The Punkling's Guide to Japanese Meridian Therapy

Version 0.9

Robert Hayden

Copyright 2015

POCA TECH STUDENT COPY NOT FOR GENERAL DISTRIBUTION PLEASE DO NOT SHARE WITHOUT PERMISSION

1 Introduction NOTE: This is an unedited copy of the first half of a longer work.

This book’s ostensible purpose is to be a textbook for the class I am slated to teach on Japanese acupuncture at POCA Technical Institute. So, this first section of the book is going to be a presentation of that very thing, a sort of basic introduction to a rather orthodox version of Japanese Meridian Therapy. I decided to mostly stick to a very simple, almost skeletal form of JMT; my view is that the more basic and skeletal the structure is, the more it is open to possibilities of personal variation and thus the more practical it is for purposes of one’s own particular clinical context. Certain chapters will present some variations I have learned that I have found useful, but for the most part, what you will find is a very rudimentary version of the style.

I will state right now for the record that there are far better books on the subject, which will be referenced in the text and/or listed in the bibliography. I highly encourage anyone who is interested in learning more to seek out one or more of those books.

Since this book is aimed at second or third year acupuncture students (and beyond), I assume that the basic theories of Yin Yang and Five Phases have been learned. For discussion of those theories, I refer the reader to basic texts such as John Pirog’s Dark Warrior Guide to Chinese Medicine. I will discuss Five Phase correspondences which directly relate to the material, as well as more advanced theories such as Ten Stems.

Terms and Names As regards the nomenclature of Chinese medicine, I have not adhered to any single standardized term set. I chose to use terms which I feel are easily understood by the reader. Some standard conventions have also influenced my choices; since the Japanese term Keiraku Chiryo is most often translated in English as Meridian Therapy, I have decided to adopt that term and thus Keiraku or Jing Luo is rendered as “meridians” rather than “channels”. Japanese and Chinese names are rendered in their standard order (family name first) except in cases in which the person in question is already well known in the West under their name rendered in the Western convention (given name first, family name last).

It is my hope that this work proves useful to the students of POCA Tech, and whoever else happens to read it.

Robert Hakim Hayden Hollywood, Florida, 2016

2 Part 1

Bits of Theory

3 NAN JING

The Nan Jing, or Classic of Difficulties, is a text written sometime during the Han period (about 300 CE). Its author is usually named as the legendary physician Bian Que, though we can’t be sure who really wrote it. The book is a short work of 81 chapters, each answering a “Difficult Question” on Chinese medicine; in other words it is meant to clarify some issues which were raised in previous classical texts such as the Huang Di Nei Jing Su Wen and Huang Di Nei Jing Ling Shu. More than merely a commentary on the Nei Jing, the Nan Jing itself introduces some revolutionary concepts not found in earlier works. While a complete discussion is outside of the scope of this book (I would refer the reader to Paul Unschuld’s exhaustive work on the text), I think it is important to point out some features of the work and its importance to the formation of JMT.

It is almost entirely a work on acupuncture.

It is internally consistent.

It is a based almost entirely on Five Phase theory.

It is brief and thus amenable to memorization.

I remember visiting the clinic of one of my Japanese instructors in Tokyo. On the wall was a large framed work of calligraphy; it was the first chapter of the Nan Jing. The sensei, who was blind (one of the many blind practitioners I took instruction from), proceeded to recite the entire passage from memory. It was a very touching moment, to see the reverence he gave the classic, and it underscored how the Nan Jing is seen as the foundation of JMT.

SOME AXIOMS

JMT makes use of some fundamental axioms which guide the practitioner in organizing one’s thinking about diagnosis and treatment. They aren’t absolute dictates to be followed slavishly; rather they help explain why the system is set up as it is. Some of them are similar to other styles of East Asian medicine and some are dissimilar. The explanations of each reflect some of what I was taught and some of my own thinking on the subject.

Yin Leads, Yang Follows In some ways this may seem counterintuitive; Yang after all is the active principle and one may say that those who are naturally more active are more apt to lead. The first number (after zero, which

4 is neither odd nor even) is one, an odd number and odd numbers are Yang. But consider that our day begins at Midnight, the most Yin time, and in the Abrahamic religions such as Islam and Judaism the day begins when the sun has set (when Yin overtakes Yang). The first stem is Yang in that it is numbered one and ruled by the Gallbladder, but consider also that of all the Yang organs, the Gallbladder has the function of storing and thus behaves like a Yin organ; this is why it has the designation of being an Extraordinary Fu organ.

In any event, a simple explanation of this axiom is that it refers to the organs themselves, and that the Yin organs are charged with storing Vital Substances such as Qi and Blood. The Yang organs have the function of transmitting, separating and excreting food and waste. Without the function of storing Qi, no transmission, separation or excretion will take place. The beginning of life outside the womb primarily involves the Lung and Kidney, with the initial breath of the newborn sparking the Mingmen. So, as far as the organs are concerned, the function of the Yin organs is primary.

Yin tends to Deficiency, Yang tends to Excess Since Yin organs store, their dysfunctions tend to involve deficit of Vital Substances. The Yang organs, on the other hand, tend to manifest accumulation and “stuckness” if their functions go awry.

First Deficiency, then Excess Following the above axioms, if Qi is depleted, nothing will move or transform. If there is sufficient Correct Qi (ability of the body to resist and recover from disease), no external pathogens will penetrate the body’s defenses. So underlying all problems of excess is a component of deficiency, and unless the deficiency is addressed, the condition of excess will reappear no matter how often it is drained.

First Tonify, Then Drain Here is a key difference in treatment principle between JMT and TCM. In TCM, the basic idea is if you are looking at an excess, it needs to be cleared before tonification can take place. As my first year theory teacher would say, if you want to redecorate a room, you have to clear the old furniture out first. This is very important in Chinese herbal medicine; since tonic herbs tend to be heavy, starchy or sticky, it is difficult for the body to digest them if there is any accumulation in the digestive system. But JMT takes a little more vitalistic approach; the goal is to help the body to heal itself, and this is done through enhancing its ability to store and use Qi. As we shall see later, the emphasis is on using what healthy Qi the body has - according to what I was taught, tonification is first done on the side of the body that has more Qi, in order to circulate it to

5 the less healthy side.

All of this taken together means that in JMT treatment usually begins with tonifying deficiencies in the Yin organs, and afterward draining excess in the Yin and Yang organs that are determined to be excess.

FIVE PHASES

Japanese Meridian Therapy is grounded quite firmly in the theory of Five Phases; this follows from its adherence to the Nan Jing, which is perhaps the most rigorously consistent example of the application of Five-Phase theory to be found in the Chinese medical classics.

Five Phase theory is usually learned in the earliest weeks of a standard TCM-oriented acupuncture program, and, once tested on, summarily forgotten. Beyond the Five Tastes, Chinese herbalism has little use for Five-Phase theory (indeed, the Five Tastes themselves often get short shrift when teaching the Materia Medica), and TCM acupuncture largely follows the priorities of herbal medicine. Invariably, when reviewing for the acupuncture boards in third year, students need a refresher on Five Phases. What follows here is not a complete review - you’re invited to go to one of the standard textbooks for that - but some reminders which may be useful to the discussion at hand.

The Five Phases themselves Phase Wood Fire Earth Metal Water

Correspondences to Organs, Meridians, Tissues and Orifices Phase Yin Organs/Meridians Yang Organs/Meridians Wood Liver Gallbladder Fire Heart (Pericardium) Small Intestine (Triple Burner) Earth Spleen Stomach Metal Lung Large Intestine Water Kidney Urinary Bladder

6 These are fundamental correspondences. In order to use this system, you need to remember which organ/meridian goes with which phase. While the Yin Meridians are most important, their Yang meridian pairs are also necessary if you are going to apply the Ten Stem strategies and understand six-position pulse patterns.

Phase Tissues Orifices Wood Sinews Eyes Fire Blood Vessels Tongue Earth Flesh (muscle mass) Lips/Mouth Metal Skin/Body hair Nose Water Bones Ears/Two yin (urethra & anus)

These correspondences are important to classify the diagnostic signs and symptoms into the four Sho, or patterns of disharmony. For example, the sinews (also sometimes referred to as tendons) correspond to the active aspect of the muscles and joints; Liver or Gallbladder meridian would be considered to be involved in problems of these tissues. Likewise eye disorders would point to Wood disharmony. Remember that while single correspondences don’t necessarily indicate the primary pattern, they are always something you need to consider when determining the Sho.

Phase Yin Meridian Points Yang Meridian Points Wood Jing-Well Shu-Stream Fire Ying-Spring Jing-River Earth Shu-Stream He-Sea Metal Jing-River Jing-Well Water He-Sea Ying-Spring

These correspondences are useful for understanding point selection, especially in applying the theories found in Nan Jing chapter 68 and 69. The difference between the phase-point correspondences in the Yin and Yang meridians also gives a bit of insight into the Ten Stem theory discussed later.

The two major cycles of inter-Phase dynamics: Generating (Mother-Child) Cycle

Phase Generates (Mother) (Child) Wood Fire Fire Earth Earth Metal Metal Water Water Wood

7 This comes from Chapter 69 of the Nan Jing. It is important to understand the patterns of deficiency which make up the Four Sho, as well as the process of meridian and point selection to treat the primary Sho.

Control (& Over-Control) Cycle; this is sometimes called the Grandmother-Grandchild cycle.

Phase (Grandmother) Controls (Grandchild) Wood Earth Fire Metal Earth Water Metal Wood Water Fire

This is important to understand patterns of Excess and relative Excess. The Control and Over-Control cycles are really the same, it is really only the balance between the Controlling and Controlled Phases that separates the two. If the two Phases are equal and harmonious, the control cycle is just an expression of natural checks and balances. If there is an imbalance, the Controlling Phase will disrupt the function of the Controlled Phase, thus “Over-Controlling” (or “Overwhelming”) it. This cycle can help clarify the six-position pulse findings; we will discuss this further in the chapter on pulse diagnosis.

There is a corollary to this cycle as well, which is far less often used in JMT. It is known as the “Insulting Cycle”. The sequence is the reverse of the Controlling cycle:

Phase Insults Wood Metal Fire Water Earth Wood Metal Fire Water Earth

I include this here for the sake of completeness, though it shows up rarely in JMT theory. One place you may see the relationship occur is in the Secondary or Sokoku sho. In this case, it is possible to have a Wood Primary and Metal Secondary Sho, for example. More discussion will occur in the chapter on Sokoku Sho.

8 There are many other correspondences, of course, but these are the most important to the chapters that follow. Knowing the organs, tissues and orifices helps in diagnosing the Sho, or Pattern. Knowing the Generating and Control cycles helps in understanding the pathology and treatment principles. Knowing the point classifications helps in point selection. It is recommended to familiarize yourself with the Yin meridian points especially, since this gives you the ability to modify point prescriptions based on individual circumstances.

9 TEN CELESTIAL STEMS

The Ten Celestial Stems is a part of Chinese astrology, used to mark cycles of time along with what is called the Twelve Earthly Branches. It also represents a development of Five Phase theory, splitting each phase into Yin and Yang designations. When applied to acupuncture meridians, the Ten Stems represent Yin-Yang Five Phases and the Twelve Branches denote the meridians themselves. I first heard of the application of this concept to acupuncture in the book Five Elements, Ten Stems by Matsumoto and Birch, where there is a more detailed explanation of it; for further reading, I recommend that book.

The application of Ten Stems in JMT comes primarily from Nan Jing Chapter 33:

“Yi Jiao (the Yin stem and musical tone associated with Wood) is the softness (Yin partner) of Geng (the Yang stem of Metal). The larger meaning of Yi Geng is Yin and Yang, and the smaller meaning is husband and wife… Xin Shang (the Yin stem and musical tone associated with Metal) is the softness (Yin partner) of Bing (the Yang stem of Fire). The larger meaning of Xin Bing is Yin and Yang, and the smaller meaning is husband and wife… “ So according to this passage, there is a Yin Yang relationship between the stems and branches. Yin Wood and Yang Metal are paired in this passage, as are Yin Metal and Yang Fire.

The Ten Stems, their names in Chinese, and their Phase and Yin Yang designations are as follows:

# Stem name Phase + Yin/Yang Meridian 1 Jia Wood Yang GB 2 Yi Wood Yin LR 3 Bing Fire Yang SI 4 Ding Fire Yin HT 5 Wu Earth Yang ST 6 Ji Earth Yin SP 7 Geng Metal Yang LI 8 Xin Metal Yin LU 9 Ren Water Yang UB 10 Gui Water Yin KI

In the passage above from Nan Jing, the Ten Stems are paired by splitting the list in two and juxtaposing the first and second halves of the list as follows

10 1 Wood Yang GB —> 6 Earth Yin SP 2 Wood Yin LR <— 7 Metal Yang LI 3 Fire Yang SI —> 8 Metal Yin LU 4 Fire Yin HT <— 9 Water Yang UB 5 Earth Yang ST —> 10 Water Yin KI

As an aside, this passage also gives an answer to the frequently asked question of why the Five Phase points begin with Wood on the Yin meridians and Metal on the Yang Meridians. The question itself is answered in Nan Jing 64, but the fuller explanation leads back to Nan jing 33. Since Yin leads and Yang Follows, and Wood Yin is paired with Metal Yang, the cycle plays out in the designation of the points:

Point Yin Meridians Yang Meridians Jing-Well Wood Metal Ying-Spring Fire Water Shu-Stream Earth Wood Jing-River Metal Fire He-Sea Water Earth

Anyway, within the passage from Nan Jing is the phrase, “the smaller meaning is husband and wife”. The “Husband” controls the “Wife”, so to speak, meaning that given the maxim that Yang is always in Excess and Yin in Deficiency, means that the Yang meridians on the Overacting Cycle are the meridians which are actually in Excess and need to be drained, rather than the Yin meridians.

GB (Yang Wood) Overacts on SP (Yin Earth) LI (Yang Metal) Overacts on LR (Yin Wood) SI (Yang Fire) Overacts on LU (Yin Metal) UB (Yang Water) Overacts on HT (Yin Fire) ST (Yang Earth) Overacts on KI (Yin Water)

So, rather than the Five-Phase scenario of SP deficiency with LR excess, AKA Liver Invading the Spleen, it is the Gallbladder which is overacting on the Spleen and which needs to be drained. This opens the door to control-cycle dual deficiency, or Sokoku Sho, which we will cover in a later chapter.

I haven’t actually seen much (if any) specific reference to Ten Stem theory in other books on JMT, and my teachers never really mentioned it; it made sense to me, though, and has been helpful in clarifying certain issues, such as how to integrate the Yang meridians into the Sho. I found I could set up a sort of protocol

11 for Root Treatment on both Yin and Yang meridians. Once one learns these relationships, one can treat the Mother-Child meridians in the Sho, add points for the Ten Stem meridians and have a complete treatment. In fact my interest in it became renewed when I was searching for a more efficient way to determine the Sho in a shorter period of time. I realized that the symptoms and other examination findings involving Yang meridians can be followed backward to point to the Sho; if there are symptoms specific to one Yang meridian, one can just treat that meridian and the Yin meridian that it is overacting on.

Though it sounds complicated, it really isn’t, once one has learned the sequence. For me it is very quick to sort things out using this method, though it is true that I have been using it for a long time.

What does it look like in practice? Here are some sample point combinations that I use, with some examples of working backward from the symptom:

Symptom: Scapular pain; Small Intestine meridian involved. Sho: Lung Sho: LU5, LU7, SP6, SP9, SI7

Symptom: Katakori (Stiffness in shoulders, especially upper trapezius); Gallbladder meridian involved. Sho: Spleen Sho: SP6, SP9, P3, H5, GB34

Symptom: Hypertension with flushed face and headache; Large Intestine meridian involved. Liver Sho: LR3, LR8, K3, K10, LI11 (or LI4)

Symptom: Diabetic disease with hunger and thirst; Stomach meridian involved. Kidney Sho: K6, K10, LU5, LU7, ST44

Note that these are five-point combinations. In a lot of cases, I will needle these bilaterally, which takes me through a two fivers or a ten pack of DBC needles. I will either quit there, or use another pack to treat symptoms.

12 Part 2 Diagnostic Stuff

13 THE CONCEPT OF SHO

The Sho (Chinese: Zheng), usually translated as Pattern or Conformation, is the basic unit of diagnosis in JMT. In this it is no different than in TCM or numerous other styles of East Asian Medicine that are based on what Unschuld termed Systematic Correspondence.

What is a Pattern? Taking a cue from Fukushima, we can say that a Pattern is a holistic interpretation of the signs and symptoms of the patient, expressed in Chinese medical terminology, with an aim to rendering treatment. The pattern expresses the disharmony, and gives the practitioner a path toward treating it; the treatment strategy and points are suggested by the pattern itself.

Like most of the basic concepts of JMT, the Sho comes from Nan Jing, specifically Chapter 16, which outlines for each of the Yin organs a characteristic pulse, abdominal finding, emotional state and symptom picture. If they all line up, the Nan Jing states, we can be certain of the diagnosis; if not, we need to give the pattern more consideration. Like most of the Nan Jing, the pattern descriptions are quite concise.

Most of the acupuncturists currently practicing in the West were taught pattern differentiation according to the TCM system. Patterns of TCM and JMT differ in some significant ways: JMT has far fewer patterns: in its original form, JMT has four patterns to the dozens of patterns proposed by TCM. JMT is based on Yin-Yang and Five-Phase theory as applied to Organs/Meridians; there is some influence of pathogen and substance theory, but it really doesn’t extend much beyond Yin-Yang categorization of Correct/Pathogenic Qi and Qi/Blood. TCM is far more extensive in its use of differentiation of Pathogens (Heat, Cold, Dampness, Wind) and Substances (including Essence and Fluids); Eight Principles are more important in the diagnostic process, and Five- Phase theory is limited to the table of correspondences and a few instances of pathogenesis (the primary example being Liver-Spleen Disharmony).

As was noted earlier, the two styles were compiled in roughly the same time period, but the range of texts incorporated into TCM was far more extensive than JMT; the latter can be fairly said to be based on a few chapters of Ling Shu and Nan Jing. Leaving aside any judgement on the veracity of one style versus the other, or the “correctness” (Shang Han Lun, after all, was based on one passage in Su Wen), the two styles arose in different circumstances to fill different needs. TCM is first and foremost a system based on classification and application of the Chinese pharmacopeia and

14 formulary, where JMT answers only a need for a system of needling therapy.

As time has passed, there are some very influential practitioners who have thought JMT to be overly limited and incomplete, and have sought to extend it theoretically to incorporate herbal medicine and other modalities. However, for a practice which is based largely on needling and seeks to treat a high volume of patients, it is arguable whether such developments are an improvement or a needless complication.

The four sho are derived from the idea that the core of any disharmony in the body arises from a deficiency in one of the Five Zang, or Yin organs. The root meaning of the word Zang is “storage”, and the general idea is that an inability of a particular Zang to store its vital essence causes the manifestation of pathology. The pathology can show up in other organs, Yin or Yang, but the pattern more or less follows the dynamics of the Generating and Controlling cycles of the Five Phases. A single-organ pathology is possible, but generally more than one organ is involved. Deficiency is usually passed along through the Generating cycle, and it is here that the treatment is focused. In Chapter 69 of Nan Jing, there is an axiom that in cases of Deficiency, it is necessary to tonify the “Mother”, meaning the organ which precedes the Deficient organ on the Generating cycle. Since one is admonished to not tonify excess nor drain deficiency, the Mother organ is assumed to also be Deficient; thus the Mother and Child will both provide some evidence (the etymological meaning of Sho/Zheng) of deficiency, usually in their respective pulse positions. So each of the Sho will involve assessment and treatment of Deficiency in two Zang.

This framework applies to all of the Five Zang. However, the Heart is seen as an exception in treatment; if it becomes Deficient, it is judged as being too grave a pathology to treat with acupuncture. This is because the Heart stores the Shen, or Spirit, and “When the Spirit is lost, the patient will perish”. So, practically speaking, we are left with Four Sho.

The Four Sho are: • Lung Sho: Lung and Spleen are Deficient • Spleen Sho: Spleen and Heart (Pericardium, in practice) are Deficient • Liver Sho: Liver and Kidney are Deficient • Lung Sho: Kidney and Lung are Deficient

Each of the Four Sho, with their diagnostic indicators and standard treatments, will be explained in the following sections.

15 Later, we will consider the idea of a Heart/Pericardium Sho. In the descriptions, I have mostly stuck to Japanese sources though I have interjected some of my own observations as well. Under Emotional Aspects I have included some of the Western Five-Element school interpretations which I have found to be helpful; Japanese sources generally downplay psycho-emotional aspects but Western patients often include mention of their emotional life and I have found some of these ideas to be helpful.

Bear in mind that the Sho is an interpretation of the patient’s current state of well-being. It is more art than science. Experience and intuition are important elements of the process. Even so, experienced practitioners can sometimes stumble about in determining the Sho; Masakazu Ikeda gives an example (citation) of going through three Sho before hitting the fourth and last, which turned out to be the most appropriate. I am reminded of conversations I overheard among students at a Five-Element school which I taught; they would speak of treating someone on various Elements (basically their version of the Sho) before getting the one that seemed to fit. So give it your best guess, and don’t be afraid of getting things wrong. Despite the opinions of some I have heard, treating the wrong Sho won’t do some irreversible damage to the patient. Sometimes it takes a number of visits to really get a sense of certain patients; I say this not only in the context of community acupuncture but also as one who has had many more years of private room treatments with extensive intakes. I will say more about my current process of Sho determination in a community setting in the part 2 of the book.

16 PULSE DIAGNOSIS - INTRODUCTION

Pulse diagnosis is the most important diagnostic examination in Japanese Meridian Therapy and the main basis for the Sho, or treatment pattern. It is so important, one of the Japanese senior teachers told us foreign students, that Meridian Therapy is sometimes known as “pulse diagnosis acupuncture”.

Pulse diagnosis is notoriously subjective, though some of the Meridian Therapy associations have demonstrated a good amount of inter-rater reliability. There are schools of pulse diagnosis in AOM which are extremely complex; the Shen-Hammer system and the Dong Han system are two popular examples. Pulse diagnosis in Meridian Therapy is, by contrast, fairly easy to grasp, though the subtleties of it can be difficult to master. The pulse diagnosis of Meridian Therapy is specifically used to determine the Sho and detect any Ja Ki (Evil Qi) in the meridians; in other words, it is not aimed at diagnosing any diseases as the term is understood in biomedicine. This also separates it from some other systems which attempt to diagnose organic disease from the patient’s pulse.

Positioning The pulse examination in Meridian Therapy is generally done with the patient in position for treatment. This differs from other systems as well, most notably TCM, which, being based on herbal medicine, has the pulse examination performed with the patient seated at the physician’s desk with their wrist resting palm up on a small pillow. One key reason for examining the pulse with the patient lying down is that Meridian Therapy makes use of the pulse (and other examinations) as feedback to determine how the treatment is progressing. Any abnormal qualities of the patient’s pulse should improve during the treatment. Some Meridian Therapists can become almost obsessive about pulse taking in this way, rechecking it constantly. This feedback concept will be elaborated on further in a later chapter.

The pulse examination in Meridian Therapy consists of two main parts: pulse quality diagnosis and six-position pulse diagnosis. The two will be considered in the sections immediately following. As with any skill, practice is important. The more pulses you feel, the more familiar you will get with the procedure.

Some final thoughts on the examination in general.

Be Efficient Some styles of pulse taking require the examiner to palpate the patients’ pulses for an extended period of time, twenty minutes or

17 more. This is most emphatically not the way I was taught to perform this examination, and I have never seen any of the very experienced practitioners palpate pulses for more than a few minutes (if that). In fact, one of the most revered teachers I studied with told us not to take too much time examining the pulse, or indeed determining the Sho. I think that it is important to approach the pulse examination with as open and clear a mind as possible, and then learn to trust your initial impressions. In my experience, patients tend to get very worried when the pulse exam goes on for more than a minute or so. They begin to ask if anything is wrong, and their fretting about your prolonged, focused concentration changes the pulses anyway. So be efficient, and whether you pick up something abnormal in their pulse or not, it is best to be as reassuring as possible.

Establish Consent Before Making Contact One more thing to keep in mind: often times palpating the pulse will be the first physical contact you have with the patient. Especially on the first visit, it is important to establish consent. Usually I just say “I’d like to check your pulse. Is that okay?” The patient will generally inquire as to what you are feeling for. I try to keep the explanation brief, telling them it helps me determine what points I am going to use. I try to keep the contact gentle but firm, purposeful, and professional. Often I will be asked how it feels, which I generally take to mean that the patient wants to know if I feel anything wrong. Most of the time I just say that it feels normal, or something similar.

PULSE QUALITY

After getting oriented to the pulse, where it is located and where to place your fingers, the first thing we are looking to determine is the pulse quality. Pulse quality is important in many respects - it can give an indication of the state of health and constitution in general, and how to proceed in treatment. It can also serve as feedback, which is a characteristic of Japanese acupuncture in general; you want to notice if and how the pulse has changed by means of your treatment. Once the quality is noted, the examination can proceed to feeling the pulse underneath each individual finger, which is what we refer to as “six-position” pulse diagnosis.

There are six basic qualities we look for in pulse-taking, arranged in Yin-Yang pairs: Yin Yang Sinking Floating Slow Rapid Deficient Excess

18 A good pulse shows a balance between all of these qualities. The pulse can be felt most clearly in the medium depth, is of a moderate speed and has a calm, harmonious quality with a healthy resilience and no hardness.

Pressure at which to gauge the various positions varies. The right pulse is usually more superficial and the left pulse deeper. The first (distal) position is also more superficial than the third (proximal). In Nan Jing, the pressure was expressed in terms of the weight of beans:

Proximal (Chi) Middle Distal (Guan) (Cun) Right 9 beans 6 beans 3 beans Left 12 beans 9 beans 6 beans

Basically, to summarize the process: Place your fingers along the radial artery to locate the pulse. I was taught to locate the styloid process (LU8) with my middle finger, then place my index and ring fingers alongside the middle finger. Shift your fingers off the bone toward the meat of the medial forearm and feel for the pulsation of the radial artery.

Press your three fingers (I use the pads, though some use the tips) into the flesh slightly until you feel the pulse. Get a feel for how much you need to push in to feel it clearly, or if it gets weaker as you press. If you don’t start to feel the pulse until you’ve applied a lot of pressure, you would say that the pulse is more sinking, or deep. If you feel it strongly near the surface, but it disappears quickly as you press, then it would be more floating, or superficial. You may need to slowly press your fingers in and the slowly lift them up a few times to get a feel for where the middle depth lies.

Speed is a relative thing, and the usual advice from the classics is 3 beats per breath cycle as the norm. Smaller people, like children and petite sized men and women, will have a faster pulse than someone larger. Generally fast pulses indicate heat and slow pulses indicate cold. This may influence your choice of points; for example, you may decide to treat fire or water points on the affected meridians if the pulses are very rapid or very slow. Some medications can affect pulse speed as well, so it is worth asking what medications the patient may be taking when you make the initial consultation.

19 Deficiency and excess are a little more subtle. The usual advice for beginners is that a soft pulse is more of a deficiency pulse and a hard pulse is more of an excess pulse. This is not always the case, but as a starting place, it is good enough. One of my teachers told me that an excess pulse is “coming” and a deficiency pulse is “going”. An excess pulse rises up to meet your fingers, and puts up a fight against you as you apply pressure on it. A deficiency pulse does the opposite: it lays down or runs away.

An excess pulse can mean one of two things: either 1) a relative excess, due to the imbalance in Five-phase or Yin-Yang dynamics, or 2) true excess, due to the presence of Evil Qi (Ja Ki) in the channel. Ja Ki typically presents as a hardness in either the Yin or Yang levels -- the pulse wave does not feel smooth, rather it feels like there is debris stuck in the pulse itself. In the case of relative excess, tonification alone may be enough to correct the imbalance, but in the case of Ja Ki, dispersion is needed.

These are the basic pulse qualities that I was taught to pay attention to in Meridian Therapy. Classically, there are 28 pulse qualities and in acupuncture school one needs to memorize the descriptions of each. But for purposes of a beginner in Meridian Therapy, these six are plenty. And, lest someone decry Japanese Meridian Therapy (or even acupuncture in general) as an inferior art compared to Chinese herbal medicine, I will state that my very first teacher, a Chinese TCM herbalist with decades of experience, once told me that one need really only pay attention to four qualities: fast, slow, excess and deficient.

What of the beans? The gist of that passage is that in the distal positions the artery lies closer to the skin, and deepens proximally. So one needs to apply a little more pressure to the proximal positions to accurately gauge the pulse.

Then, press the artery close to the bone and take note of which fingers the pulse begins to disappear beneath. This is the beginning of six-position pulse diagnosis, which we will cover in the next section.

When noting the pulse qualities above, we are establishing a baseline. The pulse will probably change in some way during or after the treatment. In the pulse feedback session, we will discuss pulse changes in more detail.

20 SIX POSITION PULSE DIAGNOSIS

Once the basic overall quality of the pulse has been determined, the next step is to examine the pulse underneath each of your fingers. This is known as “Six Position Pulse Diagnosis”. This examination is important to help determine the Sho, or pattern of disharmony, which serves as the diagnosis and is the basis of treatment in JMT.

Six position pulse diagnosis comes from Chapter 18 of Nan Jing. One of the many revolutionary assertions of the Nan Jing is found in the first chapter, which states that pulse examination — which in the Nei Jing took various forms such as palpating pulses at the neck or over the head, neck and extremities — could be conducted solely and completely at the radial artery of the wrist. Yin meridians are found on deep level and Yang meridians on superficial level. The way to find these is to first determine the middle depth of the pulse as we looked at in the previous chapter, and then determine the Yin and Yang depth levels.

1) First adjust all three fingers on each hand to find the depth where the pulse is felt most clearly beneath each finger; this is the middle depth.

2)Then, SINK the fingers toward the bone to find the YIN level, and FLOAT the fingers towards the surface to find the YANG level

In the diagram above, the different pulse positions are shown in Yin- Yang pairs, with the inside orb of the pair indicating the Yin level and the outside orb indicating the Yang level.

According to the principles of Yin-Yang, a pulse cannot be deficient in both Yin and Yang levels; if the Yin level is deficient,

21 then the Yang level must be relatively excess, as illustrated in this diagram:

Here, the Spleen pulse is deficient and the Stomach pulse is excess, where the other pulses on the wrist are balanced on Yin and Yang levels. Sometimes, when you examine the pulse, one position may feel strong in both levels; this may be an indication of a Yin-Yang imbalance, and the Yin level may actually be deficient. Some authorities on JMT say that one way to determine the most deficient Yin merisian is to look for the largest Yin-Yang imbalance. That can show up as a very full Yang level pulse in one position, which can hide the deficient Yin pulse. It is always good to check the pulse according to the Generating and Control cycles, as explained below, just to make certain.

Comparing Pulses Using Generating and Control Cycles

If you look closely at the pulse positions, you can see that they follow a sort of pattern with regard to the Generating and Control cycles of the Five Phases. The generating cycle follows each wrist from proximal to distal pulse position, and between both wrists makes a sort of infinity symbol:

22 The Control cycle shows up as a kind of zigzag between the pulse positions on the wrist:

The most efficient way to do this comparative examination is to take the pulses at both wrists simultaneously. This is commonly done with the patient lying supine (face-up) on a table. I find this awkward to do with the patient in a chair, so I generally take each wrist separately, note what I find, and line everything up mentally. I practiced for many years on tables, though, and I think the years of experience has made it easier to do it this way.

When taking the pulses simultaneously, the process of looking at the control cycle goes like this: • Compare both Distal positions (Heart and Lung) with the index fingers. Which is stronger/weaker? • Compare Right Distal and Left Middle positions with your left index finger and right middle finger (Lung and Liver). Which is stronger/weaker?

23 • Compare both Middle positions with both middle fingers (Liver and Spleen). Which is stronger/weaker? • Compare Right Middle and Left Proximal positions with your left middle and right ring fingers (Spleen and Kidney). Which is stronger/weaker?

When learning this method, I would sometimes make a quick note with pluses and minuses to indicate the stronger and weaker pulses, respectively. So, for example, a pulse comparison might look like this: Heart +, Lung - Lung -, Liver + Liver +, Spleen - Spleen -, Kidney +

Add up the pluses and minuses: Heart + Lung - - Liver + + Spleen - - Kidney +

Lung and Spleen are the weakest positions. The two meridians line up nicely in a Mother-Child relationship (Lung follows Spleen on the Generating cycle), which is what we are looking for. Since the Child is the primary meridian to treat, this would be the pulse picture for a Lung Sho.

Qualities in Positions In addition to the overall pulse quality, you may feel different qualities in each of the positions. For example, the Heart position may feel thin or the Lung pulse may feel choppy. These individual qualities will usually improve with the treatment, and in my opinion, as a beginner you shouldn’t be overly concerned with each quality in each position. When starting out, the best thing to focus on is determining which of the positions feels weakest, and looking for correlations between the weak or strong positions according to the Generating or Control cycles. I was taught to go back to the pulse repeatedly to look for aberrant qualities in the different positions, and apply various needle techniques to correct them; frankly this led to a lot of frustration and wasted time. It may come down to philosophy, but I have come to think that the most important priority is to help the body expel pathogens and restore balance on its own.

24 PULSE QUALITY AS FEEDBACK: AN EXPLORATION

One of the most useful features of pulse taking is that the pulse itself gives a sort of real time gauge of what is going on in the body. The pulse quality can change dramatically in an instant, for example if one is suddenly startled or frightened. The pulse is under the command of the autonomic nervous system (ANS), which consists of the sympathetic (fight or flight) and parasympathetic (rest and digest) systems. The pulse will change based on activation of one or the other of these two branches. So, I was always told that typically a good treatment would cause the pulse to slow, relax and sink, at least a little. This is consistent with parasympathetic activation.

An interesting facet of pulse taking is that the pulse responds to subtle stimuli as well. In other words, the pulse can change in response to stimuli that the patient is not consciously aware of. This makes it useful as a feedback mechanism in many regards. One can use the pulse as feedback to confirm point location, selection, even the Sho itself.

One of the exercises we used to practice in studying Meridian Therapy was to get together in a group and have everyone in the group locate the same point. Each of us would locate it in a slightly different spot,and we would each have a different colored fine point marker with which we would mark our located point. The teacher would have us each feel one of the pulses on the body (not just the radial artery, but the temporal and pedal arteries as well) while he lightly touched a small probe (teishin or rounded needle) to each of the various colored marks. It was remarkable how the pulse quality could vary from touching one point and then another, even though they could be a few millimeters apart.

Sometimes, when locating a point, if I have trouble finding one that feels like a good location to use, I will check the pulse while palpating around the area of the point. If I find one that gives a good pulse change, that is the location I figure it is best to use, regardless of whether it is in the correct textbook location. Even in selecting points, say whether to use Sp6, Sp8 or Sp9, touching each of the points while checking the pulse can be useful in determining if one point is better to use than another.

Another technique I will use, especially when I feel confused about the pattern or whether to use a certain protocol, is to check the pulse while thinking about the different choices of patterns or protocols. For example, if I was undecided on whether to treat the Liver or Kidney patterns, I would do the following:

25 First get a baseline on the pulse. I do this by palpating the pulse while mentally thinking the word “clear”. I note the pulse quality in terms of the six basic qualities mentioned earlier.

Next, I would think “Liver Pattern” and note any changes in the pulse. Then I would think “Kidney Pattern”, and note whether there was any change. The biggest change (ideally for the better) would indicate the pattern to use.

This method has some similarities to a chiropractic technique known as Applied Kinesiology (AK). This technique, developed originally by a DC named George Goodheart, involves testing the strength of a particular muscle, often one in the arm, while various stimuli are presented. AK has gone beyond chiropractic and is used by all kinds of people, professionals and laypersons alike. It is used to test points, nutritional supplements, homeopathic remedies, allergens and just about anything else. Look in the supplement aisle of your local natural foods store and you are likely to see a shopper muscle testing herself or her child to see which supplement she will buy.

Other similar methods of feedback include the Bi-Digital O-Ring test (BDORT), a type of muscle testing developed by the Japanese physician Yoshiaki Omura, and much used by the legendary Dr Yoshio Manaka. Another famous acupuncture theorist and practitioner, Dr Tadashi Irie, developed a type of finger test which one can do on oneself, to check for all of the same types of reactions that would come up during an AK session.

The pulse can be used in the same way. I remember one evening at dinner after class, watching the teacher picking from the restaurant’s wine list while checking his own temporal pulse.

In some ways, I would say that pulse feedback is possibly more reliable than muscle testing in that the pulse is not under the conscious control of the patient in the same way that resisting an arm push would be. Pulse feedback takes the patient’s will out of the picture, and also is a guard against any possible biasing by the examiner (such as pushing harder on the arm on some tests and not as hard on others). However, it is still a very subjective phenomenon.

One caveat in using this method is that it can be a big time suck. The usual advice is that practice makes perfect and that the more you use the method, the easier (and quicker) it will get. Even so, sometimes the pulse doesn’t give much clarity. If you don’t get any feedback when doing this technique, no big deal. Just give it your best guess and move on.

26 Although I was taught to feel for improvement in the pulse as a positive indicator, sometimes I’ve gotten caught up in going back and forth between choices, feeling for which improved the pulse more. One way to avoid this is something I learned from a video, Extreme Kinesiology by Dr William Gustafson, DC. He teaches that ANY change is a “yes” answer. Since acupuncture tends to push the body toward homeostasis, even a push in the opposite direction one wants to go can cause the pendulum to swing back in the intended direction. I remember hearing the renowned acupuncturist Masakazu Ikeda advising us students not to be too timid in our approach to treating patients. I once read that the osteopathic physician Dr William Sutherland, the founder of cranial osteopathy, would often write in his treatment notes simply “S.H.”, short for “Something Happened”. Too often, we can’t be certain that our treatment is the most correct under the circumstances; in many cases, just getting things moving in the body is the best we can do.

27 HARA (ABDOMINAL) DIAGNOSIS

Abdominal diagnosis is based on Nan Jing theory, primarily Chapter 16, which correlates pulse, symptoms and abdominal conformations into what we know today as the pattern (Sho). It has been adapted from the original, to better fit the theories of primary deficiency on which the Meridian Therapy system is based. There is some variation among schools of Meridian Therapy, and it us worth noting that other styles of Japanese acupuncture and Shiatsu use abdominal maps quite different from the Nan Jing model.

Palpation basics Palpation of abdomen, channels, points, etc, is basically the same process. The first step is to lightly palpate the surface of the skin. You are looking for differences in temperature, texture and tone. Does one area feel warmer or cooler than other areas? Rougher, smoother, drier, stickier? Are there areas which feel looser, where the skin bunches up slightly under your fingers? Are there areas where the surface feels more taut than others? When you have passed over the surface of the body part you are palpating, go back over it, pressing in slightly to feel the subcutaneous tissues and surface of the underlying muscle. Are there areas which feel more weak, or tight, or are there any areas where you feel a gritty sensation, or ropiness? Do any of the areas feel painful to the patient - do they wince, or tense the muscles to guard the area?

We classify these areas into deficiency and excess: • Deficiency (kyo) will manifest depression, coolness, roughness, weakness, etc. • Excess (jitsu) will manifest tautness, hardness, discomfort or pressure pain.

For abdominal diagnosis in Meridian Therapy, the standard position of the patient is lying face up, with legs straight. This differs from the process of abdominal palpation in contemporary biomedicine,where the objective is to palpate the organs themselves. In Meridian Therapy, the idea is to palpate superficially, examining the reflex zones for the Zang-Fu.

28 The reflex zones according to Nan Jing are • Spleen - Navel area (Periumbilical) • Heart - Above the navel (Epigastrium) • Kidney - Below the navel (Subumbilical) • Lung - Area to the patient’s right side of navel • Liver - Area to the patient’s right side of navel

This is the basic map, but over time there have been numerous variations. Several of these are discussed in Shudo’s Introduction and Matsumoto and Birch’s Hara Diagnosis. I will include a couple of the ones from people I have been taught by.

Alternate version, from Kodo Fukushima’s Meridian Therapy: • CV-7 to CV-12 = Spleen DX area. • CV-14 and CV-15 = Heart DX area. • GB-24 to SP-16 (to side of navel) right side = Lung DX area; same area left side = Lung comparison. • The flanks from GB-26 to GB-29 (left side) = Liver/Gallbladder DX area. • CV-7 to CV-2 = Kidney DX area.

29 Another alternate version, from Denmei Shudo’s Introduction to Meridian Therapy:

Note that the Lung area has been moved to the area of LU1-2 bilaterally, and the Liver is diagnosed on the subcostal and ASIS areas on both sides. In this, the notion of the Lung area on the right and Liver on the left (as well as limiting the examination area to the abdomen) has been discarded. The variations in this example do make sense: LU1 is the Mu point for the Lungs, and anatomically the Liver is located on the costal-to-subcostal area on right side rather than the left. It does go to show, however, that the classics are more a guide and starting point than a literal set of commandments.

30 The abdomen can also be used as feedback, similar to the pulse. When the appropriate treatment techniques are applied, the condition of these abdominal areas will improve: pressure pain will be relieved, cold areas will warm up, loose pores will tighten, and so forth.

OTHER DIAGNOSTIC PROCEDURES

Meridian Palpation Palpation of the meridians and points themselves can be extremely valuable in both diagnosis and treatment. Palpation specifically of the cubital region (usually taken to mean the area on the forearm around LU6) is given equal weight to pulse and complexion examination (traditionally the two pillars of diagnosis before the advent of tongue diagnosis in the XYZ Dynasty) in Nan Jing 13, a feature which was mentioned in passing in my JMT training but not emphasized. It does give one the idea that, in the absence of an abdominal examination, the examination of the cubit can give confirmation to the pulse findings.

The forearm findings outlined in Nan Jing 13 are as follows: • Wood = Tense • Fire = Hot • Earth = Relaxed • Metal = Rough • Water = Slippery

Another idea which was presented to me when studying JMT was examining certain points to give an indication of the condition of the meridian. Most frequently mentioned were the Yuan-Source points, which, according to Nan Jing 66, is where the Source Qi (the Essential Qi of the body) “stops and rests”.

An interesting list can be found in one of the first books on Japanese acupuncture to be published in the West, Masae Hashimoto’s Japanese Acupuncture. While not strictly speaking JMT (in fact, Kodo Fukushima refutes some of her assertions in his book Meridian Therapy), I think the technique is worth considering. The points on the list are as follows:

• Lung: LU6 • Large Intestine: LI11 • Stomach: ST34-36 • Spleen: SP9 • Heart: HT7-HT9

31 • Small Intestine:SI3-SI4 • Urinary Bladder: UB59-60 • Kidney: K7 • Pericardium: PC4 • Triple Burner: TB4-10 • Gallbladder: GB33-39 • Liver: LR8

Visual Diagnosis Visual diagnosis was not emphasized in my training, which is not surprising given that so many of my Japanese teachers were blind. Nan Jing 13 gives us the standard Five Colors of Green (Qing, actually a bluish-green), Red, Yellow, White, and Black for Wood, Fire, Earth Metal and Water, respectively. While the face (complexion) was given as the location to examine in Nan Jing 13, my eachers mentioned looking at the cubit area, since it is naturally covered from the sun and weather. It is important to keep in mind that the colors given were originally for use with a homogeneous population of Han Chinese, and may be less useful in a practice environment with a highly diverse population. One of the appendices to Matsumoto and Birch’s book Extraordinary Vessels contains some interesting findings largely gleaned from Sorei Yanagiya’s Diagnosis Without Asking. There are some visual clues I look for to help determine the Sho; I will present those in the section summarizing each of the Sho individually.

32 SYMPTOMOLOGY

Symptomology is an important part of the selection of Sho, though one might get differing opinions on how important it is. There is a sort of distrust of the patient’s reporting of symptoms displayed in many writings by prominent Japanese practitioners (see Yoshio Manaka’s book, for example), and a seminal work of JMT was a guide to diagnosing without asking the patient anything. The Sho, as I was told, is primarily decided by the pulse and confirmed by the abdomen; the symptoms may or may not be obviously related. Be that as it may, some senior practitioners that I have observed seemed to give a lot of weight to symptoms in diagnosing the Sho. Certainly for beginners, it is extremely important. If the pulse is unclear and the abdomen unrevealing, what do you have to go on? You can go from the symptoms and work backward to the Sho by means of Zang-Fu pairs, or control-cycle or Ten-Stem relationships, but the symptoms themselves can also directly point to the Sho.

Ogawa’s Symptom Study I attended a seminar in 1996 given by a prominent Meridian Therapy practitioner, Takayoshi Ogawa. Ogawa sensei seemed very keen on introducing some evidence basis into the practice of acupuncture, and among the things he presented were the following tables. I didn’t quite get the exact details of the process, but the gist of it was that he surveyed a sample of the most senior Meridian Therapy practitioners in Japan on classifying symptoms into the various Sho. The respondents were given a list of symptoms and asked to classify them and give a ranking of how important they were to the diagnosis of each Sho. The numbers as I understood them were a composite of how many classified them into each Sho and what weight they gave each symptom. This was presented to us as a kind of diagnostic shortcut, which I found to be rather useful; thus I am including it here. Note that some of the symptoms appear in more than one Sho, though the numerical scores are different.

LUNG • Sniffling, nasal discharge 11.2 • Cough, phlegm 10.12 • Throat Pain 9.44 • Chills 9.4 • Asthma 9.35 • Interscapular Pain 8.58 • Stiff Neck & Shoulders 8.55 • Frequent Urination 6.95

33 HEART • Palpitation 8.8 • Interscapular Pain 7.76 • Chest Pain 7.35 • Epigastric Pain 7.2 • Shortness of Breath 6.95 • Difficulty Speaking 5.9 • Inability to Taste 5.65

SPLEEN • Lack of Appetite 10.45 • Diarrhea, Loose Stool 10 • Easily Fatigued 9.89 • Edema of Limbs 9.4 • Nausea, Vomiting 8.91 • Indigestion 8.38 • Epigastric Pain 8.2 • Midback Pain 7.85

LIVER • Vertigo, Dizziness 11.25 • Irritability 9.85 • Low Back Pain 9.85 • Headache 9.78 • Eye Strain 9.35 • Hypochondriac Pain 9.2 • Deteriorating Eyesight 9.15 • Menstrual Disorders 9.13

KIDNEY • Low Back “Heavy” 10.83 • Low Back Pain 9.9 • Cold Limbs 9.75 • Edema of Limbs 8.75 • Easily Fatigued 8.43 • Hot Limbs 8.4 • Tinnitus 8.35 • Lack of Energy 8.32

34 I will say that I still take pulses and factor in the other exams (such as the Looking examination), but in a pinch, I think these are good to keep in mind.

Shudo’s Manual At one of the Denmei Shudo seminars I used to help conduct, Shudo sensei presented the participants with a short manual of treatment which I’ve found to be extremely useful. It is organized by chief complaint, in the medical sense; this is what would be called in TCM “Bian Bing” or treatment according to the disease. Shudo sensei acknowledged that the official method is to determine the Sho and treat accordingly, but noted “there is a back door as well as a front” and presented his point selection according to the one or two most common Sho he would see clinically for each malady. One of the many things I have always admired about Shudo sensei is his candor, and I would wager most senior practitioners have their own shortcuts for determining treatment according to the patient’s complaint. That having been said, no method works 100% of the time, and it is always worth examining the pulse and other diagnostic indicators, even if only when the treatment doesn’t seem to be working as well as one had intended.

35 Part 3 “It's Sho Time!”

36 LUNG DEFICIENCY PATTERN HAI KYO SHO

Pulse picture The Right Distal (Cun) and Middle (Guan) pulses on the Yin level are the most deficient. There may be a Yin-Yang imbalance in which the same positions on the Yang level especially the distal, or Large Intestine pulse) are flooding and superficial, which can make it difficult for a novice to detect the deficiency in the Yin positions. There may be a feeling of excess in the Left Distal (Cun) and/or Middle (Guan) pulses, either on the Yin or Yang level.

Symptomology History of: Respiratory problems, sore throat, feeling of heat in the head, intrascapular tension, shoulder pain, numbness in arms, hemorrhoids, cold hands & feet, frequent urination. Reaction at: GB-20, GB-21, UB-13, UB-43, GV-12, LU-5. Pain, tension or reduced ROM in neck and shoulders.

Hara Diagnosis The abdomen to the right of the navel may be sunken, lacking surface tension or rough and without luster. The navel wall may be indistinct. The substernal area and/or abdomen to the left of the navel may be tight and pressing in with the hand may cause discomfort.

Other Palpatory Signs The skin may feel dry, or as if there is a layer of dust on it, especially around the LU6 area.

37 Emotional Aspects The Lung stores the Po, or Corporeal Soul(sometimes referred to as the Animal Soul). This is the part of the soul that stays with the body after death. The Po is related to the limbic system and pre- verbal parts of the brain. The intuitive sense,especially as felt with the body, is related to the Po. If you meet someone or go somewhere that somehow gives you the creeps, or conversely feel instantly at home, but you can’t quite verbalize it or put your finger on it, then this is the response of the Po. The Lung is related to the skin and body hair,and those situations that give you goosebumps or make your hair stand on end are related to the Po - they are the same senses that cause other mammals’ hair to stand up.

Lung sho people are often sensitive to needles, and often can not tolerate excessive needling. Consider using Japanese #02 or #01 needles. Interestingly enough, I have found that many of them (especially younger ones) are covered with tattoos.

The Lung is related to grief and Lung sho people can be sentimental, easily moved to tears.

Lung sho constitution tends toward a pale complexion. There may be a lot of body hair, which can make up for weak Wei Qi function by giving external pathogens an extra barrier to cross.

They may suffer from chronic respiratory ailments or immune system weakness, allergies and so forth. The Lung governs the skin and so there may be a history of skin problems especially of an allergic nature (atopic dermatitis is common in both children and adults). They may also suffer from depression and anxiety, which they have in common with the Spleen sho.

The Lung Sho should be considered in cases of shoulder pain. The Lung is the uppermost of the Zang and its Back Shu point is located alongside the scapula. The primary meridians associated with the shoulders are the Large Intestine (exterior pair of the Lung), and the Triple Burner, Small Intestine and Gallbladder (Ten Stem relationship to the Lung).

38 SPLEEN DEFICIENCY PATTERN HI KYO SHO

Pulse picture The Right Middle (Guan) and Left Distal (Cun) pulses on the Yin level are the most deficient. There may be a Yin-Yang imbalance in which the same positions on the Yang level especially the Right Middle (Guan), or Stomach pulse) are flooding and superficial, which can make it difficult for a novice to detect the deficiency in the Yin positions. There may be a feeling of excess in the Left Proximal (Chi) and/or Middle (Guan) pulses, either on the Yin or Yang level.

Symptomology History of: Digestive problems, fatigue, edema, arthritis, gyne disorders, mid-back pain, worry/anxiety, insomnia. Greasy tongue coat. Reaction at: abdominal exam (discomfort or ticklishness), CV-12, CV- 14, LIV-13, SP-8.

Hara Diagnosis The area around the navel may be sunken, lacking surface tension or rough and without luster. The navel wall may be indistinct. The substernal area may be sunken and pressing in with the hand may cause sloshing sounds. The abdomen to the left of the navel or below the navel may be tight and pressing in with the hand may cause discomfort. The abdomen may be ticklish overall.

39 Emotional Aspects The Spleen stores the Yi, or reflection. This aspect is sometimes called rumination, especially if it is imbalanced. Spleen sho people tend to over-think things. Past hurts are not easily forgotten. There may be an obsessive quality to them, especially if their condition is complicated by Phlegm. They tend to like to please other people, and can tend to be nurturing, even excessively so. They may have difficulty sleeping because they cannot easily shut down their minds. Because of this,they may be tired during the day and will feel sleepy after eating, especially carbohydrates (which they often crave).

Physically Spleen types tend to be fleshy, with a good deal of mass, even if they are not technically overweight. They can tend to be slow moving though their minds and conversation may be quick. They tend toward accumulating Dampness and may suffer from muscle aches or metabolic problems. They may also suffer from depression and anxiety, which they have in common with the Lung sho.

40 LIVER DEFICIENCY PATTERN GAN KYO SHO

Pulse picture The Left Middle (Guan) and Proximal (Chi) pulses on the Yin level are the most deficient. There may be a Yin-Yang imbalance in which the same positions on the Yang level especially the Left Middle (Guan, or Gallbladder pulse) are flooding and superficial, which can make it difficult for a novice to detect the deficiency in the Yin positions. There may be a feeling of excess in the Right Distal (Cun) and/or Middle (Guan) pulses, either on the Yin or Yang level.

Symptomology History of: Liver disease, dizziness, headache, eye problems, acute low back pain, hip or knee pain, pain along medial leg, Uro-genital disorders, menstrual problems, irritability. Reaction at: medial knee, subcostal, GV-20, GV-22, CV-4, SP-6, LIV-8.

Hara Diagnosis The abdomen to the left of the navel may be sunken, lacking surface tension or rough and without luster. The area lower down on the left, toward the ASIS, may have a feeling of fullness or hardness. The navel area and/or abdomen to the right of the navel may be tight and pressing in with the hand may cause discomfort.

41 Emotional Aspects

The Liver stores the Hun, or Ethereal Soul. This is the part of the soul that comes from Heaven and returns there after death. The Hun is active during dreaming, and what is referred to in metaphysics as Astral Traveling is related to the Hun. The emotion associated with the Liver is Anger. Liver imbalances can result in anger, though the anger may be expressed or held in to give a kind of underlying seething quality. Hun imbalances may manifest in various ways. The Liver is known as the General in charge of Planning and Strategy; an imbalanced Hun can cause a lack of direction or inability to plan. On the other hand, the Liver sho person may be good at conceptualizing, coming up with ideas but never able to follow through with them; they may fail during the planning stages. The usual picture in TCM is of a Type A personality, driven and overbearing, with a sharp tongue and a cutting, commanding tone to the voice. The other side of Liver imbalances is a tendency to be lost in the Astral realms, and they may seek to escape reality by hallucinogenics or cannabis.

Physically, Liver types tend to be sinewy, and have lots of visible veins which can give areas like the forearms a sort of greenish cast. They may suffer from joint stiffness or conversely hypermobile joints which can be injured easily. Headaches and hypertension are common among Liver sho complaints. They may suffer from vision disorders or dry eyes.

42 KIDNEY DEFICIENCY PATTERN JIN KYO SHO

Pulse picture The Left Proximal (Chi) and Right Distal (Cun) pulses on the Yin level are the most deficient. There may be a Yin-Yang imbalance in which the same positions on the Yang level especially the Left Proximal (Chi, or Urinary Bladder pulse) are flooding and superficial, which can make it difficult for a novice to detect the deficiency in the Yin positions. There may be a feeling of excess in the Left Distal (Cun) and/or Right Middle (Guan) pulses, either on the Yin or Yang level.

Symptomology History of: Kidney disease, low blood pressure, dizziness upon standing, hearing loss, lowered libido, coldness below waist, chronic low back pain, fatigue, edema. Reaction at: CV-7, CV-9, SI-19, K-7, UB-23, UB-52.

Hara Diagnosis The area beneath the navel may be sunken, lacking surface tension or rough and without luster. Pressing in with the hand, one will feel a lack of resistance beneath the navel. The abdomen to the right of the navel may feel similarly rough and without luster. The substernal area may be tight and pressing in with the hand may cause discomfort.

43 Emotional Aspects

The Kidney stores the Zhi or Will. Imbalances of the Zhi can be either too little or too much use of Willpower. On the one hand,they may give up easily, either due to fear (the emotion associated with the Kidney) or pessimism. Their fear makes them unwilling to take risks for fear that they will fail. They can have an underlying sense of doom,of being beaten before they start. On the other hand, they may tend to excessive use of willpower and seek to dominate themselves. They may gravitate toward extreme physical activities, or take stimulants or performance-enhancing drugs (this may include drugs to enhance sexual performance). This type may be obsessed with youthfulness and they may undergo plastic surgery.

Physically Kidney types may either have a sort of puffy, watery appearance or conversely a sort of thin, dried-out appearance depending on whether they tend toward Yang or Yin deficiency. They may suffer from diseases of the bones, either under or overgrowth. Fertility and sexual problems are often associated with Kidney deficiency. They often get dark bags beneath their eyes.

44 SOKOKU (CONTROL-CYCLE) SHO

Briefly, the primary pattern is needled on one side of the body (usually the stronger or asymptomatic side), the secondary on the other. The basic point selection for the primary pattern is the same as the standard four Sho; the secondary pattern treatment point is often simply the Yuan-Source or Luo-Connecting point of the Sokoku meridian (see table).

The usual procedure in Meridian Therapy is to decide on the Sho and treat it, whether bilaterally or on one side of the body. In my training with the blind acupuncture practitioners, in the organization founded by Kodo Fukushima, I learned a unique concept known as Sokoku Control, based on unilateral patterns of needling. This breaks with the standard in that along with the primary sho, needled on the stronger side, a secondary sho, involving a single meridian opposite the primary sho meridian on the control cycle, is needled on the other side of the body. For example, there can be a situation where the primary sho is Spleen deficiency, which involves needling the Spleen and heart / Pericardium meridians on one side, and the sceondary sho is Liver Deficiency, which means that the Liver meridian would be tonified on the opposite side.

How is the stronger side of the body determined in the absence of clear one-sided symptoms? The easiest way is to look at the patient’s feet. Usually one of the feet will be pointing more upright and the other will be drooping to the side. The more upright foot is taken to be on the stronger side.

This is a concept that is more or less unique to Fukushima’s group; I have heard prominent meridian therapists in other groups refer jokingly to it as “cheating” (hikkyo). Perhaps I am biased as most of my early training in Meridian Therapy was with Fukushima’s group, but it makes a lot of sense to me. As I mentioned in the section on Ten Stems, the idea that it is the Yang meridians on the control cycle that are primarily in excess opens the door to the Sokoku sho concept. Indeed, the link between these two approaches seems to be the great acupuncturist Keiri Inoue,one of the founders of Meridian Therapy. His approach is detailed in Matsumoto and Birch’s Five Elements, Ten Stems as exemplary of the Ten Stem model, and he is cited by Fukushima as being the inspiration for Sokoku control needling. Clinically, I have found the Sokoku control concept useful and I can’t say that I have seen any real ill effects in using it.

45 The chart I used to use when teaching this method looked like this:

Primary Sho + Points Secondary Sho + Points

Lung LU9, SP3 Liver LR3

Spleen SP3, P7 Liver LR3 or Kidney K3

Liver LR8, K10 Lung LU9 or Spleen SP3

Kidney K7, LU5 Spleen SP3

The standard version is that the most common point chosen for the Sokoku sho is the Yuan Source point. Other points are certainly possible to use, including the Luo point, though points that have phase associations could be regarded by some as problematic given their possible secondary effects on other meridians.

A couple examples of how I use this concept as the framework for larger treatments:

Back Pain Healthy Side Painful Side LR8, LR4, K3, K10 LU5, LU6

Blood Stasis Right Side Left Side LU5, SP8, SP6 LR4

46 Part 4 Treatments and Such

47 ROOT AND BRANCH TREATMENT

Treatment Staging One of the features of Japanese classical and related styles is the staging of the treatment into discreet steps, each with its own aim, diagnostic procedures and feedback system. In the simplest form, most JMT can be divided into two steps: Root Treatment and Branch Treatment.

Root Treatment (Honchi Ho) In Meridian Therapy, the most essential aspect of the treatment is what is known as the Root Treatment (Honchi Ho in Japanese). This is usually the first step of the needling portion of the clinical encounter, and is considered to be indispensable.

From notes on a lecture by Akira Takai-sensei, on the subject of “the correct way of Keiraku Chiryo”: “Keiraku Chiryo is a healing practice of touching patients, based on clinical trial-and-error. It has its own unique diagnosis and treatment system. It does not treat individual symptoms, rather it uses the essential points to adjust the Ki of the whole body, to adjust the life force. Its basic intent is to enhance the body’s own healing power, and strengthen its constitution.”

Here are some points of view on the meaning of root treatment. First, from the book Acupuncture, A Comprehensive Text, which is a translation of the Shanghai CTCM textbook:

“In Chinese Medicine, emphasis is placed upon distinguishing the relative importance of the Root and Branch. In terms of disease, the first to be contracted is considered to be the Root, and later complications the Branch. Between the Organs and their pertaining channels, the former are considered the Roots and the latter the Branches. Points on the limb are Roots, those on the trunk and head are Branches. Sometimes the Root is treated before the Branch, but at other times this sequence is reversed. Occasionally, both may be treated simultaneously, or one treated exclusive of the other. Generally an acute illness is treated first, a chronic illness second, Exterior disease first, Interior complications second. However, the more general balance between the normal and abnormal forces in the body must also be taken into account.

For example, if the Normal Qi is particularly Deficient, i.e., the body is very weak, the most immediate concern is to ʻsupport the normalʼ, since the expulsion of the abnormal Qi from the body depends primarily upon the organisms ability to resist disease.”

48 Helpful comments from Denmei Shudoʼs excellent Japanese Classical Acupuncture: Introduction to Meridian Therapy, in which he quotes other sources:

“Root treatment is performed in accordance with the pattern of the disease, and symptomatic treatment in accordance with the symptoms of the disease. The first priority is to correct the abnormal relationships of deficiency and excess among the meridians. To do this we must determine the overall picture of the disease known as the pattern by identifying and analyzing those relationships of deficiency and excess among the meridians and organs that are abnormal, and those that are not.” (Yamashita, 1971)

“(Root treatment) is the treatment in which the imbalances in the meridians, which are the essence of the disease, are corrected by tonification and dispersion using the five-phase points and five essential points. Symptomatic treatment is the treatment rendered according to the...complaints of the patient by treating localized areas.” (Fukushima, 1979)

“(Root treatment) is the correction of imbalances in the meridians by using the essential points on the four limbs in accordance with the primary pattern, which is derived from the various diagnosis and analysis of the symptomology. Symptomatic treatment is performed simultaneously in accordance of the symptoms by directly tonifying or dispersing reactive points or acupuncture points [resulting from] imbalances. There are, of course, cases in which the symptoms are relieved by root treatment alone. In such cases, symptomatic treatment is unnecessary. However in most situations these two treatments are equally important and necessary. (Takeyama, 1944)”

Shudo himself writes: “There are considerable differences of opinion regarding just how important root treatment is relative to symptomatic treatment. Some believe that root treatment takes care of 70-80% of the symptoms...others believe that while root treatment corrects imbalances of Qi in the meridians, it is not immediately effective in ameliorating the symptoms...{which must be} treated separately with symptomatic treatment. Finally, some practitioners believe that root and symptomatic treatment are of equal value... All practitioners of meridian therapy agree that root treatment comes first, and symptomatic treatment second.”

*Be that as it may, one well-regarded practitioner, Meizo Okada (a second generation Meridian Therapist, his father being one of the progenitors of the school), once confided to me that sometimes he would do the symptomatic treatment first, or only the symptomatic

49 treatment for the first few visits, because “Patients don’t understand the root treatment”.

The majority of Japanese schools use more gentle treatment methods than their PRC counterparts, and often it is necessary to have a system of feedback to monitor the progress of therapeutic events. It is not uncommon that the root treatment requires confirmation of efficacy before the treatment is allowed to proceed to the next step.

As Shudo explains it, “After the root treatment...is completed, there must be some way to determine if the desired effect has been achieved. In root treatment, unlike symptomatic treatment, relief from symptoms is not the primary indicator of success. Nonetheless, after tonifying a point, one still needs to know if the needling accomplished its objective.”

These he sums up into various indications, having to do with the relative balance between pulse positions and changes in pulse quality, changes in the abdomen and the skin in general, disappearance of abnormal palpatory findings such as pressure pain, increase in circulation to the extremities and in digestive motility, and subjective improvements such as relief from symptoms in the patient. He continues, “The immediate, subtle response of the body to needling sends a very important message to the practitioner about the correctness of the treatment.”

The Root Treatment is, in short, a holistic concept, aimed at enabling the body to better heal itself and recover from disease. In Meridian Therapy, it is directly related to the Sho. While symptoms are considered in determining the Sho, the Root Treatment is not in itself considered to be symptomatic in nature. In theory, at least, if the correct Sho is treated, the symptoms will disappear on their own. The point selection for Root Treatment may be altered to address symptoms, but this is (again in theory) not absolutely necessary. The symptoms themselves may be addressed directly in a later stage of the treatment, known usually as the Branch Treatment (Hyochi Ho). In practice, most Meridian Therapists will do some kind of symptomatic treatment, but some practitioners I observed do the Root Treatment and little else. Those who forgo the symptomatic treatment tend to be very senior practitioners with very busy practices. The symptomatic treatment is important if only for its value as customer service; patients usually are anxious for relief of their symptoms as soon as possible,and understandably so.

50 Root Treatment in My Community Acupuncture Practice In my private practice, I followed a very orthodox path in terms of doing Meridian Therapy. I would stage the treatment with the Root Treatment first, either with contact needling or 15 minutes of retention, before proceeding to the symptomatic treatment. In Community Acupuncture practice, as I got busier, it became difficult if not impossible to go back and pull the Root Treatment needles and insert another set to address symptoms. I was also learning to treat complaints like back pain using distal points. I will elaborate on my process in a later chapter, but in short I began to do mainly complaint-centered treatments using standard protocols. I more or less gave up on doing Meridian Therapy for a while. But I found that, especially in more internal cases (as opposed to musculoskeletal problems, which are considered external in Chinese medicine), I wasn’t getting the results I wanted. I started to do Root Treatments again, and found this to be very helpful. In many cases now, especially when I’m in the middle of a busy shift, I will do a Root Treatment on the Yin channels with maybe some symptomatic points on Yang channels and/or auricular points. I find the results to be quite satisfactory in most cases. I also, after a period of agnosticism about whether the selection of Sho really made a difference, have come back to the conclusion that it does indeed.

Liberation Acupuncture: The Root Treatment is The Room Appended to the present work is a piece I wrote for the Liberation Acupuncture website. The idea is that the context of the open room with all participants sharing the space and healing together becomes in a sense the larger root treatment, and one which ties all acupuncture in a community setting together. It is crucial to realize that this greater context demands a shortening and simplification of the diagnostic and treatment process, even with regards to the feedback and treatment staging mentioned above. Since all processes in the clinic are inextricably linked, excessive intervention in one area of the clinic will affect all of the other treatments happening in the room at the same time. This idea cannot be overemphasized.

51 POINT SELECTION FOR ROOT TREATMENT

Point selection for Meridian Therapy follows a few different sets of principles. The first and most important is from Chapter 69 of Nan Jing. This is the so-called Mother-Child Rule. Chapter 69 states “When Deficient, Tonify the Mother; When Excess, Drain the Child”. The most common interpretation of this, and the strictest, is from what has become known as Korean Four Needle Method.

Korean Four-Needle Technique Four points are chosen; two are tonified, two are drained. A slightly different protocol is followed depending on whether the affected meridian is excess or deficient. If the affected meridian is Yin, Yin meridians are chosen for treatment, if it is Yang, Yang meridians are chosen.

For Deficiency, Tonify the Mother Example: Lung Deficiency: Lung is Metal, Mother of Metal is Earth, Metal is Controlled by Fire 1) Tonify the Mother Point on the Affected Meridian: LU9 (Earth point on Metal Meridian) 2) Tonify the Same-Phase (Horary) Point on the Mother Meridian: SP3 (Earth point on Earth Meridian) 3) Drain the Same-Phase (Horary) Point on the Controller Meridian: HT8 (Fire point on Fire Meridian) 4) Drain the Controller Point on the Affected Meridian: LU10 (Fire point on Metal Meridian)

For Excess, Drain the Child Example: GB Excess: GB is Wood, Child of Wood is Fire, Wood is Controlled by Metal 1)Drain the Child Point on the Affected Meridian:GB38 (Fire point on Wood Meridian) 2)Drain the Same-Phase (Horary) Point on the Child Meridian: SI5 (Fire point on Fire Meridian) 3)Tonify the Same-Phase (Horary) Point on the Controller Meridian: LI1 (Metal point on Metal Meridian) 4)Tonify the Controller Point on the Affected Meridian: GB44 (Metal point on Wood Meridian)

It is from Korean Four Needle that we get the list of points usually labeled “Tonification” (or supplementing) and ”Sedation” (or draining) points. For example, LU9 is the Earth point on the Lung channel, which belongs to Metal, whose Mother is Earth, and so it is the “Tonification Point”. LU5 is the Water point on the Lung channel, which belongs to Metal, whose Son is Water, and so it is the “Sedation Point”.

52 Korean Four Needle is the original basis for point selection in Root Treatment. However, there are some key differences.

First, since the diagnostic emphasis in Meridian Therapy is on patterns of Deficiency in Yin Meridians, tonification of Yin Meridians is emphasized.

Second, the point selection for tonification of Yin Meridians is somewhat more flexible in Meridian Therapy. In most cases, the “Mother” in Chapter 69 of Nan Jing is interpreted at the “Mother Meridian”, and the idea of a single “Tonification Point” or “Sedation Point” is not followed.

Within this framework of choosing the meridians of the primary imbalanced organ and its Mother, the point selection is usually more empirical than anything, and the choice may be a standard reached by broad clinical consensus, or by palpation of the meridians of the individual patient (i.e., choosing the most deficient of the command or essential points on the meridian), or even by points least likely to be painful to the patient.

Standard Consensus Root Treatment Points In reading textbooks of Meridian Therapy and in taking many seminars, I’ve found there are some standard variations from the Korean Four Needle Method in the point selection for the Sho. Note that the Korean Four Needle method uses four points for each pattern, two of them tonified and two of them drained. In Meridian Therapy, there is some disagreement on whether Yin Meridians should be drained at all, so what I’m calling here the Standard Consensus (for lack of a better term), shows only the tonification points, as the choice of draining meridians and points becomes much more varied and complicated.

Lung Deficiency Four Needle: Tonify LU9 and SP3; Drain H8 and LU10 Standard Consensus: Tonify LU9 and SP3

Spleen Deficiency Four Needle: Tonify SP2 and H8; Drain LR1 and SP1 Standard Consensus: Tonify SP3 and P7

Liver Deficiency Four Needle: Tonify LR8 and K10; Drain LU8 and LR4 Standard Consensus: Tonify LR8 and K10

53 Kidney Deficiency Four Needle: Tonify K7 and LU8; Drain SP3 and K3 Standard Consensus: Tonify K7 and LU5

Bear in mind that the points used in the Root Treatment can vary greatly, but that the constant is the principle of choosing the meridian with the primary imbalance and its Mother meridian.

There are some alternate ways to choose points based on classical theory. For example, symptoms may be addressed by the application of the principles of point selection in Chapter 68 of Nan Jing:

For Fullness Below the Heart, choose Wood points: Lung Sho: LU11 & SP1 Spleen Sho: SP1 & P9 Liver Sho: LR1 & K1 Kidney Sho: K1 & LU11

For Heat in the Body, choose Fire points: Lung Sho: LU10 & SP2 Spleen Sho: SP2 & P8 Liver Sho: LR2 & K2 Kidney Sho: K2 & LU10

For Heaviness in the Body, or Joint Pain, choose Earth points: Lung Sho: LU9 & SP3 Spleen Sho: SP3 & P7 Liver Sho: LR3 & K3 Kidney Sho: K3 & LU9

For Coughing or Dyspnea, choose Metal points: Lung Sho: LU8 & SP5 Spleen Sho: SP5 & P5 Liver Sho: LR4 & K7 Kidney Sho: K7 & LU8

For Counterflow Qi or Diarrhea, choose Water points: Lung Sho: LU5 & SP9 Spleen Sho: SP9 & P3 Liver Sho: LR8 & K10 Kidney Sho: K10 & LU5

Yang Meridian Point Selection for Root Treatment Yang meridians are not often tonified, rather they are seen as places where Ja Ki hangs out, so draining is the order of the day. Some Meridian Therapists will tonify Yang Meridians as a way to treat

54 Excess Yin Meridians indirectly by addressing the Yin-Yang balance between two Meridians paired in the same phase. To give an example, say the Lung and Spleen pulses are deficient and the Heart pulse is felt to be excess. Rather than drain the Heart directly, its Yin-Yang paired meridian, the Small Intestine, is chosen,and the Luo-Connecting point, SI7, is tonified.

Sometimes Yang meridians will be seen to be Deficient, for example the Stomach meridian in cases of serious fatigue. But for the most part, Yang meridians are drained. The choice of points generally does not follow the aforementioned concept of “Sedation Points”. It is more common to use the Luo-Connecting points or Xi-cleft points, or to choose points based on palpation. In this case, palpation usually reveals points which are tender or indurated.

There are several different ways to choose which Yang meridians should be treated. • Choose by a theoretical principle, such as balancing of Yin and Yang in the primary phases (for example,choosing the Large Intestine meridian in the Lung Sho) or using the Ten Stem method (for example, choosing the Small Intestine meridian in the Lung Sho). • Choose by feeling the presence of Ja Ki in one or more Yang Meridian pulses. This may or may not correspond with any Five- Phase theoretical models. • Choose by the location of symptoms along one of the Yang Meridians. This also may or may not correspond with any Five- Phase theoretical models.

Application to Community Acupuncture Practice All of the above is very theoretical in nature and can get to be quite complicated in application. Where do you start? I will cover my standard points for Root Treatment in the second half of the book, but here I will give my best recommendation for someone just starting out.

• Remember the basic principle of choosing Yin Meridians, which follows naturally from the selection of the Sho. Tonify the meridian with the primary imbalance, along with its mother meridian. • Use the Standard Consensus points for the Yin Meridians. They are the most commonly used points in Meridian Therapy because they have been found to be the most useful for the greatest number of practitioners and patients. • Choose Yang Meridians based on the location of symptoms. So if the patient complains of sinus problems, use the Large Intestine

55 meridian, or if the complaint is scapular pain, use the Small Intestine meridian.

In most cases, you’ll be fine with that. As you go on, if you want to start trying to detect Ja Ki in different pulse positions, or utilize pulse feedback, or figure out Ten Stem strategies, you can add those in once the basics become second nature.

In another section, we will cover different concepts of tonifying and draining. My advice is to not get too hung up on that. Indeed, in Chapter 79 of Nan Jing, it says that needle technique is less important than the Mother-Child concept. The primary consideration is choosing the Sho, which is based on Mother-Child theory, and using the two meridians listed in the Sho. One of the best pieces of advice I got in needling was to not be too concerned with thinking “Okay, now I’m tonifying the Lung meridian” or whatever; the body is intelligent enough to know what to do, and the simple solution is often the best.

56 POINT LOCATION -- WHAT AM I LOOKING FOR?

The first principle in point location is the "Live Point" concept. Anatomical locations are just a guideline; real treatable acupuncture points need to be located by other criteria.

According to Sodo Okabe, there are five types of changes associated with acupuncture points: 1) Induration - a small nodule is felt at the point which may produce a dull pain when pressed 2) Tenderness - a hard area which produces a strong pain when pressed 3) Hyperesthesia - pain felt on the surface of the skin when stroked or lightly pinched 4) Depression - a small area into which the finger falls, often at source or tonification points 5) Congestion - a superficial, slightly bloated, pillow- like stagnation often found on the abdomen

Indurations tend to come in three types: Soft/spongy, medium and hard. The softer indurations are less chronic and easier to treat. If a person has significant amounts of hardened tissue, their prognosis is accordingly much worse.

Depressions and sticky congestions are usually felt when looking for tonification points on Yin channels. Points on Yang channels usually have more tenderness or indurations.

The best way to find Live Points is to begin stroking lightly on the channels about five cm either side of a standard anatomical location. Concentrate of the fingertips and note any changes that you feel. Does your finger stop anywhere along the channel? Examine what you feel if it does -- is there a depression, a sticky feeling, a puffy feeling, or a nodule? Watch the face of the patient -- are they wincing, or has their breathing changed? You can also monitor the pulse for changes when palpating around acupuncture points, especially for tonification points. If the pulse improves while lightly touching the point, then the point should be good for tonification.

57 NEEDLE TECHNIQUE

Needle Gauges and Materials It’s no exaggeration to state that Japan was instrumental in developing the fine needle to the extent that we have it now. The insertion tube was a Japanese invention, attributed to the 18th- century blind acupuncturist Waichi Sugiyama. The tube enabled the insertion of finer and finer needles, even those made of softer metals like gold and silver.

I have heard it stated that the most popular needle gauge in Japan is Japanese #2 (.18mm, Chinese 38), which is quite thin by Chinese standards. Bear in mind that the majority of Japanese acupuncturists do not practice Meridian Therapy, rather they practice a more physiotherapy oriented style. In Meridian Therapy, the needles used are often thinner than #2; #1 through #02 (.16-.12mm) are quite common in stainless steel. I trained with #2 needles made of silver when I studied with the blind teachers, and #01 or #02 stainless when I attended Dr Shudo’s seminars.

Silver and gold are considered to be more tonifying and stainless more draining, while thicker needles are more draining and thinner gauges more tonifying. So, the theory goes, try to get as thin and soft a needle as you can get.

One thing I have noticed in using different needle gauges - even with higher quality needles - is that the super-thin gauges are not always the least painful. In theory, they should be, of course, but I find that it really varies with the patient, particularly the kind of skin they have. In patients with thicker or tougher skin, the really fine gauges often won’t penetrate, and end up stinging. Slightly thicker gauges - #2/.18/38 or #3/.20/36 will actually feel more comfortable, since they are sturdy enough to pass through the outer layer of skin and the cutaneous nerves into the underlying fascia. If you keep a variety of needle sizes around, you can switch up if the patient remarks that the needles are hurting. If you want to keep it simple and stock one gauge of needle, then #2/.18/38 is a good compromise; like I said, it is probably the most popular gauge in Japan.

When we talk about tonifying and draining, one of the main ideas in Meridian Therapy, beyond all of the various techniques, is that the more one feels pain or other strong sensations from the needling, the more draining the needling is. This is quite distinct from the more standard Chinese practice of deqi, which is considered necessary in TCM acupuncture whether the technique calls for tonifying or draining. The Japanese view is similar to the Arndt Schultz law which

58 states that weak stimulation tonifies while stong stimulation drains. There is a definite correlation with the two parts of the Autonomic Nervous System, which we will discuss in more detail later on.

Part of the characteristic nature of most of the Japanese classical styles is this idea that weak stim is therapeutically useful, even desirable. Where TCM acupuncture relies on the patients’ report of the needling sensation, or the eliciting of the muscle twitch which grabs the shaft of the manipulated needle, Meridian Therapy and its related styles rely on their systems of subtle feedback (pulse, hara, etc) to inform the clinician that the needling is having the desired effect.

Choice of needle Choosing needles is a very personal matter. Some practitioners will use just about anything, and others are very picky. The gauge, sharpness, flexibility, etc can vary from one brand to another. Handle material and length are further considerations. For purposes of community acupuncture practices, where the profit margin tends to be quite small, price is an important issue, as is availability, since this type of practice relies on high patient volume and thus a high quantity of needles.

I have gone through many phases of using different brands and lengths of needles. A little over a year ago, I had decided to simplify my practice and use only 15mm needles(usually used for ear and facial acupuncture points) with manual insertion, which enabled me to needle more quickly. I found a brand of needle that I liked, with long colored plastic handles, in five-packs. I like the handle size, which fits my large fingers well; doing manual insertion with smaller handles causes me pain in the thumb of my needling hand after a while. The colored handles are easy to see when removing or picking up dropped needles from the floor. There were a few drawbacks to this choice, however. First, the plastic handled needles are more expensive than metal handled needles - up to twice the cost per needle of the more popular metal-coil handled needles. Second, the particular brand is only carried by a couple of vendors, and when they go out of stock, it is usually a long time before they become available again. So I still sometimes use the 30mm metal handled needles with a tube, at least for body points, still employing the 15mm plastic handled needles for ear and face points. I was reminded of something one of the Japanese teachers said to me many years ago: don’t get too attached to one particular brand of needle, because if they stop making it, you’ll be forced to change. It’s best, at least for community acupuncture, to choose a popular brand that you like so you can be assured of getting it in volume from a wide variety of vendors.

59 Needle Techniques There are many techniques taught by the various acupuncture organizations in Japan, though they break down to only a few basic techniques. On the one hand, there is inserted and non-inserted needling, and on the other there is retention and non-retention of needles.

Inserted Needles There are two basic types of inserted needles: Retained needles and non-retained needles. Retained needles are inserted, either with a tube or manually, and the needle is left in the point for some time after the insertion. There may be manipulation of the needle before leaving it retained, or it may just be inserted to the desired depth and left without manipulation. Retained needles are the most common technique in community acupuncture. For Meridian Therapy,the depth of insertion is usually less than 10mm, often between 3-7mm. Depending on the brand of needle, just tapping the needle through the tube gives an insertion depth of 3-5mm. Some sources say that the optimum depth of insertion for tonification is 1-2mm, so that the needle tends to flop over unless it is very short and thin.

Non-retained inserted needling is sometimes called “simple insertion”. In simple insertion, the needle is inserted, sunk to the desired depth, and removed. There may be brief manipulation, or it just may go in and come out at once. I use simple insertion often, mostly on points where it would be either difficult to retain the needle or possibly hazardous to retain it. An example would be GB21; I would rather not retain the needle there since there is a risk of hitting an important structure such as the Lung. Many patients move around quite a bit in the chair and retained needles can go in deeper or at a different angle than one intended. Sometimes I will do simple insertion on the back, before the patient reclines; retaining a needle there is difficult and possibly dangerous since the patient would then be lying on top of the needle when reclining.

Simple insertion is a common technique in Japan, but in my experience it is virtually unheard of in America. Sometimes when I mention it to other acupuncturists, they think I am joking. But I find it quite effective and it solves some problems with retaining needles in awkward places.

Non-inserted needling is sometimes called “contact needling”. In contact needling,the tip of the needle just makes contact with the surface of the skin. This is the foundation technique of the blind acupuncturists I studied with for many years. To accomplish this technique, the needle shaft needs to be supported by the non-dominant

60 hand, usually with the thumb and index finger. This is called “oshide” or “pressing hand”. In truth, the oshide is used in Japan even when inserting needles, as the light pressure from the fingers helps to reduce the sensation of needling and keeps the thin needles from bending. In America, however, Clean Needle Technique discourages this technique, so it is best to use it only when doing contact needling or very superficial insertion.

As subtle as it is, contact needling can be surprisingly effective, especially on the sensitive areas of the hands and feet. It is seldom used in the West (except by Japanese style practitioners of course), though it is not unheard of. Felix Mann writes about it, calling it micro acupuncture, and he states that he uses it often (indeed, he apparently takes credit for it and seems to be unaware that it is a common technique in Japan.

Contact needling is most often done on acupuncture points, but there is a technique of contact needling called sanshin, “scatter needling”, which is performed over a larger area such as the upper back or abdomen. In this technique, a single needle is touched to the skin repeatedly in a somewhat random fashion, quickly stimulating the desired area. It requires a great deal of practice, the early stages of which usually results in the acupuncturist sticking their own fingers a few times. I occasionally use this technique on areas such as the scalp, but to be honest I find it easier to do with the patient lying flat, so I seldom use it anymore. A safer way to do this and get a similar effect is to use a teishin or rounded needle, or just to use the insertion tube and tap it over the surface of the skin.

The Vibrating Needle I’d been using shallow needle retention for many years when my attention was called to a subtle but interesting aspect of it. I taught at an acupuncture college in Miami and would sometimes do clinic supervision. In the student clinic, the instructors were required to do treatments that the students would observe. I did a treatment one day, with my usual techniques including retaining needles with shallow (~5mm) insertion of #2 needles. One of the Chinese instructors was watching, and as I finished up the needling and left the retained needles in place, she remarked that the needles were vibrating. I just nodded, but I must confess that I’d never really noticed that before. We left the patient with the needles retained for about 30 minutes, and when we returned, the Chinese instructor remarked that the needles were still vibrating. She had never seen this before and found it very interesting. I admit that I found it interesting too, and I did some thinking about it.

61 I remember reading an article in the North American Journal of Oriental Medicine, a publication dedicated to Japanese styles of acupuncture, which posited vibration of the needle - manually, done by the practitioner - as a key characteristic of Japanese acupuncture. The needle techniques done by Japanese practitioners often involve flicking the needle handle, which imparts a vibration that subtly stimulates the point. What my colleague noticed was that the thin, flexible needles with the metal handles will vibrate by themselves when retained, just by the rhythms of the patient’s breathing and heartbeat. This means that by using this simple technique with this type of needle, the points will be constantly stimulated throughout the treatment. I believe this is one of the keys to the effectiveness of this technique.

62 Here is a handout I prepared for my old Continuing Ed classes:

Arrival of Qi -- How Do I Know If I’m Doing It Right?

Since the emphasis is on changes the practitioner feels when needling and not on the patient feeling a needle sensation, how do we know that the needling is effective? Eventually, the practitioner develops a sense of whether or not the needling is effective based on their experience, but for the beginner the following are things to look for:

1) The pulse positions become more evenly balanced, or the pulse quality and Yin/Yang balance becomes more harmonized (pulse moves toward the middle depth, slows down, becomes less scattered, etc)

2) Changes occur on the skin -- not just at the point, but along the channels, abdomen and face. The skin becomes more lustrous, color returns to the cheeks, etc.

3) Tender or hard areas become reduced

4) Cold hands or feet begin to warm up

5) The patient begins to breathe more deeply and evenly

6) Abdominal sounds become audible during needling

7) Symptoms are improved, feel “lighter” or disappear

8) The arrival of Qi at the point underneath the tip of the needle or the left hand

Some of these phenomena are subtle and take a while for the practitioner to recognize. The most obvious are the improvement in breathing, abdominal sounds and improvement in symptoms. Look for these first, and when they happen, notice any other changes, such as feelings in needling and supporting hands. Be aware of memorizing any physical sensations associated with good treatments, and you will be better able in the future to judge whether or not your treatments are effective.

63 SUPPORTIVE TREATMENT

Meridian Therapy represents just one branch of Japanese acupuncture. It is probably the most prevalent of the classically- based styles, which are themselves a minority of acupuncture styles in Japan. Japanese Meridian Therapy, as explained earlier, has the Nan Jing with its emphasis on Five-Phases as its basis. There are other systems, however, which have been developed from the various descriptions of meridian systems and techniques found in the Nei Jing, the grand-daddy of all of the Chinese medical classics, as well as those from Nan Jing that weren’t originally incorporated into JMT. In fact, one of the most striking features of Japanese acupuncture is its diversity; attempts to describe one particular style as “Japanese acupuncture” do not hold up well under scrutiny. While Japanese practitioners tend to group together into professional associations, each of which has its own particular style of treatment, it is quite common for practitioners to look at other groups to see if they may have something clinically useful which can be incorporated as well. This may necessitate some theoretical re-arranging in order to make the new information fit into the existing treatment model. This, in the JMT association I belonged to, was the concept of the “supportive treatment”. Where the root treatment featured the flagship technique of the group, the one that was used to rectify the fundamental condition of the patient,and the branch treatment treated the presenting symptoms of the patient, the supportive treatment stood somewhere in between. Generally non-local but usually directly related to the patient’s symptoms, the supportive treatment was taught to me as an optional middle step between root and branch.

Depending on the practitioner and the case, the supportive treatment may be several steps in itself, using several different systems. As an example, a treatment might start with the Root Treatment based on the pulse and hara, then progress to treating Extraordinary Vessels, Midnight-Noon, and neck and/or pelvic areas. A general harmonizing treatment may be done. After all that, symptomatic areas might be treated (Branch Treatment). This can make for a long and labor-intensive treatment. It is worth noting that many (if not most) practitioners with sizeable clinic volume have assistants to facilitate the delivery of the treatment.

64 EIGHT EXTRAORDINARY VESSELS (KI KEI HACHI MYAKU)

From my earlier work: <

Though often used singly or in combination with other points unrelated to the Extraordinary Vessel paradigm, these point pairs became in some schools of thought entire treatments in themselves. Their use in twentieth-century Japan has been almost inextricably linked with the concept of “polarity agents”, i.e. treating the master point and its coupled point with materials or techniques of dissimilar, unequal or “opposite” composition . Examples of this range from tonifying and dispersing needle techniques to north and south poles of magnets to needles coated with different metals; this creates a “gradient” effect similar to a battery. In some cases, devices have been invented solely to treat these four pairs of points. It is worth noting that, though it makes use of more “scientific” theory, this technique is so prevalent in Japan that it has been adopted by even the staunchest of traditionalists, though often only when treating the Extraordinary Vessels .>>

Extraordinary Vessels theory had its beginnings in the Nan Jing, chapters 27-29. Where some of the Vessels had been mentioned singly in the Nei Jing, the idea of Extraordinary Vessels as a unified part of the meridian system was first mentioned in the Nan Jing. As such, it is perhaps natural that it would find a place in a style based so squarely in that classic. However, the symptomology described was minimal and there was no real treatment method other than striking the Vessels with a (sharp) stone; as mentioned above, there was no treatment system described for another thousand years. Furthermore, the Extraordinary Vessels did not conform to the Five-Phase dynamic that is woven through the rest of Nan Jing, and so doesn’t really fit into the scheme of Root Treatment in JMT.

65 So, as far as JMT is concerned, EV is consigned to the status of Supportive Therapy. In some other Neo-Classical Japanese styles which were developed subsequent to JMT, EV is seen as a kind of Root Treatment; it is used as Yoshio Manaka’s Step One of his Five Step protocol, for example.

Even though EV is not officially considered a Root Treatment in conventional JMT, introducing it into the Root Treatment is not too difficult. In the cases of the Yin Meridians, the EV pairs fall into a Mother-Son pattern: Yinqiao Mai and Ren Mai Master points K6 and LU7 can be used in cases of Kidney Sho, and Chong Mai and Yinwei Mai Master points SP4 and P6 can be used in the Spleen Sho. The Yang master point pairs fall into Upper-Lower or Great Meridian pairs: Yangqiao Mai and Du Mai Master points UB62 and SI3 are both found on Taiyang meridians and Yangwei Mai and Dai Mai Master points TB5 and GB41 are found on Shaoyang meridians. This pattern is also found in the extended Extraordinary Vessel pairs used by Kodo Fukushima’s group, which is detailed below; the additional Yin pair is H5 and LR3 (a Mother-Son relationship and a sort of cheat around the lack of a Heart Sho), and the additional Yang pair is LI4 and ST43 (both points on Yangming meridians). I make use of these point pairs constantly.

As mentioned above, the point pairs are often treated with “polarity agents”, and when I began doing CA I strove to follow this idea with Ion Pumping cords*. After a while I found the process too unwieldy and just used the needles by themselves. I can’t say that I noticed a dramatic difference in outcomes for better or worse. Whether I am no longer treating EV and just treating the Sho or Great Meridian pairs is open to debate. Suffice it to say that I rely on the body’s own ability to sort out what it needs to do once the needles are in place.

Since the classical theories of EV are less than comprehensive, a lot of work has been done in the last half-century to develop theories, treatment strategies and methods based around what we have of EV theory from pre-modern sources. This has led to a lot of speculation, and the views on EV range from symptomatic applications to different (in some cases contradictory) maps of abdominal palpation, to psychospiritual aspects. The “official” version I learned from Fukushima’s group was largely based on symptomology with some palpation (I also learned a method of abdominal diagnosis from a prominent member of the Fukushima group that was not considered part of the approved curriculum). I have compiled those symptom conformations along with those of other authors below. I have also included some palpatory indications from Fukushima and Yoshio Manaka. I currently stick to these symptoms almost exclusively when deciding whether to include the EV points in treatment.

66 COMPARATIVE SYMPTOMOLOGY OF EXTRAORDINARY VESSELS

REN MAI Gynecological problems; hemorrhoids; asthma; bronchitis; lung problems; neurosis; toothache; ear, nose and throat problems;1 skin diseases; 3 Symptoms along the courses of the meridians; tooth and gum pain in the front of the mouth; phlegm disorders; epigastric pain; nausea and vomiting; distension and pain in the epigastrium, middle or lower abdomen; general pain; diarrhea; constipation; urinary incontinence, anuria or hematuria; birthing difficulties; special circulatory problems particular to women; cold or hot feet; kidney diseases; general lack of vigor.2

REN MAI (palpation) Pressure pain or reaction may be found on: the whole length of the Ren Mai, especially below and above the umbilicus; Lung meridian, especially LU1 and LU7.

YINQIAO MAI Urinary problems; gynecological problems; cold feet; intestinal problems;1 peritonitis; hepatitis; nephritis;3 Insomnia; chronic pharyngitis; intestinal poisoning; jaundice; menstrual cramps; uterine bleeding; late labor; leukorrhea; prostatitis; impotence; bladder spasms; constipation.4

YINQIAO MAI (palpation) Pressure pain or reaction ST9, ST12, K16, K8, K6, K2. The area below the umbilicus is weak or has less tension than the area above the umbilicus; back muscles are jitsu while abdominal muscles are Kyo**; weakness of the abdomen with areas of tension around the umbilicus.

DU MAI Epilepsy; fatigue; spine and neck problems; neurosis; insomnia; superficial invasion of e.p.f. (Taiyang syndrome);1 inflammation of the joints; neuralgia; emotional problems;3 overexcitement; nervous breakdown; lack of concentration; insomnia; melancholia; lethargy;4 Symptoms along the course of the meridians; pain in the top or back of the head and the back of the neck; apoplexy accompanied by paralysis or speech disorders; general disorders of the eyes, ears or nose; trigeminal neuralgia of the second or third branches; tooth and gum pain; swollen or sore throat accompanied by sore points along the Du Mai in the back of the neck; Yang Kyo: fatigue, spontaneous sweating, night sweats; Alzheimerʼs disease; lack of mental clarity; hemorrhoids.2

67 DU MAI (palpation) Pressure pain or reaction on: the Du Mai, particularly the upper back and GV3, GV4 and GV20; the Small Intestine meridian, especially SI3.

YANGQIAO MAI Manaka: Whiplash; epilepsy; speech disorders; shoulder pain; lumbar pain; unusual sweating; trigeminal neuralgia;1 any bleeding problem; stroke; hemiplegia;3 edema; tinnitus.4

YANGQIAO MAI (palpation) UB41, UB43, UB40, UB57, ST19, UB61, UB62; GB21, SI9 and SI10, alongside the cervical vertebrae

CHONG MAI Manaka: Heart problems; neurosis; stomach problems; gynecological problems; cold feet; liver/gallbladder problems; problems of anus1; pain that moves; late menses causing suffering of the heart and palpitations that lead to insomnia; intestinal spasms4; swollen and sore throat; chest or heart pain or discomfort; general pain; abdominal distension or pain; pain, cramping, palpitations or upward flushes on the sides of the abdomen (Spleen) or around the umbilicus (Kidney); nausea or vomiting; diarrhea; constipation; bleeding affiliated with the stomach, kidneys or large intestine; endocrine disorders; menopausal ailments; hemorrhoids.2

CHONG MAI (palpation) Spleen meridian in the legs and feet and the Kidney meridian in the chest and abdomen. Diagnostic points ST11, K16, SP6, SP4; K1.

YINWEI MAI Nervousness; heart problems; palpitations; psychological problems; insomnia; stomach problems1; difficulty breathing; phobias2; easily upset; talks a lot; forgetful; easily excited; excessive emotional sympathy; suffering in the chest; borborygmus; no appetite and weight loss with stabbing pain in the intestines at the side of the abdomen or around CV-15 with cold or exhaustion.4

YINWEI MAI (palpation) CV22, LR14, SP16, SP15, SP13, K9. Pericardium meridian in general, PC6 in particular

DAI MAI Coldness or achiness in lower back; gynecological problems; menstrual problems; problems in lower abdomen1; any joint pain; neuralgia; menstrual pain; toothache3; general muscle pain; menstrual pain or gum pain associated with weakness or fatigue4; Symptoms along the course of the meridian; headache accompanied by edema; general eye and ear afflictions; trigeminal neuralgia; tooth and gum pain in the

68 sides of the mouth; dizziness; Meniereʼs syndrome; spontaneous sweating; night sweating; alternating chills and fever; liver and gallbladder disorders; distension of the ribs and lower abdomen; abnormal vaginal discharge.2

DAI MAI (palpation) LIV13, GB26, GB27, GB28, GB29, Gallbladder meridian, particularly GB41.

YANGWEI MAI Dizziness; headache; whiplash; sweating problems; trigeminal neuralgia; fatigue; eye and ear problems.1 Mainly any pain on one side of the body (e.g. migraine, neck pain); joint inflammation; symptoms similar to Dai Mai but more Yang in nature (inflammation, etc.).3; gingivitis; writerʼs cramp; eye tick; poor circulation; hypotension; rapid pulse; arteritis; oversensitivity to seasonal change; thrombosis; skin inflammation; eczema; pimples; skin swelling; irregular breathing; hemoptysis; epistaxis, stuttering; ankle sprain; bedwetting; heartburn.4

YANGWEI MAI (palpation) GB21, TB15, GB29, GB34, GB35, TB5.

Additional EV Combinations (NOTE: In addition to the classic Extraordinary Vessel combinations, Kodo Fukushima’s group has added two point combinations to its Extraordinary Vessel treatments: LI4 is combined with ST43, and HT5 is combined with LR3. Occasionally LR3 will be combined with HT7 or PC6, depending on specific symptoms.)

GOKOKU / KANKOKU (LI4/ST43) Symptomology: Symptoms along the course of the meridians; growths and abcesses on the face, neck, arms or back; stye or pinkeye; inflammation of oral mucosa; swelling and pain in teeth and gums; sore throat; stomach pain and distension; diarrhea; skin diseases; acute emotional disorders. Palpation:“GoKoku point is affiliated with the Large Intestine meridian. Its diagnostic points are LI4, LI7, LI15, LI17, LI20.” “KanKoku point is affiliated with the Stomach meridian. ST43, ST1, ST2, ST12, ST25, ST36.”

TAISHO / TSURI (LR3/H5) Symptomology: Symptoms along the course of the meridians; vertigo; Alzheimerʼs disease; emotional disorders; eye afflictions; disorders of the endocrine system; thoracic or flank pain and distension; muscle cramping; sweling; coldness; lack of motivation.

69 Palpation: “TaiSho point is affiliated with the Liver meridian. Its diagnostic points are LR3, LR5, LR8, and LR14.” “TsuRi point is affiliated with the Heart meridian. Its diagnostic points are H5, H7, H4, H1.”

Sources 1 Manaka 2 Fukushima 3 Nagatomo 4 Bachman

* Ion Pumping Cords (sometimes abbreviated IPC) are long thin electrical wires with an alligator clip at either end. One clip is colored black and the other one red. Somewhere in the apparatus, usually in one of the clips, is a diode which acts as a gate, forcing the electrical current to go only one way (black to red). There is no outside current used; rather the body’s own electrical currents will travel, either through the wire or along the subcutaneous tissues, from one needle to another. One way to think of it is as a jumper cable for the body’s own natural current.

** Kyo = Deficiency, Jitsu = Excess

70 MIDNIGHT-NOON (SHIGO) TREATMENT

ShiGo is the Japanese pronunciation of Zi Wu, which refers to the system of Stems and Branches in Chinese astrology. Stems and Branches are part of the cycle of time. They are more properly known as the Ten Heavenly Stems (which relate to the Ten Stems we saw earlier) and the Twelve Earthy Branches. The Ten Stems are related to the Yin and Yang aspects of the Five Phases, as we’ve seen, and the Twelve Branches are related to both the hours of the day, and the twelve main meridians.

You likely learned the so-called “Chinese clock” correlation between the 12 bihourly units of the 24-hour day cycle with the meridians,but lets recap with the names of the Earthly Branches included: (#)(Name) (Hours) (Meridian) 1 Zi 11PM-1AM GB 2 Chou 1AM-3AM LR 3 Yin 3AM-5AM LU 4 Mao 5AM-7AM LI 5 Chen 7AM-9AM ST 6 Si 9AM-11AM SP 7 Wu 11AM-1PM HT 8 Wei 1PM-3PM SI 9 Shen 3PM-5PM UB 10 You 5PM-7PM KI 11 Xu 7PM-9PM PC 12 Hai 9PM-11PM TB

So ShiGo refers to the hours around Midnight and Noon, and in Fukushima’s book, the name is translated as Midnight-Noon Needling. I learned this system with Fukushima’s students, though it is fairly widespread among acupuncturists (it is one of Richard Tan’s 5 systems, for example).

If you split the table in half, you will see complementary bihourly units, for example Shi is 11PM-1AM and Go is 11AM-1PM. The meridians associated with those units have a complementary relationship as well,they are “opposites on the Chinese clock”. The table looks like this: 11PM-1AM GB 11AM-1PM HT 1AM-3AM LR 1PM-3PM SI 3AM-5AM LU 3PM-5PM UB 5AM-7AM LI 5PM-7PM KI 7AM-9AM ST 7PM-9PM PC 9AM-11AM SP 9PM-11PM TB

71 You can see a couple of interesting things when you look at this table. First, as in the Ten Stems, in every case a Yang meridian is paired with a Yin meridian. Also, each pair has a meridian on the hand and one on the foot: GB (Foot Yang) HT (Hand Yin) LR (Foot Yin) SI (Hand Yang) LU (Hand Yin) UB (Foot Yang) LI (Hand Yang) KI (Foot Yin) ST (Foot Yang) PC (Hand Yin) SP (Foot Yin) TB (Hand Yang)

So what does this relationship mean? Well, clinically,it means that you can treat one of the meridians in a pair and it will have an effect on the other paired meridian. This explains some actions of certain points which may be difficult to explain otherwise; for example P6 is well known for treating nausea which is associated with the Stomach. LU7 treats the nape of the neck and back of the head, neither of which is traversed by any of the branches of the Lung meridian; it is the area through which the Bladder meridian runs, and the Bladder is opposite the Lung on the Midnight-Noon cycle.

How is this used clinically? There are a number of ways. The way I was taught in Meridian Therapy was that if there is an Excess symptom on one meridian (usually pain), then one can treat it by choosing a point on its paired meridian in the Midnight-Noon cycle and applying strong tonification to that point. In the system I was taught, the technique was to use a very thick gold needle (gold is considered the most tonifying of needle metals) and applying contact needling to the point. Direct moxa (15-30 times) or gold pressballs may also be used. The point selection could vary, but it usually ended up being the Xi-Cleft point, which is used to drain excess symptoms of its own channel, but when tonified with the big gold needle would drain the excess on the opposite Midnight-Noon channel. For problems restricted to one side, the opposite side is treated; so, for pain in the right elbow that runs along the Large Intestine meridian, left K-4 or K-5 would be treated. For bilateral pain or organ problems, the most painful side is treated. For symptoms occurring at a specific time, the patient may be given instructions to apply moxa or finger pressure to the relevant point at the time when the symptoms occur.

I first used this technique in the clinic when I stopped an asthma attack by using UB63 with the big gold needle; it was a bit of beginner’s luck, I think, but it did show me that the system can actually work. A very popular method today is to use imaging (imagining that the body is superimposed on the section of the channel you are

72 treating and finding the corresponding area to the pain on that section), or just finding tender points along the channel, but I most often fall back on my training and use the Xi-Cleft or Luo Connecting points and it works pretty well for me. I don’t use the big gold needle anymore, though, I just use the regular stainless needles and retain with the other points I’m treating.

This technique can come in handy in other situations as well. I have a fair number of Muslim women patients who cover everything but their hands and face. One such patient was pregnant and had placenta previa. I determined that the Spleen, Liver and Kidney meridians were involved, but since I couldn’t get to her feet, I used TB5, SI6 and LI6 (opposite the SP, LR and KI meridians). The situation resolved nicely; though placenta previa usually resolves itself by the term period, her OB-GYN told her that she had never seen a case resolve so quickly before.

SAWADA WHOLE BODY (TAIKYOKU) TREATMENT

Takeshi Sawada was a seminal figure in the Japanese neo- classical acupuncture movement in the early Twentieth century. He was actually not an acupuncturist at all, but instead used moxibustion as his modality of choice. He had a very succinct theoretical basis for his treatments which involved disturbances in the Triple Burner. His treatments were based largely on his Taikyoku (Taiji, Grand Ultimate, same characters as the internal martial art) treatment, with added points, mostly empirical,to treat symptoms. His style was widely adopted by succeeding generations of acupuncturists in Japan. Even among some Meridian Therapists, his Taikyoku therapy is used as a sort of general harmonizing treatment given after the Sho is treated.

Sawada’s basic Taikyoku treatment used these points: ST36, LI11, CV(Ren)12, GV(Du)12 CV6, TB4 especially left, K3 (close to K6) UB17, UB18, UB20, UB23, UB32, UB52

Sawada's typical sequence was to treat the abdomen (CV12, CV6) first, followed by the back(UB channel points), then finishing with the limbs (LI11, S36, TB4, K3).

I have my own CA mini-Taikyoku treatment which I will elaborate on later in the Protocols section.

73 Unilateral Vs Bilateral Treatment

The question of what side of the body to treat when can be a complicated one. There are many factors involved. Are the symptoms more internal or external? Do they present mainly on one side? Are some on one side and some on the other? In addition, there are different styles of acupuncture which use different principles, and there are proponents of each style who insist that their way is correct.

I will give you the answers I learned in studying Meridian Therapy, and then give you what I usually end up doing. And then you get to figure it out for yourself.

Some of the approaches I learned in Meridian Therapy (studying with different teachers from different organizations) are as follows:

• Needle all points bilaterally. • Needle Yin Meridian points on one side and Yang meridian points on the other. • Needle the Yin Meridian points pertaining to the Sho on the right for female patients, and on the left for male patients. • Use the female-male principle above, then re-check the pulse. If there is insufficient improvement, needle the same points on the opposite side. • Needle Yang Meridian points on the side on which the Yang meridian pulse is found (e.g. Stomach pulse is found on the right wrist, so needle the Stomach meridian on the right). • Needle the Yin Meridian points pertaining to the Sho on the healthier (e.g. less symptomatic) side and the Yang meridian points on the more symptomatic side. The idea here is that the healthier side contains more Sei Ki (Zheng or Correct Qi), and tonifying that side helps the Sei Ki to circulate through the body. • Needle the Yin Meridian points pertaining to the primary sho pattern on the right for females and the left for males, and the Yin Meridian points pertaining to the secondary (Sokoku or control cycle) sho on the opposite side. • Needle the Yin Meridian points pertaining to the primary sho pattern on the healthier side, and the Yin Meridian points pertaining to the secondary (Sokoku or control cycle) sho on the less healthy side.

I use all of these approaches at various times, and they are all useful. Needling unilaterally has many advantages. It saves needles, especially when there are lots of symptoms the patient wants

74 addressed. In sensitive or anxious patients, it causes less distress because it cuts down on the number of times the skin is punctured. Needling unilaterally also has a sort of dynamic effect; it seems to encourage movement where bilateral needling has more of a stabilizing effect. There are some drawbacks too. Needling bilaterally ensures that if one needle drops out (a frequent occurrence when retaining shallowly inserted needles), the needle will likely remain in the same point on the opposite side. I have found also that there are some patients (though not many) who are bothered by asymmetrical needling. On the other hand, for patients with few complaints, who just want to relax, choosing a few points unilaterally can make them feel like they are not getting much of a treatment, so needling those points bilaterally can make them feel a little more like they are getting some value for their money. For us, it can seem silly to equate the quality of a treatment with the number of needles, but there are some people for whom it is an issue.

I’ve heard it said somewhere that needling points unilaterally primarily treats meridian problems where needling bilaterally treats organ problems. While I don’t know where this comes from and am inherently suspicious of such tidy axioms, I have had some experience that would seem to support this assertion. In cases where the Sho is relatively clear, and the patient’s complaints are primarily internal, needling points bilaterally does seem to focus the treatment and provide a better result.

I will usually needle Yin points (i.e., the Sho) on one side and Yang points on the other in cases where the symptoms present on the same side of the upper and lower body. If the patient is sensitive and I want to limit the number of needles, I may choose to assign the Yin and Yang points on the sides of the body according to gender or the principle of using the healthier side (i.e the side that has more Sei Ki), especially if there is no clear side of the body to treat. If I am needling the Sho bilaterally and want to limit the number of needles, I will usually needle the Yang points on the side in which they appear on the pulse.

If I am needling a Sokoku pattern, I will usually follow the principle of assigning the primary and secondary Sho sides according to which side of the body is healthier.

75 Part 5 Some Protocols

76 BACK PAIN

Back pain is probably the most common complaint in any acupuncturist’s practice (unless they specialize in fertility or something like that). It has also been perhaps the biggest challenge for me (and likely many others) in transitioning fully to a chair- based Community Acupuncture practice. Long after I had gotten comfortable treating virtually every other complaint in reclining chairs, I hung onto the massage table to treat back pain. Since this is such a common complaint, and I had worked up to scheduling six patients an hour, often I would find one or even two tables to be insufficient to accommodate all the back pain cases which would come through the door. Add to this the fact that patients often show up late, at the wrong appointment time or without an appointment, and soon I found the whole situation very frustrating. I decided that the table had to go, and that I had to make the distal back pain treatments work.

There was another compelling reason. I found that, while in many cases local treatment of lumbar pain would work, there were numerous cases in which it did not. To make matters worse, in some cases the pain would be aggravated by local treatment. This might happen because of the needling (often with electric stimulation), because of the positioning of the patient on the table,or both. In my private room practice, I often found it necessary to forgo the root treatment for lumbar pain, because it was so painful for the patient to turn over from a supine to a prone or side-lying position. Getting the patient into a comfortable position, or even getting them to undress - in some cases, to even remove their shoes - took inordinate amounts of time, and then the back pain could be aggravated by maintaining the position for too long. In the earlier years of my Community Acupuncture practice, when I still used tables, I began to implement a strict 30-minute retention time. In some cases, even this was too long. After much frustration and deliberation, I decided the table had to go.

The back pain protocol that I use most often is a variation on the one outlined in Acupuncture Is Like Noodles. I got some clarification on the treatment from Skip Van Meter and other punks. The result is as follows:

I ask the patient to indicate the more painful side. If there isn’t one, then I usually just pick a side to treat. I had started by treating bilateral back pain bilaterally, but in most cases I think it was no better than treating one-sided and wasted a lot of needles. I have the protocol down to fifteen needles, and add more if necessary.

77 The protocol is reminiscent of Richard Tan’s style,but I have come to think of it as a Liver-Kidney sho with Lung sokoku and some shigo thrown in. (For comments of the points, my needling methods and location notes, see the Points section in the forthcoming book)

Painful side: Leg: UB39, GB34, UB62, UB63 (or UB65), GB41. Arm: LU5, LU6. Ear: Spinal level of lesion (or Sciatic or Shenmen)

Non- (or less-) Painful side: Leg: K10, K3, LR4. Arm: LI4, LI3 (AKA Ling Gu and Da Bai), TB5, SI4 (or SI3)

Points I may add include GB31 and/or 32, LR3 and/or 8, H3. If the pain is severe, I usually start with the 5-point Battlefield Acupuncture protocol on the painful side and finish with it on the opposite side.

This protocol has worked remarkably well for me. In many ways, the most challenging aspect of it has been convincing the patient that it will work, without having to resort to local needling. Occasionally, if the patient is insistent, I will start by doing simple insertion on the back near the spinal level of the pain. The insertion is always shallow (I mostly use 15mm needles for everything) and it takes all of 1 minute. But in most cases, I just make sure the patient is comfortable in the chair and just get on with the protocol.

MIDDLE AND/OR UPPER BACK PAIN

This can be very challenging to treat. Mid-back pain is usually taken as a Spleen sho symptom and upper back pain as a Lung sho, so I would start there. Sometimes the problem is diaphragmatic reactivity, and the Shaoyang treatment (see following) is indicated. For this I usually look for Katakori (shoulder stiffness at the top of the trapezius and tight scalenes/SCM). There may be TMJ problems as well, so ST6 and 7 and the TMJ ear point can be helpful.

78 CENTRAL PAIN PROTOCOL

There is another protocol I will use for back pain. I began using this specifically for cases of spinal stenosis, but it has become my go-to treatment for central back pain or pain along the spine. I started using this in cases where the regular protocol wasn’t quite getting the results I wanted. I’d used the Manaka Whiplash Protocol early on in chair treatments, especially with elderly patients, and saw some good results with it, particularly with cases in which the spine had some degenerative pathology.

The Manaka Whiplash Protocol is usually done with Ion Pumping Cords, but after a lot of trial and error, I finally just ditched them and did the treatment with just needles. It works just fine.

For this protocol, I usually combine it with a Root Treatment for Kidney sho. Bilateral: Legs: K10, K3, GB41, UB62. Arms: LU5, LU6, SI3, TB5.

I often add UB39 and GB34. If the patient’s legs get cold easily, or if for some other reason I can’t get to K10, I will substitute K7.

SHAOYANG

This is a general protocol I use quite often. It is usually indicated by a preponderance of symptoms along the Shaoyang channels (Gallbladder and Triple Burner). There may be one-sided or temporal headaches, stiff shoulders (katakori), clenching of the jaw, TMJ problems, ringing in the ears or feelings of stuffiness in the ears. The scalenes and SCM are often very tight and the patient usually complains of stress. Pulse tends to be wiry.

The points I use are GB21 (simple insertion), TB9, TB5, GB34, GB40 or GB41, SP9

There is a variation I use with more Liver-y types of people, in which I substitute LR3 for SP9. I often add Ear Shenmen and the ear TMJ point, which is the same ear point that is used often for Depression.

79 BLOOD STASIS

Blood Stasis is not a concept in earlier versions of JMT. It may reflect the ideas of other streams of thought, most notably Kampo (Japanese herbal medicine). It is, of course, a very important concept in TCM, especially herbalism which employs a wide variety of blood-moving herbs.

I’ve been a big fan of Blood moving strategies for many years. Blood Stasis is a secondary pathogen, by which I mean that it is usually a byproduct of some other kind of pathogenic process. In terms of the San Yin, or Three Disease Causes, it can be caused by External factors, like Cold or Dampness, Internal factors like emotional imbalance, or by miscellaneous causes such as trauma, either physical or psychological. Anything that interrupts the Qi dynamic can lead to Blood stasis. Since the Qi is the Commander of the Blood, once the flow of Qi is compromised, then Blood flow will be impeded as well, leading to Blood stasis.

In an article for the North American Journal of Oriental Medicine, Stephen Birch wrote that one of the key things to look for in prognosis is the presence of Blood Stasis. Since stagnant Blood is obstructive, it slows down the healing process, and significant Blood stasis signs can indicate that the course of treatment will be significantly lengthened. The famous 20th-century Chinese doctor Yan Dexin wrote a book entitled Aging and Blood Stasis, in which he posited Blood Stasis as a primary factor in age-related illnesses, and recommended treatment of Blood Stasis in favor of many of the tonification strategies which are more the norm in TCM geriatrics.

Blood stasis in TCM is usually indicated by the presence of fixed stabbing pain with a purplish tongue and wiry or choppy pulse. Birch points out that his mentor Dr Yoshio Manaka would add darkened or rough patches of skin, and the presence of spider nevi and other visual signs to the diagnosis of Blood Stasis.

In addition, since the Spirit travels in the Blood, I frequently put emotional depression in the category of Blood Stasis, if it presents with other Blood Stasis signs. The topic of herbal medicine is outside of the scope of this book, but in my practice some of the most dramatic turnarounds in treating depression and emotional trauma have come from using Blood-moving herbs and formulas.

Often I have found that treating stubborn cases in the clinic can benefit from switching the treatment strategy to a course of Blood-moving. Once there has been some improvement, the original treatment strategy can be reinstated if that is called for.

80 In acupuncture, there are a few ways to deal with Blood Stasis. The first is bloodletting. This can either be done to Jing-Well points or to local areas which are populated by little spider nevi. One important place to look for these congested capillaries is around the area of the base of the neck, especially C7. Behind the knee in the UB40 area is another popular place to bleed. A good bleed-able capillary will look purplish or reddish, and will disappear on pressure, only to refill again moments later. If the capillary does not disappear, it may still be used but you may get more blood than you care to, so I would advise starting small. Use a small diabetic lancet, puncture the capillary and let out a few drops of blood. You can repeat this but some of the teachers I learned from warned against doing it more than a couple of treatments in a row.

The other approach, which I favor, is using Blood-moving points. There are few designated points which are used for Blood pathologies in TCM acupuncture. They are points such as SP10 and UB17. I use a combination of points on the Liver, Lung, Spleen and Pericardium channels, which I put together from various sources. It has worked well for me. The points are as follows:

LU5, P4, SP9, SP8, SP6, LR3, LR4

If I use all the points bilaterally, I refer to it as my “Big Blood Stasis” protocol. I will also split the points as a Sokoku sho:

Right LU5, SP9, SP8, SP6; Left P4, LR3, LR4.

If I want to even up the number of needles on both sides, I will choose between SP9 and SP8 based on palpation or pulse feedback.

LU5 right and LR4 left is a combination I picked up from Kiiko Matsumoto’s book; it is specifically for Blood stasis in her system. P4 is the Xi-Cleft point for the Pericardium, which constricts the Heart to move the Blood. SP9 moves fluids, including the fluid component of the Blood. I have found that draining Dampness is an important adjunct to moving Blood, and conversely that moving Blood is an important adjunct in draining Dampness, especially if it is stubborn (as often it is). SP8 is the Xi cleft point for the Spleen and is related to Blood as well as being empirical for dysmenorrhea, which is often an important indicator of Blood stasis in women. SP6 has a specific affect on the Blood, being both a Liver and Spleen point. Much like the herb Angelica Sinensis or Dang Gui, it both nourishes and moves Blood. Finally, LR3 is one of the most important points for restoring the Qi dynamic, and thus helps unblock Blood stasis and move Blood.

81 Other points can be added, depending on the location of the Blood stasis. If it is in the lower abdomen, as is often the case in women, ST28 moves both Blood and fluids, as does K14. Ren6 is an important point for moving Qi.

It is not unusual for women getting this protocol to experience a shortening of their menstrual cycle or second period shortly after treatment. It generally lasts for a short time and/or doesn’t disrupt future cycles. I have seen this happen many times and it is good to discuss this possibility with the patient.

TAIKYOKU

I have an abbreviated version of the Taikyoku treatment that I like to use. I usually use it when the patient is looking for something to relax, if they have a chief complaint of fatigue, or when they come in with a wide variety of complaints. I also use it often on new patients, or when I’m swamped with patients and need to treat quickly.

My Taikyoku protocol for CA: Bilateral LI11, TB5, ST36, K3

Often I will add one or two body points and perhaps some ear points. So I will add LI4 and LR3 if there is pain or stagnation, or if the patient wants to “detox” (5NP goes well with this too). SP9 and Du20 if the chief complaint is fatigue. GB40, H5, Yintang and/or Ear Shenmen if there is difficulty sleeping. LR8 if there is Blood deficiency. And so forth. I generally get a lot of positive comments from patients when I use this protocol, and so I tend to use it a lot.

A lot of punks like to use the 5-point protocol developed by Miriam Lee, as detailed in her book, ”Insights of a Senior Acupuncturist”. The points in that protocol (LI4, LI11, LU7, ST36, SP6), from a meridian perspective, come from one of the three major circuits, namely Yangming/Taiyang. One of the things I like about the Taikyoku protocol is that it takes from all three of the circuits; two from Yangming (which connects to Taiyin), one from Shaoyang (which connects to Jueyin) and one from Shaoyin (which connects to Taiyang). So, as was Sawada’s intent, it functions as a “Whole-Body Treatment”, which is how it is often looked at in Japan. As such, where many punks will use Miriam Lee’s 5 points, I will use my basic Taikyoku protocol.

82 Afterword

Well, there you have it. Should be enough to keep you busy for a while. If the material here speaks to your condition, then please use it in clinic. It may take a while to get the hang of it, but as the Japanese are fond of saying, “Ganbatte!”, or “Hang in There!” “Keep At It!”.

As I mentioned, this tome is a section from a longer work in progress, which I'm hoping is coming out this year (2016). As such, please excuse any awkward wordiness or mistakes. And, again, please don't share it without permission of the author (me, Robert Hayden).

Any questions about the material can be addressed by emailing me at [email protected] . Best of luck in your studies and your punking career.

Robert

83