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Palpation diagnosis is a method where the practitioner directly touches and presses certain areas of the patient’s body to understand local abnormal changes, thereby inferring the location, nature, and severity of the disease.
(1) The Method and Significance of Palpation Diagnosis
1. Method
① Position: During palpation, the patient should be seated or lying supine. Generally, when palpating the chest and abdomen, the patient must lie supine, fully relaxed, with legs extended and hands by their side. The practitioner stands on the patient’s right side, using the right hand or both hands to perform palpation. When palpating for abdominal masses or muscle tension, the patient may be asked to flex their knees to relax the abdominal muscles, facilitating palpation.
② Techniques: The techniques of palpation can be broadly categorized into four types: touch, feel, push, and press. Touch involves lightly contacting the patient’s skin, such as the forehead and limbs, to assess temperature and moisture. Feel involves stroking the area, such as swollen regions, to determine sensation and the shape and size of masses. Push involves applying slight pressure to move the area back and forth or side to side to assess the mobility of masses and their relationship with surrounding tissues. Press involves applying pressure to areas such as the chest or abdomen to determine the presence of deep tenderness, the shape and texture of masses, and the degree and nature of swelling. In clinical practice, various techniques are used in combination, often starting with touch, followed by push and press, progressing from light to heavy, and from superficial to deep, layer by layer understanding the pathological changes.
During palpation, the practitioner should be considerate of the patient, using gentle techniques to avoid sudden force. In cold weather, hands should be warmed before examination. Generally, start with touch, then press, with finger pressure increasing from light to heavy, and from superficial to deep. The patient should be encouraged to cooperate actively, reporting their sensations, while the practitioner observes the patient’s facial expressions to understand their discomfort. Palpation should be thorough and meticulous, not overlooking any area related to the disease.
2. Significance
Palpation is a part of the diagnostic process and an indispensable link in the four diagnostic methods. It further deepens the understanding of the location and nature of the disease based on observation, listening, and inquiry. For conditions such as chest and abdominal pain, swelling, phlegm retention, and masses, palpation can provide essential information for diagnosis and differentiation.
(2) Content of Palpation Diagnosis
The application range of palpation is quite broad. Clinically, it is commonly used to palpate the skin, hands and feet, chest and abdomen, and specific acupoints, which are described as follows:
1. Palpation of the Skin
Palpation of the skin is to determine the temperature, moisture, and swelling of the entire body surface.
Generally, a body with strong Yang Qi tends to be warm, while a body with weak Yang Qi tends to be cold.
Palpation of the skin can reveal not only temperature differences but also discern between superficial and deep conditions. If the body feels very hot upon initial touch but becomes less hot with prolonged contact, it indicates heat on the surface; if prolonged contact maintains high heat, it indicates internal heat.
Soft and moist skin that enjoys being touched indicates a deficiency condition; hard and painful areas that resist touch indicate a full condition. If light pressure causes pain, the disease is superficial; if only heavy pressure causes pain, the disease is deep.
Dry skin indicates a lack of sweat or body fluids; shriveled skin indicates insufficient body fluids; moist skin indicates sweating or no damage to body fluids.
Skin with a rough texture indicates Yin deficiency or internal dryness. Palpating swollen areas can differentiate between edema and emphysema. If pressing leaves an indentation that does not immediately return, it indicates edema; if it returns quickly, it indicates emphysema.
Palpation can also differentiate between Yin and Yang conditions and whether there is pus. A hard, non-hot swelling indicates a cold condition; a hot, painful swelling indicates a heat condition. A flat, diffuse swelling indicates a deficiency condition, while a raised, firm swelling indicates a full condition. Hard areas are often non-purulent, while soft areas may indicate the presence of pus. For deep muscle abscesses, the presence of pus can be determined by the response to pressure, using both hands to apply varying pressure and feeling for any wave-like sensation.
2. Palpation of Hands and Feet
Palpation of the hands and feet primarily assesses temperature to determine the nature of the disease as either deficient or excess, internal or external, and to predict prognosis. If both hands and feet are cold at the onset of illness, it indicates Yang deficiency and cold excess, representing a cold condition. If hands and feet are sensitive to heat, it indicates Yang excess and heat, representing a heat condition.
Palpating the temperature of the hands and feet can also differentiate between external and internal diseases. If the back of the hands and feet is hot, it indicates an external febrile disease; if the palms are hot, it indicates an internal febrile disease. Additionally, comparing the temperature of the palms and forehead can help differentiate between exterior heat and interior heat. If the forehead is hotter than the palms, it indicates exterior heat; if the palms are hotter than the forehead, it indicates interior heat. This diagnostic method is of reference value.
In pediatrics, cold fingertips in children indicate a risk of convulsions. A hot middle finger indicates an external wind-cold condition. A cold tip of the middle finger indicates a sign of impending measles. Assessing the temperature of the hands and feet can provide insight into the status of Yang Qi, which is crucial for determining the prognosis of certain Yang deficiency conditions. If the limbs are warm, it indicates that Yang Qi is still present and treatment is possible; if the limbs are cold, the prognosis is often poor.
3. Palpation of the Chest and Abdomen
The division of the chest and abdomen is as follows: the upper part is the chest, and the lower part is the abdomen. The lateral chest area from the lower abdomen to the eleventh and twelfth ribs is the flank. The area just below the xiphoid process is referred to as the heart area. The epigastric region corresponds to the upper abdomen. The large abdomen is above the navel, while the small abdomen is below the navel, and the lower abdomen refers to the sides of the small abdomen.
Palpation of the chest and abdomen is performed purposefully based on the patient’s condition, touching and pressing the chest area, flanks, and abdomen, and tapping if necessary to understand local pathological changes.
The content of chest and abdominal palpation can be divided into palpation of the interior, palpation of the chest and flanks, and palpation of the abdomen.
(1) Palpation of the Interior: The interior is located at the apex of the heart under the left breast, where all pulses converge. Exploring the pulsation of the interior can reveal the strength of the vital energy and the nature of the disease, as well as the prognosis. Ancient practitioners placed great importance on this.
When palpating the interior, a soft, non-tight, and gentle pulsation indicates health; a weak pulsation indicates deficiency; a pulsation that responds to clothing indicates excessive leakage of vital energy. A pulsation that is strong and broad indicates a critical condition.
In pregnant women or those with tuberculosis, caution is advised. If the pulsation is high after fright, anger, or intense exercise but returns to normal after resting, it is a physiological phenomenon. If the pulsation ceases, and other pulses stop, it indicates death. Palpation of the interior is significant for diagnosing life and death when there is no pulse under the fingers.
(2) Palpation of the Chest and Flanks: If the front chest is elevated and palpation causes shortness of breath, it indicates a lung condition. If palpation of the chest and flanks reveals distension and pain, it may indicate phlegm-heat obstruction or water retention.
The liver is located within the right flank, with its upper boundary at the midclavicular line at the fifth rib and its lower boundary at the lower edge of the right rib arch, so it is generally not palpable below the ribs. If the liver is palpable and enlarged, whether soft or hard, it often indicates Qi stagnation or blood stasis; if the surface is uneven, it raises suspicion of liver cancer.
Pain in the right flank with heat upon palpation indicates a liver abscess. In chronic malaria, a mass may appear under the flank, referred to as the maternal malaria.
(3) Palpation of the Abdomen: Palpation of the abdomen primarily assesses temperature, softness, hardness, distension, masses, and tenderness to assist in diagnosis and differentiation.
To differentiate temperature: By assessing the temperature of the abdomen, one can discern the cold or heat nature of the disease. A cold abdominal wall that prefers warmth indicates a deficiency-cold condition; a hot abdominal wall that prefers cold objects indicates a full-heat condition.
To differentiate pain: Abdominal pain that is relieved by palpation indicates deficiency; pain that resists palpation indicates excess; if the area is hot and painful, it indicates an internal abscess.
To differentiate abdominal distension: If the abdomen feels full upon palpation, with tenderness and a heavy sound upon percussion, it indicates fullness; if it feels empty and without tenderness, it indicates Qi distension, often associated with deficiency.
Severe abdominal distension, resembling a drum, is termed distension. This is a serious condition that can be classified into water distension and gas distension. By placing hands on both sides of the abdomen, one hand can lightly tap while the other feels for wave-like sensations. If the abdomen feels like a water-filled bag with indentations, it indicates water distension; if it sounds like a drum without wave-like sensations and no indentations, it indicates gas distension. Additionally, some severely obese individuals may have a distended abdomen that feels soft and lacks other severe symptoms, which should be differentiated from distension.
To differentiate fullness: Fullness is a sensation of blockage or discomfort in the heart area or epigastric region. If palpation reveals softness without tenderness, it indicates deficiency; if it feels hard with resistance and tenderness, it indicates excess. If the epigastric area is palpable and distended, with a gurgling sound upon pushing, it indicates water retention in the stomach.
To differentiate masses: When palpating masses, attention should be paid to their size, shape, hardness, and tenderness.
Accumulation refers to a lump in the abdomen that may be painful or not. However, accumulation and mass are different. Pain with a fixed location and palpable mass indicates accumulation, which belongs to the blood level; pain without a fixed location and no palpable mass indicates a mass, which belongs to the Qi level.
Pain in the left lower abdomen with hard lumps indicates fecal impaction in the intestines. Pain in the right lower abdomen with palpable masses indicates intestinal abscess.
Parasites in the abdomen have three major characteristics: one is a shape resembling a knot; prolonged palpation may cause movement; two is careful examination reveals a sensation of movement like a worm; three is an uneven abdominal wall that rises and falls upon palpation, indicating irregular movement.
4. Palpation of Acupoints
Palpation of acupoints involves pressing specific acupoints on the body to infer certain internal organ diseases based on the changes and responses at these points.
Changes at acupoints mainly include the appearance of nodules or cord-like structures, or tenderness and sensitivity. Clinical reports indicate that patients with lung diseases may have nodules at the Feishu (Lung Shu) acupoint, while tenderness may be found at the Zhongfu (Central Palace) acupoint. Patients with liver diseases may experience tenderness at the Ganshu (Liver Shu) or Qimen (Liver Gate) acupoints. Gastric diseases may show tenderness at the Weishu (Stomach Shu) and Zusanli (Leg Three Miles) acupoints. Intestinal abscesses may show tenderness at the Tianshu (Heavenly Pivot) acupoint.
Additionally, acupoint palpation can be used for experimental treatment to assist in differential diagnosis. For example, in cases of abdominal pain due to biliary ascariasis, pressing both sides of the Ganshu (Liver Shu) acupoint may relieve pain, while pain from other causes will not respond, aiding in differentiation.
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