Temperature

When palpating the abdomen one should first of all feel the temperature of different areas: if the abdomen feels cold on palpation this indicates either Cold or Yang deficiency; if it feels hot on palpation this indicates Heat. If the pulse picture indicates Heat but the abdomen is not hot on palpation, this indicates exter-nal Heat. In children, a hot sensation of the abdomen on palpation often indicates retention of food.

Texture

Next, one should check the texture of the abdomen, that is, whether it feels soft or hard. The normal abdomen should feel relatively soft on a superficial palpation but firm with a deeper pressure. If the abdomen feels very soft and flaccid on palpation, this indicates a deficiency condition of the Spleen and Stomach if it is the epigastrium, or the Spleen and Kidneys if the lower abdomen; the latter sign is common in women who have had several children.

If the abdomen feels hard on palpation, this indicates a Full condition, which is usually Qi stagnation, Blood stasis, Dampness or retention of food; each of these conditions presents with different subjective symptoms, which are distension, pain and fullness respectively.

Palpation of the abdomen is quite important in invasions of Wind, especially in children, because if the abdomen feels soft the pathogenic factor is usually still on the Exterior, whereas if it feels hard the pathogenic factor has penetrated to the Interior.

Box 51.1 summarizes the significance of different textures on palpation.

Distension versus fullness

One can distinguish distension from fullness on palpation. Besides being subjective symptoms, distension and fullness are also objective signs. The distended abdomen feels hard but elastic, like a drum, whereas fullness of the abdomen manifests with a hard-ness of the abdomen but without distension on palpation.

Tenderness

The abdomen should then be palpated to check for tenderness and pain. If a light palpation elicits tenderness or pain, this indicates a Full condition, which may be Qi stagnation, Blood stasis, Dampness, retention of food, Heat or Cold. If the pressure of palpation relieves the pain, this indicates a deficient condition of the Spleen and Stomach if it is in the epigastrium, or of the Spleen, Kidneys and Liver if in the lower abdo-men. If the abdomen feels tender only under deep pressure, this usually indicates Blood stasis. If superficial pressure of the abdomen relieves a pain but deeper pressure elicits a discomfort, this indi-cates a combined condition of Deficiency and Excess (e.g. stagnation of Liver-Qi with Spleen-Qi deficiency).

Box 51.2 summarizes the significance of tenderness on palpation.

Lumps

Abdominal masses are called Ji Ju. Ji indicates actual abdominal masses which are fixed and immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood and I call them ‘Blood masses’. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable. If there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi and I call them ‘Qi masses’.

Actual abdominal lumps therefore pertain to the category of abdominal masses and specifically Ji masses (i.e. Blood masses).

Another name for abdominal masses was Zheng Jia, Zheng being equivalent to Ji (i.e. acute, fixed masses) and Jia being equivalent to Ju (i.e. non-substantial masses from stagnation of Qi). The term Zheng Jia normally referred to abdominal masses occurring only in women, but although these masses are more frequent in women they do occur in men as well.

When palpating the abdomen one should feel for lumps. Lumps that come and go and are associated with distension indicate Qi stagnation, whereas lumps that are fixed and painful indicate Blood stasis. Soft and movable abdominal lumps may indicate Phlegm. Lumps in the left-lower abdominal region may simply indicate faeces in the colon.

Palpable lumps in the lower abdomen may be due to Qi stagnation, Blood stasis, Damp-Phlegm or Damp-Heat.

Abdominal lumps, if due to Qi stagnation, normally feel soft and come and go with emotional moods; if due to Blood stasis they feel hard on palpation and are usually associated with pain; if from Damp-Heat they may also be painful and, when palpated, very tender; if from Damp-Phlegm, they feel softer than lumps from Blood stasis or Damp-Heat. A typical example of an abdominal lump from Blood stasis is a myoma, whereas an example of that from Damp-Phlegm or Damp-Heat is an ovarian cyst.

Box 51.3 summarizes the types of abdominal masses.

Apical pulse

The apical pulse can be palpated in the fifth intercostal space; from a Western, anatomical point of view, it is the palpation of the left ventricle of the heart, whereas in ancient Chinese medicine it was called the pulsation of Xu Li, which relates to the Great Connecting channel of the Stomach and reflects the state of the Gathering Qi (Zong Qi). For a description of the ancient interpretation of this pulsation, see Chapter 13 in Part 1, ‘Diagnosis by Observation’.

The pulsation of the apical pulse reflects the state of the Gathering Qi and, under normal conditions, it should be felt clearly but not be hard and it should be relatively slow; this indicates a normal state of the Gathering Qi. If the pulsation of the apical pulse is feeble and without strength, this indicates a deficiency of the Gathering Qi and therefore of Lungs and Heart. If the pulsation feels too strong and hard, this indicates an Excess condition of the Lungs or Heart, or both. However, in some cases, when the left ventricle is enlarged, the apical pulse may feel ‘large’ but empty and this indicates Heart-Qi deficiency.

If the apical pulse stops and starts, this may indicate that the patient has suffered a severe shock; the same sign may also be seen in alcoholism.

The pulsation of the apical pulse should also be compared with that of the radial pulse and the two should be similar to each other (e.g. if the apical pulse feels feeble, the radial pulse should also feel Weak, Empty or Choppy). A discrepancy between the apical and the radial pulse is a poor prognostic sign and it often indicates heart disease.

The apical pulse may become affected by short-term influences such as shock, fright or a severe outburst of anger in which case it becomes very rapid.

Box 51.4 summarizes findings on palpation of the apical pulse.

Chest

The centre of the chest corresponds to the Heart and the rest of it to the Lungs. Palpation of the chest reveals the state of the Heart, Lungs and Pericardium and generally speaking, tenderness on palpation indicates a Full condition of one of these organs. For example, if the chest feels very tender even on light palpation in the centre, in the area of Ren-17 Shanzhong, this may indicate Heart-Blood stasis.

If the chest is tender on palpation in the areas around the centre, it usually indicates an Excess condition of the Lungs and often retention of Phlegm in the Lungs. By contrast, if palpation of the chest relieves discomfort, it indicates Deficiency of the Heart or Lungs. If superficial palpation of the chest relieves a pain but the patient feels discomfort with a deeper pressure, it indicates a combined condition of Deficiency and Excess.

Box 51.5 summarizes findings on palpation of the chest.

Area under xyphoid process

The area under the xyphoid process reflects the state of the Stomach, Heart and Penetrating Vessel. This area readily reflects patterns deriving from emotional problems. For example, if the area feels relatively hard and knotted, this indicates Heart-Qi stagnation from emotional problems such as sadness and grief. If the area is soft but painful, it indicates Stomach-Heat combined with Stomach-Qi deficiency. The Penetrating Vessel also affects this area and a knotted and full feeling in this area occurs often in the pattern of rebellious Qi of the Penetrating Vessel, but only when it is associated with other abdominal, chest and throat symptoms.

Box 51.6 summarizes findings on palpation of the area under the xyphoid process.

Breast

Palpation of the breasts in women is carried out when there are breast lumps. Breast lumps may be malignant or benign. The purpose of palpation in Chinese medicine is never to replace the Western diagnosis – we should never rely on palpation to distinguish benign from malignant lumps – but to identify the patterns causing them. The palpation of lumps should take into consideration their hardness, their edges and their mobility:

Small, movable lumps with distinct edges that change size according to the menstrual cycle normally indicate fibrocystic disease of the breast, which is usually due to a combination of Phlegm and Qi stagnation. A single, relatively hard, movable lump with distinct edges which may be also slightly painful usually indicates a fibroadenoma, which from the Chinese point of view is due to a combination of Phlegm and Blood stasis. A single, hard, immovable lump with indistinct margins, without pain, may indicate carcinoma of the breast which, in Chinese medicine, is usually due to a combination of Phlegm, Qi stagnation and Blood stasis occurring against a background of disharmony of the Penetrating and Directing Vessels.

Box 51.7 summarizes the causes of the most common breast lumps.