Anatomy, Dissection, and the Chong Mai

 
I just finished leading two 5-day dissection classes for the University of Tampa Physician Assistant program. While I was teaching ‘standard’ Western anatomy and guiding the student teams through the full body dissection, the Chinese medical channel system was never too far from my mind. I did occasionally share some of this information to the PA students, but it is obviously not the anatomy that they are studying, and I was sparing with this information. Below is one aspect I shared, and something that I got an even better appreciation of: the anatomy associated with the chong mai, or penetrating vessel.

Inferior epigastric artery and vein connecting
into iliac artery and vein.

One of the tables (there were teams of 5 people working on each donor) produced a very similar view to this image on the left. This is created by slowly resecting the obliques, then cutting the rectus abdominis from the pubic bone and resecting it superior. Underneath the rectus abdominis are these vascular structures which are the epigastric artery and vein. There is some complicated anatomy associated with the fascial layers inferior to the umbilicus (look up the arcuate line if you want more information), but suffice it to say that these vascular structures run deep to the rectus abdominis, and that the fascial plane that they run in dives a bit deeper as these blood vessels connect with the iliac artery and vein.

Epigastric artery and vein running
deep to the rectus abdominis

This fascial plane is what I associate with the Spleen sinew channel; it is the fascial plane that runs deep to the rectus abdominis, connects with the anterior diaphragm and then follows the diaphragm around to the crura (attachments on the lumbar spine) of the diaphragm. However, this fascial plane also houses these epigastric arteries and veins. These vascular structures change names as they reach the thoracic cavity, becoming the internal thoracic artery and vein (also called the internal mammary artery and vein), and running along the deep surface of the sternum and anterior ribcage. During dissection, we cut a window through the sternum and ribcage to access the thoracic cavity; when we remove this window and look at the undersurface, these vascular structures are apparent.

Internal thoracic artery and vein
running just posterior to the
anterior ribcage

Traveling superior, these arteries and veins join with the subclavian artery and brachiocephalic vein. It is not necessary for this discussion to get too detailed about this anatomy, but there is a relationship between these vessels coming from the thoracic cavity and similar vessels in the neck which supply the neck and face.

Collectively, these vessels supply the skin, muscles, and bone on the anterior region of the body, umbilical region, diaphragm, pleura, pericardium, thymus, and important structures of the neck.

Finally, in the thoracic cavity, these blood vessels branch into the intercostal arteries and veins; they drain into the thoracic aorta and a venous structure called the azygos vein, all in the posterior portion of the thoracic cavity and consistent with the posterior branch of the chong mai. Clinically, these vessels act as a collateral circulation for blood movement from and to the heart. If there is obstruction in the aorta, blood will take this collateral circulation route. If the blood is abundant, these vessels can be filled, so they act as a bit of a reservoir.

Go back and review the chong mai with this anatomy in mind and you will see it in an entirely different light. These structures are in the myofascial plane of the Spleen sinew channel, regulated by a Spleen channel point, SP 4, and they clinically match the description and topography of the chong mai.

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The Great Luo-Connecting Channel of the Stomach and Heart Palpitations

All of the primary channels along with the Du and Ren vessels have luo-connecting points, which are where the luo-connecting channels branch off of the primary channels. In addition to these luo-connecting channels, the Stomach and the Spleen channels each also contain a great luo-connecting channel. The Spleen great luo-connecting channel is the more widely discussed in acupuncture texts, but is still a bit mysterious in its own right. I will discuss this in another post. The Stomach great luo-connecting channel (xu li) is infrequently discussed in acupuncture texts and, possibly has even more mystery associated with it.

Claudia Focks' Atlas of Acupuncture describes it thus: The great luo-connecting channel of the Stomach begins in the Stomach, passes through the diaphragm, intersects with Ren-17, and spreads in the Lungs, trachea, and larynx. From the Lung, it travels to the Heart and emerges in the region of ST-18 where the heartbeat is visible.¹

Pathology, like other luo-connecting channels, can be separated by full and empty conditions and are listed as thus:^1,2,3

Great Luo of Stomach Full: Rapid, irregular breathing, chest congestion, congestive heart failure
Great Luo of Stomach Emptied: Palpitations, fibrillations, tachycardia.

Fig. 1: The heat and stomach in situ

Why would this secondary channel of the Stomach network cause palpitations of the heart? We can gain a more precise understanding by exploring the anatomy of the stomach and the heart, their topography in the body, and the way in which dysfunction of the upper portion of the stomach can contribute to the above symptoms.

Looking at the topography first, one sees that the upper portion of the stomach is in close proximity to the heart. In fact, the upper portion of the stomach is called the cardia due to its close proximity to the heart, as it is essentially just on the other side of the diaphragm (Fig. 1).

While many organs are close to each other, the research about to be published by an osteopath in Italy named A.J de Koning helps illustrate the link between these two organs. De Koning is coordinating with an Italian cardiologist, Dr. Stefano Bianchi, who regularly performs cardiac ablation for irregular heart beat due to atrial fibrillation (AFib).

A.J. de Koning is a visceral manipulation practitioner and teaches with the Barral Institute. Dr. Bianchi invited de Koning to work with him and has him evaluate the patients first using osteopathic 'listening' techniques to feel for dysfunction. When applicable, visceral manipulation techniques are performed, and the result has been a greatly reduced necessity for ablation procedures. In particular, visceral manipulation techniques for the stomach have been particularly beneficial. Many of these patients with atrial fibrillation who benefit from visceral manipulation applied to the stomach have a history of gastric problems such as gastritis.

De Koning theorizes that the effectiveness of this approach is due to the dual innervation of the heart and stomach by the vagus nerve. When the stomach is stimulated, the signal is sent to the CNS to a region in the brain which has an effect on the arrhythmia. Essentially, this is a viscero-visceral reflex between the stomach and the heart.⁴

Here is a summary of de Koning's research

Fig. 2: The Influence of the Chongmai

Now back to the channels. Can we have a similar effect working with acupuncture and the channel system? To regulate the great luo-connecting channel of the Stomach, an acupuncturist could treat the Chongmai via the command point SP-4 along with PC-6 (Fig. 2). SP-4, in addition to being the command point of Chongmai, is also the luo-connecting point of the Spleen channel. Wang Juyi, in his book Applied Channel Theory, discusses how this point has the ability to clear the collaterals of the paired yangming stomach channel to clear heat. Symptoms include nausea/vomiting, stomach pain, insomnia, and irritability, He explains that trapped yangming heat moves upward to affect the heart.⁵

In addition, Dr. Wang likens PC-6, a point that is frequently used for stomach conditions such as gastritis and stomach spasms in addition to heart conditions such as angina, to the parasympathetic nervous system. Jueyin closes inward and is the most yin aspect of the six divisions, describing a physiology that reflects the parasympathetic nervous system regulation. It is worth remembering that 90% of the parasympathetic nervous system is innervated by the vagus nerve.

So, in effect, this point combination can be viewed as having a regulatory effect similar to de Koning's description. It can be especially useful when this link occurs between dysfunction in the Stomach affecting the Heart (history of gastitis, ulcers, acid reflux, etc, might serve as clues) as opposed to dysfunction which comes from problems with the Heart directly and might better be treated with the Heart collateral point, HE-5.

In addition to this point pair, the acupuncturist can consider treating joint fixations in the thoracic spine using huatuojiaji points and tuina mobilizations.⁶ These fixations could manifest anywhere in the thoracic spine, and it would not be surprising to find them in the region of the back-shu of the heart, the stomach, or both.

Fig. 3: Convergence of the Heart and Stomach
sinew channels

Assessment and treatment of the sinew channels can also be useful for these types of arrythmias; especially assessing for dysfunction in the region of the convergence of the Stomach and Heart sinew channels (Fig. 3). Both of these channels include the rectus abdominis and rectus fascia. This would cover the region of the front-mu points of the Stomach and the Heart, but it would also include the area under the abdominal portion of the pectoralis major which extends all the way to rib 5. Myofascial release and/or motor point and trigger point work to this region allows more space and freedom on the outside and will reinforce any internal work performed with acupuncture, visceral manipulation, or other techniques that are addressing the zangfu.

Fig. 4: Cardiac arrythmia TrP

located on right side at the 5th

intercostal space. The vertical line

indicates the midpoint between the

sternal margin and nipple and the

horizontal line indicates the lower

border of the xiphoid process.

One final thought: Dr. Janet Travell, in her book Myofascial Pain and Dysfunction: The Trigger Point Manual, mentions a pectoralis major trigger point (TrP) which can develop on the right side in the 5th intercostal space and can contribute to arrhythmia of the heart (Fig. 4). Travell suggests that this TrP might be in the intercostals rather than the pectoralis major.⁷ I think it is also possible that this TrP is in the superior rectus abdominis attachments. Either way, it is at the area where the rectus abdominis meets the pectoralis major, or, to put it another way, where the Stomach and Heart sinew channels converge.

Dr. Travell discusses treatment of this TrP and its effect on heart rhythm as a somato-visceral reflex. Her colleague and co-author, Dr. David Simons, describes witnessing several occasions of conversion of atrial fibrillation to normal rhythm with the application of a vapo-coolant to deactivate this TrP and he states that pressure or needling could also be employed.⁸


References:

1. Focks, Claudia, Ulrich März, Ingolf Hosbach, and Johanna Schuster. "Acupuncture points of the twelve primary channels." Atlas of Acupuncture. Edinburgh: Churchill Livingstone/Elsevier, 2008. 125. Print.

2. Maciocia, Giovanni. "Identification of patterns according to the 12 channels." The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists. Edinburgh: Elsevier Churchill Livingstone, 2005. 751-55. Print.

3. Cecil-Sterman, Ann, and Pat Didner. "The luo channels. Advanced Acupuncture: A Clinic Manual. New York: Classical Wellness Press, 2012. 49-128. Print.

4. "Atrila fibrillation, the stomach and visceral manipulation." International Alliance of Healthcare Educators. N.p., n.d. Web. 28 Dec. 2016. https://www.barralinstitute.com/docs/articles/atrial-fibrillation-aj-de-koning-research.docx

5. Wang, Ju-Yi, and Jason D. Robertson. "The source, cleft, and collateral points." Applied Channel Theory in Chinese Medicine: Wang Ju-Yi's lectures on channel therapeutics. Seattle: Eastland Press, 2008. 513-15. Print.

6. Lau, Brian. "The sinew channels & vertebral fixations." The Illinois Acupuncturist 1 (Mar. 2016): 24-27. Print.

7. Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1, Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. p.821-2, 829-30.

8. Simons, David G. “Cardiology and Myofascial Trigger Points: Janet G. Travell’s Contribution.”Texas Heart Institute Journal 30.1 (2003): 3–7. Print.

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