Diagnosis by Palpation

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Presentation used briefly to explain the basics of Traditional Chinese Medicine diagnosis by palpation. It includes (and mainly focuses on) pulse diagnosis, skin palpation, abdomen palpation, point palpation and limb palpation.

References cited include Chinese Acupuncture and Moxibustion, Foundations of Chinese Medicine, Diagnosis in Chinese Medicine, A Manual of Acupuncture, Pulse Diagnosis.

1. Diagnosis by palpation DME-312 Handouts 7,8,9

2. Palpation Diagnosis by feeling generally includes the following Palpation of the pulse Palpation of the skin Palpation of the limbs Palpation of the hands Palpation of the chest Palpation of the abdomen Palpation of the points

3. Performed by placing fingers along the Radial Artery. Pressure is applied with different kinds of strength at three different points. The patient’s arm should be horizontal and not held higher than heart level. PULSE DIAGNOSIS

4. We use the pads of the fingers to take the pulse because they are the most sensitive area. We place the first three fingers (not counting the thumb) on the Radial artery. Pulse Diagnosis

5. Pulse is felt by moving the fingers in 4 different ways: Lifting (upwards) Pressing (downwards) Pushing (side to side) Rolling (proximal – distal) We also keep the fingers still (searching) in order to be able to decide the speed of the pulse. Pulse Diagnosis

6. Pulse diagnosis Sections of Pulse Inch (CUN) - Front Barrier (GUAN) - Middle Cubit (CHI) - Back Pulse Depth Superficial – resting fingers very gently on the artery Deep – almost obliterate pulse then release very slightly Middle – in between these two kinds of pressure Altogether, 3 Sections x 3 Depths = The 9 Regions

7. PULSE DIAGNOSIS Correspondence of each organ and section / level according to the Mai Jing (Pulse Classic)

8. PULSE DIAGNOSIS Main importance of Pulse Diagnosis Gives detailed information about state of internal organs Reflects whole complex of Qi and Blood Other Notes Pulse counts as a clinical manifestation that shows you the entire body The tongue also does this, but with less clarity

9. PULSE DIAGNOSIS Drawbacks to Pulse Diagnosis Extremely subjective Skill is subtle and hard to master Subject to external, short-term influences Advantages to Pulse Diagnosis It can reflect older disharmonies not showing on tongue, as well as others due to discoloration or physical manipulation of it (such as scraping)

10. Pulse Diagnosis What you should pay attention to (IN THIS SPECIFIC ORDER) Feel the Pulse as a whole Feel whether the pulse has spirit, Stomach Qi and root Feel the three levels and the three positions Feel the strength of the pulse Feel the quality of the pulse

11. Pulse Diagnosis Qualities of Pulse that we are looking for Force Movement Rate Rhythm Shape Presence of Shen

12. PULSE DIAGNOSIS What is a Normal Pulse? Has Stomach-Qi Feels “gentle”, “calm” and relatively slow (4 beats per respiratory cycle / breath) Has Spirit Soft but with strength; neither big or small Regulated – should not change type very easily Has root Deep level is clearly felt along with rear position Kidneys are felt strong

13. PULSE DIAGNOSIS Factors that affect the Pulse Seasons Pulse is deeper in wintertime; superficial in summertime Gender Male pulse is naturally stronger than women’s Men have stronger left pulse; women, the right pulse Men have stronger front pulse; women, the rear Occupation People who perform strong physical labor should have a stronger pulse than those who do not

14. Pulse Diagnosis Factors that affect the Pulse Body build Pulse will be stronger, larger and longer in robust, large people; weaker, smaller and shorter in small, frail people Menstruation Becomes slippery the week before the onset, especially on the right rear position; then it becomes weak and slower Pregnancy Becomes slippery, therefore it is considered normal Fan Guan Mai and Xie Fei Mai These are abnormalities on the pulse

15. Pulse Diagnosis Fan Guan Mai is a radial artery displacement that is present in about 5% of people. The radial artery lies in the dorsal aspect of the arm instead of the inner aspect. In these cases, the pulses on the nine regions of the head, hand and feet are recommended.

16. Deep Pulse Chinese Name Chen Mai, a.k.a. Sinking Description Can only be felt with heavy pressure; felt near the bone Clinical Significance Indicates an interior condition Indicates the Yin organs to be the problem Indications Deep and Weak: Yang and Qi deficiency Deep and Full: a) Stasis of Qi; b) Blood in the Interior; c) Interior Cold or Heat

17. Floating pulse Chinese Name Fu Mai Description Can be felt with a light pressure, resting fingers on artery Clinical Significance Indicates presence of exterior pattern from pathogen Indications Floating and Tight: Wind-Cold Floating and Rapid: Wind-Heat Floating Superficial / Empty Deep: Yin deficiency

18. SLOW Pulse Chinese Name Chi Mai Description Three beats per respiration cycle (breath) of practicioner Can also be counted using a watch Clinical Significance Indicates a Cold pattern Indications Slow and Empty – Empty-Cold from Yang Deficiency Slow and Full – Full Cold

19. SLOW Pulse Typical Slow Pulse Speeds (estimated) Age (Year) Rate (beat/min) 1 – 4 90 or more 4 – 10 84 10 – 16 78 / 80 16 – 35 76 35 – 50 70 / 72 50+ 68

20. Rapid Pulse Chinese Name Shu Mai Description 5 or more beats per cycle (or higher than slow chart) Clinical Significance Indicates a Heat pattern Indications Rapid and Empty – Empty-Heat from Yin Deficiency Rapid and Full – Full Heat or Excessive Heat

21. empty Pulse Chinese Name X u Mai (a.k.a. Vacuous, Deficiency) Description Feels rather big, but soft; feels empty with more pressure Clinical Significance Indicates Qi or Qi AND Blood deficiency

22. FULL Pulse Chinese Name Shi Mai (a.k.a. Excess type, Replete) Description Feels full; rather hard and long Clinical Significance Indicates a Full pattern Indications Full and Rapid – Full-Heat Full and Slow – Full-Cold

23. Slippery Pulse Chinese Name Hua Mai Description Feels smooth, round, oily to the touch; rolls under fingers Feels like “rolling pearls in a porcelain bowl” Clinical Significance Indicates Phlegm, Dampness, Food retention, Pregnancy Indications It’s full by definition, but can be weak as well It can be weak, indicating Phlegm, Dampness and Qi deficiency

24. Choppy Pulse Chinese Name Se Mai a.k.a. Hesitant, Rough Description Rough under the fingers; like a jagged edge Feels like “a knife scraping bamboo” Also means a pulse that changes rapidly in rate and quality Clinical Significance Indicates stasis or deficiency of blood Could mean exhaustion of fluids, especially after profuse sweating or vomiting

25. LONG Pulse Chinese Name Chang Mai Description Longer than normal; extends slightly beyond normal pulse Clinical Significance Indicates a Heat pattern May indicate that there is no Pathological condition

26. Short Pulse Chinese Name Duan Mai Description Occupies shorter space than normal position Clinical Significance Indicates a severe Qi deficiency Frequently appears on Front position; either left or right Specifically denotes deficiency of Stomach-Qi

27. Overflowing Pulse Chinese Name Hong Mai, a.k.a. Surging, Flooding Description Feels big and extending beyond normal pulse position Superficial; generally “overflows” normal pulse channel Clinical Significance Indicates an Extreme Heat pattern Frequently appears during Fever, and Interior Heat diseases Indications Overflowing and Empty on pressure – Empty Heat from Yin deficiency

28. Fine Pulse Chinese Name X i Mai, a.k.a. Thready , Thin Description Feels thinner than normal Clinical Significance Indicates a deficiency of Blood May indicate Dampness with severe Qi deficiency Indications Thin and Rapid – Heat brought by Yin deficiency

29. Minute Pulse Chinese Name Wei Mai, a.k.a. Faint Description Thinner than the Fine pulse; harder to feel; very small Clinical Significance Severe deficiency of Qi and Blood

30. Tight Pulse Chinese Name Jin Mai, a.k.a. Tense Description Feels twisted, like a thick rope It also can be felt as it “vibrates” Clinical Significance Indicates a Cold pattern, exterior (i.e. Wind-Cold) or Interior May indicate pain from an interior condition Indications Tight and Floating – Exterior Cold Tight and Deep – Interior Cold

31. Wiry Pulse Chinese Name Xian Mai, a.k.a. Stringlike , Bowstring Description Feels taut, like a guitar string Thinner, more taut and harder than the Tight pulse “No fluidity or wave-like qualities” Clinical Significance May indicate Liver disharmony May indicate Pain May indicate Phlegm

32. SLOWED- DoWN Pulse Chinese Name Huan Mai, a.k.a. Moderate Description Four beats per respiration cycle Clinical Significance Generally considered a healthy pulse If Dampness is suspected by other signs, it can be used to indicate its presence

33. Hollow Pulse Chinese Name Kong/Kou Mai, a.k.a. Scallion-stalk Description Felt at superficial and deep; any middle pressure makes it empty Clinical Significance Indicates a loss of Blood Usually appears after a hemorrhage Indications Hollow and s lightly Rapid – Forthcoming loss of Blood

34. Leather Pulse Chinese Name Ge Mai, a.k.a. Drumskin Description Hard, tight and stretched superficially; empty at Deep level Large pulse, not thin Clinical Significance Indicates severe deficiency of Kidney-Essence or Yin

35. Firm Pulse Chinese Name Lao Mai, a.k.a. Confined, Prison Description Only felt at Deep level; felt hard and rather wiry Could be described as a Wiry pulse at the Deep level Clinical Significance Indicates Interior Cold (if it is also Slow) Indicates Interior Stagnation and Pain

36. Soggy Pulse Chinese Name Ru Mai, a.k.a. Soft, Weak-Floating Description Only felt on superficial level; very soft and slightly floating Disappears when pressure is applied to feel Deep level Clinical Significance Indicates presence of Dampness if there are other signs that represent a Qi deficiency May also indicate lack of Yin or Essence

37. Weak Pulse Chinese Name Ruo Mai, a.k.a. Frail Description Only felt on Deep level; also soft Clinical Significance Indicates a deficiency of Yang or of Blood

38. Scattered Pulse Chinese Name San Mai Description Small and relatively superficial Feels as if it was broken into small dots Clinical Significance Severe deficiency of Qi and Blood, especially Kidney-Qi ALWAYS indicates a serious condition

39. Hidden Pulse Chinese Name Fu Mai Description As if it was hidden beneath the bone Extreme case of Deep pulse Clinical Significance Extreme deficiency of Yang If strong, indicates an obstruction of Cold

40. Moving Pulse Chinese Name Dong Mai, a.k.a. Spinning-Bean Description It is short and “trembles” under the finger Does not have a definite shape; shaking and also slippery Combination of short, tight, slippery and rapid pulses Clinical Significance Indicates shock, anxiety, fright or extreme pain F ound in people with deep emotional problems, especially fear, or those who have suffered severe emotional shock

41. Hasty Pulse Chinese Name Cu Mai, a.k.a. Abrupt, Skipping, Hurried Description Rapid pulse, stops at irregular intervals Clinical Significance Indicates extreme Heat and a deficiency of Heart-Qi Also felt in conditions of Heart-Fire

42. Knotted Pulse Chinese Name Jie Mai, a.k.a. Bound Description Slow and stops at irregular intervals Clinical Significance Indicates cold Indicates deficiency of Heart-Qi or Heart-Yang

43. Intermittent Pulse Chinese Name Dai Mai, a.k.a. Regularly Interrupted Description Stops at regular intervals; feel the pulse and feel the stops Clinical Significance Indicates a serious internal problem of one or more Yin organs If it stops every four beats or less, the condition is serious It can also indicate a serious heart problem (in the Western medical sense)

44. Racing Pulse Chinese Name Ji Mai, a.k.a. Swift Description Pulse is very rapid, but agitated and very urgent Clinical Significance Indicates an Excess of Yang, with Fire in the body exhausting Yin

45. PULSE DIAGNOSIS 28 Different Pulse Qualities (with similar Grouping) (The groups have been been grouped on a Yin-Yang level) Deep Floating Slow Rapid Empty Full Deep Floating Slow Rapid Empty Full Firm Hollow Knotted Hasty Weak Overflow Hidden Leather Choppy Hurried Fine Wiry Soggy Moving Minute Tight Rolling Soggy Long Short Firm Scattered

46. Pulse Diagnosis 8 Principles General Pulse Quality Description Specific Pulse Quality Exterior (Yang) superficial Felt with light pressure Superficial; floating; hollow; leather; soft Interior (Yin) deep Felt with deep pressure Deep; Firm; Hidden Hot (Yang) rapid More than 80 BPM (>5 per breath) Rapid; Hasty; Moving Cold (Yin) slow Less than 65 BPM (3> per breath) Slow; Tight; Knotted; Intermittent (not necessarily slow but often) Full (Yang) full Large, long, substancial Full; Big; Overflowing; Wiry; Tight; Long; Slippery; Flooding; Empty (Yin) empty Small, short , insubstancial Empty; Weak; Fine; Minute; Short; Scattered; Choppy

47. SKIN PALPATION Palpating the skin involves focusing on three major topics: Temperature of the skin Moisture of the skin Texture of the skin We do this by three different methods: Touching Stroking Pressing

48. Palpating the Body There are three different palpation techniques: Touching - Light touch of the patient’s skin Detecting temperature, moisture and sweat Stroking – stroking in the skin and deeper tissues of the patient Usually carried out in chest, abdomen and limbs Determines presence of tenderness and swelling Pressing – pressing relatively hard to deeper levels Usually done in the abdomen Determines presence of pain or masses

49. SKIN PALPATION Key things to Know Temperature Subjective feeling of heat does not always correspond to the objective feeling of heat of the skin Skin feels hot to the touch – often indicates Damp-Heat Cold feeling indicates Cold pattern; often felt in loins, lower abdomen or lower back (indicates Kidney-Yang deficiency) Hot on first touch, ceasing to feel hot with sustained pressure – indicates Wind-Heat invasion, still on exterior Skin over vessel hot on medium pressure but not on heavy pressure – interior Heat in Middle Jiao or Heart Skin hot on heavy pressure nearly nearing the bone – Empty Heat from Yin deficiency

50. Skin Palpation Key Things to Know Moisture and Texture Moist skin may indicate invasion of the Exterior by Wind-Cold, or more commonly, Wind-Heat Moist skin with absence of exterior symptoms indicates spontaneous sweating from Lung-Qi deficiency Dry skin indicates Blood or Lung-Yin deficiency Rough-like skin may indicate Painful Obstruction Syndrome from Wind S caly and dry skin indicates exhaustion of body fluids Swollen skin with a pit left after pressing indicates oedema Swollen skin, no pit indicates retention of Dampness

51. Limb Palpation Key Things to Remember: Hands and feet cold to the touch indicate Yang deficiency Whole arm and leg feel cold indicate Kidney-Yang deficiency (Empty-Cold) Only forearm and lower leg feel cold may indicate Interior Cold from Qi stagnation (Full-Cold) Only hands and feet feel cold may indicate Qi stagnation Limbs feeling hot indicate a Heat pattern Hands hot on the dorsum indicate Full-Heat Hands hot on palms indicate Empty-Heat from Yin deficiency

52. Chest Palpation Process Palpate the area over the left ventricle of the heart (called “Interior Emptiness” or Xu Li in Chinese Medicine) Pulse of heart can be felt in this area; sometimes seen Area reflects the state of Zong Qi (Gathering Qi)

53. Chest Palpation Key Things to Remember Faint but clear pulsation indicates Gathering Qi deficiency Too strong pulsations indicate “outpouring” of Gathering Qi, i.e. a state of hyperactivity due to over-pushing oneself Pulsation not felt indicates Phlegm or a hiatus hernia Area below xyphoid process feeling full and painful on pressure indicates a Full pattern

54. Abdomen Palpation The Abdomen is generally palpated in 5 areas: Hypochondrium Epigastrium Umbilical area Lateral-lower abdomen Central-lower abdomen

55. Abdomen Palpation Hypochondrium Includes the lateral side of the rib cage and area immediately below it Reflects state of the Liver and Gall-Bladder

56. Abdomen Palpation Epigastrium Area contained between the xyphoid process, costal margins and the umbilicus Reveals the condition of the Stomach and Spleen

57. Abdomen Palpation Umbilical Region It is the area right around the umbilicus It reflects the state of the Kidneys, the Penetrating and Directing Vessels Umbilical area has a palpable pulse as well

58. Abdomen Palpation Lateral-lower Abdomen Also called Shao Fu Reflect the state of the Intestines and the Penetrating Vessel

59. Abdomen Palpation Central-lower Abdomen Also called Xiao Fu Reflects the state of the Small Intestine, Kidneys, Bladder, Uterus and Liver

60. Japanese Hara DX Step 1: Compare Big and Small Abdomen Big Abdomen Deficient – LU or SP Small Abdomen Deficient – LV or KD

61. Japanese Hara DX Step 2: Determin Nan Jing Abdominal Diagnosis Area: SP – Umbilical, CV7 – CV12 HT – Substernal , CV12 – CV15 LU – Right of Navel / Right Ab LV – Lower left of Navel / Left Ab KD – Subumbilical , CV7 - Pubis

62. Point Palpation Main point of point palpation is checking for tenderness Very tender on superficial pressure – Full condition on that channel or local stagnation Pressure relieves pain – Empty condition on that channel Pressure relieves but then causes discomfort – mixed Deficiency and Excess condition All acupuncture points (and Ah Shi points) can be used diagnostically.

63. POINT PALPATION Main Points for Palpation Diagnosis Front Collecting (Mu) Points Back Transporting ( Shu ) Points Lower Sea Points Source (Yuan) Points Ah Shi Points

64. Front Mu Points Mu – “raise, collect, enlist, recruit” Points where the Qi of the relevant organs get collected

65. Back Shu Points Points are all located on the Bladder channel Reflect specifically the condition of the relevant internal organ instead of its channel

66. Back Shu Points

67. Lower Sea Points Points are used to treat their respective Yang organs Organ Point Channel Organ Point L.Int . ST-37 Yang Ming Stomach ST-36 San Jiao UB-39 Shao Yang Gall-Bladder GB-34 S. Int. ST-39 Tai Yang U. Bladder UB-40

68. Yuan Points “If the 5 Yin organs are diseased, abnormal reactions will appear at the 12 Source points. If we know the correspondence of Source points to the relevant Yin organ, we can diagnose when a Yin organ is diseased.” Spiritual Axis, Ch. 1

69. Yuan Points Source Points for the Yin Organs Yin Organ Source Point Lungs LU-9 Taiyuan Heart PE-7 Daling Spleen SP-3 Taibai Liver LIV-3 Taichong Kidneys KI-3 Taixi

70. Ah Shi Points Ah Shi Theory If there is soreness on pressure (whether on a channel or not), there is a point Body is completely covered by different channels so every area is irrigated by them Pressure and description of the condition will reflect the channel which it is closest to

71. Reference / credits Kaptchuk , Ted - “The Web that has no Weaver Maciocia , Giovanni – “Diagnosis in Chinese Medicine” Maciocia , Giovanni – “Foundations of Chinese Medicine” Xin Nong , Cheng – “Chinese Acupuncture and Moxibustion ” Zheng , Li Shi - “Pulse Diagnosis” Flaws, Bob – “The Secret of Chinese Pulse Diagnosis”