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General palpation
按诊 〔按診〕àn zhěn
Also body palpation. Part of the palpation examination (which also notably includes the pulse examination) in which the body's surface is palpated with the hand to determine the presence of heat or cold, moistness or dryness, swelling, and distension, and to observe the patient’s reaction to pressure to determine the presence of pain. General palpation may be divided into five parts: palpation of the skin, the limbs, the chest and abdomen, and acupoints.
Scope and Aims
General palpation involves feeling the body's surface with the hand to determine the presence of heat, cold, moistness, distension, and pain, and to observe the patient’s reaction to pressure. Body palpation may be divided into four parts: palpation of the skin, limbs, abdomen, and acupoints.
Techniques
There are four basic palpation techniques: touching, feeling, pressing (or palpating), and percussing (tapping). The first three of these entail differences in the amount of pressure applied.
Touching is light contact with the skin. It is used to detect the presence of heat or cold and the presence of moistness or dryness. Note that the back of the hand is often more sensitive to heat than the palmar aspect.
Feeling means exploring with the hands for the presence of masses and for determining their shape or size.
Pressing means applying relatively light pressure (but greater pressure than in feeling) to determine the borders and consistency of masses.
Heavy pressing means applying the greatest pressure on an area. It is used to determine if there is pain or if there is pus.
Percussion means tapping an area with the fingers or hand for sounds, rippling, or vibrations (direct percussion) or for the patient’s reactions (indirect percussion).
Precautions
When conducting palpation, the practitioner must take care that patients do not catch cold if required to undress. The patient should be completely relaxed. The practitioner should ensure that her hands are warm and that she applies pressure gently and evenly.
Palpation of the Skin
The principal goal of skin palpation is to assess the degree of heat or cold and the degree of moistness on the skin.
Cold and Heat
Palpating the skin to see if it is cold or hot to the touch enables the practitioner to determine the presence of heat or cold, as well as of vacuity or repletion.
- In cases of exuberant heat evil, the skin is usually hot; when yáng qì is debilitated, the skin is cold.
- When there is generalized heat effusion, and there is pronounced heat on initial palpation that becomes less pronounced after prolonged palpation, the heat is in the exterior.
- If the heat feels more pronounced after prolonged palpation, the heat is coming from the inner body, as occurs in damp-heat or vacuity taxation disease. In damp-heat, this is called
generalized heat failing to surface
(身热不外扬 shēn rè bù wài yáng). In vacuity taxation, it is calledsteaming bone tidal heat
(骨蒸潮热 gǔ zhēng cháo rè).
Moistness and Dryness
Feeling the skin for moistness and dryness enables the practitioner to detect the presence or absence of sweating and whether or not the fluids have been damaged.
- Moisturized skin, i.e., skin that has its natural healthy moisture and is not dry, usually means that the fluids have not been damaged.
- Markedly moist skin indicates that the patient is sweating. Skin that is dry to the touch means that the patient is not sweating.
- Dry skin lacking in natural moisture means insufficiency of the fluids.
- Shriveled dry skin indicates damage to liquid, humor desertion, or major damage to qì and yīn.
- Encrusted skin (肌肤甲错 jī fū jiǎ cuò), that is, dry course scaly skin mostly observed in sick elderly patients, indicates damage to yīn or blood stasis in the inner body.
- Hot moist skin generally indicates heat in the qì aspect and, in some cases, qì vacuity heat effusion. It may also indicate sweating prior to the abatement of heat effusion.
- Cold damp clammy skin may indicate yáng collapse vacuity desertion or a bout of sweating the reduces heat effusion. The correct diagnosis becomes clear when correlated with other signs.
Swelling
A broad distinction is made between (a) localized red, hot, and tender swelling, which constitutes toxin swelling
(肿毒 zhǒng dú) and (b) swelling and enlargement of the face, limbs, and sometimes the whole body, without any redness or pain on pressure, usually referred to puffy swelling
(浮肿 fú zhǒng). Especially when it pits under pressure and does not rebound easily when pressure is released, it is sometimes called vacuity puffiness
(虚浮 xū fú).
Puffy swelling and vacuity puffiness are symptoms indicating water swelling
(水肿 shuǐ zhǒng), which in Chinese medicine is the name given to the disease. Distinction is made between yīn water
or yáng water.
In addition, there is qì swelling and toxin swelling. These are described under water swelling.
Welling- and Flat-Abscesses ; Sores
These are lesions characterized by localized swelling and suppuration. They are mostly attributable to heat toxin, which gives rise to painful red swelling, often called toxin swelling
(肿毒 zhǒng dú). Palpation of welling-abscesses and sores helps to determine whether they form yīn or yáng patterns and whether or not pus has formed.
- Yīn patterns are characterized by hard swellings that are not hot and have a flat, diffuse base.
- Yáng patterns are characterized by elevated swellings that are scorching hot to the touch and have a clearly circumscribed base.
- Pus has formed if the tip and sides of the sore are soft and markedly hot.
- Pus has not formed if the sore is still hard and not very hot.
- If pain is felt on slight pressure, the pus is near the surface. If pain is only felt on heavy pressure, the pus in located deeper in the body.
- When pus has formed, the amount of pus can be roughly gauged by using two fingers placed flat on the sore. One finger presses and pushes, while the other finger senses the waving sensation. The stronger the waving sensation, the more pus there is. This provides some indication of how close the sore is to rupturing and may be significant in the choice of treatment.
Palpation of the Limbs
Cold and Heat in the Extremities
Lack of warmth in the extremities
and cold limbs
denote mild conditions; counterflow cold of the limbs
(四肢逆冷 sì zhī nì lěng) (also called reversal cold of the extremities
四肢厥冷 sì zhī jué lěng) denotes more severe conditions of pronounced cold up from the tips of the limbs to the elbows and knees.
- If all the extremities are cold at the onset of illness, this is attributable to exuberant yīn cold.
- Lack of warmth in the extremities in enduring illness or in people with weak constitution means yáng vacuity with cold.
- Heat in the extremities in those suffering from vigorous heat effusion means intense yáng heat.
- If only the chest and abdomen are scorching hot, but there is reversal cold of the extremities, this is called
heat reversal
(热厥 rè jué). It is a pattern of true heat and false cold, which arises when yáng heat congests the inner body and fails to reach the outer body (seeexuberant yáng repelling yīn .
Cold and Heat in Specific Parts of the Hands and Feet
Heat and cold in specific parts of the hands and feet are often of great diagnostic significance.
- A lack of warmth in the extremities is a sign of yáng vacuity.
- In externally contracted disease with heat effusion, heat is normally more pronounced in the back of the hands and dorsum of the foot.
- In internal damage conditions, yīn vacuity with internal heat is usually characterized by heat in the palms and soles, with heat unpronounced elsewhere. This is called
vexing heat in the five hearts
(五心烦热 wǔ xīn fán rè). - In infants and children, vigorous heat effusion with cold fingertips may portend the stirring of wind with convulsions (child fright wind).
- In children suffering from measles, eruption of the measles papules is often heralded by cold in only the middle finger.
- Generalized heat effusion with cold at the tips of the fingers and toes may portend yáng collapse vacuity desertion or
heat block tetanic reversal
(heat block with loss of consciousness and severe spasm). This sign should be accorded special attention when it occurs in infants and children.
Palpation of the Chest and Abdomen
Palpation of the chest and rib-side is limited by the presence of the ribs, which prevent the tissues they enclose from being felt. However, the palpation of the apical pulse just below the left nipple is of value in some cases. Palpation of the abdomen enables the practitioner to detect cold or heat, softness or hardness, fullness and distension, and abdominal masses. Palpable symptoms indicate disorders of the specific bowels and viscera. These should be correlated with any subjective sensations reported by the patient in the context of the inquiry examination.
Correspondence of abdominal positions and the bowels and viscera: The correspondences between location of pathologic symptoms and the relevant diseased organs are as follows:
- The chest corresponds to the heart and lung.
- The rib-side, which is the side of the rib cage, corresponds to the liver and gallbladder. Remember that subjectively felt distending pain in the rib-side is ascribed to depressed liver qì, while scorching pain is ascribed to liver fire.
- The stomach duct, which is the area occupied by the stomach, corresponds to the stomach and spleen, especially the former.
- The abdomen in general, centering on the umbilical region, corresponds to the spleen, stomach, or intestines, most commonly the spleen.
- The lower abdomen, which in Chinese medicine is called the
smaller abdomen
(小腹 xiǎo fù) corresponds to the liver, bladder, or kidney. - The
lesser abdomen
(少腹 shào fù), that is, the lateral parts of the lower abdomen, corresponds to the uterus and specifically the ovaries. Remember, subjectively felt distending pain in the lesser abdomen is often associated with menstrual irregularities attributable to depressed liver qì. - The breasts also correspond to the liver. Remember, subjectively felt distending pain in the breasts is often associated with menstrual irregularities attributable to depressed liver qì.
Apical pulse, Vacuous Lǐ
: Palpation of the apical pulse, which in Chinese medicine is called Vacuous Lǐ,
is the main aspect of chest palpation. Vacuous Lǐ is located just below the left nipple. Described as being the source of all blood vessels,
it is the point where the heart is closest to the body surface. The strength of the pulsation at Vacuous Lǐ can help to assess the strength of ancestral qì, identify vacuity and repletion, and gauge the patient’s prognosis. Inspection of the Vacuous Lǐ is especially important in severe vacuity or repletion patients, where the radial pulse may not be felt.
The pulsation is best felt with the patient in supine posture. The practitioner stands at the patient’s right side and places her hand gently on the spot. The pulsation can be felt by pressing gently. In a healthy person, the pulsation is gentle and relaxed, and unhurried. The pulsation is relatively indistinct in corpulent people and more pronounced in thin people. These variations have no clinical significance.
- After a powerful emotional stimulus such as fright, fear, or anger or after strenuous exercise, the pulsation may be strong, but this subsides quickly, and hence is normal.
- If the Vacuous Lǐ pulse is faint, this means vacuity of ancestral qì. If the pulsation is excessively strong, this means that ancestral qì is discharging outward.
- If it flicks against the hand and is surging and large, the condition is critical. Occurring before or after childbirth or in patients with pulmonary consumption, it is an especially critical sign.
- A Vacuous Lǐ pulse on the verge of expiration may indicate impending death when this is suggested by other prominent signs. However, without accompanying signs of impending death, a Vacuous Lǐ pulse on the verge of expiration may be a sign of phlegm-rheum.
Palpation of the rib cage: Palpation just below the rib cage allows abdominal masses stretching up into the rib cage to be felt. The liver is partially enclosed by the rib cage. Enlargement of the liver felt through palpation indicates qì stagnation or blood stasis. If the surface of the liver feels bumpy, this may indicate liver cancer (not traditionally recognized as such in Chinese medicine). If there is distending pain in the right rib-side that feels palpably hot and tender, this is a welling-abscess of the liver. In malarial disease, there may be a palpable mass under the rib cage, which is traditionally called mother-of-malaria,
corresponding to hepatosplenomegaly in biomedicine.
Abdominal palpation: The purpose of this is to determine the nature of fullness, distension, and pain. Fullness
is a subjective feeling of bloating in the chest or abdomen. Distension
means pronounced fullness that is objectively palpable or even visible expansion of the abdomen. Fullness and distension may or may not be associated with pain. Pain may or may not be associated with fullness and distension.
- Pain that likes pressure, that is, is relieved by pressure, is cold pain or vacuity pain.
- Pain that refuses pressure, meaning that it is exacerbated by pressure, indicates heat or repletion pain.
- Fullness and distension that feel solid, offer resistance when pressed, and produce a dull sound when tapped are called
and hence constitute a repletion pattern.repletion fullness - Fullness and distension that feel soft and produce a hollow sound when tapped are referred to as
a vacuity pattern.vacuity fullness , - If the abdomen is visibly distended and enlarged, this is called
drum distension.
- A palpable ropelike mass in the abdomen may indicate worm accumulation.
- Palpable hard fullness below the heart, that is, in pit of the stomach, indicates
chest bind
(结胸 jié xiōng), which arises in cold damage when offensive precipitation is administered in greater yáng (tài yáng) and causes the exterior heat to fall into the interior to bind with water-rheum. It may also occur in greater yáng (tài yáng) disease progressing to yáng míng (yáng míng), where repletion heat combines with pre-existing water-rheum.
Abdominal masses: Abdominal masses are often referred to as glomus lumps
(痞块 pǐ kuài). (Remember that glomus
is a lump or localized feeling of blockage and fullness.) Distinction is made between concretions (癥 zhēng), conglomerations (瘕 jiǎ), accumulations (积 jī), and gatherings (聚 jù): Also called glomus lump.
- Hard masses of fixed location that resist dispersion under pressure are
concretions
(癥 zhēng) oraccumulations
(积 jī). They arise when repletion evils such as static blood or phlegm-rheum gather and bind. - Soft masses of unfixed location that are soft and disperse under pressure and that may disperse spontaneously and reoccur are called
conglomerations
(瘕 jiǎ) orgatherings
(聚 jù). They are generally attributable to qì stagnation. - Accumulations and gatherings chiefly occur in the center burner.
- Concretions and conglomerations chiefly occur in the lower burner. Many are gynecological in nature. Uterine fibroids (myomas) with distension and pain generally fit into these disease categories.
In short: Concretions are hard lower burner masses, while conglomerations are soft lower burner masses; accumulations are hard center burner masses, while gatherings are soft center burner masses.
Masses that are large, irregular in shape, and do not feel smooth indicate a serious condition, especially if as a hard as stone.
An abdominal mass that feels like a sinew and that on long palpation appears to move or even wriggle or that gathers and disperses intermittently is usually a sign of a worm accumulation.
Palpation of Acupoints
Morbidity of the organs may be reflected in palpatory tenderness (that is, when pressure applied causes pain) or sensitivity at many acupoints. The following deserve special attention.
- Lung disease is sometimes reflected in a palpable node at BL‑13 (fèi shù, Lung Transport) or in palpatory tenderness at LU‑1 (zhōng fǔ, Central Treasury).
- Liver disease is reflected in palpatory tenderness at LR‑14 (qī mén, Cycle Gate) and BL‑18 (gān shù, Liver Transport).
- Diseases of the gallbladder are reflected by palpatory tenderness at BL‑19 (dǎn shù, Gallbladder Transport) or Gallbladder Point (dǎn náng xué).
- Diseases of the stomach are reflected in tenderness at BL‑21 (wèi shù, Stomach Transport) and ST‑36 (zú sān lǐ, Leg Three Lǐ).
- Intestinal welling-abscess (acute appendicitis) is reflected in palpatory pain at Appendix Point (lán wěi xué).
Diseases are not only reflected at these points but may also be treated by acupuncture or tuī-ná (massage therapy) at the sensitive spots.
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