Friday, November 30, 2012

SHEN AND HUN: THE PSYCHE IN CHINESE MEDICINE


This article will discuss the nature and functions of the Shen and Hun in the human psyche. This will be based on classical texts and on my own thoughts and clinical experience. There will be five parts to this
discussion:

1) The nature of the Shen
2) The nature of the Hun
3) The Shen and Hun and the pre-frontal cortex
4) The Shen and Hun and mirror neurons
5) The Shen and Hun and Jungian psychology.

The longer I practise, the more I think that in clinical practice we can interpret most mental-emotional problems in terms of the "five spirits" as well as of "patterns of disharmony".  The "five spirits", in Chinese called the"Five Shen" [五 神], are the Shen, Hun, Po, Yi, and Zhi residing respectively in the Heart, Liver, Lungs, Spleen and Kidneys.

For example, irrespective of the pattern of disharmony involved, I see depression as a manifestation of lack of movement of the Hun and manic behaviour as a manifestation of excessive movement of the Hun. To give another example, I see bipolar disease mostly as a Hun disharmony while I see anxiety mostly as a Shen and Po disharmony.

Please note that I am not advocating treating mental-emotional problems purely by treating the "five spirits" and not the patterns of disharmony.  I am advocating treating such problems using both approaches.  To give an example, if someone suffers from depression, I interpret that as a lack of movement of the Hun and I would nearly always stimulate that movement by using G.B.-40 Qiuxu.  However, it is also important to treat this person by addressing the pattern of disharmony which may be Liver-Qi stagnation, Heart- and Lung-Qi deficiency or many other patterns. 

When discussing the nature of the Shen, I will in particular explore the Confucian and Neo-Confucian influence on the concept of Shen and Xin (Heart) in Chinese medicine.

1) THE SHEN
The word "Shen" can be translated in many different ways such as "mind", "spirit", "consciousness", "vitality", "expression", "soul", "energy", "god", "God", "psychic", "numinous".  From a grammatical point of view, it can be a noun, adjective or verb.

The Chinese character for "Shen" is composed of two parts, one on the left, the other on the right. Often when a character is composed of two parts, one part gives it a meaning and the other is purely phonetic, i.e. it tells a Chinese speaker how that word is pronounced. Let us look first at the left side which gives the character its meaning.

The left part of the character "shen" is a contracted form of "shi" which indicates “influx from heaven", "auspicious or inauspicious signs by which the will of Heaven is known to mankind", "altar for sacrifices.”
The non-contracted form of "shi" shows two lines at the top which are the old form of "shang" [上]  (superior, above, high, hence “Heaven”) and three vertical lines representing what is hanging from Heaven,
i.e. the sun, the moon and the stars, the mutations of which reveal to people transcendent things.

Therefore, we can say that the left part of "Shen" conveys the idea that the Shen is something spiritual, pertaining to Heaven, numinous, non-material (bearing in mind that we are talking about the Chinese and not
a Christian concept of "Heaven").

The right part of the character is pronounced "shen" [申] and it confers the word this sound.  However, very often the phonetic part of a character is not just phonetic but it also has a meaning.  In the case of "Shen", I believe it gives it a very important meaning.  In fact, "shen" means "to state", "to express", "to explain", "to stretch", "to extend" (it also is the 9th Earthly Branch).

Shen [申] means "to extend", "to stretch". The seal writing shows two hands stretching a rope and hence the idea of stretching, expansion.  Later the rope was straightened by the scribes and was explained as a man standing and with both hands girding his body “I” with a sash. The form 申  is simply an easier way of writing the pictogram below.




The combination 神  is probably phonetic but the idea of spirit may have some connection with an increased or extended 申 [shen] spiritual revelation 示 [shi].

However, some find early forms representing forked lighting 電 。  They think, probably rightly, that these became the sign for deity from superstitious dread of lightning. It gradually took the form 申  and 示  was added when it meant Shen 神 , while 雨  rain was added when it meant lightning.


Shen 神 is cognate with shen 申 and shen 伸.
申 means "to state", "to express", "to extend"
伸  means "to stretch", "to extend"


I believe that this part of the character for "Shen" reflects an extremely important function of the Shen, i.e. the capacity to "extend" outwards, to project outwards, to relate, to communicate with others: it is what makes us relate to the world and other human beings and what makes us truly "human".  Incidentally, this capacity to "extend" and to relate is missing in autistic children.  As we shall see below, this capacity of the Shen to "extend" is also partially dependent on mirror neurons.

The Shen's capacity to extend and project outwards may also be reflected by an expansive, centrifugal movement (called "shen") which is often compared and contrasted to a contracting, centripetal movement (called "gui"). As we shall see below, the Shen's capacity to extend and project outwards depends partially also on the movement of the Hun.

The Hun moves upwards towards the Shen and its movement gives the Shen the capacity to extend and project outwards. The movement of the Hun towards the Shen is a psychic equivalent of the physiological ascending movement of Liver-Qi.

De Bary translates “shen” as “numen” or “spirit” according to context.  The word "numinous" means "pertaining to a numen", "divine", "spiritual", "revealing or suggesting the presence of a god", "inspiring awe and reverence." Hence the words "numinosity", "numinousness" meaning the condition or state of being numinous. 
     "Numen" itself means "deity", "divinity", "divine" or "presiding power or spirit".


The Book of Rites (Li Ji) of the Zhou dynasty clearly refers to this use of the word "shen": “Mountains, forests, streams, valleys, hills and mounds that were able to produce clouds and thus make wind and rain and make prodigies visible were all referred to as shen.”
    However, as we shall see, “numinous” is only one possible translation of the word "shen" and one that does not really apply to Chinese Medicine.

[Keightley D N, The Ancestral Landscape, Institute of Asian Studies University of California Berkeley, 2000.
Theodore de Bary Sources of Chinese Tradition, Columbia University Press, New York, 1999.]


Sinologists always translate the word "Xin" 心 [Heart] as “mind” (rather than "spirit"). Many of the characters that refer to different modalities of “thinking” are also constructed with xin as a component.  In the classical Chinese world view, the Mind cannot be divorced from the Heart. The cognitive is inseparable from the affective.

One of the Neo-Confucian schools of the Ming dynasty (Wang Yang Ming) was the Xin Jia or “School of Mind” as all sinologists translate it. 


Nature of Shen in Chinese medicine
The Shen is one of the vital substances of the body. It is the most subtle and non-material type of Qi.  Most authors translate the word Shen as “spirit”; I prefer to translate Shen of the Heart as  “Mind” rather than as “Spirit”.
     I translate as  “Spirit” the complex of all five mental-spiritual aspects of a human being, i.e.;
                
                          



    "Shen" indicates the activity of thinking, consciousness, self, insight, emotional life, memory, and volition, all of which depend on the Heart.  I translate this as "Mind“ when it refers to the Shen of the Heart.
     "Shen" also indicates the complex of all five mental-spiritual aspects of a human being, i.e. the Shen itself, the Hun, the Po, the Yi and the Zhi.  I translate this as "Spirit".

                          

These five are called Five Shen 五 神 or Five Zhi 五 志.  Please note that I am not saying that “shen” cannot mean “spirit”, of course it can.  What I am saying is that, in the context of the Shen of the Heart, I prefer “Mind” as a better translation of it.

Regarding the issue of how to translate Shen (i.e. as ‘Mind” or “Spirit”), it is interesting to note that, in serious mental illnesses such as schizophrenia and bipolar disorder, the Shen is said to be “obstructed”,  “misted” or “clouded”.

We know that very many great artists suffered from bipolar disorder and it is clear in their case that it is the Mind that is clouded, not their Spirit which soared to great heights. This would confirm that the Shen of the Heart (clouded in mental illness) is indeed the Mind.


There is another meaning to the word Shen which is frequently mentioned in relation to diagnosis.
In this context the word shen indicates an undefinable and subtle quality of “life”, “flourishing”, "lustre" or “glitter” which can be observed in health. This quality can be observed in the complexion, the eyes, the tongue and the pulse.

Please note that “mind” is not the same as “consciousness”.  In fact, many of our mental processes are unconscious (or rather, subconscious).  I do not mean here “unconscious” in a psychoanalytic sense but simply in the sense that some processes and even feelings do not reach consciousness. The Shen is definitely involved in consciousness but what about unconscious processes and feelings?

I think the Shen is involved with unconscious processes too but in conjunction with the Hun as far as thoughts and emotions are concerned and with the Po as far as feelings are concerned.

 
Thinking (or cognition) depends on the Shen. If the Shen is strong, thinking will be clear. If the Shen is weak or disturbed, thinking will be slow and dull. The Chinese characters for “thought” (yi 意), “to think” (xiang 想) and “pensiveness” (si 思) all have the character for “heart” as their radical.


Memory has two different meanings. Explicit memory consists in remembering facts and past events. This depends on the Shen and therefore the Heart, although also on the Spleen (Yi) and Kidneys (Zhi).

Implicit memory consists in muscle memory, i.e. remembering how to ride a bicycle, to dance or to knit, etc.



Insight indicates our capacity of self-knowledge, self-examination and identity of self. The Shen of the Heart is responsible for our identity of self as individuals. This is lost in serious mental illness such as schizophrenia or bipolar disease and is caused by obstruction of the Shen.
    Obstruction of the Shen, however, may occur in different degrees of severity and it does not always lead to serious mental illness.

Edelman distinguishes between primary and higher-order consciousness.
    Primary consciousness – the ability to generate a mental scene in which a large amount of diverse information is integrated for the purpose of directing present or immediate behaviour – occurs in animals with brain structures similar to ours. Such animals are able to construct a mental scene but, unlike us, have limited semantic or symbolic capabilities and no true language. = PO
    Higher-order consciousness is built on the foundations provided by primary consciousness and is accompanied by a sense of self and the ability in the waking state to construct and connect past and future scenes. In its most developed form, it requires a semantic and linguistic capability. Only individuals with higher-order consciousness can report conscious states and speak about consciousness: they are conscious of being conscious. = SHEN

[Edelman G and Tononi G, A Universe of Consciousness, Basic Books, NY, 2000, pp. 103-4.]

The Shen of the Heart is also responsible for hearing, sight, taste and smell. Practically all Confucian and Neo-Confucian philosophers mention the control of the senses by the Heart (and Shen).
    Many of the ancient Daoist and Confucianist texts view the senses (sight, hearing, smelling, taste) as “dangerous”. They “pull” on the Shen out of itself and dissipate its energy.

Emotional life also depends on the Shen of the Heart. With regard to emotions, only the Shen (and therefore the Heart) can recognize them. When we say (or think) "I feel angry" or "I feel sad" who is the "I" that feels angry or sad?  It is the Shen of the Heart.

Of course emotions definitely affect all the other organs too, but it is only the Shen that actually recognizes, feels and assesses them. For example, anger affects the Liver, but the Liver cannot feel it because it does not house the Shen. Only the Heart can feel it because it stores the Shen which is responsible for insight. When one feels sad, angry or worried, it is the Shen of the Heart that feels these emotions. 
 
It is for this reason that all emotions eventually affect the Heart (in addition to other specific organs), and it is for this reason that the tip of the tongue becomes red in emotional problems from whatever emotion. 



The Shen of the Heart is a form of Qi and the following is a summary of its functions:
Is the Qi that
•     Forms life (but also with Po) from the union of the Jing of the parents
•     Allows the individual to be conscious of his or her self
•     Permits the cohesion of various parts of our psyche and emotions
•     Defines us as individuals, confers sense of self
•     Feels and assesses the emotions
•     Is responsible for perceptions, feelings and senses (with Po)
•     Is responsible for thinking, memory, intelligence, wisdom, ideas
•     Determines consciousness (being conscious)
•     Allows insight and sense of Self
•     Is responsible for cognition
•     is responsible for relating, relations with others (shen = stretch, extend, project outwards)
•     Controls sleep
•     Governs the senses (sight, hearing, smelling, taste)

                                         
Shen and the body
The Chinese concepts of Shen and Xin cannot be separated from the Chinese view of the body.  Although made of different script, when some characters share the same sound it is not a coincidence and it often has a deep meaning.  Characters sharing the same sound are called “cognate”.
     The word "Shen"  神  (Mind) is cognate with shen 申, shen 伸 (to extend) and shen 身 (body).

There are three terms for “body”:
SHEN    身 (body, life, oneself, personally, one’s moral character and conduct) (the original script depicted a pregnant woman)
XING    形  (form, shape, body, entity)
TI    体 (body, part of body, substance).  Old form was (bone on the left and vessel on the right).


Interestingly, the character for "body" is composed of that for "bone" on the left and that for "ritual vessel" on the right.

 

Bone




Vessel, ritual vessel





It is interesting to note the similarity between the character for "body" that has a ritual vessel on the right and a bone on the left, with that for "rites" which has a ritual vessel on the right and "shi" on the left, the same "shi" that is on the left of the character "shen".  Therefore the body is like a "ritual" that must be cherished.

Li, rituals, rites
The “shi” on the left side of “Shen”

Interestingly, the etymology of the word “body” comes from the Old German “budha” which means “tub” or “container”. This is interesting as it would reflect the dualism that has affected Western philosophy and religion for centuries, i.e. that between the "soul" and the "body" in which the body is a "container" for the soul.  As we know, this dualism is absent in Chinese philosophy, as body and Shen are nothing but two different states of aggregation of Qi.

Therefore translating “shen” [身] as “body” does not do it justice as it is more than a “body”.  It may mean the “self”. There are several expression involving shen 身 that indicate that this term refers to the “self” rather than “body”.

An Shen 安 身 = settle down in life
Shen Fen 身 分 = social status
Ben Shen 本 身 = oneself
Zhong Shen 终 身 = to end one’s life
Shen Shi 身 世 = personal history

[Yanhua Zhang, Transforming Emotions with Chinese Medicine, State University of New York Press, NY, 2007.]

The Self in ancient China
There are three words to express "I" or "self" in Chinese:
SHEN 身 
WO  我
JI   己

Of these three, shen [身 ] is not just the body but also the “self”, the unity of body and mind.  The fact that it is cognate with Shen is very significant. Wo and Ji, by contrast, are most often used  as a negation, i.e. with wu (not, non-) in front, i.e. wu wo 无 我 or wu ji  无 己 (i.e. "non-self"). These expressions refer to the Daoist concept of “losing oneself”, “following”, “at ease”, etc, all states indicating not strictly a negation of the self but a state in which the self merges with the natural order of the Dao.

Negative expressions that occur in conjunction with wo 我 are wu 無 (nothing), shi 失 (to lose), sang 丧 (to lose), xu 虚 (void, empty) and qu 去 (to remove). By contrast, shen [身 body] is something that we should xiu 修 (repair), bao 保 (preserve) or yang 养 (nourish).


While forgetting wo 我 or ji  己 is good, forgetting shen [身] is a bad idea. This is apparent from this passage from Zhuang Zi:
I have been guarding my physical form [xing but forgot my person [shen-body] [伍 守 形 而 忘 身]. I have been observing the turbid water but am oblivious to the clear depths.

Please note that the Daoist “negation of the self” could not be further removed from the Christian negation and punishment of the self and body. In the Christian religion the self and body was seen as a dangerous temptation which should be kept apart from the soul. None of the three religions (or rather philosophies) of China (Buddhism, Confucianism and Daoism) has any concept of “sin”.


The Heart in Confucian philosophy
The term Xin [心 heart] indicates both the physical heart and a wide range of emotional and mental functions, not a distinct entity with a strictly mental or spiritual nature. In other words, it lacks the same qualities of the “self” or “soul” in Western philosophies and religions that shen [body] and shen [mind] also lack.

All sinologists who study the Confucian and Neo-Confucian philosophers of the Song and especially Ming dynasty, translate School of Xin as “School of Mind”, i.e. they translate the word “Xin” (meaning Heart) as “Mind”. All talk about “Heart-Mind” or "Mind-Heart".  Bear in mind that in ancient China Xin includes cognitive and affective functions.

De Bary translates Xin as “Mind-Heart”.  He thinks this is necessary to render the Chinese Xin to convey both its cognitive and affective functions.  In another statement, he highlights the concept of the Heart as the “ruler”. “Confucius taught that cultivating the person lies in rectifying the Mind-Heart [Xin]. The Mind  [Xin] is the master of the person. When the Mind’s control is right, the person’s conduct cannot go astray.” “If one can rectify the person, one can regulate the family…govern the State..and pacify the world.”

[De Bary T, Neo-Confucian Orthodoxy and the Learning of the Mind and Heart, Columbia University Press, New York, 1981.]


The idea that the Heart (and therefore Shen) is the “ruler” of course pervades the Nei Jing but it is found also in many other philosophical texts from the Warring States period down to the Ming dynasty.

For example, Xun Zi (310-220 BC) says: “Xin is the lord of the body [形 之 君] and master of the spiritual intelligence [神 明 之 主]. It issues commands but does not receive commands. On its own authority it forbids or orders, renounces or selects, initiates of stops.”


Xun Zi’s view of Xin (and therefore Shen) is not only cognitive but also volitional. It could be argued that a Confucian human-body cosmology is based on the Heart being at the top as the imperial ruler, while a Daoist human-body cosmology is based more on the Kidneys below, the source of Jing and the basis for Daoist Qi Gong.

The Confucian view of the Heart as the ruler and the most important organ derives also from Meng Zi’s (372-289 BC) views on the Heart-Mind.

Meng Zi often talked about “losing one’s heart” (and therefore Mind) and “retaining one’s heart”.  The gentleman [jun zi] retains his heart; according to Meng Zi “a gentleman differs from other men in that he retains his heart”.  He thought it necessary to emphasize retention of the heart because it is something that is easy to lose.  Since the heart is something we possess originally it is also called the “original heart”.

                                                                           Meng Zi

Meng Zi describes a man who loses his sense of shame, for example, and comes to do things for unworthy motives as a man who has lost his “original heart”.  Meng Zi also calls it the “true heart”.  “It is not the case that a man never possessed the benevolent and righteous heart [according to him we all have it] but that he has let go of his true heart”.

According to Meng Zi, the main function of the Heart is to think (hence my translation of Shen as “Mind”). If a man loses his heart, his senses cause him to be attracted by outside things.

The organs of sight and hearing are unable to think and can be misled by external things”. “The heart organ can think, but it will find the answer only if it does think. Otherwise, it will not find the answer. This is what Heaven has given me”.

We can see from this passage why Meng Zi attaches the greatest importance to the Heart. Without the ability to think, a living creature is completely determined by its desires and the desires are at the mercy of their objects. It is the gift of the True Heart from Heaven that marks human being off from animals; but the mere possession of the Heart is not enough, we must think with it.

What Meng Zi meant by “thinking” is not only cognitive thinking but also emotional, ethical and volitional, i.e. our thinking about moral duties, priorities, the purpose and destiny of man. As we shall see below, these are functions of the pre-frontal cortex.  According to Meng Zi, in the human body, the heart is the highest member and the senses are lower members. The difference between a gentleman and lesser men is the relative importance that they give to the highest or lower members. The “gentleman” [jun zi] gets his priorities right, while the small man gets them wrong.

The Four Heart of Meng Zi

According to Meng Zi there are four incipient tendencies in the heart (“sprouts”). These are the tendencies to:
-     Compassion
-     Shame
-     Modesty and courtesy (or deference)
-     Right and wrong  (i.e. ability to distinguish right from wrong)

Meng Zi called these incipient tendencies the “four hearts”: they germinate into the Confucian qualities of compassion (ren),  righteousness (yi), ritual propriety (li) and wisdom (zhi).


1)    The Heart of compassion is the sprout of benevolence (ren 仁)
2)    The Heart of shame is the sprout of righteousness (yi 義)
3)    The Heart of deference is the sprout of ritual propriety (li 禮)
4)    The Heart of right-wrong is the sprout of  wisdom (zhi 智)


Please remember that the above "four hearts" can only be understood in the context of Confucian philosophy and ethics.  Ren, Yi, Li and Zhi are the four fundamental Confucian qualities that ensured harmony in the individual, family, society and the State. A discussion of these four qualities is beyond the scope of this article and a translation is very difficult.  They roughly correspond to "benevolence", "righteousness", "rites" and "wisdom".

Both Meng Zi (372-289 BC) and Xun Zi (310-220 BC) place the Heart at the top of a hierarchy and view it as the “ruler”: this is of course, the view of Chinese medicine. Despite this picture of the Heart as the ruler, for Meng Zi, the Heart is also linked to emotions and desires. The ethical desires of the Heart lead to the “four sprouts”. Meng Zi places the Heart at the centre of human nature and also at the “top” of a hierarchy (influence on Chinese medicine).

It could be argued that a Confucian human-body cosmology is based on the Heart being at the top as the imperial ruler, while a Daoist human-body cosmology is based more on the Kidneys below, the source of Jing and the basis for Daoist Qi Gong.

Zhuang Zi (369-286 BC) disagreed with the idea of the Heart being the ruler.  He insists that the Heart, being only one of the organs, is no more “me” than any other organ. We suppose that it could control the others, but in fact the various members are interdependent and “take turns as each other’s ruler and subjects”. According to him, the true ruler is not the Heart but the Dao.

                                                                              Zhuang Zi

The Heart and human nature (性) in Confucian philosophy
In conclusion, the Confucian (and especially Meng Zi’s) discussion of Heart and Mind dating back to the 4th century BC is pivotal in the development of Chinese philosophy and Chinese medicine.  The Confucian did nothing less than “discover” the Heart and Mind [Xin 心] and made it an essential part of our human nature.  This certainly had an influence on the concept of "Heart" and "Shen" in the Nei Jing also considering that this text is heavily influenced by Confucian philosophy. 

Meng Zi introduced his own version of this philosophy producing a moral version of the Heart and Qi. According to Meng Zi, the unique feature of the make-up of a human being is his Heart and so, when we speak of human nature, we should have the Heart in mind primarily.  In other words the Heart is our human nature.

Meng Zi not only described the essence of “human nature” (Xing  性) but provides it with a structure as well, with the Heart at the top of the hierarchy of Zangfu. 

We can say therefore that the view of the Heart as monarch is Confucian, while the Daoist view would put the Kidneys at the top (Jing, Minister Fire). In fact, as we shall see below, the Daoist text Nei Ye talks a lot about Jing as well as Xin.


School of Mind Xin Jia  心 家

The School of Mind (or Heart-Mind) is one of the Neo-Confucian Schools of the Song (960-1279) and Ming (1368-1644) dynasties. Its main advocate was Wang Yang Ming (1472-1529). 

He considered Xin the ultimate reality in contrast to the great Zhu Xi who considered Li [理] the ultimate reality.  Zhu Xi’s doctrine of Li is one of ontological dualism: there is a xing er shang [Above Form  形 儿 上] and a xing er xia [Below Form 形 儿 下] reality, i.e. a metaphysical and a physical reality respectively.

By contrast, Wang’s philosophy is ontological monism, i.e. there is only one universal principle and that is Xin or Mind. He said: “Xin is the same as Li. Under Heaven and Earth, is there anything that exists beyond the Mind, or any principle that exists beyond the Mind?
    Also “The substance of Mind is nature (xing) and nature is the same as Principle. How can Principle be external to the Mind? Xin is the ruler of the body.”

Wang Yang Ming has an interesting statement about emotions: “Joy, anger, sorrow, fear, love, hatred and desire are called the seven emotions; these are inherent in the Mind of man…when the seven emotions follow their natural course, they are all functions of the intuitive knowledge and cannot be classified into good or evil.”

Although Zhu Xi was the founder of the School of Li, he wrote extensively about Xin. He considered Xin and the “controlling ruler”, as Chinese medicine does.
    He said: “Xin is that which has consciousness.”  He also said: “The Mind [Xin] is the master of the body and it is unique. It is the host not the guest. It is the commander and not a receiver of commands. Mind is the master or determining factor of the body.”


The Neo-Confucian philosopher Wang Fu Chi (1619-1692) explored the nature of Shen and the relationship between Shen and Qi.
 
According to him, Shen is an indwelling principle of Qi, associated with its unifying and dynamic functions. “Shen" is Qi’s ability to transform and reunite when undivided; it is so called because of Qi’s unfathomable unity – it is not that Shen exists apart from Qi.
 
Shen implies unity in contrast to hua (transformation), but it is unity of a kind that permits change. The term “shen” is also used as a pole of the immaterial-material polarity.  Zhang Zai: “Earth is a thing; Heaven is Shen.” [Di wu ye; Tian Shen ye.地 物 也 天 神 也]

[Black A H, Man and Nature in the Philosophical Thought of Wang Fu-chih, University of Washington Press, Seattle, 1989.]

Zhuang Zi, the great Daoist philosopher often used the term "shen" as “unfathomable” or “daemonic”. The word “daemonic” is not used in the sense of “demon” but to indicate supernatural powers.
 
Oxford English Dictionary entry for “daemonic”: "of, relating to, or of the nature of, supernatural power or genius" = Ger. dämonisch (Göthe). (In this sense usually spelt dæmonic for distinction.)

Zhuang Zi said: 
Nothing is more shen than Heaven.
Heaven and Earth are perfectly shen.
The way to preserve the shen is to preserve one’s Jing in unadulterated purity. It is by his Jing-Shen that the sage mirrors the myriad things in the stillness of his heart.

[Roth H D, A Companion to Angus Graham’s Chuang Tzu, University of Hawai’i Press, Honolulu, 2003.]

Fan Zhong Yan (989-1052) clearly states the equivalence between ruling one’s Mind and ruling a country, thus showing the political dimension of Confucianism.
The basis of the state lies in the ruler and the basis of rulership lies in the Mind-Heart (Xin). The learning of the ruler should be directed at rectifying his Mind-Heart, making his intentions sincere, taking humanity (Ren) as the basic substance and not letting heterodox and superficial notions take hold. Only thus will the issuing of orders and promulgation of decrees serve the welfare of the state and dynasty.”

[De Bary T, Neo-Confucian Orthodoxy and the Learning of the Mind and Heart, Columbia University Press, New York, 1981.]

Wang Wei thought that the essence of Zhu Xi’s teaching was the Learning of the Heart-Mind (Xin Xue):
What is most subtle and refined in the human person, and yet most broad and great, is the Mind-Heart [Xin]. It ranges out to Heaven and Earth, connects past and present, coordinates human principles and binds together human affairs through all their vicissitudes – indeed there is nothing to which thought does not extend. Thus the sages had the Learning of the Heart-Mind.
    First, seeking the lost mind; second nurturing it. Therefore, if there were no learning of the Heart-Mind, it would be as if man’s possessing a mind made no difference to him. Without the learning of the Heart-Mind, there is no way to direct the person and the person becomes a mere thing, undeserving of the name ‘person’.”

[De Bary T, Neo-Confucian Orthodoxy and the Learning of the Mind and Heart, Columbia University Press, New York, 1981.]

Graham says that Xin is the ordinary word for "heart", the Chinese having always located mental activities there rather than in the brain. It seems likely that when Mencius spoke of having an "unmoved heart" he was not drawing a sharp line between mental disturbances and physical palpitations.

But by the time of the Song dynasty Xin is used consciously in two senses, for the physical organ and for something inside it which controls the movements of the body and is the agent in knowledge. Mental activities are conceived as "functions" varying according to the stimulation of the underlying "substance" by outside things.

[Graham A. C., The Book of Lieh-tzu – A Classic of the Tao, Columbia University Press, New York, 1990.]

Graham also concurs that the word "shen" is sometimes used as "daemonic power". He says that, for the authors of the appendices of the Book of Changes, Shen is not a personal spirit but a daemonic power or intelligence which is active within the operations of heaven and earth and which emanates from the person of the sage.  In the appendices of the Book of Changes the word is less frequent as a noun than as an adjective, for which the least unsatisfactory English word is perhaps "psychic", applied to the Way, the Changes, the divining stalks, the sage, and the inner power or De as in Dao De Jing (usually wrongly translated as "virtue").

Occasionally, shen may even be used as a transitive verb, "to make one's inner power psychic":

[Graham A. C., The Book of Lieh-tzu – A Classic of the Tao, Columbia University Press, New York, 1990.]

Even when shen is used in the appendices as a noun, it does not refer to any entity distinct from things which are shen. The shen of the divining stalks is not a "psyche" within them, but, so to speak, their "psychicity".     Graham therefore says that we cannot afford to use the standard English equivalent "spirit" even when the word is used as a noun, since to do so would disguise the fact that the Neo-Confucians treat it not as an entity like "principle“ [Li], “Qi", "nature", "mind", but as a state like "integrity", "composure", "equilibrium".

For this reason, Graham often calls "shen" "psychicity", adding that he would not wish "to recommend this abominable word as a permanent addition to the English language or even as a regular equivalent of shen."


According to the Great Appendix: "Psychicity [shen] is without confines and the Changes are without body."

[Graham A. C., The Book of Lieh-tzu – A Classic of the Tao, Columbia University Press, New York, 1990.]

For the best discussion of the notions of “Xin”  in Chinese philosophy see:
Lee J, Xunzi and Early Chinese Naturalism, State University of New York Press, Albany, 2004.

The Nei Ye
Nei Ye is a chapter of the Guan Zi.  The Nei Ye is a typical Daoist text dedicated to Daoist techniques of breathing, meditation, exercise and generally “Yang Sheng” (nourishing life) practices. It also discusses the cultivation of Jing-Qi-Shen.

Guan Zi is a text that is influenced by Legalism, Daoism and Confucianism. It is named after the 7th century BC philosopher Guan Zhong, Prime Minister to Duke Huan of Qi but it dates to the Warring States Period (476-221 BC).

The following is an example of passages from the Nei Ye which highlight its Daoist roots and its being an early source of Daoist Qi Gong.  We tend to think of the Dao De Jing as the main Daoist text, which it is; however, the Dao De Jing is primarily a philosophical and political treatise while the Nei Ye is a quintessential text on Daoist exercises. 

When you enlarge your mind [xin ] and let go of it,
When you relax your vital breath [Qi ] and expand it,
When your body is calm and unmoving:
And you can maintain the One and discard the myriad disturbances.
You will see profit and not be enticed by it,
You will see harm and not be frightened by it.
Relaxed and unwound, yet acutely sensitive,
In solitude you delight in your own person.
This is called "revolving the vital breath“ [Qi]:
Your thoughts and deeds seem heavenly.

The Nei Ye talks a lot about Jing as in the following passage:

The vital essence [Jing ] of all things: it is this that brings them to life.
 It generates the five grains below and becomes the constellated stars above.
When flowing in Heaven and Earth we call it ghostly [gui ] and numinous [shen ].
When stored within the chests of human beings, we call them sages.
Therefore this vital energy is:
Bright! - as if ascending from the heavens;
Dark! - as if entering an abyss;
Vast! - as if dwelling in an ocean;
Lofty! - as if dwelling on a mountain peak.
This vital energy cannot be halted by force, yet can be secured by inner power [De ].
It cannot be summoned by speech, yet can be welcomed by awareness.
Reverently hold onto it and do not lose it: this is called "developing inner power." [De ].
When inner power develops and wisdom emerges, the myriad things will be grasped.

All the forms of the mind are naturally infused and filled with it [the vital essence],
are naturally generated and developed [because of] it.
It is lost inevitably because of sorrow, happiness, joy, anger, desire, and profit-seeking.
If you are able to cast off sorrow, happiness, joy, anger, desire and profit-seeking,
your mind will just revert to equanimity.

The true condition of the mind is that it finds calmness beneficial and, by it, attains repose.
Do not disturb it, do not disrupt it and harmony will naturally develop.

The Nei Ye also uses the word “Shen” which Roth translates as “numinous” in this passage.

There is a numinous [Shen ] naturally residing within
One moment it goes, the next it comes,
And nobody is able to conceive of it.
If you lose it you are inevitably disordered;
If you attain it you are inevitably well ordered.
Diligently clean out its lodging place
And its vital essence [Jing ] will naturally arrive.
Still your attempts to imagine and conceive of it.
Relax your efforts to reflect on and control it.
Be reverent and diligent,
And its vital essence [Jing] will naturally stabilize.
Grasp it, and don’t let go
Then the eyes and ears will not overflow
And the mind [Shen] will have nothing else to seek.
When a properly aligned mind [Shen] resides within you,
The myriad things will be seen in their proper perspective.

[Roth H D, Original Tao – Inward Training (Nei Ye) and the Foundations of Taoist Mysticism, Columbia University Press, New York, 1999.]

Roth thinks that "Shen" should be translated as “numinous mind” or “numinous” and "Xin" as Mind. He thinks that this translation is preferable to “spirit” to avoid confusion with Western views of “spirit”. The Nei Ye mentions both Shen and Xin. The term Shen also frequently refers to the external “spirits” or “numina” of nature like mountains and rivers; it may also refer to ancestors. These “spirits” are the powers that descended into early Chinese shamans and shamanesses during their ritualized trances.

Graham says that in the philosophical literature the term ‘shen’ tends to be used as a verb rather than a noun. A verse of the Nei Ye seems to confirm this:

By concentrating your vital breath [Qi] as if numinous [Shen],
The myriad things will all be contained within you.

Here the text speaks not of some internal numen or spirit but, rather, of a spirit-like or numinous power than can foreknow. It details how the practice of concentrating and refining Qi into Jing leads to the ability to divine the future without tortoise shells or milfoil stalks. This foreknowledge also occurs without relying on ghostly [gui] or numinous [shen] powers outside or within oneself but, rather, because of the utmost refinement of Qi and Jing.

Nei Ye, however, also sees the Heart as the ruler: “The Heart-Mind [Xin] has the position of the ruler. The roles of the nine orifices are shared out as those of the officials [guan官]. If the Heart-Mind [Xin] holds the Way [Dao], then the 9 orifices will follow their natural pattern. But if the taste and desires give way to excess, then the eyes will no longer see and the ears no longer hear. So it is said ‘If the ruler diverges from the Dao, then the subordinates will fail in the their tasks'.”

[Lewis M E, The Construction of Space in Early China, State University of New York Press, Albany, 2006.]

Interestingly, chapter 8 of the Nan Jing calls resistance to pathogenic factors “Shen”: it says that the Yuan Qi between the Kidneys is the the "shen" that protects us from pathogenic factors (or evils).


In conclusion, the view of Shen in the Nei Jing is very different than that in the Nei Ye.  In the Nei Jing, Shen is equivalent to the Xin of the Confucians and Neo-Confucians. It is the Mind that must be trained. It is also the monarch of the body in the Confucian view of the State.

In the Nei Ye, Shen is a numinous power that can even apply to mountains, rivers, etc. It is a psychic state that, typically for Chinese medicine and philosophy, can be developed by developing and nurturing Jing.


2) THE HUN
The Chinese character for "Hun" is composed of a "ghost" or "spirit of a dead person" on the right (which gives it its meaning) and if a "cloud" [yun] on the left which is phonetic and gives it is sound (hun being similar to yun).

The character for "ghost" is "gui" in Chinese. Its old pictograph represents the head of a dead person (without a body) and the swirling movement of this ghost after death. As we shall see, the them of "movement" is an essential aspect of the nature of the Hun.











The Hun enters the body 3 days after birth and is imparted by the father. Ethereal in nature, after death it survives the body in the realm of the dead. This idea is very ancient and it is already in the Book of Rites (Li Ji) of the Zhou dynasty (1046-476 BC): “[At death]The Hun returns to Heaven and the Po returns to Earth.


The Shen and Hun and inseparably linked and together they form our consciousness, mind and spirit. Zhang Jie Bin in the “Classic of Categories” says: “The Shen and the Hun are Yang...the Hun follows the Shen, if the Shen is unconscious the Hun is swept away”. It also says: “The Shen corresponds to Yang within Yang; the Hun corresponds to Yin within Yang”.

When describing the Hun, the theme of  “movement", "swirling", "wandering", “searching” etc. is ever present. The old form of the Chinese radical within the word “hun” depicts the swirling movement of the soul of a dead person in the realm of spirit.

The Hun is described as the “coming and going of the Shen” or “what follows the Shen in its coming and going is the Hun” (sui shen wang lai wei zhi hun)  随 神 往 来 为 之 魂

Movement of the Hun
The Hun provides movement to the psyche in many ways:
1)    movement of the soul out of the body as in dreaming
2)    movement out of one's everyday life as in life dreams and ideas
3)    movement towards the others in human relationships
4)    movement in terms of plans, projects, vision
5)    Movement in terms or creativity, inspiration.  

Excessive movement of the Hun may cause manic behaviour while complete movement of the psyche out of itself may result in mental illness.

The Hun as a "gui"
Hun is the “gui”, i.e. the intuitive, non-rational side of human nature. Note the contrast between the character for "Shen" that takes its meaning from "shi", something spiritual, ethereal, pertaining to Heaven, and that for "Hun" that has a "gui" on the left side.

The gui in the character hun for the “Hun” has also another important meaning.  The fact that the Hun has the nature of gui means that it has an independent existence from the Shen.  The Hun has its own life and “agenda” over which the Shen has no say: the interaction and integration of the Shen with the Hun is the basis for our rich psychic life.



Unlike the Hun, the other two mental-spiritual aspects of Yi of the Spleen and Zhi of the Kidneys do not have an independent existence but could be said to be part of the Shen of the Heart. Like the Hun, the Po also has its own independent existence although on a physical level.




Hun assists the Shen in mental activity
The Hun assists the Shen in its mental activities. The "Five-Channel Righteousness” (Tang dynasty), says: "Knowledge is dependent on the sharpness of the Hun”. The Hun provides the Shen (which is responsible for rational thinking), with intuition, vision and inspiration.  It also gives the Shen “movement” in the sense that it allows the Shen the capacity of insight and introspection as well as the ability to project outwards and relate to other people.  Remember the term "Shen" being cognate with “shen” 申 and 伸, i.e. "to extend".

This capacity for movement and outward projection is closely related to the Liver-Qi quality of quick and free movement. The words “movement”, “coming and going”, “wandering”  are often used in connection with the Hun. The free flow of Liver-Qi is the physical equivalent of the Hun’s capacity for smooth movement and “coming and going”.



The free flow of Liver-Qi helps the Heart and the Shen. Note that Liver also has a physiological ascending movement. That movement is towards the Heart; on a psychic level, it is the role that subconscious thinking, intuition and inspiration play in cognition.

Relationship between Shen and Hun
The Shen can only cope with one idea at a time originating from the Hun and it must therefore exercise some form of control over the material coming from the Hun. It must also integrate the material deriving from the Hun in the general psychic life.

Therefore the Shen “gathers” the Hun. Thus, the Hun brings movement to the Shen, and the Shen provides some control and integration. If the Shen is strong and the Hun properly gathered", there will be harmony between the two and the person has calm vision, insight, wisdom and the right balance between “extending” and “withdrawing”.



If the Shen is weak and fails to restrain the Hun (or if the Hun is overactive), this may be too restless and only bring confusion and chaos to the Shen, making the person scattered and unsettled.  This can be observed in some people who are always full of ideas, dreams and projects none of which ever comes to fruition because of the chaotic state of the Shen which is therefore unable to restrain the Hun. I broadly define this as "manic behaviour" bearing in mind this is much milder than the one observed in bipolar disease.


In psychiatric terms, signs and symptoms of mania (or a manic episode) include:
    •  Increased energy, activity, and restlessness
    •  Excessively "high," overly good, euphoric mood
    •  Extreme irritability
    •  Racing thoughts and talking very fast, jumping from one idea to another
    •  Distractibility, inability to concentrate well
    •  Little sleep needed
    •  Unrealistic beliefs in one's abilities and powers
    •  Poor judgment
    •  Spending sprees
    •  A lasting period of behavior that is different from usual
    •  Increased sexual drive
    •  Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
    •  Provocative, intrusive, or aggressive behaviour       
    •  Denial that anything is wrong

Mild “Manic Behaviour” is mania in people who are not mentally ill.
    It includes:
•     Mental restlessness
•     Hyperactivity
•     Working and being active at night
•     Spending a lot
•     Having many projects simultaneously none of which     comes to fruition
•     Mental confusion
•     Obsessive thoughts
•     Laughing a lot
•     Talking a lot
•     Often artistic

Mania can occur in many degrees of severity and there is a broad area of behaviours that, while not normal, do not constitute “mental illness”.  In other words, in its milder forms, “mania” and “manic behaviour” are relatively common.


If the movement of the Hun is lacking (which could be due to over-control of the Hun by the Shen), the person lacks vision, imagination, creativity and will be depressed.  The left part of the diagram below illustrates the situation when the movement of the Hun is deficient; the right part of the diagram below illustrates the situation when the Shen is over-controlling the Hun (thereby restraining its movement).

The relationship between Shen and Hun is all about expansion (stimulation of coming and going of the Hun) and contraction (restraint of coming and going of Hun) in our psychic life.  These two polarities of expansion and contraction are called "shen" and "gui" in Chinese philosophy.



This is reflected in herbal medicine by the two very important herbs:
YUAN ZHI: pungent, bitter, warm dispersing and draining, resolves Phlegm, opens the Heart orifices = stimulates expansion, i.e. coming and going of Hun.
SUAN ZAO REN: sour, sweet, astringent, promotes sleep, anchors Hun = stimulates contraction, i.e. restraint of coming and going of Hun.

Thus "Shen" 神 and "gui" 鬼 are used as codewords for "expansion" and "contraction".

Wang Chong (27-100 AD) said:
When a person dies, his spirit ascends to Heaven and his flesh and bones return to Earth.  To be an earthly gui means to return...to be a heavenly shen means to expand. When the expansion reaches its limit, it ends and begins again. A person is born of gui and at death returns to them. Yin and Yang are called gui-shen.  After people die, they are also called gui-shen”.

Note how in this passage “return” is counterposed to “expansion”.  This is because “return” has also the meaning of “converge” and “contraction”.

The following diagrams illustrate this concept of cycles of expansion and contraction in our psyche.  In the first diagram we have an illustration of normal cycles of expansion and contraction in the psyche. 



In the diagram below, on the top we have a state of more or less permanent expansion, i.e. when expansion prevails over contraction: this person will be "manic".  The part below illustrates the opposite, i.e. a state of more or less permanent contraction: this person will be depressed. 


Hun and art
Artistic inspiration comes from the Hun, not the Shen (at least in Western art, not Chinese art). It is for this reason that there is a disproportionate incidence of bipolar disease in (Western) artists (see Kay Redfield Jamison). The same psychic energy that makes you artistic also, potentially, makes you “mad”.

Redfield Jamison K, Touched with Fire, The Free Press, New York, 1993.


3) SHEN AND HUN AND THE PRE-FRONTAL CORTEX
The discovery that there are centres in the brain that are responsible for the personal, ethical and social dimensions of reasoning irrespective of cognition and language came about after the accident that occurred to Phineas Gage.  Phineas Gage was a railroad construction foreman in charge placing the dynamite charges that were necessary to blast rock.

On September 13, 1848 25-year-old Gage was foreman of a work gang blasting rock while preparing the roadbed for the railroad. Gage was tamping his iron rod when the iron struck a spark against the rock and the powder exploded. The tamping iron entered on the side of his face passing back of the left eye, and out at the top of the head.  


After the accident, Gage's cognition and language skill were unaffected but there was a drastic change in his personality. This was the first time that neurologists realized there were centres in the brain responsible not for cognition but for ethical choices and planning. Such centres are in the pre-frontal lobe.

Gage retained “full possession of his reason” after the accident, but his wife and other people close to him soon began to notice dramatic changes in his personality. A report published in the Bulletin of the Massachusetts Medical Society:

"His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint of advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was 'no longer Gage'.”

Before the accident, Gage had a strong sense of personal and social responsibility, cared for the quality of his work, and attracted the admiration of his colleagues and superiors. He was adapted in social conventions and was ethical in his dealings.  After the accident, he no longer showed respect for social convention; ethics were violated; he was given to lying and inventing tales.

Gage’s injury showed for the first time that there were centres in the brain responsible for the personal and social dimensions of reasoning. The observance of previously acquired social conventions and ethical rules could be lost as a result of brain damage, even when neither cognition nor language were affected.

Gage’s injury showed that something in the brain was concerned specifically with unique human properties, among them the ability to anticipate the future and plan accordingly within a complex social environment; the sense of responsibility towards the self and others. 

From a Chinese perspective, this shows that there are centres in the brain that control the interaction between the Shen and Hun.  Gage’s injury affected the “Hun part of the Shen”.  From a Western point of view, this is the prefrontal cortex.

The Pre-Frontal Cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.

This brain region has been implicated in planning complex cognitive behaviors, personality expression, and modulating correct social behavior. The basic activity of this brain region is considered to be orchestration of thoughts and actions in accordance with internal goals and social rules.



The most typical neurologic term for functions carried out by the pre-frontal cortex area is executive function. Executive function relates to abilities to differentiate among conflicting thoughts, determine good and bad, better and best, same and different, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions, and social "control" (the ability to suppress urges that, if not suppressed, could lead to socially-unacceptable outcomes).

Many authors have indicated an integral link between a person's personality and the functions of the prefrontal cortex.  Skills of comparison and understanding of eventual outcomes are harbored in the prefrontal cortex but the prefrontal cortex (when functioning correctly) controls the mental option to delay immediate gratification for a better or more rewarding longer-term gratification result. This ability to wait for a reward is one of the key pieces that define optimal executive function of the human brain.

The prefrontal cortex (PFC) is responsible for the executive functions, which include mediating conflicting thoughts, making choices between right and wrong or good and bad, predicting future events, and governing social control -- such as suppressing emotional or sexual urges.

From a Chinese perspective, many of the above-mentioned functions of the prefrontal cortex are functions of the Hun, e.g. executive functions, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions.  All this broadly corresponds to the “planning” of the Hun.  The PFC also influences social "control" (the ability to suppress urges that, if not suppressed, could lead to socially-unacceptable outcomes).  This reflects the control of the Shen over the Hun.

The Pre-Frontal Cortex as the arena of Shen and Hun
The pre-frontal cortex is responsible for planning complex cognitive behaviors, personality expression, modulating correct social behavior; also orchestration of thoughts and actions in accordance with internal goals and social rules.

This is often described as "executive function", ability to differentiate among conflicting thoughts, determine good and bad, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions, and social "control".

When the pathways between the prefrontal cortex and the rest of the brain are damaged due to head injury, massive personality changes can result. One might say that the prefrontal cortex is the neurological basis of the conscience.

Weak interconnections between the prefrontal cortex and the rest of the brain have been observed in criminals, sociopaths, drug addicts, and schizophrenics.

The prefrontal cortex has expanded greatly in size throughout hominid evolution, culminating in Homo Sapiens, suggesting a strong selection pressure in favor of its continued growth. In the past five million years of human evolution, the size of the prefrontal cortex has increased six-fold. The size of the prefrontal cortex relative to the rest of the brain has also increased throughout these five million years since the brain itself has increased in size about three-fold.

The prefrontal cortex is fed information from all the senses, and combines this information to form useful judgments. It constantly contains active representations in working memory, as well as representations of goals and contexts.

At the Hospital Barra D'Or in Rio de Janeiro, Eslinger tested a group of normal adults by asking them to view images of emotionally charged scenes with and without "moral" content while lying inside an fMRI magnet. Pictures of physical assaults, war carnage, and abandoned children were included in the moral category; the non-moral images depicted body lesions and dangerous animals.

Certain brain regions (the amygdala, thalamus, and upper midbrain) were consistently activated by both types of emotional stimulus. But some areas, including the orbital prefrontal cortex and the superior temporal sulcus, at the furrow between the frontal and temporal lobes, fired specifically in response to moral content.

Moreover, the researchers found that this activation was very fast. "People detected that something was wrong very quickly. It's almost as if the moral content is embedded within the perception. You don't have to stop to think." When they later showed the same pictures to a group of diagnosed sociopaths, he adds, their reactions differed, and these "cortico-limbic circuits" did not consistently activate.

Thus, the prefrontal cortex is also involved in the so-called moral or social emotions, i.e. shame, guilt and disgust.  The emotion of disgust played an important evolutionary role in steering us away from toxic plants, poisons and spoiled food.  However, “disgust” has also a moral dimension, i.e. moral disgust when observing immoral, unethical or criminal behaviour.

From a Chinese perspective, the prefrontal cortex is the arena of interplay between Shen and Hun. The Shen represents the executive function that needs to interact with but also somewhat control the desires of the Hun. The Shen also represents the moral and social dimension of our life, i.e. interaction with others in family and society (the Hun has nothing to do with ethics and that is why it need the “control” of the Shen).

The location of certain acupuncture points on the forehead presents interesting observation as to the effect these points might have on the prefrontal cortex.  The main point is Du-24 Shenting which, in my opinion, has a profound influence on the regulation of Shen and Hun, finding the right balance between excitation and restraint of the Hun and the right balance of enough (but not too much) control of the Shen over the Hun and also enough movement (but not too much) of the Hun towards the Shen.

For this reason, this point helps both depression and anxiety as well as manic behaviour.  Moreover, it helps memory and the prefrontal cortex is the location of working memory.

Du-24 Shenting Courtyard of the Spirit
Du-24 is a very important and powerful point to calm the Mind. It is frequently combined with G.B.-13 Benshen for severe anxiety and fears.

An important feature of this point which makes it particularly useful is that it can both calm and lift the Mind: therefore it is used not only for anxiety and insomnia but also for depression and sadness. It is also used in psychiatric practice for schizophrenia and split thoughts. Manic behaviour.

The name of this point refers to its strong influence on the Mind and Spirit.  The courtyard was traditionally considered a very important part of the house as it was the one that gave the first impression to visitors; it is the entrance.  Thus, this point could be said to be the “entrance” to the Mind and Spirit and its being a courtyard, highlights its importance. Being the “entrance”, it controls our relationships with others.
James LeDoux says that the prefrontal cortex, the site of working memory, is the gateway to consciousness!  Du-24 Shenting is the courtyard or gateway.

[LeDoux J, Synaptic Self, Penguin Books, London 2003]

G.B.-13 Benshen Shen Root
G.B.-13 has a powerful calming effect on the Shen.  G.B-13 Benshen “gathers” Jing to the head. Its deep mental and emotional effect is also due to its action of “gathering” Jing to the head.  Kidney-Jing is the root of our Pre-Heaven Qi and is the foundation for our mental and emotional life. A strong Jing is the fundamental prerequisite for a clear Mind (Shen) and a balanced emotional life.  This is the meaning of this point’s name “Root of the Shen”, i.e. this point gathers the Jing which is the root of the Shen.

Kidney-Jing is the source of Marrow which fills up the Brain (called Sea of Marrow): G.B.-13 is a point where Jing and Marrow “gather”.  The “Great Dictionary of Acupuncture” says that this point “makes the Shen return to its root”: the “root” of the Shen is the Jing, hence this point “gathers” Jing to the Brain and affects the Shen.

[Cheng Bao Shu 1988 Great Dictionary of Acupuncture (Zhen Jiu Da Ci Dian), Beijing Science Publishing House, Beijing, p.  11.]

As it connects the Shen and Jing, this point also treats both the Heart and the Kidneys and therefore the Shen and Will-Power (Zhi): for this reason, it is an important point in the treatment of depression. When combined with other points to nourish Jing (such as Ren-4 Guanyuan), G.B.-13 attracts Jing towards the head with the effect of calming the Mind and strengthening clarity of mind, memory and will power. 

The connection between G.B.-13 and Jing is confirmed by the text “An Enquiry into Chinese Acupuncture” which has among the indications of this point: “excessive menstrual bleeding, impotence and seminal emissions.”

[Jiao Shun Fa 1987 An Enquiry into Chinese Acupuncture (Zhong Guo Zhen Jiu Qiu Zhen), Shanxi Science Publishing House, p. 52.]

4) MIRROR NEURONS: THE ARENA OF SHEN AND HUN?
In 1992 an Italian neurophysiologist in Parma was doing brain research using macaque monkeys. They were specifically researching an area of the brain called F5, located in the premotor cortex. 


Area F5 contains millions of neurons that specialize in coding for one specific motor behaviour: actions of the hand, including grasping, holding, tearing and, most important, bringing objects (food) to the mouth.

As Iacoboni explains “For every macaque these actions are as basic and essential as they come. We Homo Sapiens are grasping and manipulating objects from the moment we fumble for the snooze button in the morning until we adjust our pillows at bedtime.  All in all, we perform hundreds, if not thousands, of grasping actions every day.” That it why the Rizzolati team chose area F5 for close investigation.

[Iacoboni M, Mirroring People, Picador, New York, 2009, p. 10.]


One day the neurophysiologist Vittorio Gallese was moving around the lab during a lull.  A monkey was sitting quietly in the chair; suddenly, as Vittorio reached for something, he heard a burst of activity from the computer that was connected to the electrodes surgically implanted in the monkey’s brain. 

To an experienced neurophysiologist, this signalled a discharge from the pertinent cells in area F5. Vittorio immediately thought that this was strange as the monkey was sitting quietly not grasping anything, yet the neurons affiliated with the grasping action had fired nevertheless.

Through many painstaking other experiments, the neurophysiologist came to the discovery that, within the F5 motor area, there are dedicated neurons (about 20%) that fire not when one performs an action but when one watches someone else performing an action e.g. grasping, bringing objects (usually food) to the mouth, kicking a ball, playing tennis, etc. 

They even fire when one simply hears a word such as “kick”.   Mirror neurons imitating a grasping action fire even when the object grasped is hidden from view (behind a screen), but not if the monkey knows that there is no object. 

Crucially, mirror neurons are involved in predicting the meaning of a certain action: this is essential in communicating and relating to others.  Iacoboni says: “The action recognition process implemented [by the mirror neurons] is some sort of simulation or internal imitation of the observed action. Given that our own actions are almost invariably associated with specific intentions, the activation in my brain of the same neurons I use to perform my own actions may also allow me to understand the intentions of other people.”

[Iacoboni M, Mirroring People, Picador, New York, 2009, p. 10.]

For example, if I watch someone grasping a cup soon after having an argument with that person, thanks to the mirror neurons, I know whether he or she is grasping the cup to get a drink or whether they are about to throw the cup at me. Quiet simply, mirror neurons differentiate between the same action associated with different intentions.   

After years of experiments by many different neurophysiologists, mirror neurons are now thought to be involved in much more than “imitating” motor actions in one’s brain when watching someone else performing a motor action.  They are now thought to be involved in emotional bonding, empathy and language.

It is now thought that mirror neurons play a role in empathy, the capacity to feel other people’s emotions. The brain area connecting mirror neurons to the limbic system (responsible for our emotions) is the insula. In other words, we feel and understand the emotions of other people thanks to our own mirror neurons which are activated by the sight of someone’s smiling, frowning, crying, etc. Thus, “our mirror neurons fire when we see others expressing their emotions, as if we were making those facial expressions ourselves. By means of this firing, the neurons also send signals to emotional brain centres in the limbic system to make us feel what other people feel.”

Essential to this empathy based on mirror neurons are other people’s facial expressions that trigger the firing of our mirror neurons. To James (of the James-Lange theory of emotions), this phenomenon means that “our mental life is knit up with our corporeal frame, in the strictest sense of the term.”  Incidentally, that is the connection between emotions and the Po in Chinese medicine.

Mirror neurons also play a role in the development of a sense of self. Social context is critical in developing a sense of self. Isolation seems to inhibit the ability to develop a sense of self; rich social context facilitates it.
    The presence of others, the continuous relations and interactions one must have with others facilitates the development of our sense of self.  Mirror neurons fire when we observe actions and when we perform those same actions.  There is a strong link between social environment and a sense of self and this link is at least partly due to mirror neurons.

There is now a mirror neuron hypothesis in relation to autism. In autism there is an “imitation deficit”, i.e. the child is unable to translate from the perspective of another individual to one’s own perspective.  It is now believed that the key neural deficit in autism is a dysfunction of mirror neurons. As Iacoboni says, “a deeply felt mirroring that moves people closer to each other and makes emotional connectedness possible seems to be the main deficit of patients with autism.”

I predict that mirror neurons will do for psychology what DNA did for biology: they will provide a unifying framework and help explain a host of mental abilities that have hitherto remained mysterious and inaccessible to experiments.”
    -V.S. Ramachandran

 [Ramachandran V.S., The Tell-Tale Brain, W.W. Norton & Co., New York, 2011]

What has all this to do with Chinese medicine and, in particular, with Shen and Hun?  I think there are interesting connections between the role of Shen and Hun and mirror neurons. Shen and Hun together are responsible for emotional empathy and relating to others.  Consider the Chinese ideogram for “shen” especially its right side.

As we have seen, the right side of the ideogram is pronounced “shen” and it means “to express, to explain, to stretch, to extend”. The last two meanings, “to stretch” and “to extend”, are crucial to an understanding of what the Shen does. It is responsible for “extending” towards others, for connecting with others, for emotional connection and empathy.  In other words, for the function of the mirror neurons.

However, the Shen cannot perform that function alone: it relies on the help of the Hun and that is why ancient books say that Shen and Hun are related work in unison (they are both Yang in nature), as opposed to the relation between Po and Jing (both Yin in nature).

The Hun perform these functions through its movement in the sense of searching, exploring ideas, nurturing life dreams, etc. Without the input of the Hun the Shen would be an inert consciousness. The input of the Hun is therefore essential for the Shen to perform its function of relating and connectedness with others.  Again, this is the Chinese medicine equivalent of the function of mirror neurons.

It is possible that  autism in children is due to a deficient movement of the Hun that leads to an impaired function of the Shen in relating to others. As we have seen, this has been related to a dysfunction of mirror neurons.

Conversely, I relate hyperactivity in children to an excessive movement of the Hun and, interestingly, hyperactive children are often artistic (which is a function of the Hun).

How does one stimulate the movement of the Hun? I use the Gall-Bladder channel and especially GB-40 Qiuxu.  To restrain the movement of the Hun, I use LIV-3 Taichong. Other points that regulate the Shen and Hun are Du-24 Shenting and GB-13 Benshen.

BL-47 Hunmen regulates the movement of the Hun (it can restrain it or stimulate it).

5) SHEN AND HUN AND JUNGIAN PSYCHOLOGY
Although it is difficult to make direct connections between the Chinese and the psychoanalytical view of the psyche, there are some connections between the Shen and the conscious and between the Hun and the  unconscious.


The arrows coming out of the Hun towards the Shen and out of the unconscious towards the conscious illustrate the psychic contents stemming from the Hun and unconscious.  Note that there is a single arrow coming out of the Shen and of the conscious: this illustrates the control that needs to be exercised by the Shen and the conscious.

In myths and fairy tales the unconscious is often symbolized by the sea.  The Hun is an underwater world and a total immersion of the Shen  in it means insanity.  The Hun is like an ocean that is the source of archetypes, symbols, ideas, images: the Shen  draws from this sea through the intermediary of the Hun. The material coming forth is controlled and integrated by the Shen , one at a time (“Control” and “integration”)
There are some connections between the Hun, Shen and Yi and the Jungian anima and animus.
The anima and animus, in Jung's school of analytical psychology, are the two primary anthropomorphic archetypes of the unconscious mind. The anima and animus are described by Jung as elements of his theory of the collective unconscious. In the unconscious of the male, this archetype finds expression as a feminine inner personality: the anima.  In the unconscious of the female it is expressed as a masculine inner personality: the animus.

The anima and animus can be identified as the totality of the unconscious feminine psychological qualities that a male possesses or the masculine ones possessed by the female, respectively. Although in the original Jungian view the anima is the unconscious of men and the animus unconscious of women, most analysts now believe that men and women both have both an anima and an animus.
  
The anima is generally responsible for inspiration, feelings, intuition, connectedness; the animus is generally responsible for thinking, rationality.  I believe that the anima may be related to the Hun and the animus to Shen and Yi.



Sunday, September 30, 2012

Video on Tian Gui in gynaecology - Video sobre el origin de Tian Gui

Check out this Youtube video (in both English and Spanish) on the physiology and pathology of Tian Gui in gynaecology. 
En este vídeo Giovanni explica el origen y significado del Tian Gui; grabado durante los seminarios de Madrid en IEN en Marzo de 2011.
http://www.youtube.com/watch?v=F-SyYjoJLqw

Monday, September 24, 2012

THE TREATMENT OF MENOPAUSAL PROBLEMS

THE MENOPAUSE IN WESTERN MEDICINE
"Menopause" indicates the complete and permanent cessation of menstruation: an interval of 6-12 months is usually necessary to establish the diagnosis. "Climacteric" indicates the phase in a woman’s life during which she makes the transition from a reproductive to a non-reproductive stage: this transition is a period of declining ovarian function which usually spans 2-5 years around the menopause.

Thus, when we refer to the discomfort and symptoms appearing during these years, it would be more appropriate to call them climacteric syndrome rather than menopausal syndrome.

Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51. The very first chapter of the "Su Wen" describes the 7-year cycles of women, according to which menopause occurs at 49 (7x7): this is not far from the above-mentioned median age of 51. Furthermore, data analyses indicate that the menopausal age has remained unchanged for centuries. Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also other countries. A survey of Malaysian women showed a mean age at menopause of 50.7 years, and another of seven Asian countries found that most women reached menopause at around 50.

The primary basis for the progressive decline of reproductive power in women is in the ovary itself, as ovarian follicles are greatly depleted by the time of the menopause. This is very important to remember when interpreting menopausal problems from the point of view of Chinese medicine. The symptoms of hot flushes (flashes) and in particular vaginal dryness are due to a decline of oestrogen and therefore Tian Gui in Chinese medicine; Tian Gui derives from Kidney-Jing.

It is interesting to note that there is a progressive decline of follicles even from the time before birth. In fact, at the time the ovaries are formed in the foetus, there are approximately 6,000,000 primordial follicles, which decrease to about 600,000 at birth, to 300,000 at menarche and to about 10,000 at the time of the menopause.

This would seem to confirm that the menopause is not an event that takes place suddenly in a woman’s life but one that reflects a gradual physiological process throughout her lifetime, starting even before her birth.
This confirms that the biological basis of the menopause is determined during a woman’s lifetime, i.e. although the decline of Kidney-Jing is gradual, lifestyle and dietary habits from childhood onwards determine what kind of menopause a woman is going to have.

If a woman has a poor diet and if she overworks for several years prior to the onset of the menopause, she will be more likely to develop more severe symptoms during the climacteric years.

The main menopause-linked symptoms are three:
vaginal dryness
hot flushes (flashes)
night-sweating.

By far the commonest symptom is hot flushes (flashes), from which 85 per cent of menopausal women suffer; 45 per cent may experience them for 5-10 years after the menopause.

Indeed, some gynaecologists say that, strictly speaking, only hot flushes and vaginal dryness are oestrogen-deficiency-related manifestations; according to their view, most of the other manifestations are due to increased stress at this time of life.

Other symptoms that they may appear during the menopause are headaches, tiredness, lethargy, irritability, anxious mood, nervousness, depressed mood, insomnia, inability to concentrate.

THE MENOPAUSE IN CHINESE MEDICINE
 

From a Chinese perspective, menopausal symptoms are due to a decline of Kidney-Jing in its Yin or Yang aspect; however, within this basic pathology there can be many variations of patterns. I must stress that I am discussing only the "normal" menopause that occurs around age 50 and not premature menopause that may occur even in the 30s. While the "normal" menopause is due to a physiological decline of Tian Gui, premature menopause is always a pathology.

Since menopausal symptoms (especially vaginal dryness, hot flushes and night-sweating) are due to the decline of oestrogen occurring at this time, from the Chinese point of view, they are due to the physiological decline of Tian Gui. Tian Gui is discussed in the very first chapter of the Su Wen which says that, in girls, it arrives when she is 14 (7x2) and it dried up when she is 49 (7x7): "At the age of 14 the Tian Gui arrives, the Ren Mai begins to flow, the Chong Mai is flourishing, the periods come regularly and she can conceive… At the age of 49, the Ren Mai is empty, the Chong Mai depleted, the Tian Gui dries up, the Earth Passage [uterus] is not open, so weakness and infertility set in."

The Golden Mirror of Medicine (Yi Zong Jin Jian, 1742) says: "At 7, Kidney-Qi is abundant and the Motive Force (Dong Qi) between the kidneys is abundant. At 14, Tian Gui arrives, i.e. the Dong Qi within the Water of the pre-natal Tian Gui, and it enters the Uterus."

This is an interesting statement that makes the point that what he calls "Dong Qi", essentially the Yuan Qi, is pre-natal and is therefore already active when a girl is 7. By contrast, Tian Gui is post-natal and it is the transformation of Yuan Qi into Water when it enters the Uterus making the girl fertile.

Although I myself think that we should be careful in making direct connections between Western and Chinese medicine, in this case I think we can definitely say that "Tian Gui" is an expression of ovarian activity and of oestrogen which is what determines puberty and menopause. As Tian Gui derives from Kidney-Jing, it follows that, during the menopause, there is a (physiological) decline of Kidney-Jing.
 

Finally, I would like to stress that the menopause is neither a "disease" nor a pathology: it is the natural, physiological decline of Kidney-Jing. Indeed, many women go through the menopause without marked symptoms. Of course, it may become a pathology when a woman suffers from a pre-existing deficiency of the Kidneys and other patterns which will cause distressing symptoms which require intervention.

Pathology of menopausal symptoms
I often hear that menopausal symptoms such as hot flushes are due to Kidney-Yin deficiency: not so! Half of the menopausal women I see have a Pale tongue and suffer from Kidney-Yang deficiency. That is because Kidney-Jing deficiency may manifest with a Yin or Yang deficiency; indeed, many herbs that nourish Jing are in the category of tonics of Kidney-Yang (e.g. Bu Gu Zhi, Yi Zhi Ren, Suo Yang, Jiu Zi, Sha Yuan Ji Li).

My experience is that in menopausal women, more often than not, there is an overlapping deficiency of Kidney-Yin and Kidney-Yang, albeit always with a predominance of one (i.e. it is never 50% Kidney-Yin and 50% Kidney-Yang deficiency).

1) Simultaneous Kidney-Yin and Kidney-Yang deficiency
Hot flushes are easy to explain when there is Kidney-Yin deficiency as Empty Heat rising from Kidney-Yin deficiency, but how to explain them in Kidney-Yang deficiency? As mentioned above, during the menopause there is usually an overlapping Kidney-Yin and Kidney-Yang deficiency. Therefore when Kidney-Yang deficiency predominates, the tongue is Pale and the woman has many Cold symptoms such as feeling cold, cold feet and/or back, pale urine, etc. However, since Kidney-Yin is also deficient, there will be some Empty Heat rising and causing hot flushes. Figure 1 illustrates this concept; as can be observed, both Kidney-Yin and Kidney-Yang are deficient in both cases (albeit in different proportions) so that a woman suffering from Kidney-Yin deficiency may also experience cold feet and one suffering from Kidney-Yang deficiency will have hot flushes.

2) Minister Fire

There are also other aspects to the menopausal pathology that explain the hot flushes with Kidney-Yang deficiency. One aspect is the Minister Fire. The Minister Fire is the physiological Fire of the Kidneys that plays a vital role in supporting the physiological activity of all organs. The Minister Fire is a "formless" Fire that has special characteristics: crucially; it is a Fire that does not dry up Water as it even nourishes Water. When there is a deficiency of the Minister Fire there is a Kidney-Yang deficiency and, since the Minister Fire may even nourish Water, there is also a (secondary) Kidney-Yin deficiency.

3) Derangement of Qi
There is yet another aspect to the menopausal pathology that has not to do with Yin and Yang but with Qi. With the onset of the menopause and the decline of Kidney-Jing, there also develops a weakening of the Ren and Chong Mai in the Lower Burner and an "instability" of Qi in the Lower Burner. Thus, during the menopause, Qi is easily deranged and, because it is unstable in the Lower Burner, it rises above contributing to the hot flushes. Thus, in explaining hot flushes, one should not concentrate purely on the Heat aspect of them, but also on the derangement of Qi aspect. Therefore, besides clearing Heat, hot flushes should be treated also by consolidating Qi of the Ren and Chong Mai in the Lower Burner and subduing it in the upper part of the body.

4) Vaginal dryness
So far, we have concentrated on the pathology of hot flushes but the pathology of vaginal dryness is equally important and very distressful. The pathology of vaginal dryness is more directly related to Kidney-Jing than that of hot flushes is. In vaginal dryness we must obviously nourish Yin but remember that it also occurs with Kidney-Yang deficiency for the reasons explained above. What it means in treatment is that, if we are treating vaginal dryness in a woman with Kidney-Yang deficiency with herbal medicine, we must definitely modify the formula with the addition of herbs such as Sheng Di Huang Radix Rehmanniae and Nu Zhen Zi Fructus Ligustri lucidi.

5) Full patterns
Finally, the menopause obviously does not occur in a vacuum and every woman of around 55 will always have a pre-existing pathology that will aggravate the menopausal symptoms. It is important to understand that such pathology will aggravate the menopausal symptoms but is not menopausal as such. The only strictly menopausal pathology is a decline of Tian Gui and a Kidney deficiency.

Thus, in addition to a Kidney deficiency, there will also be some Full patterns such as:
Dampness
Phlegm
Qi stagnation
Blood stasis
Liver-Yang rising
Rebellious Qi of the Chong Mai

All these patterns will contribute to the development and severity of menopausal symptoms and they must be treated in addition to tonifying Kidney-Jing.

Aetiology of menopausal problems
As we discuss "aetiology" for diseases, to discuss the "aetiology" of menopausal problems seems to contradict what I stressed above, i.e. that the menopause is not a "disease". However, the factors discussed below are factors that definitely aggravate menopausal symptoms.

1) Emotional stress
Emotional stress is an extremely important aggravating factor in menopausal problems, building up for year after year before the onset of the menopause.

Anxious, fear or guilt weaken the Kidneys and lead to Yin deficiency, especially when these emotions occur against a background of overwork as is usually the case. In the long run, as Kidney-Yin fails to nourish Heart-Yin, they also lead to Heart-Yin deficiency and Heart Empty Heat and this would aggravate hot flushes.

Worry, anger and fear may lead to Liver-Yang rising which would aggravate hot flushes.

2) Overwork
In my experience, overwork, in the sense of working long hours without adequate rest usually combined with irregular diet and worry, is the most important and frequent cause of Kidney-Yin deficiency in Western women. As there is a pre-existing Kidney-Yin deficiency, this will aggravate the symptoms of vaginal dryness and hot flushes.

3) Smoking
Tobacco smoking injures not only the Lungs but also the Kidneys. It dries up Jing and Blood and it therefore leads to Kidney-Yin deficiency which would aggravate menopausal symptoms.
Tobacco has an interesting history in Chinese society and medicine. When tobacco was first introduced in China (1575), Chinese doctors started testing it to see whether it could be used as a medicinal herb. The Zhen Nan Ben Cao (Ming dynasty) concludes that tobacco is pungent in taste, hot and toxic without any medicinal effect.

Cu Ci Shan (Qing dynasty) made the most interesting statement when he said: "Tobacco is pungent and drying, it burns Jing (Kidneys) and the Fluids, damages the throat, the sStomach and the Lungs…it enters the Heart orifice causing mental confusion as if one were drunk. It makes the tongue coating dark-yellow or black, food and drink have no taste, the medical texts have no treatment for this." The most interesting part of the statement is the reference to tobacco burning Jing: this would therefore aggravate a Jing deficiency and aggravate menopausal symptoms.

4) Irregular diet
Eating irregularly and eating excessive amounts of dairy foods and greasy-fried foods leads to the formation of Phlegm. This often aggravates menopausal symptoms.

5) Tea/coffee and alcohol
Tea, coffee and alcohol are Yang in nature and would aggravate menopausal symptoms and hot flushes.
Based on the above aetiological factors, I now advice young women about the menopause. If I see a, say, 35-old woman who is overworking, eating a lot of dairy foods, drinking excessively and smoking, I tell her that now is the time to do something about the menopause and I list below the advice I give them.

Not to overwork
Do moderate exercise
Not to smoke
To consume only moderate amounts of alcohol
To avoid emotional stress (easy to say!)
To consume tea and coffee in moderate amounts
Not to eat dairy foods

Treatment of menopausal problems
1) Acupuncture
The acupuncture treatment must be based on tonifying the Kidneys and strengthening the Ren and Chong Mai. When treating menopausal problems, I nearly always treat the Ren Mai and the three points I use every time are LU-7 (on the right), KI-6 (on the left) to open the Ren Mai and Ren-4 Guanyuan. In addition, I would also reinforce KI-3 Taixi and SP-6 Sanyinjao. In case of Kidney-Yang deficiency, I would use the same points plus BL-23 Shenshu.

In addition to points to tonify the Kidneys, I also use points to subdue Qi and clear Empty-Heat. I do this with: L.I.-4 Hegu, P-7 Daling and HE-6 Yinxi. In case of severe emotional stress and anxious mood, I add Du-24 Shenting and Ren-15 Jiuwei.

In case of rebellious Qi of the Chong Mai, I use the Chong Mai instead of the Ren Mai with these points: SP-4 Gongsun (on the right), P-6 Neiguan (on the left), plus L.I.-4 Hegu on the right, LIV-3 Taichong on the left, KI-13 Qixue (bilateral), Ren-4 Guanyuan.

2) Herbal treatment
I shall now discuss the treatment of the main patterns involved in menopausal problems.
 
a) KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY WITH PREDOMINANCE OF KIDNEY-YIN DEFICIENCY
Clinical manifestations
Dizziness, tinnitus, poor memory, hardness of hearing, night-sweating, dry mouth and throat at night, lower backache, ache in bones, tiredness, depressed mood, slight anxious mood, cold feet, abundant-pale urine.
Tongue: normal-coloured without coating or with rootless coating. The tongue will be red if there is Empty Heat.
Pulse: Floating-Empty or Weak on both Kidney positions.
Acupuncture
Ren-4 Guanyuan, KI-3 Taixi, KI-10 Yingu, KI-9 Zhubin, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai).

a) Prescription
Zuo Gui Wan Restoring the Left [Kidney] Pill plus Ba Ji Tian Radix Morindae officinalis.

b) Prescription
EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun 
Sheng Di Huang Radix Rehmanniae glutinosae 6g Shu Di Huang Radix Rehmanniae glutinosae praeparata 6g Gui Ban Plastrum Testudinis 12g Mu Li Concha Ostreae 12g Gou Teng Ramulus Uncariae 6g Suan Zao Ren Semen Ziziphi spinosae 4.5g Fu Ling Sclerotium Poriae cocos 6g Fu Shen Sclerotium Poriae cocos pararadicis 6g.
Explanation
This formula is also primarily for Yin deficiency without much Empty Heat. Compared with the previous formula, it is more absorbent and therefore better suited to sweating. It also calms the Mind more.

c) Prescription
GENG NIAN FANG Menopause Formula
Sheng Di Huang Radix Rehmanniae glutinosae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Han Lian Cao Herba Ecliptae prostratae 4.5g Suan Zao Ren Semen Ziziphi spinosae 4.5g Long Chi Dens Draconis 12g Gou Teng Ramulus Uncariae 6g Lian Zi Xin Plumula Nelumbinis nuciferae 4.5g Fu Ling Sclerotium Poriae cocos 6g He Huan Pi Cortex Albizziae julibrissin 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g.
Explanation
This formula places the emphasis on nourishing Yin, absorbing fluids and calming the Mind: it is therefore used for hot flushes with sweating and mental restlessness.

d) Prescription
GENG NIAN AN Peaceful Menopause 
Shu Di Huang Radix Rehmanniae glutinosae praeparata 9g Ze Xie Rhizoma Alismatis orientalis 6g Fu Ling Sclerotium Poriae cocos 6g Mu Dan Pi Cortex Moutan radicis 6g Shan Yao Radix Dioscoreae oppositae 6g Shan Zhu Yu Fructus Corni officinalis 6g Sheng Di Huang Radix Rehmanniae glutinosae 6g Shou Wu Radix Polygoni multiflori 6g Xian Mao Rhizoma Curculiginis orchioidis 6g
Explanation
This formula nourishes both Kidney-Yin and Kidney-Yang, but primarily Kidney-Yin.

Modifications
These modifications apply to all the above formulae.
-Itching: add Chan Tui Periostracum Cicadae, Fang Feng Radix Ledebouriellae divaricatae, Hai Tong Pi Cortex Erythrinae variegatae, Yu Zhu Rhizoma Polygonati odorati.
-Dizziness, headache: add Tian Ma Rhizoma Gastrodiae elatae, Gou Teng Ramulus Uncariae, Shi Jue Ming Concha Haliotidis, Niu Xi Radix Achyranthis bidentatae seu Cyathulae, Sang Ji Sheng Ramulus Sangjisheng.
-Liver-Yin deficiency: add Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae prostratae.

The list below compares and contrasts the four above formulae for menopausal problems from Kidney-Yin deficiency.


SYMPTOMS & ACTIONS:

ZUO GUI YIN
Nourish Yin
Exhaustion, dry throat, hot flushes
Peeled and slightly Red
Fine, Weak-Deep on both Rear positions

Dr MENG JING CHUN
Nourish Yin, absorb fluids, calm the Mind
Exhaustion, dry throat, night-sweating, hot flushes, mental restlessness
Red, without coating
Floating-Empty

GENG NIAN FANG
Nourish Yin, calm the Mind, subdue Liver-Yang
Exhaustion, dry throat, hot flushes, mental restlessness, anxiety, irritability, headaches
Red and Peeled
Floating-Empty, Overflowing on both Front positions and Weak-Deep on both Rear positions

GENG NIAN AN
Nourish Yin and Blood, tonify Kidney-Yang, subdue Liver-Yang
Exhaustion, dry throat, hot flushes, cold feet, headaches
Red and Peeled
Fine, Deep.

e) Prescription
ER XIAN TANG and ER ZHI WAN Two Immortals Decoction and Two Solstices Pill 
Xian Mao Rhizoma Curculiginis orchioidis 6g Yin Yang Huo Herba Epimedii 9g Ba Ji Tian Radix Morindae officinalis 9g Huang Bo Cortex Phellodendri 4.5g Zhi Mu Radix Anemarrhenae asphodeloidis 4.5g Dang Gui Radix Angelicae sinensis 9g Nu Zhen Zi Fructus Ligustri lucidi 12g Han Lian Cao Herba Ecliptae prostratae 9g
Explanation
The formula Er Xian Tang specifically nourishes Kidney-Yin and tonifies Kidney-Yang.
Nu Zhen Zi and Han Lian Cao (together forming Er Zhi Wan) nourish Kidney-Yin, clear Empty Heat and stop night-sweating.

f) Prescription
EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun 
Yin Yang Huo Herba Epimedii 4.5g Xian Mao Rhizoma Curculiginis orchioidis 4.5g Bai Zhu Rhizoma Atractylodis macrocephalae 6g Dang Shen Radix Codonopsis pilosulae 6g Mu Xiang Radix Aucklandiae lappae 3g Gou Teng Ramulus Uncariae 6g Fu Ling Sclerotium Poriae cocos 6g Fu Shen Sclerotium Poriae cocos pararadicis 6g Sheng Di Huang Radix Rehmanniae glutinosae 6g.
Explanation
This formula is better if Kidney-Yang deficiency predominates; it also addresses headaches deriving from Liver-Yang rising, itself stemming from Kidney-Yin deficiency.

g) Prescription
GENG NIAN LE Happy Menopause 
Chai Hu Radix Bupleuri 6g Dang Shen Radix Codonopsis pilosulae 6g Ban Xia Rhizoma Pinelliae ternatae 6g Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata 3g Huang Qin Radix Scutellariae baicalensis 4.5g Fu Xiao Mai Semen Tritici aestivi levis 6g Da Zao Fructus Ziziphi jujubae 6 dates Shan Zhi Zi Fructus Gardeniae jasminoidis 4.5g Zhen Zhu Mu Concha margaritiferae 12g Yin Yang Huo Herba Epimedii 6g.
Explanation
The first five herbs constitute the formula Xiao Chai Hu Tang Small Bupleurum Decoction which harmonizes the Lesser Yang and therefore treats feeling of heat and cold alternating.
This formula tonifies Liver and Kidneys and harmonizes Yin and Yang when they are both deficient. It is especially for sweating and hot flushes and to calm the Mind.

h) Prescription
GENG NIAN FANG (Two formulae)Menopause Formulae 
Formula I 
Sheng Di Huang Radix Rehmanniae glutinosae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Han Lian Cao Herba Ecliptae prostratae 6g Suan Zao Ren Semen Ziziphi spinosae 6g Long Chi Dens Draconis 12g Gou Teng Ramulus Uncariae 6g Lian Zi Xin Plumula Nelumbinis nuciferae 6g Fu Ling Sclerotium Poriae cocos 6g He Huan Pi Cortex Albizziae julibrissin 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g 

Formula II 
Yin Yang Huo Herba Epimedii 6g Xian Mao Rhizoma Curculiginis orchioidis 6g Huang Qi Radix Astragali membranacei 6g Dang Shen Radix Codonopsis pilosulae 6g Suan Zao Ren Semen Ziziphi spinosae 4.5g Fang Ji Radix Stephaniae tetrandae 4.5g Fu Ling Sclerotium Poriae cocos 6g Lian Xin Plumula Nelumbinis nuciferae 6g Xu Duan Radix Dipsaci asperi 6g He Huan Pi Cortex Albizziae julibrissin 6g 
Explanation
These two formulae should be alternated. They tonify both Kidney-Yin and Kidney-Yang and calm the Mind.

i) Prescription
FU GENG YIN Woman's Menopause Decoction
 Sheng Di Huang Radix Rehmanniae glutinosae 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g Yin Yang Huo Herba Epimedii 6g Sang Ji Sheng Ramulus Sangjisheng 6g Dang Gui Radix Angelicae sinensis 6g Gou Teng Ramulus Uncariae 6g Xiang Fu Rhizoma Cyperi rotundi 4.5g Mai Ya Fructus Hordei vulgaris germinatus 6g.
Explanation
This formula nourishes Yin and tonifies Yang, cools Blood and subdues Liver-Yang.

List 2 below compares and contrasts the last five formulae. 

SYMPTOMS & ACTIONS:

ER XIAN TANG and ER ZHI WAN
Tonifies Kidney-Yang, nourishes Kidney-Yin, clears Empty Heat
Hot flushes, cold feet, night- sweating, frequent urination, feeling of heat in the evening
Red without coating
Floating-Empty or Rapid-Fine

Dr MENG JING CHUN
Tonifies Kidney-Yang (primarily), nourishes Kidney-Yin, tonifies Qi, subdues Liver-Yang
Hot flushes, cold feet, frequent urination, night sweating, tiredness, loose stools, headaches
Pale
Deep-Weak on both Rear positions

GENG NIAN LE

Harmonizes the Liver and the Lesser Yang, calms the Mind, stops sweating
Night- sweating, hot flushes followed by feeling cold, irritability
Red, unilateral coating
Wiry, Empty on the deep level

GENG NIAN FANG (two formulae)
Nourishes Kidney-Yin, tonifies Kidney-Yang, subdues Liver-Yang, calms the Mind, tonifies Qi, resolves Dampness
Hot flushes, night- sweating, cold feet, frequent urination, tiredness, loose stools, headaches, irritability, swollen ankles
Red or Pale (depending on predominance of Kidney-Yin or Kidney-Yang deficiency)
Floating-Empty or Fine-Rapid

FU GENG YIN

Nourishes Kidney-Yin, tonifies Kidney-Yang, nourishes Blood, subdues Liver-Yang
Hot flushes, night sweating, cold feet, frequent urination, headaches, blurred vision, poor memory
Pale or Red
Floating-Empty or Weak-Deep on both Rear positions


Case history
A 53-year-old woman complained of menopausal problems for the previous 3 years, after her periods stopped. Her main problems were severe hot flushes, night-sweating, depression, anxiety, mood swings, a tingling feeling all over and insomnia. She also complained of severely cold feet and frequent urination. Her tongue was Red with a slightly rootless, yellow and dry coating and her pulse Rapid, Overflowing on both Front positions and Weak and Deep on both Rear positions.
Although most of these symptoms started after her periods stopped, she had a history of severe stress in the years leading up to the menopause (husband’s redundancy, father’s death and daughter’s breakdown) and this obviously accounted for the severity of the menopausal symptoms.
Diagnosis
Most of this patient’s symptoms are due to deficiency of Kidney-Yin with Empty Heat affecting the Heart and harassing the Mind. The symptoms of Kidney-Yin deficiency are hot flushes, night-sweating, Red tongue with a slightly rootless coating and a Weak and Deep pulse on both Rear positions. The symptoms of Empty Heat affecting the Heart and harassing the Mind are depression, anxiety, mood swings, insomnia and a pulse that is Rapid and Overflowing on both Front positions. As in the previous case history, in this case too there is an overlapping of Kidney-Yin and Kidney-Yang deficiency; although the primary condition is one of Kidney-Yin deficiency, there is also some Kidney-Yang deficiency as evidenced by the cold feet and frequent urination.
Treatment principle
The treatment principle adopted was to nourish Kidney- and Heart-Yin, clear Heart Empty Heat, and calm the Mind; a secondary aim was to tonify Kidney-Yang. She was treated with acupuncture and patent remedies.
Acupuncture
The points used were selected from the following:
- LU-7 Lieque and KI-6 Zhaohai to regulate the Ren Mai, strengthen the Uterus and nourish Kidney-Yin.
-Ren-15 Jiuwei to calm the Mind and clear the Heart.
- Ren-4 Guanyuan to nourish the Kidneys and calm the Mind.
- Du-24 Shenting and G.B.-13 Benshen to calm the Mind.
- Du-20 Baihui to lift depression.
- HE-6 Yinxi and KI-7 Fuliu to stop night-sweating and clear Heart Empty Heat.
- SP-6 Sanyinjiao to nourish Yin, calm the Mind and promote sleep.

b) KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY WITH PREDOMINANCE OF KIDNEY-YANG DEFICIENCY
Clinical manifestations
Lower backache, cold knees, sensation of cold in the back, feeling cold in general but also occasionally hot in the face, menopausal hot flushes, night-sweating, weak legs, bright-white complexion, weak knees, decreased libido, tiredness, abundant-clear urination or scanty-clear urination, urination at night, possibly swelling of the legs, loose stools, depressed mood.
Tongue: Pale.
Pulse: Deep-Weak.
Acupuncture
BL-23 Shenshu, LU-7 Lieque and KI-6 Zhaohai (Ren Mai), Ren-4 Guanyuan, Ren-6 Qihai, KI-3 Taixi, KI-7 Fuliu, BL-23 Shenshu, BL-52 Zhishi. Moxa is applicable is Yang deficiency is pronounced.
Prescription
You Gui Wan Restoring the Right [Kidney] Pill plus Sheng Di Huang Radix Rehmanniae glutinosae and Tian Men Dong Tuber Asparagi cochinchinensis.

Case history
A 50-year-old woman had started experiencing menopausal problems 2 years previously after her periods stopped. She complained of hot flushes, night-sweating, some hair loss, nails breaking easily and backache. Her tongue was slightly Pale and her pulse was weak in general and especially Weak and Deep on both Rear positions.
Diagnosis
Although she had few symptoms, the prevailing patterns are those of Kidney-Yang deficiency and some Liver-Blood deficiency. The menopausal symptoms of hot flushes and night-sweating indicate Empty Heat from Kidney deficiency; the backache and hair loss indicate Kidney deficiency.
Since the pulse is Weak on both Rear positions, the only factor that points to Kidney-Yang deficiency is the Pale colour of the tongue. As we have discussed, in women over 50 a deficiency of the Kidneys nearly always involves a deficiency of both Yin and Yang, albeit always in differing proportions. Thus, when Kidney-Yang is primarily deficient, Kidney-Yin also becomes slightly deficient, giving rise to the Empty Heat symptoms that cause the hot flushes. In this patient, the brittle nails indicate some Liver-Blood deficiency.
Treatment principle
The treatment principle in this case is to tonify Kidney-Yang primarily and nourish Kidney-Yin secondarily, and to nourish Liver-Blood. She was treated only with herbal medicine.

c) KIDNEY-YIN AND LIVER-YIN DEFICIENCY WITH LIVER-YANG RISING
Clinical manifestations
Irritability, headaches, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night-sweating, sore back.
Tongue: Red without coating possibly redder on the sides.
Pulse: Floating-Empty, Wiry on the left-Middle position.
Treatment principle
Nourish Kidney- and Liver-Yin, subdue Liver-Yang, calm the Mind, settle the Hun.
Acupuncture
LU-7 Lieque and KI-6 Zhaohai (Ren Mai), KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8, SP-6 and Ren-4 with reinforcing method, the others with reducing method.

Prescription
 
KUN BAO TANG Female Treasure Decoction  
Sheng Di Huang Radix Rehmanniae glutinosae 9g Bai Shao Radix Paeoniae lactiflorae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Ju Hua Flos Chrysanthemi morifolii 6g Huang Qin Radix Scutellariae baicalensis 4.5g Suan Zao Ren Semen Ziziphi spinosae 6g Long Chi Dens Draconis 12g 
Explanation
This formula nourishes Liver- and Kidney-Yin, subdues Liver-Yang, calms the Mind and settles the Hun.

Prescription
 
QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill  
Shu Di Huang Radix Rehmanniae glutinosae praeparata 24g Shan Zhu Yu Fructus Corni officinalis 12g  Shan Yao Radix Dioscoreae oppositae 12g Ze Xie Rhizoma Alismatis orientalis 9g Mu Dan Pi Cortex Moutan radicis 9g Fu Ling Sclerotium Poriae cocos 9g Gou Qi Zi Fructus Lycii chinensis 9g Ju Hua Flos Chrysanthemi morifolii 6g
Explanation
This formula is a variation of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill which nourishes Liver- and Kidney-Yin. The first six ingredients make up the original prescription.

Prescription
 
QING XIN PING GAN TANG Clearing the Heart and Balancing the Liver Decoction 
Huang Lian Rhizoma Coptidis 3g Mai Men Dong Tuber Ophiopogonis japonici 9g Bai Shao Radix Paeoniae lactiflorae 9g Bai Wei Radix Cynanchi baiwei 9g Dan Shen Radix Salviae miltiorrhizae 9g Long Gu Os Draconis 15g Suan Zao Ren Semen Ziziphi spinosae 9g
Explanation
This formula nourishes Liver-Yin, clears Heat, absorbs fluids (to stop sweating) and settles the Hun.

List 3 below compares and contrasts the formulae for menopausal problems from Liver- and Kidney-Yin deficiency and Liver-Yang rising.

SYMPTOMS & ACTIONS:

KUN BAO TANG

Nourishes Kidney-Yin, subdues Liver-Yang, calms the Mind, settles the Ethereal Soul
Night- sweating, hot flushes, feeling of heat in the evening, mental restlessness, anxiety, insomnia, headaches
Red without coating, redder tip
Floating-Empty

QI JU DI HUANG WAN
Nourishes Liver- and Kidney-Yin, subdues Liver-Yang
Night- sweating, hot flushes, feeling of heat in the evening, headaches
Red without coating
Floating-Empty

QING XIN PING GAN TANG
Clears Heart- Heat, nourishes Heart-Yin, calms the Mind, settles the Ethereal Soul
Mental restlessness, bitter taste, anxiety, insomnia, feeling of heat in the evening, night sweating
Peeled, red and swollen tip, Heart crack
Floating-Empty, relatively Overflowing on both Front positions


Case history 
A 55-year-old woman had started suffering from menopausal symptoms a year after the stoppage of her periods. Her main problems were hot flushes, night-sweating, a "prickly feeling" over her skin, depression, tiredness, dry eyes and mouth, headaches, and irritability. Other symptoms included backache, frequent urination, constipation and cold feet. Her tongue was Red on the sides and her pulse was Weak on both Rear positions and slightly Overflowing on the left Middle and Front positions.
Diagnosis
The main underlying pattern is that of Kidney-Yin and Liver-Yin deficiency (hot flushes, constipation, night-sweating, dry eyes and mouth). As often happens, there is also a concurrent deficiency of Kidney-Yang (tiredness, frequent urination, backache, cold feet). The depressed mood is due to the weakening of Will-Power (Zhi) consequent to the Kidney deficiency. In addition to the Kidney deficiency, there is Liver-Yang rising (from Kidney-Yin deficiency) as evidenced by the headaches, irritability, Red sides of the tongue and pulse Overflowing on the left Middle and Front positions.
Treatment principle
The treatment principle adopted was to nourish Kidney-Yin, tonify Kidney-Yang, subdue Liver-Yang, strengthen Will-Power and calm the Mind. She was treated with acupuncture and patent remedies.
Acupuncture
The points used were selected from the following:
- LU-7 Lieque and KI-6 Zhaohai to regulate the Ren Mai, strengthen the Uterus and nourish Kidney-Yin.
- Ren-4 Guanyuan to nourish the Kidneys.
- P-7 Daling to calm the Mind.
- LIV-2 Xingjian to subdue Liver-Yang.
- SP-6 Sanyinjiao to nourish Yin and calm the Mind.
- BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to tonify the Kidneys, strengthen Will-Power, pacify the Liver and settle the Hun.

d) KIDNEY-YIN AND HEART-YIN DEFICIENCY WITH HEART EMPTY HEAT
Clinical manifestations
Hot flushes, palpitations, insomnia, night-sweating, blurred vision, dizziness, tinnitus, anxiety, mental restlessness, backache, a malar flush, feeling of heat in the evening, dry mouth and throat, poor memory, dry stools.
Tongue: Red body without coating with a redder tip. Pulse: Rapid-Fine, or Floating-Empty, or Weak-Deep on both Rear positions and Overflowing on both Front positions.
Treatment principle
Nourish Kidney-Yin, calm the Mind, clear Empty Heat.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue, HE-6 Yinxi, KI-7 Fuliu, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting. HE-6, HE-8 and P-7 with reducing or even method; all the others with reinforcing method.

Herbal treatment

a) Prescription
TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill 
Sheng Di Huang Radix Rehmanniae glutinosae 12g Xuan Shen Radix Scrophulariae ningpoensis 6g Mai Men Dong Tuber Ophiopogonis japonici 6g Tian Men Dong Tuber Asparagi cochinchinensis 6g Ren Shen Radix Ginseng 6g Fu Ling Sclerotium Poriae cocos 6g Wu Wei Zi Fructus Schisandrae chinensis 6g Dang Gui Radix Angelicae sinensis 6g Dan Shen Radix Salviae miltiorrhizae 6g Bai Zi Ren Semen Biotae orientalis 6g Suan Zao Ren Semen Ziziphi spinosae 6g Yuan Zhi Radix Polygalae tenuifoliae 6g Jie Geng Radix Platycodi grandiflori 3g 
Explanation
This formula nourishes Kidney-Yin, clears Heart Empty Heat and calms the Mind: it is ideally suited to treat menopausal problems occurring with these patterns.

b) Prescription
LIU WEI DI HUANG WAN and HUANG LIAN E JIAO TANG Six-Ingredient Rehmannia Pill and Coptis-Gelatinum Corii Asini Decoction 
Shu Di Huang Radix Rehmanniae glutinosae praeparata 24g Shan Zhu Yu Fructus Corni officinalis 12g Shan Yao Radix Dioscoreae oppositae 12g Ze Xie Rhizoma Alismatis orientalis 9g Mu Dan Pi Cortex Moutan radicis 9g Fu Ling Sclerotium Poriae cocos 9g Huang Lian Rhizoma Coptidis 3g Huang Qin Radix Scutellariae baicalensis 9g Bai Shao Radix Paeoniae lactiflorae 9g Ji Zi Huang Egg yolk 2 yolks E Jiao Gelatinum Corii Asini 9g 
Explanation
The formula Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, already explained, nourishes Liver- and Kidney-Yin. The formula Huang Lian E Jiao Tang Coptis-Gelatinum Corii Asini Decoction, clears Heart-Heat and nourishes Yin.

TREATMENT OF FULL PATTERNS DURING THE MENOPAUSE
As we have discussed above, every menopausal woman is bound to suffer from patterns other than those purely related to the decline of Kidney-Jing. Therefore, every menopausal woman will suffer from a combination of Kidney deficiency and some Full patterns such as Qi stagnation, rebellious Qi of the Chong Mai, Phlegm and Blood stasis. However, remember that such Full patterns are not "menopausal" syndromes in the same way hot flushes and vaginal dryness are.

Therefore, when the clinical picture is significantly complicated by some of the above Full patterns, I will tend to use a custom formula rather than a prepared remedy. If the above Full patterns are pronounced, then it might be advisable to deal with these first by using a decoction that resolves Phlegm, moves Qi or invigorates Blood.

For example, were the deficiency of the Kidneys accompanied by a pronounced stasis of Blood, one might invigorate Blood and eliminate stasis first by using for a few months a formula such as Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction .
Similarly, were Phlegm pronounced, one might start with a decoction to resolve Phlegm such as Er Chen Tang Two Old Decoction.

However, prepared remedies may also be used in these cases combined with the menopausal remedies.



PROGNOSIS AND PREVENTION

Chinese medicine can help women to minimize their problems in the transition from a reproductive to a non-reproductive age. Herbal treatment is more effective than acupuncture because herbs are better at nourishing Jing. Acupuncture is very effective at controlling menopausal symptoms but it needs to be administered regularly, so that herbal medicine is cheaper for the patient.

Generally speaking, if menopausal problems occur against a background of Kidney-Yin deficiency, the treatment will be more difficult and one can say that the redder the tongue body and the less coating there is, the more difficult the treatment. The tongue indicating the worst prognosis would be one with a dark-Red body, completely without coating, cracked and dry.

As mentioned earlier, the severity of menopausal symptoms depends on the pre-existing condition of the Kidneys and therefore on the woman’s diet and lifestyle throughout her lifetime. Thus, it is important that the patient understands this and is willing to be patient; Chinese medicine can help a woman in this transition period only in a slow and gradual way. It is becoming more difficult to explain this to patients given the "quick results" they are offered (and sometimes experience) through hormone replacement therapy (HRT).

We should now discuss the integration of Chinese herbal medicine with HRT, is such integration is possible. In my experience, there is no problem in using Chinese herbs while the patient is taking HRT because they work in different ways and at different levels. HRT works by "tricking" the hypothalamus in thinking that the ovaries are still working so that it will stop stimulating the pituitary gland to secrete FSH. Chinese herbs work by gently nourishing Kidney-Jing to minimize the effects of the menopausal transition. However, while it is possible to combine the two in the short term, it does not make sense to combine them in the long term. In any case, menopausal women generally come to us wither because they do not want HRT or because they want to stop it.

Finally, another question that arises is: how long can a woman go on taking Chinese herbs for the menopause? In my experience, these can be taken for years without any side-effects. However, when a patient takes a remedy for the long term, I usually ask them to suspend it for about 1 month every 6-9 months.

WESTERN VIEW
The ovarian changes associated with the menopause have already been mentioned in the introduction. The main endocrine change is a decreased oestrogen production by the ovary which is the main source of oestrogen (in the form of oestradiol) in the reproductive years. After menopause, the ovarian oestrogen production decreases markedly and the main circulating oestrogen is oestrone rather than oestradiol. Most of the oestrogen present in menopausal women is derived from adipose tissue from the conversion of androstenedione to oestrone. The amount of oestrone produced in adipose tissue is determined by the overall amount of this tissue. Therefore thin women convert a smaller percentage of androstenedione to oestrone (1.5 per cent) compared with obese women who may convert as much as 7 per cent. The main source of androstenedione is the adrenal glands.

The time preceding the menopause is characterized by an increasing irregular menstrual cycle which may become either scanty or heavy and irregular in timing. The symptoms associated with the menopause may be classified according to the organ or tissue involved:

∙ Brain: hot flushes, depression, anxiety, insomnia, poor memory and concentration
∙ Vagina: vaginal dryness and atrophy
∙ Heart: coronary heart disease
∙ Blood vessels: arteriosclerosis
∙ Bone: osteoporosis
∙ Skin: thinning, slow healing, itching

As mentioned before, some gynaecologists consider only hot flushes and vaginal dryness as oestrogen-related menopausal symptoms. Hot flushes are the most common menopausal symptom: up to 85 per cent of menopausal women suffer from them and 45 per cent of them do so for up to ten years after the menopause. Associated with an increase in temperature, increased pulse rate, and increased blood flow in the hand, each hot flush lasts on average 2.7 minutes.

Hot flushes are a mechanism for dissipating heat through vasodilatation and perspiration in response to the thermoregulatory centres in the anterior hypothalamus. The vasomotor symptoms (hot flushes) occurring during the climaterium are probably due to fluctuating pulses of pituitary follicle-stimulating hormone (FSH) which rises to abnormal blood levels at this time in an effort to provoke ovulation from increasing unresponsive follicles. Oestrogen in the form of HRT (hormone-replacement therapy) "deceives" the pituitary that normal ovulation and oestrogen production is continuing so that the overproduction of FSH ceases and so do the hot flushes.

The Western treatment of menopausal problems is based on the administration of hormone replacement therapy (HRT or ERT) in different forms: these could be native oestrogens (oestradiol, oestrone, oestriol), conjugated equine oestrogens, and synthetic oestrogens (such as ethinyl oestradiol) in a dose ranging between 5 and 10 μg. This is a lower dose (usually about 1/7th) than the one used in the contraceptive pill and, for this reason, many gynaecologists believe that the potential side-effects of HRT have been wrongly extrapolated from those of the contraceptive pill.

Indeed, they say that some of the side-effects, far from being that, are actually indications: for example, while the contraceptive pill carries the potential adverse reaction of cardiovascular disease, HRT is, presumably, effective in "protecting" menopausal women from cardiovascular disease.1 However, this thesis is hotly debated as we shall see shortly.

In any case the potential adverse effects of HRT include endometrial hyperplasia and cancer, thromboembolism, strokes, hypertension, breast cancer, gall-bladder dysfunction, gall stones, and lesser symptoms such as nausea, vomiting, water retention, and headaches.2 As most practitioners will know, in spite of the potential adverse effects, menopausal women are increasingly being prescribed HRT almost routinely. The one adverse effect that is usually taken seriously is the potential risk of breast cancer: for this reason, HRT should never be given to a woman who has or has had breast cancer or to a woman who has a breast lump of an unknown nature. However, this view is also debated as there are doctors who think that women who have been "cured" of their breast cancer can receive HRT without risk.3

The oestrogen present in HRT is often supplemented by the administration of progestins principally to oppose the effect of oestrogen on the endometrium (hyperplasia and increased risk of endometrial cancer). There are two classes of progestins used: native progestins (progesterone and 17-hydroxyprogesterone) and synthetic progestins (19-nortestosterone derivatives and 21-carbon-atom compounds such as medroxyprogesterone and megestrol). If oestrogen is given for 25 days (with a break of 5 days), progestin is added in the last 12 days. If oestrogen is given continuously for 30 days without a break, progestin is usually administered in the last 12 days.

Vaginal bleeding usually occurs with cyclic oestrogen/progesterone therapy and is caused by the progesterone component. Progesterone therapy for menopausal women has not proved of much benefit and also has potential side-effects such as depression, breast fullness and tenderness, a distended feeling, weight gain and symptoms like those of pre-menstrual tension. However, the theoretical side-effects of progesterone rarely manifest in practice when it is combined with oestrogen for the relief of menopausal symptoms. Progesterone’s undisputed role in HRT is to neutralize oestrogen’s potentially carcinogenic effect on the endometrium and breast.

HRT therapy can be administered in the following forms:

∙ Oral (tablets)
∙ Transdermal (patches)
∙ Percutaneous (gel)
∙ Subcutaneous (implants)
∙ Vaginal (creams, pessary, tablets)

Contraindications to oestrogen treatment are:

∙ Hormone-related cancer
∙ Active liver disease
∙ A history of hormone-induced thromboembolism
∙ Vaginal bleeding of an unknown cause
∙ Untreated hypertension4

Please note that I have reported the above contraindications mostly for the practitioner’s information; it should be borne in mind, however, that new research is being carried out on the effects of HRT all the time so that new findings are reported every few months. Thus, not all gynaecologists would agree with the above list of contraindications: for example, there are some who claim that having had breast cancer is not always a contraindication for HRT. From a Western point of view, menopausal problems are almost exclusively attributed to a deficiency of oestrogen and the "cure" is therefore HRT.

In modern industrialized societies HRT is increasingly prescribed almost routinely as soon as a woman approaches the menopause, both to alleviate menopausal symptoms and because of its alleged protective effect against osteoporosis and heart disease. More and more, the menopause has been medicalized and defined as a "deficiency disease". For example, a recent text on women’s problems in general practice says: "In the USA, Australia and Western Europe, the concept has emerged of the menopause as a deficiency disease which needs treatment by hormone replacement therapy."5 There are many flaws in this thinking.

First of all, the menopause is not a "disease" and it needs medical intervention only if its symptoms are uncomfortable and distressing.

Secondly, the decline in oestrogen levels following the reduction in follicles is a natural, physiological process that is part of a woman’s biological rhythms. Seen from this perspective, menopause is no more a "disease" than menarche is.

Thirdly, the "protective" effect of HRT against osteoporosis and heart disease is hotly debated and not at all conclusively proven. The many studies which have been conducted are confusing and contradictory. For example, a review of English-language literature on oestrogen therapy from 1970 to 1992 concluded that oestrogen use by menopausal women reduces the risk of coronary heart disease (CHD) by about 35 per cent and the risk of hip fracture in post-menopausal women by about 25 per cent.6 Moreover, meta-analysis of epidemiological data demonstrates that women using HRT after menopause experience lower rates of heart disease.7

On the other hand, a study of 1,234 post-menopausal women observed over a period of twelve years found that women using oestrogen had over a 50 per cent elevated risk of cardiovascular morbidity and more than a twofold risk of cerebrovascular disease. The study also concluded that no benefits from oestrogen use were observed in the study group.8 Moreover, two other studies demonstrated a (small) increased risk of venous thromboembolism in users of HRT.9

Fourth, and probably most important, there are many studies showing that HRT does increase the risk of endometrial and breast cancer. The review of literature mentioned above found that since 1970 at least thirty-five epidemiological studies have shown a significantly increased risk of endometrial cancer in women who have taken oestrogen. Similarly, the same review showed that the risk of breast cancer increases with long-term use of oestrogen.10 In fact, a Swedish study of 23,000 hormone users reported that the incidence of breast cancer compared with that in non-users was increased after six years’ use.11

One of the most recent British studies of 5,000 women taking HRT showed that breast cancer mortality in these women compared with the general population rose from 0.55 per 1,000 in the earlier period of follow-up to 1984, to 1 per 1,000 between 1984 and 1988.12 In both the Swedish and British studies no protective effect was observed when progestogen was given.13 However, other studies show that the risk of breast cancer is reduced or nullified if progesterone is administered (in addition to oestrogen) continuously rather than sequentially.14

Fifth, "protecting" a woman from osteoporosis and heart disease must surely depend on very many factors such as diet and lifestyle before the onset of the menopause: thus, it is simplistic, at best, to think that oestrogen taken as soon as the menopause approaches is going to "protect" a woman from these diseases.

Although the potential impact of HRT on the risk of endometrial and breast cancer it still debated and not conclusively proven, taking all the above factors into account, it does seem that Chinese medicine, with its gentle and steady tonification of the Kidney-Jing without side-effects, can offer a safe, effective and logical alternative to HRT, even though its effects will never be as rapid as those of HRT. In any case, the treatment of menopausal problems with acupuncture and Chinese herbs should not necessarily be seen as an "alternative" to HRT as the two may also be combined because HRT and a Chinese treatment work in different ways. HRT works by "tricking" the body into thinking that it is still ovulating but it does not tonify the Kidneys.15 Chinese medicine, on the contrary, works by gently tonifying the Kidneys and the Kidney-Jing to help the woman in this transition time of life.

The interesting thing is that, as the ovaries reduce their production of oestrogen, nature has something else up her sleeve. Women are also able to produce a form of oestrogen (called oestrone) from the adrenal glands in order to compensate for the decline from the ovaries.

Women also produce oestrogen from fat cells, so being ultra-slim will not have health benefits in the long run, particularly if you are going through menopause. Of course obesity presents its own health problems, but from an oestrogen-production point of view, it is better to be slightly overweight than very thin.
 

WOMEN’S HEALTH INITIATIVE RANDOMIZED CONTROLLED TRIAL ON THE RISKS AND BENEFITS OF OESTROGEN PLUS PROGESTIN IN HEALTHY POSTMENOPAUSAL WOMEN
The Women’s Health Initiative in the USA conducted a trial to assess the risks and benefits of Hormone Replacement Therapy (HRT) in healthy postmenopausal women. 16,608 postmenopausal women aged 50-79 with intact uterus were given conjugated equine oestrogens 0.625 mg plus medroxyprogesterone acetate 2.5 mg or a placebo. The trial was to last 8.5 years.

The main outcomes checked were breast cancer and coronary heart disease. On May 31 2002, after 5.2 years, the trial was stopped because it showed an unacceptable increased risk of breast cancer (26%), coronary heart disease (29%) and stroke (41%) in the women who were taking HRT. The investigators concluded that the overall health risks exceeded the benefits from use of combined oestrogen and progesterone.

This study does not come as a surprise as other studies have highlighted the risks inherent in HRT. In fact, some studies show that women on HRT have an increased risk of breast cancer. A Swedish study of 23,000 hormone users reported that the incidence of breast cancer compared with that in non-users was increased after six years’ use. One of the most recent British studies of 5000 women taking HRT showed that breast cancer mortality in these women compared with the general population rose from 0.55 per 1000 in the earlier period of follow-up to 1984, to 1 per 1000 between 1984 and 1988. Thus, excessive oestrogen, as the above studies show, increases the risk of developing breast cancer.

MILLION WOMEN STUDY

Growing evidence about the risks of breast cancer and other serious illnesses posed by hormone therapy for menopause has led many women to give up the drugs, and many doctors to stop recommending them.

But there has been a lingering belief, according to some, that for younger women in the early stages of menopause, hormone risks may be negligible, at least for a while. So those who are really suffering from hot flushes, insomnia and other symptoms are often told that it is probably all right to take the drugs, as long as they use the lowest possible dose for the shortest possible time. Some researchers are even testing an idea, called the timing hypothesis, that starting hormone treatment early in menopause may help protect women from heart disease.

Now, information from a huge observational study in Britain suggests that the women thought to be at the lowest risk from hormones may actually be at the highest risk, at least when it comes to breast cancer. The study found that women with the greatest risk of breast cancer from hormones were those who took them earliest — before or soon after menopause began. These findings are not considered to be the strongest type of evidence because they do not come from a randomized trial. However, this particular observational study also has a unique strength — it included more than a million postmenopausal women, i.e. one in four British women who were aged 50 to 64 during the enrolment period, from May 1996 to December 2001.

The research, called the Million Women Study, found that in women aged 50 to 59 who had never taken hormones, 0.3 percent a year developed breast cancer. The rate was higher, 0.46 percent a year, in women who started taking the most commonly used hormones — estrogens combined with progestin — five or more years after menopause began. But it was highest of all — 0.61 percent a year — in women who started taking the drugs before or less than five years after menopause began. And the risk was increased even in women who took the drugs for less than five years.

The lead investigator of the study, Prof. Dame Valerie Beral, a professor of epidemiology at the University of Oxford, said that her research group had decided to look at the interval between the start of menopause and the start of treatment because other studies had found evidence of higher risk among women who started earlier. But in the other studies, the numbers of women who had started early were relatively small, and so the evidence was not statistically significant. In the Million Women Study, 90 percent of the women taking hormones had begun them before or within five years of the start of menopause, so there was a better chance of finding an answer.

One of the studies that had detected a possible but inconclusive link between earlier hormone use and increased cancer risk was the above-mentioned Women’s Health Initiative, the randomized trial that in 2002 found that combined hormones were causing small but significant increases in the risk of breast cancer, heart disease, strokes and blood clots in the lungs.

END NOTES:
1. A. Govan, D. Hart and R. Callander 1993 Gynaecology Illustrated, Churchill Livingstone, Edinburgh, p. 477.

2. Gomel V. and Munro M. 1989 Gynaecology: a Practical Approach, Williams and Wilkins, Baltimore, p. 131.

3. I S Fentiman “Hormone Replacement Therapy and Breast Cancer: Proceed with Caution”, Journal of the British Menopause Society, Vol. 1, No. 2, October 1995, p. 21.

4. V. A. Ravnikar “Barries for Taking Long-term Hormone Replacement Therapy: Why Do Women not Adhere to Therapy?” in European Menopause Journal, Vol. 3, no. 2. (Suppl.), 1996, p. 93.

5. Women’s Problems in General Practice, p. 198.

6. D. Grady et al “Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women”, Annals of Internal Medicine, Vol. 117, No. 12, 15 December 1992, pp. 1021-3.

7. V. Mijatovic and A. Pines “Menopause-induced Changes in Cardiovascular Functions and HRT”, European Menopause Journal, Vol. 2, No.1, 1995, p. 4.

8. P. W. F. Wilson et al “Postmenopausal Oestrogen Use, Cigarette Smoking, and Cardiovascular Morbidity in Women over 50", New England Journal of Medicine, Vol. 313, No. 17, 24 October 1985, p. 1038.

9. E. Daly et al “Risk of Venous Thromboembolism in Users of Hormone Replacement Therapy”, The Lancet, Vol. 348, No. 9033, 12 October 1996, p. 977.

H Jick et al “Risk of Hospital Admission for Idiopathic Venous Thromboembolism among Users of Postmenopausal Oestrogens”, The Lancet, Vol. 348, No. 9033, 12 October 1996, p. 981.

10. “Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women”, pp. 1018-20.

11. L. Bergkvist et al “The Risk of Breast Cancer after Oestrogen and Oestrogen-Progestin Replacement” in New England Journal of Medicine, Vol. 321, No. 5, 3 August 1989, pp. 293-297.

12. K Hunt et al “Mortality in a Cohort of Long-term Users of Hormone Replacement Therapy: an Updated Analysis”, British Journal of Obstetrics and Gynaecology, Vol. 97, December 1990, pp. 1080-1086.

13. Women’s Problems in General Practice, p. 216.

14. B G Wren “Hormonal Replacement Therapy and Breast Cancer”, European Menopause Journal, Vol. 2, No. 4, 1995, p. 13.  

15. The relationship between HRT and Chinese treatment is similar to that between antibiotics and Chinese treatment: antibiotics kill bacteria but they do not release the Exterior, restore the descending and diffusing of Lung-Qi, clear Heat or resolve Phlegm.  Thus, if a patient is already taking antibiotics, this is not a contraindication for treatment with Chinese herbs.

16. Grady D et al 1992, pp. 1018-20.

17. Bergkvist L et al 1989 The Risk of Breast Cancer after Oestrogen and Oestrogen-Progestin Replacement.  New England Journal of Medicine, vol. 321, no. 5, pp. 293-7.

18. Hunt K et al 1990 Mortality in a Cohort of Long-term Users of Hormone Replacement Therapy: an Updated Analysis.  British Journal of Obsetrics and Gynecology, vol. 97, pp. 1080-6.