HONCHI HO, HYOCHI HO: Root and Branch Treatment Staging in Contemporary Japanese Acupuncture

by Robert Hayden

submitted April 2, 1996, in fulllment of major paper requirement (A572 Major Paper Completion) Midwest Center for the Study of Oriental Medicine, Racine, WI and Chicago, IL

Table of Contents Introduction......................................................................................................................4 Part I: Survey of Paradigms and Clinical Approaches Paradigms .....................................................................................................................10 ! ! ! ! Five-Phase ..........................................................................................................10 Eight Extraordinary Vessels ................................................................................12 Biorhythmic/Stem-Branch ...................................................................................13 Other Paradigms .................................................................................................15

Clinical Approaches .......................................................................................................16 ! ! ! ! ! Approaches to Diagnosis of Root condition ........................................................16 Methods of Assessment ......................................................................................16 Systems of Feedback .........................................................................................21 Approaches to Treatment of Root Condition .......................................................21 Tools and Techniques ..........................................................................................21

Part II: Comparison of Styles: Toyo Hari & Manaka Toyo Hari ........................................................................................................................23 Paradigm---Five Phase/ Four Sho Model ......................................................................24 Root Treatment ..............................................................................................................25 ! ! ! ! ! Approaches to Diagnosis ....................................................................................26 Assessment of Root Condition (Sho Determination) ..........................................26 Feedback systems.....28 Approaches to Treatment .28 Tools and Techniques ...31

Assessing Treatment 34

Supplemental (Branch) Treatment ..34 ! ! ! ! Methods ..35 Midnight-Noon 35 KiKei 37 Naso & Muno .38

Yoshio Manaka ..40! Paradigm---Multi-Model 41 Root Treatment 43 ! ! ! ! ! ! ! Approaches to Diagnosis ..43 Assessment of Condition .43 Feedback systems ..48 Approaches to Treatment .48 Choice of Method .48 Tools and Techniques .49 Assessing Treatment 51

Supplemental (Branch) Treatment ..51 ! Methods ..51

Conclusion .53 Appendices Comparison of Point Selection of Meridian Therapy Founders ..57 Comparative Symptomology of Extraordinary Vessels 62 Bibliography .74

Introduction ! An important concept in acupuncture is that of Root and Branch (Chinese: Ben-

Biao). These words that can have a variety of meanings, and be applied to a variety of situations. For example, concepts of pathophysiology, body areas, or clinical events can all be subdivided into root and branch. The present study will focus mainly on the latter, specically, the way in which acupuncturists in Japan treat what they see as the root of a given patients problem. The treatments are prioritized in such a way that there exist specic divisions and guidelines for each stage of a single patient encounter. These guidelines vary with the practitioner, and are often dictated by the association with which the practitioner identies him- or herself. ! The purpose of this paper is to show how the Japanese view the concept of Root

and Branch within the context of clinical practice - which is, after all, the major concern of the pragmatic Japanese - and to show the root and branch treatments as an orderly and consistent staging of clinical events, each of which must be satisfactorily completed according to certain (often palpatory) criteria before proceeding to the next stage. While opinions differ as to the proper proportions of root versus branch stages, most practitioners with any classical background will concur that the root stage is very important and is usually the initial event in treatment. ! We aim to show that:

-Root treatment is important -It usually occurs rst in the staging of the treatment -It uses different diagnostic criteria than the branch treatment -It uses different treatment methods than the branch treatment

-It is usually monitored and measured against some criteria to be judged effective -It may itself be subdivided into stages ! The paper is divided into two main sections. First is an overview examining the

paradigms, diagnostic and treatment techniques commonly associated with root patterns. This section will briey review a variety of paradigms as they are used clinically in Japan. Major exponents of the various schools will be noted, though some who may not t into one or the other may be excluded (Akabane, for example). This list will of course be limited to practitioners whose styles and ideas have been described in English-language texts. It should be noted that the emphasis of the paper is on those schools that acknowledge the classics as a major inuence, and not on those schools that seek a purely scientic approach. Second is a more detailed examination of the clinical approaches developed by two of the most prominent Japanese acupuncturists of the twentieth century, Yoshio Manaka and Kodo Fukushima . Appendices follow. ! First, let us consider 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 rst 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 rst, a chronic illness second, Exterior disease rst, 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 Decient, i.e., the body is very weak, the most immediate concern is to support the normal, since the expulsion of the abnormal Qi from the body depends primarily upon the organisms ability to resist disease. ! Helpful comments from Denmei Shudos 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 rst priority is to correct the abnormal relationships of deciency 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 deciency 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 tonication and dispersion using the ve-phase points and ve 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 emphasizes the importance of both root and symptomatic treatment. No

authority on meridian therapy claims that treatment of localized areas is unnecessary...The only real difference between meridian therapy and the conventional approaches to acupuncture in Japan is that root treatment is performed to balance the body energetically before the specic symptoms are treated...The distinctive feature of meridian therapy is that root treatment comes rst...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... The concepts of root and symptomatic treatment were redened with the advent of meridian therapy. The classics mention treatment of the root (honji/ben zhi) and treatment of the manifestation or branch (hyoji/biao zhi), but this is generally just a matter of emphasis, rather than two distinct aspects of treatment. Root treatment is emphasized so much in meridian therapy because the majority of practitioners in Japan are only concerned with symptoms and the stimulation of tender points. Since root treatment in acupuncture is a

unique approach introduced with meridian therapy, it is naturally presented as the more important aspect of treatment. All practitioners of meridian therapy agree that root treatment comes rst, and symptomatic treatment second. (all italics mine) ! Yoshio Manaka provides an excellent denition of root treatment in his

posthumously published work, Chasing The Dragons Tail: -As the procedure performed rst, it serves to clear the way for the procedures that follow. When successful it can be sufcient in itself, and at the very least, it simplies the rest of the treatment. -Specic factors, such as individual and constitutional differences, can be taken into consideration. -It requires some simple, veriable diagnostic conrmation. -Such checks allow selection of points for patients who are otherwise difcult to diagnose by other means. -The method of treatment can de decided for incipient diseases that are beyond detection by means that depend on symptoms. -Problems and imbalances can be detected and treated at preclinical or functional stages before a pathology becomes evident. In ancient China, there was a tradition that the superior physician treated diseases before they occurred. ! While it is difcult to generalize about Japanese acupuncture, given the vast

array of approaches developed there since the Second World War, it is fairly certain that each acupuncture association has developed its own root style, with its own diagnostic requirements and treatment techniques. 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 conrmation of efcacy before the treatment is allowed to proceed to the next step, i.e., the practitioner must pass a sort of test before entering the next grade. 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 ndings 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. ! Even if we accept Shudos assertion that the present emphasis on root treatment

began with the meridian therapy school, we shall see that the concept has spread outside their stylistic boundaries to a wide range of different practitioners and their philosophies. It is important to note the scope of acupuncture practice in Japan, and to realize that the present paper will only hint at the diversity of techniques and models that are found there. In many cases, the various practitioners involved will adapt each others methods.

In the rst part of our exploration into concepts of root treatment, we will examine

two of the most common paradigms in contemporary practice of traditional Japanese acupuncture, namely those of the Five Phases and of the eight Extraordinary Vessels. These two theoretical models have preoccupied much of the Japanese view of root treatment since the Second World War, and are present in many forms of acupuncture today. In addition, we will note other paradigms that have been more or less discussed in the extant translated literature on this subject.

Part I: Survey of Paradigms & Clinical Approaches Paradigms ! In the Japanese acupuncture literature that has come to the West, it is striking for

the student educated in most U.S. acupuncture colleges to note the absence of the TCM paradigm (i.e., the eight guiding criteria or Ba Gang Bian Zheng) in favor of concepts of pathophysiology and therapy hardly taught in most schools here. While each paradigm is enormous enough in it own right to merit at least one full-length book on the subject, for our purposes a quick mention of each in the context of contemporary Japanese practice is warranted. Recommended reading on each may be found in the bibliography.

Five-Phase (GoGyo) ! The history of the Five-Phase (Chinese: Wu Xing, Japanese: GoGyo) paradigm

is long and controversial; its inuence on virtually all aspects of Chinese thought is enormous and outside the scope of this work. Its application in medicine dates to at

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least the Huang Di Nei Jing Su Wen , and it is the model of choice for what is probably the most classically-oriented of all styles of acupuncture in Japan today, Keiraku Chiryo (Meridian Therapy) . ! Among those schools in Japan that claim adherence to classical principles,

perhaps none is as widely known as the Meridian Therapy movement, founded in the 1930s and 1940s in Tokyo. Traditional medicine had been largely supplanted by modern theories of anatomy and physiology which had been introduced in Japan by the Dutch as early as the seventeenth century . An acupuncturist and philosophy scholar named Seisuke Yanagiya (also known as Sorei Yanagiya) was dissatised with the prevailing Westernized methods being practiced at the time and sought an approach that was more grounded in classical theory. He began to attract students. Two of them, Fukuji Okabe (also known as Sodo Okabe) and Keiri Inoue, joined forces with journalist-turned-acupuncturist Shinichiro Takeyama; the three of them are considered to be, along with Yanagiya, the founders of the Meridian Therapy style . ! The classics they used were primarily the Huang Di Nei Jing Su Wen, the Huang

Di Nei Jing Ling Shu, and, most prominently, the Nan Jing. The Nan Jing was made the basis for the clinical practice of Meridian Therapy, Shudo says, because of its antiquity and because it presents a systematized and self-contained system of acupuncture treatment. Paul Unschuld, perhaps the most prominent Nan Jing scholar writing in English, calls the work the mature classic of systematic correspondence. In the history of this particular conceptual system it occupies a prominent place since it appears to be the only work we know of that combines a high degree of innovative thinking with a consistent - in the Chinese sense - body of thought. . The clinical procedures outlined

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in the Nan Jing were largely based on the Five Phase paradigm, and made extensive use of the Five Transporting points ; thus their prominence in Meridian Therapy. ! Perhaps the greatest contribution of the Nan Jing to Meridian Therapy - and

indeed, it is arguable, to the art of acupuncture as a whole - is the concepts it introduced regarding radial pulse diagnosis. The idea that the pathophysiology of the organs and meridians could be determined largely from the radial pulse revolutionized the practice of medicine in China and continues in some form in virtually all systems of acupuncture extant today. So, too, the treatment principles revealed in Difculty 69, from which developed the four-needle technique and other point selections derived from it. This is the mother-child principle, which is the foundation of not only the Meridian Therapy associations, but others such as various Korean and European schools. A third strong Nan Jing inuence in Meridian Therapy is the abdominal mapping based on Difculty 16, about which more will be said below. ! It is perhaps worth noting that this model, though very inuential in Japan and

other parts of Asia, has fallen out of favor in the PRC. In the U.S., many schools today barely teach this paradigm, which at one time was central to the practice of acupuncture. It doesnt t well with the eight guiding criteria, and is largely discarded as an anachronism, a pseudo-mystical historic curiosity no longer relevant to the practice of Chinese medicine. Thus, it is not well understood by many (if not most) of those who have graduated from acupuncture schools in this country. In Japan, however, extremely sophisticated principles of point selection and treatment have been developed and used with outstanding clinical results; these reect a deep understanding of the principles of Five-Phase dynamics.

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Eight Extraordinary Vessels (Ki Kei Hachi Myaku) ! In a manner similar to the Five Phases noted above, the Eight Extraordinary

Vessels paradigm (C: Qi Jing Ba Mai, J: Ki Kei Hachi Myaku) has a long history, though far less dened than that of virtually any other aspect of acupuncture meridian theory . Cohesive writings regarding methods of diagnosis and treatment began to emerge only during the Ming period. A notable development was the concept of jiaohui points, sometimes translated meeting or master points. These are points on the extremities that, while not necessarily lying within the vessel trajectory itself, are seen to control or open the particular vessel. Furthermore, these eight points are combined into four pairs of points, and thus four pairs of vessels, which are seen to treat a more or less wide variety of conditions. These point pairs are as follows: L-7 is combined with K-6, SP-4 is paired with P-6, GB-41 is paired with TB-5, and SI-3 is combined with UB-62. ! 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; more about these will be said later. It is worth noting that, though it makes use of more scientic theory, this technique is so

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prevalent in Japan that it has been adopted by even the staunchest of traditionalists, though often only when treating the Extraordinary Vessels .

Biorhythmic/Stem-Branch (Un-Ki, ShiGo) ! A collection of therapeutic methods based on the principles of Chinese astrology,

biorhythmic acupuncture reached its zenith of development during the later Ming period. Several forms are being somewhat revived today, both in Japan and in the PRC. In Japan, the major proponent was Yoshio Manaka; since his demise, his disciples have apparently continued using these methods in addition to the others described above. ! Briey, the methods Manaka employed center on the concept that certain points

become open or particularly active at certain times during various cycles of one, ten, or sixty days duration. The daily cycle is based on the meridian circuit described in the Ling Shu (the so-called Chinese clock); the points that are open are the tonication or dispersion points (mother and child) described in the Nan Jing. The ten-day cycle (Midnight-Noon Flowing and Pooling or Zi Wu Liu Zhu) is based on the generating cycle of the Five Phases, and uses the points associated with the Five Phases and the Yuan-Source points. The sixty-day cycle (Eight Methods of the Mysterious Turtle or Ling Gui Ba Fa) is formulated by a complex series of calculations based on the Chinese calender, and is associated with the Latter-Heaven sequence of the Eight Trigrams of the I Ching; the only points that appear in the cycle are the eight jiaohui points of the Extraordinary Vessels. ! The Chinese clock is also the basis for Manakas polar meridian pairs, which

are Yin-Yang meridians on opposite sides of the clock: for example, the Heart meridian,

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active between 11 a.m. and 1 p.m., is paired with the Gallbladder meridian, active between 11 p.m. and 1 a.m.. An associated method used by the Toyo Hari association is called ShiGo; it is based on the same meridian pairings, but used in a different way. A more detailed discussion can be found later.

Other Paradigms ! Though Five-Phase and Extraordinary Vessel models make up a large part of the

traditional diagnostic paradigms in Japan, there are important practitioners whose classically-based or integrated systems are being introduced to the West. One example out of many is Tadashi Iriye, a revered master and teacher of noted acupuncturist Miki Shima, who has a wealth of interesting techniques based on divergent meridian diagnosis and treatment , and is the developer of his own kinesiological technique, the Iriye Finger Test. ! Other systems barely exposed in the body of translated literature include those of

moxibustion master Takeshi Sawada and his disciple, the noted classical scholar Bunshi Shiroda, as well as the equally revered moxibustionist Isaburo Fukaya. Kobei Akabane, creator of the intradermal needle that revolutionized the practice of acupuncture in Japan, wrote several works that remain untranslated into English, and fascinating systems such as the traditional Shaku-Ju school have been only supercially explored if at all in the West.

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Clinical Approaches (diagnosis-treatment) Approaches to diagnosis of Root condition Methods of Assessment ! Of the classical four examinations (visual, auscultation/olfaction, inquiry,

palpation), the palpatory exam is, among virtually all Japanese practitioners, the most important. Different schools emphasize different aspects of palpation: just what one presses at what depth in what order, etc., is not at all uniform across the spectrum of acupuncture practice in Japan. Even in the uniquely Japanese method of abdominal palpation, or hara diagnosis, there is little consensus between styles, as we shall soon see. One may look for generalities, such as overall tone, shape and degree of moisture in the skin; or probe for very specic ndings in certain locations, such as the classical Mu points (which may themselves have alternative locations between practitioners) or other points which elicit pressure pain or other abnormal ndings. ! Classical pulse examination, one of the two pillars of Chinese diagnosis, is

emphasized heavily in the Meridian Therapy schools and marginally or not at all in the styles of Manaka or Ito. Palpation of the extremities, usually in the context of meridians or meridian points, is generally used, though again there is some disagreement about the amount of pressure and even the location of points or meridians. Points that are important in one style may be ignored in another. Pulse Diagnosis ! Radial pulse diagnosis, as stated earlier, was a major contribution of the Nan

Jing. The pulse scheme partially delineated in Nan Jing 18, in particular, became the foundation for what has become known as six-position pulse diagnosis. Briey, the left

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and right wrists are divided along their length into three sections, with the middle section usually centered somewhere in the proximity of the styloid process of the radius. These are the six positions. In addition, the pulse may be divided into Yin and Yang areas according to the depth to which one presses when palpating. Thus, the twelve meridians may all be examined from the palpable portion of the radial artery. In addition, the arrangement of the positions makes it relatively easy to detect imbalances along the generating and controlling cycles of the Five Phases, further contributing to its status as the root examination in Meridian Therapy. Shudo cites Sodo Okabe, who gives a further interpretation of root and branch in the four examinations: Pulse diagnosis is the root and the other examinations are the branches. Even if a certain grouping of symptoms is found through looking, listening and questioning, it is very difcult to put them in a uniform pattern [without pulse ndings]. ... In meridian therapy, pulse diagnosis is the foundation and all other ndings are secondary. ! Pulse diagnosis is less commonly used in Extraordinary Vessel Therapy (KiKei

Chiryo); although some theorists have devised methods for nding disturbances in the Extraordinary Vessels from pulse palpation, many practitioners contend that a workable system has yet to be found . One notable exception is Michi Tokito, a modern Japanese practitioner whose diagnostic framework and treatment protocols are outlined in Extraordinary Vessels by Matsumoto and Birch. Tokito operates within the nowstandard six-position pulse scheme; however, she concentrates largely on the left and right proximal positions at the depth of the Yin meridians. She compares the balance between them, and decides on one of two patterns of Master-Coupled point pairs, one of which is further differentiated by the balance between the left and right middle

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positions at the supercial level. She apparently uses this method exclusively, and no mention is made of anyone else who has adopted her innovations . Palpation of the abdomen (Hara) and meridians ! Among practitioners of Meridian Therapy, the prototype for abdominal diagnosis

comes from the Nan Jing, Difculty 16 (see diagram). Most practitioners of Meridian Therapy follow some variant of this scheme.

One example of variation comes from the Toyo Hari association, a large

organization of Meridian Therapy practitioners, about which more will be said in part II: Abdominal diagnosis (fukushin) is based on Meridian Therapy theory. The tone of the abdomen is noted, and palpation is to nd the presence of Kyo or Jitsu, warmth or cold. The luster or dullness of the skin is noted. The left palm lightly touches the abdomen. The navel is the starting focus.
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*CV-7 to CV-12 = Spleen diagnosis area *CV-14 & CV-15 = Heart diagnosis area *GB-24 to SP-16 right side = Lung diagnosis area; same area left side = Lung comparison *The anks from GB-26 to GB-29 = Liver/Gallbladder diagnosis area *CV-7 to CV-2 = Kidney diagnosis area

In Meridian Therapy, the abdominal examination is used generally to conrm the

pulse nding; it is a vitally important component of the diagnostic process, but not one that may stand alone, as in some other Japanese styles. ! As in other palpatory aspects of Meridian Therapy, the depth to which one

presses is generally supercial; though diagnosing diseases of the Blood level may require deeper pressure, and some adjunct methods (such as Extraordinary Vessels therapy) may need even more.

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In contrast to the light touch employed by most Meridian Therapy practitioners,

the style of Yoshio Manaka uses sensations of pressure pain or tightness in assessing the condition of the patient. Manakas abdominal congurations are reective of his investigative nature and his multiparadigmatic way of thinking; different models employed in root treatment have different abdominal congurations, and ones ndings during the abdominal examination indicate the choice of paradigm in treatment. Details of Manakas hara congurations may be found in Part Two of this paper. ! Palpation may also include meridian palpation to assess the deciency or excess

of the meridians themselves. In Meridian Therapy, it is primarily used to check the condition of the ve-phase points, though some schools use distal point palpation to choose adjunct methods such as Extraordinary Vessel therapy. In Manakas style, it may indicate Extraordinary Vessel treatments, but is usually used to assess and treat Yang meridian points during the second or third step of his treatment plan, in addition to symptomatic points to be treated. ! Some practitioners use reex areas discovered during their own long clinical

experience, and which are unique to their own practice. Consider Mr. Osamu Ito, whose magnetic treatments are outlined in Extraordinary Vessels. His experience in bone manipulation led him to develop palpatory schema of the knee and sacrum to diagnose and conrm the Extraordinary Vessel imbalances in his patients; this method is apparently limited to his own practice, and is based in no other Oriental medical source.

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Systems of Feedback ! In contrast to the treatment methods of TCM-style acupuncture, where efcacy of

treatment is thought to be dependent upon the amount of needle sensation (deqi) elicited, most Japanese styles monitor treatment by repeating parts of the examination to see if any changes have taken place. Thus, the pulse may be rechecked, the hara repalpated, reactive points reexamined, or kinesiological tests repeated to demonstrate that the root treatment is indeed achieving its goal. Whatever is emphasized during the examination is likely to be the focus of feedback assessment: so the pulse will be the proof of the patients improvement in a Toyo Hari clinic, whereas in Manakas hospital the abdomen or o-ring test is used to indicate success in the rst stages of treatment. Ms Tokito is also likely to recheck the pulse, as well as the relative tension of the sternocleidomastoid muscles, to determine the treatment progress. Osamu Ito would use his own palpatory zones or leg lengths to conrm the efcacy of the therapeutic events.

Approaches to treatment of Root condition Tools and Techniques ! In contrast to the limited number of implements routinely employed in TCM-style

acupuncture, the Japanese have developed a dazzling array of clinical tools and techniques with which to render an effective treatment. Needles are fashioned from or plated with various metals, based on their classical associations or on modern electromagnetic research. An entire school of acupuncture created around the use of complementary pairs of metals (the so-called M-P or Minus-Plus school of Tsugio

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Nagatomo and Gerhard Bachmann) has become inuential in Japan. These principles have stimulated a variety of non-invasive procedures utilizing magnets or complementary metals placed on the skin; one prominent example is Osamu Itos work with his PIA or Ito magnets, which are bipolar pairs of magnets with complementary metals (copper and zinc, or gold and aluminum) embedded in the magnet face. Ito was a student of Nagatomo, and Nagatomo himself was inuenced by Yoshio Manakas work with polarity agents, most notably the ion-pumping cords, the use of which will be described later. ! A common phenomenon is the use of very specic instruments and methods for

each stage of treatment. These will vary from school to school; often the same techniques will be utilized and dened differently between schools according to their treatment-staging methods. Stephen Birch has remarked that each association of acupuncture in Japan identies itself with its own root style or primary diagnostic and treatment framework (which may or may not be based whole or in part on any number of classical texts or traditions), for which it researches and develops very specic techniques and implements. There are practitioners, for example, for whom bloodletting would be considered a root treatment, and those who use primarily cutaneous techniques such as tapping or warming the surface of the skin over meridians or specic zones. Each association then adds techniques for supplemental treatment based on the vast array of root techniques developed by these various associations. The Toyo Hari association, for example, will use paired copper and zinc in a fashion similar to the M-P advocates; however, this method is considered supplementary and not part of the root treatment, for which silver or gold needles are used with very specic

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techniques unique to the Toyo Hari. Similarly, the intradermal needles (hinaishin) developed by Akabane and used by him as the primary method of treatment become a symptom-control tool for Yoshio Manaka, to be used only at the conclusion of a treatment. The direct moxibustion that forms the sole method for the treatments of Sawada (though, curiously, not for the style that has evolved bearing his name, in which needles may be routinely used) becomes a supplementary technique in Meridian Therapy and Manaka styles, and is not used at all in other systems, such as those of Ito or Tokito. The Toyo Hari association has even developed a method which combines direct moxa with M-P principles, though, again, it is not considered part of the root treatment. ! In the next section, we will examine more closely two approaches to treatment

staging, each with its own denitions of which stage constitutes root and branch and each with its own unique methods for root treatment.

Part II: Comparison of Styles: Toyo Hari & Manaka Toyo Hari ! The Toyo Hari Gakkai (East Asian Acupuncture Medical Association) was

founded in 1959 by Kodo Fukushima, a student of Inoue. Fukushima, blinded during the Pacic War, had originally formed the organization for blind Meridian Therapy practitioners. The methods he and his association developed were based on extremely delicate and rened techniques of examination (largely palpatory) and needle technique. As the association continued to grow, sighted members were trained in

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these methods. The organization is now well integrated, and has begun to grow overseas as well. ! The Toyo Hari method differs from other Meridian Therapy schools in several

respects; these are in many ways related to the origins of the association. Since the Meridian Therapy movement was founded by sighted practitioners, blind acupuncturists wishing to study this material encountered obstacles in a system that was not designed for them. Fukushima and other founders of the Toyo Hari association at rst developed their own methods of learning until they could be integrated more fully into the Meridian Therapy movement. In this way, their theories and methods, though similar to and largely inspired by those of Yanagiya and especially Inoue, for example , grew into an emphasis on clinical research and didactic methods that set them apart and are very much responsible for the strength and exibility of the organization today. In recent times, unique theories, such as Sokoku harmonization, and even entire subsystems of acupuncture, such as Naso therapy, have emerged from the Toyo Hari Gakkai. In this, it is perhaps not representative of other Meridian Therapy associations, but it is nonetheless a fascinating system with which the author is well acquainted. A basic overview with some specic examples follows.

Paradigm---Five Phase/ Four Sho Model ! The primary paradigm in Toyo Hari, as in other schools of Meridian Therapy, is

that of the Five Phases. It is imbalance in the Five Phases that is seen as the cause of morbidity in humans, and it is this imbalance that is addressed in the root treatment.

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Other paradigms, such as Extraordinary Vessels, may also be used, but are assigned a secondary role in the hierarchy of therapeutic methods. ! In the process of diagnosis and treatment, special attention is paid to the state of

the Yin Meridians, and the pathology associated with them is generally though to be one of vacuity. As Shudo states, ...in this school of acupuncture the basic pattern of imbalance is always dened in terms of a deciency of a yin organ or meridian...the yin organs or meridians have a tendency to become decient, and the Yang organs and meridians to develop excessive conditions. From these patterns of deciency of the Yin organs associated with the Five Phases come the four Sho (Chinese: Zheng) or patterns. The Sho number four rather than ve because of a view that the Heart itself will rarely be vacant, and if it is, consequences are so serious that acupuncture therapy will be of little avail. ! The four Sho are the foundation of Meridian Therapy theory; without them, one

may not properly treat with acupuncture. Shudo elaborates: The four basic patterns in meridian therapy are the simplest expressions of the most common and fundamental types of imbalances in the meridians, all of which involve deciency of Qi. One or another of these basic patterns can be utilized in every clinical situation... The assumption which underlies meridian therapy is that all imbalances, no matter how complex, initially begin with a deciency in one of the Yin organs that is reected in its corresponding meridian. ! Fukushima, using the Japanese alternate term akashi (instead of Sho, which is

a Japanese pronunciation of the Chinese Zheng): Symptoms are the manifestation of disease and represent the condition of the body. Akashi is of a higher level. It is the

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fundamental nature of the disease and represents the goal of its treatment. Akashi is an abstraction derived from an interpretation through meridian theory of the complex symptoms of the patient... (it) is a holistic interpretation of the disease and contains the practical information that determines how to conduct the therapy.

Treatment staging I: Root Treatment ! In Meridian Therapy, Fukushima describes root treatment (here translated as

Fundamental Healing) thus: Fundamental Healing involves the application of ho (tonication) and sha (dispersion) needling techniques...to correct imbalances in the 12 meridians...The patients illness must be interpreted holistically in terms of imbalances in ki (qi)and ketsu (blood), identied through the kyo (deciency) and jitsu (excess) of the meridians. Ho and sha techniques are applied with hari (acupuncture) and okyu (moxibustion) to correct these imbalances. This process constitutes true East Asian medicine. It is Fundamental Healing based on rebalancing meridian ki that makes Meridian Therapy a unique and outstanding medical discipline.

Approaches to diagnosis Assessment of Root Condition (Determination of Sho) ! ! ! ! The diagnostic process, or determination of Sho, proceed in three orderly steps: 1. Choose the treatment method 2. Analyze symptoms according to the twelve meridians 3. Select the primary meridian by pulse diagnosis. This is the Sho.

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-In the rst step of Sho selection, one considers the Yin or Yang constitution of the patient, Yin or Yang nature of the disease, and selects appropriate techniques of tonication or dispersion with appropriate needles in an appropriate quantity. Determine the patients constitution; decide what kind of needle to use; what kind of stimulation and how much; how many points to treat. -In addition to ve-phase diagnosis, you must determine if they are of Yin or Yang constitution. Look at the pathology...is it Yin or Yang? Old or New? Slowly-developing or Quickly-developing? Yin diseases are often inapparent, while Yang diseases are often apparent. -In the second step, one collects signs and symptoms and correlates them to the twelve meridians. -Finally, pulse diagnosis is used to determine the primary pattern or Sho. Palpate the pulse, hara and the meridians. By now you already have some sense of what to look for. Determine the Sho based on these ndings. -It is very important to follow all these steps in order to correctly determine Sho. ! ! ! Signs and symptoms are largely derived from the symptomology described in the

Ling Shu. They are not very different from those described in modern TCM texts, but they become weighted in terms of their importance by the subsequent step of the diagnosis. Thus, the diagnostic process is not simply counting up how many symptoms are those of the Spleen, Kidney or whatever; and the state of the body uids or substances is not of great concern. What is being addressed is the quality and circulation of the Ki-Ketsu (Qi and Blood) of the body.

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Complicating the process is the fact that methods continue to be developed in

Toyo Hari; it is a dynamic process rather than a static system etched in stone. A key development in the evolution of Toyo Hari was the concept of Primary and Secondary Sho, or Sokoku Control needling. This came during years of clinical application of Five-Phase theory in which patterns would present that were seen to be contrary to the rules of treatment formulated during the early years of the Meridian Therapy movement. !

Feedback systems ! A key in diagnostic conrmation is meridian palpation; the meridians diagnosed

are lightly stroked in the direction of their circulation while the pulse is checked. A positive response, i.e. normalizing pulse, conrms the diagnosis. It is worth noting that this same method may be employed in locating the exact point to be treated. In fact, the pulse is checked routinely during the decision making process in much the same way as the o-ring or other tests are performed in the eld of applied kinesiology.

Approaches to treatment Point selection ! Root treatment point selection in Meridian Therapy is based on Nan Jing 69; it is

the Mother-Child scheme. The standard tonication point patterns for the four Sho are as follows:

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 Lung Sho: LU9, SP3 Spleen Sho: SP3, P7 Liver Sho: LV8, K10 Kidney Sho: K7, LU5 The point selection may be altered as necessary; sometimes specic symptoms may require alternate points, as described in Nan Jing 68 (for example, jing-river points may be selected in cases involving coughing or dyspnea). Phase energetics may also play a hand in more complex selection schemes. However, the principle of tonifying the mother Phase of the affected meridian is rarely violated. The perceptive reader may notice the substitution of Earth points for Fire points in the Spleen Sho, and the substitution of LU-5 for the more orthodox LU-8 in the Kidney Sho. The former is to avoid tonifying the Fire phase , while the latter seems to be an empirical choice . ! As mentioned earlier, Toyo Hari makes use of a unique concept known as

Sokoku Control, based on unilateral patterns of needling. Briey, 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 YuanSource or Luo-Connecting point of the Sokoku meridian (see table).

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Once the primary and secondary Yin meridian imbalances have been addressed,

the pulse is reassessed, and the state of the Yang meridians is examined. Tonication and dispersion is then applied to those Yang meridians that are decient or excess. In theory, this should t into a neat Five-Phase scheme (e.g., in a Lung pattern, the Lung and Spleen are decient and the Large Intestine and Stomach are excess), but, in practice, one treats what is under ones ngers without regard to theory. The point selection in treatment of the Yang meridians, too, is far more based on pragmatic concerns; the points needled are generally Yuan-source, Luo-connecting, Xi-cleft, or any of the Five-Phase points which are reactive (i.e., tight, edematous, tender, etc.). Generally only one point per meridian is needled.

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Tools and Techniques ! As Shozo Takahashi-sensei, vice-president of the Toyo Hari Medical Association,

said in conversation with the author, technique is everything in Toyo Hari . In general, the techniques rely on very delicate manipulation of ne needles (usually .16 or .18mm in diameter, and 25-40mm in length), characteristically made of silver and sometimes gold. In contrast to the techniques used in the PRC, which are aimed at eliciting a strong sensation of distension or soreness (called deqi or obtaining Qi) by deep insertion and pronounced manipulation, the Toyo Hari practitioners advocate subtle techniques in which the needle is manipulated in ones consciousness as much as with ones ngers. The needles are often not inserted (i.e. they do not penetrate the epidermis) but are held with the tip either just touching or slightly above the skin. Even in more dispersing techniques where the skin is broken, the needle rarely reaches a depth of more than a few millimeters. Needles are seldom left in situ; once the arrival of Ki (C: Qi dao, J: Ki itaru) is felt - by the acupuncturist rather than the patient - the needle is withdrawn in a strictly prescribed manner according to the ndings gleaned during selection of Sho.! ! All one really needs when treating patients is a needle and ones own two hands.

The right hand, called sashide, holds the handle of the needle and is used to insert and manipulate. The left hand, called oshide, holds the tip of the needle and is used to stabilize the needle and keep the Ki from leaking out. Both are important but the formation of a good oshide is considered crucial, especially during tonication. The thumb and index nger are brought together in an o shape; the prole should be at and there should be as much contact as possible between the very tips of the thumb

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and index nger. The needle tip may be just barely seen between the tips of the two ngers. When placed on the skin, there should be no gap between the ngertips themselves, nor between the ngertips and the skin. ! The following description of techniques used in the root treatment is based on

notes taken by the author during the course of his Toyo Hari training. The most basic ideas behind Toyo Hari technique: 1) Ho (tonication) is achieved with Left-Right pressure, ie. the ngertips of the oshide must press against each other to seal the point so that no Ki escapes during needling. Amount of Left-Right pressure during needling varies with the individual patients constitution, but the important thing to remember is that the oshide must be tightened when the needle is withdrawn, so as to close the hole to prevent leakage of Ki, and, with it, deterioration of the pulse (as well as the patients condition). 2) Sha (dispersion) is done with downward pressure, i.e. the oshide presses down into the skin as the needle is being withdrawn in order to expel the evil Ki in the meridian. HO Technique: -Rub the area gently with left index nger to locate the point -Right hand lightly grasps the needle handle -Bring the tip of the needle to rest lightly alongside the left index ngertip -Form the oshide -Apply Left-Right pressure on oshide: 70% for weaker patient, 30% for stronger patient -Apply slight downward pressure with the needle and rotate it back and forth slightly -When the arrival of Ki is felt, apply 100% Left-Right pressure and quickly remove needle

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-Recommended needles: 0.8-1.3 cun, #1 or #2 silver needle SHA Technique (general): -Use thicker needle; #2-#5 silver or stainless -Locate point, bring needle tip to oshide -Manipulate, apply downward left-hand pressure and remove needle -Sha Technique is further classied according to: " " 1. type of Jitsu (external or internal) 2. particular pulse quality

-EXTERNAL EVILS are differentiated into two types: Fujitsu & Genjitsu. 1. Fujitsu Pulse is related to Ki; it is Floating and Rapid, indicates febrile condition " -#3 silver or stainless needle, angled against meridian ow, 1-2 mm depth -Lift and thrust slightly, withdraw needle with downward pressure as if pushing out pus 2. Genjitsu Pulse means pathogen is on Ketsu level; it is Sinking and Wiry -#3 stainless needle placed against meridian ow, push in 2-3 mm -Hold handle more tightly, lift and thrust and rotate with relatively large amplitude -When resistance at the tip lessens, press down harder and slowly withdraw needle

In addition to these basic techniques, there are a group of techniques which are

in between Ho and Sha; these address the modern problem of Kyo Ja, or deciency evil, pathology that arises from Phase imbalances which are seen in patients who are overall so decient that standard Sha techniques would cause more harm than good. Again, they are differentiated by pulse type, and include elements of both Ho and Sha techniques.

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Assessing treatment ! Assessing the effects of treatment involves basically a reexamination of the pulse

and abdomen. Pathological qualities noted in the pulse will begin to normalize; a pulse that was noted during the initial examination as sinking will begin to rise, a oating pulse will begin to sink, a slow pulse will accelerate, and a fast pulse will slow down. Differences between individual positions may become less apparent, and the pulse overall should become smoother and more dened. The abdomen itself may begin to normalize, and temperature and texture differences are likely to even out. Even the shape of the navel may become more symmetrical. ! In addition, the patient should feel relaxed and comfortable, and any pathological

changes in the face or skin should resolve. The skin should take on an added luster; signs of over-treatment include excessive moisture of the skin. If this occurs, needle treatment should stop and corrective measures may be applied.

Treatment staging II: Branch Treatment ! The second stage of clinical procedure, or branch treatment, is called Targeted

Healing in the translation of Fukushimas Meridian Therapy. This is contrasted with Fundamental Healing or root treatment, described above. Fukushima describes it thus: Targeted Healing is a system for the direct treatment of the local afictions accompanying a patients illness. The strengthening of Vital Energy through Fundamental Healing will eventually result in the removal of all the symptoms...but certain complicated cases...may require a long period of time to cure. Targeted Healing

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speeds up the process...In terms of the overall care of the patient...its value is far less signicant than that of Fundamental Healing. ! I feel it is further necessary to comment upon what the Toyo Hari training

methods call supportive treatment, and to differentiate this from the more commonly held notion of branch treatment as local. While it is true that supportive treatment targets symptoms and that the goal is the elimination of same, the treatment is often as not conducted upon locations remote from those where the symptoms may be found. Thus (as noted above) the branch treatment in Toyo Hari may employ the same methods used by other associations as a root treatment. In addition, the affected body areas themselves may be treated in a more standard local treatment. The majority of methods outlined below more closely match the denition of supportive treatment rather than local treatment.

Methods Midnight-Noon (ShiGo) ! ShiGo (Chinese: Zi Wu) is a system of point selection based on the circadian

rhythm of the the twelve meridians as outlined in the Ling Shu. The cycle is said to begin with the Lung meridian at 3:00 a.m. and progress through the meridian circuit as follows: 3-5 a.m.: Lung 5-7 a.m.: Large Intestine 7-9 a.m.: Stomach 9-11 a.m.: Spleen

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11 a.m.-1 p.m.: Heart 1-3 p.m.: Small Intestine 3-5 p.m.: Bladder 5-7 p.m.: Kidney 7-9 p.m.: Pericardium 9-11 p.m.: Triple Burner 11 p.m.-1 a.m.: Gallbladder 1-3 a.m.: Liver ! When opposite sides of the diagram are combined, a Yin-Yang/hand-foot

meridian pair is created. For example, 3-5 a.m. is the time designated for the Hand Taiyin Lung meridian. This would be combined with the opposite time on the clock, namely 3-5 p.m., which is the active period for the Foot Taiyang Bladder meridian. The meridians are paired thus: Lung-Bladder Large Intestine-Kidney Stomach-Pericardium Spleen-Triple Burner Heart-Gallbladder Small Intestine-Liver ! Problems affecting a given meridian may be treated by needling its ShiGo paired

meridian, i.e., for pain along the Heart meridian, the Gallbladder meridian would be treated. The most common indications for ShiGo treatment are either symptoms that recur during a specic time (patient awakes every night at 2 a.m., for example) or

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symptoms that occur along the course of a specic meridian. Some practitioners also use it for organ-specic symptoms, such as treating the Bladder meridian for acute asthma. ! The methods used generally employ a thick #30 gold needle (non-inserted);

direct moxa (15-30 times) or gold pressballs may also be used. Luo-connecting points or Xi-cleft points are routinely selected, depending on reactivity. 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 specic time, the patient may be given instructions to apply moxa or nger pressure to the relevant point at the time when the symptoms occur. ! ShiGo was originally utilized in the Toyo Hari system only for acute emergency

situations. Often the procedure is done before the standard root treatment. Recently, the Toyo Hari association began to investigate this technique in the treatment of chronic ailments, and the results so far look encouraging, especially with chronic asthma.

KiKei ! In contrast to other styles in which Extraordinary Vessel therapy (KiKei Chiryo) is

used as the primary treatment, Toyo Hari practitioners employ it as a supplemental treatment, and often use it for a specic symptom or set of symptoms. The methods used are strikingly familiar to those acquainted with M-P school techniques: originally gold and silver needles were used, but currently dime-sized discs of copper and zinc are taped to the master and coupled points on opposite sides of the body, or north and

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south magnets are used in their place. Moxa may also be used for home treatment: ve cones for the master point and three for the coupled point. One example from the authors experience: a patient with signs and symptoms indicating a Kidney Sho. The patient, among other complaints, was developing a goiter; after the root treatment of the Kidney Sho, tonication or dispersion of various Yang meridians, and various local treatment techniques, the patient was instructed to use magnets or moxa on K-6 (north or 5 cones) and L-7 (south or 3 cones). It was explained to the patient that this was for the goiter specically. ! In Meridian Therapy, the section on KiKei mentions that the therapy was added to

the Toyo Hari repertoire in 1972; this is certainly late enough to admit the profound inuence of the M-P school and Yoshio Manaka (who is mentioned in the KiKei section of this book). The Toyo Hari association, however, has added two new point combinations (for a total of six) to the KiKei point formulary. In addition to the standard point pairs (see section above), Toyo Hari added LV-3 + H-5 and LI-4 + ST-43. Symptoms and palpatory signs for all the KiKei point combinations may be found in the appendix following.

Naso & Muno ! Naso and Muno are supportive treatments, performed around the clavicle and

symphysis pubis respectively. Naso is employed for pain or dysfunction above the waist, including neck, chest, shoulders, upper limbs and back. Any problem below the waist may be addressed by Muno. As they are taught today, they may be used for internal problems as well (such as treating respiratory or gastric problems with Naso,

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and intestinal or urogenital problems with Muno). They are essentially the same procedure: knots or lumps in the tissues are palpated, a needle is inserted until it reaches the knot, manipulated until the knot loosens, withdrawn and another knot in the area is sought. The Toyo Hari categorize the various lumps according to the degree of hardness, and correspondingly harder needles and techniques are employed for each. Needle sensation along the meridian may be felt here, but in contrast to the cramping or distending sensation of TCM acupuncture, a warming sensation in the affected area or meridian is considered a positive sign. As in other techniques in Meridian Therapy, strong needling is avoided and is considered detrimental to proper treatment. ! Naso itself has grown and developed over time into a unique system which

strongly corresponds with the Sho. Clinical research has indicated reex zones which may be palpated to conrm the Sho, and/or treated to extend the Root treatment still further. Originally viewed as roughly correlating to the muscle meridians in the neck area, they are increasingly being rened to the extent that Naso can hardly be called a local treatment anymore. It has become a whole-body treatment, a complex microsystem of acupuncture in which virtually any complaint may be addressed. ! Local areas themselves are often treated by fast and light touching

needle (sanshin) techniques, and other types of implements such as the rounded needle (teishin, which may be used in diagnosis and root treatment as well), and curiously shaped needles designed to stroke or scratch the cutaneous meridians (zanshin, enshin, shonishin) are routinely employed in the clinic. The Toyo Hari association also uses other techniques more familiar to other Japanese styles, such as

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direct moxibustion, microbleeding, intradermals, and needling into various empirical points commonly used in Japan. ! As we have seen, the methods of treatment utilized by Toyo Hari Gakkai

encompass a fairly broad range of modalities; yet, their concept of root treatment is very strictly dened, limited to the ve-phase paradigm. This seems to present no real obstacles to clinical success, given that the parameters of supportive treatment are a bit more open. I have heard it said that Fukushima himself, at least towards the end of his career, relied almost entirely on root treatment ; this stage of clinical procedure is certainly given heavy emphasis in the Toyo Hari training program. As the organization continues to grow, it is likely that the repertoire of treatment options will grow with it. However, the original spirit of classical ve-phase root treatment is fundamental to the philosophy of the Toyo Hari Gakkai. It is unlikely that this will change.

In the next section, an overview of a much broader style of clinical procedure will

be attempted: this is the style developed by Dr. Yoshio Manaka. Yoshio Manaka ! ! Yoshio Manaka (born April 23, 1911; died November 20, 1989) was perhaps the

best-known gure in Japanese acupuncture. Stephen Birch has called him the archetypal Japanese acupuncturist; he was both scientist and classical scholar, a painter, sculptor, author, and a true renaissance man. He graduated medical school and went on to get PhD in physiology in 1930s. An army surgeon during the war, he spent last years of war in prison camp in Okinawa. He studied East Asian medicine, acupuncture, moxibustion and Kanpo (herbal medicine) on his own, and exclusively

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practiced these modalities from 1960s on. He founded Manaka hospital in Odawara, Japan in 1945 and was its director until his death in 1989. Thus, he had resources to experiment and collect data to test his theories. He studied as many styles of traditional medicine as he could, and evaluated each according to his own research. ! As he went on in his career, he gravitated more to the subtle methods of those he

studied, and developed his own unique paradigm to explain the profound effects such methods could elicit. This he called the X-signal system; he described it as a primitive information system in the body that has embryological roots, but is masked by the more advanced and complex control (regulation) systems... cannot be explained by neurophysiology because it manifests and is manipulated clinically with minute stimuli or inuences that cannot be clearly said to affect the nervous system... we feel it is a biological system as yet undiscovered by biologists and anatomists. Manaka developed devices to affect this system without stimulating the nervous system; the most famous and widely used of these is the ion-pumping cord, described in greater detail below. It is worth noting that his work in this eld has inuenced most of the use of magnets and other polarity agents in acupuncture.

Paradigm---Multi-Model ! Manakas model is based on a number of paradigms, rened by his own

research. The Extraordinary Vessels were of particular importance, especially during the initial developments of his approach. Later, he began to add the polar meridian pairs, i.e. the hand-foot -Yin-Yang pairs formed by opposing meridians on the Chinese clock (see above section on ShiGo). Musculoskeletal imbalances were framed in the

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context of the meridian sinews (jing jin). He developed indications for each paradigm, and treated according to what he found. If the ndings were inconclusive, he had a paradigm for that too. The biorhythmic open point could be treated, or moxa could be applied in a whole-body approach that Manaka adapted from master moxibustionist Sawada. Unusual treatment methods, such as shining colored LED lights on ve-phase points or applying sonic stimulation at various frequencies to different meridians, were also routinely employed. ! Manakas clinical protocol is lengthy and involved; Stephen Birch has noted that

it may be done in 45 minutes, if youre brisk . Manakas protocol is constructed in ve steps, the rst three of which he considered the root treatment and the remaining two the supplemental treatment. ! The protocol can roughly be charted as follows: Step One: Treat the Yin (front) side of the body Paradigms: Extraordinary Vessels; Polar Meridian Pairs; Biorhythmic Methods; Taiji Moxibustion Methods: Mainly Ion Pumping Devices (see below) Step Two: Treat the Yang (Back) side of the body Step Three: Treat the Meridian-Sinew imbalances Paradigms:

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Related Back-Shu points (Step Two); Reactive points along Yang Meridians Methods: Kyutoshin (Needle Moxa); Fire Needle; Moxibustion; Sotai exercise

Manaka observes that Step Two and three often overlap, as their goals are similar. ! The examination would generally begin with palpation, usually starting with the

abdomen. Manakas Mu points would be pressed, and the Extraordinary Vessel congurations would be tested. Reactive Mu points that appeared in polar meridian combinations would be conrmed with palpation of relevant areas on the gastrocnemius muscles. Any ndings regardless of paradigm could be conrmed by positive o-ring test. If both polar meridian ndings and Extraordinary Vessels ndings occurred during the examination, the more appropriate of the two paradigms would be determined; step one treatments generally used only one paradigm. If no positive ndings occurred and/ or the examinations were otherwise inconclusive, biorhythmic open points from any of the three commonly-used methods outlined above could be employed. Another possibility would be the Taiji moxa treatment developed by Sawada and rened by Manaka.

Treatment staging I: Root Treatment (Steps 1, 2 & 3 ) Approaches to diagnosis Assessment of Condition ! In his book, Chasing the Dragons Tail, Manaka offers this explanation of akashi

(or Sho, as described above) as opposed to diagnosis in the modern biomedical sense:

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Akashi is a collection or pattern of signs and symptoms that center on a

treatment adaptation or method. Thus, depending on what treatment method is selected, the akashi will be different, where in Western biomedical terms, several cases might all be the same disease entity, regardless of treatment possibilities. ! Akashi can be said to depend on the intentional consciousness with which we

observe the patient... However, this makes the akashi dependent on the style, experience sensitivity, and ability of each practitioner. ! In Manakas style, the main method of assessment is palpation, and the primary

site of palpation is the abdomen. Manaka determined his own set of Mu-Alarm points for the various Zang-Fu (see Table), as well as zones of reactivity for the various Extraordinary Vessel pairs (see Table). The polar meridian pairs are indicated by reactive Mu point combinations, along with a system of palpation of reactive zones on the gastrocnemius muscles (see Table). Manakas Mu Points Lungs - LU 1 to LU 2 area Percardium - PC 1 Heart, Pericardium - CV 17 Heart - KD 23 Heart - At the sides of CV 14 Liver - LV 14 to GB 26 (esp right subcostal) Gallbladder - GB 24 to GB 29 region Stomach - Beside CV 12 (including ST 21) Spleen - GB 26 to SP 21 region

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Kidneys - KD 16 (occasionally GB 25) Triple Warmer - ST 25 (or slightly lateral) Upper Warmer - CV 17 Middle Warmer - CV 12 Lower Warmer - CV 5 Small Intestine - ST 26 (or slightly lateral) Large Intestine - ST 27 (or slightly lateral) Urinary Bladder - KD 11

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46

The pattern selected for Step One usually sets up the rest of the procedure

through Steps Two and Three. Points on the back would be selected which strongly correspond to the assessment for step one. For example, if Step One were an Extraordinary Vessel pattern, step Two would follow thus: ! ! ! ! ! -Yinqiao Mai-Ren Mai, kyutoshin (moxa-needle) on UB 23 and/or 25 -Yangqiao Mai-Du Mai, kyutoshin on UB 27 and/or 28 -Yinwei Mai-Chong Mai, kyutoshin on UB 18 and/or 20 -Yangwei Mai-Dai Mai, kyutoshin on UB 19 and/or 22 -Cross-Syndrome, kyutoshin on UB 18 and/or 27, 25, 23

All of these may be supplemented or supplanted by points of pressure pain. ! Step Three generally hinges on examination of leg and arm lengths and

muscular imbalances on the sides of the spine. If these are present, further examination typically reveals the following associated with organ patterns: With Liver problems, the paravertebral muscles on the right between UB-17 to 20 may be tight or swollen; problems with the right shoulder and left low back may appear. Problems of the Spleen may show paravertebral problems to the left, from UB-18 to 22, and problems in the left shoulder. Lung problems often result in shoulder and intrascapular tension, as well as stooped shoulders and upper back. Kidney problems often manifest as lumbar problems from UB 23 to 52. ! Often step three could be completed with a simple exercise combined with direct

moxa or re needle to UB-18 (the Liver Shu, as the Liver controls the sinews).

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Feedback systems ! Feedback in this style is largely gauged through the relief of pressure pain or

tightness in the previously palpated abdominal or gastrocnemius zones. Omuras o-ring test is also employed. This is an applied kinesiology test, developed by Yoshiaki Omura MD, in which the patient holds their right index nger and thumb tips together in an oring shape while the left index nger touches a diagnostic point on their own body. The therapist attempts to separated the ngers in the o-ring and gauges the resistance given by the patient to this action. The test is considered positive when the resistance is weaker than usual. A number of points may be tested this way, and in certain cases the presence of pathology may be evident only with this technique. Stretching exercises in step three would begin and end with range-of-motion tests to gauge the extent to which the imbalances in the meridian-sinews have been corrected.

Approaches to treatment Choice of Method ! Manakas view of root treatment was fairly broad: Treatments that take

advantage of the signal system are considered root treatments. Treatments utilizing channel characteristics, ve-phase points and extraordinary vessels are root treatments. Treatments that harmonize Yin and Yang are also root treatments. In our experience, for root treatment, selecting from classical channel therapy, channel sinew therapy, extraordinary vessel therapy, or biorhythmic treatments has provided the greatest effectiveness and utility.

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Step One treatments, as noted above, are chosen primarily from Extraordinary

Vessel or Polar Meridian pair models; barring clear indications of either of these, biorhythmic open points or Sawada/Manaka Taiji moxibustion treatments may be used. Taiji moxibustion, as practiced by Manaka, would consist of tiny direct moxa on CV-12, ST-25, CV-4 or CV-7, TB-8, Manakas own 3-yin crossing point (above SP-10), K-7, LV-3, LV-4, GV-12, GV-20, UB-18, UB-20, UB-23, UB-32, UB-52, GB-31, GB-34, GB-40. ! As is evident from the above quote, Manakas denition of root treatment was far

more open and encompassing than that of the Meridian Therapy schools. As we have seen, the Toyo Hari Gakkai would consider the classical channel therapy (Mr. Birchs translation of the term Keiraku Chiryo, implying a ve-phase paradigm) alone as constituting proper root treatment; the channel sinew, extraordinary vessel, or biorhythmic treatments would all be seen as supportive treatment. ! In this way, Manakas root treatment concept could be spread over three stages

of clinical events, so step Three of a ve-step plan is as much a root treatment as step one.

Tools and Techniques ! In Manakas system, tools are generally more important than techniques; this is

especially true in the rst step of treatment, in which the polarity agents do the work that in other systems would be accomplished with manipulation of the needle or other forms of tonication and dispersion. ! Step one treatments are generally done with ion-pumping devices, instruments

invented by Manaka himself. There are three varieties, developed over time. The

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oldest, ion-pumping cords, were developed during the second World War to treat burn victims, but their use in subsequent years has been conned to the eld of acupuncture. They consist of one or more pairs of cords of thin copper wire, each with an alligator clip at either end. The clips are partially covered in colored rubber; one clip is black and the other red. The red clip contains a germanium diode which allows the current to ow in only one direction. As Manaka states: Theoretically, attaching the positive and negative clips of an ion cord to two needles...will create a polarity between the needles and electronic and ionic currents will begin to ow inside the body . The needles to which they are attached are inserted shallowly (2-3 mm) with no manipulation. They are retained for ten to twenty minutes, after which the abdominal reactions should improve. ! Newer (and costlier) alternatives which use no needle insertion and save

considerable time are the ion beam apparatus and the electrostatic adsorbers. The ion beam consists of a small electronic box into which two small cylindrical coaxial conductors are plugged; the conductors, also colored red and black, conduct very weak negatively and positively charged electrical current (beams). They are touched to the relevant points for twenty to sixty seconds to produce the desired effect. The electrostatic adsorbers are metal rods with built-in ceramic capacitors, connected by a cord and also designated red and black; the device withdraws static electrical charges that are caught or stored in body tissues and redirects them via a diode similar to the ion pumping cords. Again, they need only be touched to the skin for twenty to sixty seconds to accomplish their mission. ! Alternative Step One modalities include the use of colored lights and pens on the

ve phase and source points; these may be used to conrm diagnoses (repalpate after

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applying colors) or to treat, in some cases. Briey, the colors used follow the classical ve-phase associations: green/blue for Wood, red for Fire, yellow for Earth, white for Metal, black for Water, and orange for Source points. ! Step two treatments are done with kyutoshin, moxa-needle. Back-shu points

relevant to the akashi (for example, UB-18 for cross-syndrome or Liver-Small Intestine polar meridian pair) are needled and moxa is burned on the handle of the needle. This is the most common technique for step two, although moxa is not always used. Step three is accomplished with the re needle (Chinese: Fa zhen) or direct moxa, utilizing simultaneous stretching of the affected meridian or specic exercises chosen from the Sotai system developed by Keizo Hashimoto .

Assessing treatment ! Treatment may progress from step one to step two when the abdominal reactions

noted during the diagnostic process are reduced or eliminated. A positive o-ring test may also conrm that the treatment has achieved its purpose. As noted above, distinctions between steps two and three are often blurred, as their goals are similar, and sometimes one or the other is eliminated.

Treatment staging II: Supplemental (Branch) Treatment (Steps 4 & 5) Methods ! Manaka referred to his branch methods as symptom control; sometimes the

root treatment would provide sufcient relief, and further treatment would be

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unnecessary. In general though, the supplemental methods would be added to make a complete treatment. ! Manakas symptom control methods were too numerous to detail; some of his

more common methods will be mentioned here. Manaka often used what he termed an isophasal approach, selecting points that resonated with each other; often he would apply intradermals (hinaishin) on corresponding points on the body, hand and ear. For example, a Liver problem might warrant an intradermal on UB-18, on the corresponding UB-18 point on the hand (according to the Tae Woo Yoo system of Koryo Hand Acupuncture ), and on the Liver point of the ear (usually according to the Chinese map, though sometimes Nogier points would be used). More typical applications of Japanese techniques, such as direct moxibustion for specic symptoms, were often employed. In stubborn cases, Manaka might have used TCM points and methods in symptom control, or bloodletting; even scalp needling and barefoot doctor acupuncture were used on occasion. ! Step ve, nally, would concentrate on home therapy, whether exercise, diet or

home moxibustion or Hirata zone therapy . The patient would be given instructions on how to apply these therapies, sometimes with innovative variations, such as using a blow-dryer and cardboard shield in place of warming moxibustion. Another innovation is the use of Manakas wooden hammer and needle, which is also used as an alternative to the re needle in Step Three. Briey, the rounded tip of the wooden needle is placed against a relevant point and the needle is tapped lightly with the wooden hammer in time to a metronome. The metronome is set to specic speeds, determined by Manaka, which have an effect on various meridians. For example, a toothache could be treated

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by tapping LI-4 at 108 beats per minute, as that is the rate described by Manaka as affecting the Large Intestine meridian. In some cases, assistance is needed.

Conclusion ! In Japan, as we have seen, the denition of precisely which methods and models

constitute root treatment and which are purely symptomatic is largely dependent on ones personal ideas or on the ideology of the association one chooses to join. The denitions of the Toyo Hari Gakkai, and most of the Meridian Therapy associations, are rather narrow in scope; yet this does not hinder their ability to treat effectively, given the variety of methods used in supportive treatment (the applications of which continue to grow as these organizations strive to expand their research activities and their membership). The view of Manaka, as well as the organization he helped found, the Shinkyu Topology Gakkai (Acupuncture and Moxibustion Topology Association, a more scientically integrated organization than the traditional Meridian Therapy schools and one that includes other famous modern practitioners such as Miki Shima and Tadashi Iriye), is that the denition of root treatment is much broader and allows one to be quite creative in ones diagnosis and treatment. Yet the goals remain very similar: a holistic approach is generally applied before addressing specic complaints, and the energy of the body must be balanced properly before any real lasting results can be achieved. ! As interest in the myriad of Japanese styles grows in this country, the practice of

acupuncture will doubtless incorporate some of their key elements. Palpation, perhaps the most notable feature of Japanese diagnostic practices, will become more important, as will other non-verbal clues to the condition of the patient. Because the methods

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involved are so subtle, one must be able to increase ones perceptivity in the clinical context. ! Didactic approaches from Japan, such as the Toyo Hari associations Kozato

method, can lead to new ways in which to teach acupuncture in this country. The Japanese emphasis on hands-on training enables the student to feel the subtle differences in tissues and gain the tactile understanding crucial to effective point location, for example. Learning the methods of feedback can help to discriminate core issues in treatment and keep the therapy on track, instead of chasing symptoms. ! Mark Seem, in his book Acupuncture Imaging, notes ...the tremendous

importance of Kiiko Matsumotos own work in this country, as she tries to engage American practitioners in...a phenomenological approach...intervening in terms of the patients own present condition whether or not it ts some preconceived clinical syndrome or pattern...When a practitioner probes the patients body very carefully, showing that he knows where to palpate, this reinforces the patients own internal knowledge and awareness that her signs and symptoms are all connected to the same underlying imbalance... ! An understanding of Japanese methods is not only advantageous for the student

and educator; longtime professionals may gain new insights and benets as well. As the practice of acupuncture turns more towards complementary medicine (with consequent time constraints), more efcient methods of assessment may be needed; the empirical palpatory styles of Japan offer ways to rapidly combine assessment and treatment virtually at the same time. As a greater variety of people curious about acupuncture begin to seek treatment, the practitioner can only benet from cultivating

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approaches to adapt to those who are needle-phobic, or others for whom the more aggressive methods brought to us from the PRC are odious. ! As was noted earlier in this paper, the dizzying variety of approaches in Japan

have only recently (and thus incompletely) come to light in the U.S.; there exist many fascinating and potentially useful methods that have yet to be introduced here. Even approaches which have been fairly well exposed in the English-speaking world such as Meridian Therapy have many varying ways of diagnosis and treatment; for example, Bunkei Ono, Meridian Therapy master and founder of the association known as Toho Kai, has developed a variety of special techniques not found among those of other associations. Though famous in Japan, he is virtually unknown here. Of the various Meridian Therapy organizations, only the Toyo Hari Association, highlighted in this paper, is currently beginning to expand into the United States. Denmei Shudo has lectured in this country several times. It is through the work of Kiiko Matsumoto, her erstwhile writing partner Stephen Birch and his wife Junko Ida (both of whom studied with both Manaka and Fukushima), Shudo disciple and translator Stephen Brown and his colleague Junji Mizutani (who produce the North American Journal of Oriental Medicine, or NAJOM, an excellent publication highlighting mainly Japanese styles), Miki Shima, and others that more systems of diagnosis and treatment will be brought to the West. ! The practice of acupuncture in this country can only benet from further exposure

to these clinical methods. The Japanese emphasis on prioritizing treatment towards the holistic reintegration of the body processes rather than focusing on more symptomatic concerns may help acupuncture in the U.S. reach new levels, beyond the Oriental

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physical therapy cage in which many earnest practitioners nd themselves. Perhaps further scientic research will bring us closer to Manakas X-signal hypothesis, or a similar validation of the subtle, intangible effects of acupuncture and moxibustion that seem at once unprovable yet impossible to deny. What is certain, though, is that Japanese styles, with their respective Roots and Branches, are becoming more a part of Oriental Medicine in North America and will make their unique imprint on practitioners here as the art continues to evolve.

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Appendix I Point Selection for Standard Sho: Comparison of Meridian Therapy Founders

Sorei Yanagiya MRDN LIVER SPLEEN LUNG KIDNEY ! 1. HO LIV-8, K-10 SP-2, H-8 LU-9, SP-3 K-7, LU-8 2. SHA LIV-4, LU-8 LIV-1, SP-1 H-8, LU-10 SP-3, K-3

Yanagiyas point selection outlined here is identical to the four-needle technique

taught in most schools of acupuncture. Here the mother(representing the preceding phase on the engendering cycle) point of the affected meridian is combined with the same-phase point of the mother meridian to tonify the deciency. The controlling point (representing the controlling phase on the controlling or overacting cycle) of the affected meridian is combined with the same-phase point of the controlling meridian to disperse the relative excess. This pattern is uniform throughout the four Sho here.

Sodo Okabe

MRDN LIVER SPLEEN LUNG KIDNEY

1. HO LIV-8, K-10 ST-36, SP-2, H-7 LU-9, SP-3 K-7, LU-8, LU-5

2. SHA LU-5 LIV-1 H-7 SP-4, K-3

3. HO GB-43 SP-6, ST-41 ST-36, LI-11 UB-67

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Okabes logic is more complex. In the Liver Sho we see rst the standard four-

needle combination of LV-8 and K-10. This is followed by the son (representing the phase following an excess meridian on the engendering cycle) or dispersion point of the Lung meridian, which represents the controlling phase. Then, in the third step, GB-43, the mother point of the Gallbladder meridian (the YinYang paired meridian of the Liver), is tonied. This suggests that Okabe tended to think in terms of the phase as a whole being decient or excess. ! The second example, Spleen Sho, begins with tonication of ST-36, which is the

Earth point of the Yang Earth meridian (as well as a good overall tonication point), followed by a variation of the four-needle scheme. SP-2, the mother point, is tonied, along with HT-7; this latter point deviates from the standard four-needle plan in that it is the Earth point (in this case the son point, as well as the Source point) of the mother meridian rather than the same-phase (in this case Fire) point. This is followed by dispersion of the same-phase point of the controlling meridian, LV-1, a standard fourneedle application. The third step begins with SP-6, presumably as a general tonication of the Spleen, as it is without ve-phase association; as a crossing point for the Spleen and Liver channels, it could also be said to have a harmonizing effect on those two meridians (as well as the Kidney meridian, which also intersects there). This is followed by ST-41, the mother point for the Stomach meridian. Again, Okabes aim appears to be an overall tonication of the Earth Phase. ! The Lung Sho is a fairly standard application of four-needle technique, except

that, again, HT-7 is substituted for HT-8. Note also that the decient meridians themselves are not dispersed (e.g., LU-10 is not dispersed, as in the standard four-

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needle scheme), and the overall process is geared toward tonication. The third step again tonies the Yang paired meridians of the Lung and Spleen; LI-11 is the mother point, and ST-36 is preferred here over ST-41. ! Finally, the Kidney Sho begins with standard four-needle technique, except that

LU-5 is added (or perhaps substituted, the reference sources are not clear on whether all or just some of these points would be treated); the combination K-7 and LU-5 is a popular one in Meridian Therapy. The dispersion phase here is the only one of the four Sho to include a point on the decient meridian itself; the fact that it occurs in the Kidney Sho strikes this author as curious, as the Kidney is seen as always decient and never excess in Meridian Therapy. Finally, UB-67 is tonied; it is the mother point of the paired Yang channel.

Keiri Inoue

MRDN LIVER SPLEEN LUNG KIDNEY

1. HO LV-8, K-1 (LV-5, K-4) SP-2, P-7 (SP-4, P-6) LU-9, SP-5 (LU-7, SP-4) K-7, LU-5 (K-4, LU-7)

2. SHA ST-45, LI-11, LI-4 (ST-40, LI-6) UB-65, GB-43, GB-40 (UB-58, GB-37) GB-38, SI-3, TB-4 (GB-37, TB-5) SI-8, ST-41, ST-42 (SI-7, ST-40, H-3)

Inoues logic is even more sophisticated. He maintained that the Yin meridians

tended toward deciency, and as such should not be dispersed; while the Yang meridians tended toward excess, and as such should not be tonied. ! In the all of the Sho treatments here, he rst treats the mother point of the

affected meridian. Then he selects the point representing the phase of the decient

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meridian on the mother meridian itself (which coincides with the son point). Thus, in the Liver Sho, he pairs LV-8, the Water point on the Wood meridian, with K-1, the Wood point on the Water meridian. This pattern is consistent throughout the four Sho. One may note also the substitution of the Pericardium meridian for the Heart meridian in the Spleen Sho; this was to avoid treating the Heart directly. In addition , or as a substitution, he would treat the Luo-connecting point of the two meridians to further enhance the tonication process. This is also consistent throughout the four Sho here. ! It is the dispersion step that constitutes perhaps the most Byzantine aspect of

Inoues treatment strategy. It was perhaps through pulse patterns that Inoue decided that the Yang pairs of the controlling-cycle meridians were to be dispersed; this logic can also be found in Toyo Hari rules of treatment, for example . In any case, points on both the Yang paired meridian of the controlling as well as controlled cycle would be dispersed. As an example, decient Yin Wood requires dispersion of Yang Metal (controlling) and Yang Earth (controlled). ! Specically, in the Liver Sho, LI-11 (mother point of the controlling Yang meridian)

and LI-4 (Source point of the controlling Yang meridian) are dispersed; ST-45 (son point of the of the controlled Yang meridian) is dispersed as well. The Luo points may also be added to reinforce the dispersion. This same scheme is repeated in the Spleen Sho: GB-43 and GB-40 (mother point and Source point of the controlling Yang meridian) are dispersed, as is UB-65 (son point of the controlled Yang meridian). Similarly, the Kidney Sho: ST-41 and ST-42 (mother point and Source point of the controlling Yang meridian) are dispersed, as is SI-8 (son point of the controlled Yang meridian). The Lung Sho here differs slightly in that both the Yang Fire meridians (Small Intestine and Triple

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Burner) are dispersed, presumably to counter the overacting cycle. So, SI-3 (mother point of one of the controlling Yang meridians) and TB-4 (Source point of the other controlling Yang meridian) are dispersed, as is GB-38 (son point of the controlled Yang meridian). Again, the Luo points may be added or substituted.

Denmei Shudo

MRDN LIVER SPLEEN LUNG KIDNEY

!

1. HO LIV-8, K-10 SP-3, P-7 LU-9, SP-3 K-7, LU-5

2. SHA SP-3, SP-5; GB-37; UB-58 LIV-1; GB-37, GB-40, GB-43 LIV-1, LIV-2; GB-38; P-8, H-7; SI-4; LI-4; ST-40 SP-3, SP-4

Shudos point selections for tonication here are common in Meridian Therapy.

The Liver Sho and Lung Sho follow standard four-needle formulae. The Kidney Sho is the same as that of the Inoue example. The Spleen Sho is a common adaptation of the four-needle technique: Earth points are used to avoid indirectly tonifying the Fire phase, and the Pericardium is used in place of the Heart, as in the Inoue example. ! The dispersion points are not all treated; rather, Shudo explains, these are the

most likely points to be dispersed in each particular Sho. In reality, Shudo would usually disperse points according to the presence of tenderness or induration. In some cases, for example in the Spleen Sho, points on the Gallbladder meridian (such as GB-37, GB-40 or GB-43) may be tonied to control the excess of the Liver, if one does not wish to directly disperse Yin meridians.

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Appendix II Comparative Symptomology of Extraordinary Vessels REN MAI Manaka: Gynecological problems; hemorrhoids; asthma; bronchitis; lung problems; neurosis; toothache; ear, nose and throat problems. Nagatomo: Emphysema; catarrh; asthma; lower abdominal diseases; skin diseases. Bachmann: Respiratory tract diseases; lower abdominal diseases; diabetes; eczema; tumor. Fukushima: (with Yinqiao; Nin/In-kyo) Symptoms along the courses of the meridians; tooth and gum pain in the front of the mouth; coughing; asthma; 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; general gynecological disorders; birthing difculties; special circulatory problems particular to women; nervous disorders; hemorrhoids; anal prolapse; cold or hot feet; kidney diseases; general lack of vigor. Shanghai CTCM: Pathological symptoms of the Yin channels, especially Liver and Kidneys; uterine disorders; infertility; urogenital disorders; leukorrhea; irregular menses; colic. Feit/Zmiewski: (repletion) menstrual disorders; vaginal discharges; male urogenital disorders; head and neck pain; abdominal distension and pain; mouth and tongue abscesses. (depletion) pruritis; heaviness of loins and lumbar area; shan qi pain.

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REN MAI (palpation) Fukushima: ...can be thought of as the Lung Meridian. Its diagnostic points vary greatly with the type of illness involved and must therefore be located by applying pressure to points along the entire meridian. Manaka: Pressure pain or reaction may be found on: the whole length of the Ren Mai from CV-1 to CV-22; in particular, below and above the umbilicus, with a band of tension on the midline above the umbilicus; Lung meridian, especially LU-1 and LU-7.

YINQIAO MAI Manaka: Urinary problems; gynecological problems; cold feet; intestinal problems. Nagatomo: Peritonitis; hepatitis; nephritis (related to hypoxia or acidosis). Bachmann: Insomnia; chronic pharyngitis; intestinal poisoning; jaundice; menstrual cramps; uterine bleeding; late labor; leukorrhea; prostatitis; impotence; bladder spasms; constipation. Fukushima: (see Ren Mai) Shanghai CTCM: Eye diseases; tightness and spasms along medial leg muscles with accidity of lateral leg muscles; lower abdominal pain; pain along the waist to the genitals; hernia; leukorrhagia. Feit/Zmiewski: (repletion) General weakness of Yang organs and functions with corresponding tension of Yin organs and functions; aggravations that worsen at midday and improve in the evening or are worst at sunrise; migraines; congestive headaches; tightness and spasms along medial leg muscles with accidity of lateral leg muscles; diurnal epileptic seizures; watery eyes; heavy sensation of eyelids or inability to open

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eyes; hypersomnia. (depletion) Aggravations during the night; nocturnal headaches, cramps or convulsions; insomnia.

YINQIAO MAI (palpation) Fukushima: ...can be thought of as the Kidney meridian. Its diagnostic points are JinGei (ST-9), KetsuBon (ST-12), KoShin (K-8), ShoKai (K-6) and NenKoku (K-2). Manaka: Pressure pain or reaction may be found on: the Ren Mai, particularly when 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, K-16, GB-29 (ASIS), K-11, CV-2; ST-12; ST-9; Kidney meridian between ST-12 and K-8, especially K-8; K-6 and K-3.

DU MAI Manaka: Epilepsy; fatigue; spine and neck problems; neurosis; insomnia; supercial invasion of e.p.f. (Taiyang syndrome). Nagatomo: Rheumatic arthritis of the spine; inammation of the joints; neuralgia; head and neck pain; emotional problems. Bachmann: Rheumatic arthritis of the spine; inammation of the joints; neuralgia; head and neck pain; emotional problems; overexcitement; nervous breakdown; lack of concentration; insomnia; melancholia; lethargy; epilepsy. Fukushima: (with Yangqiao; Toku/Yo-kyo) 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

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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; Taiyang disorders such as headaches, chills, anhidrosis, and systemic pain; Yang Kyo: fatigue, spontaneous sweating, night sweats; Alzheimers disease; lack of mental clarity; hemorrhoids; epilepsy. Shanghai CTCM: Stiffness and pain along the spine (obstructed Qi); heavy sensation in the head, vertigo, shaking (decient Qi in the channel); mental disorders (Wind in the channel); febrile diseases; Qi of the channel rushing upward to the Heart produces colic, constipation, enuresis, hemorrhoids, functional infertility. Feit/Zmiewski: (repletion) Opisthotonos; back pain; stiffness of the spine; headaches; hallucinations; jing-shen disorders; eye pains; hyperexcitability; seizures. (depletion) Head slumping forward; walking with rounded shoulders; lack of physical and mental strength; weak personality; hemorrhoids; sterility; impotence.

DU MAI (palpation) Fukushima: ...Can be thought of as the Small Intestine Meridian. Its diagnostic points vary greatly with the type of illness involved and must therefore be located by applying pressure to points along the entire meridian. Manaka: Pressure pain or reaction on: the Du Mai from GV-1 to GV-20, particularly the upper back and GV-3, GV-4 and GV-20; the Small Intestine meridian, especially SI-3.

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YANGQIAO MAI Manaka: Whiplash; epilepsy; speech disorders; shoulder pain; lumbar pain; unusual sweating; trigeminal neuralgia. Nagatomo: Any bleeding problem; stroke; hemiplegia. Bachmann: Any skin bleeding disorder; edema; swelling; CVA; hemiplegia; tinnitus. Fukushima: (see Du Mai) Shanghai CTCM: Eye diseases; tightness and spasms along lateral leg muscles with accidity of medial leg muscles; lumbar pain and stiffness. Feit/Zmiewski: (repletion) General weakness of Yin organs and functions with corresponding tension of Yang organs and functions; aggravations at the end of the day and at night; nocturnal congestions, pains or crises; tightness and spasms along lateral leg muscles with accidity of medial leg muscles; nocturnal epileptic seizures; dry or itchy eyes; restless sleep or insomnia. (depletion) Aggravations during the day that improve at night; fatigue, lassitude or weakness during the day.

YANGQIAO MAI (palpation) Fukushima: ...can be thought of as the Bladder meridian. Its diagnostic points are FuBun (UB-41), KoKo (UB-43), IChu (UB-40), ShoZan(UB-57), FuYo (ST-19), and BokuShin (UB-61). Manaka: Pressure pain or reaction may be found on: ASIS; alongside the cervical vertebrae; around SI-9 and SI-10; K-11; the Bladder meridian, especially between GB-29 and UB-36; UB-62; GB-21.

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CHONG MAI Manaka: Heart problems; neurosis; stomach problems; gynecological problems; cold feet; liver/gallbladder problems; problems of anus. Nagatomo: Painful diseases of the abdomen or chest; non-xed rheumatic symptoms. Bachmann: Pain that moves; late menses causing suffering of the heart and palpitations that lead to insomnia; intestinal spasms. Fukushima: (with Yinwei; Sho/In-i) Symptoms along the course of the meridian; swollen and sore throat; chest or heart pain or discomfort; epigastric pain; general pain; abdominal distension or pain; pain, cramping, palpitations or upward ushes on the sides of the abdomen (Spleen) or around the umbilicus (Kidney); nausea or vomiting; diarrhea; constipation; bleeding afliated with the stomach, kidneys or large intestine; gynecological diseases; endocrine disorders; menopausal ailments; hemorrhoids. Shanghai CTCM: Gynecological disorders; male sexual disorders including impotence; abdominal pain; colic. Feit/Zmiewski: (repletion) Weakness of abdominal organs; menstrual block or irregularity; ! insufcient lactation; nervous or motor atony; impotence. (depletion) Lower abdominal spasms or pain; prosatitis; urethritis; orchitis; seminal emission; metrorrhagia, menorrhagia; hematemesis.

CHONG MAI (palpation) Fukushima: ...thought of as the Spleen meridian in the legs and feet and the Kidney meridian in the chest and abdomen. Diagnostic points are KiSha (ST-11), KoYu (K16), SanInKyo (SP-6) and KoSon (SP-4).

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Manaka: Pressure pain or reaction may be found on: K-16 and around the umbilicus; ST-11; the Spleen meridian between ST-11(sic) and SP-6, particularly SP-6 and SP-4; ST-30; K-1.

YINWEI MAI Manaka: Nervousness; heart problems; palpitations; psychological problems; insomnia; stomach problems. Nagatomo: Symptoms similar to those of the Chong Mai, but with less emphasis on pain; palpitations; difculty breathing; phobias. Bachmann: Symptoms similar to those of the Chong Mai, but with less emphasis on pain; weakness in the heart; palpitations from fear; phobias; 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. Fukushima: (see Chong Mai) Shanghai CTCM: (not listed) Feit/Zmiewski: (repletion) All deep pulses stronger than supercial ones; repletion of thoracic organs; heart pains; hypertension; delirium; nightmares; thoracic oppression; dyspnea; (with external depletion) weakness of homolateral shoulder, upper arm and hand, and contralateral lower extremity. (depletion) All deep pulses weaker than supercial ones; depletion of thoracic organs; timidity or fear; apprehension; nervous laughter; emotional depression; hypotension; weak respiration. (with external repletion)

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pain in homolateral anterior shoulder, upper arm and hand, and contralateral lower extremity.

YINWEI MAI (palpation) Fukushima: ...can be thought of as the Heart Constrictor (Pericardium) meridian. Its diagnostic points are TenTotsu (CV-22), KiMon (LIV-14), FukuAi (SP-16), DaiO (SP15), FuSha(SP-13) and ChikuHin (K-9). Manaka: Pressure pain or reaction may be found on: subcostal regions; CV-22; the Pericardium meridian in general, PC-6 in particular; the Kidney meridian from CV-22 to K9, particularly the abdomen and K-9; the areas from SP-13 to SP-15.

DAI MAI Manaka: Coldness or achiness in lower back; gynecological problems; menstrual problems; problems in lower abdomen. Nagatomo: Any joint pain; neuralgia; menstrual pain; toothache. Bachmann: Rheumatic arthritis or neuralgia of the joints, toes, ngers, shoulders, elbows, wrists, hips knees, ankles; muscular pain of the neck, head, and general muscle pain; menstrual pain or gum pain associated with weakness or fatigue. Fukushima: (with Yangwei; Tai/Yo-i) Symptoms along the course of the meridian; headache accompanied by edema; general eye and ear afictions; trigeminal neuralgia; tooth and gum pain in the sides of the mouth; dizziness; Menieres syndrome; spontaneous sweating; night sweating; alternating chills and fever; liver and gallbladder

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disorders; distension of the ribs and lower abdomen; general pain; coldness and pain in the lower back; irregular menses; abnormal vaginal discharge. Shanghai CTCM: Fullness in the abdomen; irregular menstruation; leukorrhea; lumbar pain; weakness and motor impairment of the lower limb. Feit/Zmiewski: (repletion) Supercial repletion of Yang channels; lumbar and loin pain; pain in lower extremities; weakness of shoulders and upper extremities on opposite side; weakness of opposite eye, breast or ovary. (depletion) Cold or heaviness or weakness in lumbar and loins; white vaginal discharge; uterine prolapse; abdominal distension; pain and inammation in opposite shoulder, upper extremity, eye, breast or ovary.

DAI MAI (palpation) Fukushima: ...can be thought of as the Gall Bladder meridian. Its diagnostic points are ShoMon (LIV-13), TaiMyaku (GB-26), GoSu (GB-27), YuiDo (GB-28) and KyoRyo (GB-29). Manaka: Pressure pain or reaction may be found on: K-16 or around the umbilicus in general; the Dai mai, including LIV-13, ST-25, GB-26, GB-27, GB-28 and GB-29; Gallbladder meridian, particularly GB-41; UB-23.

YANGWEI MAI Manaka: Dizziness; headache; whiplash; sweating problems; trigeminal neuralgia; fatigue; eye and ear problems.

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Nagatomo: Mainly any pain on one side of the body (e.g. migraine, neck pain); joint inammation; symptoms similar to Dai Mai but more Yang in nature (inammation, etc.). Bachmann: Headache; joint inammation; migraine; neck pain; gingivitis; writers cramp; eye tick; retinitis; poor circulation; hypotension; rapid pulse; arteritis; blepharitis (swelling along eyelid); oversensitivity to seasonal change; thrombosis; skin inammation; eczema; pimples; skin swelling; irregular breathing; hemoptysis; epistaxis; stuttering; ankle sprain; bedwetting; heartburn. Fukushima: (see Dai Mai) Shanghai CTCM: Chills and fever; vertigo; muscular fatigue, stiffness and pain; pain and distension in the waist. Feit/Zmiewski: (repletion) General repletion of all Yang channels; fever; headaches with heat symptoms; symptoms that worsen with violent weather such as thunderstorms; pains or skin problems during weather changes; articular pains, especially in wrists and ankles; mumps; diarrhea. (depletion) General lack of body heat; loss of energy and physical strength, especially during snowy or rainy weather.

YANGWEI MAI (palpation) Fukushima: ...can be thought of as the Triple Heater meridian. Its diagnostic points are KenSei (GB-21), TenRyo (TB-15), KyoRyo (GB-29), YoRyoSen (GB-34), and YoKo (GB-35). Manaka: Pressure pain or reaction may be found on: ASIS; TB-5; the Gallbladder meridian between GB-29 and GB-21; GB-34 and GB-35.

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Additional Toyo Hari KiKei Combinations (NOTE: In addition to the classic Extraordinary Vessel combinations, the Toyo Hari Gakkai has added two point combinations to it s Extraordinary Vessel treatments: LI-4 is combined with ST-43, and HT-5 is combined with LV-3. Occasionally LV-3 will be combined with HT-7 or PC-6, depending on specic symptoms.)

GOKOKU / KANKOKU (LI-4/ST-43) Symptomology: Symptoms along the course of the meridians; growths and abcesses on the face, neck, arms or back; stye or pinkeye; inammation 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 afliated with the Large Intestine meridian. Its diagnostic points are GoKoku(LI-4), OnRu (LI-7), KenGu (LI-15), TenTei (LI-17) and GeiKo (LI-20). KanKoku point is afliated with the Stomach meridian. Its diagnostic points are KanKoku (ST-43), ShoKyu (ST-1), ShiHaku (ST-2), KetsuBon (ST-12), TenSu (ST-25) and Ashi SanRi (ST-36).

TAISHO / TSURI (LV-3/H-5) Symptomology: Symptoms along the course of the meridians; vertigo; Alzheimers disease; emotional disorders; eye afictions; disorders of the endocrine system; thoracic or ank pain and distension; muscle cramping; sweling; coldness; lack of motivation.

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Palpation: TaiSho point is afliated with the Liver meridian. Its diagnostic points are Taisho (LV-3), ReiKo(LV-5), KyokuSen (LV-8), and KiMon (LV-14). TsuRi point is afliated with theHeart meridian. Its diagnostic points are TsuRi (H-5), ShimMon (H-7), ReiDo (H-4), and KyokuSen (H-1).

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Bibliography Acupuncture Texts Fukushima, Kodo. Meridian Therapy, A Hands-on Text on Traditional Japanese Hari ! Based on Pulse Diagnosis, Toyo Hari Medical Association, Tokyo, 1991

Hashimoto, Keizo, with Yoshiaki Kawakami. Sotai, Balance and Health Through Natural ! ! ! ! Movement, translated by Stephen Brown and Richard Held, Japan Publications, Tokyo, 1983

Johnson, Larry. Magnetic Healing and Meditation, White Elephant Monastery, San ! ! Francisco, 1988

Li Shi-Zhen. Pulse Diagnosis (Bin Hu Mai Xue), translated by Hoc Ku Huynh and G.M. ! ! Seifert, Paradigm Publications, Brookline, Mass., 1985

Liu, Bing Quan. Optimum Time for Acupuncture, Shandong Science and Technology ! ! Press, Jinan, PRC, 1988.

Manaka, Yoshio, and Ian Urquhart. The Laymans Guide to Acupuncture, Weatherhill, ! ! New York/Tokyo 1972

Manaka, Yoshio, with Kazuko Itaya and Stephen Birch. Chasing The Dragons Tail, ! ! Paradigm Publications, Brookline, Mass., 1995

Matsumoto, Kiiko, and Stephen Birch. Five Elements, Ten Stems, Paradigm ! ! Publications, Brookline, Mass., 1983

----. Extraordinary Vessels, Paradigm Publications, Brookline, Mass., 1986 ----. Hara Diagnosis; Reections on the Sea , Paradigm Publications, Brookline, Mass., ! ! 1988

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Omura, Yoshiaki. Acupuncture Medicine, Its Historical and Clinical Background, Japan ! ! Publications, Tokyo, 1982.

Seem, Mark. Acupuncture Imaging, Perceiving the Energy Pathways of the Body, ! ! Healing Arts Press, Rochester, VT, 1990.

----. A New American Acupuncture, Acupuncture Osteopathy, The Myofascial Release ! ! of the Bodyminds Holding Patterns, Blue Poppy Press, Boulder, CO, 1993

Shanghai CTCM. Acupuncture, a Comprehensive Text, translated by John OConnor ! ! and Dan Bensky, Eastland Press, Seattle,1981

Shudo, Denmei. Japanese Classical Acupuncture, Introduction to Meridian Therapy, ! ! translated by Stephen Brown, Eastland Press, Seattle, 1990

Unschuld, Paul. Medicine in China, A History of Ideas, University of California Press, ! ! Berkeley, 1985

---. Medicine in China: Nan Jing, The Classic of Difcult Issues, University of California ! ! Press, Berkeley, 1986

Veith, Ilza. The Yellow Emperors Classic of Internal Medicine (Revised Edition), ! ! University of California Press, Berkeley, 1966

Wu, Jing-Nuan. Ling Shu; the Miraculous Pivot, Taoist Center, Washington D.C./ ! ! University of Hawaii Press, Honolulu, 1993

Yoo, Tae Woo. Koryo Sooji Chim: Koryo Hand Acupuncture vol 1, Eum Yang Mek Jin ! ! Publishing Company, Seoul, 1988.

Zmiewski, Paul, and Richard Feit. Acumoxa Therapy, A Reference and Study Guide, ! ! Volume 1, Paradigm Publications, Brookline, Mass., 1989

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Papers Birch, Stephen. Dr. Manakas Yin-Yang Balancing Treatment (Parts 2 & 3), North ! ! ! ! American Journal of Oriental Medicine, Vol. 2, No. 3, March 1995, p 4-6; Vol. 2, No. 4, July 1995, p 5-7

Kuwahara, Koei. If You Dont Try to Fix it, it Fixes Itself North American Journal of ! ! Oriental Medicine, Vol. 2, No. 5, November 1995, p 22-25

Manaka, Yoshio. Japanese and Chinese Acupuncture: Similarities and Differences, ! ! ! ! North American Journal of Oriental Medicine, Vol. 1, No. 2, November 1994, p 5-9

Nakada, Koryo. Basic Needling Techniques of Toyo Hari North American Journal of ! ! Oriental Medicine, Vol. 2, No. 4, July 1995, p 24-26

Romano, Augusto. Toward your own style of acupuncture, American Journal of ! ! Acupuncture, Vol. 20, No. 2, 1992

Shima, Miki. Looking Forward, North American Journal of Oriental Medicine, Vol. 2, ! ! No. 5, November 1995, p 5

Van der Poorten, Nancy. A Visit by Dr. Iriye to Toronto, North American Journal of ! ! Oriental Medicine, Vol. 2, No. 5, November 1995, p 35

Other Sources Shima, Miki. JAAF Video Series: Mysteries of the Needle, Japanese American ! ! Acupuncture !Foundation, Corte Madera, CA, 1992

Stephen Birch lecture at AAAOM convention, Austin, TX, 1990 (unpublished audio tape)

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Lecture notes and private conversations during the course of authors Toyo Hari ! ! ! ! ! ! training, 1995-96 (Lectures by and conversations with Akihiro Takai, Toshio Yanagishita, Shozo Takahashi, Koryo Nakada, Koei Kuahara, Stephen Birch, Junko Ida)

Private interviews with Stephen Brown, L.Ac., Augusto Romano, L. Ac., and David ! ! ! Fuselier, L.Ac., by the author

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