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１．The meaning of palpation
The phrase “seeking truth based solely on the facts” appears in the Book of Han. The Japanese, In opposition to this, have a deep seated doubt about theory and because of this tend to put importance on hands on practicer rather than theory. Furthermore, there is a tendency to not hold or create a common or unified understanding because each person tends to base their truth on personal experience. With this drawback stated, I would like to present my personal belief concerning the theme of palpation based on personal perception.
In the chapter Heavenly Dao of the book Zhuangzi a wheel maker named Rinpen tells a King, “A person who has exceptional professional mastery (the ability to perform ones work) cannot express the essence of their aged wisdom in words. Even if following generations did read the words they left, it would be mere dregs (the boring things that remained) of the ancients. Cerebral understanding is meaningless.”
While I am of the same opinion, I will still try to explain what a Japanese acupuncturist thinks and feels when using simple acupuncture tools like needle and moxa to transmit suitable vibrations to the patients body and soul.
There are many kinds of palpation. One aspect of palpation concerns feeling the pulse during diagnosis. This is when the hardness, force, weakness, heat and pernicious ki of the pulse can be felt. Normally a stroking palpation is used for the meridians of the legs and feet. The stomach is rubbed and stroked for the hara diagnosis. The same is true for the diagnosis of the back. Weight is applied to acupuncture points to find those that should be treated. Direct palpation can confirm the condition of pain and unpleasant feelings felt by the patient. These are just a few types of palpation.
While the area of concern and the area of palpation may differ, confirming something via touch creates a common ground. A differential diagnosis of cold/heat and deficiency/excess can be conjectured from the confirmation of the areas condition, e.g., cold/hot, soft/hard, dry/damp, swollen and the presence or non-presence of pernicious ki. Palpation is not simply the direct verification of information deduced from seeing, listening and asking. It decides which meridians, points, and objects of attention will become the goals of treatment and the treatment expectations for depth, direction, and tool manipulation.
Japanese tend to have moist, elastic skin. This is reflective of their damp and mild environment which boosts four, distinct seasons. In fact, many Japanese are sensitive and live in abundance. Perhaps this is why the conditions of the skin and the subcutaneous tissue has been focused on more so than in other countries. Rather than diagnostic based theory, there is a strong tendency to connect personal palpation findings to subtle treatments methods. It can be said that the Japanese have long standing custom of adeptly utilizing the Tao as the common foundation for traditions like kendo, judo, tea ceremony and calligraphy.
Palpation is also an excellent diagnostic method because it can also quality check the efficacy of the treatment after completion and observe the changes in the body. Rough skin can begin to hold moisture. A white, cold complexion may begin to become warm and vibrant. Strained subcutaneous tissue can become supple. Muscle fibers that are contracted and have indurations can gradually soften. Slack skin may regain its tension. All of these changes are indicators that the body is recovering good circulation of ki and blood.
2. Specific information that can be grasped from palpation
① Low temperature
Cold skin implies poor circulation of ki and blood in the outer layers of the body as a matter of course. Specifically cold that presents from the elbows to the fingers and knees to the toes emerges on the hand/foot meridians and is related to cold residing in the neck, shoulders, chest and back (the trunk of the body). This means it correlates to cold in the zangfu, stagnation of blood and fluids, indurations/shakuju and it often involves a functional decrease of the zangfu. Sometimes the specific meridians of the hand/foot are warm and correlate to inflammation and pernicious heat in the trunk and zangfu. Low temperatures in the trunk will be expressed with cold in the meridians and a specific cold point should be palpable.
②Hardness and softness
Hardness of the skin and subcutaneous layer can be due to cold, mental tension, a change in constitution, and old age. For example, the skin of a diabetic may be pathological factors such as blood stasis and bodily waste. Hardened skin will need a stronger needling technique. Skin tension due to cold and mental tension will require the use of the needle tip, or sanshin technique, to relax the skin (like a drunken needle technique which applied to many superficial points on the skin). The skin of areas that are inflamed and uncomfortable will show pathological tension along the related meridians and hypersensitive sensory nerves. Doing a dispersive needling technique here will reversely create more pain and muscle tension. It is imperative to first disperse the pernicious heat from the surface before needling.
Normally it is good if the skin and subcutaneous layer is soft however if the skin isn’t moist and the subcutaneous doesn’t have tension than often the muscle layer will be contracted and have indurations. This is a hindrance to the skins circulation of ki and blood. The treatment goal should then be to strengthen the skin, increase moisture, and restore the circulation of ki and blood in the related meridians.
③Dryness and moisture
Dry skin indicates poor circulation of ki, blood, and fluid. It can also be a sign of blood stasis. For blood stasis the skin can be dry and tea-brown tinged color. The root cause of body fluid deficiency is usually a functional decrease of the digestive tract absorbing water. In this case, palpation will show a splashing sound in the stomach/intestinal area indicating water stagnation. The patient will be thirty and the membrane of the throat dry.
Oppositely, some people have wet, cold, and white skin. They will have cold in the zangfu and their entire body constitution will have poor water metabolism. The leg yin channels will particularly be cold. For this patient it is imperative to warm the stomach and back and improve the function of the spleen and kidney zang.
Swelling is a result of chronic malfunction of the spleen and kidney. Water flows from high to low where it collects. So if a person has to stand a lot for their job or sit down all day then they will have swelling below their knees. Someone who lays down a lot will have swelling around the upper and lower back and buttocks.
Poor circulation of blood will create cold and muscle tension in the lower half of the body. This type of person will have rushes of blood to the face and swelling of the face. This is blood stagnation. People who have tight neck and blood stasis will have swelling in the fingertips, stiff fingers and the skin will be rough. Those with a stiff back and a cold lower abdomen will often have swelling in the toes and lower heel pain.
⑤Potential presence of pernicious ki
A practitioner can roughly grasp the patients constitution and the unbalances of their internal organ function by palpating the skin and surface of the patients’ body. Importantly, there will be pernicious ki in the area(s) of the body, skin, and the surfaces of related meridians of those patients experiencing pain and feelings of unpleasantness. The practitioner should feel for areas that have a different reaction from the surroundings like cold or heat, hardness or softness, dryness or dampness; however, directly identifying the area(s) and origin of disease and those with or without pernicious ki is of the upmost importance.
The practitioner may feel a stinging or vibration coming from the surface of the patients’ skin in their fingertips or palm. Practitioners who don’t feel anything can palpate with their fingertips to feel muscle tension. The patient will also facially express being uncomfortable and in pain.
Even if a detected outer layer shows a reaction that differs from the surrounding area, the absence of pernicious ki will indicate it as no more than the expression of a chronic predisposition. Thus, distinguishing it from the current condition. It is imperative to train the palm and fingertips to be sensitive to the presence or non-presence and the strength or weakness of pernicious ki.
3) Specific ways to palpate
Consciously check, in particular the forearm (from the elbow to fingertips), for low or high temperatures, hardness or softness, cold or heat, and deficiency or excess of the meridians. Gently search for a live point, an area that feels different, by touching and stroking with the first and middle fingertips.It is ok to massage with the fingertips for hardness, softness, and/or sinew strain if it is not possible to distinguish this on the skin surface. Check the legs in the same way.
I have drawn the hara diagnostic chart, below, which was originally featured in Vol.24-Nu.70 for reference. Gently palpate the chest with the palm of the hand in order 1 through 5. Verify feelings of heat, vibrations, palpitations, abdominal distention, and the presence or non presence of pernicious ki.
Gently place and diagnosis the abdomen with the palm following the chart number 1-6. Next, using 1st, 2nd, 3rd and 4th fingertips massage somewhat deeply to diagnosis contraction and indurations in the muscle layer. Check for feelings of cold or heat in the area, tension, relaxation of the muscle layer, shakuju (lumps due to gas, constipation, water stagnation and blood stagnation), and for the presence or non-presence of pernicious ki.
Palpate to the left and right of the back bone by sliding the palm from top to bottom. Examine each area for cold or heat, hardness or softness, dryness or moisture, and the presence or non-presence of pernicious ki. It is easy to check the tension of the erector spines muscles by pushing the tendons to the left and right with the four fingertips. It is important relate the combined information of hara and back diagnosis to the deficiency/excess of the zangfu function while palpating. Also, diagnosis the curve of the spinous process and interspinous spacing. The cause of a condition can be latent orthopedic problem, i.g. bones and joints.
4) The danger in focusing solely on palpation
The goal of palpation is to physically check touch the patients body for cold/heat, deficiency/excess and toxins/pernicious ki in the body while referencing the information gathered during the oral history, and pulse and tongue diagnosis. From that, conjecture an image of the condition of the whole body and build a treatment procedure. What part is the root of the condition? Which meridian should be utilized? How will the condition of the body change in accordance to treatment? These should be grasped and checked via palpation. This is why palpation is the most important diagnostic tool of the four.
However, an element of palpation relies heavily on the sensitivity of the practitioner and many practitioners rely solely on palpation and are therefore unable to fully grasp the patients condition. This leads many to perform only localized and ashi point treatments. Also, if the practitioners fingertips are overly sensitive they will be distracted by located temperature difference and unneeded information. Oppositely, when the practitioner isn’t feeling well the sensitivity of their hand will be dulled and they will be unable to catch the needed information from palpation. By relaxing the spirit and centering the mind and body the practitioner will be able to catch the needed information via palpation. Also, effective palpation is understanding and being able to diagnosis the progression of the patients whole body and condition in entirety.
I belong to Iyashi No Michi. Our group uses the Shang Han Lun to study the dynamic, fluidity of disease and to learn the 6 levels of disease mechanisms. Please reference my previous article in Vol.24-Nu.70. I have also tested several methods to improve the sensitive of my hands. I have illustrated some of them at the end of this text. First pull from the above quote: repeated practice in necessary to improve palpation, “…Transmission directly from the hand to the soul.” As expected, one cannot really come close to the truth through words. One is obliged to join their hands and soul.
・「毒」と「邪気」を目標とした腹診と鍼灸治療、大浦慈観著、NAJOM Vol.24-Nu.70,July 2017。