Volume 7, Number 2 | Summer 2012

Clinical Report 1 (Acupuncture)
Oriental Medical Acupuncture and Moxibustion Treatment
Based on Multifaceted Body Surface Observation- A Case of Low Back Pain and Diarrhea Kazuma Ito
Kyoto University Graduate School of
Human and Environmental Studies,
Kyoto University
Furokaku, Acupuncture and Moxibustion Clinic

body surface". Thus, "body surface findings" isdefined as findings obtained through observation of
the body surface. "Healthy qi" is defined as a generic
term

for

primordial

original

vital

energyenergy), ancestralqi,(vitalenergy,nutrient qi,

protective qi, yin qi and yang qi.
II. Case
Age: 35 years; male, first examination in December

I. Introduction
In modern Japan acupuncture and moxibustionof 20XX.

treatment employs various forms of examinations,right inguinal region; #2 diarrhea (watery)therapeutic theories and techniques1). These forms[Examination details]of acupuncture and moxibustion treatment currently[Anamnesis (medical interview)]

practiced in Japan are defined in the body of this text

[Present illness]

as acupuncture andmoxibustion2).

characteristics

JapaneseofRegarding theacupuncture

andChief complaint: #1 pain from the right hip to the#1 pain from the right hip to the right inguinal
regionmoxibustion the extensive amount of information

Junior high school period: He practiced basketballobtained through touching and observing the bodyand started to experience pain in the right lumbar

surface has been described many times before3-12).

region from that time on.

Touching the body surface is not restricted to pulse

In April 20XX: Started hang a heavy bag over his

diagnosis, but includes the palpation of theright shoulder. From that time on the patient started

meridians according to Oriental medical concepts as

to experience the pain in the right lumbar region.

well as the palpation of skin, muscles, tendons, bones

November of the same year: Started to strongly feel

etc. according to Western medical concepts. Thesedull pain in the right lumbar region (because hetechniques play an important role in the assessment

carried luggage on the right side).

of pathologies based on these findings and theCurrently:

evaluation of therapeutic results.

Type and severity of the pain is the same as it was in

In

the

present

multifaceted

November. The pain extends from the right lumbar

observations based on the conduction of the four

region to the right inguinal region. As long as he isexamination techniques, in particular palpation, in

working, it does not bother him, but during rests, thea case with low back pain and diarrhea. And I believe,

pain starts to bother him. When he is exhausted or

the Oriental medical treatment was effective.

it is cold, the patient experiences numbness down

Additionally I would like to make some observations

into the right leg.

regarding

Relieving factors: taking a bath; warming; extendingthereportI

madecharacteristics

ofJapanese

acupuncture and moxibustion.

the hip.

Moreover, the term body surface observation used in

Aggravating factors: hanging luggage over the right

this text is defined as the Oriental medical

shoulder; upon rising in the morning.

examination#2 Diarrhea (watery stool)techniques

observation,

listening,smelling and palpation. Observation, listening,

4-5 days ago: He attended a drinking party but

smelling and palpation are considered to represent

drank only iced tea. Later, diarrhea developed.

an "observation of phenomena manifesting on the

Frequency was 4-5 times per day.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 7, Number 2 | Summer 2012

Currently:[Present status]

The watery stool continues. Frequency is 4-5 times○ Height: 175 cm. Weight: 68 kg.

per day; there is almost no smell. After its onset the○ Diet: Has appetite; eats three meals a day; timing

low back pain developed almost daily in the morningof meals: breakfast 6:40～7:00, lunch after 12:00;

after which he then passed loose stools. After thedinner 20:00～21:00 (or 22:00). Approximately one

onset of the diarrhea the low back pain was neither

month ago the patient started to crave cake orrelieved nor aggravated. After a bowel movement insimilar sweet foods and eats them. He did not do thatthe morning there is no feeling of residual stools, but

before.

otherwise there is a feeling of residual stools○ Micturition: 7-8 times/day; sensation of incomplete

following bowel movements. The patient experiences

emptying.

a mild degree of fatigue after bowel movements.

○ Bowel movements: Normal condition is 1-2
times/day; always somewhat soft (slipping out○ Normal stool condition: 1-2 times/day; always

stools).

somewhat soft (slipping out stools).

○ Sleep: Goes to bed around midnight or half past

[Past history]

midnight; rises at 6:30; no nocturia; almost does not

March 20XX-1: Pancreas cancer; underwent surgery;dream; stays for a while in bed after awakening in

resection of pancreas body, head and spleen; surgicalthe morning.

removal of aortic lymph nodes.

[Physical examination]

August of the same year: liver metastases were

○ MMT (manual muscle testing):

discovered.

extensor hallucis power: right = 5, left = 5

October of the same year: Initiation of chemotherapy,

flexor hallucis power: right = 5, left = 5

because the metastatic lesions had grown. Therapy○ Sensory test of legs: the right 5th digit is a little

consisted of daily administration of TS-1. Gemzar

numb.

administration once/week. After the chemotherapy○ SLR (straight leg raising test): negativeloss of appetite and diarrhea developed.

○ FNS (femoral nerve stretch test): negative

By July 20XX:○ Thomas test: negativeloss of appetite and diarrhea did not

develop any more.
Currently:[Oriental medical findings]

TS-1 is used for 2 weeks followed by one week rest.

○ Tongue diagnosis

Gemzar is no longer administered.

Tongue surface: dark pink tongue; there is darkened[Family history]color, slightly soft consistency (lifeless swelling), no

The father had hypertension. Currently the patient

fissures or no dental indentations, somewhat

lives with his father and mother in a 3-person household.

marked moisture, no ecchymosis or petechiae, white[Social history]

coat.

Between the age of 22 and 31 the patient was a

Tongue underside: dark faintly red – red color; there

company employee (salesperson).

is darkened color; markedly engorged sublingual

Currently: attending vocational school.

veins.

[Personal history]○ Meridian diagnosis*):Alcohol consumption: has not been drinking.

Listed here in the order of the severity of deficiency

Smoking: Had been smoking until the discovery ofof both channels and collateral channels13) (sweating

the pancreas cancer (20 years).

→ surface weakness → dimpling, coolness).

Twenty cigarettes/day.

Note)

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 7, Number 2 | Summer 2012

Meridian diagnosis refers to a diagnostic method,

Inch pulse (cun mai) … the width from the skinwhere careful palpation of the skin over both

surface to the radial bone (below called pulse width)channels and collateral channels from the very

extends from the floating to the deep position.

superficial down to the deep layers and thus allows

The shape of the pulse is distinct, albeit somewhat

to assess a variety of conditions (example: sweating,soft.

weakness, dimpling, tension, induration, bulging,

Bar pulse (guan mai) … the pulse width extends

coolness, heat etc.).

from the floating to the deep position. The pulse on
the right side is a little hard.

(1) Tai yang bladder meridian of the foot … weakness

Cubit pulse (chi mai) … the pulse width extends fromand coolness (right > left). (← this indicates left andthe middle to the deep position. The pulse lacks aright as viewed from the therapist; same applies

little strength, but in the deep position has viscous

below.

properties. This is particularly marked on the right(2) Lesser yin kidney meridian of the foot …

side.

weakness and coolness (right > left).
(3) Greater yin spleen meridian of the foot …

tensioncoolness (right ≧ left).
(4) Greater yin lung meridian of the hand …
sweating and weakness (right ≧ left).
○ Abdominal diagnosis (Figure 1):
hypochondrial region … tension (right > left); flanks… tension (right > left).
paraumbilical region … tension (right > left);hypogastric region … weakness and coolness.
○ Back diagnosis (Figure 2):
Left and right BL12 (Fengmen), left and right BL13
(Feishu) … weak; left and right BL15 … tension (left> right).
Left and right BL17 (Geshu) … weak surface,

Weakness, coolness

subcutaneous tension. Tension in the region of theupper back in general is stronger on the left side.

Figure 1

Left and right BL18 (Ganshu), left and right BL19

(The shaded portion indicates tension; increasingly darker(Danshu), left and right BL20 (Pishu), left and right

Abdominal diagnosis

slanted lines indicate increasingly higher tension)

BL21 (Weishu), left and right BL22 (Sanjiaoshu), left
and right BL23 (Henshu), left and right BL24
(Qihaishu), left and right BL25 (Dachangshu) …
weak surface, subcutaneous tension.
The lumbar region of the back in general shows aweaker surface on the right than on the left, while
subcutaneously there is strong viscous tension.
○ Condition of the toes: pain in the left and right fifth
digit, difficulties moving the toes.
○ Pulse diagnosis:

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 7, Number 2 | Summer 2012

deficiency), <the diarrhea is considered mainly be
due to kidney deficiency>[Pattern identification]
First the individual patterns are indicated and thentension in the depth

the details of the pattern identification shown.
[Eight-principle pattern identification]
The surface was in general softer on
the left than the right, showing astrong, viscous

Exterior and interior: exterior pattern (floating pulse,neck stiffness, chills) is not observed. Therefore thisis an interior pattern.
Concrete details will be verified through the qi, bloodand body fluid pattern identification, yin-yang
pattern

identification

andorgans/visceraandmeridians/channel pattern identification.
Cold and heat: cold pattern. Concrete details will beverified through the qi, blood and body fluid pattern
identification and yin-yang pattern identification.
Deficiency and excess: complex deficiency and excess
pattern; the large number of dental impressions

Figure 2 Back diagnosis△: tension ○: weakness □: tenderness: widened spaces between the spinous processes

found during tongue diagnosis verify a qi and yangdeficiency.
Other concrete details will be verified through the qi,[Assessment of the pathophysiology][Modernwestern

medicalassessment

blood and body fluid pattern identification, yin-yangofthepathophysiology]

pattern

identification

andorgans/visceraandmeridians/channel pattern identification.

#1 Suspicion of myofascial low back pain (problemsof the iliocostal, longissimus, lumbar quadrate[Qi, blood and body fluid pattern identification]muscles as well as the oblique and transverse

Qi stagnation: #1 during

muscles of the abdomen are conceivable)

development of discomfort during rest.

Suspicion of some anomaly of the first sacral

Extension of the lower back is a relieving factor for

vertebra (however, a herniated intervertebral disc is

#1.

based

Conditiononthefindings

ofvariousphysical

found

work

through

alleviation

abdominalanddiagnosis

examinations unlikely)(tension of hypochondral regions and flanks).

#2 The acute diarrhea raises suspicions of aQi deficiency: verified through organs/viscera andnoninfectious diarrhea

meridians/channel pattern identification.
Yang deficiency: Bathing and warming (note that

[Oriental medical assessment of the pathophysiology]

this phenomenon also appears in cases of qi#1 Kidney deficiency (mild form of kidney yangstagnation) is a relieving factor for #1.

deficiency centering on a kidney qi deficiency), qi#2 Watery stools (kidney yang deficiency symptom).

stagnation in the greater yang bladder meridian of#2 The stools have almost no smell.

the foot#2 Prior to the onset of the diarrhea the patient#2 Kidney deficiency (kidney qi and kidney yangingested large amounts of cold drinks.

deficiency), spleen deficiency (mainly spleen qi

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 7, Number 2 | Summer 2012

[Organs/visceraandmeridians/channel

pattern

Tai yang bladder meridian of the footidentification]#1 Manifestation of lumbar symptoms (note theKidney:course of the tai yang bladder meridian of the foot).

#1 Low back pain since junior high school (kidney qi

Meridian diagnosis showed some weakness in the

deficiency)

course of the tai yang bladder meridian of the foot,#1 Condition of the low back (kidney (qi, yang)surface findings of coolness.

deficiency that affected the tai yang bladder

Lesser yin kidney meridian of the foot:meridian of the foot).

Meridian diagnosis showed weakness in the course#2 Diarrhea early in the morning (wu geng xie:of the lesser yin kidney meridian of the foot, surface

kidney yang deficiency condition).

findings of coolness.

#2 Fatigue after bowel movements (kidney (qi, yang)

Greater yin spleen meridian of the foot:deficiency condition).

Meridian diagnosis showed surface coolness in theAnamnesis showed that the patient had undergone

course of the lesser yin kidney meridian of the foot.

surgery (injury of the congenital qi).
Abdominal diagnosis showed weakness and coolness[Cause and mechanism of disease] (Figure 3)of the abdomen.

Presumably the kidney qi and yang deficiency

Back diagnosis showed surface findings at the leftcondition had been present from before. At the sameand right BL23, BL24, BL25 and BL22.

time the presence of problems with the middle

Pulse diagnosis showed intermediate chi pulse.

energizer, in particular the spleen, was also

◎ Both kidney qi and kidney yang deficiency are

surmised. They probably led to the development ofconceivable.

the pancreatic cancer. The surgery for the pancreatic

Spleen:cancer and the chemotherapy caused a progression,#2 Occurrence of diarrhea (spleen (qi, yang)leading to an aggravation of the kidney qi and yangdeficiency condition).

deficiency and the spleen qi deficiency. From April#2 Bowel movement induced fatigue (spleen (qi,20XX hanging a heavy bag over the right shoulderyang) deficiency condition).

presumably disturbed the body balance and impeded

Normal stool condition (tends to be soft).

the flow of qi, leading to a qi stagnation. Pathogenic

Began to crave sweets about one month ago (sweet isqi caused by qi stagnation often influences sites of

one of the five tastes associated with the spleen).

weakened healthy qi. In this patient the qi

Development of pancreas cancer (presumably there

stagnation is considered to have influenced the tai

has been a problem with the middle energizer).

yang bladder meridian of the foot. Before aUpon initiation of the chemotherapy the patient lostbackground of a weakened tai yang bladder

his appetite and developed diarrhea (spleen (qi,meridian of the foot there is a kidney deficiency. Iyang) deficiency condition).

assume, the chief complaint #1 has developed for

The back diagnosis revealed body surface findings atthat reason. Further, drinking large amounts of cold

the left and right BL20, BL21 and BL22.

drinks during a drinking party led to an aggravation

Pulse diagnosis showed somewhat hard properties ofof the kidney (qi and yang) deficiency and spleen

the right guan pulse.

deficiency◎ A spleen yang deficiency is conceivable as adevelopment of the chief complaint #2.

problem with the spleen and because of the absence

The author places great importance on body surface

coolness as a body surface finding, this was

findings from the back transport points and theconsidered mainly due to spleen qi deficiency.

meridians in order to learn more about the pastandI

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

assumed,

this

led

to

the

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Volume 7, Number 2 | Summer 2012

condition of the patient's body. In this patient the

manipulated, applying the thrusting and lifting andtime of development of the current findings of thethe twirling techniques.

individual back transport points and meridians is

After treating (1) the body was in the following state.

unknown.

Tongue diagnosis: appearance of some brightness as

However,

based

on

the

author's

experiences of the condition of those back transportcompared to before treatment of (1).

points and meridians have probably developed years

Pulse

diagnosis:

improvement

of

the

(1)

pretreatment intermediate guan pulse position, but
the pulse was still hard and viscous in its deep

[Cause and mechanism of disease]

position.

Middle energizer(spleen) problem

Kidney (qi, yang)deficiency: surmised

Right low back pain: some pain remained. VAS:

Development ofpancreas cancer

Surgery,
chemotherapy

Progression of kidney(qi, yang) deficiency

Carries a bag
always over
the right
shoulderInfluence on the tai yang
bladder meridian of the foot(before a background of kidney
deficiency)(pretreatment) 10→2 or 3 (after treatment of (1)).

Spleen qi
deficiency

Pathogenic qi often influences
regions of weakened healthy qi

Disturbance ofbody balanceleads toQi stagnation#1 Pain from theright lumbar to theright inguinal
region
Excessive
amounts ofcold drinks

Drinking
party(2) Right KI3; 0.14/40 mm (Seirin made stainlessinsertion under the skin) for 3 minutes.

Further progression of kidney (qi, yang)deficiency and spleen qi deficiency

After treatment of (2) the body was in the following*It is unknown when the current findings of the individual back transport points andmeridians have developed. However, based on the author's experiences the conditionof those back transport points and meridians have probably developed years ago.

state.
Tongue diagnosis: appearance of some brightness ascompared to before treatment of (1).

ago.

Pulse diagnosis: pulse strength and width increased

Figure 3

in the guan pulse position. The hardness of the pulse[Cause and mechanism of disease]

had improved in particular on the right side in the
deep position.

[Treatment plan and objective]
The treatment plan was to treat the right-sided low
back pain and diarrhea. Treatment was carried out
mainly according to Chinese medical and Oriental
objectives.

Concreteobjectives

were

tonification of kidney and spleen (tonification of bothspleen and kidney), while promoting qi flow
(regulating qi).

Abdominal diagnosis: chilling of the hypogastricregion decreased and it became slightly warmer. The
weakness also become a little firmer.
III. Results[Effects immediately afterward] (after treatment (2))
#1 Right low back pain: patient almost did not feelpain. VAS: (pretreatment) 10→1 or 2.
Right inguinal region: the patient did not feel any

Treatment details
Acupuncture was the chosen treatment technique.
First the problems of the organs were addressed.
(1) Right BL20; 0.14/40 mm (Seirin made stainlesssteel needle)(1) Right BL23; 0.14/40 mm (Seirin made stainlesssteel needle)
The needles were retained in both points for 8
minutes. While retaining the needles, they were also18

I next used a meridian approach.
steel needle); applied twirling at the skin surface (no#2 Diarrhea

medicalSince problems at the right inch pulse still remained,

pain but still experiences some discomfort. VAS:
(pretreatment) 10→3 or 4.
#2 Diarrhea: currently under follow-up.
#1 The symptom remains, but since the surface
findings of tongue, pulse and abdominal diagnosis
showed improvements, the treatment was cut off at
this time.
[Health preservational instructions]

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 7, Number 2 | Summer 2012

Refrain from cold drinks and food. Return for a

to independently assess treatment induced changes

reexamination in 3-4 days.

in symptoms and conditions.
For this patient I performed multifaceted body

[Reexamination report]

surface observations and emphasized in particularThree days later the patient contacted me.

palpation. As palpation I performed not only pulse#1 On the day following the acupuncture treatment
the discomfort in the right inguinal region had been
alleviated. The right-sided low back pain had
improved to a degree, where it did not bother thepatient any longer.
#2 Diarrhea had stopped immediately after theacupuncture treatment. The stools had return totheir usual consistency. Based on this condition thetreatment was terminated.
One month later I had a chance to meet the patient.

diagnosis, but also meridian, abdominal and backdiagnosis. This practice can be called a concrete
example for "the richness of palpatory quality andthoroughness" said to be a characteristic of Japanese
acupuncture.

The

multifacetedbodysurfaceobservational findings also provide the ground forhighly varied Oriental medical interpretations of thefindings. This is conceivably one of the reasons
giving rise the high degree of diversity of Japanese

When I inquired about the above describedacupuncture and moxibustion.

symptoms, he replied that neither the right-sided

In this case the examination also included physicallow back pain nor the diarrhea had recurred since.

examinations.

Theobtained

physicalfindings

allowed to assume the Western medical assessment
IV. Discussionof the pathophysiology of #1. Japanese acupuncture

For this patient I performed a multifaceted bodyand moxibustion school education comprises thesurface observational examination centering on

study of both Western and Oriental medicine. Also,

anamnesis and palpation. This information was thenmany study meetings held in Japan provide theanalyzed according to Chinese medical and Oriental

opportunity to study a great variety of subjects

medical concepts to assess the pathophysiology. For

pertaining to acupuncture and moxibustion. The

the treatment I chose only few acupoints. As shownconcretein this case is a treatment with few acupoints one

acupuncture and moxibustion dealt with during

effective method, when the therapist is aware of thethose various study meetings depend on the specifictherapeutic effects of the individual acupoints andviews of the relevant study groups, their concepts of

their compatibility with examination results anddiseases, treatment, examination techniques anddiagnosis. It is also a good method to comprehend thethe relevant theories as well as therapeutic

Oriental medical body and illness concepts.

techniques. Study of these various concepts allows

The evaluation of the therapeutic effects was madethe practitioner to broaden his/her therapeuticin this case based on changes in body surface

horizon. A broader range of treatment options thenfindings

thanmakes it possible to treat patients with a variety ofobservations of changes in the symptoms. The

different diseases. The abundance of acupuncture

author thinks, these changes in body surface

and moxibustion treatment options forms the basis

findings reflect alternations in symptoms andof the great diversity of Japanese acupuncture anddisease status (improvements, aggravations, nomoxibustion, and at the same time also the basis forchanges). This conceivably enables the practitioner

the complexity of Japanese acupuncture and

in

the

supinepositionratherdetailsofsubjects

pertaining

tomoxibustion.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 7, Number 2 | Summer 2012

V. Conclusions

studiesA patient presenting with low back pain extending

Conference

from the right lumbar to the right inguinal region

Moxibustion, 2010

and diarrhea was treated with acupuncture. Based

7)

from

Shin
of

Kinoshita–",

ClinicalJapan

Acupuncture

Shoji Shinohara, Nao Wazuchi, Katsuyuki

on the therapeutic results I came to the conclusion,

Watanabe: "Current Situation and Problems ofthat the acupuncture treatment was effective.

Japanese

Examination particularly emphasized multifaceted

Treatment Forms", supervised by Kazushi

body surface observations centering on palpation.

Nishijo,This was also used to evaluate the therapeutic

Acupuncture

effects. Body surface observations effectively allow

Ishiyaku, 2000, pp. 3-28

the practitioner both for the evaluation of the

8)

Takao

and

Kumazawa

andMoxibustion"Science

MoxibustionofClinics",

Denmei Shudou: "Recommendation of Meridian
Therapy", Ido no Nippon, 1988, pp.126-198

therapeutic effects and an assessment of possible
future conditions of the patient. Multifaceted

Acupuncture

9)"Obtaining

Body

SurfaceFindings",

observation, in particular palpation, lie at the base"Acupuncture and Moxibustion OSAKA", Vol. 19,of the diversity of Japanese acupuncture andNo. 3 (2003), pp.4-90
10) Renpu Fujimoto: "Body Surface Observation –moxibustion.

theKazuma Ito: "Current situation of the various11) Hirokimi Matsuda: "Collection of Interviews

Schools"; in "Research into Social Acupuncture

Acupuncture and Moxibustion I"; Midori Shobo

and Moxibustion 2011", Vol No. 6; 2012, pp.5-9

Co., Ltd., 2010, pp.250-253

AcupunctureandShuichi Katai: "Acupuncture and MoxibustioninJapan"

and"Japanese

Acupuncture and Moxibustion" in "Research
into Social Acupuncture and Moxibustion 2011",

4)12) Kanpu Yokota, Shuichi Katai: "Touch, talk 9";
Ido no Nippon Vol. 69, No.1 (consecutive Vol. 796,
2010), pp.227-237
13) Renpu Fujimoto: "Body Surface Observation –Vol No. 6; 2012, p.i.

thewisdomSodou Okabe: "Acupuncture and Moxibustion

Moxibustion; Midori Shobo Co., Ltd., 2012,

Meridian Therapy"; Sekibundo, 1974, pp.68-79

pp.66-67

Shuichi Katai, Hirokimi Matsuda: "Japanese
Acupuncture and Moxibustion in Crisis; facing
various problems pertaining to global strategies
of Chinese acupuncture and moxibustion" in"Oriental Medicine; Journal of Acupuncture &Moxibustion", Vol. 12 (2010), pp.15-33

5)

Shuichi Katai: "Development of the Hands ofClinicians – Essay on reactivity and palpation",
Rokuzensha, 2002

6)

Shinichi Kinoshita (author), Kenji Okamoto,
Yoshiki Sano, Shin Suzuki et al. editors:

20

Acupuncturewith Hirokimi Matsuda; in search of Japanese

Treatment

3)

Japanese

Moxibustion

Japanese2)ofMoxibustion; Midori Shobo Co., Ltd., 2012

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wisdom"Textbookfor

MasteringTechniques

–the

Basic

Needling

teacher-student

education

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

ofJapanese

Acupuncture