This article is also available as a PDF in its published form CJOM, Vol. 10, No. 4, Fall 1999 (pdf)
An Introduction to Hara Diagnosis, Kiiko Matsumoto Style
The Nagano-Matsumoto style of treatment is the one of the most powerful tools available to acupuncturists, yet few people seem to utilise it. This might be because Master Kiyoshi Nagano has not been actively pursuing fame in the great centers of acupuncture around Tokyo and his technique has gotten wider exposure through Kiiko Matsumoto’s work. However, I suspect this is primarily because many acupuncturists find this style to be confusing and difficult both intellectually and physically.
One cannot learn a whole system of acupuncture from one or two article, nor from one or two seminars. It has taken me years of following Kiiko to “get it.” However, it is possible to improve the results one gets by incorporating elements of this style and slowly increasing one’s understanding. The purpose of this article is to introduce the reader to some of the most common abdominal findings and their treatment. I have been teaching this style for the past 5 years, and those attending always attest to the effectiveness of these treatments. As beginners, they will often say they still use TCM or other methods (e.g., Miriam Lee/Richard Tan style), but that the addition of these simple procedures increases treatment effectiveness many fold.
The basics of abdominal diagnosis are the same as for pulse diagnosis: anything you find or feel has significance. When a baby is born, if they are totally healthy (and assuming a clean karma) the pulse should be smooth, without glitches, reflecting nothing but a clean slate upon which life will imprint its experiences. The newborn baby would likewise have a smooth abdomen, a Buddha belly, so to speak. As life goes on, experiences are accumulated, pathologies settle in, patterns are being created, all of which will imprint their signature on the cellular memory of the body and can be reflected in various places. It is the nature of Chinese medicine that it recognises that the microcosm reflects the macrocosm. Thus, the pulse reflects the whole body, as do the palms, feet, and, of course, the abdomen. It is the ability to attune ourselves to a particular modality of diagnosis, perhaps to combine more than one tool, that makes us good at what we do. The reality of pulse taking is that it is an extremely subtle art. Most practitioners can read gross qualities, such as wiry, slippery, strong, weak, etc., but the reading of a life history requires lifelong practice.
Abdominal diagnosis, on the other hand, is easier. Here the patient can give you feedback. If an area pressed is hard, or ropy, or produces pain, that is hard to dispute, there is nothing “subtle” or mysterious about it. The problem in using this form of diagnosis is that the patient is fully aware of the process: they can tell when the abdomen is getting better and the pressure pain disappears. Unlike pulse diagnosis, the practitioner has no information that the client does not. This makes us, practitioners, rather vulnerable and appear less “smart,” possibly another reason for resistance to this style.
On a healthy abdomen, one should be able to press the abdomen to the depth of one knuckle (that is from the finger tip to the distal interphalangeal joint) without producing pain, and without the practitioner feeling resistance, hardness, ropiness, cold, or other “weird” sensations. I use 3 fingers, the index, middle, and ring fingers all together. This gives the patient a more comfortable feel when I press. Never press the abdomen with the thumb, this can feel very violating (and violent) to the patient. By using 3 fingers, I minimise the discomfort felt. However, my attention is at the tip of my middle finger: this is where most of the pressure is focused, and this is also my sensing finger (it is possible to do this with any other finger, it is a matter of individual preference). I tend to first touch the area to be pressed and then move in. At first you may want to move your fingers from side to side as if making space: this will ensure that you are not moving in too fast. As you gain more experience you will learn the pace that is comfortable to the patient.
At any area that you find pain, “weird” feeling (some patients say it feels like “finger nails” – be sure yours are closely clipped, if a patient feels “finger nails” it is considered a “finding”), ropy, hard, etc., indicates a pathology: we call this a “reflex area.” We have many maps of the abdomen, depending on the patient history as well as other findings. Any one area in the abdomen can reflect more than one pathology. For example, the area around the navel reflects the Spleen (Nan Ching), but the points just below Kid16 reflect the Adrenals. Furthermore, in physical kidney disease (e.g., kidney stones or kidney infections) the area around the navel will be painful/ropy, especially Kid16. It is possible that the patient be only Spleen deficient with allergies, and have no kidney or adrenal involvement, thus the area around the navel will show. On the other hand this allergy patient may well have depleted adrenals, in which case the area below Kid16 (we call this 4 o’clock and 8 o’clock) reflects simultaneously the Spleen and the adrenals, while pressure pain elsewhere around the navel is a reflection of the Spleen only. Another example is pressure pain on Ren9. This can reflect S.I./digestion problems, Water problems (edema – the name is Dividing Water), or sadness (almost as a substitute to Ren8 – the Gateway to the Shen). Which of these problems the pressure pain on Ren9 reflects can only be ascertained when we try to treat it: if the water treatment works, it was a reflection of water, if digestion points release Ren9, it must be that Ren9 reflected digestion, etc.
Once we have identified the various abdominal areas that show pressure pain, we interpret them, taking the whole picture into consideration. Our treatment goal is to eliminate all pressure pain (on the abdomen, the neck, throat, and back). Once this happens, the symptoms the patient is complaining about tend to subside. We can then further work more symptomatically on specific complaints once the abdomen has been cleared. Clearing the abdomen (neck, throat, and back) is our “root treatment.”
The way we determine the points to needle is by pressing on the point and ensuring that it has a good effect on the abdominal reflex(that is it alleviates the pressure pain). Here is how this works. Suppose we found pressure pain on left ST27 area. We call this Oketsu (see below), and normally treat this with Liv4 and LU5 (both on the left). We let go of the pressure on left ST27 and ask the patient to remember what it felt like. We press on left Liv4 (upwards in the direction of the channel), and then press again on left ST27, while still holding on with pressure on Liv4. If the pressure pain on left ST27 is improved, we found the correct Liv4, if not, we look for a slightly better location. Finding the exact location for a point has absolutely nothing to do with its description in the book. It also has little to do with how painful the point is. All that really matters is that the point selected (and the angle of pressure) does indeed alleviate the pressure pain on the reflex. I often spend time finding the point that does the best job at clearing the reflex (preferably 100% clearing!). It is not uncommon to find a point that clears an abdominal reflex by 50%, but a point 3mm off it that clears it by 90%. Obviously one chooses the latter.
When you press on a reflex point, you need to remember at what depth and angle the pain was elicited and what it feels like to your fingers. It helps to have an image of the tissue under your fingers. Once you press on the remote treatment point, you need to reproduce the same location, angle, depth, and pressure, at the reflex point and make sure it has been cleared. I recommend that you leave your hand just touching the skin at the reflex point and that with your other hand palpate and press the treatment point. Once you are pressing the treatment point, re-apply the pressure on the reflex area. This way there is no argument about the location. It is common for the novice patient to claim that you are not pressing as hard or that you are pressing on a different spot. The changes are truly dramatic when pressure pain disappears, and thus you want to be sure you got the correct reflex area.
Although I cannot elucidate all abdominal findings, the following 4 treatment ideas should prove to be a great start. These are the most common findings and most commonly used points in the Matsumoto style.
The most common finding is called Oketsu. Oketsu means non-physiological, sluggish, dirty, piled-up blood. It can be translated as Stagnant Blood, however, this connotes the TCM understanding of a pathology resolved by herbs such as Hong Hua and Tao Ren, which is not our understanding. We understand Oketsu to be an impingement of microcirculation (this is very similar to modern Chinese emphasis on blood vitalizers to improve microcirculation to counter the effects of aging). This can be due to a fever, infection, repeated trauma, operations or bruises, etc. 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. Be aware that this is an area, not a matter of exact point location. This is originally Liver reflex according to the Nan Jing. We understand this to be so because the portal vein that leads to the liver comes from the left side, and thus an “obstruction” in the liver will cause a more sluggish flow that will show on the left side. While it is true that Oketsu will show in Liver disorders (hepatitis, cancer, etc.), it most often shows without any liver involvement. (We diagnose Liver on right Liv14 and below on the right subcostal line.)
If you find Oketsu, you must clear it. There is no point in treating other issues if microcirculation is sluggish. After all, if Qi and Blood are not moving well, it makes it harder to address other issues. Once Oketsu is cleared, many other abdominal findings will improve, or even clear up, without adding other needles.
The standard treatment of Oketsu is left Liv4 with left LU5. We take Liv4 as a thumb’s width below the medial malleolous, on the medial side of the tibialis anterior (somewhat close to SP5). We needle it at a 10o-30 o upwards with the meridian flow, with 10-15mm of the needle. Obviously when we press on the point to test it, we press it in the same direction (toward the ankle bone). LU5 is taken almost a thumb’s width laterally to where TCM textbooks describe it, that is, it is closer to L.I.11 than you might expect. There is a “weird” tendinous feeling at the correct point. We needle it superficially towards the thumb (that is with the flow). We then recheck the Oketsu reflex area (left ST27 area) and ascertain that the Oketsu is indeed cleared. If there is a little bit left, tiny manipulation of LU5, just moving the needle up and down in a shaking-like fashion, will probably clear the rest. The patient need not feel anything. We are not after a Qi sensation, but after breaking down gummy connective tissue which will communicate to other tissue the effect of the stimulation. (I use Seirin #2 needles: they are very fine but not too much so.)
Sometimes you feel a hard lump feeling at the Oketsu area. We call this Oketsu Kai (Oketsu Lump). When you feel Oketsu Kai, the combination of left Liv4 with left LU5 is likely to alleviate the Oketsu reflex area by only 30% or so. This is often because of blocked circulation at the inguinal joint. After you tested and needled Liv4 and LU5, palpate the left inguinal ligament. This is the area between G.B.27/28 and ST30. Press this area toward the left leg (that is laterally and downwards). Find the ropy area and press it. Now test the Oketsu reflex area, and it should improve. Needle into the ropy area that helps release Oketsu the most. The area of the left inguinal groove (inner thigh – around left Liv12) might also be blocked and obstruct the clearing of Oketsu. Press this area up toward the pubic bone (this is also the direction of the needle). Both the inguinal ligament and the inguinal groove are needled shallowly, you need only tap the needle in.
(Note that if there is a lot of pain on either the inguinal ligament or inguinal groove, we would treat those areas as reflexes first and release that pressure pain, prior to needling them.)
The treatment of Oketsu is absolutely essential and must come before any other treatment as it not only clears other abdominal findings it also clears the way for other treatments. Be aware that Oketsu can be complicated by other syndromes, primarily Immune and poor circulation, and might not fully clear until those elements are addressed. I will discuss the Immune points below. There are two main circulation problems, the first is lack of blood flow, which we consider to be a Spleen problem. This typically shows in patients who have a pulse that has no third position (Kidney position – Nagano calls this “not enough blood to fill the pulse,” and categorises it as Spleen). In this case tonifying the Spleen (by use of SP9, needled superficially upwards, toward Inner Knee Eye, and SP10, both bilaterally) will help clear the Oketsu. The other circulatory problem is related to the autonomic nervous system and blood pressure. This tends to show as a tight pulse (a tight pulse by Nagano is what TCM practitioners might call wiry, thin, and superficial, and which looses this quality when pressed deeply), especially if rapid. The subject of treating ANS is rather complicated and is beyond the scope of this article.
Adrenal Shock is another extremely common pattern. When we suffer fear or shock, or feel we are deeply threatened without possibility of escape, we contract the body inwards, toward the navel (think of your physical reaction at your worst nightmare, chances are you contract your navel). Thus, shock shows just below Kid16. This reflex is one of the few that has a strict location, in that it cannot be above Kid16, and it must show on both sides (people do not experience a shock or adrenal depletion on one side only). We call these reflex points 4 o’clock and 8 o’clock. This is a reference to a clock around the navel, with Ren9 being 12 o’clock, left is Kid16 3 o’clock, Ren7 represents 6 o’clock, and right Kid16 is 9 o’clock. These points reflect not just shock and trauma (such as car accident, trauma, etc.), but also slower and continuous exhaustion of the adrenal glands, hence we find them so commonly in our fast-paced culture.
It is important to remember that the whole area around the navel (including 4 o’clock and 8 o’clock) reflects the Spleen and allergies, so when a patient has pressure pain on the Adrenal-Shock reflex it does not immediately indicate shock or adrenal exhaustion. A patient can have both Spleen deficiency and Adrenal-Shock, or one witout the other and have pressure pain on 4 o’clock and 8 o’clock. The only way to ascertain what these points reflect is to attempt to release them. If they reflect Spleen deficiency with allergies, they will respond (pressure pain will be reduced) to Spleen points (usually SP9), while if they reflect the adrenals they will respond to Kidney points. (Note, if you find only 4 & 8 o’clock, and no other points around the navel, this is probably the adrenal pattern, and not the Spleen pattern.)
The Kidney channel goes up the spine and into the Kidneys, coming out to the front at Kid16 (Huang Shu – Missing/Hidden Organ Shu) where one branch moves downwards (Kid15 to Kid11) and the other moves up (Kid17 to Kid27). We can see Adrenal-Shock as severing of the Kidney channel, or the Kidney channel’s inability to nourish the Jing (in its movement downwards). The treatment of Adrenal-Shock is Kid6 with Kid27, bilaterally. One can think of it as a way of reinforcing/uniting the Kidney channel, or a Yin Qiao treatment variation. Master Nagano says that Kid6 treats the adrenals and Kid27 calms down the parathyroid. (When the ovaries have weakened in menopause, the parathyroid appears to become hyperactive and depletes calcium from the bones to the blood, thus Nagano believes it is important to calm the parathyroid when boosting the adrenals/ovaries).
Kid6 is needled superficially and toward the achilles tendon (down toward the table), and Kid27 is needled superficially toward the Ren line: we use ¼ of an inch of the needle, or less. Manipulation (tiny up and down movement, like shaking, again – the patient should not feel this manipulation) on Kid27 might be needed.
In some cases we substitute other Kidney points for Kid6:
1. We use Kid7 for people with a slow pulse, if there is bone pain, if there is pressure pain on G.B.26, if there is a history of ovary problems (reflect on ST28), post-menopause, or if there is pressure pain on Kid2. Kid7 is not at a fixed location. As you slide up from the ankle bone and close to the achilles tendon, look for the puffy/weird feeling: this is Kid7. It can be from 2 fingers above the internal malleolus, up to 4 cun above it. We needle Kid7 at a 30 o angle upwards, using up to 30mm (1 inch) of the needle, and manipulating it (our typical up and down “shaking” – Kiiko calls it “old lady” shaking the needle). Pressure pain on Kid2 indicates Fire in the Kidney channel, and is best treated by the combination of Kid7 and Kid10 (we call this Metal/Water overcoming Fire). When you find pressure pain on Kid2 (with 3kg pressure) as well as Adrenal-Shock (4 o’clock and 8 o’clock) you need to choose between the Kid7/27 combination and Kid7/10 combination by determining which combination releases the most abdominal findings most effectively. Kid2 is typically painful in hyperthyroid, ovary diseases, and advanced diabetes.
2. Kid3 is used in lieu of Kid6 if the pulse is very rapid, in cases of asthma with difficulty on inhalation, or where the disease history clearly involves mumps or salivary glands, though it is not common to do so. Kid3 is needles toward the achilles tendon.
3. Kid9 replaces Kid6 in the Adrenal-Shock treatment for the very elderly, very exhausted patients, or those with chemical/drug toxicity (I find it useful also if there is liver damage). It is found at the base of the gastrocnemous muscle, and I look for a nodule/gummy like feeling to find the exact point.
Immune issues can be involved in just about any problem. Specifically, we may find immune weakness whenever we find Oketsu (as Oketsu can be a result of infections, lung problems, and other immune problems), and treating the Immune points is often the key to treating Oketsu (after Liv4 and LU5). Also, people who are continuously battling with weak immunity easily reach a threshold and start to tax their adrenals. If they are continuously battling an infection or are in constant pain, they can easily develop adrenal exhaustion as well as an autonomic nervous imbalance.
Nagano says that our first line of defense are the nose and tonsils. Many people who have had their tonsils removed belong to the category of “immune type” (as do appendectomy and sinus allergy patients). Typically, immune problems reflect behind the SCM, on S.J.16 and below (a point known as East Wind). This is a Wind-related area by Chinese medical thinking, and a gland reflection by western thinking. I press this area from behind the SCM up toward the nose (the patient is lying face up), pressing three different areas from the mastoid down the SCM (down to about half way down the neck), finding the sore/gummy spot. The Immune points will release this area (left releases left, and right releases right). The Immune point is a point between L.I.10 and L.I.11 but closer to the San Jiao channel, on the edge of the bone. Look for the gummy adhesion on the edge of the bone. The needle is directed towards the bone, and direct moxa is always added (to “melt” the adhesions).
When you find S.J.16/East Wind (gland reflex), this is a great opportunity to practice your palpation sensitivity. Leave your fingers just touching S.J.16, and with your other hand look for the Immune point. When you find the Immune point and press on it, you will feel the tissue at S.J.16 expanding or melting: when this happens you found the correct Immune point. You can now re-press S.J.16 and make sure it has indeed been released. (Often there will be very tender points in the area of the Immune point, but they do not necessarily release S.J.16. Beware of points that are tender, as they masquerade themselves as treatment points, but they fail when taken to the test against the reflex site they are supposed to release.)
Immune issues may also reflect on the abdomen in the area around right ST26/ST27. However, this area can also reflect lung issues (treat LU5/LU8), digestion (treat SP9), or a tailbone shift (treat LU8). Pain along the posterior edge of the iliac crest is also immune related and responds to the Immune points (this area again has something to do with adhesions at the edge of the bone). Weak ligaments, and thus knee problems, achilles tendinitis, plantar fascitis, etc.) are often a result of weak immunity.
We always treat both front and back. The diagnosis on the back is somewhat more simplistic, as the reflex points often become treatment points (the back does not have the same complex network of channels as the front). We check the back Shu points, but we are especially interested in the Hua Tuo points as those correspond to the control of the organs and structure. (We take the Hua Tuo point not just level with the lower border of the spinous process, between vertebrae, but also level with the vertebra, looking for pain, gummyness, or squeezed vertebrae.)
Perhaps the most common finding on the back is Sugar. The Sugar points are the Hua Tuo of T11, T12 (give or take a vertebra – do not be dogmatic on your point location). When you find pain, weirdness, gummy tissue, or sqeezed-together vertebra, it must be treated. We needle these points 45o toward the spine, using 15mm (1/2 inch) of the needle, or slightly more. We add direct moxa on these points, or on the Du line if we find sensitivity on the Du line at that level. Sugar issues are pervasive in our culture as our busy schedules and lots of “convenience” eating, not to mention Chips Ahoy and other sweets, continuously challenge our metabolic systems. When sugar imbalance occurs, it will naturally affect every cell and every system in the body, of special note is the effect sugar imbalance has on weakening muscles and contributing to numbness and muscular pain. Thus it is extremely important to treat. Treating the sugar points may not seem in some cases as dramatic as some of the other treatments outlined above, but it is often the part of the treatment that really stabilizes the treatment and facilitates it, and makes it last longer.
In this article I tried to outline four treatment ideas by Master Kiiko Matsumoto. This style of treatment does require a different kind of approach than TCM or other systems, however it is extremely powerful and well worth studying. Even the application of the above four simple treatments is likely to improve your patients healing success. Do not be afraid to mix this style with what you already practice. Master Matsumoto is not a purist, her method is a synthesis of many other Masters. While Master Matsumoto concentrates on palpatory findings, Master Nagano is an expert pulse diagnostician. Nonetheless, Nagano clearly agrees with Matsumoto’s interpretation and supports this style. This tells us that there can be many approaches to solving any particular problem and that we need not be afraid of experimenting.
Unfortunately, a full discussion of this treatment style would take hundreds of pages. The good news is that Ms. Matsumoto will be publishing a book, accompanied by video, on this style in the next year, making it easier to learn.