Moxibustion Articles and the ST36 Meridian Point

 Leg Three Miles (Stomach 36)

The Household Physician

Taking a bath the Tibetan way

Location: On the front of the leg, one hand width (four fingers) below the kneecap, on the outside, in the depression between the shinbone and the leg muscle. What can go wrong is that you may be locating it somewhat too low on the leg. The point is immediately one hand breadth below the kneecap, so if you'd use something thick, like a finger, you might get half a finger breadth to low. It's at the outside of the bone that's on the front of the lower leg, one finger breadth from the crest of that bone.

Use: Press. A fingernail or thumbnail is particularly suited for this point, as you will be able to press more closely to the bone and on a broad range.
Warning: Using this point to go beyond your limits (e.g. overwork) will damage your health even further.

Effects: Increases stamina and energy. Provides stability and grounding. Heals effects on the body of too much worrying and thinking.

Maximum Oxygen Uptake AND ST 36

Translation: Shinjiro Kanazawa, L.Ac., MTOM

Health maintenance, "preventing illness before it shows its symptom" is the core idea in acupuncture and moxibustion theory. Clearly, ancient people had a concept of that stage of illness that comes before illness shows its symptom, and they believed it best to treat illnesses at this stage. This stage is called, in Chinese, "Mi Bing," and in Japanese "Mi Byo," which means "before illness."

"Mi Bing" is closely related to the idea of longevity and moxibustion on the acupuncture point St 36 (stomach 36: Zu San Li in Chinese, Ashi-no-san-ri in Japanese). A Japanese folk tale from the Edo era (1603-1867) about Farmer Manpei tells that when Manpei was asked whether he had any secret to maintaining long life, he answered that he had no secret other than burning moxa on St 36 every day, just as his ancestors had done. It is recorded that Manpei lived 243 years; his wife, Taku, lived 242 and their son, Mankichi, lived 196 years. In recent records, it is well known that Doctor Shimetaro Hara (deceased) used to burn moxa on his St 36 every day and he lived to be over 100 years of age.

A story about St 36 which is very familiar to the Japanese is the first sentence of Haiku Master Basho Matsuo's diary (1689) "Okuno Hosomichi (Narrow Passages In The Back Country)." He writes, "I have sewn a torn part of my undergarments. I have changed the strings of my hat. I have burnt moxa on my St 36. My mind is now totally occupied with the moon over the Matsushima islands..." He was ready for a long walk of 1,500 miles after burning moxa on St 36. This means that our ancestors knew very well that moxibustion on St 36 has the effect of speeding recovery from fatigue.

We studied the effect of stimulation on St 36 in our laboratory by creating a fixed quantity of lower leg fatigue and observing recovery by measuring the successive changes in carbon dioxide partial pressure through the skin. As a result, we found that stimulation on St 36 speeded recovery from fatigue. We presume that the factor of speeding up recovery might be the improvement of the minute circulation of the blood.

Here, I would like to introduce one of my cases that showed an extreme improvement in minute circulation. This was a case of intermittent claudication. The male patient was given an angiogram, which revealed right occluded arteriosclerosis. I could not detect the digital plethysmogram of the right lower leg. The balloon catheter was not attempted to expand his clogged vessel. Prostaglandin and other medications which have strong vasodilation effects were ineffective. In this case, he had intermittent claudication every 50 m (150 ft) when walking. I stimulated his St 36 by injecting physiologic saline subcutaneously every week and he extended his walking distance little by little until finally he could walk without any pain. I did the angiogram again and found the vessel still clogged. This means that even when the large vessel of the lower leg was clogged, needed oxygen for walking was sufficiently supplied. Successive stimulation treatments on St 36 enhanced the development of minute circulation of blood in the lower leg.

Minute circulation of blood is one of the normal factors of Maximum Oxygen Uptake. There is a possibility that stimulating St 36 increases Maximum Oxygen Uptake.It is known that increased Maximum Oxygen Uptake prevents and improves recovery time from diseases caused by lifestyle, such as hypertension and diabetes. Maximumu Oxygen Uptake also decreases the cancer rate. Thus, we could assume that the modern idea of maintaining health by increasing Maximumu Oxygen Uptake is based on the same mechanism as our traditional wisdom for attaining longevity by stimulating St 36.

We could also assume that moxibustion on St 36 has an effect on maintenance and improvement of health in the modern sense, but this has already been proven by the monk Kenko Yoshida, around 1330, who says "If people over 40 years of age do not practice moxibustion on their bodies by burning St 36, they will get flushing (uprising Qi). They should get moxibustion without fail." He pointed out that moxibustion on St 36 is necessary for the maintenance and improvement of health for the person over 40 years of age.

Increasing Maximumu Oxygen Uptake through exercise therapy is a policy of the Japanese government, and it is a modern way of "preventing disease before it shows its symptom." It is essential to remember that the intensity, amount and duration of exercise has to be adequate. In the premodern era, people had to walk, having few or no other means of transportation. In those days life itself provided the amount of exercise that modern exercise therapy suggests people should have. So then, where did our ancestors get the idea that burning moxa on St 36 would "prevent disease before it shows its symptom"?

We find the answer in the idea of meridians, which is the basis of the theory of acupuncture and moxibustion. According to this idea, St 36 is located on the network called the Stomach Meridian, and stimulation on St 36 not only stimulates the point but also the entire meridian and stomach organ. According to this classic medical theory, the organ and meridian of the stomach are a part of the foundation of our life energy. Thus, stimulation on St 36 not only affects the leg where St 36 is located, but also affects the health of the whole body.

Moxibustion (Moxa + combustion) is a heat application treatment on the acupuncture points with the use of a herb called "Moxa".
In moxibustion, usually a grain-size cone of moxa or dry yellow spongy substance made from a herbal plant "mugwort " is placed on the acupoints and lit with an incense stick. The burning moxa is then pinched out or taken away by the therapist before it burns down completely to the skin. The patient experiences a very comfortable sensation of heat that penetrates deep into the skin (Direct moxibustion). Another popular way of using moxa is to burn a moxa cone on the head of inserted acupuncture needles, or use a cigar-type stick moxa to warm the acupuncture points at a distance (Indirect moxibustion). Because of the difference of quality and processing of moxa between Japan and China, Japanese acupuncturists in general prefer direct moxibustion while Chinese therapists do indirect moxibustion, especially stick moxa. It requires a great deal of training for a therapist to master the direct moxibustion techniques, but it is much more effective than indirect moxibustion.


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Moxibustion in general has more or less the same efficacy as acupuncture. However, medical experiments have shown that moxibustion exerts much wider and stronger effect on overall biochemical changes in the body than acupuncture. For example:

(1) It increases the production of white blood cells. The white blood cell count begins to increase immediately after direct moxibustion, and reaches a peak 8 hours later. This peak is maintained for 24 hours. The number remains elevated for four or five days after treatment. The white blood cell count almost doubles with moxibustion, but when applied continuously for six weeks, the increase is sustained for up to even three months after moxibustion is discontinued.

(2) It increases the produciton of red blood cells and haemoglobin. For subjects who had an average haemoglobin ratio of 78% just before direct moxibustion, the ratio increased steadily to reach a peak of 90% in eight weeks. Applying direct moxibustion continuously for 15 weeks, it takes 22 weeks for the red blood cell count to return to what it used to be before moxibustion. It also shows a substantial increase in the following blood components: the sedimentation rate of red blood cells, platelet count, the speed of blood coagulation, blood calcium, blood glucose count and the capacity to produce antibodies.

(3) It improves the overall blood and lymph circulations. Due to rather intense heat of burning moxa on acupoints, impulses from nerve endings of the skin cause the dilation of capillaries
( the smallest vessels) to increase the blood and lymph circulations in the entire body. In fact it is well known that the patient feels very warm, relaxed and sleepy from this effect after moxibustion treatment. People who suffer from constant circulation or "cold feeling" in the hands and feet can greatly benefit from moxibustion.

(4) It is more effective for internal chronic ailments than acupuncture. Because of stronger effects on the overall biochemical changes, especially in blood components and immune system, moxibustion is much more effective for various chronic diseases of internal organs. From my clinical experiences of over 25 years, I can say that acupuncture can be a better choice for the treatment of rather acute cases or when the ailment is still in early stage.

(5) It is a safer treatment than acupuncture and can be used as a home therapy.

Both acupuncture and moxibustion must be practiced by licensed medical professionals. However, since moxibustion is a much safer method than acupuncture, it has been widely used as a very handy and effective folk remedy for centuries in Asia. Especially in Japan, various new types of moxa for home treatment are available on the market now. You can use moxa not only for the treatment of specific ailments but also for continuously maintaining good health.


Moxibustion, or Moxa for short, is an ancient form of heat therapy. Moxa uses the ground up leaves of the plant Mugwort (Artemesia vulgaris). These are either rolled into sticks for indirect moxa, or the powdery substance is made into tiny cones and burned on ointment or a ginger slice. That is called direct moxa. In Chinese, the term for acupuncture is "Zhen Jiu." The "Zhen" means "needle," and the "Jiu" means "moxa." Thus, acupuncture and moxibustion have been paired therapies for hundreds of years.When the needles are in the body, the indirect moxa heats them, and the metal conducts the heat down into the muscles, where it is most needed. However, moxa can be effective by itself, and is an inexpensive form of home therapy for many types of pain, such as sore joints or menstrual cramps.

Burning moxa has a distinct odor, which some people find relaxing. Some people with severe sensitivities to smoke may not be able to tolerate moxa. The essential oils in moxa have a significant effect, as a type of aromatherapy or medicinal incense. All over the world, mugwort has had a good reputation as a plant that keeps evil away. In European folk tradition, mugwort was put into dream pillows to keep bad dreams away. The 'sagebrush' of the west is mostly Artemisia tridentata, closer to mugwort than to sage.

During indirect moxa, the smoldering moxa stick is held a couple inches away from the skin, usually around the inserted needles. The practitioner will monitor the heat level, and work with the patient to provide a therapeutic level of heat while maintaining comfort and safety.

One of the most interesting moxa techniques is for extreme cases of diarrhea. For this, the acupuncturist puts salt in the navel of the supine patient, and puts a cone of direct moxa on top of this. The salt protects the skin and conducts the heat well. This technique is very effective; it seems to regulate the large intestine's resorption of water immediately.

Moxibustion takes skill and caution. It is equivalent to holding a red-hot coal an inch above someone's skin. One needs to exhibit great care when removing the ashes from the end of the stick--if too much force is used while tapping the stick into an ashtray, the "cherry" of the moxa stick may become loose and fall out. Depending on the moxa technique, one may want to let the heat build up as much as the patient can tolerate. When the body's pain threshold is reached, this sends a signal to the body to send more attention to the area being treated: anti-inflammatory compounds, white blood cells, endorphins, etc. I often say that with acupuncture and moxa, we're just trying to encourage the body to prioritize its healing attention on an area it's been ignoring. In some traditions of moxibustion, blistering or scarring was intentionally induced. While that's still used in some areas, it's fortunately uncommon in America. I once treated a Zen Buddhist monk from Japan who had moxa scars all up and down his back. He still complained of back pain, so the scarring moxa wasn't a complete cure.

Gentle moxa is also effective. One of the most famous preventative moxa therapies is to do indirect moxibustion on Zu San Li (Stomach 36), a point on the lower leg. Zu San Li means "Foot Three Miles" and increases endurance, digestive power, and stimulates the immune system.

I use indirect moxa almost daily in the clinic. Most of my patients love it, as the focussed heat feels wonderful on an area which has been tight, in pain, and lacking circulation for some time. I most commonly use moxa on the lower back, sacrum, shoulders, trapezius, and knees.

With some training and much caution, moxa can be an effective home therapy for joint and muscle pain. Improperly handled moxa can lead to burns or pain, so please seek personal instruction before using moxa at home.

Moxa should not be used on diabetics, as they have reduced heat tolerance and skin weakness. Moxa has been shown effective at turning a breech baby using the BL-67 point. Moxa could bring on labor, so extreme care should be taken when using this technique.

Why do Acupuncture treatments relieve Chemotherapy induced nausea?

Acupuncture, as a branch of TCM (Traditional Chinese Medicine) is uniquely suited to counteracting nausea of all kinds, including morning sickness and chemotherapy-induced nausea, because nausea is seen as a symptom of qi moving in the wrong direction.

Qi—often loosely referred to as energy, or life force, or vital force, and these are part of qi but not its sum total, as it is a moment in time when energy becomes matter, and therefore a process rather than a measurable substance—has various natural means of movement in the environment and in our bodies. When qi moves smoothly through the body, health is balanced, and a person is free of pain. However, when qi begins to be blocked in its smooth movement, it moves in different directions—nausea is referred to as "rebellious stomach qi" because the stomach qi is naturally supposed to move downward (the path of digesting food).

With chemotherapy, from a TCM perspective, the patient is consuming drugs that are classified as energetically cold. This makess sense from a TCM perspective because cancer is classified as blood heat toxin—in other words, the patient's own body has created a mass (tumor) from blood heat that has reached an extreme (toxic) level. This idea of toxin, by the way, is different than that of the natural health movement. While environmental toxins may contribute to many health problems, a balanced body can move through whatever the environment brings it with health. The Chinese recognized that a longstanding inbalance in the body could create a tumor. So to use energetically cold drugs to counteract this heat makes sense.

However, the stomach is susceptible to cold—simpler ways people can make themselves nauseated by accident is eating too many cold foods too fast (a child getting sick off of ice cream, for example). So nausea as a result of chemotherapy points the acupuncturist to two things: open the pathways that the qi is flowing 'backwards' (rebelling) so that it moves down, tonify (support) the stomach, and if the patient normally complains of cold symptoms (getting chilled easily, cold hands and feet, etc.) warm them.

The main acupuncture points to open the extraordinary meridian that courses up the midline of the body and branches out across the chest, the Chong Mai (penetrating meridian) are Pericardium 6 (located two proporational inches up from the wrist between the tendons, over the median nerve—the median nerve is NOT to be stimulated by the needle, this creates hand numbness) and Spleen 4 (located just inferior to the head of the first metatarsal bone of the foot, along the arch of the foot).

A secondary point, which also has the effect of relieving fatigue, stimulating appetite, and strengthening the immune system is Stomach 36, in the space just lateral to the tibial crest, below the head of the tibia, below the knee. The chinese name, zusanli, means "three more miles" indicating that the point was recognized as essential to producing endurance. It supports the immune system function because it helps the body to make both qi and blood from the food (our primary source of both things throughout life).

Moxibustion (the burning of stick or cone moxa, made from mugwort/artemisia vulgaris and possibly wormwood/artemisia absinthum and sage/salvia) is a technique that warms the body and relieves pain. It can be burned over Stomach 36, or over other points, such as on the abdomen or low back, to add to the warming of the patient's entire body.

Finally, since the acupuncturist treats the entire patient, they treat the body in question, chemotherapy and all. Other points may be selected in addition to these important anti-nausea points to address the patient's constitutional imbalances (a general tendency to fatigue, or to stress, or concurrent menopause, etc.). Pain can also be treated. Dietary recommendations may be offered to deal with nausea (adding ginger in all forms to the diet, since it relieves nausea also; adding cooked rice, which is an easily assimilated food, and so on).

While the patient may not in all cases be entirely free of nausea the day of or after chemotherapy, the severity of the nausa will be drastically reduced, the recovery time will be shortened, and the appetite will be maintaned (so that a patient doesn't begin skipping meals as a result). Fatigue will be relieved, which also improves the patient's general sense of well-being and promotes optimism about their course of treatment with chemotherapy.

 by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

   Zusanli is one of the most frequently used of all acupuncture points and is certainly the most intensively studied single point treatment in acumoxa therapy.  The
indications for use of this acupuncture point are many, and the claimed benefits are substantial.  Many proposals for acupuncture research in the West rely upon
complex treatment protocols involving several acupuncture points; single-point acupuncture research to confirm Chinese reports is rare.  If one wishes to demonstrate
that acupuncture is therapeutically beneficial, and to do so with a simple treatment that is easily reproduced, needling zusanli seems most appropriate.  While many
acupuncturists would prefer, on the basis of their training, to administer a more complex treatment, few can deny that the proclaimed benefits of treating this point,
even alone, are worthy of investigation.

The Household Physician

With Dr Paul Peterborough NH_December 12 2011
With Dr. Paul, Peterborough NH Dec 13 2011
A very sweet person with tons of young children and families in the audience.
Dr. Paul delivered over 4000 babies_he said he went into gynecology medicine so he could deliver babies because
he thought it would be a happy type of career.


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Zusanli is one of the 365 classical acupuncture points, located on the leg portion of the stomach meridian (see Figure 1).  According to the analysis presented in
Grasping the Wind (1) the point has had several names attributed to it, though most of them include the term sanli.  In fact, in traditional acupuncture texts, such as
the Internal Classic (Nei Jing, ca. 100 B.C.) and the Systematic Classic of Acupuncture (Jia Yi Jing, 1601 A.D.), the point is usually referred to simply as
sanli.  Most authors agree that, as described in Essential Questions (Nan Jing, ca. 100 A.D.), sanli refers to the method for locating the point on the leg: it is three
cun (about three inches, or about 4 finger widths; see Figure 2) below the knee.  More specifically, it is 3 cun below the Stomach-35 point, dubi, parallel to the bottom
of the knee cap.  Although the term li is a standard Chinese distance measurement that normally corresponds to about one-third mile, the term sanli is a grander one,
more fitting the naming system used for acupuncture points, than sancun.  It has been suggested that li might also have been selected because it sounds the same as
the related character li meaning to rectify or regulate; for example, sanli could secondarily imply regulating the three burners.
   Zu refers to foot, indicating that the point is on the portion of the meridian that runs to the foot: the stomach meridian is often referred to as the foot yangming
meridian.  In fact, there is another acupuncture point, shousanli (Large Intestine-10) which is located 3 cun below the prominent bone of the elbow; shou refers to
hand, indicating that the point is on the hand yangming meridian, the large intestine meridian that runs from the hand along the arm.
   One other name for zusanli that is of particular significance is xiaqihai, meaning lower sea of qi.  The upper sea of qi, simply called qihai (Conception Vessel-6),
is located at the dantian (which is below the navel about 1.5 inches).  The dantian is thought to be the primary reservoir of the body’s qi, at least according to the
Taoist tradition.  One of the key Taoist breathing exercises involves abdominal breathing with visualization of air, a type of qi, being drawn to this spot (“breathing into
the dantian”).  In the Ling Shu (2) it is said that “the center of breathing is the sea of qi.”  Thus, the term xiaqihai implies that needling this point may have an effect
comparable to needling qihai.
   In the Nei Jing Su Wen (3), the bilateral zusanli points are mentioned as two of the eight points for eliminating heat from the stomach.  Zusanli is also mentioned
as a treatment for knee pain that “feels so severe that the tibia feels broken.”  Zusanli is described as a he point (confluence point) of the stomach meridian.  He points
are where the qi submerges in its flow along the meridian; it submerges into the vast interior ocean of qi and blood.  According to Essential Questions, confluent
points are indicated for treating diarrhea caused by unhealthy qi.  The Ling Shu mentions that confluent points are indicated for disorders in the fu organs (the
stomach is one of the fu organs).  The Systematic Classic of Acupuncture (19) includes these indications for zusanli:
     For cold in the intestines with distention and fullness, frequent belching, aversion to the smell of food, insufficiency of the stomach qi, rumbling of the
     intestines, pain in the abdomen, diarrhea of untransformed food in the stools, and distention in the region below the hearts, sanli is the ruling point.
   In a collection of odes to acupuncture (20), also obtained from the Systematic Classic of Acupuncture, the following statements about zusanli are made:
   ·         Acute diarrhea and vomiting, search out yingu (Kidney-10) and sanli (Stomach-36).
   ·         Who knows in a weakening cough to search instantly for sanli?
   ·         A sound like cicadas in the ear which you want to diminish, be certain to keep in store the point sanli below the knee.
   ·         A little boy with indigestion, sanli is noblest.
   ·         If perhaps the bladder does not disperse water, then again it is suitable to seek within sanli.
   ·         If there is dizziness as you plunge the needle in [while performing acupuncture], immediately reinforce zusanli or reinforce renzhong (Governing Vessel-26).
   ·         If the mind is perturbed and anxious, pierce sanli.
   ·         Sanli removes great debility arising from malnutrition—Hua Tuo mentioned this.
   ·         Cold and numbness when the kidney qi is shriveling—select the earth point of foot yangming [zusanli]
   ·         Heal a breath blocked above with zusanli.
   A more lengthy discourse on the value of this point is included (20) in “Ma Danyang’s song on the twelve points shining bright as the starry sky and able to heal all
the many diseases”:
     Sanli under the eye of the knee, three cun, in between the two tendons, one can reach into the center of a swollen belly, it is splendid at healing a cold
     stomach, intestinal noises, and diarrhea, a swollen leg, sore knee, or calf; an injury from cold, weakness or emaciation, and parasitic infection of all sorts;
     when your age has passed thirty, needle and moxa at this point; change your thinking to find it, look extremely carefully; three cones of moxa, eight fen in,
     and peace.
   There are also references in the book to using zusanli along with other points to treat beriberi (this medical term refers to swelling of the legs that is due to vitamin
B1 deficiency, a common problem in the Orient; obviously, the original statement did not specify the cause of the leg swelling).  In addition, there is an explanation of
why needling zusanli during pregnancy is contraindicated, except at the time of delivery:
     At one time in the past, the Song Dynasty Crown Prince loved the medical arts.  He was out wandering in his park when he came across someone
     looking after a pregnant woman.  The Crown Prince made a diagnosis on her and said: “The baby is a girl.”  He ordered the physician Xu Wenbai to
     make a diagnosis; Wenbai replied: “There are twins, a boy and a girl.”  The Crown Prince was furious and wanted to cut the woman’s belly open to find
     out.  Wenbai stopped him, saying: “please may I use my humble needles?”  The he drained zusanli, and reinforced hegu (Large Intestine-4), and the
     fetuses responded to his needle and fell.  And it turned out to be as Wenbai had predicted.  Therefore, it is now said one should not needle these points on
     pregnant women.


The current standard indications for zusanli, as reviewed in Advanced Textbook of Traditional Chinese Medicine and Pharmacology (21) are: stomach ache,
abdominal distention, vomiting, diarrhea, dysentery, indigestion, appendicitis, flaccidity and numbness of the lower limbs, edema, mastitis, mania, epilepsy, cough, vertigo,
palpitation, and emaciation due to consumptive disease.  This latter indication corresponds to the concept that needling this point can tonify the sea of qi and thereby
help to stop the wasting disease and restore ones body weight and vitality.
   To illustrate the uniformity of indications amongst the Chinese authorities, the following were listed in Chinese Acupuncture and Moxibustion (22, 23), with
slight differences on translation between the original Chinese and later Western publications: gastric pain, hiccup, abdominal distention, vomiting, diarrhea, dysentery,
emaciation due to general deficiency, constipation, mastitis, intestinal abscess (acute appendicitis), numbness (motor impairment) and pain of the lower extremities,
edema (beriberi), manic depressive psychosis.
   In another book by the same name, Chinese Acupuncture and Moxibustion (24), these are listed: gastric pain, vomiting, hiccup, abdominal distention,
borborygmus, diarrhea, dysentery, constipation, mastitis, enteritis, aching of the knee joint and leg, beriberi, edema, cough, asthma, emaciation due to general deficiency,
indigestion, apoplexy, hemiplegia, dizziness, insomnia, mania.
   As these indications may suggest, zusanli is often applied in emergency situations.  In a report on emergency acupuncture (25), Zhang Xiaoping mentioned use of
zusanli, accompanied by other points, for treating high fever, syncope, pulmonary abscess (with expectoration of sticky, foul, or bloody sputum), sudden vomiting,
sudden diarrhea, fulminant dysentery, acute jaundice, acute hypochondriac pain, acute epigastralgia, acute abdominal pain, acute stranguria, sudden swelling (acute
edema), and dysuria with vomiting (usually due to renal failure).


There have been two main directions taken in modern clinical research with treatment at zusanli.  One is the treatment of abdominal pain and spasm, usually affecting
the stomach, gallbladder, or kidney.  In this case, stimulation of the acupuncture point is reported to have immediate effects (within seconds or minutes) and patients
often receive only one treatment.  These reports are presented first.  The other is the treatment of impaired immune functions, especially deficits in leukocyte and
immunoglobulin production.  In this case, stimulation of the acupuncture point is carried out daily, usually for 10–14 days consecutively, and this course of therapy might
be repeated (sometimes after a short break of a few days).  One of the studies mentioned below combines these two areas of concern: treatment of cancer patients
suffering from abdominal pain (cancer patients usually have impaired immune functions, either spontaneously or as the result of medical therapies).
   As might be expected, the relationship of zusanli to stomach function has been one of the main aims of research into the action of acupuncture stimulus applied at
this point.  It has been reported generally that needling zusanli can strengthen the contraction and digestive function of the weak stomach and relax the spasms of the
stressed stomach.  This latter indication has been investigated directly.
   For example, in the 1984 Journal of Traditional Chinese Medicine (4), a group at the Gastroenterology Section of the hospital affiliated with Guiyang College of
Traditional Chinese Medicine published a report on needling zusanli while administering the fiberoptic gastroscopy test.  This test, in which a fiber optics tube is
inserted through the mouth, down the throat, and into the stomach and then into the duodenum, tends to cause gastric and pyloric spasms.  The authors of the study,
relying on previous laboratory animal and clinical acupuncture investigations, believed that needling zusanli would be a reasonable treatment for the induced gastric
spasms.  In the article’s discussion they said that “No few recent studies indicate that zusanli needling has a regulatory effect on gastrointestinal tract function.”
   Their patients were treated by standard Western medical methods that included premedication with atropine sulfate and valium; but about 10% of their patients
suffered from persisting gastric or pyloric spasm, and these patients were treated by needling zusanli on the right side (the patients were lying on their left side during
the gastroscopy procedure, making the right leg more accessible).  The needle technique was to use rapid insertion, an insertion depth of 3.5–4.0 centimeters (about
1.5 cun), and an insertion angle towards the abdomen.  The needle was twisted and rotated with “moderate stimulation,” until a propagated sensation from the treated
point to the abdomen was felt.  The needle was retained until the examination was over.  According to the authors, this treatment relieved the spasms of 59 of the 60
patients so treated.  The duration of needling required to get relief was within a few seconds in 9 cases, one minute in 13 cases, 2 minutes in 13 cases, 3 minutes in 12
cases, and 5 minutes in 12 cases.
   A similar study was reported in the 1987 Journal of Traditional Chinese Medicine (5).  In this case, the authors, from the China Medical University affiliated
hospital, treated the control group with atropine and valium, but not the acupuncture group, who were treated, instead, at zusanli.  The point hegu (Large Intestine-4)
was also needled.  As with the other study, patients were lying on their left side and acupuncture was administered only on the right side.
   Electroacupuncture was utilized after obtaining the qi reaction by manual stimulation.  The electric stimulus, at 2.5 Hz, was administered for 10–15 minutes prior to
beginning gastroscopy.  The needles were withdrawn after the gastroscopy was completed.  The authors reported that 68 out of 70 patients had satisfactory
introduction of the gastroscope; it worked as well as the drug therapy.  Further, while patients in the control group reported some dizziness and malaise after treatment
(probably due to the drug effects), this was not reported in the acupuncture group.
   Along somewhat similar lines, elderly patients with epigastric pain were recruited for a study of zusanli at the Wuhan Hospital of Traditional Chinese Medicine,
reported in the 1992 Journal of Traditional Chinese Medicine (6).  The author pointed out that this pain syndrome usually arises from stagnation (which is a type of
excess) on a background of overall deficiency, and that zusanli is an ideal point because it can alleviate the gastrointestinal local disorder while providing tonification.
   Zusanli was punctured to a depth of 1.5 cun, followed by twisting and thrusting the needle to attain the propagated qi reaction (soreness and distension that radiates
to the epigastrum).  The needle is retained for 10–20 minutes, during which time it is maneuvered 1–2 times in cases of severe pain.  The author presented three
sample cases of successful treatment: two with billiary pain and one with stomach pain.  According to the reports, the pain would be alleviated within 10–20 minutes of
beginning the treatment.
   A short report on needling zusanli to alleviate renal colic, which, in China, is usually treated with atropine or dolantin, appeared in the 1993 Journal of Traditional
Chinese Medicine (7).  The author needled patients bilaterally at zusanli with a needle depth of 2–2.5 cun (which is deeper needling than usual), with rapid twisting and
rotation for strong stimulation for 1–2 minutes.  The pain was reported to be alleviated promptly.  The same treatment would be given again if the pain returned, in
place of using injection of drugs.
   An extensive review of using zusanli in abdominal surgical applications and abdominal pain, alone or as the main point in an acupuncture treatment, was presented
recently by Cui Yunmeng and Qi Lijie (35).  Among the applications and findings (outcome details not included here) were these:
   ·        Acute appendicitis: patients would first be treated at zusanli with strong stimulation applied for 3–5 minutes after getting the qi reaction; if the abdominal pain
      was obviously reduced, the patient would then be treated by non-surgical methods, mainly by additional acupuncture applied at zusanli; if the pain could not be
      reduced, the patient was treated surgically.
   ·        Post-operative pain: patients could be treated by injection at zusanli.  According to the report, injection of vitamin K3 at this point, but not intramuscularly
      elsewhere, would provide pain relief for all patients; injecting water at the point brought pain relief to 73% of those treated.  Referring to previous research, the
      author mentioned that needling zusanli could raise the pain threshold and inhibit pain transmission in the nervous system, especially in the abdominal area.
   ·        Acute abdominal pain from various causes: electro-acupuncture at zusanli was used to treat pain due to acute pancreatitis, appendicitis, biliary ascariasis, renal
      and urethral calculus, and adhesive intestinal obstruction.  Treatment provided prompt pain relief; and recurrence of pain within 24 hours was only 30% in those
      receiving acupuncture at this point.  Differential treatment (using various acupuncture points according to standard Chinese medical diagnostic categories) did
      not improve the outcomes.
   Although abdominal pain is the main focus of treatment with zusanli, the point is also used for leg pain and for temporomandibular joint pain.  The latter application
comes about because the stomach meridian runs along the face, crossing the temporomandibular joint (see Figure 3).  A report by Cui Yunmeng (30), detailed the
results of treating 60 patients with temporomandibular joint pain, difficulty opening the mouth, and problems with mastication.  The author used single point
acupuncture, stimulating zusanli only on the side of the body corresponding to the side of the face that was affected.  The needle was stimulated to get the qi reaction,
with an insertion depth of 1 cun, retaining the needle for 20–30 minutes.  Patients received just 1–6 treatments, typically 3–4 treatments.  According to the author, 39
patients were cured, and 15 cases were markedly improved; the other 6 showed minor improvement.  Cui also reported (35) treating chest pain in the area of the
mammary gland caused by soft-tissue injury, intercostal neuralgia, and acute mastitis, needling zusanli only on the same side as that affected by pain.  As with the
facial pain, the rationale for using zusanli for chest pain was that the stomach meridian runs upward across the ribs, through the mammary area.
   The treatment of abdominal pain by needling zusanli was investigated in cancer patients at the affiliated cancer hospital of Harbin Medical University, reported in
the 1995 Journal of Traditional Chinese Medicine (28).  The patients were not getting relief from standard pain medication.  The cancer cases included liver cancer,
post-surgical stomach cancer, recurrent colon cancer, and abdominal lymphosarcoma.
   Zusanli was treated on both sides, using either the reinforcing or reducing stimulation technique, depending on the traditional diagnosis of the patients.  After
attaining the needling sensation, the needles were retained for 15 minutes.  Acupuncture was administered daily for two weeks as a course of therapy.  In all but 11 of
the 92 cases so treated, there was some degree of pain relief.  Minor pain was alleviated in all cases, but more severe pain was usually only partially remitted.  Still, in
the group rated as having moderate pain, one-third attained pain relief that persisted for one month or more.  The authors reported that there was pain relief during the
needling session, and that persisting results could be attained after several consecutive days of treatment (typically, the full 2 weeks).  They summarized the ability of
the single point treatment to alleviate the cancer pain as follows: “If the duration [of suffering from cancer pain] is short, pain grade is low, tumors are small in size
with no or little metastasis, the effect [of acupuncture at zusanli] is good....Also, the effect is related to the mental state of the patients.  If they are full of confidence
and cooperative in the treatment, better results can be expected.”
   The authors cited earlier research (1989) that purported to show that needling zusanli could inhibit the nerves that cause the condition known as qi counterflow,
which often causes spasms and vomiting.  They also cited earlier research (1987 and 1990) with laboratory animal studies revealing that the corresponding zusanli
point on animals yielded significant analgesic effects.  Finally, they suggested that needling zusanli could have an anticancer activity (thus alleviating pain by reducing
the impact of the cancer), because earlier research (1989) had shown that needling this point could increase the number of T-cells and improve the activity of natural
killer cells.
   The immunological action of needling zusanli has been the subject of some clinical research.  For example, a group or researchers at the Zhong Guan Cun Hospital
in Beijing and members of the Chinese Academy of Traditional Chinese Medicine (9) reported on the effects of stimulating zusanli with laser radiation or heat
(provided with a focused flashing light source that measurably raised the skin temperature).  They stimulated the bilateral zusanli points by either of these methods for
10 minutes at a session, once daily for 14 consecutive days.  According to their report, healthy elderly individuals (60–77 years) treated by either method showed
significant increases in peripheral blood leukocytes and total immunoglobulins.
   A study exploring the ability of needling at zusanli to treat leukopenia was reported in a recent issue of the 1998 Journal of Traditional Chinese Medicine (10).  In
this case, leukopenia from various causes, mainly unknown etiology, with some cases from side effects of drugs and radiation or secondary effects of advanced
diseases, was treated with acupuncture in 14 days of consecutive sessions.  After a one week break, another 14 days of consecutive sessions was applied.  The
needles were inserted to zusanli on both legs, at a depth of about 1 cun.  With twirling and lift-and-thrust maneuvers, the qi reaction was attained (soreness and
distension), and then the needle was retained for 20 minutes with manipulations every 5 minutes.  According to the report, there were significant improvements in
immunoglobulin levels (IgG, IgA, and IgM; though IgG, which causes joint inflammation in arthritis patients was reported to be reduced in 2 patients of this group who
had advanced arthritis), in C3 (complement protein 3), and in phytohemagglutinin test.  According to the author:
     Zusanli is a point for recuperating the depleted yang, and also one of the important points for strengthening the body resistance.  Its action in health
     preservation has been paid due attention by doctors of successive dynasties....Acupuncture at zusanli can enhance both the specific and non-specific
     immunological function of the body.
   Interestingly, although zusanli has been described in the past as treating cold conditions of the stomach (but, in the Nei Jing it is indicated for stomach heat), it is
not usually depicted in the traditional literature as recuperating depleted yang.   The one exception cited in the historical review above is the statement in the Jia Yi
Jing that one could stimulate zusanli to treat “cold and numbness when the kidney qi is shriveling.”  Rather, the point is frequently said to “regulate qi and blood.”
Nonetheless, the depiction of zusanli invigorating the yang, which is not specifically mentioned in the modern acupuncture textbooks, is relied upon clinically in the
treatment of impotence (zusanli is combined with a few other points).  While one can say that anything that improves body function strengthens resistance to
pathological influences (in the case quoted above, specifically to infections, since immunological function is then described), the traditional literature does not appear to
emphasize this action.  The author’s statement thus reveals how Chinese researchers can skew the explanation of what has been done in past dynastic periods to fit
their particular findings.


Because of the importance attributed to zusanli in modern times, it has been a point commonly tested in evaluations of how acupuncture might work.  That is, in
attempting to find modern medical descriptions for the functions of acupoint stimulation, various responses of laboratory animals are determined.  Zusanli on animals is
located on the lateral tibial prominence, 1/5 of the distance from the knee to the ankle (11).  This method of finding the point corresponds to the human measurement
system, in which the distance from the knee to the ankle is said to be 16 cun (zusanli, at 3 cun, is thus about 1/5 the distance).
   One suggestion about how acupuncture functions is that nerves are stimulated at the point (this yields the qi reaction as the sensory aspect, but can also involve
non-sensory signals), and signals transferred along nerve pathways yield the ultimate therapeutic effect.  There are two possibilities that may be considered:
1.      The nervous system transfers signals directly from the acupoint to the organ that is being treated.  The importance Chinese doctors attach to obtaining a
   propagated qi sensation along this pathway would imply this mechanism is involved.
2.      The nervous system transfers information to the brain first, which then yields the response that affects the target area.
   Both of these mechanisms could be involved in the total effect, along with release of substances from the nervous system into the blood stream during the
transmission of signals.  The released substances could interact with the endocrine and immune systems to generate systemic effects.  As Cai Wuying concluded in his
article on acupuncture and the nervous system (33): “Acupuncture stimulates peripheral sensory nerves and their endings, increases cutaneous blood flow and
microcirculation, and releases neurotransmitters, neuropeptides, and hormones.”
   To test the involvement of the nervous system, laboratory animal experiments were utilized in which nerves in the legs of animals were severed and it was shown
that the effects of needling the point equivalent to zusanli could be stopped (23).  Other experiments indicated that by blocking the nerve trunks related to the
acupuncture points with procaine, the increase in white blood cell counts that are accomplished by stimulating zusanli (usually along with other points) is also blocked.
This would suggest that nerve transmission is, in fact, an important part of the full range of therapeutic functions.
   In the case of epilepsy, a laboratory animal experiment was reported in the 1992 Journal of Traditional Chinese Medicine (12), with needling at zusanli.  The
authors concluded that: “All the observations lead to the presumption that electroacupuncture when applied at zusanli exerts seizure-suppressing effect through a
pathway of hypothalamic arcuate nucleus to brain stem raphe nucleus, to hippocampus.”  The pathway leading from the acupuncture point to the brain stimulation,
which released neurotransmitters to affect the other parts of the brain, was not investigated in this study, but a transmission via nerves is certainly a reasonable
explanation.  This is especially so since the effects on the brain were immediate: showing up shortly after the electro-acupuncture was started and diminishing when
acupuncture therapy was stopped.  The transmission from the acupuncture points were depicted in another study (26) this way: “the afferent impulses from the
acupuncture points may activate the enkephalinergic neurons in the periaqueductral gray matter, especially in the dorsal part, and trigger the release of opiate-like
substance which in turn acts on the nucleus raphe magnus.”  The afferent impulses refer to nerve transmissions from the acupuncture site to the brain.  In this study,
bilateral zusanli were the points selected for stimulation.
   Another study of zusanli on the brain was conducted in rabbits (29), in which it was shown that stimulating the zusanli point markedly increased blood flow in the
cerebral tissues.  The effect could be seen immediately after the stimulation began (first measurement one minute after initiating needle stimulus), and it increased
during the next several minutes).  The authors compared the effects of electroacupuncture stimulation with manual twirling manipulation of the needle using either the
reducing or the reinforcing method.  They reported that electroacupuncture had a much greater effect on the cerebral blood flow, while the two manual methods
produced a lesser effect of the same nature, with no evident difference between the results of reducing or reinforcing methods.  Presumably, the change in blood flow,
which has also been reported to be a result of scalp acupuncture (see: Synopsis of scalp acupuncture), is accompanied by changes in brain activity.
   In a study of immunological effects of needling zusanli mentioned in a review article (13), it was reported that the total white blood cell count of rats and rabbits
could be increased markedly by needling zusanli, reaching a peak value with five consecutive days of treatment.  However, this effect could only be achieved when
the nervous and adrenal systems were intact. Aside from white blood cell counts, several other beneficial immunological effects of needling or moxibustion application
at zusanli, either alone or in combination with other points, were mentioned in the review article.
   In a study of hormonal effects, electro-acupuncture at zusanli was administered to dogs who had impaired adrenocortical function after three weeks administration
of prednisone (34).  Zusanli was treated bilaterally for 30 minutes, three times per week, for three weeks.  Control animals received a similar stimulus either at points
on the bladder meridian close to the adrenal glands (BL-22, -23, and ­24) or at a non-acupuncture point.  According to the report, ACTH was markedly improved
during acupuncture therapy at zusanli, was only slight improved by acupuncture on the bladder meridian points, and not affected by treatment at the non-acupuncture
point.  Serum cortisol markedly improved in the zusanli group during the three week course of therapy.  The authors pointed out previous research indicating that
needling zusanli in several animal models (rabbits, cows, and sheep) could increase plasma hormones, and that the adrenocortical hormones were being stimulated via
the hypothalamus (which is encompassed by the brain).  An effect of acupuncture on the higher brain center was suggested as a possible basis for the
hypothalamic-adrenal response.
   It is not clear that such mechanistic explanations contribute very much to the actual clinical practice of acupuncture, though they do lend support to the Chinese
contention that attaining the qi reaction and, in some cases, the propagated qi sensation, may be critical to attaining success in the treatment (see: Getting Qi).  These
reactions are felt by the patient and obviously represent successful interaction with the nervous system.
   For example, in a study reported in 1989 Journal of Traditional Chinese Medicine (14), in which asthma patients were treated at acupuncture points zusanli and two
lung points (taiyuan and chize, Lung-9 and Lung-5), it was found that the patients experiencing a strong propagated needle sensation got good results, while those who
experienced little of this sensation had poorer results.  In the case of zusanli, the direction of propagation was downward; for chize, it was mainly upward, with 20% of
patients reporting radiation in both directions.  The authors commented:
     Whether or not acupuncture produces needling sensations bears a close relationship to the therapeutic results.  Centuries ago, it was pointed out in the
     Nei Jing that the results of treatment can be obtained only when needling sensation reaches the site of disease....During acupuncture, the doctor’s
     attention should be given to needle manipulation in order to elicit adequately strong sensations.  Strong sensations not only lead to more ideal results but
     also improve the objective indicies....”


Because zusanli is so widely used by acupuncturists, it is naturally included in combinations with numerous other points.  Certain combinations appear with especially
high frequency.  Below are some examples of treatments that specifically involve a small number of points.  Probably the most frequent combination is with hegu
(Large Intestine-4).  This combination was mentioned in the story about inducing childbirth and in one of the gastroscopy trials, and is also described in some of the
acupuncture mechanism experiments.  In Modern Clinical Necessities for Acupuncture (15), treatment of this combination of points is cited as a successful
treatment for the new application of giving up smoking.
   In a study on the immunological effects of acupuncture (16), 120 patients suffering from pain syndromes were treated with acupuncture at zusanli and hegu.  The
researchers selected these points because:
     For years, Chinese authors described that acupuncture can have a stimulating effect on cell-mediated immunity.  In fact, some experimental research
     suggests a fairly good increase of T-lymphocytes after acupuncture stimulation at zusanli and hegu acupoints, as well as an increase of lymphoblast
     transformation which persists for 24 hours after stimulation.
   Treatment was carried out with perpendicular insertion of the needles, with varying depth depending on the patients constitution (range: 0.8–3.3 cm).  Twisting and
twirling manipulation of the needles was used to attain the qi reaction.  Stimulation was continued, with one minute of stimulation at a time, bilaterally, for each point,
with a one minute break between stimulus sessions.  After 15 minutes, stimulation of hegu continued by the same method, but zusanli was stimulated by electrical
apparatus at 90 Hz.  The needles were withdrawn after 30 minutes.  According to the authors, 77% of the treated patients showed an increase in CD3 and CD4 cells
30 minutes after completion of the acupuncture treatments.  Based on analysis of immune changes over time, the authors concluded that antibody-dependent cell
cytotoxicity by monocytes was strengthened, which is important for treating infectious diseases.  Also, natural killer cells were stimulated by the acupuncture; these
yield cytotoxic activity against virally infected cells and cancer cells.  The authors believed that their results, which included analysis of vasoactive intestinal peptide
(VIP) and endorphins, confirm the recent findings with regard to neuroimmunomodulation (the regulation of the immune system via the nervous system).
   Other common pairings:
   ·        Zusanli and neiguan (Pericardium-6).  These two points were the primary ones used in a study of cancer therapy (8), though others were sometimes added
      for specific symptoms.  It was claimed that the acupuncture treatment ameliorated the typical side effects of chemotherapy and radiation therapy (poor
      appetite, nausea, vomiting, diarrhea, dizziness, insomnia, and fatigue) and improved the immune functions (including leukocyte count and immunoglobulin
      levels).  In a review article on acupuncture research (32), Kuang Yihuang and Wei Jia made reference to research published in 1981: “Not a few patients
      suffering from drug intoxication and allergy [reaction to drugs] have been treated by acumoxibustion.  Reactions such as vomiting, arthralgia, involuntary
      muscle movements, tachycardia, proxysmal chronic bronchitis and hypertension from antimony artrate injection and T273 administration have been cured by
      needling zusanli and neiguan bilaterally for 10–13 sessions.”
   ·        Zusanli and sanyinjiao (Spleen-6).  In a study of cancer patients receiving radiation therapy (17), patients were treated with microwave stimulated
      acupuncture at zusanli and sanyinjiao.  The needles were inserted to 1.5 cun depth, and manipulated by hand to attain the qi reaction.  The needles were then
      attached to microwave stimulus to maintain a needling sensation.  Treatment time was 20 minutes each day, for 10 consecutive days.  Leukocyte levels, which
      had been lowered by the radiation therapy, were monitored.  According to the report, this acupuncture therapy was more effective in raising leukocytes than
      Western drugs (including leucogen) given to a control group.  Further, the acupuncture group started with greater impairment of leukocytes.   In another study,
      the same two points were reported to aid recovery of movement in the intestines following abdominal surgery and to lower liver enzyme levels that were
      raised as the result of tissue damage during surgery (35).
   The four acupuncture points mentioned here, zusanli, hegu, neiguan, and sanyinjiao, were used together as the main points in a study involving the treatment of
pain due to stomach cancer (31).  Needle stimulus was carried out by reinforcing or reducing method and needles were retained for 20 minutes.  The patients were
asked to concentrate their minds on the diseased part (the stomach) during the treatment.  Acupuncture was given daily for 14 days; after a break of 2–3 days another
course of 14 days treatment was given for a total of 4 courses of therapy lasting two months.  The authors reported that 80% of patients experienced immediate
analgesic effects; about half of those patients maintained good analgesic effects 12 hours after the treatment.  After two months of regular treatment, over 90% of the
patients attained good analgesic effects.  Among a control group receiving Western medications for pain (including codeine and dolantin, prescribed as needed), the
immediate effects of the drugs were superior to acupuncture analgesia, but after two months of therapy, the acupuncture effects were as good as the drug effects.
The authors also monitored the effects of their treatments on the immune system, on chemotherapy side effects, and quality of life, indicating that acupuncture had
notable benefits not matched by the Western medicine group.
   Previous reports have shown similar responses to treatment at zusanli alone, so it remains unclear whether the more complex therapy used in this study was really
necessary.  Needling several points with adequate stimulus is more complicated for the practitioner and is more confusing for the patient who is asked to focus his or
her mind on the diseased part.
   There are also some needle groupings that are larger but have become somewhat standard practice and involve zusanli.  For example, Miriam Lee, in her book,
Insights of a Senior Acupuncturist (18), describes the combination of “antique points,” sometimes called “ten old needles,” which is comprised of bilateral
acupuncture at five sites, including three of the sites mentioned above:
zusanli (Stomach-36)
hegu (Large Intestine-4)
sanyinjiao (Spleen-6)
quchi (Large Intestine-11)
lieque (Lung-7)
   This combination is used for a wide range of disorders.  Regarding zusanli, Lee reports:
     It increases digestion, helps the body to absorb food, increases the production of gastric acids, and stimulates hunger.  I needle it first because it
     tranquilizes the patient and protects them from fainting reaction to the needles.  It increases the flow of energy and oxygen to the head, since the stomach
     channel begins on the head.  When needling the stomach channel on the feet, all the qi is sent upward.  After stimulating zusanli, you can see the face
     become infused with redness, glowing and warm.  Technique is very important.  I put in both needles and then de qi (obtain the qi).  Then with my right
     hand on the needle in the left leg and my left hand on the needle in the right leg, with the needles inserted shallowly, I move both thumbs forward 240
     degrees and backwards 120 degrees (2/3 of a full turn around forward and 1/3 turn back).  This is done 3 times and then the needle is thrust a little
     deeper, turned as above 3 times, again thrust deeper and turned 3 times, for a total of 9 turns.  It is important that both needles be turned at the same
     time....Repeat the turnings 9 times until the propagation of qi reaches the toes....After the qi has reached the end of the channel, pull the needle up above
     the channel and above the muscle but not out of the skin and leave it shallow, pointing in the direction the channel flows.  In the case of the stomach
     channel, point it towards the foot.  This is the technique for supplementation.
   Although Lee emphasizes a particular stimulation technique, the previously mentioned research appears to demonstrate effective response to other methods of
   A similar approach was used by Wang Leting (27), a well-known acupuncturist in China who practiced there from 1929 to 1979.  Regarding zusanli, he is reported
to have said “For hundreds of diseases, don’t forget zusanli.”  In his records of treatment for gastro-intestinal diseases, it was found that he had used zusanli more
often than any other point, in 72% of 126 cases treated.  His own formula for ten old needles was:
zusanli (Stomach-36)
zhongwan (Conception Vessel-12)
qihai (Conception Vessel-6)
tianshu (Stomach-25)
neiguan (Pericardium-6)
   Although this differs markedly from the one mentioned by Miriam Lee, he had a similar formulation which he referred to as Shiquan Dabu Tang acupuncture.
Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination), is a qi tonifying and blood nourishing herbal formula that has numerous uses, including counteracting
adverse effects to Western medical therapies.  His formula is the same as Lee’s, except that liqie (Lung-7) is deleted and replaced by a combination five points:
lingquan (Gallbladder-34), zhongwan (Conception Vessel-12), taichong (Liver-3), zhangmen (Liver-13), and guanyuan (Conception Vessel-4).  He recommended
this set for the treatment of spleen-heart deficiency, spleen-kidney deficiency, and liver-kidney deficiency syndromes.


1.      Ellis A, Wiseman N, and Boss K, Grasping the Wind, 1989 Paradigm Publications, Brookline, MA.
2.      Wu Jing-Nuan (translator), Ling Shu, or The Spiritual Pivot, 1993 Taoist Center, Washington, D.C.
3.      Maoshing Ni, The Yellow Emperor’s Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA.
4.      Cheng Yiqin, et al., The use of needling zusanli in fiberoptic gastroscopy, Journal of Traditional Chinese Medicine 1984; 4(2): 91–92.
5.      Chu Hang, Zhao Shuzhen, and Huang Yuying, Application of acupuncture to gastroscopy using a fiberoptic endoscope, Journal of Traditional Chinese
   Medicine 1987; 7(4): 279.
6.      Zhang Jueren, Treatment with acupuncture at zusanli for epigastric pain in the elderly, Journal of Traditional Chinese Medicine 1992; 12(3): 178–179.
7.      Liu Guoliang, Treatment of renal colic with acupuncture at zusanli, Journal of Traditional Chinese Medicine 1993; 13 (4): 265.
8.      Xia Yuqing, et al., An approach to the effect on tumors of acupuncture in combination with radiotherapy or chemotherapy, Journal of Traditional Chinese
   Medicine 1986; 6 (a): 23–26.
9.      Peng Yue, et al., Effects of laser radiation and photobustion over zusanli on the blood immunoglobulin and lymphocyte ANAE of the healthy aged,
   Journal of Traditional Chinese Medicine 1987; 7(2): 135–136.
10.  Wei Zanmei, Clinical observation on therapeutic effect of acupuncture on zusanli for leukopenia, Journal of Traditional Chinese Medicine 1998; 18(2):
11.  Hua Xingbang, On animal acupoints, Journal of Traditional Chinese Medicine 1987; 7(4): 301–304.
12.  Wu Dingzong, Mechanism of acupuncture in suppressing epileptic seizures, Journal of Traditional Chinese Medicine 1992; 12(3): 187–192.
13.  Cui Meng, Present status of research abroad concerning the effect of acupuncture and moxibustion on immunological functions, Journal of Traditional
   Chinese Medicine 1992; 12(3): 211–219.
14.  Sheng Lingling, et al., Effect of needling sensation reaching the site of disease on the results of acupuncture treatment of bronchial asthma, Journal of
   Traditional Chinese Medicine 1989; 9(2): 140–143.
15.  Wang Qi and Dong Zhi Lin, Modern Clinical Necessities for Traditional Chinese Medicine, 1990 China Ocean Press, Beijing.
16.  Petti F, et al., Effects of acupuncture on immune response related to opioid-like peptides, Journal of Traditional Chinese Medicine 1998; 18(1): 55–63.
17.  He Chengjiang, Gong Kehui, and Xu Qunzhu, Effects of microwave acupuncture on the immunological function of cancer patients, Journal of Traditional
   Chinese Medicine 1987; 7(1): 9–11.
18.  Lee M, Insights of a Senior Acupuncturist, 1992 Blue Poppy Press, Inc., Boulder, CO.
19.  Huang-fu Mi, Systematic Classic of Acupuncture and Moxibustion, 1994 Blue Poppy Press, Inc., Boulder, CO.
20.  Bertschinger R (translator), The Golden Needle, 1991 Churchill Livingstone, London.
21.  Ming Shunpei and Yang Shunyi, Advanced Textbook of Traditional Chinese Medicine and Pharmacology, Volume 4 1997 New World Press Beijing.
22.  Zhang Enquin (Ed. in Chief), Chinese Acupuncture and Moxibustion, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine.
23.  Qiu Mao-liang (Man. Ed.), Chinese Acupuncture and Moxibustion, 1993 Churchill Livingstone, London.
24.  Chang Xinnang (Chief Ed.) Chinese Acupuncture and Moxibustion, 1987 Foreign Language Press, Beijing.
25.  Zhang Xiaoping, Indications and contra-indications in emergency acupuncture treatment, Journal of Traditional Chinese Medicine 1996; 16(1): 70–77.
26.  Zhu Lixia and Shi Qingyao, Activation of nucleus raphe magnus by acupuncture and enkephalinergic mechanism, Journal of Traditional Chinese Medicine
   1984; 4(2): 111–118.
27.  Yu Hui-cha and Han Fu-ru, (Shuai Xue-zhang, Trans.), Golden Needle Wang Le-ting, 1996 Blue Poppy Press, Inc., Boulder, CO.
28.  Xu Shuying, Liu Zhiqiang, and Liyu, Treatment of cancerous abdominal pain by acupuncture on zusanli, Journal of Traditional Chinese Medicine 1995; 15(3):
29.  Shi Renhua, et al., Effects of electroacupuncture and twirling reinforcing-reducing manipulations on volume of microcirculatory blood flow in cerebral
   pia mater, Journal of Traditional Chinese Medicine 1998; 18(3): 220–224.
30.  Cui Yunmeng, Treatment of 60 cases of dysfunction of the temporomandibular joint by puncturing zusanli acupoint, Journal of Traditional Chinese
   Medicine, 1993; 13(3): 191.
31.  Dang Wen and Yang Jiebin, Clinical study on acupuncture treatment of stomach carcinoma pain, Journal of Traditional Chinese Medicine 1998; 18(1): 31–38.
32.  Kuang Yihuang and Wei Jia, An introduction to the study of acupuncture and moxibustion in China, part III: Review of clinical studies on acupuncture
   and moxibustion, Journal of Traditional Chinese Medicine, 1984; 4(4): 249–254.
33.  Cai Wuying, Acupuncture and the nervous system, American Journal of Chinese Medicine, 1992; 20(3–4): 331–337.
34.  Lin JH, et al. Treatment of iatrogenic Cushing’s Syndrome in dogs with electroacupuncture stimulation of Stomach 36, American Journal of Chinese
   Medicine, 1991; 19(1): 9–15.
35.  Cui Yunmeng and Qi Lijie, Application of zusanli in surgery, International Journal of Clinical Acupuncture, 1998; 9(3): 317–321.

                                                       December 1998

                                                          Figure 1.

                                                          Figure 2.

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Practical Considerations for Modern Use of an Ancient Technique

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon


Practitioners of Chinese medicine usually receive limited training in moxibustion therapy. The training is mainly comprised of presentation of a few basic moxa techniques and a listing of some indications for use of moxibustion (e.g., to treat cold syndromes) and contraindications (e.g., in heat syndromes). The actual experience of utilizing moxibustion therapy is often confusing. Practitioners, patients, and others wonder about the smoke emanating from the moxa in terms of safety as well as other impacts. Practitioners are left without much instruction as to how intensively to apply moxa to get the desired results. Sometimes they are instructed to use moxa very mildly, with short duration, and infrequent administration in contrast to its actual use in China; and there remain questions about its mechanism of action and how effective it is. This article reports on an exploration of the literature on moxibustion to help clarify some of these matters. It is an expansion on a section of a previous START article from 1998, Borneol, Artemisia, and Moxa. That article makes reference to the herb material used for moxa (artemisia, also called mugwort) and one of its active components, borneol, which is isolated (provided in the form of crystals, called bingpian) and commonly used in topical therapies for its antiseptic and analgesic effects.
A primary source used for this literature survey was the Journal of Traditional Chinese Medicine, published since 1982 in English and reviewed through 2003. This journal presents numerous articles on the various forms of traditional Chinese medicine practice, including a variety of techniques for acupuncture, moxibustion, cupping, blood-letting, therapeutic massage, as well as internal medicine (herb prescriptions) and topical applications of herbs. The journal includes articles that review techniques generally, as well as articles on treatment of specific diseases, or uses of specific acupuncture points or herbs. A limitation of this review is reliance on English language publications (translations from the Chinese), but an advantage is that readers will be able to examine most of the referenced texts and articles.


The original Chinese term for what we today routinely call acupuncture is zhenjiu, which refers to both needling (zhen) and moxibustion (jiu), two techniques understood to be essential parts of one fundamental approach to treating disease and maintaining health. Nonetheless, compared to acupuncture, moxibustion is usually deemed a secondary practice. In the Huangdi Niejing (comprised of the Suwen and the Lingshu), the textual basis of ancient and modern concepts about acupuncture and moxibustion treatments, only a few sentences are devoted to moxibustion. Paul Unschuld, in his detailed translation and analysis of the Neijing Suwen (1), devoted four pages to discussion of its application in a section on heat therapies. The origination and main application of moxibustion is described in the Suwen as follows:
The North is the region where heaven and earth secure and store. Its land lies at a high altitude, its people live in earthen mounds. Wind and cold and icy chilliness dominate; its people find joy in living in the wilderness and in consuming milk. Their depots are cold and generate diseases of fullness. For their treatment, moxa burning is appropriate. Hence, moxa burning originated in the North.
The reference here is to the north of China, specifically to the tribes of Mongolians, who drank mare's milk and lived at high altitude (the average altitude of Mongolia is 1,580 meters-about 5,000 feet-and its lowest point is 552 meters. Mud huts were the standard Mongolian housing in ancient times, and are still prevalent in smaller villages. The Mongolian winters are fiercely cold and windy and its climate is so difficult that only about 2.5 million Mongolians live in its vast territory today. It is clear that the purpose of moxa, a heating therapy, is to deal with the cold. Its role, as depicted in Unschuld's discussion, is to impart yang qi to the body. The typical diseases among these Mongolian people living in the cold north are categorized in this passage as involving fullness. This description is partly a reference to the concept that the north is devoted to securing and storing. Thus, for example, the Mongolians would gather plant and animal foods during the brief summer, and then store the materials for use throughout the year. The people, likewise, would store up foods within their body by eating heartily when food is abundant and relying, whenever possible, on rich, fatty foods, and on milk, which is to be used cautiously in those with spleen yang deficiency and fluid or phlegm retention (33). The cold could contribute to stagnation of the excess food essences, engendering a disease of fullness (e.g., excess yin). Often, such diseases would initially produce abdominal pain with gastric and intestinal spasms; if the disease advanced, it could cause swellings under the skin and formation of other masses. It is also mentioned in the Suwen that:
In the case of harm caused by food, one should use moxa. If the disease does not come to an end, it is essential to watch for those conduits excessively filled with yang qi: pierce the respective transporters several times and give herbs.
The situation where moxa fails, as described here, reveals some of the thinking about its effects. The harm caused by food is an accumulation, which should be dispersed by the warm moxa. The yang qi that the moxa treatment bestows is the basis of the dispersing effect. However, if the moxa fails to disperse the stagnation, then it has simply added a new excess, the yang qi, to the former excess of yin. Therefore, the response must be to drain the channels by blood-letting, so as to get rid of all the excesses.
The case of treating accumulation associated with food stagnation and cold environment is one of the few instances in the ancient literature where moxa is recommended as the first therapy to try; in most instances, it is the resort should acupuncture fail. This fact is mentioned in the book Chinese Acupuncture and Moxibustion (2), with reference to the Neijing Lingshu as well as a later text:
Chapter 73 of the Lingshu states: 'A disease that may not be treated [is not successfully treated] by acupuncture may be treated by moxibustion.' In Introduction to Medicine [1575 A.D.], it says: 'When a disease fails to respond to herbs and acupuncture, moxibustion is suggested.'
A search for commentary on the history of moxibustion since the Neijing turns up little; apparently, the subject has not generated widespread interest, despite its continued use as a therapy. In the well-known text Huangdi Zhenjiu Jiayi Jing (Yellow Emperor's Classic of Acupuncture) by Mi Huangfu (214-282 A.D.), moxibustion goes unmentioned, even in the chapters on diseases of cold (10). A monograph on the herb relied upon for moxibustion, artemisia (Aiye Chuan), published around 1500 A.D. by Li Yenwen, was lost. Its title is recorded, but nothing is quoted from it, not even in the Bencao Gangmu, published later that century by Li's son Li Shizhen, which carried quotations from his other monograph on ginseng (3).

After the Chinese revolution in 1949, a great reorganization of traditional Chinese medicine was undertaken. One of the first steps was to investigate and evaluate the traditional methods of acupuncture and moxibustion therapy. The results of such studies were published in a series of reports in the English language Journal of Traditional Chinese Medicine in 1984. In the first article of the series (4), devoted to history of the practices, only the following was noted specifically about moxibustion:

Some fifty kinds of moxibustion methods have been summarized through research into ancient literature on moxibustion. In these [documents] are discussed different materials for moxibustion, various shapes of mugwort cone or roll, materials to be placed between the point on the skin and the burning moxa, and different temperatures and manipulation of moxibustion.

The second part of the series on acupuncture and moxibustion (5) is devoted to the variety of techniques employed currently (e.g., scalp acupuncture, wrist/ankle acupuncture, ear acupuncture, etc.). The article offers the following about moxibustion, with emphasis on the clinical efficacy of scarring moxibustion and attempts to introduce greater use of the other non-scarring methods:

Some units have modified their moxibustion apparatus to facilitate the manipulation. Of the various methods of moxibustion, the ones in common use today are those using moxa cone, moxa stick for warm moxibustion, warm cylinder, and in certain cases, burning [the skin] with moxa. It has been pointed out that moxibustion therapy is especially effective for treating deficiency-cold disease, while it is contraindicated in excess disease and in fever due to yin deficiency. However, some workers have presented clinical cases of febrile disease successfully treated by moxibustion therapy. Ancient medical records support this claim. These workers have explored the problem and declare the banning of moxibustion therapy in febrile disease to be groundless. Still, the two opinions coexist and are debated.

Moxibustion therapy is effective in simple and infantile diarrhea, chronic gastroenteritis, peptic ulcer, bronchial asthma, rheumatism of muscles and joints, neurasthenia, hypertension, menstrual disorders, chronic pelvic inflammation, and climacteric syndrome [menopause]. Definite effect was obtained in the treatment of pulmonary tuberculosis, and thromboangitis obliterans. A report of 182 cases of asthma treated with scarring moxibustion at acupoints selected on the basis of differential diagnosis resulted in a shot-term effective rate of 76.9%, with 70% long-term effective rate on follow-up examination for three years. Other reports claim that scarring moxibustion may markedly lower blood pressure, reduce blood viscosity, and dilate various vessels.

These reports indicate that scarring moxibustion decreases the incidence of fulminant apoplexy by lowering blood pressure. Observation over 17 years of 54 cases of high blood pressure revealed that only 5 suffered from fulminant apoplexy after receiving scarring moxibustion, while 4 out of 12 in the control group did. These results of the therapy are obvious. Experimental and clinical studies have pointed to further health benefits of scarring moxibustion. An example is 299 cases of asthma treated by purulent moxibustion in which 70.6% were effective and 29.1% markedly effective. Abnormal WBC count in 20 cases before treatment were corrected in 19 cases….Animal experiments have showed moxibustion to markedly strengthen the immunity of the organism.

Finally, it should be pointed out that although moxibustion has been extensively used clinically, it has received far less attention than acupuncture, a point deserving some thought.

One can take note of the shift in therapeutic indications for moxibustion from accumulation (a type of excess) with cold to deficiency cold, where moxibustion is considered a means to tonify the deficiency. This shift may reflect a change from using moxibustion as a one-time treatment for dispersion to use of it in repeated daily treatments, since tonification of deficiency often requires prolonged therapy. Scarring moxa, also called purulent moxa, is where severe blistering and ulceration of the site occurs (sometimes with unintended infection of the sore), resulting in formation of a scar. This method reflects the dominant form of moxibustion until very recently; for this reason, many writers translate moxibustion as "cauterization." Instructions for moxa application in the Chinese literature would typically involve repeated burning of numerous small moxa cones on the skin directly, causing blistering or further damage. This type of moxa therapy is not discussed in any detail as part of Western acupuncture training because it is not allowable in Western practice.

The production of useful moxa rolls for indirect heating is a modern technological development, compared to the simple practice of forming moxa wool into small cones by hand. Moxa rolls for indirect treatment were introduced at the end of the Ming Dynasty, but did not become common place until after 1950 when factories were established that could turn out thousands of them daily. Still, traditional doctors were used to employing the standard cones for direct moxa and many of them did not easily make the transition to this other method.

In a report on scarring moxibustion presented at a conference in Beijing in 2000, Wang Kenliang (21) points out that:

Moxibustion sore paste must be applied immediately after the moxibustion in order to protect the injured skin and promote non-bacterial suppuration. In one week after the moxibustion treatment, the exudate becomes more and the sore will suppurate gradually…after more than one month, the pus will disappear and the new flesh will grow, the injured skin will get recovered with only slight scar remaining. The patient must take good rest after suppurative moxibustion treatment and avoid heavy labor and abnormal emotions such as sadness and anger; the patient should also take proper food, limit sexual life, and prevent exposure to pathogenic cold or heat. More nutritious food should be taken such as fresh meat, beans, and fresh vegetables; all these foods help the recovery of the moxibustion sore and remove pathogenic factors….This therapy can treat tuberculosis, bronchial asthma, arthritis, hiccup, facial paralysis, and tuberculosis of the neck lymph.

The author of the Journal of Traditional Chinese Medicine review article brings up point that moxa is used extensively in Chinese clinics but receives far less attention than acupuncture. This comment no doubt refers to limited reports of its use as a primary therapy and one can see from Wang's description that moxa treatment can sometimes be a rather serious ordeal, limiting its use in the large hospitals from which most medical reports are generated. One can speculate about other reasons for its infrequent mention in the literature. Most articles on acupuncture therapy report on complex treatment patterns involving numerous acupuncture points. Needles can be inserted one by one and then the practitioner can perform manipulations on each, leaving them in place for 20-30 minutes. Moxibustion is usually done on only one or two of the points in a complex treatment pattern including acupuncture. As a result, the main part of therapy is the needling, with moxa as a small portion of the treatment. It is difficult for the authors of reports on these treatments to make the proclamation that the therapy is based on moxibustion or that the outcome was reliant on the moxibustion portion of treatment.

Relatively few diseases are treated by moxa alone or with it as the primary therapy. Thus, little attention is given to this technique, in part, because it accompanies acupuncture where the latter is used with more points and with more specific manipulation. Articles on moxibustion as the primary technique tend to be short, and little is said about the point selection or method of applying the moxa. In an article purporting to describe diseases effectively treated by moxibustion (44), three cases are singled out and only one of them (treatment of pterygium) involved moxa alone, the others (carpal tunnel syndrome and throat neuralgia) involved moxa plus acupuncture.

In fact, a search for clinical research on moxibustion in the Journal of Traditional Chinese Medicine (in publication for more than 20 years) revealed few articles on moxibustion, and the majority of the articles that mention this technique made use of it as a seemingly minor adjunct to acupuncture therapy. Articles that mention acupuncture and moxibustion in the title often are merely giving the translation of zhenjiu, while the treatments described involve needling only.

In part 3 of the series reviewing acupuncture and moxibustion (6), with focus on the disorders the various techniques are considered useful in treating, moxibustion is specifically mentioned as successful for one application-correcting abnormal fetal position:

The success rate of moxibustion on zhiyin (BL-67) in checking abnormal fetal position markedly exceeds the figure for manual restoration reported abroad. Two to 4 sessions sufficed, though cases with very loose or very tense abdominal wall, with fixing of the fetal head below the subcostal region, and with partial descent of the fetus into the pelvic cavity were less successful or even ineffective.

The other reports summarized in that review involve either acupuncture alone or "acu-moxibustion," referring to use of acupuncture and possible inclusion of moxibustion in at least some of the treatments (with no mention of specific moxibustion techniques). A rare example of a report in which non-scarring moxibustion was used as a primary therapy for a chronic disease was published in 1992. It involved 183 patients with coronary heart disease. Here is the description of the technique, using moxa rolls:

The acupoints selected included neiguan (PC-6, bilaterally), shenzhong (CV-17), and xinshu (BL-15 bilaterally). During treatment, the patient was in a lying position with full exposure of the acupoints. The ignited end of the moxa roll pointed directed toward neiguan (one side), with the burning end 0.5-1.0 cun away from the skin, for 5 minutes until the patient had a warm but not burning feeling and the skin color turned slightly red. Then, the same method was applied to neiguan of the other hand, shanzhong, and xinshu (both sides), each for 5 minutes. The treatment was given once a day, 6 times constituting one treatment course. There was one day of a rest before the second course of treatment started. The acupoints used for the control group were the same as for the moxibustion group, only acupuncture was used instead of moxibustion….Usually, the patients in both the moxibustion and control groups were given 5-10 courses of treatment, covering a period of 1-2 months.

In their summary, the authors, echoing the comment that moxibustion does not receive much attention, noted that: "In recent years most clinical and experimental studies have proved that acupuncture with neiguan as the main point has good therapeutic effect in the treatment of coronary heart disease; however, few reports on moxibustion in the treatment of this disease have been seen." They also noted that: "There is no significant difference between the moxibustion and acupuncture groups in their effects." Unfortunately, in the absence of a placebo control, it is difficult to know how much of the effects were due to stimulation of the points and how much were due to other factors not specifically related to the treatment (such as responses usually attributed to "placebo effects"). The claimed benefits included relief of symptoms, improvement of ECG, and lowering of blood pressure and blood lipids. In this case, the authors suggested that the indirect moxibustion was preferred by patients over acupuncture because of lack of pain and discomfort (needling in Chinese clinics is far more vigorous than in Western clinics). This is in contrast to the situation with direct moxibustion, which can be more painful than acupuncture; the painful nature of the usual direct moxibustion being mentioned in several texts.

The intensive moxibustion described in this clinical report where moxa rolls were used contrasts with common practice in Western clinics. Moxibustion was given for 5 minutes at each point, with five points treated, for a total of 25 minutes of moxibustion and the treatment was given daily for 30-60 days consecutively. Heating was done until there was an obvious reddening of the skin. In Acupuncture: A Comprehensive Text (27), the importance of adequate heating is mentioned: "A text of the Qing Dynasty, The Golden Mirror of Medicine, explains: 'When treating diseases with moxibustion, for there to be any effect, the heat must be sufficient to obtain the Qi.'"

In another case of treating a chronic disease, herb-interposed moxibustion was administered in the treatment of Hashimoto's thyroiditis (28). Two groups of points were selected for treatment on alternate days: dazhui (GV-14), shenshu (BL-23), and mingmen (GV-4) made up one set; shanzhong (CV-17), zhongwan (CV-12), and guanyuan (CV-4) were in the second set. Each time, five cones of moxa, 2 grams each, were burned continuously on each point of the set. In patients were treated daily, out patients were treated every other day, with a total of 50 treatments for a course of therapy. Many of the patients were said to have benefited in terms of symptoms and findings in blood tests with regard to thyroid hormones and antithyroid antibodies.

References to the use of moxibustion have declined in recent issues of the Journal. Two very brief articles in recent issues described use of moxibustion, both by the herb interposed method, one with ginger, the other with garlic:

The second report involves moxibustion at a skin lesion. This method appears common in the practice of treating skin disorders, as relayed in the book Treatment of External Diseases with Acupuncture and Moxibustion (15), where this is the primary role of the moxibustion component presented by the authors.


While it is evident from most presentations on moxibustion therapy that the heat administered during the treatment is a key element in dealing with cold and stagnation, the question arises as to what must be used to produce the heat. An explanation for use of moxa wool (shredded artemisia) is that it grows everywhere, so is cheap and easy to get, it readily holds its shape in cones, and its burning characteristics are ideal: it burns slowly, stays lit, produces an even heating, and has a pleasant fragrance (27). But entrance of moxa ingredients into the body doesn't seem to be essential. In Tibet, moxibustion was applied with a hot rod rather than burning moxa, and in China it is not uncommon to put something between the moxa and the skin (as in the cases above, with ginger or garlic) so that any elements of the moxa smoke are unlikely to get into the skin. In almost all Western practices and several of the modern Chinese practices, the elements of the burning moxa mainly go into the air, very little gets to the skin. Thus, one would expect that heat is the aspect of moxa being relied upon.
Nonetheless, some authors describe the value of moxa in relation to its herbal nature. Here is what the authors of Chinese Acupuncture and Moxibustion (2) have to say:
Artemisia vulgaris produced in Qizhou is known as the best kind for moxa, as the climate and soil is good for its growth. The leaves of Qizhou Artemisia are thick with much more wool [soft fibers]. Moxa cones and sticks made of this kind of artemisia are thought to be the top quality used in moxibustion. In A New Edition of Materia Medica appears the following description: 'The moxa leaf is bitter and acrid, producing warmth when used in small amount and strong heat when used in large amount. It is of pure yang nature, having the ability to restore the primary yang from collapse. It can open the 12 regular meridians, traveling through the three yin meridians to regulate qi and blood, expel cold and dampness, warm the uterus, stop bleeding, warm the spleen and stomach to remove stagnation, regulate menstruation, and ease the fetus....When burned, it penetrates all the meridians eliminating hundreds of diseases.' Yang can be activated by the Artemisia leaf by virtue of its warm nature. The acrid odor [spicy fragrance, volatile oil] of the leaf can travel through the meridians, regulate qi and blood, and expel cold from the meridians, and its bitter nature resolves dampness. As a result, it is used as a necessary material in moxibustion treatment.
It seems that the authors confuse the Materia Medica description of artemisia used as an internal remedy with its use in moxibustion. A contribution of the herb material is also mentioned by the authors of the recent text Manual of Dermatology in Chinese Medicine (9):
Moxibustion is an important and perhaps underutilized therapeutic method in traditional Chinese medicine. It may be used alone or in combination with other modalities, such as acupuncture....This method involves the burning of moxa on or above the skin at the location of specific acupoints, or on or near the lesion [to be treated] itself. The heat of the cauterization, as well as the properties of the moxa itself, serve to warm the qi and blood in the channels, expel cold and dampness, restore yang, and, in general, help to regulate the organs and restore health.
Unless the depiction of the herb penetrating through the meridians with application of moxa is understood to involve a spirit-essence that travels from the mugwort into the body and has an effect as strong as the herb when used in decoction, it must be understood that a significant amount of the mugwort vapors and smoke enter the body, either through the skin where the moxa is burned or through breathing the fumes, or both. A question arises, though, as to whether or not it would be better to consume moxa orally (e.g., using artemesia in a decoction or an ingredient in a complex formula in the form of decoctions or pills) than to rely on tiny amounts penetrating the skin during the treatment or larger amounts inhaled as smoke.
This issue is an important one if the practitioner is to select moxa materials and specific techniques. For example, when moxa cones are burned on the end of acupuncture needles (in China, this is typically done for 15 minutes after needling to get the deqi reaction), the constituents of the moxa do not interact with the skin and the local effect is limited to transferring heat through the needle to the acupoints (it is called "warm needling"). Smokeless moxa provides heat, but very little of the vapor; the way it is prepared eliminates those acrid components referred to above that are supposed to warm up the circulation by entering the meridians. Similarly, if one uses an interposing substance, the moxa ingredients are not going to penetrate the skin (though a very tiny amount of the substance from the interposing material might). Most modern clinics are designed to vent the moxa smoke or utilize air purifiers to eliminate as much of it as possible; this approach thus removes a large part of the inhaled smoke with moxa ingredients that might serve a therapeutic function. Further, herbal moxibustion is sometimes substituted by heat lamps or other techniques that eliminate the artemisia altogether; a lotion of herb extracts (that may or may not include artemisia) can be applied to the skin with heat delivered through such lamps in an effort to provide both warmth and some local penetration of herb constituents.
In China, an additional impact of moxibustion was to help sterilize the atmosphere of the rooms in which it was being used; until recently, Chinese hospitals were not clean, and it was easy for patients to pass on infections. Visitors to China noted that acupuncture needles were not sterilized, but merely dipped in an alcohol solution, and the lack of hygienic rigor extended to other aspects of the hospitals. This role of moxa became recognized and some hospitals decided to use the approach routinely, even in rooms where moxa treatment wasn't being given. Hence, an incense made of artemisia and atractylodes (cangzhu) would be used to reduce the bacterial count in the air; it also apparently inhibited viruses (13). According to Chinese evaluations, it could be used in kindergartens and nurseries to reduce the transmission of diseases, including chicken pox, mumps, scarlet fever, common cold, and bronchitis. Thus, when used in an acupuncture clinic, the smoke from moxibustion might help to prevent transmission of disease from one patient to another, which is especially important when dealing with immune-compromised patients. However, with modern Western clinics, the rooms tend to be clean and the smoke of moxa or incense in any large quantity goes unappreciated.


Detailing the functions of moxibustion, the authors of Chinese Acupuncture and Moxibustion (2) say that it is used for the following purposes:
  1. To warm meridians and expel cold. Abnormal flow of qi and blood usually results from cold and heat. Cold causes obstructed flow or even stagnation of qi, and heat results in rapid flow of qi. Normal heat activates blood circulation and cold impedes its smooth flow. Since stagnation of qi and blood is often relieved by warming up the qi, moxibustion is the right way to generate the smooth flow of qi with the help of the ignited moxa wool. In Chapter 75 of the Lingshu it says: 'If stagnation of blood in the vessels cannot be treated by warming up with moxibustion, it cannot be treated by acupuncture.' In Chapter 48 of the Lingshu it states, 'Depressed symptoms should be treated by moxibustion alone, because depression is due to blood stagnation caused by cold, which should be dispersed by moxibustion.'
  2. To induce the smooth flow of qi and blood. Another function of moxibustion is to induce qi and blood to flow upward or downward. For example, moxibustion is given to yongquan (KI-1) to treat the disorders caused by excess in the upper part and deficiency in the lower part of the body and liver yang symptoms due to upward flowing yang qi so as to lead the qi and blood to go downward....If the disorder is due to deficiency in the upper portion and excess in the lower portion of the body and due to sinking of qi caused by deficiency, such as prolapse of the anus, prolapse of the uterus, prolonged diarrhea, etc., moxibustion to baihui (GV-20) may lead yang qi to flow upward.
  3. To strengthen yang from collapse. Yang qi is the foundation of the human body. If it is in a sufficient condition, a man lives a long life; if it is lost, death occurs. Yang disorder is due to excess of yin, leading to cold, deficiency, and exhaustion of the primary qi, characterized by a fatal pulse. At this moment, moxibustion applied can reinforce yang qi and prevent collapse. In Chapter 73 of the Lingshu it says, 'Deficiency of both yin and yang should be treated by moxibustion.'
  4. To prevent diseases and maintain health. In Thousand Pieces of Gold it states: "Anyone who travels in the southwest part of China, such as Yunnan and Sichuan Provinces, should have moxibustion at two or three points to prevent sores or boils and to avoid pernicious malaria, epidemic diseases, and pestilence." It is often said, "If one wants to be healthy, you should often have moxibustion over the point zusanli (ST-36)." In Notes on Bian Que's Moxibustion, it says, "When a healthy man often has moxibustion to the points guanyuan (CV-4), qihai (CV-6), mingmen (GV-4), and zhongwan (CV-12), he would live a very long life, at least one hundred years."
These treatments might include scarring moxibustion depending on the particular case. The different styles of moxa application and the method of keeping-fit moxibustion (the fourth application listed above) were elaborated by Yuan Liren and Liu Xiaoming (11), though with reliance on different points, namely shenque (CV-8), zhongwan (CV-12), yongquan (KI-1), and zusanli (ST-36), the latter point was mentioned above and is a standard for many acupuncture and moxibustion treatments. According to the authors, these points are selected and treated as follows:
zusanli (ST-36): Frequent moxibustion on zusanli can invigorate the spleen and stomach, assist in digestion, hence, strengthening the body and slowing down the process of aging. Some ancient experts advocated the use of scarring moxibustion, placing moxa wool directly on the skin over the point so that a scar is formed after the local skin has developed a boil with pus. Constant application of scarring moxibustion will maintain the moxibustion boil, and this will help to strengthen the body and prolong life. Another similar method, known as hanging moxibustion, is composed of hanging an ignited moxa stick 3-7 centimeters over the point without touching the skin for 5-10 minutes.
Shenque (CV-8): Frequent moxibustion on this point can replenish qi and strengthen the body; it is especially suitable for the middle-aged and elderly. The particular procedure of this kind of moxibustion is as follows: put some salt on the navel, knead some moxa wool into the shape of a cone to be ignited and placed on the salt for moxibustion. The size of the moxa cone should vary with the individual conditions. For people of strong constitution, use big cones in the size of a broad bean and for those of weak constitution, use the middle-sized cones as big as a soybean or use small cones in the size of a wheat grain. The burning up of one moxa cone is referred to as one zhuang. Moxibustion on shenque point requires 7-15 zhuang.
zhongwan (CV-12): This point is an important point for reinforcement, capable of strengthening the spleen and stomach. Both moxa stick and moxa cone are advisable for moxibustion on this point, the duration of which may last 5-10 minutes.
yongquan (KI-1): Frequent moxibustion at this point can strengthen the body and contribute to longevity, for it replenishes the kidney and invigorates yang. When using moxa sticks for moxibustion, it should last 3-5 minutes, and in the case of using moxa cones, 3-7 cones are usually needed each time.
The authors state that the duration of moxibustion should be at least 3-5 minutes, but not more than 10-15 minutes. A relatively longer duration of treatment is indicated for recovery from a serious disease or injury to recapture good health, in autumn and winter, on points of the abdomen (i.e., CV-8 and CV-12), and when treating young and middle-aged adults. Relatively shorter duration of treatment is indicated for simple health maintenance and longevity promotion, for spring and summer treatments, when applying moxibustion to the limbs (i.e., KI-1 and ST-36), for the aged and for children. They caution that:
The aim of strengthening the body and achieving longevity cannot be attained by just applying moxibustion once or twice, it requires persistence for a long time. This does not mean that one should receive moxibustion every day. For the purpose of convalescence for the weak and sick, the moxibustion may be applied once every 2-3 days in the early stage; yet for reinforcement of the body or longevity, it should be once a week in the early stage. And when it has shown some effect, the frequency can be reduced to once a month, and later, once or twice every three months, or even once or twice a year. So long as the practice is persisted in, good effect is sure to ensue.
Another description of life-prolonging moxibustion was offered by Liu Zhengcai (17), with primary focus on zusanli (ST-36), qihai (CV-6), guanyuan (CV-4), and zhongwan (CV-12). The technique was intensive moxibustion. For example, the experience of Wang Chao is mentioned: he said that he never failed to burn 1,000 cones of moxa at guanyuan between summer and fall; or the experience of Liu Jiesheng, who used moxa once a day for five days at beginning of Spring and again at the beginning of Autumn, using large cones on sliced ginger, a total of 30 cones each day of treatment.

Wang Leting, a famous physician in Beijing who practiced from 1929-1979, also commented on using moxa for prolonging life, as described by Dr. Wang's students (22):

The Bian Que Xin Shu (Bian Que's Book of Heart Teachings) says: 'A person without disease should moxa himself for a long time [i.e., regularly]….Although one cannot obtain long life [is not destined to have a long life span], one can achieve longevity of more than 100 years.' Because moxibustion has a warming action and it supports yang, it can be used to course and free the flow of the channels and network vessels, move the qi and quicken the blood, dispel dampness and cold, disperse swelling, and scatter nodulation, secure yang and stem counterflow. For instance, constantly moxaing zusanli (ST-36) is able to regulate and rectify the spleen and stomach function, increase and strengthen the bodily constitution. Constantly moxaing feishu (BL-13), it is not easy to catch an external affliction. Dr. Wang Leting was 88 years old, with the exception of being a little bit hard of hearing, he was still very healthy, his thinking was very keen, and he was still reading and writing books. His secret was mainly doing moxibustion on himself among other methods of protecting his health. He held that after age 40, one's kidney qi declines day by day. Hence, between Summer and Fall every year, when yang qi declines day by day, he began to do moxibustion at qihai (CV-6) and guanyuan (CV-4) with moxa cones. At first, he used 7 moxa cones per day. Then, he gradually used 10 per day and up to a total of 500 for the season. This method greatly strengthened his bodily constitution. He persisted in doing moxibustion for decades and obtained great benefit from it.

The basis for using moxa in the late summer and early fall can be understood by comments in the classics, including the teaching of Li Dongyuan in his Pi Wei Lun (Treatise on Stomach and Spleen). Although Li was an herb specialist and didn't describe use of moxa in this text, he noted that it was traditionally said that diseases of the spleen would heal in the Autumn and that "Blood must be nurtured by all means and the defensive must be warmed by all means. With blood warm and the defensive in harmony, one will live out one's heaven-decreed life span (36)." Moxa provides a warming therapy at this time of year to invigorate the circulation and activity of defensive qi (weiqi) and protect the spleen from the declining yang qi that is occurring as part of the annual cycle, and the blood can be nourished by eating healthy foods, which are digested, and the resulting essence is transported, by the strong spleen function. Failure to take care of this would lead to repeated illness during the cold months, and overall weakening of the body. The important role of the stomach and spleen in generating ying and wei qi helps explain the emphasis on moxibustion at ST-36.

Aside from these uses of moxa for preventive health care, moxa is often applied for alleviating acute symptoms. In an attempt to relieve herpes zoster outbreaks, moxibustion was applied to dazhui (GV-14). According to the report of this application (23), the technique to be used would depend on the patient: for the elderly and weak, warming moxibustion (using a moxa roll) was administered, but for the strong and robust, direct moxa (9 cones, but non-blistering) was done. Treatment was given once per day, with pain alleviation and change of the zoster lesions to scabs occurring in 3-7 days of treatment. A report on moxibustion for gastric spasm by Song and Zhu (12) in the Journal of Traditional Chinese Medicine involved 97 patients with either gastric spasms or intestinal spasms who were treated primarily on the abdomen points CV-8 (along with ST-37 for intestinal spasm) and CV-12 (along with ST-34 for gastric spasm). The authors report that nearly all the patients had their abdominal pain alleviated with one moxa treatment. The technique used was:

The moxa roll was ignited and placed over the selected points to produce a comfortable warm feeling. When the heat became excessive, the moxa roll was moved around the points or a little higher to avoid burns. A piece of gauze could be laid over the point to protect the skin from accidental injury. 30 minutes constituted one session of treatment.

Unlike the concern expressed here to keep the patient comfortable and uninjured, many traditional moxa specialists (such as Wang Kenliang, quoted previously) believed that blistering of the skin was essential to the success of moxibustion when treating serious ailments, much the way that getting the qi reaction and propagated sensation in response to needling was deemed essential to successful acupuncture therapy. This blistering and scarring method is even mentioned in relation to Keeping-fit Moxibustion, which is for preventive health care. Such intensive moxibustion is avoided in the Western practice, which follows more closely the method used for the gastric and intestinal spasm treatments.


There are certain points mentioned repeatedly in the literature on moxibustion; the accumulated experience with using these points suggests that they might be uniquely effective. Aside from zusanli (ST-36), which is also the most frequently mentioned of all the points used for needling, the primary moxibustion points are located on the governing and conception vessels. On the conception vessel, points 4, 6, 8, 12, and 17 are mainly utilized. On the governing vessel, points 4, 14, and 20 are mainly used. One of the important moxa points is dazhui (GV-14), which is the meeting point of the governing vessel with the six yang channels of the hand and foot. An article reviewing the many uses of moxibustion at this point (31) listed the following examples of applications for moxa at this point:
Dazhui was also described separately as the acupoint suitable for treating herpes zoster by moxibustion (23). Reflecting the common usage of the points, the students of Wang Leting noted that the points he used for moxibustion were relatively few. They included conception vessel points 4, 6, 8, and 12, and governing vessel points GV-4 and 20 (he also used the back shu points fenshu, BL-13, and shenshu, BL-23). A harmonizing treatment for the yin and yang is moxibustion at guanyuan (CV-4) and dazhui (GV-14). Robert Johns, in his book The Art of Acupuncture Techniques (32), mentions that this ancient formula is well suited to helping cancer patients recover from the adverse effects of modern cancer therapies. Other moxibustion therapies for helping patients with leucopenia mentioned in Chinese texts include dazhui with zusanli, usually along with one or two other points. One other point frequently mentioned is yongquan (KI-1), a point relied upon for treatment of collapse of yang, for which moxibustion seems appropriate. It might also be used, with slow heating, to help tonify yin.


One theory of the effects of both moxibustion and acupuncture is that the local tissue damage (twisting of tissue fibers when stimulating acupuncture needles, extended cellular damage by the intense heat of moxibustion) initiates a non-specific healing reaction that can have effects throughout the body. This healing reaction is stimulated by production of immunological mediators and neurotransmitters. Modern techniques of acupuncture and moxibustion therapy used in the West may rely, instead, on lesser stimulation that does not produce significant tissue damage (e.g., using thin needles minimally manipulated, using moxa to gently warm the skin). However, it must also be recognized that some modern techniques may do little more than induce general relaxation, without some of the other effects that Chinese physicians have long depended on.
The impact of the local heat stimulus was studied in the laboratory to follow-up on the suggestion that the production of inflammation mediators, mainly histamine, at the site of burning skin were important to the impact of moxibustion therapy (24). After burning a single cone of moxa, the authors found that:
The maximum temperature of the treated spot was about 130° C at the outer skin, and about 56° C at the inner skin. Therefore, moxibustion treatments are naturally considered heat stimulation with inflammatory response. In general, inflammatory response induces vascular changes. Our results of moxibustion as a heat stimulation induced vasoconstriction at the site under the moxibustion spot and vasodilation around the moxibustion spot. The cause of cutaneous vasodilation was histamine and substance P….Our results indicate that moxibustion induces an increase in capillary permeability mediated by histamine; additionally, this enhancement of permeability can be correlated with the degree of mast cell degranulation [release of inflammation mediators by the cells], which relates to the weights of moxa cone used.
The authors concluded from this study and from others (25) that a likely mechanism of moxa was the enhanced activity of the host defense mechanism in response to the local inflammation. They described the response to the localized heating of cone moxibustion as distinctly different from that of a widespread burn, which can impair immunity. Other researchers have also indicated that carefully controlled moxibustion as performed in the laboratory produced immunological responses, including increased lymphocyte numbers, and that it could aid the restoration of immune functions impaired by radiation (26). Moxibustion was suggested to have potential use in treating cancer by virtue of enhancing immune activity mediated by the red blood cells (30). In a laboratory animal study of moxibustion at the point equivalent to dazhui (GV-14) in mice, it was claimed that growth of implanted tumors could be inhibited by enhanced cellular immune functions, probably mediated by enhanced production of favorable cytokines (e.g., IL-2) and resulting increased natural killer cell activity (42). While moxa therapy appears to bolster immune responsiveness, it does not necessarily exacerbate autoimmunity. For example, moxa treatment was shown to reduce delayed type hypersensivity reaction in mice; this action may be accomplished by enhancing the function of suppressor T-cells (37).
Substance P is a neurotransmitter, and one of several that are thought to be induced by acupuncture and moxibustion stimulation; for example, galanin is another neurotransmitter observed to be synthesized in response to moxibustion (38). These neurotransmitters are thought to be important in the regulation of pain, spasm, and neurological disorders, such as depression and anxiety; they are also invoked in response to exercise, and may be part of the explanation for several of the health benefits attributed to higher levels of physical activity (40).
In a laboratory study on rabbits, the point equivalent to zusanli (ST-36) was treated by moxibustion and it was shown that intestinal smooth muscle spontaneous movements declined (39), suggesting a role of the neurotransmitters. This antispasmodic effect is consistent with what is seen during clinical treatment of gastric and intestinal spasms with alleviation of diarrhea. The neurotransmitters evoked by acupuncture (especially electro-acupuncture) and moxibustion may act in parallel with the modulation of immune responses and contribute to a broad systemic change.


One of the frequently investigated functions of moxibustion mentioned in modern Chinese clinical literature is boosting the immune system. It remains unclear whether moxibustion differs in its effects from acupuncture in this regard. In elderly patients, both acupuncture and warm needle acupuncture (with moxa applied to the needles for 20 minutes, using daily treatment for 10 days) applied to zusanli (ST-36) enhanced production of IL-2 (45). In a review article on research examining immunological effects of acupuncture and moxibustion (18), no distinction was made regarding the two techniques, only the points treated and the outcomes were noted for each method interchangeably.
The author of the review article concluded that the effect of the techniques on the immune system might be a secondary result of their effects on the whole body, rather than a specific action. This interpretation does not necessarily contradict the results of animal studies on mechanism of moxibustion: the technique might have an initial effect on the immune system that then produces, via the action of various mediators, a systemic effect that goes beyond the initial immune response, eventually causing a greater immunological improvement. In the report on moxibustion treatment of coronary heart disease, some immune parameters of the patients were measured (including lymphocyte conversion rates and levels of immunoglobulins), showing an enhanced immunological response. The authors had concluded that "moxibustion treats coronary heart disease through regulating the internal environment of the organism and reinforcing its ability to fight disease." This interpretation of results is consistent with the idea that the techniques produce non-specific improvements in the entire body that manifest in better immune function as well as better function of all the internal organs.
In the TCM system, spleen deficiency (a subcategory of qi deficiency) syndrome is often associated with weak immune functions. Evaluation of immunological effects of moxibustion in spleen deficiency patients has been conducted (19, 20) with claimed benefits in immune function tests that accompany alleviation of symptoms. A clinical report on treatment of chronic diarrhea associated with ulcerative colitis or simple chronic colitis with moxibustion focused on immunologic mechanisms (29). Herb-interposed moxibustion was used with two sets of points alternated daily: zhongwan (CV-12), qihai (CV-6), and zusanli (ST-36) made up one set; dachangshu (BL-25), tianshu (ST-25), and shangjuxu (ST-37) made up the second set. The number of moxa cones used would vary by site and syndrome, but ranged from 2 to 7 cones. Daily treatment was provided for 12 days, followed by an interval of 3 days, and then another course of 12 days, for a total of 60 treatments. It was claimed that along with resolution of the diarrhea there was a reduction in the excess IgM and complement that were present at the beginning of treatment for those with ulcerative colitis, and an improvement in the T-lymphocyte subgroup of suppressor cells that inhibit autoimmune reactions.
An improvement in an autoimmune based disorder was also noted for Hoshimoto's thyroditis (28). Immune parameters that were normal at the beginning of the studies did not change. In an outline summary of laboratory and clinical studies of the immunological effects of moxibustion, it was reported that moxibustion could reduce the level of rheumatoid factor (considered a measure of the autoimmune aspect of the disease) in rheumatoid arthritis and improve symptoms of allergic rhinitis (41).
Such findings suggest that the immunological and organ system changes may reinforce and contribute to one another, and that the immune functions are regularized by reinforcing the weak portion of the immune system rather than simply stimulating the immune system generally.


The primary contraindication for moxibustion has historically been the presence of a heat syndrome. This goes along with the idea that moxa introduces heat to the system and does so effectively, and thus the treatment method fails to meet the criteria of balancing a hot condition with a cooling therapy. Theoretically, it could cause the disease to worsen by increasing the imbalance. There are some who have argued against this, as noted above. In similar manner, there are cases where herbalists have argued against the view that in febrile diseases one must always avoid heating herbs and rely only on cooling herbs. However, this contraindication for moxibustion still remains listed in all standard texts. In particular, moxa is considered entirely inappropriate for a deficiency heat syndrome (one based on yin deficiency) and it must be used cautiously in cases where there is local dryness. In a report reviewing indications for acupuncture and moxibustion (43), the authors noted that "We found in our practice that most of the herpes zoster patients responded to moxibustion and round needling…although there were some cases with obvious local dryness due to skin injury where the patients experienced increased pain the more that moxibustion was applied." They suggested that since herpes zoster is a heat syndrome that responded well to the treatment in most of the cases, one should not automatically discount use of moxibustion for heat syndromes, especially those with localized heat as occurs with a zoster outbreak.
Other contraindications for moxibustion involve the sensitive areas of the body, such as the face (where one especially avoids the scarring therapy, but also avoids getting smoke directly into the eyes or nose), the nipples, and the genitals. Ancient texts specify certain points on the head as being contraindicated for moxibustion (27), such as shangxing (GV-23), chengqi (ST-1), sibai (ST-2), touwei (ST-8), jingming (BL-1), zanshu (BL-2), sizhukong (TB-23), heliao (LI-19), and yingxiang (LI-20). Concerns are raised about using moxa during pregnancy for the region of the abdomen and lower back (14, 27).


As noted in the Journal of Traditional Medicine review article on acupuncture and moxibustion in China (4), there are about 50 techniques that have been elaborated. Many of these are minor variations: different substances used in interposed moxibustion (mainly fresh ginger slice, garlic slice, aconite cake, salt), different methods of applying heat to a broad area (moxa rolls, containers with large amounts of moxa), different size cones, applying moxa to the end of an acupuncture needle, and using materials other than artemisia to burn (such as juncus) or to cause hot sensation and blistering without using fire (e.g., with mustard seed or mylabris, an insect with irritant properties). For purposes of this article, the techniques most likely to be used in the modern clinic will be described, taken primarily from the recent compendium Acupuncture and Moxibustion (14), prepared by the Beijing University of Traditional Chinese Medicine.

1. Non-Scarring Moxibustion with Moxa Cones

A moxa cone is placed on a point and ignited. When about 2/3 of it is burnt or the patient feels a burning discomfort, remove the cone and place another one. Three to seventeen cones are continuously burnt to cause flush in the local site, but no blister should be formed. This method is used widely, often for cold and deficiency disorders such as asthma, chronic diarrhea, and indigestion.

2. Indirect Moxibustion (Interposed Moxibustion)

The ignited moxa cone does not contact the skin directly, but is insulated from the skin by a layer of ginseng, salt, garlic, or aconite cake. Depending on the technique used, this kind of moxa may induce blistering, but it is often used for non-scarring moxibustion.
Ginger: cut a slice of ginger about 2-3 cm wide and 0.2-0.3 cm thick, punch numerous holes in it and place it on the point selected. On top of this, a moxa cone is placed and ignited. When the patient feels scorching, remove it and ignite another. Repeat this until all the cones burn and the skin becomes reddish. This method has the effects of warming the spleen and stomach and dispersing cold. It is therefore indicated for symptoms caused by weakness and cold of the spleen and stomach, such as abdominal pain, diarrhea, painful joints, and other symptoms due to yang deficiency.
Garlic: cut a slice of garlic 0.2-0.3 cm thick (a large single clove of garlic is desirable), punch holes in it, put it on the point with the ignited moxa cone on top. Renew the cone when the patient feels scorching. This method has the effect of relieving swelling and pain, and is often used for the early stage of skin ulcer with boils or scrofula.
Salt: this method is usually applied at the umbilicus. Fill the umbilicus with salt to the level of the skin, place a moxa cone on the top of the salt and then ignite it. When it burns out, renew another until all the cones have combusted. As this method has the action of restoring yang from collapse and warming the spleen and stomach, it is effective for the symptoms of sweating, cold limbs, and undetectable pulse resulting from acute vomiting and diarrhea, or flaccid-type of wind stroke and post-partum fainting.
Aconite cake: punch holes in a cake made of aconite powder mixed with alcohol, 3 cm in diameter and about 0.3 cm in thickness. Place on the site for moxibustion with the moxa cone, which is ignited and burnt on top of it. This method is good for warming and strengthening kidney yang, and thus, is adopted to treat impotence, infertility, and ruptured abscess resistant to healing.

3. Moxibustion with Moxa Stick

Mild-warm moxa: Ignite a moxa stick and place it 2-3 centimeters away over the site to bring mild warmth to the local place, but not burning, for some 15 minutes until the skin becomes slightly red. It is suitable for all the syndromes indicated for moxibustion.
Sparrow-pecking moxibustion: In this method, the ignited moxa stick is moved up and down over the point like a bird pecking, or moving left and right, or circularly. It is indicated for numbness and pain in the limbs.

4. Warming Needle Moxibustion

Moxibustion with warming needle is an integration of acupuncture and moxibustion, and is used for conditions in which both retention of the needle and moxibustion are needed. It is applied as follows: after the arrival of qi and with the needle retained in the point, get a small section of a moxa stick (about 2 cm long) and put on the handle of the needle; ignite the moxa stick from its bottom and let it burn out. This method has the function of warming the meridians and promoting the flow of qi and blood so as to treat bi-syndrome caused by cold-damp and paralysis. Application to cold-damp syndrome was the subject of a clinical evaluation involving patients with rheumatoid arthritis (46). Acupuncture was performed by deep needling of the shu (stream) points, and then moxa was applied to the needles for 30 minutes, performed daily (with short breaks) during a two month course of therapy. The original technique described in the classics is different and was called the fire needle. This involved holding the needle in a lamp flame until very hot, and then inserting to the appropriate depth in the body quickly and removing it (34). Warming needle, as now used, allows longer retention and gentler heating.


Just as there are needling techniques associated with tonification (reinforcement) and draining (reducing), moxibustion can be applied with these two different approaches. The basis for the different methods is the intensity and duration of heating during the moxa treatment. The distinction has been described by the followers of Wang Leting and relayed here with slight editing:
As for the problem of supplementation and drainage by moxibustion, these are generally administered in the clinic based on the theory of the Lingshu chapter on back transporting points: 'To supplement by fire, do not blow on the fire, but let it burn out. To drain by fire, quickly blow on the fire and let it burn out spontaneously.' The former method involves letting a slow burning cone burn out by itself: although the heat power is weak, it is persistent and substantial. The latter is quickened by blowing on it. Although the heat power is violent, it is temporary and short. If the supplementing technique is to be used, do not blow on the moxa cone after igniting it. Just allow it to burn gradually and burn itself out. Then, press the point with the hand to concentrate the qi and make the warming persistent. If the drainage technique is to be used, blow on the ignited moxa to increase its speed of burning, then let it burn out or remove it when too hot; do not press the point, but let the pathogenic qi be scattered externally.
When using moxa rolls or other techniques, the basic approach to tonification or draining can still be applied. Tonification utilizes a more steady and prolonged heating, while drainage involves a more rapid and more intense but shorter duration heating of the point (bird pecking moxa is often used, with the end of the moxa roll being brought quite close to the skin with repeated thrusts to get more intense heating of the skin).
A description of reinforcing and reducing techniques of moxibustion was included in a broader report on these techniques for needling (35). The commentators noted:
In ancient times, reinforcement and reduction techniques were attributed to moxibustion, while in modern textbooks they are seldom mentioned. We treated a patient suffering from impotence due to deficiency of the kidneys with moxibustion using reinforcing manipulations; the patient was cured after 5 sessions of treatment. In herpes zoster, moxa cones were ignited and the fire blown with mouth to increase the temperature and thus produce a reducing effect. We have treated dozens of patients in this way with an alleviation rate of 95% immediately after the first session. All the patients were cured after 2 to 3 sessions of treatment. In a case of chronic cold syndrome of the insufficiency type, mild moxibustion (a moxa roll is held approximately 3.5 cm above the skin to produce a sensation of warmth until the skin becomes slightly flushed) and revolving moxibustion (circling the lighted end of a moxa roll around the acupuncture point until the skin becomes flushed) are most often used. In case of acute heat of the excess type, direct moxibustion and bird-pecking moxibustion are most often used….When mild moxibustion is applied to stimulate baihu (GV-20), an action of invigorating yang and arresting prostration is produced, curing organ prolapse. When garlic paste moxibustion or bird-pecking moxibustion is applied to stimulate yongquan (KI-1), an obvious effect of nourishing yin to purge pathogenic fire results, providing a cure for hemoptysis and epistaxis (i.e., bleeding due to heat).


Though not widely used in China, an increasingly popular method in the West is the use of smokeless moxa. The following is the description for use in the modern clinic.

Smokeless moxa
Smokeless moxa is a rod of charcoal impregnated with moxa. It burns hot, but slowly, at an average rate of just 2.7 inches per hour; the rods are about 4.5 inches long, so the total burning time is about 90 minutes before the rod becomes too short to use. The moxa is not easily lit, so it is common to use a torch rather than a simple lighter. Once lit, it burns consistently.

The smokeless moxa pole produces ash at the burning end which tends to stick to the rod. When trying to safely remove the ash from smokeless moxa, the stick should not be tapped against something (e.g., against an ashtray). The tapping, aside from making undesired noise, can crack the charcoal, generating a risk for a piece to fall off and burn the carpet, treatment table, or patient. Instead, the burning end of the moxa stick should be gently rubbed against the top edge and inside of a moxa extinguisher, which will be a quiet operation that dislodges the ash and does not crack the moxa rod.
Moxa snuffer

The moxa extinguisher can be carried in an ashtray, so that the ash is contained. At the end of the moxa session, the moxa stick may be carefully retained while still burning for use with another patient (if it is to be used within minutes) or put out. It is important to check from time to time that all moxa rods are in their proper place so that none are left burning where they can cause damage.
Moxa technique
Moxa can be carried out using a single pole to provide intense heat to a specific point, or with two poles held side by side to heat a larger area. Moxa may be applied to acupuncture needles, but take care not to hold the lit end near the plastic holders, as this can cause melting or evaporation of the plastic (or rely on metal handle needles). While a brief moxa treatment can feel good to the patients, all Chinese texts refer to prolonged heating, usually by repeated application of heat to the same site over a period of several minutes. Be careful not to lose most of the potential benefits by applying moxa for a very brief period or by trying to apply moxa to too many sites, so that each site is only briefly treated.


In contrast to the intense direct heating of points for treating diseases, heat therapy may also be employed to relax tense muscles and gently relieve aching and mild pain. Self-heating moxa pads for these purposes have been available from Korea for more than 20 years. This technology involves having a bag of mugwort and charcoal with an oxygen-sensitive system (iron that reacts strongly with oxygen), so that when the sealed package containing the bag is opened and the bag of material is vigorously shaken for a moment, it heats up. Within five minutes, the pack is heated and it maintains a temperature of 60-75°C (140-165°F) for hours. This is the same technology used for the popular new drugstore products, such as ThermaCare, which are self-heating pads applied to the body (but without the artemisia). 
Moxa pad

Typical applications of the moxa pads include treatment of injuries, back pain, knee pain, and menstrual pain. In addition, these pads are applied for chilliness and discomfort following exposure to excessive air conditioning, frigid outdoor winter conditions, or damp windy weather. A belt to hold the pad over the abdomen is also available. The pads can be used following a treatment with acupuncture and moxibustion to extend the effects of the initial therapy, or as an alternative to those treatments when professional help is not convenient. Moxa pads should not be applied to skin that is broken or to areas that display red inflammation or that develop greater discomfort with application of heat.
TDM lamp
Another method of applying heat is the infra-red heat lamp; a useful variant of this was developed in China, called the "TDP-lamp." It was invented in 1980 by a group of scientists and physicians headed by Dr. Gou Wenbin at the Chinese Medicine Institute in Chongqing. Unlike conventional infrared therapeutic devices, the TDP device features a plate coated with a mineral formation (a low conductance metal with diverse composition). When heated by an electric heating element, the mineral plate emits waves in the infrared range. It produces a uniform heating that makes it more useful than ordinary glass bulb lamps. To increase the heating of a region by the lamp, a medicated oil can be rubbed on the skin; the oil helps retain the heat and its herbal constituents may contribute to the improvement of local blood circulation. Although the makers of the TDP lamp make claims about the special value of its frequency of infrared emissions, there is no evidence that it performs a unique function on this basis.


The report presented here may offer the practitioner some insights into practical aspects of moxa applications. There are a number of unanswered questions about moxa, and this section contains some conclusions of the current author derived from this literature survey.
A certain part of the theory of applying moxibustion is simply based on the traditional Chinese medicine dogma and may not have important implications for practice. For example, the role of the moxa wool appears to be primarily for introducing heat rather than for pharmacological effects of artemisia promoting circulation, warming the meridians, and so on. Similarly, the special applications depicted for moxa with interposing herb materials (ginger, aconite, garlic, or complex herb formulations) appear to be based on the traditional roles of the herbs when taken internally, but these actions are probably not conferred by this method and would certainly be better accomplished by providing such herbs orally. The interposing substances serve primarily as suitable media for conveniently providing moxibustion without direct contact to the skin. Salt interposed moxa works well for treating the umbilicus because of its form; direct moxa would be inappropriate for this sensitive spot, especially in children who are likely to receive this particular therapy.
There has been a heavy reliance on scarring moxibustion in the Chinese tradition. This method is listed first in most of the modern texts that describe moxa, and is featured prominently in the review article about moxa in clinical applications. There is a theory of acupuncture whereby the main function is to induce tissue damage at the acupoints. The twirling, lifting, and thrusting is shown to grab and pull fibers in the subcutaneous level, forcing the body to respond. Another aspect is stimulation of nerves leading to effects in the brain as well as effects of locally-produced neurotransmitters; such stimulation is especially noted with the "deqi" reaction, including tugging of the tissues at the needle and sensations of distention, numbness, and radiating tingling. Scarring moxa also damages the tissues and produces a strong nerve stimulus. Such severe treatment may not be essential, but Chinese specialists repeatedly emphasize the benefits of strong stimulus to the points and laboratory studies suggest that the inflammatory response to local damage by moxibustion is important. At the least, the skin must become sufficiently reddened that there is a healing response to limited damage. Some of the reliance on scarring moxibustion may be based in archaic ideas that would no longer be widely accepted. In Treatment of External Diseases with Acupuncture and Moxibustion (15), it is pointed out that sometimes the sores induced by direct moxa not be allowed to heal:
The Thousand Pieces of Gold says: 'People who tour Wu and Shu should moxa some points regularly and leave the sores unhealed for some time. This will keep the toxic qi of miasma, leprosy, and warm malaria away from them.' The Great Compendium also says, 'If one intends to be safe and sound, one should keep zusanli (ST-36) wet' [that is, from the drainage of a moxibustion sore]….The blister and its sore are called a moxibustion flower. In former times and still by some practitioners, the production of such a moxa flower has been considered crucial for successful treatment. The Taiping Shenghui Fang (992 A.D.) says: 'Suppose a sufficient number of cones are burned up. Only when a sore develops and weeps pus may the disease be cured. If no sore is produced or no pus engendered, the disease will not be relieved.' In modern times, some Chinese practitioners continue with this practice, and their clinical experience confirms that intentionally produced moxa sores do have something to do with the curative effect. In spite of the effectiveness, only a few patients are undaunted enough to receive this therapy because of the pain it inflicts.
Clearly, the thinking about moxibustion by most modern clinicians is moving away from the concept that scarring (with or without maintaining the drainage) must be used. The claims for superior effectiveness of scarring moxibustion have to be questioned since there are no studies comparing scarring versus non-scarring moxibustion. These claims are only impressions of the practitioners who obviously believe enough in the therapy to put the patients through the ordeal. On the other hand, it might be reasonable to assume that intense heating of the skin by direct moxibustion is likely to produce more of a response than mild heating as sometimes administered with use of moxa rolls held at a distance from the skin.
When non-scarring moxibustion is used, the duration of treatment in reported clinical trials is usually long and probably much longer than administered by most Western practitioners. Numerous moxa cones and moxa sticks are applied typically for 15 minutes or more in total, with 5-15 minutes per point (longer for warm needle technique). Thus, the treatment is still strong in nature even if there is no blister formed.
Practitioners in the West might consider the following:
  1. If one wishes to avoid the smoke of regular moxibustion, it seems acceptable to use other methods of heating, so long as they can provide similar levels of heat and as long as one can maintain adequate control over the heating (e.g., to prevent burning and also to prevent the heating from becoming too light). As such, smokeless moxa may be satisfactory. In fact, moxibustion may be replaced by acupuncture in most applications, providing that the acupuncture stimulus is sufficiently strong to generate an immunological and neurological response.
  2. When using herb-slice or cake interposed moxibustion, do not forget to punch holes in the material; this allows the heat to penetrate. The thickness of the slice should be just 0.2-0.3 cm; thicker slices may prevent adequate heating. For practical purposes, ginger slices may be most convenient and it is not evident that one must choose the interposing substance based on its pharmacological properties in relation to the condition to be treated.
  3. For moxibustion to be effective, it needs to cause significant local heating and inflammatory response and should be done for a prolonged period, not just a minute or two. Therefore, specific points for moxa heating should be chosen and treated effectively, rather than trying to warm numerous points with only a little stimulus. Warming a broader region is an acceptable treatment for relaxing tension and moderating pain at the site; this is a different application than trying to stimulate the immune system, alter internal organ functions, or otherwise rapidly heal a disease. For chronic ailments, Chinese physicians typically administer moxa daily for several treatments, up to 50-60 sessions. Moxa treatments might be alternated with acupuncture and patients may appreciate the variation in treatment methods.
  4. The most frequently mentioned applications of moxa are gastro-intestinal disorders, asthma, organ prolapse, bi-syndromes, and herpes zoster. These are reasonable targets for modern clinicians to consider for this type of therapy, which may otherwise be too inconvenient as a method (at least, when done properly). In particular, herpes zoster is emphasized as a case where moxibustion is effective. For asthma, both acupuncture and cupping have also been claimed to be highly effective, and these might be more appropriate for those who are sensitive to inhaling smoke from moxibustion.
  5. The risks of exposure to moxa smoke are probably similar to that for any other smoke, and total exposure time, particularly when it involves prolonged exposure, is the key concern. Occasional use of ordinary moxa would be associated with low risk, while routine exposure to moxa smoke during much of the day would be a moderate risk. Therefore, venting or filtering is an appropriate step when moxa is done regularly. There is no evidence that moxa smoke contains any unusually harmful substances. Standard commercial moxa materials do not contain realgar (an arsenic compound), though this substance has been rarely included in blends made by individual doctors in China for their own use.
  6. There are certain points that are most frequently mentioned in the moxibustion literature which may be a good basis for consideration by modern practitioners. These points may be relatively convenient to treat from a physical perspective, may be well accepted by most patients, and may have a higher response rate than others. Most of the points are on the conception and governing vessels, plus zusanli and yongquan, and shu points on the back.
It is difficult to know, based on the literature review, whether moxibustion is more effective than acupuncture or other stimulus methods administered for the same condition. In the absence of more detailed studies, moxa is applied primarily on the basis of the Chinese traditional medical descriptions, such as treating syndromes associated with cold, retention of food, spasms, immune deficiency, and local stagnation of fluids with formation masses. Moxa may be utilized in some cases of heat syndromes.


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January 2004

The Household Physician


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