Moxibustion: Practical Considerations for Modern Use of an Ancient Technique

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.

RELATIVE POSITION OF MOXIBUSTION IN ACU-MOXIBUSTION

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:

• Gastroptosis (7): First, moxa was applied on a fresh ginger slice on baihui (GV-20) while the patient is sitting still and relaxing. When that part of the treatment is concluded, the patient lies down, and moxa is applied to zhongwan (CV-12) and qihai (CV-6). Treatment time was just 15 minutes (5 minutes per point), and the treatment was given once or twice a day. The patients were also given exercises to do daily to improve strength of the abdominal muscles. After a 15-day course of treatment, it was said that 30 of 50 cases were cured and that all other cases showed some degree of improvement. The authors stated that: "baihui is a point of the governing channel, which dominates yang of the whole body. Moxibustion on it can tonify qi and promote qi ascending in the middle jiao. zhongwan and qihai of the conception vessel are selected as the essential local points. Moxibustion on these two points may warm up the middle-jiao, replenish qi, promote ascending of yang qi, so as to relieve the prolapse."
• Acute lymphagnitis (also called "red-thread furuncle;" 8): A three-edge needle is used to let out blood at both ends of the furuncle. Thin slices of garlic are placed on these two blood letting points, and then moxa is applied. The therapy involved 1 to 3 treatments, with claim of cure in all cases, most of them requiring 2 treatments.

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.

IS THE MOXA-WOOL IMPORTANT?

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.

INDICATIONS AND APPLICATIONS FOR MOXIBUSTION

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.

THE PRIMARY MOXIBUSTION POINTS

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:

• Expelling wind, clearing heat, and dispersing the lung to relieve the exterior (for acute feverish diseases);
• Dispersing the lung, eliminating cold, and activating yang to relieve asthma;
• Restoring consciousness, tranquilizing the mind, and calming internal wind to relieve epilepsy;
• Removing obstruction in the governing channel to relieve spasm and dispersing yang to eliminate pathogenic factors (for cervical spondylopathy and other disorders of the spinal column);
• Warming the channels, restoring yang, and replenishing qi to consolidate resistance (protecting from recurrent common cold and influenza).

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.

POSSIBLE MECHANISMS OF ACTION OF MOXIBUSTION

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.

MOXIBUSTION AND IMMUNE SYSTEM FUNCTION IN HUMAN CLINICAL WORK

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.

CONTRAINDICATIONS FOR MOXIBUSTION

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).

THE TECHNIQUES OF MOXIBUSTION

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.

TONIFICATION AND DRAINING STRATEGIES

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).

SMOKELESS MOXA

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 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.

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 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.

HEAT LAMPS

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.

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.

INTERPRETATION

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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