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Analysis of the historical evolution of the Tong Luo method

Mao Xiao
Shanghai University of Chinese Herbal Medicine,
department of education & research

Abstract

Through an investigation and summary of the historical


evolution of the network vessel diseases and the ‘free the
network vessels’ method (Tong Luo, tong meaning ‘to
connect; to communicate; to free the flow’, luo meaning
‘network vessels’), this article puts forward that Tong Luo
method and Luo disease theory originated in the ‘Classic of
Internal Medicine’ (Nei Jing) and the ‘Classic of Difficulties’
(Nan Jing), concrete treatment methods germinated in the
‘Discussion on Cold-induced and Miscellaneous Diseases’
(Shang Han Za Bing Lun) and went through endless
transformations in the successive dynasties of the Jin, Tang,
Song, Jin, Yuan and Ming. In the Qing-dynasty work by Ye
Gui (Ye Tianshi), entitled ‘Clinical pattern guide and medical
case histories’ (Linzheng zhinan yi’an), the Luo disease
theory and Tong Luo method started to be basically
formalized and nowadays the convergence of Chinese and
Western Medicine in combined clinical explorations indicates
that there are new developments in the applications of the
Tong Luo method.

The Tong Luo method, meaning the coursing and connecting


of the network pathways, is one of the main clinical methods
for treating diseases in ancient and modern times. In
therapies for various enduring diseases with difficult and
stubborn patterns, which are called ‘Luo diseases’, the Tong
treatment method has unquestionably demonstrated its
unique curative effects. Nevertheless, important scientific
terms like Tong Luo and Luo disease are not listed in the
‘Great Dictionary of Chinese Medicine’ (Zhongyi dacidian)
and there is no mention of it in educational books like
‘Fundamental Theory of Chinese Medicine’ (Zhongyi jichu
lilun) and ‘Therapeutics of Chinese Medicine’ (Zhongyi
zhiliaoxue). With regard to the revision of modern clinical
disease manuals, the increasing occurrence of cardio- and
cerebro-vascular diseases, diabetes mellitus, gout and other
diseases is calling for renewal of theories and a systematic
carding of the Tong Luo method and the historical
development of the scientific problems related to it, in order
to extract the fundamental essences for clinical service.

1. Cradle and germination

The Tong Luo method theory originates in the classics of the


Qin-Han period: the [Huangdi] Neijing [Suwen and Lingshu]
([Huang Di’s] Inner Classic [Basic Questions and Divine
Pivot]), Nanjing (The Classic of Difficult Issues) and
Shanghan zabing lun (Treatise on Cold Damage and
Miscellaneous Disorders).

1.1 Definitions of the network vessels and ‘Luo


needling and bleeding’ method in the Neijing

The Lingshu (Divine Pivot) in chapter 17 (entitled ‘Vessel


Measures’) says: "Channels and vessels are interior,
horizontal branches are called Luo, those which diverge from
the Luo are called Sun (‘Grandchildren’)" and in chapter 10
(‘Channels and Vessels’): "Of all the vessels those which are
superficial and constantly visible are the network vessels".
This makes clear that luo mai (network vessels) refers to the
branches of the jing mai (channels and vessels), including
the relatively big bie luo (divergent vessels), the fu luo
(floating vessels) which manifest on the body surface and
the tiniest sun luo (grandchild vessels). At the same time
they include branches of the blood vessels, like is said in
chapter 39 (‘On Blood Network Vessels’) of the Lingshu:
"Fresh fluids ooze into the network vessels" and "Strange
evils which are not in the channels, … … refers to the blood
network vessels".

[The Lingshu] also says that damage of the network vessels


may lead to blood disease patterns, like in chapter 66 (‘On
the Origin of Hundred Diseases’): "When yang network
vessels are harmed, blood spills out [of the body], if blood
spills out then there is nose bleeding" and "When yin
network vessels are harmed, blood spills out in the inside
[of the body], when blood spills out in the inside this results
in blood in the stools". From this we can learn that in the
Neijing the network vessels already comprised ‘blood
network vessels’. Network vessels and blood network
vessels can be located on the body surface and also reside
deep in the depots and palaces (zang fu – bowels and
viscera; internal organs). In respect to treatment methods,
the ‘needling and bleeding of the Luo’ in the Neijing is an
embryonic form. The Suwen (Basic Questions) in chapter 66
(‘On the Three Sections and Nine Indicator[-levels]’) says:
"In diseases of the channels treat the channels; in diseases
of the (grandchild) network vessels, treat the (grandchild)
network vessels with bleeding, in blood diseases with body
pains treat the network vessels. If the disease is due to a
strange evil, then use the method of cross needling, if the
disease endures and does not change, causing emaciation,
then needle moderately. When there is repletion (shi) above
and vacuity (xu) below, trace the knotted network vessel by
examining the pulse and needle it with bleeding in order to
connect the flow". (note: the word ‘grandchild’ is an
uncertain addition following the Zhenjiu jiayi jing (AB Classic
of Acumoxa).

The Suwen in chapter 62 (‘On Harmonizing the Channels’)


further states that needling the network vessels with
bleeding can be used to prevent contraction of diseases by
the channels and vessels, like in: "Water overflowing in the
grandchild vessels results in retention of blood in the
channels, needle with bleeding to prevent malign blood
entering the channels, causing disease". And chapter 6 of
the Lingshu (‘Lifespan and Hardness and Softness’) further
records the external treatment of cold obstruction (cold bi
syndrome) by means of herbal cauterisation – this also
belongs to the roots of the Tong Luo method using herbal
substances.

Explorations regarding blood network vessel diseases are


reflected in other relevant documents as well. In the in-
depth analysis of the problem of the generation of illness as
recorded in the Lingshu chapter ‘Channels and Vessels’, the
Nanjing (in the 22nd difficult issue) says: "The [Nei] Jing
states that when the vessels are excited, illnesses may
generate. Now how can two kinds of illnesses arise from one
vessel? It is like this: what the Neijing calls ‘excitement’
means qi and the generated illnesses refer to blood. When
there is evil in qi, qi will be excited; when there is evil in
blood, blood illnesses generate. Qi rules genial warmth,
blood rules moistening. When qi lingers and does not move
then qi is affected by illness first; when blood is obstructed
and does not moisten, then blood is diseased thereafter.
Thus what first comes is excitement, thereafter illnesses are
generated."*

* note of the translator: ‘excitement’ may be


replaced by ‘arousal of the movement (in the vessels)’

1.2 Network vessel disease in Chunyu Yi’s


‘Consultation Records’ (Zhen Ji)

Canggong (‘Master of the Granary’, the title of Chunyu Yi)


left us the earliest extant clinical case records related to
Network Vessel disease transformation. The record on ‘Qi
obstruction in the chest’ says: ‘’Upon examining the pulse,
[he concluded]: it’s heart qi, turbidity restlessly [moves in]
the channels, it is a network vessel yang disease … …
therefore there is irritation and fullness, inability to eat,
resulting in a surplus of the network vessels, when there is a
surplus of the network vessels, blood rises and exits and
when blood rises and exits, the patient dies. This is
generated by a grieved heart; the illness is contracted by
sorrow."

What Chunyu Yi calls ‘surplus of the network vessels’ is not a


common illness, but a disorder in the flow of blood,
triggered by harmful affections and emotions and failure of
the qi mechanism to function normally. In general it
resembles the cardio- and cerebrovascular diseases of
modern times and obviously falls in the category of blood
vessel diseases.

1.3 Germination of the treatment of blood network


vessel disease in Zhang Zhongjing’s Shanghan zabing lun

Under the influence of the Neijing and Nanjing theories, the


clinical experience of Chinese medicine accumulated vastly
and brought forth the Shanghan zabing lun. Gradually a
treatment system for blood network vessel disease patterns
and the understanding of the disease mechanisms like blood
obstruction (blood bi), vacuity taxation (xu lao),
accumulation and gathering (ji & ju), oedema and
stagnation of liver qi and blood started to be based on the
viewpoint of network vessel stasis and obstruction. Taking
‘liver qi & blood stagnation’ (ganzhu) as an example, Zhang
Zhongjing said: "In ganzhu disease, the patient constantly
desires to drum on the chest, there is bitterness as didn’t
exist before and a desire for hot drinks, Inula (xuanfuhua)
decoction treats this." Although the text is sketchy, the
symptoms are clear: the sufferer wants to rub his chest or
pound on it in order to relieve discomfort caused by feelings
of stuffiness and suffocation in chest and hypochondrium or
even worse feelings of distension and fullness with stabbing
pains. At the onset of the illness only hot drinks may restore
the flow of the mechanism and the result of the illness,
channel and network vessel coagulation and stasis, can only
be treated with the Inula decoction (Xuan Fu Hua Tang),
which frees the flow in the liver network vessels, moves qi
and blood and scatters the knotted stagnation. Besides
xuanfuhua, xinjiang* is used to move blood and transform
stasis and congjing (=congbai) to connect yang and disperse
knotting. Other prescriptions introduced by Zhang Zhongjing
are: Da Huang Zhe Chong Wan (Rhubarb and Eupolyphaga
Bolus, containing dahuang, tubiechong, shuizhi, mengchong,
qicao, ganqi, taoren, dihuang, shaoyao, xingren, huangqin
and others) for dry blood fatigue; Bie Jia Jian Wan (Turtle
Shell Brew Bolus) which treats ‘mother of malaria’ (enduring
malaria), Di Dang Wan (Dead-On Bolus or: Resistance
Bolus), comprised of shuishi, mengchong, taoren and
dahuang) to treat stasis-knotting and blockage of the
menses etcetera. Although Zhang Zhongjing didn’t speak
clearly of ‘blood network vessels’ and ‘connecting the
network vessels’, thoughts about patterns and treatment of
vessel disease are essentially already concealed in the
above.

* Note of the translator: about xinjiang , a commentary


states: xicaogen or honghua may be used to replace
xinjiang

2. Evolution and in-depth studies

From the Jin-Tang era onwards towards the Song, Jin, Yuan
and Ming dynasties the preliminary Tong Luo doctrine did
not exhibit advanced profundity regarding theory and clinical
medicine, but in the application of herbal substances to
connect the flow in the network vessels and in research,
analysis and practice of qi and blood theory and treatment
methods like connecting, harmonizing and quickening blood,
medical scholars reached an unprecedented level.
Objectively a scientific pillar was constructed which
promoted the ongoing development of the Tong Luo method.

2.1 Application of herbal prescriptions on a clinical level

Collections of herbal prescriptions are a great achievement


of Jin-Tang medicine. The ‘Prescriptions Worth a Thousand
Pieces of Gold’ (Qianjin yao fang, Tang-dynasty) recorded
clinical symptoms of blood stasis and blood patterns
triggered by ‘internal bleeding’ (a kind of haematemesis),
‘lung flat abscesses’ (deep rooted ulcers in the lung,
comparable to pulmonary cellulitis) and ‘stomach damage’,
mainly using dahuang, taoren, mangchong, shuizhi and
other herbs [treating] ‘vomiting of blood and cold pain in the
chest’. The Rehmannia Bolus (Gan Di Huang Wan, comprised
of ganqin, zhechong, dahuang, mangchong a.o.) was used
to treat ‘vomiting of blood with exhaustion and feelings of
restlessness and fullness accompanied by pain’. Recognised
was as well that cooked rehmannia (gandihuang) [has the
ability of] ‘breaking malign blood and connecting the flow in
the blood vessels’ and peony (shaoyao) is able to ‘expel
blood obstruction, break hardness and masses … … and
smooth the blood vessels by scattering malign blood and
expelling robbing blood (zei xue)’.

The ‘Harmoniously Composed Office Prescriptions’ (Heji


jufang) from the Song-dynasty handed down the famous
Minor Network-Quickening Elixir (Xiao Huo Luo Dan,
containing chuanwu, caowu, dilong, processed tiannanxing,
mix-fried ruxiang and mix-fried moyao), a prescription to
warm Yang, connect the flow in the channels and quicken
the network vessels, treating wind cold damp obstruction
and painful limbs. Xu Zhike (Xu Shuwei) in his ‘Generally
Beneficial Original Prescriptions’ (Puji benshi fang) uses toxic
substances from minerals, stones and insects to treat
various kinds of amassment, accumulation, coagulation and
stagnation. Outstanding in this respect is his single use of
shuizhi and mangchong. The formula Warm the Spleen
Decoction (Wen Pi Tang, comprising fuzi, dahuang, houpo,
ganjiang, guixin and gancao) especially treats ‘obstinate cold
in stomach and intestines, enduring abdominal pain and
diarrhoea and irregularity in daily routine’. Essentially this is
chronic intestinal network vessel disease being treated by
perfusing and restoring the flow with pungent and hot herbs.
In addition, we have the Sparganium Dispersing
Accumulation Bolus (San Leng Xiao Ji Wan, which includes
sanleng, ezhu, dingxiang bark, yizhiren, badou, huixiang,
chenpi and qingjupi), recorded in the ‘Discussion on
Stomach and Spleen’ from the Jin-dynasty, which treats
feelings of fullness and suffocation in heart and abdomen
and belongs to the prescriptions which pungently and
ragrantly connect the network vessels. The Spirit Protection
Bolus (Shen Bao Wan, including muxiang, hujiao, badou and
ganxie) which treats blood pain, kidney qi pain etcetera and
also conceals the method of freeing the flow in the network
vessels with pungent-hot and pungent-salty herbs.

2.2 Scientific accumulation and condensing on the


theoretical level

The scientific contend between the medical scholars of the


Jin-Yuan period accelerated the continual development of
various theories including those of ‘Luo disease’ and ‘Tong
Luo’. Outstanding are the ‘Profound Residence Qi and Fluid
Perfusing and Connecting’ and ‘Qi and Blood Free Flow’
doctrines of Liu Wansu and Zhang Congzheng respectively.
Doctor Liu’s theory holds that the interstitial subcutaneous
layers of the whole body, called ‘Profound Residence’ (Xuan
Fu), need to be unobstructed to guarantee a free flow of the
construction (ying), defense (wei), qi, blood and fluids
through the depots and palaces (zangfu-organs), the
channel network and all limbs and bones, under the control
of the ‘Spirit Mechanism’ (Shen Ji). In this way normal
functions of the body are supported, resembling the
[condition] described by Zhang Zhongjing: "When the
original and true [qi] of the five palaces (zang-organs) is
flowing unhindered, man is at ease and in harmony’’. But
once the ‘Xuan Fu’ is blocked by a disease evil, the flow of qi
and fluids are hindered, the physiology obstructed and
myriad disease patterns arise. To illustrate this, in ‘severe
heat blockage of the subcutaneous layer (couli) and
stagnation-knotting’ we often see disease signs as feelings
of stuffiness and fullness, diarrhoea and diarrhoea with
bloody and purulent stools (dysentery), vaginal discharge
(leucorrhea), painful and difficult urination (strangury),
enuresis, nodes and lumps [under the skin], throat
obstruction, deafness, blindness and also wind stroke,
dispersion thirst and the like, while ‘the gravity of the
disease follows the severity of the stagnation-knotting’.
Herbal treatment methods emphasize opening and spreading
of the stagnation-knotting, restoring the normal condition of
unobstructed flow of qi, blood and fluids, like employing the
pungent and cool [tastes] of shigao, huashi, gancao,
cong[bai] and [dou]chi to open and spread stagnation-
knotting or the combined use of cold and warm in the
‘Reaching Treasure’ and ‘Spiritual Treasure’ Pills to ‘scatter
wind clogging and open knotted stagnation’. Liu Wansu also
invented the Peony Decoction (Shao Yao Tang) which, ‘using
flowing to treat flow’, moves qi, quickens blood, unblocks
and leads out stagnation in the treatment of dysentery.

The famous medical scholar Wang Haizong (Wang Haogu) of


the Yuan-dynasty wrote in a commentary: ‘’Doctor Liu’s use
of herbs concentrates on pushing away the old to bring forth
the new, not letting a trace of glowering (bad) stagnation",
thus shedding light on the scientific characteristic of Liu
Wansu’s: stressing the importance of opening stagnation,
expelling nodes and make qi and fluids flow freely. He was
not alone in this: tracing doctor Liu’s steps was Zhang
Congzheng, who also stressed the value of ‘connecting’. The
medical circle of Xian Weizi and doctor Zhang exclusively
used the three methods of sweating, vomiting and purging,
unaware that what those three methods intended to do was
exactly dispelling evil to restore blood and qi flow in the
body. These scientific circumstances which were stressing
the importance of ‘flow and connection’ made him deeply
become aware that "in the Neijing, only the free flow of
blood and qi is regarded as valuable". Clinical attack of evils
"makes the upper and lower [part of the body] free of
obstruction, qi and blood flow smoothly and clogging and
stagnation disappear", "like old chopped straw being
expelled, the intestines and stomach resolve, when
abdominal lumps are finished, ying (construction) and wei
(defense) flourish". Doctor Zhang stressed: "In the so-called
connecting prescriptions, unobstructed flow is meant … … in
every case of painful obstruction and numbness and
abundant stagnation, the channels are hidden and do not
flow, without connecting prescriptions this cannot be cured".

Near the end of the Yuan dynasty, Zhu Zhenheng (Zhu


Danxi) proposed his doctrine of ‘the Six Stagnations’,
saying: "When qi and blood are vigorous and in harmony,
the ten thousand illnesses do not arise. As soon as there is
glowering (bad) stagnation, the various diseases are
sprouting forth from it". He created the Overcoming
Restraint Bolus (Yue Ju Wan), which moves qi and resolves
stagnation, treating all of the six stagnations. Miao Yiyong
(Miao Zhongchun) of the Ming-dynasty also makes effort to
explain the theory of: ‘One should move blood and avoid
stopping the bleeding’, stressing that in blood coagulation,
stasis and stagnation, blood not following [the flow] in the
channels may lead to new bleeding, while with the method
of moving blood, powerfully promoting guidance, the result
of ‘by not stopping it, it spontaneously stops’ can be
obtained. One of his three methods to treat qi and blood,
called ‘connecting blood’, mainly treats heat effusion,
yellowing, painful swellings and nodes, lumps and addictive
masses. To enumerate the herbs he uses to ‘connect blood’:
danggui, honghua, taoren, sumu, rougui, wulingzhi,
puhuang, jianghuang, yujin, sanleng, yanhusuo, huaruishi,
moyao, zhechong, ganqi, zirantong (natural copper), jiuzhi
(garlic juice), tongbian (little boy’s urine), muli, mangxiao
etcetera. The nature of these herbs include the following
tastes: pungent-warm; pungent-hot; pungent-neutral;
pungent-cold; pungent-salty and sweet-warm.

In the survey of the vast space of more than thousand years


from Jin to Ming, running through successive generations of
medical scholars, we see an overall interest in and close
examining of the medical contents and experience of moving
qi, quickening blood and connecting the network vessels.
The pluralistic and symbiotic development of medical schools
of thought imperceptibly established a foundation for the
depth and completeness of the Tong Luo method for later
generations.

3. Formalization and conformation

With the publication of Ye Tianshi’s ‘Luo disease’ theory, the


Tong Luo method took fundamental shape. Throughout the
‘Clinical pattern guide and medical case histories’, which was
arranged by his pupils, related information can be found.
Through an overall arrangement, aspects of his systematic
learning become generally distinct.

3.1 Essentials of Ye Tianshi’s Luo disease theory


The central argument is: "At the onset of disease qi knots in
the channels, in the long run this leads to blood damage
entering the network vessels". This means that all externally
contracted cold, summer-heat, damp-heat as well as
excessive taxation damage, yang qi being harmed, anger
stirring the liver, stagnation and knotting of the seven
emotions etcetera all can lead to qi and blood obstruction
and stagnation which harms channels and network vessels.
At the onset of disease, when evil [qi] is knotted in channels
and vessels, lack of treatment, wrong treatment or a
dragging on of the patient’s condition causes the disease
factor to gradually enter a deeper level, resulting in ‘blood
damage entering the network vessels’, that is: Luo disease
taking shape. ‘Luo’ here means the blood network vessels,
mainly situated in the deeper layers of the body. Obstruction
of the blood network vessels and movement of blood being
hindered may cause the emergence of swellings and lumps
in Luo disease, accompanied by aggravating and enduring
pain. Static lingering withered blood may express,
depending on the location, as pathological masses, [lumps
occurring in] enduring malaria, internal hernia with forceful
and deep noticeable pain, ‘hardness solid as thorns’, and,
when severe, clinical manifestations as dark complexion,
crimson-purple stasis spots on the skin, a wiry and rough
pulse etc. appear. Grounded in theory and clinical practice,
this view explains clearly that any disease reaches channels
and network vessels, qi and blood and in the course of time
shifts from superficial to deep, from channels to network
vessels, from the qi aspect to the blood level and from
formless to having form.

3.2 Dr. Ye’s four Tong Luo methods using the acrid
(pungent) flavor

Since in Luo disease blood damage is hidden deeply, violent


attack is not fruitful, harsh medicinal substances can easily
damage right (regular, zheng) qi and therefore in treating
Luo disease one should concentrate on ‘gently connecting’
and because ‘the Luo are drained with the acrid flavor’, the
acrid flavor acts as the ruler [in this method].

1) Acrid and moistening Tong Luo method


This is the fundamental method. The acrid flavor is used to
moisten (the luo). It is able to diffuse, disperse and open
and reach the subcutaneous layers (cou li), move fluids and
frees the flow of qi and blood. It is used widely to treat
hypochondrial pain, stomach pain, stagnation patterns,
blood loss, yellowing etc. Substances used are: xuanfuhua,
xinjiang* and qingcong, added: danggui, taoren, baiziren,
yujin, yanhusuo, chuanlianzi and others.

* note of the translator: about xinjiang, a commentary


states: xicaogen or honghua may be used to replace
xinjiang

2) Acrid and warm Tong Luo method

Acrid and warm medicinal substances which disperse cold


are the rulers. Widely used to treat cold damp congealing &
stagnation, internal prevalence of yin cold [causing] network
vessel obstruction, like accumulations (ji) and gatherings
(ju), stomach pain and other patterns.

Substances: rougui, fuzi, guizhi, xiebai, ganjiang,


(xiao)huixiang a.o., sometimes puhuang, wulingzhi, taoren
and others are added.

3) Acrid and fragrant Tong Luo method

Here the main medicinal substances are those with an acrid


and fragrant flavor; substances that move and penetrate.
Often used in heart pain, pain in the umbilical abdomen,
stomach pain, hypochondrial pain, conglomerations (jia: a
type of abdominal mass) and gatherings (ju: a type of
abdominal lump) and other patterns. Dr. Ye said: "In
enduring illness located in the Luo, qi and blood are
obstructed, acrid and fragrant [substances] are needed to
free their flow". Acrid and fragrant diffusing and outthrusting
(xuan-tou) and coursing and draining the qi mechanism
(shu xie qi ji) substances used are: jiang(zhen)xiang,
muxiang, xiangru, biba, (xiao)huixiang, xiebai and congbai.
Often ruxiang, moyao, danshen, jianghuang, taoren,
chuanshanjia and others are added.

4) Acrid and salty Tong Luo method


This is the method of harshly attacking, it is used in
headaches, stubborn obstruction, pathological
conglomerations, accumulations and gatherings and other
enduring and difficult to cure Luo diseases. Dr Ye said: "By
means of the tracking and expelling [action] of insects and
ants in blood, evil knotting is being attacked and unblocked”
and "Taking advantage of the velocity of insects and ants,
their flying and walking is both efficacious. In order to fly
they rise and the walkers descend; there is no blood
congealment and qi can flow freely".

Medicinal substances used are: qianglang, fengfang,


mengchong, dilong, quanxie, zhechong, chuanshanjia,
qicao, jiangcan, shuizhi, wugong and others.

The four Tong Luo methods are the inherited result of Dr.
Ye’s broad involvement in clinical practice and the
formalisation of the Tong Luo method has furnished the
treatment of various difficult and stubborn clinical patterns
with a new way of thinking.

3.3 Extended use of the Tong Luo method

Medical scholars of the late Qing paid close attention to


bleeding patterns and blood stasis, imperceptibly this
became the [focus] of development and continuation of the
Tong Luo method. ‘Treatment of blood stasis discussed in
parts and sections’ (fenbu lunzhi xueyu) is the outstanding
scientific achievement of Wang Qingren’s. Amidst four
prescriptions to treat stasis there is the Blood Mansion
Expelling Stasis Decoction (Xue Fu Zhu Yu Tang). Although it
is said that it treats blood stasis in the blood mansion above
the diaphragm, it actually can be used for blood stasis in the
whole body. What is called ‘Blood Mansion’ in essence refers
to blood network vessels, arteri