Assessing and Treating Pericardium-6 (Neiguan): Gate to Internal Well-Being
Abstract: According to Chinese medicine, the "Inner Gate," PC-6 (Neiguan), ranks as one of the most important points in evaluating the inner state of the organism, regardless of its physical or emotional nature. Through palpation that evokes an objective reaction from the patient or subjective feelings on the part of the practitioner of tissue tension, tendon hardness, etc. any stagnation or deficiency in the body, particularly Qi stagnation, can be both measured and dispersed. While stagnation is often cited as the root cause of much illness, the clinical utility of assessing stagnation becomes apparent. Additionally, the practical ease of palpitating this point makes it possible for patients to monitor their own health, which empowers them to address their life situations, and assist in restoring their internal harmony as preventive health care.
IN 1987, during a lecture on the Eight Curious Vessels,1 the esteemed Nguyen Van Nghi reviewed a case illustrating the application of the Inner Gate,2 PC-63 Neiguan). He revealed that on his flight from Paris to the United States a passenger had become ill and unconscious. The flight attendant requested a doctor's assistance to deal with the emergency, and Dr. Van Nghi, both an acupuncturist and medical doctor (as required in order to practice acupuncture in France), came to his aid. He firmly reached for the wrist area of the patient where PC-6 (Neiguan) is located and the patient revived.
Immediately, hands went up in the classroom. "Was the point needled or pressed?" "Was the treatment administered bilaterally or unilaterally?" the inquiring audience wanted to know. Steeped in wisdom and experience, Dr. Van Nghi knew this would be the reaction; after all, practitioners want clinical information. With characteristic effusiveness he quickly brushed these questions aside and proceeded to make his point — when the specific nature of an acupoint, the distinct energetics and functions that give it its unique job description or functional utility in the body, is truly understood, the number of points, the needling or pressing of the point unilaterally or bilaterally and other parameters of treatment, become meaningless.
This simple, yet dramatic case illustrates concepts that are part of a treatment strategy in Chinese medicine that "less is sometimes better" and that treating the rot may be more productive that becoming lost in aspects of the myriad symptoms of which the patient complains. To successfully respond to the immediacy and root of the problem required clarity of thought and diagnostic acumen. Such an ability is derived from an intimate knowledge of internal pathways and classical point energetics, facilitating selection of the appropriate point.
The discernment of precise point function can serve to elevate many rarely used points to greater status within the context of clinical application. Many of these points, by virtue of their intersections and pathways, function as substantial vortices of energy. For example, Neiguan certainly has always enjoyed high regard in the realm of point functions because of its simultaneous capacity as a Luo point and as a Confluent (Master) point of the Yin Wei Mai (Yin linking vessel). However, the range of clinical energetics of this point, though perhaps less known, involves a greater number of additional manifestations — with no less significance.
The energetic functions of Neiguan are discussed below and summarized in Table 1.
Summary of the energetic functions of PC-6 (Neiguan)
A. Neiguan as Luo (Connecting) Point
While Neiguan assists in communication between the three Jiaos, by virtue of its association with the Triple Warmer, its energetic association with the Upper Jiao allows for direct and effective control over disturbances in this region such as chest pain, cardiac pain, hiccough, diaphragmatic disorders, mental illness and insomnia.4 However, it is also clinically effective in Middle Jiao symptoms such as gastric pain, vomiting, nausea, and motion sickness. It calms and harmonizes the Stomach, promoting the functional Qi of the Middle Jiao. Lower Jiao disharmonies such as abdominal pain and diarrhea can also be treated through this point.
As a longitudinal Luo, Neiguan sends a stimulus to its organ/meridian complex proper, i.e., to itself. The Pericardium, as the envelope that protects the Heart, shields this organ/meridian complex from aberrant emotions and can be used as a barometer to measure how emotions are impinging on physiological functioning.
In one classical usage, Luo points were employed as channels to drain off or disperse, excessive, stuck, or perverse energy.5 Neiguan, with its close association with the Upper Jiao (chest and heart in particular), can treat clinical manifestations such as breast distention, tumors, cysts and cancer of the breast that can ensue if pathological energy is not drained. These developments are part of the sequelae of Qi stagnation, Blood stagnation, and often-times depressive Liver Fire.
Stimulating Neiguan as a longitudinal Luo activates the internal pathway of the channel. The Pericardium channel, originating in the chest, passes to its associated organ, the Pericardium, through its Front Mu point, CV-17 (Tanzhong, "chest center"; CV-17 is also the Influential point which dominates the Respiratory (Da/Kong) Qi, spreading the Qi "like a mist" to every part of the body). It descends through the diaphragm to the abdomen, regulating the Qi, keeping energy flowing in its proper pathway, preventing the Qi and Blood from being reckless or rebellious.
B. Neiguan as Group Luo of the Three Arm Yin Meridians (Sanyinshou)
C. Neiguan as Confluent (Master) point of the Yin Wei Mai
In the Six Division Energetic paradigm (liu jïng bian zhèng), Neiguan is inextricably bound with the liver, at the Jue Yin level. This energetic, coupled with Luo point usage and its internal pathway, allows Neiguan to relieve stagnant Liver Qi. In the author's opinion, Neiguan is the most clinically effective point for dredging stagnant Liver Qi. It is probably lack of appreciation of this energetic that makes Neiguan so undervalued as a point for adjusting Liver Qi stagnation.
E. Neiguan Coupled with the San Jiao in the Five Elements
F. Pericardium-Uterus-Kidney Relationship
G. Coupled with Chong Mai and its Confluent Point in the Eight Extra Vessel
Upon reviewing the functions of Neiguan, it becomes apparent that it surely ranks as a remarkable point due to the cardinal roles that it assumes. Let it be re-emphasized that one of the key functions of Neiguan is its ability to move Liver Qi stagnation. One astute student of Chinese medicine cleverly surmised, "Give me Liver Qi or give me death." This aptly summarizes the axiomatic premise that the six stagnations are frequently the root of much disease, of which Qi stagnation, frequently arising from dysfunction of the Liver, is the precursor to all of the other stagnations.
In Chinese medicine, stagnation, like many entities, has its gradations and nuances that determine its differentiating nature. In establishing any diagnosis, sufficient signs and symptoms need to support each other. Stagnation is no exception, although its early manifestations are often subclinical, i.e., below the threshold of perception or complaint. Regrettably, a major penchant in Chinese medicine both in the United States, and perhaps even more so in contemporary China, ignores the substantial role of bodily palpation in evaluating the patient's condition.
While it is not the intent of this article to make a case for palpation,7 it has been observed that palpation as a tool can supply some of the most verifiable physical, yet subtle indicators of energy states in the body.8 Accepting this hypothesis, proper palpation of Neiguan can offer a reliable indicator, not only of health but of stagnation and any of the disharmonies that would result if Neiguan was "not doing its job."
One argument for the importance of point palpation to determine pathology comes from H.C. Dung of the Departments of Anatomy and of Physical Medicine and Rehabilitation at the University of Texas Health Science Center, San Antonio, Texas. According to Dung, points have three functional phases (active, passive and latent), which refer to the status or health of a point.9 These functional phases have different clinical manifestations based upon the state of the bodily health or energetics that they represent.
According to Dung, active points arise when the province dominated or managed by those points becomes diseased. Examples would include a headache characterized by drilling pain at GB-20 (Fengchi), sinus pressure at BL-2 (Sibai), itchy palms at HT-8 (Shaofu) following an allergic reaction, or pinpoint chest tightness at CV-17. Active points are precisely that, active. They shout for help, their voices rising to the level of consciousness, screaming for attention with the cry of "help, I am dis-eased!"
Points in the passive phase are tender to pressure; however, the individual is unaware of this tenderness until the point is stimulated, e.g., during palpation, electropoint detection or other physical means. According to Dung, "...[acupuncture points] begin to convert to the passive phase once our body enters a diseased condition."10 It has been further suggested that this disease state is underway in the functional aspect of the organ/meridian complex that the point represents. Such acupoints are not clamoring for attention, initiating the spontaneous firing of nerves that evokes pain; however, their tenderness upon pressure signifies what could be called the preclinical or pre-symptomatic aspects of a syndrome.
The clinical significance of passive points cannot be overstated — it is evidence of pathology manifested by their "ah shi!" (oh yes!) response suggesting the presence of energetic imbalances in the body which may lead to disease in the future. As is indisputable in Chinese medicine, in general, the earlier a "dis-ease" or pattern of disharmony can be identified, the more generally favorable the prognosis will be.
Any point can fall into the category of a passive point. By definition, a passive point lies quiet until explored in some manner. Traditionally, certain categories of points in Chinese medicine have fallen into the realm of potentially passive points; consequently, the recommendation that some, if not all, points should actually be palpated as part of a Chinese physical exam. Each point category — be it Front Mu (Alarm points), Back Shu (Associated points), Yuan (Source points), Xi-Cleft (points of accumulation or blockage) or clinically effective points (points with known diagnostic and treatment value) — presides over a domain that can insinuate various conditions in the body. Yet, any point can be a passive point and can be adopted by the practitioner to provide verification of the diagnosis. Because of the multiplicity of roles that Neiguan serves in the body, it becomes apparent that it is both (1) a serious indicator to establish the facets of pathology and health related to this specific point, as well as (2) a consequential point in treatment.
Lastly, Dung proposes a category designated as "latent" points. These points are inactive points that neither fire spontaneously not are stimulated to the level of pain through medicinal means. Palpation of latent points may produce the typical sensations of Qi arrival (heat, numbness, distention, redness, an electrical or other sensation radiating to a particular area). However, through patient interaction and careful observation the practitioner should be able to discern the difference between pain, the absence of a response, or Qi arrival caused by stimulating the inherent healthy energy of a point. Obviously, the more latent points present on the body, the healthier it is. The lack of pain felt by the patient or the lack of tension, tightness or mushiness perceived by the practitioner at a point is indicative of the functional integrity, in this case, of the Inner Gate, Neiguan.
In short, in the most ideal circumstances, in the healthy person, Neiguan is found as a latent point. However, if any of the roles that Neiguan serves are impaired, varying degrees of tenderness are elicited at this site, thus, constituting a "passive" phase point.
Classical and European sources have alluded that points for women, if used unilaterally, should be utilized on the right in women and on the left in men due to the correspondences of yin/yang regarding gender.11 However, in my experience treating hundreds of patients, I have observed that left-sided Neiguan, in both men and women, seems to be the most reliable indicator of point dysfunction. This observation may be supported by the classical observation that each organ/meridian complex as a particular left/right affinity as expressed in many of the historical pulse systems summarized in Table 2.
An historical comparison of various pulse diagnosis systems
As can be seen in most pulse systems, the energetics of the Heart, Pericardium, Liver and Kidney tend to be relatively left-sided. The energetics of the Lung, Spleen, and Stomach have always been considered right-sided. The implications of a pattern which proposes a propensity of each organ/meridian complex towards a particular side of the body attests that palpation, as well as needling, of corresponding points on these meridians may be appropriately performed unilaterally, versus bilaterally. This approach not only fosters an economy of probing and needling, but more significantly denotes the most clinically effective points to employ.
As described in Section I of this article, one of the most salient roles of Neiguan is that of the "Inner Pass",12 that Inner Gate which can meter, e.g., internal stagnation. In Acupuncture Imaging; Perceiving the Energy Pathways of the Body, Mark Seem emphasizes an important treatment principle of Chinese medicine which merits restatement. He reminds us that as a result of freeing up local obstructions by dispersing blockages at the surface, the therapist and client become more aware of the constitution, i.e., the bodymind's energetic core.13 Because true excesses in the body are actually rare, and rather are more likely a result of underlying deficiencies,14 treatment strategies can become complicated. However, accepting the relationship of Neiguan to stagnation and the hypotheses presented above in terms of palpation that —
Having reviewed the multiple aspects of Neiguan as a diagnostic point, we now turn to a discussion of its clinical application, specifically, palpation and needling.
Palpation, as a modality in its own right, can serve as a method of treatment. Traditionally, it has been known for its treatment benefits. This realm exceeds the scope of this article; however, I reiterate Van Nghi's contention that when a point is located correctly and its Qi is contacted, issues of method — the time element and other variables — become insignificant. Palpation can clearly "move things" as well as bring energy to an area — and this is certainly the case for Neiguan.
Needling any point following palpation serves to further reinforce the therapeutic action of the point, to secure it, to "pin it down" if you will. Other variables may enter into the question of whether Neiguan or any other point simply needs to be palpated or needled; this will depend upon the practitioner's assessment of each case, their own capabilities, preferred diagnostic paradigms and other factors that are not possible to elucidate here.
Treatment guidelines for Neiguan are summarized in Table 3.
Location and treatment guidelines for PC-6 (Neiguan)
In my experience, Neiguan is either an active point (rare) or a passive point
(very common, about 75% of the time). Due to the ease of locating and
stimulating this point, patients can be shown how to regulate their own
internal conditions by rubbing this point.
The advantage of such patient "homework" is fourfold: (1) it accelerates the therapeutic process and clears patterns of disharmony so that the practitioner may perform the treatments that are difficult or impossible for patients to administer; (2) equally, if not more importantly, the patient can learn more about their bodily energetics, such that responsibility can be assumed for them. Patients are greatly empowered to help themselves and more likely to comply with educational prescriptions because they are actively involved in the therapeutic process instead of mysteriously being "fixed up"; (3) the patient can participate in their own preventive health care; and (4) the practitioner fulfills the ancient Neijing maxim to doctors that, "the superior physician is a teacher" — certainly a noble pursuit.
In conclusion, theoretical evidence for the use of Neiguan has been explored in the hope that the practitioner can add to or review their repertoire of skills. The objective of this article is to help return to preeminence the clinical significance of Neiguan and its manifold roles in both diagnosis and treatment as the criterion or gauge of internal well-being. In this regard, the emphasis on palpation as the modality for obtaining feedback and redressing illness is brought to the forefront along with other treatment strategies for moving stagnation, clearing excesses and providing patient education — all supporting the maintenance of the "inner barrier."15 Indeed, the gate to our inner well-being, thanks to the wisdom of the human body and the sagacity of Chinese medicine, is quite within our reach at the site of the Inner Gate, PC-6.
Shanghai College of Traditional Chinese Medicine: Acupuncture: A Comprehensive Text. O'Connor J, Bensky D (trans/eds). Eastland Press, Chicago, 1981, p 250.
Dung HC: Three principles of acupoints. Amer J Acupun, 1984;12(3): 263-266.
Seem MD: TCM versus non-TCM: Putting the acupuncture back into Chinese medicine. J Amer College TCM, 1989; 7(4): 10-12.
Seem MD: Integrationist acupuncture: Plurality in the practice of American acupuncture. Amer J Acupun, 1992; 20(3): 229-236.
About the Author Skya Garner-Abbate, MA, LAc, DiplAc, Dipl CH, has served as the Chairman of the Department of Clinical Medicine of Southwest Acupuncture College since 1986. She has also served as a Commissioner on the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine for seven years. She holds Bachelor's and Master's degrees in Sociology in addition to her training in traditional Chinese medicine at the Santa Fe College of Natural Medicine and two internships at the International Training Center of the Academy of Traditional Chinese Medicine in Beijing, China. She is author of Beijing: The New Forbidden City, a work about her experiences in China at the time of the Tiananmen Square massacre in 1989. Two books are scheduled for release in 1997: Holding the Tiger's Tail: A Techniques Manual in the Treatment of Disease and The Magic Hand Returns Spring: The Art of Palpatory Diagnosis. Chicago, 1981, p 250.
American Journal of Acupuncture, Vol. 23, No. 2, 1995