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Hara Diagnosis Hara is a Japanese word. Its translation is not easy because there is an entire culture that lies behind the translation. Loosely, it refers to the soft belly or dantian. I recognize that there are several different spellings of dantian. Dantian can be translated as elixir field, sea of qi, energy center. It represents a place from which the Sea of Qi can be reached and influenced. It must be viewed as an area of varying size inside the abdomen, not as a specific point. In that sense, it is the area known as the "small hara" or the "small abdomen", which is a term used in Chinese classical texts that discuss the origin and location of the Eight Extraordinary Vessels. The physical location of the hara or lower dantian is a below the navel, inside the body, close to the spine. Not referring to the physical space as much as the energetic or spiritual aspects.

The area is defined by going vertically by the lower edge of the sternum and the upper edge of the pubis and laterally by the lower border of the ribcage and the anterior iliac crest. Corresponding with the area of the peritoneum (see below), which is not covered by the ribcage, and coincides with the viscera covered by the greater omentum (see below). The peritoneum is the serous membrane that forms the lining of the abdominal cavity. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum supports the abdominal organs and serves as a conduit for their blood vessels, lymph vessels, and nerves. The greater omentum is a large apron-like fold of visceral peritoneum that hangs down from the stomach. It extends from the greater curvature of the stomach, passing in front of the small intestines and doubles back to ascend to the transverse colon before reaching to the posterior abdominal wall. The greater omentum is larger than the lesser omentum, which hangs down from the liver to the lesser curvature. The greater omentum appears to float on the surface of the intestines. It is the first structure observed when the abdominal cavity is opened anteriorly.

Here is a quote which helps explain the power of the abdomen, with regards to diagnosis and treatment, “All important energetic concepts in Chinese medicine are linked to the source, the abdominal area. From a diagnostic perspective, palpation of the abdomen is critical. It enables us to diagnose all that reflects there, the moving qi between the Kidneys, the source. Since everything springs from the tai ji, which is equivalent to the ming men and the moving qi, the extra ordinary vessels, the organs and their meridians are all reflected in the abdomen. Treating the indications found on the abdomen is equivalent to treating the problem that created the problem”. Kiiko Matsumoto & Stephen Birch (1988), “Source theory” Hara Diagnosis: Reflections on the Sea, Paradigm Publications. pg 128. The Principles of Hara Diagnosis: The basics of abdominal diagnosis are that anything you find or feel has significance. Just as the ear, the hand or the foot is used as a microcosm of the whole body, so is the hara. With hara diagnosis, you have the full participation of your patient. They know what they feel and can feed that information back to you. Gently touch the area first. Let the patient know you will be palpating this area. You will use both hands. One hand will be a stabilizing hand, it remains in a supportive position on the ribcage. This hand is sometimes referred to as the mother hand. The other hand will be the messenger hand, the hand that will be moving around the hara. You will use 3 fingers, the index, middle, and ring fingers. Make sure your nails are clipped short. Your middle finger is usually a little longer than the others so you may feel with this one first. Try to remember not to be aggressive, go slowly. You don’t want this to be an unpleasant experience. Let the patient get used to what you are doing. As the patient inhales, place your fingers over the abdomen. As they exhale begin finger pressure. If the abdomen is in a healthy condition, you should be able to press inward to the depth of one knuckle without producing pain, and without the practitioner feeling resistance. The resistance could be

hardness, a kind of ropy feel, coldness, or other sensations that the patient would report as feeling odd to them. The messenger hand moves along to assess all 12 areas of the hara. You are using a “diagnostic” touch with the messenger hand, meaning that you are inquiring about the nature of each area rather than intending to deeply penetrate the area. When palpating the hara, use a pattern that is not haphazard. Go from the patients left to right to center. Some organ channels are on both sides of the body.

Basics : Hara Diagnosis Mother hand or stabilizing hand gently placed on rib cage begin at: Heart with messenger hand at 12 o’ clock Heart area is a small ball area below the sternum. You will assess by touching the top of the ball. Gallbladder with messenger hand at 11 o’ clock Gallbladder area is a small almond left of center. Your fingers point towards the underside of the ribs, with fingertips curling back to perpendicularly meet the contour of the skin surface.

Liver with messenger hand at 10 o’ clock Liver area is the outer 2/3 of the ribcage on patients right side, practitioners left side. It is a large, solid organ. Your fingers point towards the underside of the ribs, with fingertips curling back to perpendicularly meet the contour of the skin surface. Lung with messenger hand at 9 o’ clock Lung angles in from the side. It is a hollow pouch just in front of the tip of the 11th rib. Back to Heart position to palpate the left side of patient Stomach with messenger hand at 1 o’ clock Stomach area is the right side of the ribcage closer to the midline. It is a muscular, hollow organ. Your fingers point towards the underside of the ribs, with fingertips curling back to perpendicularly meet the contour of the skin surface. Triple Heater with messenger hand at 2 o’ clock Triple Heater area is the lateral 1/3 under the ribcage. It feels like a space or a hollow. This area is typically about half the size of the stomach area. Your fingers point towards the underside of the ribs, with fingertips curling back to perpendicularly meet the contour of the skin surface. Lung with messenger hand at 3 o’ clock Lung angles in from the side. It is a hollow pouch just in front of the tip of the 11th rib. Back to Heart to assess midline of patient Messenger hand at 12 o’ clock Pericardium Messenger hand halfway between 12 o’clock and the navel Pericardium is an oval between Heart and Spleen. Hand and fingertips follow the vertical midline.

Spleen with messenger hand just above the navel Spleen is a ball that starts just above the navel and goes to the bottom of the swell of the belly. Assess it just on top of the ball, just above the navel. Kidney with messenger hand finds a hollow below the Spleen ball. Kidney is a horseshoe that is underneath and around the sides of the spleen area. Assess it on the midline, below the bottom roundness of the belly. Bladder with messenger hand at 6 o’ clock Bladder area is a horseshoe that runs below and around the kidney horseshoe. Assess it on the midline, just above the pubic bone. Large Intestine with messenger hand just in front of ASIS Large intestine runs parallel to the hip bone. Assess it at its highest point, just anterior to the ASIS (prominent hip bone) Large Intestine Opposite Side Again, Large Intestine is best felt just in front of the ASIS. Small Intestine with messenger hand finds a line running between 7 and 8 o’ clock and the navel Small Intestine area feels like a slender envelope. You have to angle your fingers just right to slide into the envelope. Small Intestine Opposite Side with messenger hand finds a line running between 4 and 5 o’ clock and the navel The information you gather from touching the hara can guide you as you work on the rest of the body, telling you where and how energy may need to be redistributed in order to restore balance.

When you place your hand on these areas, you can feel the general condition of the meridian as well as the amount of energy that has collected at that point. Some areas — where there is a lack of energy — may feel loose; other areas — where there is an excess of energy — may feel tight. What should you be feeling for? Temperature variations Is the patient cooler below the navel and warmer above? This could represent a counter flow of qi with kidney deficiency and excess above. Tightness or tension Checking below the rib cage and along the abdominal muscles if tension is present it could point to deficiency rather than excess. The muscles should feel more flexible or elastic, as this points to a more healthy abdomen.. Pain on Pressure When palpating points, the patient feels sharp pain - it is pointing to an excess or full type of stagnation. These are more significant that a dull ache. If it is relieved by pressure, then there is deficiency. Sounds There will be gurgling sounds in the subcostal / hypochondriac region, if there is fluid stagnation in the stomach. Lumps Moving lumps are more yang and considered easier to treat. Stationary lumps are more yin and more difficult to treat. Remember, it could also be gas or stool you are feeling in the intestines. These lumps are knots of muscle or tissue, and you should palpate around the lump not on it. For all kinds of lumps, both yin and yang, treat with moxa at GV 4. There are different types of treatment for lumps in the Nan Jing chapter 55 and 56.

Many people have a pulsing that can be felt under the fingertips. This could indicate deficiency and it depends on the strength, depth and location of the pulsating. A slight pulsing around the navel is considered normal and it is the kidney qi. Skin quality Normal skin turgor (fullness and elasticity) is maintained by the presence of water in and between the skin cells along with elastic fibers in the skin. In both overall body dehydration and in “isolated” skin dehydration, such as in elderly, there is less water in the skin, decreasing skin fullness and hence its elasticity. Healthy skin usually can be pinched between fingers and has a springy feeling, returning quickly to normal. You can also pinch the skin on the abdomen for hara diagnosis. Loose skin and/or dry skin, indented skin signals deficiency. Tight skin, swelling of the skin points to excess.

It is important to remember that these techniques take lots of practice. And once you get comfortable with the palpation side of it, you ask now what do I do with this information? If you simply use the palpatory findings to distinguish a deficiency or excess within a meridian you can treat as you normally would with needles for that deficiency or excess. You may also use these palpatory findings to confirm a diagnosis. As you become more familiar with what you are doing and look into other methods of treatment you can go in other directions. Here are some pathologies and findings with hara diagnosis:

Liver Yin Deficiency with Empty Heat: findings will include:

Left subcostal tension Pulsation on the side of the navel (kidney meridian) up to CV-9 Irritability, with hot flashes in the upper body with the lower body exhibiting cold. Resistance with pressure pain extending from the superior aspect of the pubic bone through the superior portion of the inguinal area. Deficient heat will rise up, causing LU-1 and CV-17 to exhibit pressure pain and feel hot to the touch. Yin Deficiency is a progression where an excess leads to deficiency and deficiency leads to excess. Yin deficiency may last a long time without symptoms or signs of Empty Heat.

Liver Deficiency Cold:

findings will include: Coldness in the chest The entire upper abdomen feels tense and stiff on the surface, as you press in with your fingers there will not be resistance underneath. Slight resistance and pressure pain around ST-25 on both sides Resistance/pressure pain in the ileocecal region. The lower abdomen will be soft and cold. There will be tension in both lateral extremes of the abdomen, pressure on the superior portion of the inguinal area to the superior aspect of the pubic bone.

Spleen Qi Deficiency with Stomach Heat: findings will include: The chest will feel very warm if not hot to the touch. The abdomen will be distended. Resistance to touch and press fingers into. Strong resistance in the epigastric region around CV-14. Patient feels fullness in the chest and abdomen. The lower abdomen along the CV line can feel slightly less resistant due to a deficiency of yin fluids caused by heat in the Stomach and Intestines.

Spleen Qi Deficiency with Cold or Deficient Heat in Stomach: findings will include: Resistance and pressure pain in the epigastrium, at CV-12. It is believed that a serious illness is indicated if the area of resistance extends to CV-14. The Stomach channel/meridian on both sides will be tense from ST-19 to ST-25 and below. The area around the navel may react to the slightest pressure producing pain. Pulsation may be felt at CV-9 in some. If these pulsations extend up as far as CV-14, it is believed that the condition will be difficult to treat. Pressure pain on both sides at LU-1. Pressure pain from ST- 25 on the left to the area of the sigmoid colon.

Spleen Deficient Cold: findings will include: When the cold pattern is mild, slight resistance will be felt at CV-12. If there happens to be phlegm retention, then resistance and pressure pain will appear also at CV-14. The lower abdomen will be soft, and cold. With a severe cold pattern, the entire abdomen will be sunken /depressed and will show no resistance.

Spleen Qi Deficiency with Excess Liver heat: findings will include: Edema and pressure pain above and below the costal margin on both sides, but more so on the right. Below the costal margin there will be resistance that may extend from LV-14 to the area around CV-14. This is caused by Liver excess heat. If there is only resistance and no pressure pain, then the Liver excess was caused by blood stasis and not by heat. Resistance and pressure pain in the epigastric region at CV-12. The Inguinal region will also produce pain on pressure.

Spleen Deficiency with Liver Excess: findings will include: Resistance and pain at CV-12. Begin at ST-19 down to ST-25 and horizontally from LV-14 to ST-19. If the area is tense and hard mass feeling like a fibrous rope inside, mostly on the right side without pain from pressure. This is in the Nan Jing and is considered Lung accumulation. Resistance and pain on pressure with a hardened mass or formation, and pressure pain extending from below ST-25 on the left, going under the navel, and over to below ST-25 on the right. New blood stasis: findings are mainly on the left Longstanding blood stasis: findings are mostly on the right.

Lung Deficiency with Liver Excess: findings will include: Subcostal tension on the right side, which corresponds to Lung accumulation, as mentioned above. Right side at ST-19 will produce pain on pressure with resistance, This is commonly caused by overeating. Resistance and pain on pressure is felt at the superior portion of the inguinal region and the area above the pubic bone Lower abdominal blood stasis just below and to the sides of the navel. Resistance and pain on pressure in the ileocecal area. Kidney Yin Deficiency with empty Heat The Conception Vessel meridian will show a deficiency below the navel because of Kidney deficiency, it may feel like a pencil. The Stomach meridian will feel tight on both sides. This is the deficient-empty heat spreading from the Kidney to Stomach meridian If CV-17 produces pain on pressure and the chest feels hot to the touch, this can be seen as a precursor to heart disease. Qi rises to the upper warmer when there is Kidney deficiency, and a resistance in the epigastric region is likely. Kidney Yang Deficiency /Cold The lower abdomen is weak and protrudes. Intestinal movement is common. The abdomen will feel cool to the touch. I find Kiiko Matsumoto one of the most influential practitioners of Hara Diagnosis. She uses special techniques. She is a master, and you cannot expect to learn these techniques by reading this course. She has several books that are very helpful. You have to practice, and have a great desire to learn. She believes that at any area that you find pain, ropy, hardness, etc., it indicates a pathology: This is called a “reflex area.” Any one area in the abdomen can reflect more than one pathology.

The procedures of diagnosis by palpation can be complex. There is not a system of one sign – one problem. There are two parts to the diagnostic procedure. First, palpation of the abdomen, followed by the palpation of points to confirm the abdominal findings. With Kiiko Matsumoto style treatments, the treatment goal is to eliminate all pressure pain that shows up on the abdomen as well as the back and neck. Clearing the abdomen (neck, throat, and back) is the “root treatment.” Below are a few of these findings and treatments. The most common finding is called Oketsu. Oketsu means non-physiological, sluggish, dirty, piled-up blood. Not blood stagnation, but poor microcirculation. Maybe caused by prior illnesses such as a fever, infection, repeated trauma, operations or bruises, etc. Approximately 70-80% of all patients show Oketsu, regardless of their complaint or other abdominal findings. Oketsu shows on the area of left ST26, ST27, Kid15. This is an area, not a matter of exact point location. The portal vein that leads to the liver comes from the left side, so any obstruction will cause a more sluggish flow that will show on the left side. This does not necessarily mean that there is liver involvement. This sluggish microcirculation must be cleared before any other treatment is considered. Matsumoto’s standard treatment to clear Oketsu is: left Liv4 with left LU5. As we know, point location is subjective. The location of Liver 4 is 1 cun anterior to the inferior margin of the medial malleolus, medial to the tendon tibialis anterior. Half-way between SP 5 and ST 41. Books describe the location of LU 5 as on the cubital crease radial side of the tendon m. beceps brachii. Matsumoto goes almost one cun / or a thumb’s width laterally making it closer to L.I.11. Needles are placed with the flow of the meridian. The Oketsu reflex area can then be rechecked with the needles in place to see if the oketsu has been “cleared”. If a remaining sensation is still there, needle manipulation at LU 5 should clear the rest. The Japanese method of needling is not looking for the patient to feel a qi sensation. Rather the intention is to break up this obstruction so that the blood will flow freely. Most times it is shallow needling and slight manipulation.

If a lump is felt at the oketsu reflex area, then there is also blocked circulation at the inguinal joint. Palpate the left inguinal ligament to find the ropy area. It should be felt around GB 27 and 28 and ST 30. Find the ropy area and press it. Go back and test the Oketsu reflex area, and it should improve. Tap the needle (very shallow) into the ropy area that helps release Oketsu the most. If there is pain, treat the area first with acupressure before needles. Check the left inguinal groove around LV 12, pressing upward with the channel towards the public bone. Be aware that Oketsu can be complicated by other syndromes. Poor circulation being one. This must be addressed before oketsu can be cleared. If the circulation problem is caused by lack of blood flow, then tonify the Spleen. Bilaterally insert needles at SP 9 & 10. Going upwards with the channel and tap the needles in. Remember, shallow needling. Adrenal exhaustion is another extremely common pattern. Adrenal reflex has a specific location and shows just below K16. It must show on both sides and it cannot be above K16. With reference to a clock around the navel where CV 9 is 12 o’clock, CV 7 is 6 o’clock, K16 is at 3 o’clock and 9 o’clock. The reflex points will then be at 4 o’clock and 8 o’clock. These points reflect trauma of any kinds (past and present), infection, inflammation, surgery, chronic illness, as well as daily continuous exhaustion of the adrenal glands from increased cortisol secretion.

Starting at K 16 work around the rim of the umbilicus pressing in at a 45% angle toward the midline. You may feel the ligament under the navel. If pressure pain is only located at 4 and 8 o’clock, and does not involve other points around the navel, it probably points to adrenals. It is important to remember that the whole area around the navel reflects the Spleen and also allergies. Pressure pain on the Adrenal reflex does not then only indicate trauma or adrenal exhaustion. The only way to confirm what these points are reflecting is to try to release them. So if you have pressure pain at the adrenal reflex point and you use SP 9 and the pressure pain is reduced then you know the cause is Spleen. If Kidney points cause the pain to be reduced then it is adrenal. Treat Adrenal exhaustion with both K6 and K27 and LU 5 on both sides. When needling the area of the umbilicus, you may feel like you are penetrating many layers on an onion. If this is the case, the more layers you feel the more treatments needed. Other points can be used. These are the most common. You can and should test other points with acupressure before needling to see what relieves the pressure pain found in the hara. For elderly patients, more exhausted patients, patients with a drug toxicity K9 is used instead of K6. A weakened immune system can also be involved with findings of oketsu. Treatment of the immune point may be necessary. The example that you have found oketsu, you treat with L4 and L5 and it only clears partly. You have to find the underlying reason. You check the adrenals. Then you check for immune issues.

Most immune problems will show at TW16 and just below it at a point known as East Wind which is the adenoid reflex. Also at LI 17 & 18 and at ST 11 the tonsil reflex. They can also show on the abdomen around ST26 and ST27. DU 14 is a diagnostic point on the back for weak immune system. A “buffalo hump” neck is a sign of adrenal cortex imbalance and a fat metabolism imbalance. For treatment, the Immune point is a point between L.I.10 and L.I.11 but closer to the Triple Warmer channel, on the edge of the bone. Kiiko always talks about a “gummy” or “sticky” feeling that can be felt at the point. Other points include DU 14, K6 TW 16 and below. Palpatory techniques are very important for this type of work. Palpating the abdomen and finding the points that relieve or change the abdominal pressure pains is a major diagnostic and treatment tool in clinical work. This is a basic overview of hara diagnosis and its many different interpretations and styles of treatment. Treatment methods include massage, needling, moxa, ion pumping cords, magnets, diode chains, pachi sparker, etc. It is important to get a patients full history so that you can be prepared for diagnosis and treatment.

Reference materials that will help you: Hara Diagnosis: Reflections on the Sea by Kiiko Matsumoto and Stephen Birch Videos: Avi Magidoff L.Ac. http://acupuncturemedical.org/kiiko-style-basic-pp/