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TCM Book Club Issue 1465
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IIntroduction: As the author states, diagnosis is not just about pulse taking, but rather “using hands to closely examine the patient’s body to diagnose diseases.” From this perspective, the experiences listed in the text are the author’s insights. Accordingly, we need to learn more about diagnosis through books and clinical practice. (Editor/Ju Ye)
Diagnosis Beyond Pulse Taking
Author/Fan Zhengyang
When it comes to diagnosis, it is generally referred to as pulse taking; however, diagnosis encompasses more than just pulse taking. It also includes examining the skin, the sides of the abdomen, the area below the heart, and the upper and lower abdomen. The term “切” (qiè) implies closeness, as in “切身” (qiè shēn) and “亲切” (qīn qiè), meaning to use hands to closely examine the patient’s body to diagnose diseases. Nowadays, many doctors focus solely on pulse taking and neglect other diagnostic methods.
In treating diseases, Zhang Zhongjing emphasized not only pulse taking but also the examination of the chest, sides, and abdomen, which is extensively described in the “Shang Han Lun” (Treatise on Cold Damage). When a patient comes for diagnosis, after greeting and understanding the basic situation, pulse taking follows. Before taking the pulse, one can use their hands to feel the temperature of the skin on the forearm; if there is fever, one can already have an initial understanding of the condition, which is the first step in diagnosis.
Especially for diagnosing fever in children, besides using a thermometer and feeling the skin, I prefer to use my lips to sense the temperature; kissing the child feels more intimate. The sensitivity of the lips is beyond that of the hands; feeling the forehead with hands is far less effective than using the lips. A person’s body temperature is not fixed and can vary; sometimes thermometers can be misleading. Asking the mother about the child’s mouth temperature while breastfeeding can provide first-hand information about whether there is a fever, when it occurs during the day, and any patterns, which can be invaluable to the doctor.
When inquiring about sweating, it is generally important to ask first. This is easy to clarify in adults, but more challenging in children. One can use their palm to feel the front and back of the chest; the dryness or moisture of the skin can clearly indicate the presence of sweat. If the skin is moist, it indicates sweating, and medication should be used appropriately. These are small details, yet they are essential skills in diagnosis.
For examining the chest, sides, and abdomen, the patient should first be positioned correctly, lying flat on the examination table, with legs bent, relaxed, and not resisting the doctor.
Let’s discuss the symptoms of Xiao Chai Hu (Minor Bupleurum) such as “chest and side fullness,” which is the patient’s self-perception. If there is “hardness under the ribs,” the patient may not be able to articulate it clearly. By pressing under the ribs and on the sides of the abdomen, one can feel fullness or resistance; if the patient frowns or expresses slight pain, this indicates a reaction. Symptoms like “urgent feeling under the heart,” “hardness under the heart,” and “pain upon pressing the heart area” indicate hardness and resistance, varying in degree.
Phlegm and fluid accumulation in the chest and sides can be detected by the patient’s self-reported feelings of fullness or pain during breathing. The doctor can also palpate the area above the diaphragm, which may elicit chest and side pain and a feeling of suffocation, indicating “hardness and fullness under the heart, leading to pain under the ribs.”
In terms of symptoms under the heart, the term “痞” (pǐ) indicates blockage. Although it differs from “结胸” (jié xiōng) which means “not approachable,” the symptom of “hardness under the heart” is contrasted with “hard fullness and pain” in “结胸.” By palpating the hardness and pain, one can discern the severity and nature of the disease, leaving no hidden details.
“Abdominal fullness with pain” indicates a preference for warmth and pressure, suggesting a deficiency, while “great fullness with pain” that resists pressure indicates excess, suggesting a Yangming condition. The choice of treatment should consider whether to relieve pain or purge.
The temperature of the abdominal skin, as well as the tension and relaxation of the abdominal muscles, can often be felt during diagnosis. The main goal of abdominal diagnosis is to understand the temperature, softness, hardness, presence of masses, and tenderness.
For instance, feeling the abdominal skin can help differentiate between cold and heat conditions. If the skin feels cool or cold, it indicates a cold condition; if the patient prefers warmth, it suggests a deficiency cold condition. If the skin is hot to the touch, it indicates a heat condition; if the patient prefers cold objects, it suggests a real heat condition. If pressing reveals heat, it indicates internal heat; if light pressure reveals a soft abdomen, while firm pressure on the navel reveals strength, it is often a normal state.
A thin abdominal wall that feels soft and weak often indicates a deficiency; a hard abdominal wall indicates an excess condition.
Abdominal distension with a feeling of fullness and tenderness, along with a heavy sound upon percussion, indicates an excess condition; if there is no fullness, no tenderness, and a hollow sound upon percussion, it indicates a deficiency condition.
Pain upon palpation, especially if it resists pressure, indicates an excess condition.
Pain that is fixed and sharp indicates blood stasis.
Pain that is variable and occurs intermittently indicates Qi stagnation.
When palpating the abdomen, if a mass is found, attention should be paid to its size, shape, hardness, tenderness, and whether the surface is smooth. Abdominal masses that are painful indicate accumulation. If the mass is fixed and painful, it suggests a blood condition; if the mass is variable and painless, it suggests a Qi condition.
Using percussion to vibrate the organs is also a diagnostic method, such as in suspected urinary stones. Small stones may not be visible on ultrasound. If there is no rupture of the urinary tract, blood cells may not be visible under a microscope, and some may not exhibit urinary tract irritation. Except for obvious renal colic, abdominal pain from stones in the ureter can often be confused with acute appendicitis or gynecological emergencies. I often percuss the affected kidney; if the pain intensifies upon percussion, it can confirm the diagnosis.
In gynecology, special attention should be paid to diagnosis; relying solely on the patient’s complaints without abdominal examination often leads to unclear conditions. The examination of the uterus and adnexa differs.
When palpating the lower abdomen, one should first assess the fullness of the uterus; fullness and enlargement often indicate an excess condition, while softness and shrinkage often indicate a deficiency. If the patient feels pain upon palpation, and the pain eases or is preferred upon pressure, it indicates a deficiency; if the pain worsens or resists pressure, it indicates an excess condition. The examination of the adnexa is located in the lower abdomen, where one can assess for masses and tenderness.
Zhang Zhongjing’s discussions on women’s diseases often focus on cold symptoms and excess conditions, as “women’s diseases arise from deficiency, accumulation of cold, and Qi stagnation, leading to obstruction of the meridians and blood, resulting in cold accumulation and blockage over the years…” This summarizes the essence of his teachings.
By examining the skin, one can discern between exterior and interior conditions, as well as cold and heat; by examining the chest and abdomen, one can explore Yin and Yang and deficiency and excess.
The knowledge gained through the doctor’s physical examination is intuitive, while the knowledge gained through cold machines is mechanical and can only serve as an auxiliary tool. Relying entirely on medical auxiliary examinations has become a bad habit, leading to a decline in diagnostic skills among practitioners, and even suggesting a complete loss of diagnostic ability, which is very dangerous.
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