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A Short Elucidation of the 18th Difficult Issue (Nan Jin)
By Z'ev Rosenberg, L.Ac., Dipl. Ac., F.N.A.A.O.M For the past fifteen years, I have repeatedly read the Unschuld translation of the Nan Jing/Classic of Difficult Issues, supplementing with other English and Chinese versions (including Bob Flaws' 'pocket book' version). With repeated study, I have slowly uncovered its 'secrets' and tested them in clinical practice. In twelve of teaching Chinese internal medicine, I have observed that most students have a difficult time learning and mastering pulse diagnosis. Recently, I observed that the Nan Jing presented a reasonably comprehensive discussion on pulse (vessel) diagnosis that provided a strong foundation for study and practice. The Nan Jing integrates channel theory with visceral/bowel theory, five phase theory with yin and yang methods of diagnosis. This is no more apparent than in chapter 18, a discussion on the information contained in each of the three divisions of the pulse - inch, bar, and cubit - as it pertains to the channels and contents of upper, middle and lower burners, respectivey. What is extraordinary in this discussion is that it seamlessly integrates information from both an acupuncture/channel-connecting vessel perspective, and an internal medicine viscera/bowel perspective in one pulse map.1 The first part of the Difficult Issue 18 states: The movement in the vessels appears in three sections; each section has four conduits, with the hand tai-yin and hand yang ming channels of the hands, and the foot tai yin and foot shao yin channels of the feet constituting upper and lower sections. What does this mean? It is like this. The hand tai yin and yang ming channels are associated with metal {this pulse is on the right hand};2 the foot shao yin and foot tai yang are water. Metal generates water. Water flows downward and is unable to ascend. Therefore, the foot shao yin and foot tai yang (can be felt) at the {cubit position, on the left}. The foot jue yin and foot shao yang channels are associated with wood; it generates the fire phase, (which is associated with) the hand tai yang and hand shao yin (channels). The flames of fire ascend; they are unable to move downward. Hence, they are able to be felt {in the inch position on the left}. The hand shao yin {xin zhu/heart governor} and hand shao yang {channels} (are associated with the phase of) fire; it generates the (phase of) earth (soil), (which is associated with the) foot tai yin and foot yang ming (channels). The soil {earth} rules the central palace and is, therefore, situated in the central section. All this is (in accordance with) the mutual generation and nourishment of the Five Phases (as in a) child-mother (relationship). Here we see the basis for applying palpation of the vessels to treatment by acumoxatherapy, and the basis for the major part of pulse/vessel diagnosis in the Japanese and Worsley systems. One can perceive qualities of the paired channels and their five phase relationships, and use the five transporting points (wu shu xue) to balance the channels. The flow of Qi from left to right, one side of the body to the other is like a figure eight, following the dynamics of the channels and five phase transformations. The next section of the Eighteenth Difficult Issue, however, takes another perspective on palpating the vessels: The movement in the vessels appears in three sections and on nine indicator (levels). By which illnesses are the (movements in these sections and on these level) governed, respectively? It is like this. The three sections concerned are inch, bar and cubit. The nine indicator levels refer to surface, center and depth (of each section). The upper section is patterned on heaven; it is governed by illness located from the chest upward to the head. The central section is patterned after man; it is governed by illness located below the diaphragm to the navel. The lower section is patterned after earth; it is governed by illnesses located below the navel to the feet. In this section, we see a more internal, viscera-bowel oriented approach to the pulse, similar to the orientation of Li Shih-zhen's, Bin hu mai xue/Lakeside Master's Pulse Study (17th century). At this point, we need to ask, what is the difference between channel/connecting vessel and viscera/bowel pattern differentiation? The former applies more to acumoxatherapy, the latter to internal medicine (i.e. treatment by Chinese medicinals). With the channels and connecting vessels, we are concentrating on the informational system that connects all parts of the body, flowing (relatively) at the exterior and connecting with the interior. The channel system responds quickly to change, constantly readjusting the flow of Qi to maintain systemic equilibrium. The channel system connects with the interior via the connecting vessels and divergent (bie) channels, allowing the viscera and bowels to send information to the exterior, and respond to external stimuli. Being more dense and su bstantial, the viscera and b owels move and respond more slowly than the channels. In severe disorders, the connection between the viscera/bowels and the channels may be severed, as discussed in Difficult Issue #24. This loss of communication is often behind many serious disorders, especially wasting of the associated tissues of the five viscera.3 The three burners are divided among the inch, bar and foot, and their contents can be palpated in great detail. Within each position, one can palpate the condition of Qi, blood and fluids, viscera and bowels, using the 28 pulse qualities enumerated in the Mai Jing/Pulse Classic to determine the qualities of disease patterns. The upper burner, as discussed in Difficult Issue 31, is treated at tan zhong/Ren 17, and governs transformation of air Qi (da Qi). The middle burner, treated at tian shu/St. 25, governs transformation of food and drink, and separation of clear and turbid. The lower burner, treated at qi hai/Ren 6, governs transformation and separation of fluids. I highly recommend that every practitioner of Chinese Medicine who wishes to use vessel/pulse diagnosis read the Nan Jing. It is a cornerstone for understanding the body and mind from a systems point of view, and will greatly enrich those who study it for years to come. I wish to mention Michael Broffman and Donn Hayes for their encouragement and inspiration to study the Nan Jing over these many years. Thanks again, dear friends and teachers. 1 By pulse map I mean an informational model that describes the movement in the vessels under the fingers. In the Chinese medical tradition, various maps have been developed to describe what physicians felt under their fingers in palpation of the vessels according to different perspectives. These perspectives could roughly be divided between a) what flowed at the exterior and moved information and substances (blood, qi, fluids) from place to place and b) the contents of the internal visceral systems and their qualities. 2 My comments are inserted with brackets; where Dr. Unschuld has augmented the text, I have it in parentheses. I have also modified the translation of jing/conduits to channels based on A Practical Dictionary of Chinese Medicine/Wiseman/Ye, and left the names of the channels in pinyin. 3 The spleen is associated with the flesh and muscle. The heart is associated with the (blood) vessels. The liver is associated with the sinews. The lungs are associated with the skin. The kidneys are associated with the bones.
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