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Four Styles of Japanese Acupuncture: A Review

Marian Fixler and Oran Kivity

First published in European Journal of Oriental Medicine, 1999

In modern day China it is apparent that there is one unifying and distinctive style of acupuncture, familiar to us all in the West as TCM. Japanese acupuncture is more pluralistic, and embraces many different styles and schools. In this article we aim to give an overview of a number of Japanese acupuncture systems. We hope to convey the characteristics of each and contrast them within the wide spectrum of Japanese acupuncture styles.

This statement by Stephen Birch, in his recent book, Understanding Acupuncture1 has taken on new meaning for us since our exploration of Japanese acupuncture began. Dynamic changes occur using the subtlest of approaches to needling. It is possible, for example, to effect an immediate change in the abdominal findings by inserting very fine needles no more than 1-2 mm below the skin. These changes, principally the release of pressure pain responses and tightness, can be observed by the practitioner and patient alike. Coming from a TCM tradition, this has been quite challenging. How can such superficial needling, which aims to avoid de qi stimulation, have any significant effect? At what level are these channels that we are needling? Becoming open to these contrasting systems, systems with demonstrably powerful effects, has challenged our conceptions and added new meaning to the concept of `maximum benefit for minimal intervention`2.

Distinguishing characteristics
One of the common diagnostic approaches in Japanese acupuncture is abdominal palpation. This was first described systematically in the Nan Jing3 which outlined areas of the abdomen relating to the zang fu. (See Figure 2 under Meridian Therapy section.) In Japanese acupuncture, where through historical circumstances, blind practitioners have exerted a strong influence since the late 17th century, palpation and a more hands-on approach to treatment have been developed to sophisticated levels. The abdomen gives us a lot of information regarding the overall qi condition of the patient, distinguishing the quality, tone and texture of the skin and musculature.

In some of the systems we have studied4 abdominal diagnosis involves deep palpation, identifying areas of pressure pain, tightness and tension; in other systems5 the pressure is almost negligible, stroking lightly to identify areas of flaccidity, puffiness, depression or increased moisture. In the first approach, the emphasis is more on identifying areas of stagnation, where qi flow has been disrupted. In the latter, these findings indicate weakness and deficiency within organ and channel systems.

Another commonality we have encountered is the emphasis given to feedback mechanisms. In all the systems described below, various feedback mechanisms such as the pulse, abdomen, mobility and pain of joints, pressure pain responses on related areas, are all checked and rechecked throughout treatment. This consists of various relatively small doses of stimulation, which are added and monitored progressively to achieve a powerful cumulative effect. This emphasis on feedback mechanisms provides a constant awareness of the appropriateness of the choice of treatment, and the accuracy of its execution.

Dose of treatment is regulated by using smaller sources of stimulation. The needles are generally very fine, 36-44 gauge inserted quite superficially using guide tubes, and moxa cones are often rice grain sized or smaller. Fire cupping is not used, because the dosage is too difficult to control. Instead, suction pumps are used, so that the strength of the suction can be regulated easily.

Dr Manaka`s Yin Yang channel balancing therapy
Yoshio Manaka (1911-1989) combined a scientific approach to research, from his training as a Western physician, with an ardent interest in East Asian traditional medicine. He developed a broad spectrum of treatment approaches that brought to life hitherto theoretical concepts. This creative approach to treatment, firmly rooted in traditional texts, was always substantiated with exhaustive and repeatable research. Many of these innovative experiments, including demonstrating the differing effects of needling with or against the direction of channel flow, or the effect of colour stimulation on the element points, are described in detail in his seminal and compelling work, Chasing the Dragon`s Tail6. This book is perhaps as close to a thriller as an acupuncture textbook can get!

Manaka experimented with a number of polarity agents, objects with positive and negative properties, including gold and silver needles, zinc and copper, north and south magnets and ion pumping cords. He did extensive research on how polarity agents could reduce or increase pressure pain reactions on channel and related abdominal points to demonstrate the direction of qi flow.7 He also invented a treatment for burns using ion pumping cords and silver foil. The Step One treatments described below use these ion pumping cords, which consist of a fine cord of copper wire with a diode in the middle. The diode allows a very small electrical current to flow in one direction only. A red or black clip at either end of the wire is attached to needles at two acupuncture points, creating a positive/negative polarity between them. Patients cannot feel any particular stimulation as the electrical current flowing is minute. They do, however, find the treatment very relaxing.8

Dr Manaka`s comprehensive and structured treatment approach applies the fundamental concepts of yin yang to treatment. It is a four step protocol which treats both the root honchiho (or ben zhi fa) and the branch hyochiho (bao zhi fa), correcting structural irregularities and symptom control. The root treatment consists of Steps 1 and 2 together. The remaining steps address the branch. Manaka describes this approach as ‘looking for the most significant paradox in the body9.

Step 1 Identifies and treats patterns of disharmony on the abdomen (yin surface).Step 2 Identifies patterns of disharmony on the back (yang surface), related to the abdominal findingsStep 3 Adjusts structural imbalances through Sotai counter-resistance stretching exercisesStep 4 Symptom control with moxibustion, cupping, bloodletting, intradermal needling, tapping with Manaka`s wooden needle and hammer[/table]

Step One aims to release pressure pain findings on the abdomen, the anterior yin surface. Manaka`s primary approach for this first step is his eight extraordinary vessel treatment. This is based on a combination of research from classical texts, which outline the areas of influence of these vessels and Manaka`s own original theoretical interpretation. He theorised that they form an octahedron in the body. The octahedral structure is described by Buchester Fuller10 as ‘the most stable in nature.?This eight sided figure is defined in the body by three axes: the superior/inferior sections delineated by dai mai, the left and right sections delineated by ren mai and du mai, and the anterior/posterior sections delineated by the master and coupled points of yin wei mai and yang wei mai, on the medial and lateral aspects respectively. Treatment aims to restore balance between these sections or quadrants, thus creating balance in the overall channel system. There are four main extra vessel treatment options based on the abdominal findings. In addition, a pattern called ‘cross syndrome? a combination of yin wei/chong mai and yang wei/dai mai frequently shows up in clinical practice. (see Figures 1.1-1.5 ) The master and couple points of the extra vessel implicated by the abdominal diagnosis are needled and connected by ion pumping cords.

Step 2 involves treating tender Back shu points which relate to the abdominal diagnosis. For example, when treating the yang wei/dai mai pair with ion pumping cords on the master and coupled points, the corresponding step 2 treatment would be Bl 19 gan shu and Bl 22 san jiao shu.

Tightness and tenderness at these points are usually treated with kyutoshin moxa technique on the handle of the needle. Japanese moxa compared to Chinese moxa is like the difference between ‘silk?and ‘cotton?tofu in its consistency. Lightly rolled balls of moxa are then placed on the handle of the needle.11 Moxa is not contraindicated in ‘hot?conditions, perhaps because the moxa balls are less densely rolled than in Chinese warm needle technique (wenjiu). The effect is to relax the muscles rather than put heat into the body.

Step 3 is indicated when the patient shows clear structural imbalances. For example, this may present as left-right irregularities at the hips, or tightness apparent more on one side of the back than the other. Manaka`s emphasis on the need for rebalancing the body at a structural level led him to incorporate a series of exercises known as sotai: these were originally developed by Keizo Hashimoto12. They involve using counter- resistance stretches to release tight muscle areas causing restriction of movement. Manaka found that rice grain moxibustion or fire needling greatly enhanced the effect of the exercises. The increased range of movement is usually immediate.

Step 4 directly addresses symptoms. Manaka again adapted a huge range of techniques into his repertoire, including ear acupuncture and Korean hand acupuncture. For pain conditions in particular, he liked to apply his ‘isophasal?treatment with intradermal needles. To treat shoulder pain, for example, he would use the shoulder point on the ear, the corresponding shoulder point on the hand, and a local tender point on the shoulder. Intradermals used together, isophasally, at different points with the same resonance, are effective to relieve pain and increase joint mobility in between treatments.

Other techniques include sophisticated bloodletting techniques, cupping, and tapping with Manaka`s wooden needle and hammer.

For this he researched tapping acupuncture points with a blunt wooden needle at specific frequencies of beats per minute. His research showed that each channel has an optimum frequency: tapping points along the channel at this frequency releases pressure pain. We have found this to be particularly helpful in the treatment of peripheral neuropathy. It can also be applied by the patient as part of a home therapy programme, which Manaka was keen to encourage.

Manaka was always aware that people react differently to similar treatments; he thus had many different treatment options for Step 1 other than his extraordinary vessel treatments. These include open point treatments using 24 hour, 10 day and 60 day cycles, and his remarkable polar channel treatments based on midday-midnight pairs of channels in the Chinese clock13

The Chinese clock represents the flow of qi through the channels in a 24 hour cycle. Prior to learning Manaka`s treatment, our understanding of the Chinese clock`s significance was limited to making connections between a particular pathological process and the time of day when it occurs. Cock`s crow diarrhoea, for example, indicates kidney deficiency, as it appears between 5am and 7am when large intestine is at its peak and kidney at its lowest ebb.

Using pressure pain responses on the gastrocnemius and abdomen, he devised a method for diagnosis and treatment using midday-midnight pairs of channels, e.g. Ht/GB, Liv/SI, etc. etc. This involves needling the tonification and sedation points on each channel of the polar pair that is found to be in disharmony and connecting them with ion pumping cords. Manaka believed this alternative step 1 approach also balanced the octahedral structure of the body. It is a also a very practical application of the Chinese clock, and the midday-midnight relationships between the channels.

Case study [/table]

These potted case histories are an illustration of the use of Manaka`s Eight Extraordinary vessel treatment for both acute and chronic cases.

Male, 73 years
Presenting condition
: Acute low back pain worse on the right side with shoulder and neck tightness. Patient has difficulty bending and shoulders are raised on left side. X-ray shows wearing of disc at L4 level. Patient has a long history of back problems, though he is presenting with an acute episode.

Palpation: Tightness and pressure pain around the inguinal area (ASIS bilaterally) and reactive with pressure pain at the sacro-iliac joint area around Bl 27 and Bl 28.

Diagnosis: The reactivity at the ASIS area corresponds to a yang qiao/du mai pattern. This was confirmed by checking for reactivity at the corresponding mu points for this pattern. Manaka`s mu points are as follows: Small Intestine mu is St 26 wai ling and Bladder mu is Ki 11 heng gu..

Treatment: Step one: yang qiao/du mai pattern. SI 3 hou xi + Bl 62 shen mai needled with ion pumping cords. This released the tightness in the inguinal area.

Step two: Back treatment: The corresponding Back shu points were needled. Bl 27 xiao chang shu ?Back shu of the Small Intestine in particular showed reactivity. Bl 23 shen shu was also tight. These were needled with kyutoshin (moxa on needle) to release tension in back. Chishin (retained needle technique with very superficial insertion) at Du 14 da zhui and Josen (extra point below L5 on the midline).

Step three: there was greater stiffness on the right side than on the left when legs were lifted to the buttocks in prone position. Sotai stretch ?knee to buttock stretch with moxa was applied. This exercise evened out the two sides and loosened the stiffness considerably.

Step four: Wooden hammer stimulation at 104 beats per minute (Du mai frequency) along the spine from bottom to top. Intradermal needles were retained for a few days in the low back area of the ear and a local point on the low back around Bl 27 xiao chang shu on the right side.

Outcome: Acute back pain cleared after one treatment and patient reported increased range of movement and flexibility. Shoulders also felt more relaxed.

Female, 37 years
Presenting condition: Endometriosis (diagnosed for four years) on both ovaries, bowel and appendix, with pain around ovulation and menses. Dysmenorrhoea since menarche. Pain used to be so severe, she would faint. Prior to coming for acupuncture, patient had had surgery (laser treatment) and hormonal treatment that had put her temporarily into early menopause. Dysmenorrhoea had gradually returned since hormone treatment was stopped. Patient also has a `slipped disc` below L4 with sciatica down the left leg.

Palpation: Tightness down anterior midline especially tight and painful above the umbilicus, with some pain and softness below the umbilicus. Congestion in upper right quadrant, subcostally. In both cases, corresponding mu points also sensitive to pressure. The midline is where this patient often experiences endometrial pain. Low back reactive at huatuojiaji points around L4 and L5.

Diagnosis: Main patterns diagnosed over the course of the treatment have been: ren mai/yin qiao mai or chong mai/yin wei mai or a combination of the two ie. Mixed yin pattern.

Treatment: The four step protocol was used. For example, with the yin qiao mai/ren mai pattern:

Step one: Lu 7 lieque + Kid 6 zhao hai bilaterally with ion pumping cords for 10 minutes.

Step two: Bl 23 shen shu + Bl 25 da chang shu with kyutoshin moxa (moxa on the needle). Bl 13 fei shu is the obvious back shu point corresponding to Lu 7 lieque, but Manaka suggests Bl 25 da chang shu, perhaps because it is easier to do kyutoshin here than over the lungs.

Step three: Sotai stretch to release tightness in the back.

Step four : Symptom control treatment involved intradermal needles at Sp 6 san yin jiao or Sp 10 xue hai (depending on which was more reactive) and the ear uterus point were retained the week leading up to menstruation. Intradermal needles were also sometimes retained in the low back area and the low back area in the ear.

Outcome: Treatment over a few months greatly alleviated this patient`s symptoms, which although not completely cleared are now at manageable levels. The diagnostic areas on the abdomen are much less reactive. Her back pain is now restricted to some discomfort around the period. Prior to treatment, this patient had to take time off from work during each menstrual cycle; this is no longer the case. Patient continues to come for treatment once a month in the week leading up to her period.

Explanation: Yin qiao mai / ren mai and yin wei mai /chong mai are two very common patterns that present with gynaecological disorders. This patient`s midline pain corresponded with the abdominal pattern relating to the yin qiao mai/ren mai pattern. This is not always the case. Regular sotai stretches on the back led to greater flexibility. The intradermal needles reinforced the treatment and continued to provide additional relief in between sessions.

Conclusion
Dr Manaka approached classical acupuncture theory with a tireless spirit of innovation and experimentation. Chasing the Dragon`s Tail is full of repeatable experiments that he devised which make traditional acupuncture theory real. This ethos has enthused us as practitioners, and helped us to become more creative in our clinical work. On the other hand, Dr Manaka`s work takes us far from the idea of the barefoot doctor. With its reliance on many diverse pieces of equipment such as ion pumping cords, intradermals, wooden hammer and needle, metronome and lancets, as well as more conventional cups and moxa, there is quite a lot to carry around!

MERIDIAN THERAPY KEIRAKU CHIRYO
In the late 19th and early 20th centuries, restrictions were imposed in Japan on acupuncture practice and education as a result of the new pre-eminence of Western Medicine. Traditional ideas and theories were not taught. Meridian therapy began in the 1920`s as a traditionalist backlash against these restrictions. Various eminent Japanese acupuncturists were concerned that useful traditional ideas were being discarded. They began a systematic and highly practical study of these theories to see which actually worked in practice. Now known as meridian therapists, this group comprises some 20% of the 60,000 acupuncturists practising in Japan today14.

Meridian therapy is based largely on the theories in the Nan Jing, which describes a system of acupuncture based on a five phase model. Nan Jing 69 states:

  • First tonify and then reduce
  • For a deficiency condition supplement the mother
  • For an excess condition drain the child

Much has been implied from these statements.

Deficiency is regarded as more serious than excess. As yin tends towards deficiency and yang to excess, we need to first treat the yin channels that are deficient, then the yang channels that are excess. Diagnosis is therefore primarily concerned with identifying yin channel deficiency.

To treat the mother does not only mean to treat the mother point on a deficient channel, e.g. Lu 9 tai yuan to supplement the lung. It also means treating the mother channel, e.g. spleen15. This is perhaps because when one channel becomes weak it fails to control through the ke controlling cycle, which means that its mother channel now becomes over-controlled. For example, when lung is weak, it cannot control liver. Liver then over-controls spleen, the mother of lung. Diagnosis is therefore concerned with finding a pair of deficient channels: the child and its mother channel16.

Logically there should be five basic diagnoses to make in meridian therapy, composed of five pairs of mother/child channels which are both deficient. In fact there are only four. The heart/liver pair is considered to be so serious a pathology that we would not see this presentation in clinical practice:

The Four Deficiency Patterns

Spleen deficiency spleen and heart deficiency togetherLung deficiency lung and spleen deficiency togetherKidney deficiency kidney and lung deficiency togetherLiver deficiency liver and kidney deficiency together[/table]

This might seem like an elementary diagnostic procedure: after all, TCM concerns itself with extensive differentiation for each zang. However, the underlying principle of five phase diagnosis is that all organs are inter-related. Pathology in one can domino and snowball into pathology in the others. Correct identification and treatment of the root problem and its subsequent interactions is thus critical.

Diagnosis is made through the four Inspections. Special emphasis, however, is put on palpation: especially taking the pulse and palpating the abdomen. Abdominal diagnosis involves gentle pressure to identify areas of tightness and pressure pain at the positions corresponding to the five zang organs as identified in the Nan Jing. (see Figure 2)17. Denmai Shudo states that an accurate diagnosis must show a match between pulse and abdomen18. This contrasts with our experience of TCM where often the tongue, pulse or symptoms do not match. The pulse is taken on both wrists at the same time, so that the relative strengths of each position can be compared. Root treatment, honchiho, is given first to address the five phase imbalance, then branch treatment, hyochiho to treat the symptoms. Shudo states that 80% of the effectiveness of treatment comes from the root treatment19.

Initial treatment consists of needling the mother point on the deficient channel, and a supporting point on the mother channel; this is commonly the phase point of that channel e.g. earth point on the spleen channel:

Spleen deficiency spleen and heart deficiency together Sp 3 tai bai P7 da lingLung deficiency lung and spleen deficiency together Lu 9 tai yuan Sp 3 tai baiKidney deficiency kidney and lung deficiency together Kid 7 fu liu Lu 5 chi zeLiver deficiency liver and kidney deficiency together Liv 8 qu quan Kid 10 yin gu[/table]

Strictly speaking, Sp 2 da du should be selected instead of Sp 3 tai bai, but Meridian Therapy is pragmatic, and favours what has been shown to work best, over what theory should dictate. It seems that Sp 3 tai bai is both less painful to needle than Sp 2 da du, and more effective. The same goes for Lu 5 chi ze. Lu 8 jing qu is the theoretical choice but Lu 5 chi ze has been found to work better.

The Ling Shu states that needling should feel very delicate, like a mosquito bite20. Shudo states unequivocally that it is impossible to tonify a point if the needling is painful.21 In Meridian Therapy needling is very superficial, between 1mm (shallow) and 3 mm (deep), with very fine 36 ?44 gauge needles. Sometimes the depth of insertion is so shallow the needles fall over under their own weight and lie flush to the skin.

Guidelines are given for needle depth and length of time the needle is retained: when the pulse is superficial or rapid, needling should be shallow or of short duration. If the pulse is deep, insertion should be relatively deeper. If the pulse is slow, retention should be longer. Implicit in this practical advice is the concept that acupuncture is like a medicine, and that dosage must be appropriate to the patient`s health and strength. This concept of dosage is also very important in Manaka`s work.

Once these points are needled the pulse and abdomen are rechecked. A systematic procedure is now used. Excess channels on the ke controlling cycle are now reduced by needling briefly against the direction of channel flow, usually at the yuan-source point. In spleen deficiency, Liv 3 tai chong might be reduced (if spleen is deficient, liver might be excess). Next, the six yang pulses are checked for signs of excess. These are usually needled at the luo-connecting point, against the direction of channel flow.

The root treatment on the yin channels is then reinforced by treating the relevant two pairs of Back-shu points. This is similar to Manaka`s Step 2, although the needling is very superficial and kyutoshin moxa on the needle is not applied.

Symptomatic treatment is taken from a wide repertoire similar to Manaka`s Step 4. Tight areas can be needled superficially, or with moxibustion, cupping, intradermals, and in serious cases, bloodletting, can all be applied. Moxibustion and cupping are used more for disorders at the blood level.

Treatment Protocol Summary
STEP 1 Tonify most deficient pair of Yin channelsSTEP 2 Reduce excess Yin channels on Ke-controlling cycleSTEP 3 Reduce excess Yang channelsSTEP 4 Reinforce root treatment through related Back-Shu pointsSTEP 5 Relieve symptoms using broad repertoire of acupuncture, auricular acupuncture, moxibustion, cupping or bloodletting techniques[/table]

We found meridian therapy to be an even greater conceptual leap of faith than Manaka`s system. Trained to insert needles to get de qi, it was with some incredulity that we noticed clinical effectiveness from such delicate intervention, without even the use of a polarity agent like an ion pumping cord, or moxa on the needle at the Back-shu points. It is worth repeating that needle depth is only 1-3 mm, no de qi is obtained, and the needles usually fall over and lie on the skin. We have observed regular changes in abdominal pressure pain reactions, pulse quality, breathing and most importantly, symptoms.

From our patients?perspective, this was an extremely comfortable new development. Meridian therapy treatments consist of a careful series of small nudges, interspersed with deeply focused monitoring of the pulse for changes.

From our point of view it has been refreshing to embrace a system where the theory matches the practice. In Meridian Therapy the theory of differentiating the root pathology is incredibly simple. There are, after all, only four main diagnoses to make, although there is of course further differentiation of qi, blood, excess and deficiency. The initial diagnosis of the root treatment is in fact only the first step in the process. As outlined above, the structured nature of the treatment plan means that diagnosis continues throughout the treatment. At each stage, feedback is assessed and helps to inform the next step. In this way, patient and practitioner enter into a quiet yet dynamic interaction in which changes are constantly monitored.

TOYOHARI
Kodo Fukushima was an active member of the anti-war movement in Japan, but was conscripted into the army during the war in China. He lost his sight in action in 1932, but was able to qualify as an acupuncturist in 1939. He founded a society of Meridian Therapy for the visually impaired, and founded the Toyohari Association in 195922. Toyohari is therefore a branch of Meridian Therapy that was developed principally by blind practitioners. It differs from Meridian Therapy in two main regards: one theoretical, the other practical.

Theory
Meridian Therapy is based on the five phase model in the Nan Jing which states that where one channel is deficient, it will fail to control another channel through the ke-controlling cycle, which will then become excessive. Fukushima controversially proposed that this second channel could also be deficient. In our previous example of lung deficiency, we found that liver became excessive. Subsequently it over-controlled spleen, which then became deficient. Fukushima did not dispute this process, but found in practice that Liver might be deficient. This means that in Step 2 above it would be necessary to reinforce, not reduce. This is a radical departure from conventional five phase theory, and led to a split between Toyohari and Meridian Therapy practitioners. Nevertheless, Fukushima was convinced that treatment according to this theoretical model was the key to his recovery from skin cancer.

Like Meridian Therapy, diagnosis is also based on the pulse and abdominal findings. The abdominal map varies slightly from the above model, in particular the positions of the liver and lung (see Figure 3). Palpation is much lighter than described above. Rather than pressure pain and tightness, deficiency signs such as puffiness, depression, moistness, roughness and emptiness are identified, using only very light touch.

Practice
The most remarkable difference between Toyohari and any other system of acupuncture we have encountered is that the needles used are not actually inserted. Instead, silver needles are held over the points with both hands, usually at a distance of about 1 mm The left hand is used to focus the movement of qi while the right hand advances or withdraws the needle.

Tonification is achieved by gradually inserting the needle into the patient`s qi system, somewhere over the skin, and then allowing it to gather at the point. This can be likened to pushing a stick slowly into a fast moving stream, and watching the eddies forming around it. To do this requires a great deal of focus and attention to one`s own posture and state of relaxation, opening up to the awareness of one`s own and the patient`s flow of qi. Familiarity with standing in a qi gong posture is a definite advantage.

Another difference is the differentiation of excess. Practitioners use five kinds of reducing technique: fujitsu for excess at the qi level, and genjitsu for excess at the blood level. For excess within deficient channels there are three subtle gradations of combined tonification and reducing techniques: jin, ko and ken. The progressive image of sweeping away dust, leaves, and twigs is used to describe each of these respectively23. This reflects a differentiation of the strength of the jiaki (pathogenic qi) felt on the pulse.

Toyohari has other unique procedures for symptom control including the use of:

Kikai: small zinc and copper discs are placed on the master and couple points of the eight extraordinary vessels. In contrast to Manaka, the eight extras are used to treat symptoms associated with each vessel, not for a root treatment. Using zinc and copper is another application of polarity treatment. It is worth mentioning that the practice of using master and coupled points without some kind of polarity agent, is very rare within Japanese acupuncture24.

Shigo: a gold needle is held over the luo-connecting point of the polar channel opposite in the midday-midnight pairs e.g. Ht 5 tong li on the left to relieve headache on the right GB channel.

Naso/Muno25 very delicate but remarkably effective techniques to release stagnation in the neck or hip region: the gateways to the torso and the zangfu, where qi and blood can easily stagnate. They involve a range of needle techniques to resolve differing degrees of stagnation. Kyoro, gomu nando, and kare bono translate as a worm, rubbery clay and withered bone, respectively. These describe accumulations that are clearly palpable.

Training
The training for Toyohari is mostly practical. Point location and needling practice is always monitored by continuous peer assessment of the pulse changes. For example, one person needles while two or three others give feedback on the minute and subtle pulse changes during the procedure. A variation on the Bronze man school of point location, the practice sessions involve comparing the point locations of students to see which one brings about the best pulse change. It was quite a revelation to discover that two points a millimetre apart brought about substantial variation in the pulse when tested (not to mention the needle technique of the practitioner!).

The deeply rooted ethic of the Toyohari association is that members meet regularly in small groups, to practise, exchange ideas and present papers to each other.

‘Each of the 60 branches is assigned areas of research and investigation, and reports of investigative and clinical findings are routinely presented at meetings or written up in the monthly journal26?/P>

It is through this rather rigorous process that the curriculum develops. All concepts taught in the curriculum have been researched and found to have clinical efficacy by study groups of highly experienced practitioners.

Case study – Male, 44 years old[/table] Presenting condition: Right shoulder pain for the last 10 days since stressful period at work began. Pain extends up into neck, and causes constant right temporal headache. Likes to work out at the gym and currently unable to. HIV positive, hospitalised with pneumonia five months previously. Now recovered, blood indices relatively normal, but feels immunity is still low.

Palpation: Shoulder painful on circumduction and abduction, pain centred on LI 15 jian yu and extra point jia neiling. Pulse shows lung and spleen weakness, and abdomen shows same. Right subcostal area is also very tender on palpation.

Treatment: Reinforce Lu 9 tai yuan, Sp 3 tai bai on left (non-insertive needling technique). Secondary pattern is liver deficiency. Liv 3 tai chong reinforced on right (non-insertive needling technique). This immediately relieves subcostal tenderness.

LI 6 zhong du and St 40 feng long reduced on right, GB 37 guang ming reduced on left (non-insertive needling technique). The headache is no longer apparent at this point.

Naso treatment on neck: tapping silver needle over deficient areas and reducing excess areas around sternocleidomastoid (SCM) relieves 60% of shoulder pain. Then needle inserted 1 mm into two knotty areas and held until both practitioner and patient feel a release.

Shigo: Gold plated needle at left Kid 4 dazhong relieves remaining pain. Retained for 10 minutes, and two 36 gauge needles inserted 2 mm into tight points on upper back while patient sleeps.

Explanation: The root treatment was lung deficiency, with a secondary liver pattern. Liver is directly connected to lung and spleen via the Ke cycle, and in this case was deficient, not excessive. Reinforcing these three channels made clear differences to the pulse and abdominal findings. The subcostal area is not the Toyohari diagnostic area for the liver, but the tightness and pain tenderness there changed after Liv 3 tai chong was treated. The yang channels were then checked for signs of excess and, in this case, it was found that the coupled channels (large intestine, stomach and gallbladder) were excessive. Whilst this finding fits neatly with the patient`s symptoms, it would have still been appropriate if the channels found had no connection with his symptoms.

Finally, branch treatment was given to relieve the pain. St 12 quepen is a very important point where all the yang channels go deep or surface. Naso treatment reinforces or reduces problem areas in the anatomical triangle defined by SCM, the upper border of the clavicle and the lateral edge of trapezius. Releasing congestion here is important for all upper limb problems, and because of the vagus nerve, can affect the entire torso.

The Shigo treatment uses the relationship between large intestine and kidney in the Chinese clock. When the large intestine is excessive, the kidney channel is deficient, so reinforcing the kidney luo point with a gold needle helps to relieve the excess in the yang channel. Authentic Toyohari practitioners use a specialised solid gold shigo needle, much like an ear probe, but, limited by availability, a gold plated disposable needle was used instead. On a point that gets less friction from socks and shoes, a standard intradermal could have been used.

Conclusions
Meridian Therapy and its even more refined relation Toyohari are delicate and subtle five phase systems of acupuncture based on pragmatic interpretations of the Nan Jing. Both systems identify and treat a root imbalance and its ramifications before addressing symptom control with a wide repertoire of supportive measures.

These styles of acupuncture are tolerated very well by patients. They are highly effective and embody the ‘less is more?approach. Both therapies, in particular Toyohari , create a meditative space during treatment. They are theoretically quite simple, but require high levels of practical skill to practise. More than any other system of acupuncture discussed here, Toyohari emphasises the methodical development of practitioner skills and qi awareness.

Kiiko Matsumoto`s integrated approach
Introduction
Kiiko Matsumoto is a contemporary Japanese acupuncturist practising and teaching in the United States. She has synthesised a unique style of acupuncture based upon her studies with Dr Manaka, Master Nagano and Master Kawaii, as well as her own interpretations of classical acupuncture texts. Her approach integrates both traditional East Asian and modern Western concepts. Very little has been published in English about this way of treating. Instead, information is passed on through observation of treatment in clinic and in workshops, and from a number of workshop handouts. Consequently, the information in this section is based mostly on our own experiences and observations of Kiiko Matsumoto and other proponents of her system such as Avi Magidoff and David Euler.

Diagnosis
The main area for diagnosis is the abdomen whilst pulse diagnosis plays a comparatively minor role. Also palpated routinely for diagnostic purposes are the neck, and the huatuojiaji points. The zangfu correspondences on the abdomen are taken from the Nan Jing, but other areas corresponding to western disease patterns have been integrated too, such as the ‘adrenal area? ‘ovarian reflex? and ‘sugar lump? the latter reflecting problems with sugar metabolism.

Diagnosis consists of identifying pressure pain responses, and tight, knotty or ‘gummy?areas. The abdomen is seen as ‘a template upon which life experiences are registered?7. Past illnesses and traumas continue to leave an impression on the body, particularly if left untreated and unresolved. For example, the area below the navel relates to the adrenal glands and is reactive when the body is holding some kind of shock, either physical or emotional. It is frequently reactive in ‘Type A?patients who tend to overtax themselves, surviving on adrenaline and ‘running on empty?

‘As we go through life the various accumulations we carry with us will reflect on certain areas in our body…one must treat the earliest injury/trauma/problem first. Any problem that is still reflected in the body (as pressure pain, etc.) is likely to be interfering with the client`s ability to heal, and thus may have relevance to their current complaint.28?/P>

Treatment
Treatment identifies these significant areas of constriction, and then releases them by using distal points. In Japanese acupuncture there are differing approaches to ‘correct?point location. This is not usually in the traditional anatomical location, but instead, where the most therapeutic effect in that general location is to be found. In Toyohari this is called the ‘currently alive point? and is identified as the point that elicits the best pulse change not only with needling, but also initially when palpated. Manaka advised checking the abdomen for change and if necessary, relocating the relevant needle in order to better release the tightness.29 In Matsumoto`s system, the treatment points are tested first with finger pressure to see if release at the diagnostic areas takes place. There must be a significant release for it to be a valid point to use. This immediate reaction confirms the point location and the direction and angle of needling. If there is significant change during palpation, a needle is inserted, always in the same direction as the fingers were pressing. This means that in effect diagnosis and treatment are one and the same, as diagnosis is only complete when treatment has been shown to be effective. Matsumoto frequently repeats that in Japanese acupuncture ‘treatment is diagnosis and diagnosis is treatment?

The distal points used are not necessarily on the same channel but are points that have an influence on a particular area or condition. For example, the shui dao St 28 area relates to the ovary reflex and may be tender on palpation in gynaecological problems past and present, including dysmenorrhoea, endometriosis or fertility issues. The distal points used to release this area are on the Kidney channel ?in particular Kid 7 fu liu.

A key diagnostic and treatment area on the abdomen is called oketsu, which means stagnant blood in Japanese. This has a different meaning to blood stasis in TCM. It refers to the presence of stasis in the body that can be a precursor to other pathology, or stasis which prevents a particular health issue from resolving. The oketsu area is in the lower left quadrant of the abdomen, around and slightly medial to St 25 – 27 tian shu ?da ju. This relates to the liver diagnostic area described in the Nan Jing. The hepatic portal vein returns to the liver from here, so stagnation and sluggish liver metabolism will reflect at these points. Matsumoto states categorically that anyone who has had three or more operations will have tenderness in the oketsu area, as a result of the disturbance to the flow of qi and blood. Oketsu must always be resolved first, before any other treatment takes place. The treatment points are located near Lu 5 chi ze and Liv 4 zhong feng.

Successful treatment requires making a systematic interpretation of the abdominal findings and then choosing the corresponding points to release them. Lecture notes give details of diagnostic areas and relevant point prescriptions. Some of these are not always immediately obvious from either a TCM or five phase model. Watching Matsumoto or Magidoff at work shows that treatment is an exploration involving much lateral thinking, and a deep and very distinctive understanding of pathology. For example, it has been observed repeatedly that a history of appendicitis in the lower right quadrant of the abdomen, may lead to a progression of pathology on the right side of the body, resulting in breast problems and shoulder problems; this may only manifest many years later. It is important to clear the congestion at the appendix area as part of the treatment to help resolve the shoulder problem. Chronology of disease is thus very important to consider when taking a case history.

Palpation
Palpation in this system is firmer and deeper than in the other systems described above. On a healthy patient, the third finger should be able to press into the abdomen as far as the first joint without discomfort. When testing a distal point to release the diagnostic area, pressure is also quite strong. Some patients fare very well with this type of palpation, because they see an instant release before each needle is inserted. Others, particularly with gynaecological problems, may not be relaxed with this level of palpation, which feels less comfortable than a Manaka style diagnosis, and incomparably more invasive than a Toyohari type exploration. This style of palpation also requires a degree of kinaesthetic clarity of expression from patients: they are asked to quantify and state how much release has taken place.

Needling is also deeper than in the other systems we have described and emphasises breaking down ‘gummy?connective tissue indicative of stasis in the body.

Root and branch
Master Nagano`s emphasis in treatment is to identify and clear significant traumas holding back the patient`s ability to heal, in the belief that in most cases this will also clear the symptoms. The division between root and branch treatment is therefore less clear than in Manaka`s approach or Meridian Therapy, as treating the root clears the symptoms. Matsumoto, however, integrates a number of procedures for treating symptoms that she adds towards the end of a session. Some of these relate clearly to Master Kawaii`s side of her integrated approach, and include the use of various polarity agents such as diode rings, triple bypass cords (a variation on ion pumping cords) and pachi pachi: this is a modified gas sparker that is connected to the cords and used to stimulate acupuncture points or areas where diode rings are attached. We have found the diode rings to be very effective for the treatment of scars and peripheral neuropathy.

The metal/water treatment is another very effective technique. It uses an interesting interpretation of the five phase model of channel relationships. This involves identifying pressure pain at the fire points on the channels, for example on a channel that has pain or other symptoms affecting it or its related zangfu. If the fire point is tender, the metal and water points are pressed. If this relieves the pain at the fire point then these points are needled. The water point is used to control fire in the channel on the ke cycle, and the metal point is used to support water as the mother phase on the shen cycle. Tennis elbow, for example, could be treated with LI 1 shang yang and LI 2 er jian if LI 5 yang xi was tender.

Front and Back
In common with Manaka`s approach and Meridian Therapy, treatment progresses from front to back. For example, oketsu is treated on the front by Lu 5 chi ze and Liv 4 zhong feng. On the back the corresponding point is BL 35 huiyang on the left, which is used to release tenderness at BL 18 on the right. Immune conditions are treated on the front with points level with LI 10 shou san li and LI 11 qu chi but closer to the triple heater channel. Matsumoto humorously refers to these as ‘Triple Intestine 10? On the back Du 12 shen zhu and Du 14 da zhui can be used, as well as tender points under the scapular spine and iliac crest.

When working on the back Matsumoto emphasises the importance of ‘fixing the basement?before working on the rest of the house. Problems at the base of the spine, such as possible past trauma to the coccyx area, need to be resolved before addressing problems further up.

Case study – male 5 years old[/table] Presenting condition: Sore throat, quite frequent infections, pain in the right forearm on pronation for last 6 weeks.

Palpation: Oketsu area tender, immune diagnostic area near TH 16 tianyou tender on both sides. Neck is tight, and SCM is more pronounced on right. Right iliac crest tight, but pressure here relieves pronation pain. Pressure at Kid 7 fu liu relieves iliac crest tightness. LI 5 ligou and TH 6 zhigou both tender.

Front treatment: Oketsu: Liv 4 zhongfeng, Lu 5 chi ze: finger pressure releases oketsu area, so points are needled in direction of channels.

Immune area: ‘Triple Intestine 10?(immune points) bilaterally, advancing needle gradually to break up ‘gumminess? Rice grain sized moxas added to point of entry of needle while needle is retained.

SCM: TH 5 waiguan and Gb 41 zulingqi on left to release SCM on right. 1 cun insertion.

Tightness at iliac crest: Finger pressure at a gummy tight point near Kid 7 fu liu relieves tightness. 1 cun insertion in direction of channel.

Fire points: Tenderness at LI 5 ligou and TH 6 zhigou: TH 1 guanchong, TH 2 yemen and LI 1 shangyang LI 2 erjian.

Back treatment: Oketsu: kyutoshin at BL 35 huiyang on left to release right BL 18 ganshu. Immune: tender immune points below iliac crests and scapular spine.

Outcome: Pronation pain and sore throat cleared during front treatment, and have maintained till time of writing (about one week).

Explanation: If found, oketsu is always treated first. If the stagnant blood is not moved, the qi will not move, so other issues cannot resolve. Once the oketsu area releases, other abdominal findings may clear without further treatment. When oketsu is severe, the portal vein congestion can extend to the rectal vein. In fact this patient does get occasional haemorrhoid problems. There is usually a tight knot in the BL 35 hui yang area which can be used to relieve this congestion, thus releasing BL 18 gan shu on the right side, the side of the liver.

The immune points need treatment with both acupuncture and moxibustion to be effective. Patients should feel the heat from the moxa cones 7 times, so if no heat is felt from one or more moxa, a patient may be given more than 7 cones. Matsumoto says it is important to feel 7 ‘ouchies? Tightness under the iliac crest and under the scapular spine reflects immune issues. The area under the scapular spine is specifically related to and treats lung related infections.

Matsumoto always tries to address how channel flow manifests in body structure. In this case the left right SCM disparity requires treatment. TH 5 waiguan and GB 41 zulingqi can be used to release SCM on the opposite side. This must be tested with finger pressure first. Other combinations include TH 8 sanyangluo with GB 40 qiuxu, TH 3 zhongzhu with GB 40 qiuxu, or TH 3 zhongzhu with GB 39 juegu.

Matsumoto states that the shoulder belongs to the hip, and the hip belongs to the kidney. By releasing the hip, Kid 7 fu liu indirectly relieves upper limb problems.

Both TH 6 zhigou and LI 5 li gou were tender. These are the fire points and are treated using the metal/water points on TH and LI channels, TH 1 guanchong, TH 2 yemen and LI 1 shangyang LI 2 erjian.

Conclusion
Matsumoto`s approach has much in common with other Japanese styles: it involves identifying a number of patterns from findings on the abdomen and other diagnostic areas. Our experience of studying this system is that it is more complex to integrate: it does not follow a structured step by step approach as other systems discussed here. Findings can be an indication of a number of possible patterns. The skill is to construct a picture that weaves these findings together into a cohesive treatment formulation; reflecting not only the patient`s current condition but also problems from the past which may be inhibiting resolution in the present.

Treatment is aimed at clearing as many of these findings as possible, though this does not always occur in one treatment. These findings can also reoccur at subsequent sessions, but with less severity, until the disharmony is resolved.

This approach can use many needles and is sometimes rather time consuming. It is, however, a dynamic system which makes use of channel connections in quite unique ways. This interconnected view of the body has produced some profound insights into pathological process, and many effective point prescriptions.

Conclusions
This table summarises some of the comparisons we have made above:

Predomin-ant Feedback Mechanism Needling depth Palpation depth Point locationManaka Abdomen and pressure pain 2 -3 mm medium Pressure pain at the pointAbdomen releases after needling at correct locationMeridian Therapy Pulse and abdomen 1-3 mm light Light touch. Pulse changes after needlingToyohari Pulse and skin tone Non-insertive Very light Very light touchPulse changes when point is correctly locatedMatsumoto Abdomen 1-2 cun deep Correct location and pressure releases abdominal & neck findings[/table]

There are a number of common threads running through this article. These are the factors that characterise Japanese acupuncture in its varied manifestations. The first is the emphasis on the meridian system and the multitude of approaches harnessed to affect the movement of qi and blood through the body. This however has not brought us any closer to answering the question ‘where are these channels??but has given us an awareness of the many depths at which they can be influenced.

Hara or abdominal diagnosis and the emphasis on palpation are also primary to the diagnostic process. Though questions do form part of the initial consultation, they are less detailed than in TCM and limited more to the current condition and past medical history. Within Matsumoto`s approach, knowledge of the chronology of illness is more important to an understanding of the development of pathology.

Treatment of the meridian system is given greater emphasis than the diagnosis and treatment of the zang fu system, particularly in the Meridian therapy and Manaka styles. If the meridian system is brought into balance, there will be a corresponding positive effect on the zang fu internally. The continuous feedback mechanisms offered by such a dynamic approach are invaluable to us as clinicians to gauge the effect of our treatment, and to patients themselves, who are instantly made aware of the powerful changes taking place.

All the above styles treat the front and the back in the same session, reflecting the importance of treating at the fundamental level of yin and yang.

Other common characteristics include the delicacy of needling and the use of guide tubes to control minimal insertion when no more than 1 ?3mm is required. Much attention is paid to dosage so that patients are not over-treated, not only in the above regard, but also when applying the myriad approaches to symptom control – from the most material to the most subtle of techniques. For example, the number of drops of blood extracted during bloodletting is prescribed for patients with different constitutions just as the non-inserted needling techniques in the naso area of the neck are monitored by observing the texture and moisture of the skin.

Our exploration of Japanese acupuncture styles has been an immensely enriching and creative experience. In our experience, Japanese acupuncture theory is relatively simple, but there is no contradiction between this simplicity and the complexity of clinical practice. In fact this simplicity seems to go straight to the heart of patients?presentations.

The closing words of Denmai Shudo`s book seem appropriate to conclude here:
‘Many approaches to treatment have been developed in the long history of acupuncture and moxibustion, and through the centuries Japan has made important contributions to this ancient art. Every approach has its strengths and its weaknesses, but any approach is most effective when applied to the specific situations for which it was intended. This being the case, it makes no sense to argue the merits of one approach over another, or to criticise another approach as being inferior or ineffective. It is far wiser to become familiar with a variety of approaches, and to learn to apply different approaches in a flexible manner.?0

Within each system we have described there is a huge variety of techniques for addressing each stage of the process. Within all the systems discussed there is room for endless integration and substitution of effective methods. For us it is the integration of all we have learnt that poses the greatest challenge.

Diagrams
All diagrams were provided with kind permission from Paradigm Publications, Copyright ?1988.

Marian Fixler and Oran Kivity

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