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Acupuncture point Large Intestine 4 (LI-4)

As the commentary in A Manual of Acupuncture puts it, Large Intestine 4 (Hégǔ LI-4) is ‘probably the best known and most commonly used of the acupuncture points’. Accordingly, it was one of Ma Danyang’s famous ‘eleven heavenly star points’. It’s also the Yuan-Source point of the Large Intestine channel. You can read the entire Large Intestine 4 section from A Manual of Acupuncture below for more in-depth information.

Research relating to Acupuncture point Large Intestine 4

A variety of research on LI-4 can be seen here.

Clinical experience with Acupuncture point Large Intestine 4

LI-4 is a point which is located in various different ways by different practitioners and sources. The description below places it at the midpoint of the first metacarpal, and close to the bone. Some will locate it further into the fleshy area between thumb and first finger, and others close to where the metacarpal bones of the thumb and first finger meet.

It’s worth noting that this point can elicit strong radiating sensations, and sudden jolts at times (when the radial nerve is stimulated), so a gentle approach is best. It can even be quite tender when used for acupressure.

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Acupuncture point Large Intestine 4 location and needling video (taken from A Manual of Acupuncture digital products)

Acupuncture point Large Intestine 4: excerpt from A Manual of Acupuncture

The following text is taken from the Large Intestine 4 section of A Manual of Acupuncture, by Peter Deadman and Mazin Al-Khfaji with Kevin Baker. A Manual of Acupuncture is the primary acupuncture point resource used in colleges and universities throughout the world, and contains extensive information on all the acupuncture points and channels. The full text includes point classifications, Chinese calligraphy, detailed location and needling instructions, point actions and indications, a summary of clinical application, and point combinations.

A Manual of Acupuncture is now available in digital form – via iOS/Android apps, and a fully-featured Online Edition website – offering students and practitioners access to a whole host of features, including location and needling videos (see example above), multiple self-testing modules, channel pathway videos and much more.

Acupuncture point li4

L.I.-4 HÉGǓ

Joining Valley 合谷

Yuan-Source point of the Large Intestine channel
Gao Wu Command point
Ma Dan-yang Heavenly Star point

Location
On the dorsum of the hand, between the first and second metacarpal bones, at the midpoint of the second metacarpal bone and close to its radial border.

Location note
Ask the patient to squeeze the thumb against the base of the index finger, and locate Hégǔ L.I.-4 at the highest point of the bulge of the muscle and approximately level with the end of the crease.

Needling
i. Perpendicular insertion 0.5 to 1 cun; ii. Oblique insertion directed proximally 1 to 1.5 cun.
Caution: contraindicated in pregnancy.

Actions
Regulates the defensive qi and adjusts sweating
Expels wind and releases the exterior
Regulates the face, eyes, nose, mouth and ears
Activates the channel and alleviates pain
Induces labour
Restores the yang

Indications
Exterior wind-cold pattern, chills and fever, injury by cold with great thirst, copious sweating, absence of sweating, febrile disease with absence of sweating, floating pulse.
Headache, one-sided headache, headache of the whole head, hypertension.
Redness, swelling and pain of the eyes, dimness of vision, superficial visual obstruction.
Nosebleed, nasal congestion and discharge, rhinitis, sneezing.
Toothache or pain of tooth decay in the lower jaw, mouth ulcers, lotus flower tongue, cracked tongue, rigid tongue, lips do not close, tightness of the lips.
Throat painful obstruction, childhood throat moth, mumps, loss of voice.
Swelling of the face, deviation of the face and mouth, lockjaw, deafness, tinnitus.
Amenorrhoea, prolonged labour, delayed labour, retention of dead foetus.
Dysenteric disorder, childhood nutritional impairment, childhood fright wind, wind rash, malaria, mania.
Painful obstruction and atrophy disorder of the four limbs, hemiplegia, pain of the sinews and bones, pain of the arm, contraction of the fingers, pain of the lumbar spine.

Commentary
Hégǔ L.I.-4 was included by Ma Dan-yang, the great physician of the Jin dynasty, among the ‘eleven heavenly star points’, his grouping of the most vital acupuncture points, and was indicated by him for headache, swelling of the face, malaria with chills and fever, tooth decay, nosebleed and lockjaw with inability to speak. The Ming dynasty author Gao Wu in his work Glorious Anthology of Acupuncture and Moxibustion also recognised the supreme importance of this point and included it among his ‘four command points’ (for the face and mouth). Some hundreds of years later it is still probably the best known and most commonly used of the acupuncture points.

Hégǔ L.I.-4 is a primary point to expel wind-cold or wind-heat and to release the exterior. It may be useful in this respect to view the yang Large Intestine channel as the exterior reflection of the yin Lung channel with which it is coupled. The Lung dominates the exterior by virtue of its function of controlling the skin and body hair and spreading the defensive qi. Attack by exterior pathogenic wind-cold or wind-heat which disrupts the exterior portion of the Lung system therefore, may be treated via points of the Large Intestine channel, most notably by Hégǔ L.I.-4. Thus the Great Compendium of Acupuncture and Moxibustion recommends this point for “injury by cold, headache, rigid spine, and absence of sweating”. This is the classic presentation of wind-cold binding the exterior portion of the body. The basic principle in Chinese medicine for the treatment of this condition is to release the exterior by inducing sweating, thereby expelling the pathogen along with the sweat and facilitating the circulation of defensive qi. In fact, Hégǔ L.I.-4 may also be used for injury by any exterior pathogenic factor which is accompanied by sweating (in this case pathological sweating which does not serve to expel the pathogenic factor). This dual action of Hégǔ L.I.-4 on both inducing and stopping sweating is reflected by the advice given in the Great Compendium of Acupuncture and Moxibustion to reinforce Hégǔ L.I.-4 and reduce Fùliū KID-7 if there is no sweating, and to reduce Hégǔ L.I.-4 and reinforce Fùliū KID-7 in cases with copious sweating. The explanation of this apparently contradictory function is that Hégǔ L.I.-4 is able to regulate defensive qi and hence adjust the pores, whatever the pattern, indeed some authorities go so far as to attribute to Hégǔ L.I.-4 the ability to tonify the defensive qi.

The passage from the Great Compendium of Acupuncture and Moxibustion quoted above includes the symptom of ‘great thirst’, which is clearly not typical of exterior patterns (where the fever and thirst are still relatively mild). This does, however, reflect the common use of Hégǔ L.I.-4, especially in combination with Qūchí L.I.-11, to reduce high fever of whatever aetiology.

Hégǔ L.I.-4 is the single most important point to treat disorders of the face and sense organs. This has been emphasised in numerous classics, for example the Classic of the Jade Dragon states “Hégǔ L.I.-4 treats all diseases of the head, face, ears, eyes, nose, cheeks, mouth and teeth”. This point is essential in the treatment of any disorder affecting these areas – whether acute or chronic, hot or cold, deficient or excess – but is least used clinically for disorders of the ears. As far as headaches are concerned, Hégǔ L.I.-4 is considered appropriate in the treatment of headache in any location due to attack by exterior pathogens, and most particularly any frontal (yangming channel) headache. In clinical practice, however, it is used even more widely, for example the Classic of the Jade Dragon recommended Hégǔ L.I.-4 for one-sided or generalised headache, whilst the Ode of the Jade Dragon more specifically recommended Hégǔ L.I.-4 for head wind without phlegm, and Fēngchí GB-20 for head wind with phlegm. The affinity of Hégǔ L.I.-4 for both the forehead and the side of the head reflects the fact that the internal pathway of the Large Intestine channel meets with the Gall Bladder channel at Yángbái GB-14, Xuánlú GB-5 and Xuánlí GB-6.

Hégǔ L.I.-4 is considered to have a particular ability to ease pain, especially in the areas discussed above, and is a commonly used point in acupuncture analgesia. According to Chinese medicine, pain of excess type arises when impaired circulation of qi and blood leads to stagnation. This is expressed in the saying “without movement there is pain, with movement there is no pain”. The special ability of Hégǔ L.I.-4 to treat pain is explained by the statement in the Spiritual Pivot “Yangming channel is abundant in qi and blood”. This emphasises the particular ability of points on the Large Intestine and Stomach (yangming) channels to promote circulation of qi and blood, and thus dispel obstruction and stop pain, for example in painful disorders such as painful obstruction. However the abundance of qi and blood in the arm and foot yangming channels means that their points are not only important to dispel stagnation, but also to tonify qi and blood in the channels and thus bring nourishment to the limbs in case of atrophy disorder and hemiplegia. In practice, Hégǔ L.I.-4 is commonly combined with Jiānyú L.I.-15 and Qūchí L.I.-11 in the ‘chain and lock’ point association method for pain, paralysis or atrophy of the upper limb.

Bilateral Hégǔ L.I.-4 and Tàichōng LIV-3 are known as the Four Gates. This combination first appeared in the Ode to Elucidate Mysteries which said “for cold and heat with painful obstruction, open the Four Gates”. The text goes on to imply that the yuan-source points of the six yang channels emerge at the four gates. Since a fundamental principle for treating painful obstruction is to select points from yang channels, this helps to explain why these two points are considered so effective in treating painful obstruction. Subsequently, the use of the Four Gates has been extended to treat a variety of disorders involving pain and spasm. This is an elegant combination. Hégǔ L.I.-4 on the upper extremity lies in the wide valley between the first and second metacarpals, whilst Tàichōng LIV-3 on the lower extremity lies in the wide valley between the first and second metatarsals. Hégǔ L.I.-4, the yuan-source point, belongs to yangming channel which is ‘abundant in qi and blood’ whilst Tàichōng LIV-3, the shu-stream and yuan-source point of the Liver channel, has the function of spreading the qi. Together they are able to activate the qi and blood and ensure their free and smooth passage throughout the body.

Hégǔ L.I.-4 has a strong action on promoting labour. The Ode to Elucidate Mysteries tells how the Song dynasty Crown Prince, in a dispute with the doctor Xu Wen-bai over whether a pregnant woman was carrying a girl or twins, ordered her belly to be cut open to find out. Xu Wen-bai begged to use his needles instead, and on reducing Zúsānlǐ ST-36 and reinforcing Hégǔ L.I.-4 two babies emerged. Due to its strong action of inducing labour, and even promoting the expulsion of a dead foetus, Hégǔ L.I.-4 is contraindicated in pregnancy.

Finally Hégǔ L.I.-4 is cited in the Song of the Nine Needles for Returning the Yang, for the treatment of collapse of yang characterised by loss of consciousness, aversion to cold, cold counterflow of the limbs, purple lips etc.

Summary of clinical application
Primary point to expel wind-cold or wind-heat and to release the exterior: chills and fever, much sweating, febrile disease without sweating, floating pulse.
For all disorders of the face and sense organs: headache, eye diseases, nosebleed, nasal congestion and discharge, rhinitis, sneezing, toothache, pain of tooth decay in the lower jaw, mouth ulcers, throat painful obstruction, mumps, loss of voice, swelling of the face, deviation of the face and mouth, lockjaw, deafness, tinnitus.
Relieves pain and spasm and promotes smooth flow of qi and blood in the whole arm: painful obstruction and atrophy disorder of the four limbs, hemiplegia, pain of the tendons and bones, pain of the arm, contraction of the fingers. Forms the ‘Four Gates’ with Taichong LIV-3 for a variety of disorders involving pain and spasm.
Promotes menstruation and labour: amenorrhoea, prolonged labour, retention of dead foetus.

Combinations
Little sweating: reinforce Hégǔ L.I.-4, reduce Fùliū KID-7. Copious sweating: first reduce Hégǔ L.I.-4 then reinforce Fùliū KID-7 (Great Compendium).
Injury by cold with absence of sweating: Hégǔ L.I.-4 (reinforce), Nèitíng ST-44 (reduce), Fùliū KID-7 (reduce) and Bailao (M-HN-30) (Great Compendium).
Injury by cold with sweating: Hégǔ L.I.-4 (reduce), Nèitíng ST-44 (reduce), Fùliū KID-7 (reinforce) and Bailao (M-HN-30) (Great Compendium).
Injury by cold with great heat that does not recede: reduce Hégǔ L.I.-4, Qūchí L.I.-11, Xuánzhōng GB-39, Zúsānlǐ ST-36, Dàzhuī DU-14 and Yǒngquǎn KID-1 (Great Compendium).
Diseases of the head, face, ears, eyes, mouth and nose: Hégǔ L.I.-4 and Qūchí L.I.-11 (Miscellaneous Diseases).
Headache: Hégǔ L.I.-4, Tiānchí P-1, Tóngzǐliáo GB-1, Yújì LU-10, Sìbái ST-2, Tiānchōng GB-9, Sānjiāoshu BL-22 and Fēngchí GB-20 (Systematic Classic).
One-sided or generalised headache: Hégǔ L.I.-4, Sīzhúkōng SJ-23 and Fēngchí GB-20 (Great Compendium).
One-sided or generalised head wind: Hégǔ L.I.-4, Bǎihuì DU-20, Qiándǐng DU-21, Shéntíng DU-24, Shàngxīng DU-23, Sīzhúkōng SJ-23, Fēngchí GB-20, Zǎnzhú BL-2 and Tóuwéi ST-8 (Great Compendium).
Head wind and dizziness: Hégǔ L.I.-4, Fēnglóng ST-40, Jiěxī ST-41 and Fēngchí GB-20 (Great Compendium).
Head wind with splitting sensation, pain between the eyebrow and the eye: Hégǔ L.I.-4, Yángbái GB-14 and Jiěxī ST-41 (Classic of the Jade Dragon).
Pain of the head and nape: Hégǔ L.I.-4, Hòudǐng DU-19 and Bǎihuì DU-20 (Great Compendium).
Dimness of vision: Hégǔ L.I.-4, Yǎnglǎo SI-6 and Qūchāi BL-4 (Supplementing Life).
Internal eye obstruction: Hégǔ L.I.-4, Tóngzǐliáo GB-1, Zúlínqì GB-41 and Jīngmíng BL-1 (Great Compendium).
“When Jīngmíng BL-1 is ineffective in treating diseases of the eye, combine it with Hégǔ L.I.-4 and Guāngmíng GB-37” (Ode of Xi-hong).
Superficial visual obstruction: Hégǔ L.I.-4, Jīngmíng BL-1 and Sìbái ST-2 (Great Compendium).
Loss of voice: Hégǔ L.I.-4, Yǒngquǎn KID-1 and Yángliāo GB-35 (Systematic Classic).
Swollen painful throat: Hégǔ L.I.-4, Shàoshāng LU-11 and Tiāntú REN-22 (Great Compendium).
Nasal polyps and nasal congestion and discharge: Hégǔ L.I.-4 and Tàichōng LIV-3 (Song of Points).
Red eyes and nosebleed: Hégǔ L.I.-4, Tóulínqì GB-15 and Tàichōng LIV-3 (Song of Points).
Bleeding from the nose: Hégǔ L.I.-4 and Tiānfǔ LU-3 (One Hundred Symptoms).
Rhinitis with clear nasal discharge: Hégǔ L.I.-4, Fēngmén BL-12, Shéntíng DU-24, Zǎnzhú BL-2, Yíngxiāng L.I.-20, Zhìyīn BL-67 and Fùtōnggǔ KID-20 (Thousand Ducat Formulas).
Deafness: Hégǔ L.I.-4, Zúlínqì GB-41 and Jīnmén BL-63 (Song of Points).
Purulent ear sores with discharge: Hégǔ L.I.-4, Yìfēng SJ-17 and Ěrmén SJ-21 (Great Compendium).
Swelling, pain and redness of the ear: Hégǔ L.I.-4, Tīnghuì GB-2 and Jiáchē ST-6 (Great Compendium).
Itching and swelling of the face: Hégǔ L.I.-4 and Yíngxiāng L.I.-20 (Ode of Xi-hong).
Swelling of the face and abdomen: Hégǔ L.I.-4, Zhōngfǔ LU-1 and Jiānshǐ P-5 (Thousand Ducat Formulas).
Deviation of the mouth and eye: Hégǔ L.I.-4, Jiáchē ST-6, Dìcāng ST-4, Rénzhōng DU-26, Chéngjiāng REN-24 and Tīnghuì GB-2 (Illustrated Supplement).
Sudden mania: Hégǔ L.I.-4, Jiānshǐ P-5 and Hòuxī SI-3 (Great Compendium).
Manic raving with fear and fright: Hégǔ L.I.-4, Yújì LU-10, Zhīzhèng SI-7, Shàohǎi HE-3, Qūchí L.I.-11 and Wàngǔ SI-4 (Thousand Ducat Formulas).
Lockjaw following windstroke: reduce Hégǔ L.I.-4, Jiáchē ST-6, Rénzhōng DU-26, Bǎihuì DU-20 and Chéngjiāng REN-24 (Great Compendium).
Loss of consciousness from windstroke: Hégǔ L.I.-4, Rénzhōng DU-26 and Zhōngchōng P-9. If this is ineffective, needle Yǎmén DU-15 and Dàdūn LIV-1 (Great Compendium).
Difficult delivery: reinforce Hégǔ L.I.-4, reduce Sānyīnjiāo SP-6 and Tàichōng LIV-3 (Great Compendium).
Absence of lactation: Hégǔ L.I.-4, Shàozé SI-1 and Shānzhōng REN-17 (Great Compendium).
Prolapse of the rectum: Hégǔ L.I.-4, Dàchángshū BL-25, Bǎihuì DU-20, Chángqiáng DU-1, Jiānjǐng GB-21 and Qìchōng ST-30 (Compilation).
Dysenteric disorder: Hégǔ L.I.-4 and Zúsānlǐ ST-36; if severe add Zhōnglǔshū BL-29 (Song of Points).
“For cold and heat with painful obstruction, open the Four Gates” [Hégǔ L.I.-4 and Tàichōng LIV-3] (Ode to Elucidate Mysteries).
Unendurable pain of the arm that radiates to the shoulder and spine: Hégǔ L.I.-4 and Tàichōng LIV-3 (Ode of Xi-hong).
Acute dysmenorrhoea: Hégǔ L.I.-4 and Dìjī SP-8.