classics. Neither the Huang Di Nei Jing, the Nan Jing, nor the Zhen Jiu Jia Yi Jing are able to shed any light on the origins of therapy utilising these points (McDonald 2000: 11). This category, as a group of points to treat the eight extraordinary vessels, first appeared in 1439, in the Zhen Jiu Da Quan (Complete Collection of Acupuncture and Moxibustion) by Xu Feng, who provided a concise description of the application of these points (Matsumoto and Birch: 1986: 5). Before this, these 8 points were grouped together in pairs in the Zhen Jing Zhi Nan (Southward Pointer of Acupuncture classics) by Dou Hanqing, where each pair had specific indications for various conditions. They were also in the same work (Zhen Jing Zhi Nan), listed as an 8 point collection in the Miraculous Turtle Eight Methods (ling gui ba fa), an early theory of time related acupuncture (McDonald 2000: 12). According to Deadman et al. these points can also be used, in accordance with the poem Lan Jiang Fu (Ode of the Obstructed River) which was published by Gao Wu in his work Zhen Jiu Ju Ying Glorious Anthology of Acupuncture and Moxibustion in 1529 CE (2007: 46).

Chart Drawing and Bronze Casting

The first attempts at standardising points were made by those in the Channels and Points Research Schools. In the Sui Dynasty, 6th Centuary Qin Chenzu wrote a number of books, and drew illustrations of the channel pathways. Qin Chenzu was the first to draw the channels of the body from different perspectives. Unfortunately, all of Qin Chenzu's works have been lost. Zhen Quan in the late sui/early Tang Dynasty, wrote Ming Tang Ren Xing Tu (Bright Hall Illustrations of the Human body) (McDonald 2006), a study of the points, after the Zhen Jiu J a Yi Jing. Not long after Zhen Quan's work, Sun Simiao in chapter 29 of his Bei Ji Qian Jin Yao Fang

(Prescriptions for Emergencies Worth a Thousand Gold Pieces), created the first coloured acupuncture charts, detailing 656 points, in 5 colours (McDonald 2006). The first cast bronze statue depicting the locations of acupuncture points was created by Wang Wei Yi in 1026 CE. Wang Wei Yi cast two full size statues with channels and corrected point locations. He wrote an accompanying text named Tong Ren Shu Xue Zhen Jiu Tu Jing (Illustrated Classic of Acupuncture Points on the Bronze Statue (McDonald 2006). Perhaps the most famous cast statue is the Gao Wu Bronze. Gao Wu, also the author of the Zhen Jiu Ju Ying (Glorious Anthology of Acupuncture and Moxibustion) 1529, and Zhen Jiu Jie Yao (Essentials of Acupuncture and Moxibustion) 1537, cast individual life size statues, of a man, woman, and child (McDonald 2006). These attempts at standardising the locations of points probably had varying degrees of success. After each successive iteration, it is likely that the locations of just a few more points solidified in future texts. The process of point location standardisation continues, with the recent attempt by the World Health Organisation (WHO), in collaboration with eminent acupuncturists representing their own regions. Coming together to pin down the exact locations of a remaining handful of disputed points, each with elaborate research tailored to support their assertions that they knew the real locations and everyone else must be wrong. In humorous anecdotes recounted by McDonald, himself a participant in the WHO standardisation process, we find that the politics and fierce protectionism over point location is still very much in vogue. While the HO did manage to publish what was supposed to be the final word in the point location saga, it was eventually retracted, and practitioners in different regions, continue to needle points according to their own traditional regional variations.

References

Deadman, P 2007, A Manual of Acupuncture, Journal of Chinese Medicine Publications, Hove, England.

Li, D 1992, Acupuncture, Meridian Theory and Acupuncture Points, China Books and Periodicals, Inc, San Francisco.

Lu, G, Needham, J 1980, Celestial Lancets – A History and Rationale of Acupuncture and Moxa, Routledge Curzon, London.

Lu, H 1975, The True Story of Chinese Acupuncture, The Academy of Oriental Heritage, Vancouver.

Maciocia, G 2006, The Channels of Acupuncture – Clinical use of the Secondary Channels and Eight Extraordinary Vessels, Churchill Livingstone Elsevier, Spain.

Matsumoto, K, Birch, S 1986, Extraordinary Vessels, Paradigm Publications, Brookline, MA.

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Childhood Asthma

Eczema and Asthma Part 2 - Childhood Asthma

Jimi Windmills

Introduction

In part two, we will look at childhood asthma, first exploring some fundamental differences between the physiology of children compared to adults, and the importance of inspection as a diagnostic technique in paediatrics. We will then compare the treatment of asthma in children to the treatment of asthma in adults, with reference to Scott and Barlow’s text on paediatric acupuncture, and other relevant texts and articles.

Physiology of Children

There are many aspects in which the physiology of children differs from that of adults. For a large part, this centres on the development of a well functioning digestive system. The spleen coordinates and drives the entire digestive process, and since, as Scott and Barlow point out, before birth, a baby has received all its nourishment from its mother, it has never had to rely on the proper functioning of its own mechanisms for generating Qi. This results in immense pressure on the spleen, as it tries to take all the food coming into the body for the first time, and convert it into Qi and Blood. This makes children particularly susceptible to disorders involving the spleen (Scott and Barlow 1999: 3-4).

Children are often Yin deficient. This is evidenced by their susceptibility to Hot diseases, fevers and convulsions. Children are Yang in nature, compared to adults, they are always moving, and always changing (Scott and Barlow 1999: 4). Given their propensity for rapid change, children are particularly vulnerable to changes in diet, succumb rapidly to viruses, and are affected quickly by hot or cold weather. When sickness takes hold, progression of the disease is often frighteningly rapid, quickly developing fevers, acute diarrhoea leading to dehydration, or chest infections that transform into pneumonia, threatening the child’s life (Scott and Barlow 1999: 4-5).

While it is certainly true that children get sick easily, and progression of disease can be very fast, it is reassuring that they also respond very quickly to all manner of treatment (Scott and Barlow 1999: 5). This capacity to be influenced easily by external forces holds true for the impact of the seven emotions on children, who having little awareness of their emotional state, are directly involved in the emotional affairs of their parents, and others close around them. Stress, anxiety and frustration in the parents are quickly mirrored by their children. In saying this, it is important to clarify that in general, children do not suffer from Qi stagnation as a result of repressing emotions. Patterns that look like Liver Qi Stagnation or Yang rising, are most often food stagnation and accumulation disorder. The most common sign of liver involvement is stirring of Liver Wind causing febrile convulsions (Scott and Barlow 1999: 5).

The Importance of Inspection

It is difficult to take a child’s pulse, and often they are unable to speak for themselves because they have not learned how, or are too shy. Sometimes an otherwise verbal child might be inhibited in a clinical setting. This makes asking (the parents), and inspection, particularly of the child’s face, the two most important methods for diagnosing children. Inspection is the most important of the four diagnostic methods for several reasons. It does not rely on subjective information provided by an anxious parent, or unwell child, who may or may not fully grasp the meanings of the questions. Inspection is the best way to assess the overall level of Qi of a child, and the vividness of the colours of the face in an immediate clue to the health of the child. It also provides a way to gauge the efficacy of previous treatments, as the child will appear healthier and more Qi-full (Scott and Barlow 1999: 58-60). The face of a child is the most important area for inspection. By looking at the face, particularly focusing on the eyes, and the quality of the Shen, a practitioner is able to assess the child's spirit, and make a prognosis on the recovery. The colour of the face also provides key diagnostic information, and is often more reflective of the health of the child, than either the tongue or the pulse. Other important aspects of inspection are the movement of the child, inspection of the orifices, and the finger vein. The finger vein is located on the radial side of the index finger, and when present can be interpreted diagnostically (Scott and Barlow 1999: 59-61).

Asthma – Treatment in children and Adults

Asthma patterns in children under 5 years of age are very different from those seen in older children and in adults, according to Scott and Barlow. When a child under 5 has asthma two factors will always be present: Phlegm and Lung deficiency. In a majority of cases there will also be an underlying lingering pathogen (1999: 229). Scott and Barlow assert that the most common aetiology of asthma is repeated use of antibiotics to treat acute coughs. Their pattern of asthma in children under 5 is accumulation of Phlegm in the Lungs, with underlying Lung and Spleen Qi deficiency, complicated by a lingering pathogenic factor. They describe the pathogenesis of the disease as beginning with accumulation of food which restricts the flow of Qi, this generates Phlegm which accumulates in the Lungs. The Lungs become deficient and combined with the already deficient Spleen, leads to asthma. This pattern can be complicated by a lingering pathogen, which may be Hot or Cold in nature (Scott and Barlow 1999: 230-1). As the signs and symptoms listed in Scott and Barlow are extensive, they will be supplied in Appendix 1.

Scott and Barlow’s stress that in this pattern with Phlegm, Lung deficiency and a lingering pathogenic factor, that it is important to treat the Lungs and the Phlegm first, and not treat the lingering pathogen until there is a reduction of Phlegm and an increase in Lung Qi.

From Scott and Barlow:

• The main points are Lu5, Lu7, Lu9, Ren12, Ren22 and St40¹.
• For Phlegm with accumulation disorder add Si Feng (M-UE-9)².
• Lung and Spleen Qi deficiency (normal and hyperactive) add Sp6 and St36.
• Lingering pathogenic factor (cold) add Bai Lao (M-HN-30), Bl12, Bl20, Bl18, Bladder points can also have moxa applied, along with moxa at Ren12³.
• Lingering pathogenic factor (hot) add Lv2, Lu10, and apply a dispersing technique to the main points, particularly Lu5 and Lu7 (1999: 233-4).

The aetiology of asthma in adults begins with Wind-Heat or Wind-Cold repeatedly invading the body, and settling in the Lungs where it impedes the flow of Lung Qi, which results in the accumulation of Phlegm. Similar to Scott and Barlow’s pattern for children, Maciocia also identifies improper diet injuring the spleen as being a contributor to the production of Phlegm. Another aetiological factor is weak constitution. A child who suffers a long illness, will develop Lung and Spleen deficiencies, impeding the transformation of fluids and leading to the production of Phlegm. While Scott and Barlow assert that adult patterns of asthma are very different to those of young children, Maciocia's, aetiology and pathogenesis seems quite similar. Asthma, according to Maciocia, can be split into two categories, acute phase, and chronic phase. Acute phase can be further subdivided into Cold Phlegm and Hot Phlegm patterns. Acute phase treatment happens during an attack, or between attacks during a period in which they occur frequently. Maciocia's differentiating features are listed in Appendix 2. The treatment principal for Cold Phlegm is to warm the Lungs, scatter Cold, resolve Phlegm, and relieve breathlessness (Maciocia 1994: 176). The point prescription is Lu7, Bl13, Lu1, Lu6, Ren22, Ren17, St40, Pc6, reducing or even technique, and moxa (Maciocia 1994: 176). The treatment principle and points for Hot Phlegm is to clear Heat, restore the descending of Lung Qi, resolve Phlegm and stop wheezing. Lu5, Lu10, Lu6, Bl13, Lu1, LI11, Pc5, St40, Ren22 (Maciocia 1994: 176).

Recent Research

In a research article published in the Journal of Traditional Chinese Medicine children diagnosed with bronchial asthma were treated using acupuncture and herbs. In the article there is very little mentioned about the pattern diagnosis, this was a common failing among most of the articles I located to do with acupuncture, there were very few dealing specifically with acupuncture to treat asthma exclusively in children. The article, Clinical Research of Acupoint Application for "Treatment of Winterdisease in Summer" Used to Prevent and Treat Bronchial Asthma in Children, was particularly interesting in that it placed a big emphasis on the season in which the treatment took place. This was an element that was not present at all in the works of Scott and Barlow, or Maciocia. In this article, points were chosen (all of which seem reasonable, in the absence of a treatment principle), including Bl13, Bl43, Dingchuan, Ren22, Ren17, Du14, Ren4, Ren8, Bl26, and Pc6, many of these were used in the other protocols previously explored, however points specifically to clear Phlegm, a pathological component in each of the other authors works, are notable in their absence. These points were needled on the hottest days in summer, and on the coldest days of winter. The authors of the study also prescribed herbal treatment.

Conclusion

In this second part of the assignment, we looked at childhood asthma, and some of the most important differences between the physiology of children compared with that of adults. We saw that the most important element of diagnosis in paediatrics is inspection, especially of the face. We then compared the treatment of asthma in children to the treatment of asthma in adults, and saw that they were quite similar. Finally we took a brief look at a research article, which in comparison to our other two texts outlined a unique method of treatment for paediatric asthma using acupuncture.

1 Scott and Barlow caution not to use St40 in cases where the patient is extremely Phlegmy for fear of provoking asthma attack. Use Ren22 and Ren12 for the first few treatments.

2 Like ST40 we are cautioned again against the use of Si Feng in cases of extreme phlegm, since the point can release a lot of heat and Phlegm into the system and make the patient worse. Again use Ren 22 and Ren12 until a lot of the Phlegm has cleared.

3 Do not treat lingering pathogenic factor until Phlegm had been resolved and deficiency almost completely tonified.

Bibliography

Crawford, M 1998, 'The Acupuncture Treatment of Skin Diseases By Dr Gu Yue Hua', Journal of Chinese Medicine, No. 26.

Maciocia, G 1994, The Practise of Chinese Medicine, Churchill Livingstone, New York.

Scott, J and Barlow, T 1999, Acupuncture in the Treatment of Children, Eastland Press, Seattle.

Wen, BL, Liu, BY, Peng, J, Wang, XF, Xiang, XX, Liu, XF, Hu, JQ, Lu, F, He, LY, Zhu, WZ, Fang, YG, Wang, Y 2012, 'Clinical Research of Acupoint Application for "Treatment of Winterdisease in Summer" Used to Prevent and Treat Bronchial Asthma in Children', Journal of Traditional Chinese Medicine, Vol. 32 No. 1 pp. 31-39. Viewed 29 October 2012 http://www.sciencedirect.com.ezproxy.endeavour.edu.au:2048/science/article/pii/S0254627212600284.

Yan, CL, and Zhu YL 2005, The Treatment of External Diseases with Acupuncture and Moxibustion, Blue Poppy Press, Boulder.

Zhang, ZD, Deng, YQ, Zhang, Y, Han, Y, Lin, L, Chao, EX 2010, 'TCM Differential Treatment of Cough Variant Asthma', Journal of Traditional Chinese Medicine, Vol. 30, No. 1 pp. 60-63.

ECZEMA

Eczema and Asthma Part 1 - Eczema.

Jimi Windmills

Introduction

It has been a while since I posted so I thought I would post a two part short article I wrote a little while back. In these two brief articles I discuss two conditions that often present simultaneously in patients, Eczema and Asthma (particularly in children).

Aetiology and Pathogenesis

In Chinese Medicine, eczema is traditionally known as seeping sap sores. It is an inflammatory response that occurs superficially on the skin. It typically presents with red skin, papules and vesicles, weeping and crusting. In more chronic cases it can eventually lead to scaling, pigmentation change, and lichenification (Crawford 1988: 18).

There are both internal and external causative factors. External Wind, and internal Heat and Damp. A person generates internal Heat, primarily by regular consumption of hot, pungent food. This causes a disruption to the spleen which leads to the accumulation of Damp, and a deficiency of Wei Qi. Wind invades while the Wei Qi is low, and having penetrated, accumulates at the skin level with the Damp and Heat to cause Eczema (Crawford 1988: 18). In the deficient pattern of eczema, Blood is consumed by a chronic heat in the intestines, causing a deficiency of Blood. This Blood deficiency leads to a rising internal Wind. The Wind and the dryness from the Blood deficiency, fail to nourish the skin, resulting in dry skin and eczema (Crawford 1988: 18).

Yan and Zhu agree that there are two predominant patterns of eczema (Yan and Zhu 2005: 89). Both agree on the acute pattern involving Wind Dampness and Heat, Yan and Zhu call it “Fulminant wind, dampness & heat” (2005: 89), while Crawford in her article titled The Acupuncture Treatment of Skin Diseases calls this pattern “Damp-Heat complicated with EPF Wind” (1998: 18). While their pattern identification is similar, their treatment principles differ, and point prescriptions utterly divergent. First we will examine the excess condition.

Excess Pattern Eczema - Wind, Dampness and Heat.

This pattern is characterised by a red rash with exudate and itching, and the expression of the pattern can change depending on which pathogenic factor predominates (Yan and Zhu 2005: 89). Crawford adds the following differentiating features; erythema, vesicles, erosion, oozing, crust, bitter taste and stickiness in the mouth, scanty deep yellow urine, constipation, a red tongue with sticky yellow coating, and a soft, rolling or rapid pulse (1998: 18-19). Yan and Zhu point out that in excess patterns of eczema, one of the three external influences will often predominate;

• Wind dominates – Most likely to affect the upper body, or widely spread with minimal exudate.
• Heat dominates – Affected area will be bright red and may have many pustules.
• Damp dominates – There will be raised blisters with excess exudate. This may be accompanied by heaviness in the chest and difficult inhalation (Yan and Zhu 2005: 89).

The treatment principle for this pattern, according to Yan and Zhu, is to expel the wind, clear the heat, and resolve the dampness (2005: 89). Crawford tells us to clear Damp-heat and relieve itching (1998: 18). It is interesting to note that while Yan and Zhu have included GB31 in their point prescription, they neglected to include 'stopping the itch' in their treatment principle. Crawford on the other hand overlooks wind clearing, from her principle and core prescription¹. Yan and Zhu and Crawford pick quite different points, with only LI11 being a common component of their core prescriptions. To treat this condition Yan and Zhu have the primary point prescription of Du14, LI11 ST36, SP6, and GB31 (Yan and Zhu 2005: 89). To this they add auxiliary points: LI4 for prevalent wind; SP6² and Ren12 for prevalent damp; LV1 prick and bleed for prevalent heat; LV5 and Ren3 for damp affecting the scrotum (Yan and Zhu 2005: 89). Needle using a sedating technique, once a day, with 20-30min needled retention (Yan and Zhu 2005: 89).

Crawford prescribes LI11, SJ5, BL25, and SP9 with a reducing method, and recommends Du14, if there is concomitant fever, and HE7 if there is itch. Crawford also suggests surround needling with electro-stimulation (Crawford 1998: 19).

Deficiency Pattern Eczema – Yin/Blood Xu, Wind and Dryness.

This is chronic eczema that tends to reoccur. The skin is dry, thick and itchy. The itch is generally worse at night. The patient is often skinny, with a fine, soggy pulse, and a pale tongue (Yan and Zhu 2005: 89). To these differentiating features Crawford adds that the affected area may have a change of pigmentation, may ooze when scratched, and that there may be some desquamation of the skin. The tongue has a white coat, and the pulse will be thready, rapid, or rolling and rapid (1998: 19).

Yan and Zhu and Crawford’s patterns for the deficient pattern of eczema are different in their emphasis. Yan and Zhu call their deficient pattern “Yin vacuity, dry blood & fulminant wind” (2005: 90), while Crawford calls it “Deficiency of Xue complicated with Dryness of Wind” (1998: 19). While at first it may seem a superficial difference, it actually changes the way they develop their treatment principle and point prescriptions. While both Yan and Zhu and Crawford admit elements of Yin/Blood deficiency, Dryness and Wind, the critical difference is the origin of the Wind. It is obvious that Yan and Zhu are treating the Wind as an external pathogen, since their principle to dispel the Wind, is matched in their prescription with the point BL12 Fengmen the Wind Gate typically used to expel external Wind (2005: 90). Crawford on the other hand, acknowledging the chronic aspect of the condition, asserts through her principle and prescription, that the Wind is born of the Blood deficiency. Her principle to nourish Xue and eliminate Wind, is matched with more appropriate points for this pattern; BL17, SP10, ST36, and SP6 (1998: 19), All of which serve to build the Blood, eliminating the Wind.

Yin vacuity, dry blood, and fulminant Wind (Yan and Zhu 2005: 89).

The treatment for this pattern is to expel the Wind, nourish the Blood, and moisten the Dryness. The point prescription given by Yan and Zhu is; LI11, SP10, BL17, BL12, with modifications of HT7 for vexation (disturbed Shen from the itch), and GB31 to relieve the itch. They suggest a tonifying needle technique (Yan and Zhu 2005: 89).

Yan and Zhu also recommend moxa to treat this type of deficient pattern eczema. Moxa is to be applied at LI11, SP10, and over the centre and periphery of the affected area. In addition to these points they also moxa DU14, LI4, SP6, ST36 and any place that is itchy (2005: 89). Yan and Zhu also suggest ear points Spirit Gate, Heart, Lungs, Liver, Spleen, and any tender ear points, and using a dermal hammer over the affected area, and parallel to the spine³, until there is a little bleeding (2005: 89).

Deficiency of Xue complicated with Dryness of Wind (Crawford 1998: 19).

As mentioned above, Crawford pays more attention to the chronic, deficient nature of the condition, recognising that the Dryness of Wind is a result of a long-standing Blood deficiency. Crawford prescribes BL17, SP10, ST36, SP6, and if there is pronounced itching, PC7. Dermal hammer is suggested to break up the thickened skin, with cups applied once there is blood seeping out. Another option to treat locally is moxa cones burned directly on area of thickened skin, between 1-7 cones, each burned down a little further as tolerance to the heat develops (1998: 19). Like Yan and Zhu, Crawford also suggests ear points for deficient patients. The auricular points Shenmen, Subcortex, Adrenal, Heart, Diaphragm, and points relating to the anatomical location of the eczema. Use only 3 or 4 of these points each treatment, retaining needles for 20 minutes. Use ear seeds unilaterally in particularly chronic cases.

Conclusion

In this analysis of the treatment of eczema with acupuncture and moxibustion, I first outlined the aetiology and pathogenesis of the disease, and described the patterns of eczema. I compared these descriptions and treatments from the set text to a journal article, with particular attention given to inspection as a diagnostic method. I also noted as a comparison, the differences between treating internal and external diseases, in particular the confusion that can arise around mis-diagnosing the source of pathogenic wind.

1  Crawford includes Du14 in her additional points, to be added in the case of fever. However if included in the core set of points, could effectively expel the wind.

2  Yan and Zhu name San Yin Jiao with no point number in their text. I believe this is an error, as they previously list Yin Ling Quan (SP9) as an auxiliary point in this treatment, and go on to list SP6 (which is already in the primary prescription) as a point for prevalent damp. I have left their prescription intact with this note to point out that it should indeed be Yin Ling Quan (SP9), in conjunction with Ren12 for prevalent damp.

3  I presume they mean to dermal hammer the Bladder channel of the back.

Bibliography

Crawford, M 1998, 'The Acupuncture Treatment of Skin Diseases By Dr Gu Yue Hua', Journal of Chinese Medicine, No. 26.

Maciocia, G 1994, The Practise of Chinese Medicine, Churchill Livingstone, New York.

Scott, J and Barlow, T 1999, Acupuncture in the Treatment of Children, Eastland Press, Seattle.

Wen, BL, Liu, BY, Peng, J, Wang, XF, Xiang, XX, Liu, XF, Hu, JQ, Lu, F, He, LY, Zhu, WZ, Fang, YG, Wang, Y 2012, 'Clinical Research of Acupoint Application for "Treatment of Winterdisease in Summer" Used to Prevent and Treat Bronchial Asthma in Children', Journal of Traditional Chinese Medicine, Vol. 32 No. 1 pp. 31-39. Viewed 29 October 2012 http://www.sciencedirect.com.ezproxy.endeavour.edu.au:2048/science/article/pii/S0254627212600284.

Yan, CL, and Zhu YL 2005, The Treatment of External Diseases with Acupuncture and Moxibustion, Blue Poppy Press, Boulder.

Zhang, ZD, Deng, YQ, Zhang, Y, Han, Y, Lin, L, Chao, EX 2010, 'TCM Differential Treatment of Cough Variant Asthma', Journal of Traditional Chinese Medicine, Vol. 30, No. 1 pp. 60-63.