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Clinical Point Selection,
Week 1CAM: 373-397Page 2 of Handouts
Lorraine Wilcox L.Ac.
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Before we turn to CAM, a littlereview...
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What causes illness?
• External factors: evils- wind, cold, fire (heat),dampness, dryness,
and summerheat. If notexpelled, they cancause internaldamage, or sometimes
they directly hit theinternal organs.
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What causes illness?
• Internal factors:emotions such as anger,
joy, thinking too much,
anxiety, sadness, fear,and fright. Thesedirectly affect the organsand movement of qi (theqi mechanism ).
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The Qi Mechanism (氣機 qi ji)
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What causes illness?
• Neither-external-nor-internal factors: diet,
exercise/activity/work,rest, sex, trauma, etc.These easily affect the
organs.
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What causes illness?
• Pathologically formed evils are
produced when there is imbalance, andthey cause further pathology: blood stasis,qi stagnation, food stagnation, phlegm,turbid fluids (rheum), internally generatedwind, heat, cold, dampness, etc.
• Constitutional issues.
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辯證 Pattern Identification
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Pattern Identification
• Pattern identification is identifying the
basic disharmony behind a set of clinicalmanifestations.
• The four examinations are used. Then thediagnostic information is classified. Allsigns and symptoms must be taken into
account.• Looking for relationships is more important
than looking for causes.
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Pattern Identification
Pattern (証 or證 zheng4): This refers to the
whole pattern of the symptoms or signsthat manifest at one point in time. It is thecomplete picture.
• In some cases, the pattern is the cause ofdisease (for example, exterior invasion of
wind-cold) but not necessarily: kidney yinvacuity may be caused by aging orlifestyle.
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The pattern itself lets us understand the cause or
the root, the location and nature of the disease,and the circumstances of the evil and the right qi.
It also implies the treatment principle.
with dampnessvacuityqispleen
evil qiright qisubstancelocation
• Treatment principle: Supplement spleen qi,transform dampness.
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Pattern IdentificationSymptom/sign (症 zheng4): any
manifestation, symptom, or sign, such asfever, cough, shortness or breath,abdominal pain, or diarrhea.
• A symptom has little diagnostic value on itsown. Diarrhea could be due to damp-heat,cold-damp, spleen qi vacuity, spleen yangvacuity, or spleen and kidney yang vacuity.
• The symptom of diarrhea cannot be treatedwithout understanding it within its context orpattern.
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症 versus証
(both pronounced zheng4)
• In many cases in Chinese language,症
(here, symptom/sign) and証 (here, pattern)are interchangeable, but in medicine, thereis a difference.
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Pattern IdentificationDisease (病 bing4): There are two types of
disease. – A Western disease is something like hypertension,multiple sclerosis, or hepatitis B.
– Chinese medicine also has the concept of disease.There are traditional names of diseases, for example,painful periods, cough, headache, constipation.Perhaps you could generally think of this as the chiefcomplaint, but sometimes it is not. A patient maycome in complaining of infertility (a Chinese disease),
but you may find that they also suffer from painfulperiods and constipation (which are also Chinesediseases). Chinese ‘diseases’ are often consideredsymptoms by Western medicine.
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Pattern Identification• Different individuals may have different patterns
for the same Chinese disease, or one individualmay have different patterns over the course of
the same disease.
indigestionkidney vacuity
painful periodscold in the uteruspre-menstrual irritabilityLiver qi
depression
liver blood stasisPainful
periods
異病同治。Different diseases have the same
treatment.
同病異治。The same disease has
different treatments.
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Pattern Identification• Only certain patterns are possible for each
Chinese disease. Therefore, whether or not youknow the name of the Western disease, take the
main clinical symptoms and find the
corresponding Chinese disease or diseases.Then check which patterns are possible andfocus your questioning on confirming or denying
these patterns.• If more than one disease manifests, look first for
one pattern that covers more than one of these
diseases.
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Pattern Identification• We can combine disease differentiation
and pattern differentiation for preciseassessment of disease.
– A disease name summarizes thecharacteristics or symptoms of a disease.
– A pattern name integrates the nature, cause,and location of the disease.
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Pattern Identification• The most common type of pattern
identification in the style called TCM isorgan pattern identification .
• This combines:
– qi, blood, and body fluid patterns – pathogenic factor (evil) patterns
– eight principles patterns
– the physiological and pathological workings ofthe five viscera and six bowels
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organ pattern identification
with dampnessvacuityqispleen
pathogenicfactor (evil)patterns
eightprinciplespatterns
qi, blood,fluidpatterns
zang-fu patterns
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Pattern Identification• Because it focuses on the organs, it is most
useful for interior patterns, although a fewexterior patterns are included, especially for thelungs.
• Pattern identification for exterior conditions ismore detailed in: – pathogenic factor (evil) patterns
– six channel patterns (cold damage)
– four levels patterns (warm disease) – triple burner patterns
– channel patterns
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Pattern Identification• Here are some important points regarding organ
pattern identification:
– It is important to understand the mechanisms ofdisease and the relationships of the organs. Youcannot simply memorize a list of signs and symptoms.
– Not all signs or symptoms are necessary to receive adiagnosis. A mild case will have fewer signs andsymptoms.
– Many times patients have a combination of more thanone pattern, but look for relationships between thevarious patterns a patient has. Look for the traditional
combination patterns, such as vacuity of heart andkidneys. – The points listed to treat a pattern are only examples.
There are many other possibilities.
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Chinese medicine is
philosophical
Don’t forget
• Holism: Be aware of the interaction of a personwith their environment (right versus evil, forexample), and internal interactions (between
organs and other aspects) within a person. – The unity of heaven and man: Heaven and earth are
a big Tai Ji ; the human body is a small Tai Ji .
– The relationship of the patient with time (day/night,four seasons, phase of the month) and space(geography, climate, weather, environment)
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Chinese medicine is
philosophical
Don’t forget
• The inseparability of body and spirit
• You can examine the exterior to know the
state of the interior.• The dynamics of change: Everything in the
universe and in the body is continuously
moving and changing. Dynamic balance.
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General principles of treatment治療總則治療總則治療總則治療總則 CAM: 373-397
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1.調整陰陽
Regulation of yin and yang
Disease means yin andyang are not balanced.
Ling Shu , Chapter 5 says:
How to regulate yin andyang is most importantin acupuncture
treatment.
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Yin-Yang Balance is Health
yinyang
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Imbalance: yang repletion (hot)
yin
excessive yang:
drain it
yang
Excessive yang willeventually damage yin.
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Excessive yang damages yin
yin
insufficient yin:
nourish it
excessive yang:
drain it
yang
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Imbalance: yin repletion (cold)
excessive yin:
drain it
yin
yang
Excessive yin willeventually damageyang.
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Excessive yin damages yang
drain it
yang
insufficient yang:
fortify it
excessive yin:
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Imbalance: yin vacuity (hot)
yin
yang insufficient yin:
nourish it
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Imbalance: yang vacuity (cold)
yin
yang
insufficient yang:
fortify it
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Su Wen , Chapter 5: Treat yin for problems
in yang; treat yang for problems in yin.
• For example:
– back shu points (yang) are more frequentlyused to treat the viscera (zang – yin organs).
– mu alarm points (yin) are more frequently
used to treat the bowels (fu – yang organs).
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2.扶正祛邪 Strengthening right qi
and eliminating evils• Right qi (or righteous or upright qi): [正氣
zheng4 qi4] the sum of all healthy qi and otherhealth-promoting substances in the body:
‘antipathogenic factor.’ Supplement it. It will
prevent evils from taking hold.• Evil qi [邪氣 xie2 qi4]: Qi, mostly from the
weather, that can cause disease: ‘pathogenic
factors.’ Evils can also arise internally. Drain it. Itwill allow right qi to regain strength.
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Right Versus EvilDisease is a struggle between right versus evils
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2. Strengthening right qi and
eliminating evils• Should we strengthen the right? (In chronic
conditions, treat the root. In this case, root usually means the body’s right qi.)
• Should we drain the evil? (In acute conditions,treat the branch. In this case, branch usually
means the evil qi.)• Should we do both simultaneously? (In most
cases we can, but be aware of which points are
strengthening the right and which are drainingthe evil, and use the correct technique on eachpoint.)
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2. Strengthening right qi and
eliminating evils
• If a very weak patient has an evil,
sometimes you cannot attack the evilwithout killing the patient. In that casesupplement first and attack the evils when
the patient is stronger.
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3.分別標本
Distinguishing root and branch治病必求于本。
《素問·陰陽應象大論》To treat disease, seek its root.
Elementary Questions ,Chapter 5 (Warring StatesPeriod)
• CAM calls this primary (本ben root) and secondary (標biao branch).
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Root and Branch
Examples:
• If insufficient spleen qi leads to bleeding,spleen qi vacuity is the root and bleedingis the branch.
• Liver yin vacuity (root) can lead to liveryang rising (branch). Liver yang rising
(root) can lead to liver wind (branch).
If t t th t ll th t ill l Th
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If you treat the root, all the symptoms will resolve. Thesymptoms are like bowling pins. You don’t want to knock
them down one by one.If you hit the kingpin just right, you will knock down all thepins with one ball. This is treating the root.
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Root and Branch • 急則治標。Usually translated as, “In acute
conditions, treat the branch.”• 緩則治本。Usually translated as, “In chronic
conditions, treat the root.”
– 急 (ji2): acute, urgent, tense, quick,
– 緩 (huan3): chronic, slack, slow, gradual, moderate,
mild.
4 因時 因地 因人制宜
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4.因時、因地、因人制宜
Treatment of disease according to climate,season, location, and individualTreat according to the
season and weather:
• In the summer, you arelikely to use lessmoxibustion and will usefewer warming herbs.
• Also the qi flowsdifferently through theseasons, for example, inthe summer qi flows moresuperficially.
• Diet and lifestyle shouldvary with climate andseason.
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Treatment of disease according to climate,
season, location, and individual
• Treat according to the
place: here in LosAngeles there is less
cold and dampness,and more dryness andheat.
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Treatment of disease according to climate,
season, location, and individual
• Treat according to the individual (age,
sex, constitution): Herb formulas and pointformulas can be adjusted for the conditionof the patient. This gives better results
than using an unmodified formula.
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1. SupplementingTreats vacuity patterns
• Example acupuncture techniques: emphasis onclockwise or thrust. Close the point.
• Supplement kidney qi or yang: Shen Shu (UB
23), Guan Yuan (Ren 4), Tai Xi (KI 3) usingsupplementing hand technique or moxibustion.
• Nourish kidney yin: Tai Xi (KI 3), Zhao Hai (KI 6),
Zhi Shi (UB 52) using supplementing handtechnique.
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1. Supplementing• Supplement spleen-stomach qi: Zhong Wan
(Ren 12), Qi Hai (Ren 6), Zu San Li (ST 36)using supplementing hand technique ormoxibustion.
• Replenish qi-blood: Pi Shu (UB 20), Ge Shu (UB
17), Zu San Li (ST 36), San Yin Jiao (SP 6)using supplementing hand technique ormoxibustion.
• Do not supplement if evils are strong, or ifexternal evils are not yet eliminated.
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2. DrainingTreats patterns with evils and accumulations
• Example acupuncture techniques: emphasis oncounterclockwise or lift. Leave the point open.
• Dispel wind, release the exterior: Drain Feng Chi(GB 20), He Gu (LI 4).
• Induce a bowel movement to drain heat: drainQu Chi (LI 11), Tian Shu (ST 25), Feng Long(ST 40).
• Bleed related points to resolve blood stasis.• Do not drain vacuity.
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3. WarmingTreats cold patterns, warms the channels,
removes blockage, fortifies yang.
• Use moxibustion or long needle retention.
• Warm the middle jiao : moxibustion or longretention on Zhong Wan (Ren 12) and Zu San Li(ST 36).
• Collapse of yang: moxibustion on Guan Yuan(Ren 4) and She Que (Ren 8).
• Do not use for heat conditions; caution in yinvacuity.
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4. ClearingFor heat patterns. Always implies clearing heat.
• Use draining technique or let blood. Shortneedle retention.
• Heat evils: Drain Da Zhui (Du 14), Qu Chi (LI
11), He Gu (LI 4).• Heat in the organs: drain related well points or
spring points.
• Resuscitation due to heat: drain or let blood atthe hand well points or Ren Zhong (Du 26).
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5. Ascending• Raises yang and lifts what has sunken: for
prolapse, chronic loose stool, lack ofnourishment to the head and sense organs.
• Supplement and use moxibustion on points such
as Bai Hui (Du 20), Qi Hai (Ren 6), Guan Yuan(Ren 4), Zu San Li (ST 36).
• Do not use with yin vacuity and hyperactive
yang.
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6. Descending• Subdues yang, wind, fire, or counterflow.
• Descend stomach qi: even technique onTan Zhong (Ren 17), Zhong Wan (Ren12), Nei Guan (PC 6), Zu San Li (ST 36).
• Subdue the liver: drain Feng Chi (GB 20),Tai Chong (LV 3), Yong Quan (KI 1).
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Basic principles forprescription andselection of points
Basic principles for prescription
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Basic principles for prescription
and selection of points1. Acupuncture Prescriptions: Treatment
plan (different than treatment principle):point selection, hand technique, number ofpoints, etc.
2. Principles for point selection: local,adjacent, and distal points, symptomaticpoints
For acupuncture-moxibustion
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For acupuncture-moxibustion,
choose:• Local points: the address on the envelope. If
you do not also use distal points, this is likesending an empty envelope. It will get there, but
there is no message inside. Local points oftentreat the branch. These are like the guiding herbin a formula; they take the effect of the pointformula to the affected site.
• Distal points: the message in the envelope.These are often points to treat the root, orrelated to the affected site by channel pathway.
Local points: the address on the envelope
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Local points: the address on the envelope
Distal points: the message in the envelope
For acupuncture-moxibustion
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For acupuncture moxibustion,
choose:• Modality: Acupuncture, moxibustion, cupping,
bleeding, etc. Each one gives a different
message. Which modality will you use on eachpoint?
• Technique: Drain or supplement? Direct orindirect moxibustion? etc. Each one gives adifferent message. Which technique will you useon each point? Some points may need to besupplemented and others drained within thesame treatment.
• Balance: Look at the overall treatment. Is itbalanced for this patient? Is it balanced overall?
Local Adjacent and Distal
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Local, Adjacent, and Distal
Points (examples)
聽會 GB 2,
翳風 SJ 17風池 GB 20
中渚 SJ 3,
俠溪 GB 43Ear
地倉 ST 4,
頰車 ST 6顴髎 SI 18
合谷 LI 4,
解溪 ST 41Mouth, cheek
迎香 LI 20上星 Du 23列缺 LU 7,
厲兌 ST 45Nose
睛明 UB 1目窗 GB 16養老 SI 6,
太沖 LV 3Eye
天柱 UB 10大椎 Du 14后溪 SI 3,
昆侖 UB 60Nape
太陽 Tai Yang ,
率谷 GB 8風池 GB 20
外関 SJ 5,
足臨泣 GB 41Temples
陽白 GB 14百會 Du 20合谷 LI 4,
內庭 ST 44
Forehead
LocalAdjacentDistalRegion
Local, Adjacent, and Distal
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Local, Adjacent, and Distal
Points (examples)
長強 Du 1白環俞 UB 30承山 UB 57Rectum
腎俞 UB 23,
大腸俞 UB 25次髎 UB 32
委中 UB 40,
后溪 SI 3Low back
関元 Ren 4天樞 ST 25
三陰交 SP 6,
曲泉 LV 8
Lower
abdomen
中脘 Ren 12梁門 ST 21内関 PC 6,
足三里 ST 36
Upper
abdomen
期門LV 14
章門LV 13
支溝 SJ 6,
陽陵泉 GB 34Rib-sides
膻中 Ren 17中府 LU 1内関 PC 6,
豐隆 ST 40Chest
廉泉 Ren 23,
天容 SI 17天柱 UB 10
魚際 LU 10,
照海 KI 6Throat
LocalAdjacentDistalRegion
Point Formulas for Symptoms
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Point Formulas for Symptoms
(examples)
膻中 Ren 17,内関 PC 6Sensation of suffocation in the chest天突 Ren 22,定喘 Ding ChuanCough, asthma
下關 ST 7,頰車 ST 6,合谷 LI 4Clenched jaws
后溪 SI 3,陰郤 HT 6Night sweating
人中 Du 26,十宣 Shi XuanComa
大椎 Du 14,合谷 LI 4,曲池 LI 11Fever
FormulaSymptom
Point Formulas for Symptoms
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Point Formulas for Symptoms
(examples)
二白 Er Bai (moxibustion)Bleeding hemorrhoids
四縫 Si Feng (prick)Digestive problems in children
上星 Du 23,合谷 LI 4Epistaxis合谷 LI 4,太沖 LV 3Convulsions
支溝 SJ 6,照海 KI 6Constipation
氣海 Qi Hai,足三里 ST 36Abdominal distention
支溝 SJ 6,陽陵泉 GB 34Rib-side pain
内関 PC 6,郤門 PC 4Cardiac pain
FormulaSymptom
The Five Shu (Transport) Points
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五腧穴
diseases of the bowels(use lower he sea),
bleeding
disease in thestomach from
irregular eating
counterflow qi, diarrhea(mostly related to the
yang organs)
He Sea (yinwater, yang
earth)
changes in the voicecough, dyspnea, chillsand fever
Jing River(yin metal,
yang fire)
intermittent orprolonged disease(eight treat malaria)
heaviness in the body,painful joints
Shu Stream(yin earth,yang wood)
changes in color(complexion)
heat in the bodyYing spring(yin fire,yang water)
clear heat, openorifices, other end of
channel, spiritdisorders
disease in the
viscera (yin organs)
fullness below the heart
(treats the chest ingeneral)
Jing well
(yin wood,yang metal)
OtherLingshu 44Nanjing 68Point
The Five Shu Points and their
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e e o ts a d t e
Corresponding Element
EarthWaterHe Sea
FireMetalJing River
WoodEarthShu Stream
WaterFireYing spring
MetalWoodJing well
Element on YangChannels
Element on YinChannels
Category
Application of specific points
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pp p p
(point categories)
PC3PC5PC7-PC8PC9+Pericardium
KI10KI7+KI3KI2KI1-Kidneys
LU5-LU8LU9+LU10LU11Lungs
SP9SP5-SP3SP2+SP1Spleen
HT3HT4HT7-HT8HT9+Heart
LV8+LV4LV3LV2-LV1Liver
He Sea
Water
Jing River
Metal
Shu Stream
Earth
Ying Spring
Fire
Jing Well
Wood
Point
Element
五腧穴 The Five Shu Points of the Yin Channels
五腧穴 The Five Shu Points
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腧穴
of the Yang Channels
UB39SJ10-SJ6SJ3+SJ2SJ1San Jiao
UB40UB40UB60UB65-UB66UB67+Bladder
ST37LI11+LI5LI3LI2-LI1Large
Intestine
ST36ST36ST41+ST43ST44ST45-Stomach
ST39SI8-SI5SI3+SI2SI1Small
Intestine
GB34GB34GB38-GB41GB43+GB44Gallbladder
Lower
He
Sea
He
Sea
Earth
Jing
River
Fire
Shu
Stream
Wood
Ying
Spring
Water
Jing
Well
Metal
Point
Element
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Nan Jing 69《難經》 says:• 虛者補其母。 In vacuity, supplement the
mother point or channel.• 實者瀉其子。 In repletion, disperse the
child point or channel.
原穴 絡穴 Yuan Luo
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原穴、絡穴 Yuanand
LuoPoints
虛里 xuliGreat luo of
stomachSP21
Great luo of
spleen
Du1DuRen15Ren
SJ5SJ4San JiaoPC6PC7Pericardium
UB58UB64BladderKI4KI3Kidneys
LI6LI4Large IntestineLU7LU9Lungs
ST40ST42StomachSP4SP3Spleen
SI7SI4Small IntestineHT5HT7Heart
GB37GB40GallbladderLV5LV3Liver
LuoYuanChannelLuoYuanChannel
Yang ChannelsYin Channels
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Application of specific points
Ren3UB28Urinary BladderLV6Liver
Ren4UB27Small IntestineGB36Gall Bladder
ST25UB25Large IntestineSJ7San Jiao
GB25UB23KidneysPC4Pericardium
Ren5UB22San JiaoKI5Kidney
Ren12UB21StomachUB63Urinary Bladder
LV13UB20SpleenSI6Small Intestine
GB24UB19Gall BladderHT6Heart
LV14UB18LiverSP8Spleen
Ren14UB15HeartST34Stomach
Ren17UB14PericardiumLI7Large Intestine
LU1UB13LungsLU6Lung
Mu PointShu PointOrganPointChannel
背腧、募穴 Back Shu and Mu Alarm Points郄穴 Xi Cleft Points
Xi Cleft Points of the
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Eight Extraordinary Vessels
KI9Yin weiKI8Yin qiao
GB35Yang weiUB59Yang qiao
八脈交會穴 Eight Extraordinary Vessels
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Confluence Point Combinations
chest, heart, stomachPC6Yin weiSP4Chong
outer canthus, behind the ear, cheek,
neck, shoulder, diaphragmSJ5Yang weiGB41Dai
lung system, throat, chest, diaphragmKI6Yin qiaoLU7Ren
inner canthus, nape, ear, shoulder, back UB62Yang qiaoSI3Du
To treat diseases of Combine
八會穴 Eight Meeting
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(Influential) Points
GB39Marrow
UB11Bone
LU9Vessels/Pulse
GB34Sinews
UB17Blood
Ren17Qi
Ren12 (also stomach’s mu point)Fu (bowels, yang organs)
LV13 (also spleen’s mu point)Zang (viscera, yin organs)
交會穴
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交會穴Crossing Points
• Too many to make a table here.
• See CAM, 3rd edition, page 393-7