söndag 6 januari 2013

Classical Chinese Medicine and the body as a living landscape: healing makes our internal landscape heal and flower again, and a look at chapters 12 and 13 of the Neijing and the Classic of Mountains and Seas, Shanghan Lun depths of treatment, Dr Wang Juyi and Jueyin, and how acupuncture must be adapted for the time it is practiced in

What kind of landscape are you?

Are you a woodland glade, where sunlight shines down in beams of gold, while birdsong echoes among the trees? Are you a windswept beach, where you walk along collecting driftwood as gulls laugh on the wind and the smell of salt fills your nostrils? Are you a quiet Sunday morning, sitting at home and eating a slow breakfast before contentedly thinking through the things you are going to do today? Or are you sitting inside your car, stuck in the middle of traffic, feeling tense and cramped, with a burning pit of irritation in your stomach, worry filling your mind, and hands gripping the steering wheel even harder as you realize you forgot your cell phone at home, on the kitchen table?..

I think most Westerners know quite well which of these they would pick to describe their internal landscape – and which ones they would prefer it to be instead!
In this blogpost we are going to look at the concept of internal landscape in Classical Chinese Medicine (CCM). Both the internal landscape in ourselves and in patients, and on how that internal landscape can be balanced, healed, and how it can begin to have better harmony with the landscape around us in our everyday life.

The concept of internal and external landscape seems to orginally come from shamanism, and has flowered in a precise system in China within Daoism. It exists both in CCM and the newer Traditional Chinese Medicine (TCM). It is stronger in CCM, however, and there is a greater focus there on shen (conscious awareness, sometimes translated as ”spirit”) and on how our shen both creates and lives in our internal landscape. You can read more about the difference between TCM and CCM in this previous blogpost: http://www.acupractitioner21.blogspot.se/2012/08/some-thoughts-on-differences-between.html

Even the acupuncture points on the body create a living, changing landscape, something seen clearly in Nanjing, the Chinese medical classic the Classic of Difficulties. An old way of illustrating this very Daoist view can be borrowed from the Chinese classic the Shanhaijing, the Classic of Mountains and Seas. It was written in the 2nd century BC and is literally a travel-guide to Chinas holy mountains:

Chapter 3. The first mountain range in the Classic of the Northern Mountains, part III, is called Mount Grandwalk. Its first peak is called Mount Goback. There is gold and jade on its summit and green jade on its lower slopes. There is an animal here which looks like an antelope; it has four horns, a horse´s tail, and spurs. Its name is the turner. It is good at wheeling round. When it cries, it calls itself ”hoo-wey.” There is a bird here which looks like a magpie; it has a white body, a scarlet tail, and six feet. Its name is the ardent. It is easily frightened. When it sings it calls itself ”Ben”.
                                                               – Shanhaijing, The Classic of Mountains and Seas, transl. Anne Birrell, Penguin 1999

Our body is like this. Our shen (the conscious awareness that also includes much of our mind, emotions and thoughts) is the sun and moon of that landscape; it will shapes how the flora and fauna inside it becomes, just like the external landscape around us affects it from the outside. (You can read more about the shen, the heart, how to nourish the heart, and chapter 8 of the Neijing here: http://acupractitioner21.blogspot.se/2011/04/heart-channel-and-xinshu-study-of.html and about the pericardium´s role in being the xinbao, the Heart Protector, and how the pericardium helps watch over our heart and shen here: http://acupractitioner21.blogspot.se/2011/04/embracing-emperor-pericardium-channel.html)

This view has always been part of the very core of Chinese medicine. Many people are not even aware of their internal landscape at all beyond that something might feel wrong, that they are uneasy in it or even really dislike it. Very few people ever get the tools to change it and let it evolve to something brighter, more verdant, green and pleasant. Few learn to land in it and relax there, and even just see what it actually looks like. It is a good exercise to do by yourself, just like in the intro to this text. What is your internal landscape like?
In a similar way, the Chinese think of each person as a cosmos in miniature. A person manifests the same patterns as does the painting or the universe. The Yang or Fire aspects of the body are the dynamic and transforming, while the Yin or Water aspects are the more yielding and nourishing. One person projects the heat and quickness of summer Fire; another person resembles the quiescence and coolness of winter Cold; a third replicates heaviness and moistness of Dampness; a fourth has the shrivelled appearance of a dry Chinese autumn; and many people display some aspects of the various seasons simultaneously. Harmony and health are the balanced interplay of these tendencies.

In each person, as in every landscape, there are signs that when balanced, define health or beauty. If the signs are out of balance, the person is ill or the painting is ugly. So the Chinese physician looks at a patient the way a painter looks at a landscape – as a particular arrangement of signs in which the essence of the whole can be seen. The body´s signs, of course, are somewhat different from nature´s signs – including color of face, expression of emotions, sensations of comfort or pain, quality of pulse – but they express the essence of the bodily landscape.”
                     – Chinese Medicine – the Web that has No Weaver, Ted Kaptchuck, Rider 1983

Daoism and Chinese medicine: the Daoist view of internal landscape infusing the Chinese medical one
Daoism, the ancient Chinese spiritual tradition, has given this view and its framework to Chinese medicine. We will look further at examples from the pure Daoists texts a bit later on in this text, but it is interesting to see how much it has shaped Chinese medicine, something visible all through the classical chinese medical texts. Here a quote from Kristofer Schipper, one of the few researchers in the West who actually spent years studying in Taiwan to become a daoshi, a daoist priest, in order to more deeply understand the tradition.
””The human body is the image of a country,” say the Taoists. There they see mountains and rivers, ponds, forests, paths, and barriers, a whole landscape laid out with dwellings, palaces, towers, walls, and gates sheltering a vast population. It is a civilized state, administered by lords and their ministers.

The vision of the human body belongs both to Taoism and to Chinese medicine. The fundamental work of medical theory, the Simple Questions of the Yellow Emperor, describes the body thus: ”The heart functions as the emperor and governs through the shen (”soul”); the lungs are liaison officers who promulgate rules and regulations; the liver is a general and devises strategies.”
                                              – The Taoist Body, Kristofer Schipper, UCP 1993

Chinese medicine is full of these maps making our internal landscape alive with characters and faces we can have good or bad relationships with, depending on how our shen works inside us:
The Yellow Emperor asked: All methods of needling must first have their basis in spirit. The blood, the vessels, the construtive qi, essence, and the spirit are all stored within the five viscera. Therefore, what are vitality (de), qi, life (sheng), essence, spirit, hun, po, the heart-mind (xin), reflection (yi), will (zhi), thought (si), wisdom (zhi) and worry (lu)? Please tell me about these.”
                                         – Jia Yi Jing, Chapter One: Treatise on Essence, Spirit and the Five Viscera. Huang Fumi, Chace and Yang transl. Blue Poppy Press 1990

And the Chinese medical, and Japanese medical, traditions that involve channel palpation – feeling and mapping the changes of the meridians, and how they reflect the balance in our internal landscape – have an even more physical and alive, felt sense, of the body and the shen that inhabits it.
Lei Gong asked: it is stated in the Jinmai that, with respect to needling, a knowledge of the channels and vessels is of foremost importance. Please tell me why this is so.”
                                               – ibid, Chapter One, Book Two: The Twelve Channels, Inclduing their Network Vessels and branches, part 1

(If you want to know more about those skills in Chinese medicine, and how channel palpation and channel therapeutics work, I think you would find it very interesting to read this blogpost that gives an overview of my teacher Dr Wang Juyi´s course in Dublin in 2012, where we look at the subject in some depth: http://acupractitioner21.blogspot.se/2012/07/channel-palpation-and-channel-theory.html.
A two-part article and interview on Dr Wang Juyi and his system will appear in the UK Tai Chi Chuan Magazine beginning February 2013.)
One of my favourite quotes from Dr Wang, from his book, talks beautifully about an acupuncturist´s own relationship with the points he uses to help the patient become healthier – basically a quote of the microcosm instead of The Classic of Mountains and Seas macrocosm.
When I first began studying, I believed that points were just measured places on the body that might be located on a cadaver or in an anatomy text. Also, I believed that all points on the body were roughly the same: that they are all openings between the various structures of the body. Later, I began to appreciate subtle differences among the points. Some have more qi or more blood, some have less. In some places the type of qi is different than in others. Importantly, the exact nature of qi sensation that should be generated from each point varies, and should be varied depending on the desired effect. Each point actually has its own nature or personality. Once I began to truly note these differences among the points on my patientes, I became more and more interested in the classical point categorizations. It is from here that I began my explaration of the source, collateral and five transport points.

In fact, after many years, I now think of many of the points on the body as old friends. I know what they are like, what their strengths and weaknesses are, and when to call on them for help. When you get to know the points in this way, treating in the clinic is kind of like waking good friends from a slumbergently prodding the points to wake them up and send them on their way. Also, as I´ve said before, some of the points are like jacks-of-all-trades, friends that you might call on to help with a wide variety of projects. Other points have very specific strengths and should be used in more specific cases. The points, to me, really do seem to have these different personalities.
                                                    - Extract from Applied Channel Palpation in Chinese Medicine, Wang Juyi´s lectures on Channel Therapeutics, Dr Wang and Jason Robertson, Eastland Press 2008

In Daoist texts there are often even further details in the internal landscape, which in the traditions is part of practical training-techniques done for decades, but they are also usually written in code to prevent outsiders from gaining access to the material or hurting themselves by trying to train it without the prerequisite knowledge and a good teacher. This quote from a text from one of the main schools of Religious Daoism, the Quanzhenpai, talks about the energy center known as the Lower Dantian in the West, and offers a long list of alternative names for it.
1.3 cun (about 3cm) inside the navel is where the primal yang Real qi is stored. The area inside the navel alone within the body is called the Central Palace, the Mansion of Life, the Spiritual Room of Primordial Chaos, the Yellow Court, the Elixir Field, the Cavity of Spirit and Qi, the Orifice for Returning to One´s Roots, the Passage for Restoring One´s Life, the Orifice of Primordial Chaos, the Cavity of 100 Meetings, the Gate of Life, the Spiritual Hearth of the Great One (Taiyi; the North Pole Star), the Original Visage. It has many different names. This place encloses the most exquisite q, which penetrates the 100 blood vessels and nourishes the entire body.”
                                                               – Xianjue Ji, The Teachings and Practices of the Early Quanzhen Taoist Masters, Stephen Eskildsen, SUNY Press 2004

Neijing chapters 12 and 13 and the teachings of changing treatments with place and time
The Neijing – Huangdi Neijing – is the core text of Chinese medicine. It contains huge amounts of information, some of it obvious, some of it hidden and taught only through a trained teacher in an apprentice setting.

The pressure from the outside world on our internal landscape of course changes depending on our surroundings and the time and place we live in. Daoism would factor all this into their studies of bianhua, change, and how it affects us and how we can learn to move more smoothly and freely with it. In Chinese medicine, this should be a deep field of study for the practitioner: how does change in place and time affect the patient, and how can it be treated well?

This is part of chapter 1 of the Neijing and then a recurring theme all throughout.

Two of the chapters that illustrate it further is chapter 12 and 13 of the Neijing; chapter 12, goes through examples of how treatments have to change depending on where people live in the different directions of the compass:

In the Northern district of mostly highland, where the weather is cold, shutting and hiding like winter, the people there live in the mountains and hills and the cold wind often sweeps the frozen land. The local people like to stay in the wilderness to drink the milk of cows and sheep. In this case, their viscera can easily contract cold and the disease of abdominal distension. In treating the disease, moxibustion therapy should be used, thus the moxibustion therapy is transmitted from the North.”
                                         Huangdi Neijing, Yellow Emperor´s Canon of Internal Medicine, translated by Wu and Wu, China Science and Technology Press, 2005

Through this and other examples, the text teaches the idea of adapting treatments depending on the external surroundings of the patient.
Chapter 13 of the Neijing deepens this further into how we must adapt treatments after the time the patient lives in.

The Neijing is a teaching-text built in the same way as a classical apprenticeship in Chinese medicine, with questions from student to teacher, in the text represented by the legendary Yellow Emperor and his adviser Qi Bo. First Qi Bo describes how people in ancient times moved much more with the seasons, kept their hearts pure and didn´t allow their ambitions and hunger to control them. Then he describes the problems people have ”now” and how badly it has gone with people´s health since ancient times. (It´s worth remembering that the text was written about 2200-2300 years ago...)

But the case nowadays is different, people are often affected by anxiety in the heart, and hurt by the toil on the body on the outside, and people are careless and no longer care to follow the natural change of the seasons, nor the coldness and heat of the day. When external influences invade the system, the patient´s viscera and bone marrow will be hurt inside, and the orifices and muscle will be hurt on the outside. If the disease contracted is mild, it will become a serious one; if it is serious, it will surely end in death. Therefore, the disease nowadays cannot be treated simply through nourishing the essence or changing the qi like it used to be.”
                                                                        – Neijing, Wu and Wu, ibid

Chapter 13 then goes on to list examples of how acupuncture doctors in older times were much more precise and careful in their diagnosis and their skill in seeing the shen, the ”spirit” (mind and conscious awareness) of the patient. Often this is translated only as ”complexion”, but it actually means really becoming aware of shen and learning the skill of seeing – feeling, being aware of – its health in both ourselves and in a patient.

In ancient times,” continues Qi Bo to his student, the Yellow Emperor, ”there was a physician whose name was Daiji. He studied the principle of seeing shen and feeling pulse to the degree of making it a heavenly skill; he could connect them to the Five Elements of Metal, Water, Wood, Fire and Earth, the five seasons, Yin and Yang, evil winds of all directions and the three dimensions, not divorcing them from the principle of their mutual change. So, it is important for one to observe the shen and pulse conditions to know the essentials of the disease.”
                                                                        – Neijing, Wu and Wu, ibid

Here we see Qi Bo talking about a very skilled practitioner of Classical Chinese Medicine indeed. The example he extols has trained so deeply himself, and studied diagnostics so well, that he can factor in both the shen of the patient, the pulse, the Five Elements in the patient as well as the Five Elements in the season at the time; Yin and Yang in the patient, the liuxie, the ”six external pathogens” as they are currently translated now, but originally the ”six evils” that affect us from the outside (wind, cold, dampness, dryness, summer heat, fire) and, again, from Chapter 12, the three dimensions, that is the place the patient lives in – and all this, this doctor can analyze from a deep understanding of the bianhua and how it manifests in Chinese medicine, the change that weaves them all together, and make a good diagnosis and treatment that will unfold in the patient and balance their health. This level of skill takes very deep training and continous research for a practitioner to reach. They first have to become very aware of all these in themselves and study them there, before being able to fully understand how it can affect the patient sitting in front of them. This is one reason that the Daoists who also worked as acupuncture doctors used qigong- and meditation-practice so much themselves.

We are going to look more into a specific affect of time further on in this text, with Dr Wang Juyi´s comment about Jueyin, the deepest yin in our system, and how living in our time affects it.

Geography in depth in the body: levels of depth in acupuncture treatment and in the Shanghan Lun

Another part of our internal landscape is the manifestation of it in physical depth in our body. Daoist practices teach that the deeper in our system we feel, the deeper levels of our emotions, mind and psyche we also activate and access, which is the reason that any qigong- or meditation-practices working on this should be taught in quite careful stages over a very long time. Speeding that process up usually creates an unstable system within the practitioner, which is one of many reasons to look for a skilled teacher one can have long-time contact with.

In Chinese medicine, there is something called the Six Levels. They are written about in the Neijing, but really reach an apex in the Chinese medical classic called the Shanghan Lun, the Classic of Febrile Disease caused by Cold. The Shanghan Lun was written in the 200´s by legendary doctor Zhang Zhongjing. The Six Levels themselves give a geography in depth of the body and mind of a patient and of the practitioner: each level is linked to two meridian systems at that depth, and their corresponding organs and emotions, and the way they help our internal landscape interact with our external one.

The first one is Taiyang, Ultimate Yang, which covers the huge area of the entire back of our body and the meridians of the Bladder and Small Intestine and their respective organs, functions, and links to our emotions and mind. Then it continues deeper by stages, all the way to Jueyin, Ultimate Yin, deepest yin, the deepest levels of blood and stillness and healing in us, which are linked to the Liver and Pericardium.
The Shanghan Lun is the root of what is now one of the main herbal traditions of Chinese medicine, since the book is primarily focused on herbal medicine in a specific form. Zhang Zhongjing wrote down diagnostics and treatments not only for each level, but also very detailed for how far it has moved in that level itself.

Clause 1-4: During the first day of febrile disease caused by Cold, the syndrome is at the Taiyang Channel. If the pulse is quiet, the syndrome is not transmitting into the next channel. When the patient is restless and nauseated, and the pulse is speedy and mighty, then the syndrome is transmitting.”
                                                            – Shanghan Lun, Zhang Zhongjing, New World Press 2007, transl. Luo Xiwen

The Shanghan Lun was later split up, and what became the second book is called the Jingguyi Yaolue, Synopsis of Prescriptions of the Golden Chamber, often less studied than what is known as the Shanghan Lun today. In the video below, Dr Arnaud Versluys also adds that the Shanghan Lun was meant to begin with external factors affecting us, and the second part of the book, before they got separated, was intended to cover internal conditions that affect us, thus giving a complete overview.

One should carefully protect one´s Body Resistance and avoid the attack of climatic pathogenic factors. Otherwise, channels and collaterals will be violated and health endangered. In case pathogenic factors have invaded the channels and collaterals, medical treatment should be given in time to stop the transmission of pathogenic factors into the viscera and bowels.”
                                        – Jingui Yaolue, Synopsis of Prescriptions of the Golden Chamber, Zhang Zhongjing, transl. Luo Xiwen, New World Press 2007

For those of you interested in learning a little bit more about Zhang´s views and his tradition, I can recommend watching this video of Arnaud Versluys, one of the most famous exponents of the Shanghan Lun tradition in the West in our time. In this video he describes the historical background around the Shanghan Lun and helps give a basic view of how it thinks.

The Six Levels help us understand how problems and illnesses can begin at different levels in us, and how they can progress to become worse the deeper they go. For a practitioner, it should help us understand how to find out what level the patient´s problem is, and how to treat that and gently allow the system to open up instead of trying to attack deeply into it to fix ”the problem” we perceive being there. (You can read a blogpost about why awareness is so important in acupuncture and Chinese medicine diagnostics here: http://acupractitioner21.blogspot.se/2011/05/chinese-medicine-and-awareness-demand.html)

Dr Wang Juyi and Jueyin, the deepest yin in our system, and how our time affects it
The character for Jue has an interesting construction. The outside of this character comes from the obsolete character han, a partial enclosure that means cliff, as on the side of a mountain. The inside of the character is a variant of the commonly used que, which usually means lacking, but can also mean vacant or an opening. The character jue therefore suggests an opening or vacancy on the side of a mountain. It is a place of absolute stillness and retreat from which one begins the process of ”reverting” back to Yang. Recall the Daoist influence on Chinese medicine, and it is not difficult to imagine the adepts of a thousand years past retreating into their caves in the mountains. This is a helpful image for jue yin, but is at odds, in some respects, with a commonly held belief by many modern practitioners who think of jue yin as a moving cauldron of emotions. Of course, for many modern patients, the cave of retreat may in fact be filled with just such chaos! In such cases, yin and blood will not have a place for restoration.” 
                                                                               – Robertson and Wang, ibid.
Jueyin is the deepest level of the primary meridian system, the deepest of the Six Levels, the place for deepest yin, stillness and healing. Or should be. Like Dr Wang says, in our time, that is very rarely the case. For many Westerners, that cave of stillness and healing in us has become a McDonald´s restaurant on Sunday lunch, with added disco-ball above and loud cell-phone conversation in our ear on a phone that keeps beeping with new texts at the same time.

This can be changed to the better.

It is fully possible to begin a healing process and change this to become calmer, healthier, more quiet, and a place more of healing again. Simple meditation-practices help with this, of course, but a good acupuncturist will be able to help you begin and stabilize that process a lot. It is often easier to do with the help from someone on the outside, in the beginning. You can read more about what healing can mean, and how we get a framework for understanding it, in this blogpost: http://acupractitioner21.blogspot.se/2012/04/acupuncture-and-how-we-can-heal-healing.html

And speaking of that cliffside enclosure, that hermitage, that deep still place, here is a poem from a Daoist tradition, the Quanzhenpai, one of the main schools of Religious Daoism in China today. It helps give a feeling of that stillness, but it´s also interesting since the author, Ma Yu, is more known as a legendary Chinese doctor under his name Ma Danyang and for his sequence of acupuncture points, Ma Danyang´s Star Points. Ma was the first generation disciple to Wang Zhe (”Lunatic Wang”), who founded the Quanzhen school.

Living in the Hut
Even though I have no fire in the winter, I embrace the primal yang.
In summer I cut myself off from the clear spring water, but I drink the jade juice.
Wax candles I do not burn, but I make bright the candle of my Nature.
Garoo wood incense I have no use for, since I can burn my heart´s incense .

Three years barefoot, my vow of three years.
My one aspiration is toward the blue skies, and this one aspiration grows.
The mountain fool who keeps mourning is in his hut.
He still has done nothing to repay the Lunatic Wang.

                                                             – Ma Yu (Ma Danyang), Eskildsen, ibid.

Summing up: our internal landscape and beliefs, how we believe it ”is” or ”must” be
What kind of landscape do you want to be?

Is the landscape inside you something you are comfortable with? Something you like and can relax into?

If we want, we can change it. Many people have a belief that their internal landscape cannot be changed, cannot heal, cannot become more whole again. But it is fully possible to do this, and to feel so much happier with who we are inside.

In China, the saying is yi bu yi bu lai, one step at a time will get you there. Whatever we want to change, we begin where we are right now. It is a huge thing to want to change to the better: after that, we simply take one step at a time to change our internal landscape into something more alive, relaxed, green, filled with flowers, sunlight, moonlight, and the stars of clear summer nights.
What kind of landscape do you want to be?

Daniel Skyle © 2013