Weblog of Kevin Zhu

Yanzhong (Kevin) Zhu

Introduction

Currently TCM tends to adopt the warm-febrile disease school’s treatment method of clearing damp-heat for chronic lower jiao disease; although this treatment principle is only treating the manifestation, while failing to address the root of the disease. Specifically, the Huangdi Neijing discusses the pathomechanism of lower jiao disease using theories and relationships of Sanjiao, Urinary Bladder, Kidney, Ministerial Fire, Liver, and Gallbladder. The intention of this study is to study and apply these theories in order to build a diagnosis, and then to develop an application of points and herbs to treat the diagnosis.

Method

The method of warming the water to submerge the Yang comes from the Neijing. The Neijing discusses the ways heaven and man are integrated, the multiple transformations between Yin and Yang, the six qi transports, and the five element generations and interactions. These are the basic theories that underlie six channel diagnoses. From these theories the method of warming to tonify Kidney water Yang in order to descend and submerge the Sanjiao ministerial fire, is developed. The result is that the Kidney Yang comes to hide and be stored in the Lower Jiao. It is the Urinary Bladder qi transformation that regulates and opens the lower orifices, restoring the Lower Jiao Yin-Yang balance.

In the clinic, we are primarily concerned with diseases of the urinary system: kidney infection, Pyelonephritis (renal pelvic infection), urinary tract infection, chronic prostatitis, enlarged prostate, seminal [epididymal?/ vas deferens?] infection, diseases of the lower limb, lower limb edema, etc. In Traditional Chinese medicine (TCM), these diseases fall under the category of ‘uninhibited urinary and lin syndromes,’ (Golden Chamber: ch. 13, ch. 14), and Lower Jiao damp heat syndromes. These are water-qi disorders.

According to the Ling Shu (The Spiritual Pivot), in the Ben Shu, chapter 2: The root of transport:

The Sanjiao Fu organ is joined with the foot Shaoyin Kidney and Foot Taiyang Urinary Bladder through its connection with their respective channels. There is one branch that comes from the foot Taiyang channel, 5 cun above the external malleolus, it penetrates the calf muscle and emerges at UB 39. The branch then enters and combines with the foot Taiyang primary channel and collateral. The Sanjiao governs the Lower Jiao. Excess will cause urinary blockage and closure. Deficiency will cause urinary leaking. In cases of urinary leakage, use the tonification technique; for urinary blockage, treat with the draining technique.

The Sanjiao stores the ministerial fire; the ministerial fire wants to hide in the Lower Jiao water, the Kidney. When the Kidney Yang is draining to the Urinary Bladder, it will cause Kidney Yang deficiency with Urinary Bladder damp heat. Kidney Yang deficiency will evidence as urinary leakage, and damp heat excess will show as urinary blockage. When there is Kidney Yang deficiency, treatment is based on the technique of tonifying, to hide the Kidney Yang. When the Urinary bladder is blocked, clearing damp heat is the basic technique used. In order to understand the Lower Jiao water and ministerial fire relationship and the basic mechanisms involved, we must first review the Zang Fu organs, Yin-Yang, the five elements, and the six qi relationships.

The basic theories of TCM state that heaven and man are integrated. There are six qi in heaven and five elements in the earth. The six qi are: wind, heat, summer heat, damp, dry, and cold. The five elements are: wood, fire, earth, metal and water. Every element contains within it a small pivot; the paired organs are representatives of the internal and external, of Yin and Yang. Heaven will form the qi and produce the phenomena; earth will produce the form. Man is the Middle Jiao qi of heaven and earth. Heaven’s qi will generate the six Fu; earth’s qi will produce the five Zang.

Of the six qi of heaven, the first is the Jueyin wind wood, on man the Liver channel corresponds with this. The second is the Shaoyin imperial fire, the Heart channel corresponds on man. The third is the Shaoyang ministerial fire, in man the Sanjiao channel corresponds. Fourth is Taiyin damp earth, in man it is the Spleen channel. Fifth is the Yangming dry metal, in man it is the Large Intestine channel. The sixth is Taiyang cold water, on man it is the Urinary Bladder channel.

The foot Jueyin wind wood is the leader of Jueyin; wind is produced by Jueyin. Wind corresponds to the heaven qi and wood corresponds to the earth qi. The hand Jueyin Pericardium is the follower of the foot Jueyin; the ministerial fire follows and transforms in to wind wood. Heat is created by the Shaoyin imperial fire. In the heavens the corresponding qi of the Shaoyin imperial fire is heat and on earth it is fire. The hand Shaoyin imperial fire is the leader of Shaoyin. The hand Shaoyin Heart is fire and the foot Shaoyin Kidney is water. The associated gua with water is the Kan gua. There is one Yang yao in the two Yin yao; this is the root of fire. The Kan Yang ascends to interact with the Li gua, transforming into fire. The fire ascends from the water; this is gui water transforming into ding fire, Yin water transforming to Heart fire. Water transforms to the fire, cold follows heat in the transformation.

Summer heat is produced by the Shaoyang ministerial fire. In the heavens it is the qi of summer and on earth it is fire. The hand Shaoyang ministerial fire is the leader of Shaoyang. The foot Shaoyang Gall Bladder uses the Yang wood to transform to the ministerial fire. The Sanjiao fire will flow downward, following the foot Taiyang, to warm the Lower Jiao water. When the Kidney water warms up it can then open and regulate the Lower Jiao. The Sanjiao alone controls the water pathway. In the Suwen basic questions, in the chapter ‘Ling Lan Mi Dian,’ it states that the Sanjiao organ is the officer for the opening of the water pathways; the Sanjiao clears out and creates the water pathways. The Urinary Bladder is the officer of the state capitol. The jing ye hides inside the Urinary Bladder and comes out after qi transformation. This concept comes out of the Neijing. The nature of water is to hide. The nature of fire is to disperse, smooth and drain. The nature of water is to close and hide, being as such, it is a good way to hide the Yang. To smooth and drain is a good way to open the orifices.

Damp is produced by Taiyin earth qi. Damp is the heaven qi and earth is the earth qi. Taiyin uses Taiyin damp earth as the leader. The dry metal will transform to the damp and follow earth. Yangming uses the hand Yangming dry metal as the leader. The Yang earth Stomach will follow the metal to transform to dryness. The damp of Spleen earth is the original qi of the earth. Normally the Stomach dryness cannot overact on the Spleen dampness. In cases of disease it is most commonly due to the Spleen dampness overtaking the Stomach dryness.

Dryness is produced by the Yangming metal qi. Dry is the heaven qi and metal is the earth qi. Yangming uses dry metal as the leader. The Stomach earth transforms to dry following the Large Intestine Yangming dry metal. Cold Taiyang water: cold is the heaven qi and water is the earth qi. The Taiyang uses the foot Taiyang Urinary Bladder as the leader. Hand Taiyang Small Intestine is the fire; foot Taiyang is the water. Taiyang uses the cold water as the leader.

On the upper part of the Li gua there are two Yang yao and one Yin yao in the center. The Yin yao is the root of water. The yin descends and interacts with the Kan location and transforms to water. Thus descending water starts from fire. The Small Intestine fire transforms to the Urinary Bladder water. The Sanjiao fire transforms to the water, heat transforms to the cold. So Taiyang qi uses the cold water as his name. The nature of water is cold; Shaoyang Sanjiao fire will descend along the Taiyang. When the fire enters the water it warms it. This warm water is not Urinary Bladder water- it is Kidney water. The nature of water is to hide and store. Fire will be stored, hiding in the interior and water will be holding from the exterior: this is the condition of a healthy person. Wood and fire (Liver and Heart) are indicative of the interior. Generation and growth comes from the interior. Thus, interior qi should be constantly warm. Metal and water (Lung and Kidney) govern the exterior, storing and hiding on the exterior. This is why external qi is clearer. Blood is generated from the wood and fire, thus blood is warm and ascends from the interior. Qi transforms from the metal and water, thus clear qi will hold from the external.

Of man’s twelve channels, Jueyin is in the interior. It is spring qi generating from the interior. Then comes Shaoyin summer qi growing from the interior. Yangming is the autumn that stores from the exterior. Taiyang is on the exterior; it is winter qi from the exterior that bind and hides. When the Yang is hiding in the interior it manifests as ‘external clear’ and ‘internal warm’. When the Yang is draining out it will lead to ‘internal cold’ and ‘external heat.’ If the Sanjiao fire is stored in the Kidney this will create warm water, if the Sanjiao fire does not come to hide in the Kidney the warm spring will turn to cold ice. If the outer has more heat due to the Sanjiao ministerial fire draining to the Urinary Bladder, the internal will be colder. If the qi is generated without root, then people will die. When the Kidney water is warm and Urinary Bladder water is cold it will be easy to treat the patient’s condition. When the Kidney water is cold and the Urinary Bladder water is warm, the patient will present with abnormal diseases. The Kidney water disease will present with cold symptoms and the Urinary Bladder water disease will present with heat symptoms; Shaoyin Zang disorder will present with cold signs and Taiyang Fu organ disease will present with heat signs.

Heaven’s Tao turns clockwise. The Middle Jiao is earth: the Spleen turns left ascending the Yang, the Stomach turns right descending the qi down. The energy on the left is the Liver, storing the blood. On the right is the Lung, storing the qi. The Liver is Jueyin wind wood and when the qi ascends Yang will be open. The Liver stores the blood; the source of blood is the Spleen. Ascending Spleen Yang assists the Liver Yang to open and ascend. The Liver is wood and is the mother of the Heart (fire), therefore it is what generates fire. The Heart stores the imperial fire and its manifestation is the spirit. At night the Heart fire follows the Lung metal on the right and descends down to connect with the Kidney water. On the left side, the west, is Lung metal. The Lung stores the qi. When the Middle Jiao earth rotates, the Spleen qi ascends and the Stomach qi descends. The descent of the Stomach aids in the descent of the Lung in its transformation to the water. The Kidney water ascends to generate the Liver wood. This is heaven’s Tao turning left.

The Sanjiao hides the ministerial fire in the Lower Jiao, in the water, making the Kidney Yang. The external organ is the Urinary Bladder; the internal is the Kidney. It is the Urinary Bladder cold that allows the Kidney to be warm. The fire that warms the water is the Sanjiao fire hiding. The earth’s Tao turns anticlockwise. This means that the Large Intestine ascends from the west to the Small Intestine to the Pericardium, which in turn descends to the Gall Bladder. The Gall Bladder descends to the Urinary Bladder, which descends to the Sanjiao, which in turn ascends to the Large Intestine.

In the Neijing the imperial fire is the bright. The imperial fire makes the light- it is like the sun illuminating. The Ministerial fire makes the warmth- it is the foundation of internal heat. The ministerial fire is like the fossil fuel within the earth. In man the imperial fire is Spirit; the ministerial fire is the body’s function, its metabolism. The physiological movement of qi, clockwise and anticlockwise, pivots from the Middle Jiao earth. Another way to understand this is to say that if there is a Middle Jiao earth disorder, there will be an energy flowing disorder. This is a physical condition.

When there is a disorder in the Lower Jiao it will present as Kidney warm water draining in to the Urinary Bladder cold water and the Urinary Bladder cold water will come to be warm. This can present as Lower Jiao damp heat, lin syndromes, inhibited or uninhibited urination, or lower limb damp heat signs. Western diagnosis can be as follows: urinary tract infection, prostatitis, enlarged prostate, prostate cancer, leucorrhea, lower limb edema diseases, and diseases of the external genitalia (e.g., herpes). The causes are primarily due to Kidney Yang deficiency with Urinary Bladder damp heat. Kidney Yang deficiency is from the Sanjiao ministerial fire draining out of the Kidney and into the Urinary Bladder. Under ordinary circumstances the Sanjiao ministerial fire hides in the Kidney, warming the water. The Urinary Bladder is outside of the Kidney. Its nature is cold water and thus hides the Yang inside the Kidney water. The meaning conveyed here is that ‘water’ can be understood as ‘yang hiding.’ The Kidney Yang will ascend the water to nourish the wood, to supply the blood. When the Sanjiao fire enters into the Kidney but is unable to hide, it will drain down to the Urinary Bladder. This pathology is primarily related to two organs: The Spleen earth damp and the Liver wood wind. If the Spleen is too damp, with not enough Yang to transform to qi, it will lead to water damp stagnation in the Middle Jiao and the Spleen qi will descend rather than ascend, as it should. This is because the ascent is blocked by the damp stasis. The Liver wood is affected because the Liver relies on the ascent of the Spleen Yang to assist it in its opening and ascent. The Spleen is the source of the blood. The Spleen sends the blood to the Liver; as the Spleen qi ascends it brings the Liver Yang to ascend, generating Heart fire. When the Spleen is blocked by damp, the Spleen qi descent will cause stasis of the Liver wood wind. Jueyin wood wind stagnation will result in the Liver qi draining down to the Kidney, causing the Lower Jiao to be more cold and thus producing Lower Jiao water stasis. This will in turn affect the Kidney Yang.

When there is Liver Jueyin stagnation, wind will be produced. Physically, the Liver Jueyin wind functions by dispersing jing ye and by opening the orifices. The eyes being open and moist are a product Liver wind opening the orifices. The Kidney orifices being open, and the Urinary Bladder being open is also due to Liver wind opening the orifices. Menstruation would be another example. If there is no wind produced by the Liver, as with Liver Yang deficiency or blood deficiency, this will result in the orifices being blocked. This might present as dry eyes, dry mouth, amenorrhea, or the Urinary Bladder orifice being blocked. In contrast, if there is too much wind it will cause the orifices to be constantly open, leaking. This can present as excess sweating, tearing, urinary leakage, heavy menses, and profuse leucorrhea. When there is Liver stasis and wind is produced, the orifices are opened and the Lower Jiao water is drained. This leads to the Sanjiao ministerial fire being unable to hide in the Kidney. The Sanjiao ministerial fire will drain out to the Urinary Bladder from the Kidney.

There are two basic presentations of Lower Jiao disorders: one is an excess condition, the other a deficiency condition. An excess condition will present as heat mixed with water stasis in the Lower Jiao. This includes Urinary Bladder damp heat and Lower Jiao damp heat syndromes. A deficiency condition will present with Kidney Yang deficiency, with the San Jiao fire in the lower Jiao unable to hide well. Clinically the presentation might include deficiency and excess symptoms mixed together. A urinary tract infection would be an example of mixed signs. There is a manifestation of Urinary Bladder damp heat- painful, urgent, frequent urination- but underlying these symptoms is the San Jiao ministerial fire draining out of the Kidney causing Kidney yang xu. The amount of excess or deficiency signs can differ from case to case. A patient might present with more excess and less deficiency, for example. Their Lower Jiao signs might be more excess UTI signs and Kidney Yang deficiency would be less obvious. This situation would be noticeable on the pulse reading. The right side chi pulse would be big and the left side chi pulse would be weaker. This would show that more heat is presenting due to damp stasis. The treatment should be focused on clearing damp heat, and either minor tonification of the Yang or not at all. Conversely, a patient might present with more Yang deficiency and less damp heat symptoms. This would be due to the Sanjiao fire being exhausted from the Liver qi descending, preventing the Kidney water from ascending. The Gall Bladder fire should descend to tonify the Sanjiao fire, but in this scenario it would be in perversion. When the Liver qi descends there is Kidney water retention in the Lower Jiao and Gall Bladder fire perversion presenting with heat in the upper. The chief signs in this particular scenario of Yang deficiency predominance would be: urinary leakage, loose stool, profuse leucorrhea, heavy menses, lower limb edema, or lower limb cold. The treatment would emphasize tonifying the Kidney Yang and minor clearing of damp heat from the Lower Jiao or not at all.

The manifestation of cold water and damp heat stagnation in the Lower Jiao also has a relationship to the south Heart fire and west Lung metal. Whether Kidney Yang hides or not is dependent on the capacity of the Heart fire and the Lung qi to descend well. On the right side the Heart fire should follow the Lung metal qi in its descent down to the Kidney, transforming from qi to water, from spirit to essence. This kind of transformation is based on the Middle Jiao Stomach qi dryness and descent. When the Stomach qi is dry it will descend, assisting the Lung qi in its descent and sending the Heart fire down to the Kidney. When there is excess damp in the Middle Jiao earth it will affect the Stomach qi, resulting in perversion, which in turn causes Lung qi perversion. If there is Lung qi perversion, the imperial fire will be blocked in the Upper Jiao. In such a scenario, the patient can present with Upper Jiao heat and Lower Jiao cold. Lung qi perversion will manifest with coughing, wheezing and panting; Stomach qi perversion will present with nausea, acid reflux, and burping. The Jin Gui Yao Lue, in the chapter “Xiao Ke: wasting and thirsting, lin syndromes and uninhibited urination,” discusses Upper Jiao and Lower Jiao water-fire disorders. Presenting on the Upper Jiao will be wasting and thirsting and on the Lower Jiao will be either excess lin syndromes or deficiency syndromes. In the Jing Gui Yao Lue, Shen Qi Wan is used to treat the condition of wasting and thirsting. Shen Qi Wan Tonifies the Yin and the blood, stops the Jueyin wind, and tonifies the Kidney Yang, making sure that the Lower Jiao Yang is hiding well. Gau Lou Qu Mai Wan is another formula that can be used to treat lin syndromes: tonifying the Kidney Yang and descending the Sanjiao fire, tonifying the Yin and clearing heat, promoting urination and clearing damp heat.

Acupuncture points: according to the treatment principles, warm the kidney water and clear heat from UB, use the basic formula: K3, K7, K10, UB66, Yinlingquan (SP9) He-Sea Point, Yanglingquan (GB34) He-Sea Point, Influential Point of Tendon, XiaXi (GB43) Ying-Spring Point, Zusanli (ST36) He-Sea Point, Neiting (ST44) Ying-Spring Point, Taibai(SP3) Shu-Stream, Yuan-Primary Point.

Explanation: K3 is a shu-stream, yuan source, earth point, and belongs to a yin channel and benefits yin essence. K3 has the properties that correspond to the sweet flavor in herbalogy. The sweet flavor is yang, and slightly opens the essence of the kidney; K7 has the properties of acrid flavor, which is yang, and opens the essence of the kidney; K10 has the properties of salty flavor, which benefits kidney essence. Yang channels belong to the heaven yang qi , and the heaven yang qi corresponds with the four Qi of the herb; UB66 is a ying-spring water point, has a cold nature, and clears heat from the UB; Sp9 is a he-sea water point, has the properties of salt flavor, promotes urination, dries dampness, and transforms spleen essence into qi; GB34 belongs to a yang channel, is an earth point, its qi is neutral, and it regulates the GB; GB43 is a water point, its qi is cold, it clears GB heat, and descends ministerial fire downward; ST36 is on a yang channel, is a he-sea earth point, has a neutral qi, and has a chief function of transformation; ST44 is a ying-spring water point, it’s qi is cold, and it clears heat from the stomach; SP3 is on a yin channel, a shu-stream earth point, opens the spleen essence, and tonifies spleen qi.

Five Shu Six points

Zang organs	Jing-well	Ying-spring	Shu-stream (yuan-source)	Jing-river	He-sea
Element	Wood	Fire	Earth	Metal	Water
Flavor	Sore	Bitter	Sweet	Acrid	Salt
Liver	1	2	3	4	8
Heart (pericardia)	9	8	7	5	3
Spleen	1	2	3	5	9
Lung	11	10	9	8	5
Kidney	1	2	3	7	10

• Qi is yang, and Its functions are ascending and descending. Qi governs generation, and is divided into the four qi, which benefits the function of qi.

• Flavor is yin, its functions are binding and dispersing. Flavor governs interaction, and is divided into the five flavors, which nourish yin.

Fu-organ	Jing-well	Ying-spring	Shu-stream	Yuan-sourc	Jing-river	He-sea
Element	Metal	Water	Wood	Imperia fire	Mistral fire	Earth
Heaven Qi	Dry	Cold	Wind	Heat	Summer-heat	Damp
Four Qi	Cool	Cold	Warm	Heat	Deam-heat	Neutral
GB	44	43	41	40	38	34
SI	1	2	3	4	5	8
ST	45	44	43	42	41	36
LI	1	2	3	4	5	11
UB	67	66	65	64	60	40
SJ	1	2	3	4	6	10

• Yang channels correspond to qi, while the yin channels correspond to flavor. Yang channel is match with the heaven qi, yin channel is match with the earth shape.

• Six shu points’ function in the yang channel is same with the five Shu points in the yin channel. The relationship is between the yin channel and yang channel, that is relationship between the qi and shape or the qi and flavor.

Results

Case study:

1.)Female, 55 years old.

Chief complaint: Painful, urgent, and frequent urination for 3 days.

The patient states that she is physically tired. For 3 days she has over-worked, gone to a party, and gone to sleep late. Her boyfriend lives in another city and comes to stay with her for a couple of days. Since then she has started to experience painful, urgent, and frequent urination. The same condition has happened three times before. Every time after this has happened she has gone to see a western medical doctor and taken antibiotics for ten days. This time she is interested in trying acupuncture and herbs.

Pulse: Right guan and chi are big. Left cun is a slightly big, wiry and slippery. The left guan and chi are deep.

Tongue: Pale, slightly purple, and a thin white coating.

Besides experiencing painful and frequent urination, the patient reports no other signs. Her digestion is fine, and her sleep is good, although her body is tired. The patient was seen on a Friday; she will be travelling the following weekend.

Diagnosis: Urinary Bladder damp heat; Sanjiao fire is draining to the Urinary Bladder from the Kidney; Kidney yang deficiency. There is also Spleen earth damp predominance and Liver wood Jueyin stagnation.

Treatment: Tonify the earth and dry dampness; warm the Kidney Yang and expel the cold.

Formula: Based on Gau Luo Qu Mai Wan- modified

[Fu Zi, Bai Zhu, Fu Ling, Sha Ren, Ze Xie, Qu mai, Gan Jiang, Zhi Gan Cao]

3 bags of tea; 1 bag constitutes 2 days.

Acupuncture points: K3, K7, ST36, SP3, SP9, UB66, UB40, GB34, GB43, Yuji (LU10) Ying-Spring Point, Quchi (LI11) He-Sea Point.

2^nd week, Wednesday: The patient reports that for five days she did not take any antibiotics, she only drank the herb tea. Within three days her symptoms improved. At present her symptoms are 90% resolved. The patient states that even during the travel over the weekend, her general condition and body energy felt fine.

Commentary: In this case the patient over-worked and partied late at night. The body’s Zheng qi became deficient. Drinking alcohol at the party, and not eating well caused the Middle Jiao earth to become damp. When her boyfriend came to visit, she engaged in intercourse and this resulted in exhaustion of the Kidney Yang. The patient’s excitement combined with the Spleen dampness resulted in some Liver wind signs. The combination of her deficient Zheng qi and having intercourse led to the urinary tract infection. The treatment focused on strengthening the Middle Jiao earth, drying dampness, and hiding the Kidney Yang so as to relieve the patient’s signs quickly. If we were only to clear the damp heat with a formula like Ba Zheng San, the damp heat could get better but the Kidney Yang and/ or the Sanjiao fire would be damaged. The patient’s acute condition would become a chronic one. The patient presents with a urinary tract infection but that is only a manifestation, the underlying root is Yang deficiency. In clinic, most cases with UTI symptoms are due to the body’s energy being exhausted first, the immune system being compromised, (Zheng qi deficiency , and Yin-Yang are imbalanced), resulting in an infection.

Case 2: Male, 60 yrs old.

Chief complaint: Seminal vesicle infection. Blood in the semen during ejaculation- coming and going for two months

Two months ago, during intercourse, the patient discovered blood in his semen. A western doctor diagnosed him as having a seminal vesicle infection and prostatitis. Antibiotics were prescribed for two months. The antibiotics caused his stomach to be very upset and he was unable to ingest the antibiotics further. Blood still remains in his semen. He has intercourse about once a week.

The patient complains of bloody semen, and of his perineum hurting. The patient is stressed, worried and scared. After taking antibiotics his stomach was troubled, and it is because of this that he has turned to acupuncture. His wife is an acupuncturist (15-20 yrs) and she has given him a few treatments with out result. Besides seminal blood and perineum pain, his bowel movements tend to be loose, 2x/ day. His stomach still hurts, though it is better since stopping the antibiotics. His sleep good, but he remains slightly tired. He evinces no thirst, his body tends to be cold and his hands and feet are easily chilled. His urination is fine. A testicle exam shows no abnormalities. He has no complaints of low back or leg pain.

Pulse: Both the right and the left cun, guan and chi are thin, weak and deep. The right Kidney is slightly bigger.

Tongue: Pale with tooth marks and a white coat. The tip of the tongue is slightly red.

Diagnosis: Kidney Yang deficiency with fire draining out into the Lower Jiao causing Lower Jiao damp heat. There is a greater preponderance of Kidney Yang deficiency symptoms and less damp heat signs. The presentation is due to Middle Jiao earth damp predominance, and Liver Jueyin wind wood stasis. The Liver stagnation results in wind draining the Sanjiao ministerial fire out of the Kidney down to the Lower Jiao. The wind opening the orifices is what causes the bleeding. The Middle Jiao earth dampness causes the Spleen qi to sink; the Middle Jiao earth not being able to hold the blood can also be a contributing factor to the bleeding.

Treatment: Tonify Spleen Yang; expel dampness; hide the Kidney Yang.

Formula: Zhen Wu Tang- modified

[Fu Zi, Bai Zhu, Fu Ling, Sha ren, Gan Jiang, Zhi Gan Cao, Ban Xia, Yi Yi Ren, Bai Shao]

Acupuncture points: K3, K7, ST36, SP3, UB2, SP9, LU10, LI11, Liv2, GB34, GB43.

The patient returns one week later. The symptoms are 50% better. He has less pain presenting, his body feels warmer and though there is still a little fresh blood in the semen it is less. He then went on a trip for 2-3 weeks and could only take the tea for a couple of days. The same formula was prescribed as well the Fu Zi Lizhong Wan. He was instructed to refrain from intercourse. His tendency is to over-worry. His wife reports that when he returned he took the tea, and was better. Blood still presented, but it was dark blood rather than fresh. His wife removed the fu zi from the formula because she saw him warming up. He continued to take the other herbs as prescribed. He continued to be worried and decided to have an MRI taken of his seminal vesicle and prostate. The diagnostic report showed an infection.

He took herbs for two more weeks, this time with the fuzi. After this, the bleeding stopped.

Commentary: The blood in the semen of the patient is due to Spleen Yang deficiency with Kidney Yang deficiency. The Spleen Yang deficiency has resulted in dampness; the patient feels cold and has loose stools. When the earth is damp and the qi is descending over a long period of time it will affect the Lower Jiao water, causing it to be cold. The Kidney controls the lower orifices; the Kidney essence hides and stores the Yang in the Lower Jiao. Long term Spleen earth damp predominance will cause Liver wood stagnation. This is because the Spleen Yang deficiency leads to blood deficiency. Blood deficiency affects the Liver function and results in the production of wind. The wind will cause the Lower Jiao orifices to drain; the Yang is unable to hide in the Lower Jiao and the essence-blood comes out of the vessels. The treatment method called for is to tonify the Kidney Yang, to strengthen the earth and to dry the dampness. It is important to make sure that the Kidney Yang is hiding in the Lower Jiao water. When the earth is strong it can control the water, ensuring that the water is able to hide the Yang. Prior to being treated with acupuncture and herbs, the patient had taken antibiotics for two months, clearing heat and damaging the body’s Yang. This is why there is Stomach qi perversion and the Lower Jiao is particularly cold. Because if this presentation, Zhen Wu Tang is used to strengthen the earth and to tonify the Kidney Yang. During the treatment period the patient’s wife had intervened, removing the fu zi from the formula for one week. This resulted in a lengthening of the curing time. The patient’s wife had thought the fuzi was too hot for the patient. If fuzi is removed from the formula then only the Middle Jiao is treated, but the patient’s condition was also in the Lower Jiao (Yang not hiding). Once the patient went back to using fuzi the symptoms stopped with in two weeks.

Case 3:Woman, 56 years old

Chief complaint: Gangrene on the left leg, on the lateral side above the external malleolus. Present for one year.

One year ago, for no apparent reason, ulcerations appeared above the ankle on the lateral side of the left leg. These gradually developed into gangrene. The skin of the ulceration was swollen and broken, and there was pus underneath. Diabetes had been ruled out. The patient is physically obese: she is 200 lbs in weight and 5’5” in height. There may be high blood pressure and high cholesterol components. The patient generally feels hot and thirsty with a dry mouth. Her bowel movements are loose and she sweats easily. The ulceration has been present for one year and has never completely healed. Some days are better and some worse. She has received acupuncture and herbal treatment for a year from another practitioner. She has also taken antibiotics for an extended length of time but with out result. Upon examination the ulceration looks to contain pus and is red, upon palpation it is soft and tender. The ulceration measures about 2” in width and 3” in length. The patient also reports depression. Her legs are swollen.

Tongue: Pale purple and big with a white, thick, and slightly greasy coat.

Pulse: Both sides are deep and slightly slippery, they tend to be soft in feeling.

Diagnosis: Middle Jiao earth damp excess; Liver Jueyin wind wood stagnation; Gall Bladder fire perversion. The Liver wood is sinking, descending down to the Kidney resulting in Kidney water cold predominance.

Treatment: Dry the Middle Jiao dampness; tonify the Kidney Yang; descend the ministerial fire down; open the Liver stagnation

Formula:

[Fuzi, Sha Ren, Banxia, Baizhu, Fuling, Yiyiren, Ganjiang, ZGC, Long Gu, Mu Li]

Acupuncture points: K3, K7, SP9, LU10, LI11, ST36, SP3, SP9, K10, UB40, Liv8, Liv2.

2 weeks later: the patient’s ulceration is beginning to heal. Based on the presenting symptoms, the formula is modified: add Shan Zha

3 weeks later: The ulceration is 60-70% healed.

1 month later: the ulceration 98% healed.

1 ½ months later: the ulceration is healed.

The patient’s fiancé came to the clinic to say thank you. Her fiancé was worried about her for a long time. He thought the ulcer would not heal and that she might even die. The healing of the ulceration was a welcome surprise to the family.

Commentary: The patient’s physical size must be taken into consideration. The largeness of her size requires us to consider the Middle Jiao earth’s dampness. The Middle Jiao earth dampness affects the pivotal turning of the earth; it affects the ascent of the Spleen and the descent of the Stomach. The Spleen dampness led to a flesh generation disorder, the blood circulation was slow, and thus ulceration occurred. The Spleen dampness also caused the Liver to be blocked such that the Liver qi descended leading to Kidney water coldness and Gall Bladder fire perversion. On the east Liver, The Gall Bladder is the pivot. The Liver ascends and the Gall Bladder descends. When there is a pivot disorder in the east the Liver descends and Gall Bladder ascends. The Gall Bladder stores the ministerial fire; when there is Gall Bladder fire perversion it will result in Stomach and Lung qi perversion. The descent of the Heart fire will also be affected. The Patient presents with fire on the surface but underlying this is a Middle Jiao damp cold and Lower Jiao water cold. The patient took antibiotics combined with tonify yin, clear heat herbs for a long time, this caused more cold in the Middle Jiao and contributed to damp accumulation. The Lower Jiao water Yang was further damaged. The patient’s hot fire feeling comes from this mechanism disorder. The focus of the treatment was to descend the ministerial fire down to the Kidney water. The method utilized was to strengthen the Middle Jiao, to dry earth dampness, to open and ascend the Liver Yang, and to descend the Gall Bladder fire down to the Kidney, warming the Kidney. The Kidney Yang will be able to hide when the Urinary Bladder water is cold. When the Middle Jiao dampness is dried the Liver Yang will be able to ascend and the Gall Bladder fire will then descend. The Lower Jiao damp heat signs will resolve and the circulation will increase. This is how the flesh was regenerated and the gangrene was healed.

Discussion

The method of warming the water to submerge the Yang comes from the Nei Jing and the Jin Gui Yao Lue. Using Yin-Yang theory, five element theory, and the six qi diagnosis method as the basis of analysis to diagnose Lower Jiao Yin-Yang disorders and diseases, appropriate treatment can be determined. The focus and emphasis is on storing and protecting the body’s Yang. When Yin and Yang are balanced Yang dominates the left turn and Yin dominates the right turn. Yang dominates the Yin; ascent dominates the descent. Ascending insures that Yang functions well, descending makes sure that when Yang moves that the pathway is open. The descent on the right is what allows the Yang to hide; the ascent on the left is what allows Yin and blood to disperse and nourish. The function of the Fu organ is to descend. This is because the Yang from the top collects and then descends to hide inside of the body in to the Yin. Thus Yang is collected from the yang channel. The three foot Yang descend to the Yin area of the body, to the Yin organs. The Yin stores the essence, the jing-ye and blood in the Zang. The Support, the generation and the dispersal of Yin to nourish the whole body is due to Yang’s function. All these processes are based on the Middle Jiao earth as the pivot. When a Middle Jiao earth disorder is present, it will exhibit as Middle Jiao dampness and pivot stasis. The key to the whole process is in drying the Middle Jiao dampness. When there is a Middle Jiao earth damp predominance it will affect the Lower Jiao water, causing it to become cold. Dampness causes wood stasis, producing wind and causing the Lower Jiao to have a Yang hiding disorder. The Ministerial Shaoyang fire will drain out of the Kidney and present in the Urinary Bladder as an excess heat or deficiency cold condition. The Kidney Yang will be exhausted. In TCM terms, this encompasses lin syndromes, uninhibited urination, upper part heat and lower part cold syndromes, and edema. The treatment method should be to warm the water to submerge the Yang; to warm the Kidney water and cool the Urinary Bladder water. To warm the water means that the strength of the Kidney Yang ascending the water up will be assisted. To submerge the yang means to descend the Yang down from the Yang channels. In clinical practice if the diagnosis is correct, the determination of the Yin-Yang level, (the level of Yang deficiency or damp heat excess predominance), will determine the appropriate formula. If we treat according to the theories stated here, the results will be miraculous.

However, diagnosis is very important when using the proposed treatment method of warming the kidney yang to treat lower jiao disease. Cases when this treatment has proven inappropriate are when the excess symptoms (UB damp heat) predominate over the yang xu symptoms. In these cases the heat symptoms can be exasperated, and provide much discomfort for the patient. It is important to have clear yang xu symptoms present simultaneously with the lower jiao damp heat.

The implications that these results have on TCM today will be a movement from an attacking method (clearing damp-heat), which is similar to an antibiotic approach that ultimately depletes the immune function, to a method that fortifies the body’s immune system by tonifying yang. The boosting of the yang and thus immune function will allow for long-lasting results, while the attacking method will leave the body depleted and susceptible to becoming re-infected. This will allow for a more effective treatment and greater clinical results.

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