Hi, good afternoon. My name is Poney Chiang. I’m a practitioner of acupuncture and traditional Chinese medicine from Toronto, Canada. Welcome to today’s American Acupuncture Council live Facebook podcast show. I’m your host for today. And since this video is taking place on the week of Valentine’s Day, I thought I would do something fun and present something that is heart-related or heart region-related. So, let’s get started with today’s presentation.

The title of my presentation is Wear Your Heart on Your Sleeve. And the subtitle, Neuro-Anatomy of Heart-Four to Heart-Seven. It’s kind of a tongue-in-cheek idea that Heart-Four and Heart-Seven are very close to our wrist, so it’s very close to the sleeve and obviously because it’s Valentine’s Day, I chose to talk about the heart meridian.

The painting you’re looking at is the painting that was done in the year 1900, and it was painted by artist named Edmund Leighton. It is, as you can see, a princess or a fair lady tying a scarf or handkerchief to the sleeve or the arm of a knight. This is supposedly one of the origins behind the English expression to wear one’s heart on your sleeve, which of course means somebody who speaks their mind, somebody has no agenda, who is very direct. What you see is what you get. And here, this knight, by wearing the sleeve from the lady, from the princess, means that he is fighting for the princess’ honor. And therefore, he is identified as vouching or speaking or defending the lady pictured here in the painting.

What we’re going to do first is we’re going to look at the historical development of these points, particularly heart meridian points in the early classics. What I mean by early classics are works around the time of the Han Dynasty or shortly after. So, as you know, the LingShu or the Yellow Emperor’s Classic of internal medicine has two volumes, the plain question, which is the Suwen and the LingShu, which is spiritual pivot. And in chapter 10 the spiritual pivot we learn about the channel theory… And the channel pathways of the different channels on the body. And there is one paragraph that is focuses on the heart channel. Now in this paragraph, on the chapter 10 of the LingShu, entitled Channel Vessel, it says that there is a Luo Channel or what the classic described as a separation.

So if you look at the second bullet under it says “Pathway: the separation of the hand, lesser yin or shao yin is named Heart Five”. And so here we actually have a point identified by its name. Of course then there’s your classic, it would be called Tong Li, the Chinese name of the point instead of heart-five. It says that it’s located one and a half cun from the wrist, separates and course upwards, follow the channel enters into the heart, connects to the tongue root, joins the eye connection and so on and so forth.

Now if you are very good at point location, you might be scratching your head a little bit and wondering, hey, wait a minute. Tong Li, it’s not one point five cun, it’s actually supposed to be one cun from the wrist. So this is an example, a lot of discrepancies we see in the classics at the time of the LingShu, heart-five was actually considered a one point five cun on their wrist, as opposed to the way it is currently taught as one cun from the wrist crease.

But that’s another reason why I’m talking about this. That’s just kind of interesting trivia. I’m introducing to the idea that in the time of the suspicion pivot, we’re starting to have a little bit of introduction to certain points in the heart Meridian, and we know at least our heart file Tong Li is supposed to be in the heart meridian or the hand lesser yin meridian. But you may be surprised that very few points from the heart Meridian are actually recognize by name and location at the time of the yellow in person internal medicine. The only other place that hints at a location of a heart point from the heart Meridian is in the insert chapter 52. The title of that chapter is called Wei Qi as in defensive Qi and there they talk about, if you look at the fourth bullet on the page: the root of the hand shao yin, it’s at the tip of the sharp bone manifest at the back shu.

So here are the top of the hand shao yin, which is the heart meridian and that the root of this Meridian, it’s at the tip of the sharp bone. We modern scholars believe that the sharp bone refers to the pisiform bone in the wrist, in the carpals of the hand which has a bony protrusion and what I want you to notice is that they’ve located this point where we would consider a heart-seven but there’s no mention of shenmen or the name or the Chinese name for heart-seven itself.

And so what that means is that at the time of the Yi Jing, we only have one point for the heart Meridian mentioned by name and location, which happened to even be in disagreement with what is taught later on. And even heart-seven or shenmen, it’s simply just described by location and as names are not mentioned at all.

So that’s only a two out of the nine points in the heart meridian that has been passed down to us today. So the other seven points and not even mentioned by name or location. They don’t actually appear in the knowledge of Chinese medicine textual history until, if you look at the last final bullet in the Jia Yi Jing. This is the meta classic of acumoxa [inaudible 00:07:49] which is probably around the third century.

I put down eight points because heart-seven wasn’t actually mentioned by name. This is why it’s a meta classic where Jia Yi Jing considered the first complete acupuncture manual. There are points that are not described at the time of the of the yellow emperor.

This a nice little zoomed in view of the points on the wrist and the center of the photo is as you can see, heart-four, five, six, seven closely juxtaposed to each other. In fact, heart-seven is right on the crease line. Heart-six said to be half a cun from the crease line, heart-five is one cun from the crease line, and heart-four is one point five cun from the crease line.

And we just saw that even that is disputed because back in chapter 10 where the LingShu, they actually say heart-five is one and a half cun, which is where we look at heart-four today. So the reason why I decided to talk about the heart Meridian points in the wrist. You know obviously you tongue in cheek play on words about the one issue one wears the heart on one’s sleeve and it happens to be Valentine’s day.

But I love examples like this because it really highlights for us the specificity and the lack of redundancy that goes behind how ancient acupuncturists and who I like to call ancient anatomist pass down these points. A lot of people would ask me in my workshops is heart-four or five, six, seven just one point. Because one looks at them as so close and any reasonably educated person would ask that question, why would you have four points? That’s such a tiny little space. Now this is where the brilliance of the ancient acu-anatomist comes in. They pass on these points for very specific reasons is because in fact they are different anatomically. And this is the focus of our presentation today.

Before we jump into very new anatomical, I’d like to just acknowledge William Shakespeare in his work, the Othello at point scene 1. Is this the first textual? A record of the saying wearing my heart upon my sleeve. So there’s a character in the play, Othello’s play, who says that “when my outward action doth demonstrate the native act and figure of my heart in compliment extern, ’tis not long but I will wear my heart upon my sleeve, for daws to peck at”, daws are apparently some kind of Ravens and not what I am.

So if I am not consistent internally and externally I’m not what I seem to be, I am therefore not worthy and deserve to be pecked at by these ravens or and as such. So just in case you were wondering what the expression means and I like to share these kind of food for thought information. It gives a little more context and also helps give us some association when we think about these points.

Now we’re going to jump into the real anatomical and this diagram here comes from Grey’s Anatomy and I would like you to note that there’s two red boxes here on the very top of the page is the ulnar nerve box. And then in the lower box if you read closely, there’s actually two different branches here. One says superficial branch ulnar nerve, the other one says the deep branch of the ulnar nerve. So what I would like you to appreciate is that if you follow the deep branch of the ulnar nerve, you can see that it kind of plunges into the thin arm muscles. And then it actually kicks across towards the left side of the slide, that horizontal branch, that is as also labeled, it’s called deep branch ulnar nerve, it innovates the interior osseous muscles.

These are the muscles that allow you to abduct and adduct the fingers. And it actually makes it all the way into the abductor pollicis muscle. And that’s the muscle that allows you to abduct the thumb. So just another [inaudible 00:12:26] muscle. But because it’s associated with the thumb we call it abductor pollicis instead of interosseous pollicis. So all these branches become important because in a moment we’re going to see how brilliant ancient acupuncturists are in their knowledge of this anatomy and assign different points to each of these specific branches.

So in this video I’m going to show you the needle is inserted into heart-four, and heart-four is assigned the ulnar nerve trunk. Obviously you can stimulate heart, the nerve channel front, I’d say small intestine eight in the elbow, but at that level, the anatomy, it also innovates some wrist extensor muscles. But once you come distally to the level of heart-four it is sort of the first stop before it branches into this deep and superficial branches I just mentioned.

Now because it is superior to the deep motor branch, which I just described, innovates the interosseous muscles, when the electric stimulates that it would stimulate everything downstream of it. So including the superficial branch, which is responsible for the cutaneous sensation of the palmar in the back of the hand, but only for the median one half fingers. Okay, so according to ulnar nerve distribution, but unfortunately because the video cannot demonstrate parasthesia or tingling sensation that the subject is feeling. All we’re going to see is the motor aspect of this mixed nerve trunk at heart-four.

So when I play this video, you’re going to see that there is movement of the fingers. The thumb is moving. In fact, when they sustain a stimulation, what you can see is that there’s an opposition. So the thumb and fingers are coming together by virtue of contraction of the Athena and hypothenar muscles. Sorry, by virtue of the contraction of the hypothenar and abductor pollicis muscles, not the hypothenar muscles. That actually is in fact innovative of the meridian, not the ulnar nerve. I’ll play the video one more time, so you can see. But in addition to the motor aspect you’re seeing with interosseous muscles moving, this subject is feeding tremendous paresthesias or numbness and tingling into the palmar side of the hypothenar and also into the dorsal side of the median one half fingers.

So this color coded image is meant to remind everybody how the ulnar nerve and median nerve covers different terrain in the hand. If I can draw your attention to the left side of the slide, you’ll see the dorsal aspect of the hand. And you can see that in pink, that’s the distribution of the meat of the radial nerve. Now, whereas in green is a distribution of the ulnar nerve. But if you look closely at the dotted line that’s pointing to the back of the hand in the green section, it actually says the dorsal branch. So we haven’t talked about that branch yet. There’s a dorsal cutaneous branch that goes to the back of the hand, but only the one and half fingers. In some people it can be two and a half fingers. Okay. As you can see by the separation where the pink and green separates in the center of the middle finger in this diagram.

Now if I can draw your attention to the right side, now we’re looking at the palmer side of the hand, and you will notice that the palmer side is innovated not by the radial nerve anymore in Brown color. We see that is innovated by the median nerve. So the median nerve is in fact responsible for the palmer innovation, including the palm and fingers of the lateral, three and a half fingers. And then whereas in green you see that the ulnar nerve, if you look at where the dotted line is pointed to the palm, you’ll see that there’s actually two sections. There’s a cross hatch section closer to the heel of the hand that is labeled as the ulnar nerve palmer branch. But when we look at the dotted line as pointing to more kind of the ball of the palm, that is innovative as the ulnar nerve digital branches.

So all in all we have seen palmer branches, digital branches, dorsal branches. Let’s take a look at how these all perfectly super impose on these acupuncture points around the wrist. This slide talks about heart-five and heart-five is also the low point, which means that it’s supposed to connect into an exterior relationship. So the exterior relationship to the heart is there is none other than the small intestine the hand tai Yin. So as a point, it is supposed to traverse from the yin side of the wrist and hand into the yang side of the wrist and the hand going from in other words, the heart to the small intestine or from the shao yin to the [foreign language 00:17:38]. And now what’s very beautiful is that there is exactly a nerve branch of the ulnar nerve that does that.

If you look at the black and white photo on the bottom portion of the slide, you can see on the left side, I have two points as labeled heart-five and small intestine five. The dotted white line on the left side of the photo here represents the outer contours of the ulnar bone. And you can see that the ulnar nerve is labeled in white here with the arrow, is continued into the hypothenar, but on its way to doing that, we have this brand exactly where heart-five is located, where the red dot is on a slide. It branches towards small intestine five in other branches from the yin side to the yang side of the body. So this branch is called the dorsal cutaneous branch and it perfectly satisfies channel theory that is a low meridian point.

This is a dissection. That is from The work that we’d done, the nerves are not naturally yellow like this. They’ve been colored in by an artist to make it more easily visible. And so I want to just start by helping you orientate yourself. You look at the legend on the bottom right, you’ll see that the arrow pointing down is distal. Arrow pointing up is proximal. So imagine this is somebody’s arm pointing downwards and then the ulnar side is actually the right side of the slide and the left side of the slide is the radial side. Let me just help orient you again. This metallic probe you see towards the left side of the wrist here is lifting up the tendon of flexor carpi ulnaris to expose the neurovascular bundle of the ulnar nerve and artery.

In this slide here, C would be the flexor carpi ulnaris muscle. B is pointed to the neurovascular bundle and A is pointing to that [inaudible 00:19:53] branch that is now going to become heart-five. Just as an aside, [inaudible] is actually ultimately bifurcates and becomes small intestine six and small intestine five later on. But that’s beyond the scope of our [inaudible 00:20:08] and discussion for today. If I can draw your attention to heart-six, the arrow heart-six, you’ll see that it is centered over the vessel and we’ll talk more about that. And then heart-seven is on the wrist line.

What’s interesting about the heart-six is that this point has an unusual location. Remember I said these points other than heart-five was just identified by name or location in the special pivot. Points like heart-four, heart-six and seven are not even mentioned by name in the yi jang. So the first time that heart-six ever appears is in the jia yi jang systematic classic and its location is kind of unusual. If you look at the description at the top of the slide I’ve bolded it and highlight it for you in red. It tells us that this point is in the pulse behind the palm, five fen towards the wrist. A fen is a 0.1 cun so, five fen basically means half a cun. But it’s interesting is that is located at a pulse. Now if you can take a look at this black and white photo.

This photograph is taken from the article, The Nerve of Henle: An anatomical & immunohistochemical study for the general hand surgery. And these hand surgeons were interested in finding out more about the anatomy of the ulnar nerve. And you can see it labeled in this diagram here. A, if you look at the left side of the black and white photo, A is the ulnar artery, n is the ulnar nerve. But you see that there’s a star labeled. That star, see how I try for a case on the right side of the photo, that’s actually the branch that goes to the palm and if you remember the colored photo of the distribution of the nerves in the hands, I talked about a cross hash portion around the heel portion of the hand. That’s in fact where those three branches towards the right side goes through.

That’s called a palmer branch. But notice that they’re asterix in addition to the star in this photo and notice how those small branches that represent labeled by the asterix are actually intimately touching the ulnar artery itself. So the significance of this is that the ulnar nerve gives innovations to the ulnar artery. What kind of innovations? Sympathetic innovations, a type of autonomic innovation that controls the smooth muscles of the ulnar artery to control its vasal constriction. And that the classics is the meta classic, we’ve mentioned that this point is in the pulse is telling us that they are more concerned about stimulation of the rich autonomic fibers associated with the artery.

Now it is of no coincidence then that we have learned through pre-occurring experience and knowledge passed on by our mentors that heart-six is one of the most important points to regulate sweating inside of body together with kidney-seven. And why would that be? Because these points are intimately related, associated with the vessels and by stimulating the vessel you are stimulating the sympathetic aspect of the nervous system and sweating is indeed a part of our physiology that is controlled by the sympathetic nervous system. Isn’t that very interesting how the function and anatomy and the historical point locations all perfectly intersect.

The last point is heart-seven. If you look at the color photo on the bottom of the slide here, you’ll see heart-seven clearly labeled. But if you just look a little bit to the right of where heart-seven’s located, you’ll see that there are three branches, right? So the letter C is pointed to two branches that corresponds to the digital branches of the palmer side of the ring, the index and the pinky finger. And then there’s our breads B. That B branch is actually that deep motor branch, the one that actually innovates interosseus muscles.

We saw how stimulation of the the mixed nerve trunk, which contains a sensory and motor aspect. What activate the interosseous and adductor pollicis muscles. So the significance of heart-three or seven, my apologies, is that it is the beginning of the superficial branches of the ulnar nerve. I hope you can see that every single location differ slightly in terms of what nerve has already left the main trunk. So that there is very, very high degree of specificity in the rationale behind why these points are passed down individually and so close to each other.

So I’d just like to finish by giving you a little bit of clinical applications. Anatomy is interesting, exciting, but at the end of the day, that information is to give us more intention, clarity and specificity in our needling. And so we want to talk about how that can be used in a day to day situation. If you are familiar with the type of nerve entrapment called Guyon’s Canal Entrapment. If you look at the picture on the bottom right, it’s also called a handlebar entrapment it’s very common in cyclists that might press the weight of their entire upper body onto the heel of their hand. And as you can see if on the red little lightening symbols, that’s where the pressure and people can feel a nervy electrical sensation. And so if you have some understanding of the… it can differentiate diagnose this type of entrapment.

One way for you to deirritate and improve neural conductance, restore proper neural conductance back into his nerves because it was impeded by pressure. You can needle points like heart-seven, points like heart-four and apply electricity to help deirritate this nerve that has been impinged. One situation that often used the heart-four point for is actually is for restoration of fine motor function. This can happen in patients who have multiple sclerosis. This can happen in patient who has suffered a stroke and they lose the ability to do fine opposition movements and I have found that electrical stimulation of their mixed nerve trunk allows a reactivation of the interosseous muscles and the adductor muscles and hypothenar muscles so that patients can increase their motor control or motor activation of these muscles so that when they do occupational therapy exercises or hand specific fine motor exercises or games, they are going to get more out of those exercises because now the nervous system is firing at it’s optimal efficiency.

Heart-five, it’s name is called Tongli which translates, that’s penetrating interior. It’s traditionally associated with the treatment of aphasia because as you know, the heart orifice is the tongue and the channel theory pathway tells us that heart-five has control and dominance on the heart. But because these points are so close, heart-four to seven, how do you know you actually stimulate heart-five? What if you stimulate heart-seven instead, right? Heart-seven stimulation would feel like palm numbness and parasthesia in the pinky and the ring finger and the palmer side. But whereas heart-five there’s just sensation or parasthesia, ought to feel like numbness and sensation on the dorsal side because of the dorsal cutaneous branch that covers that territory.

So if you are really wanting to use this point to benefit aphasia and tongue and speech and so forth, or to just open the lower vessel, the proper sensation needs to be parasthesia and numbness on the dorsal part of the hand as opposed to the Palmer side of the hand. Finally, heart-seven is called shenmen or a spirit gate, is associated with calming the nervous system. And we already talked about how things like… Points like heart-six because close association to the vessel as very rigid RNI fibers. We saw that how we can conceptualize how that can have effect on sweating, which is a sudomotor response where they get regulated by the automatic nervous system. But similarly heart-seven being able to calm their shenmen, helping insomnia means that by regularly the automatic nervous system is somehow puts the body into a parasympathetic state to improve various type of autonomic dysfunctions.

I want to finish that up this last slide as example of how to use this for a neuro rehab situation. So what you’re still about to see is a patient who has multiple sclerosis at a time that she saw me in the clinic, it’s been about four or five years. She’s developing a lot of spasticities. She has some drop foot happening and upon physical examination we noticed that she was losing fine motor dexterity of her hand. So the top video I will play to you, will demonstrate to you that she’s been instructed to open and close her fingers. The effected side is her right side and then she’s instructed to open and close her fingers. Then she’s going to be instructed to abduct and adduct her fingers. And you can notice that there’s some contracture in the index and middle finger. That’s her attempt to abduct and look at how well the left side works.

The right side cannot abduct at all. And now she’s shaking out her hand because you’d probably be embarrassed. Okay, so just play that one more time so you can just compare for yourself. I’ll stop talking. There’s not much abduction and adduction of the fingers whereas the left hand side is completely normal. And this is important because the deep motor branch of the ulnar nerve is that responsible for the innovation of those interosseous muscles. And so what I did is I put needle heart-four, apply electrical current and because heart-four is the mixed nerve trunk, it will get everything downstream. They’ll get the sensation on the palmer side, on the dorsal side. You’ll get the deep motor branch, you’ll get the supervision branches and immediately after the first treatment and there is that. Now the ability abduct and adduct the fingers is immediately improved.

And that just goes to show you how adaptive are plastic our nervous system is even for something that’s been going on for several years. One treatment, as long as you’re able to have high specificity, you can really do a lot to help these patients. So that’s all I have prepared for you guys today. I hope you enjoyed that. I hope you learn something interesting about the heart points around the wrist and that they are in fact not the same point. They are very, very specific information that ancients have passed down for us. I hope that inspires you to review anatomy. Because I firmly believe that the more you understand neural anatomy, the more specificity you can have with your needling and then the better outcome you can deliver to your patients. Thank you very much everybody for listening. I wish you have a happy Valentine’s Day and don’t forget to join us next week. Our speaker for next week is Sam Collins. Thank you.

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