JOURNAL OF CHINESE MEDICINE NUMBER 58 SEPTEMBER 1998

PRICKING THE COLLATERALS

UNDERLYING PRINCIPLES AND USE IN RECALCITRANT DISEASES
by Xie Ke-Rong & Zheng Liang-Xi
The method of pricking the collaterals has a wide clinical application and is especially useful in treating some recalcitrant and otherwise difficult to understand diseases. While sometimes used as a synonym for bleeding, pricking the collaterals utilises the physiological functions of the collaterals in order to treat diseases. For this reason we will first briefly introduce the underlying principles of this form of treatment before giving a few illustrative examples from our own practices. strengthens the exterior-interior relationship between the yin-yang related channels and organs. This serves to help keep them in balance. In addition, they also act to strengthen the relationship between the organs and the body surface. This is done through the intermediary of the primary channels. As the collaterals are relatively fine and are widely distributed, they serve as one pathway by which the qi and blood come to the body surface and pervade, moisten, and nourish the structures there.

Principles behind Collateral-pricking

The principle pathology behind diseases that are treated successfully by pricking the collaterals is stated in the adage blood collaterals are diseased and obstructed. The word collaterals (luo) in Chinese has the sense of a network, hence it is sometimes translated into English as network vessels or reticular vessels. The collaterals are branches of the primary channels and vessels that are relatively thin and small and criss-cross over the entire body. The fourteen primary channels each have a collateral; in addition, the Spleen is connected to the great collateral for a total of fifteen collaterals. Branching off from the collaterals are the even smaller minute collaterals (sun luo) while the collateral vessels of the skin or exterior of the body are called floating collaterals (fou luo). These concepts go back to the Inner Classic (Nei jing). For example, chapter 17 of the Divine Pivot (Ling shu) states, The channel vessels constitute the interior: the branches that go transversely are the collaterals; those which separate from the collaterals are the minute [collaterals]. By permeating through the various types of collaterals, the qi from the channels spreads out throughout the entire body, with the greatest spread over the surface. This is stated in chapter 10 of the Divine Pivot, That which floats and is commonly seen of the various vessels is always the collateral vessels. This shows that the collaterals are easily accessible from the surface.

Collateral Pathology
The collaterals interpenetrate internally with the organs and channels while they have an external connection with the muscles, interstices and pores, and skin. This puts them in an intermediate position and makes them vulnerable to insult from any disease process from any source. Internally generated diseases secondary to emotional upset or externally-contracted diseases from pathogenic influences can both cause pathological changes of the collaterals. One way of conceptualising the place of the collaterals in the transmission of disease is given in chapter 56 of the Basic Questions (Su wen). The initial generation of the hundred diseases must be in the skin and body hair ... When a pathogen resides in the skin the interstices and pores open. When these open the pathogen enters and resides in the collateral vessels. When the collaterals are full, [the pathogen] pours into the channel vessels and when the channel vessels are full, it then enters into and settles in the organs. This passage identifies the collaterals as an important pathway for the transmission of externally-contracted pathogens into the interior. Pathological changes of the collaterals are almost always seen when a disease goes from the outside inwards. The collaterals also serve as a pathway for diseases going in the opposite direction. Chapter 10 of the Divine Pivot states, When there is cold in the midst of the Stomach, the collaterals in the thenar eminence are mostly dark (qing). When there is heat in the midst of the Stomach the collaterals at the border of the thenar eminence are mostly dark red. (chi). This is an important concept that is

Synopsis of Collateral Physiology & Pathology

One function of the collaterals is to serve as a conduit which

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commonly used clinically. Another passage that discusses the expression of pathogens from the interior towards the exterior is found in chapter 39 of the Divine Pivot, When yin and yang [pathogens] coalesce and form painful obstruction, this is overflowing internally into the channels and pouring externally into the collaterals. In addition to this, diseases can be transmitted from one organ to another via the collaterals. The collaterals are an important pathway for such processes as Lung diseases being transmitted below to the Large Intestine, Liver diseases being transmitted to the Spleen, and heat moving from the Heart to the Small Intestine. As such the collaterals serve as a link in both the development of disease and its transmission. When a pathogenic influence invades the body or there is a dysfunction of an organ leading to constraint and stagnation of qi and blood and pathological changes of the channels, the collaterals themselves can also manifest related obstruction and problems. This makes them an important link in the process. This concept is very useful therapeutically as bleeding these diseased and obstructed collaterals can lead to relatively rapid results of eliminating the pathogen while regulating and restoring the normal functions of the organs, qi and blood. The application of bleeding as the preferred method for treating collateral problems goes back at least to the Inner Classic. For example, it states in chapter 62 of the Basic Questions The five yin organs therefore together with the yang organs make an exterior-interior [pair] and have the channels and collaterals as their offshoots. Each of them can generate deficiency and excess. Depending on where the disease is, follow and regulate [that part]. When the disease is in the vessels, regulate the blood; when the disease is in the blood, regulate the collaterals. Furthermore in chapter 29 of the Basic Questions it states, For diseases of the minute collaterals, treat the minute collaterals by bleeding. In both these passages, bleeding is the preferred method for treating collateral disorders because obstruction of blood in the collaterals is the problem. The above gives the rationale for the wide clinical use of pricking the collaterals. This method is fast and effective, especially for some diseases that are otherwise difficult to treat. Below we will give four cases from our own experiences as examples.

come for treatment. He complained of variable dizziness and light-headedness and tremors of the limbs, especially the extremities of the upper limbs. This became worse when he was upset or agitated. In addition, he had feelings of focal distention and fullness in the chest and epigastrium. He had profuse sputum and was drooling saliva. His tongue was dark purple with a white, greasy coating. His pulse was choppy (se). Diagnosis: Parkinsons disease. Pattern: Blood stasis with phlegm obstruction. Treatment principle: Dispel blood stasis, transform phlegm, and stop tremors. Areas used: the scalp lines used were the vertex-to-temporal line (bilaterally) and Qianding DU-21 to Shenting DU-24 (see Figure 1); also the lines along the phalangeal courses of the three arm yang channels. Technique: A sterilised pyramid needle was used to go along the above lines and prick the surface in order to bleed a few drops. Supplementary points: Fengchi GB-20, Taichong LIV-3, Yanglingquan GB-34 [drain]; Zusanli ST-36, Fenglong ST-40 [even]. Treatment was given daily. After six treatment sessions, the patient reported a significant decrease in upper limb tremors and dizziness. After twelve treatments the upper limb tremors were essentially gone, the head and eyes felt clear, and there was a marked decrease in the sputum, saliva and epigastric distention. As the patient needed to return to Taiwan at this time, he was counselled to continue treatment along the same lines and to take a modified version of Warm the Gallbladder Decoction (wen dan tang) with Dan Shen (Radix Salviae Miltiorrhizae), Di Long (Lumbricus), Chuan Xiong (Radix Ligustici Wallichii) and Ji Xue Teng (Radix et Caulis Jixueteng). In a letter from the patient six months later, he stated that none of the above symptoms had recurred and that his condition had stabilised. Comment: The basic pathology for this condition was phlegm obstruction leading to blood stasis with the result that the

vertex to temporal line

Qianding DU-21 Shenting DU-24

Case examples
Case 1 Male, 62 year-old businessman from Taiwan. First visit 16 April, 1990. This patient has a history of Parkinsons disease for three years. He has sought treatment in Taiwan, Japan, and the United States. Treatments have included biomedical pharmaceuticals, Chinese herbal medicine and acupuncture all without significant improvement. Recently, the slowness of movement in the upper limbs has progressed and he has gradually developed dizziness. He had come on business to Sichuan and took the opportunity to

Xuanli GB-6 Figure 1

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JOURNAL OF CHINESE MEDICINE NUMBER 58 SEPTEMBER 1998

collaterals were obstructed and the sinews and vessels lost their nourishment. This gave rise to abnormal movement from wind. This diagnosis came not only from the presentation, which was clearly one of blood stasis and phlegm, but from the fact that treatments based on other diagnoses had not been helpful. Emphasis was placed on pricking the collaterals through the scalp needling as this is a particularly effective means of eliminating blood stasis, unblocking the collaterals, and reviving the brain. Bleeding along the phalangeal courses of the arm yang channels along with needling points along the leg terminal yin (jueyin) and lesser yang (shaoyang) channels were used primarily to extinguish wind and stop tremors. The leg yang brightness (yangming) channel points were used to strengthen the Spleen and Stomach in order to dispel phlegm and turbidity. Used together these points got rid of blood stasis and phlegm while unblocking the channels. Once the channels were unblocked, the wind and resultant tremors stopped. Case 2 Male, 55 year-old college professor. First visit 9 October, 1991. This patient has a three-year history of left-sided numbness. He has been diagnosed at a few major hospitals as having autonomic nervous dysfunction. Western and Chinese medicine (including acupuncture) have not produced significant results. Recently the numbness has become worse and he has also begun to feel incessant itching. The itching becomes worse at night and this affects his sleep. He also experiences occasional chills, feverishness and sweating. On examination there was a patch of numbness accompanied by itching on the left lateral third of his trunk and a similar patch running from the lateral aspect of his left femur to his lower leg (see Figure 2). These areas were without any pain sensation when needles were stuck into them although touch and pressure sensitivity was present. There were no visible skin abnormalities such as redness or swelling. Diagnosis: Numbness. Pattern: Obstruction of the collaterals and lack of harmony between the nutritive and the protective (ying and wei). Treatment principle: Unblock the collaterals, eliminate obstruction and adjust the nutritive and protective. Treatment: A sterilised pyramid needle was used for scattered pricking over the areas of numbness. Pricking was done with the same amount of force everywhere until there was slight bleeding. Care was taken not to prick outside these areas to avoid hurting the patient. Once there was some slight bleeding, it was stopped by the application of sterilised cotton balls. This process was repeated twice more for a total of three sets of pricking during each treatment session. After the treatment the areas felt much more comfortable and both the numbness and the itching dissipated. The above treatment was given every other day for a total of six treatment sessions. At the end of that time all the numbness and itching were gone and three more treatments were
Figure 2

given to consolidate the effects. These had to be done very gently as now the areas had more normal pain sensitivity. At a one year follow up there had been no recurrence. Comment: Most cases of numbness with itching are due to an insufficiency of qi and blood, and treatment is usually directed at treating wind. However, in this case the problem was an obstruction of the collaterals with a disharmony between the nutritive and protective. This diagnosis was arrived at in part from the peculiar nature of his complaint, in that patches of numbness and itching at the surface without a decrease in touch sensitivity can be a sign of collateral obstruction and he had the classic symptoms of nutritive and protective disharmony (occasional chills, feverishness, and sweating). In addition, he had tried numerous other diagnoses without success. As the disease was located at the superficial level in the collaterals, treatment was applied at this level with superficial pricking, just enough to cause a slight amount of bleeding. This bleeding signalled the removal of the obstruction which then led to regulation of the nutritive and protective with the resultant elimination of the symptoms. Case 3 Female, 42 year-old accountant. First visit 8 May, 1995. This patient has a five-year history of a tenosynovial cyst on her left wrist. Originally she tried various forms of Western and Chinese medicine (including acupuncture) without success and so had the cyst excised. However, soon after this the cyst returned. This process recurred a total of three times. A few months before her first visit to our clinic the cyst started to grow again and this time it was painful. On examination there was a swelling approximately 1.5 cm in diameter located just distal to her left wrist. It was not discoloured in any way and was soft. It had clear borders with the sur-

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rounding tissues and was soft. Range of motion of the wrist and hand were not affected. Diagnosis: Tenosynovial cyst. Pattern: Phlegm and blood stasis obstructing the channels and collaterals. Treatment principle: Dispel blood stasis, eliminate phlegm and unblock the collaterals. Treatment: A sterilised pyramid needle was used to prick the centre of the cyst. While this was slightly painful, no local anaesthetic was used as that can decrease the efficacy of the treatment. Then finger pressure was applied to express a small amount of translucent white liquid. The pressure was continued until no more of the liquid came out. After this, sparrow-pecking moxa was applied for about 30 minutes until the affected area became red. Two days later the cyst was still leaking fluid and the above procedure was repeated. After this the moxa alone was done daily for half a month after which time the cyst was completely gone. There was no recurrence during a two year follow up period.
cyst

Figure 3

On examination the lateral aspect of her ankle showed redness and swelling of the soft tissues along with bruising. This area was exquisitely sensitive to touch and there was significant restriction in range of motion of the ankle. Diagnosis: Acute sprain. Pattern: Blood stasis obstructing the collaterals. Treatment principle: Dispel blood stasis and unblock the collaterals. Treatment: A sterilised pyramid needle was used to strongly prick the area of bruising. This was done very quickly to keep the pain from the procedure to a minimum. This led to the expression of a very dark, purplish blood which corresponds to blood stasis. When the bleeding stopped, the area was cleaned with a sterilised cotton ball. The process was then repeated twice until no more of the dark blood was expressed. When this was finished the pain had significantly decreased as had the swelling and bruising. A plaster was then applied to the area made of the herbal preparation Golden Yellow Powder (jin huang san). Two days later the above pricking treatment was again applied after which the pain was basically gone. The plaster was again applied to consolidate the treatment. Comment: Sprains come about because of injury to the soft tissues from inappropriate forces. From a traditional Chinese medicine perspective there is stasis and stagnation of qi and blood which leads to obstruction of the channel qi. This is the classic presentation alluded to in the adage with no flow there is pain (bu tong ze tong). Pricking therapy here directly expresses the bad and static blood which then unblocks the collaterals and reduces the swelling. Once this happens the vessels are open and the symptoms are significantly reduced. For this type of treatment to be effective, it has to be done within twelve hours of the injury.

Comment: This problem is usually due to a variety of factors disrupting the flow of qi and blood locally. Over time the local structures, including the sinews, vessels and collaterals become obstructed by blood stasis and phlegm. Pricking is used to express the static, obstructing matter which has the effect of dispelling phlegm, transforming blood stasis, dispersing clumps and unblocking the collaterals. Moxa is added after the pricking to increase the local flow of qi and blood so as to encourage the channels, sinews, collaterals, and vessels to relax. Once the source of the obstruction and stagnation is removed, the disease dissipates and does not return. We feel that this method is more effective in the long term than surgery, because surgery disrupts the flow in the channels which can easily lead to recurrence. Case 4 Female, 18 year-old student. First visit 6 June, 1995. The morning of her first visit she had sprained her ankle in a physical education class. She had immediately been seen in a clinic where a liniment had been applied and the area taped. However, by that afternoon the pain had become excruciating and she came to our clinic.

Conclusion
Collateral-pricking has a broad clinical application. From the few representative clinical examples cited here, one can see that it can be used for both chronic and acute problems anywhere in the body. The only criteria necessary is that the problem be due to the blood collaterals being diseased and obstructed. Understanding of the pathological process enables one to use this method with optimal efficacy. Bleeding cannot be done indiscriminately or it will do more harm than good. There is one important practical note that needs to be made here. Whenever using a pyramid needle for collateral-pricking or other forms of bloodletting, one must very stringently adhere to clean needle technique, sterilisation and antiseptic practices. Included in this is the application of iodine preparations to the areas to be pricked. Practising in this way ensures both efficacy and safety.
Xie Ke-Rong & Zheng Liang-Xi work at the Seattle Institute of Oriental Medicine.

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