Dr. Michael Tierra L.AC., O.M.D.
The Huang Ti Nei Ching Su Wen (Yellow Emperor’s Classic) was the first important text on Chinese medicine written around 2674 B.C. It records discussions between Huang Ti and six officials about the problems of medicine. It is likely a compilation by many scholars who used Huang Ti’s name for authenticity.
The original Nei Ching consists of many parts of which the most important are the “Su Wen” and the “Ling Shu.” The former deals with physiology, pathology, etiology, and health maintenance; the latter with anatomy, treatment, and the nervous system.
The “Su Wen” introduced the following methods of treatment:
- Huei Shi: early surgery using stone knives, performed along the Eastern coast in Shan-Tung province.
- Medicinals: decoctions and medicinal soups used in Shan-Si province, Western China.
- Acupuncture: Practiced in the plains of Southern China, Hu-Pei Province.
- Moxibustion: Heat therapy preferred in the highlands of Northern China, Ho-Pei Province.
- Massage: Manipulation and exercise which was popular in the plains of Central China, Hunan Province.
During the Warring States era (402-221 B.C.), Tsou Chien proposed the Five elements theory which compared the human body to a small universe.
The Nan Ching or Classic of Difficult Issues was compiled probably within 200 years after the Nei Ching. It pertains more strongly to medical issues that relate to the practice of acupuncture.
Chan Chung Ching (about A.D. 142-220) was the most famous herbal clinician writing the Shang Han Lun (Treatise on Febrile Diseases caused by Cold) and the Ching Kuei Yao Lueh (Summaries of Household Remedies. He formulated the principle of the Six Stages of Disease and the formulas which are described in his books are among the most revered and form the basis of Kanpo (Japanese-Chinese Herbal Medicine).
Palpation as one of the four diagnosis of Chinese medicine includes taking of the pulse, palpating the shu (bladder) points on the back, palpating the xi-cleft points on the meridians and palpating the mu points on the abdomen which is the basis of Hara or abdominal diagnosis.
Some quotes concerning abdominal palpation from earlier texts:
From Essential Prescriptions from the Golden Chest (200-300 B.C.)
“When one palpates an abdomen that is swollen and full, and the patient does not feel pain, this indicates vacancy. If the patient feels pain, this indicates repletion. Therefore with replete patients, one must address and eliminate the repletion.”
In the Shang Han Lun, shao yang stage disease the patient feels subcostal fullness. There may be sensation of a lump or tightness below the heart and a general feeling of stagnation.
The Japanese physicians have developed hara diagnosis most extensively. Todo Yoshimasu described the types of lumps and location as follows:
Liver pulsing lump, tightness or pain on the left side of the umbilicus. Japanese practitioners tend to center this area just below the umbilicus on the lateral left side of the abdomen which roughly corresponds to the location of the portal vein.
Spleen around the umbilicus
Lungs right side of the umbilicus
Kidneys below the umbilicus
The so called “Mu” or mother points of the abdomen are as follows:
- Liver 14 – liver
- Liver 24 – gall bladder (?)
- Gall bladder 25 – spleen
- CV12 – stomach
- CV 3 – bladder
- CV 4 – kidney
- Lung 1 – lung
- Stomach 25 – large intestine
- CV 15 – heart
- CV 14 – Pericardium
- CV 17, 9, 4 – triple warmer
- CV 4 – small intestine
These can be used for diagnosis and treatment, in fact CV 12 is considered the command point for all the internal yang organs of transportation while Liver 14 is considered the command point for all the internal yin organs of transformation. Further CV 6 is considered the sea of chi, CV 9 is considered a point that governs water metabolism, CV 25 is a point that is considered the great eliminator, Spleen 15 and 16, especially on the left, are points that are used to stimulate intestinal peristalsis, point on the lower abdomen such as CV 3 (an important point for the chong mo meridian), stomach 29, 28, 27 are considered very important for gynecological problems, especially blood stagnation syndromes in women.
What to feel for:
Temperature variations
Feel the four quadrants and determine temperature variations, also compare the three warmers with each other. Many patients are cooler below the umbilicus and warmer above. This represents counter flow chi with vacancy in the kidneys and fullness above.
Tension
Tension or lack of tension should be observed, especially below the rib cage and along the rectus abdominal muscles. Tension usually represents vacancy rather than repletion. Lack of tension in the muscles is a good sign indicating an elastic, healthy abdomen. The release of tension is a prerequisite for healing.
Pressure Pain
Pressure pain found on palpation points is almost always of the utmost significance. Severe or sharp pains are more significant than dull, achy pains. Pain is usually considered a repletion sign of stagnation. If it is relieved by touch or pressure it is a sign of vacancy.
Sometimes psychological issues can exaggerate abdominal sensitivity. Check sp-10, st-36 to st-38 and between the 3rd and 4th toes. If there is any reactiveness on any or all of these points, shiatsu would be an appropriate therapy. These points can also relax the abdomen, making it less sensitive, allowing one to resume abdominal diagnosis.
Fluid Sounds
Whenever sloshing or gurgling occurs in the subcostal region it usually affects the stomach. It represents fluid stagnation in the stomach.
Traveling or Reactive Sensations
Sometimes when palpating a particular area there is a sensation or reaction that seems to travel to certain areas of the abdomen. These can occur anywhere in the body, including the extremities. The most significant of these may radiate areas of the body where the patient has problems. Check associated organs or meridians that may be involved. Sometimes pressure on a particular area of the abdomen will eliminate a pain occurring elsewhere. For instance, pressure on the abdomen can cause or relieve corresponding back pains. Other areas near the liver or stomach may relieve a headache.
Strength or Weakness of Abdominal Musculature
Too much strength may represent repletion, while flaccidity, lack of tone, softness can indicate vacancy.
Tightness — Hardness and softness — looseness
Tightness is different from tension. With tension there will be some rebound with tightness the is less or no springiness or rebound. Tightness is harder to treat than tension. It signifies a more exacerbated condition. Softness and looseness may appear similar to weakness, except that some springiness remains in the muscles. Softness does is not as great a sign of vacancy as is weakness.
Different depths can also be palpated:
- Hardness on the surface and hardness below
- Hardness on the surface and softness below
- Softness on the surface and hardness below
- Softness on the surface and softness below
- Palpation around the midline will reveal softness on the surface and hardness below.
Lumps
Lumps have varying significance depending upon their location, size, and quality. Lumps may be soft or hard; stationary or mobile. Moving lumps are more yang in nature and easier to treat. Stationary lumps are more yin in nature and more difficult to treat. Rule out the possibility that some lumps may be gas or stools in the intestines.
Most lumps are not tumorous, but consists of knots of muscle or other tissues. Usually if a tumor feels smooth and not irregular it is probably benign, if it has irregular edges it could be more dangerous. It is generally advisable to not palpate directly on a lump, but around it.
Pulsing or Palpitations
Such symptoms and signs are usually an indication of vacancy. Their significance varies with their relative strength, depth and location. Some are visibly obvious, indicating greater vacancy. Sometimes it can be felt with slight pressure and others only with deeper pressure. It will have varying strengths.
A slight pulsing around the umbilicus is normal. It is considered the moving chi of the kidneys and is a favorable sign of health.
Skin Qualities and Textures
Loose, creased skin may indicate vacancy while tight skin may be a sign of repletion. Healthy skin will “pinch up” easily between the thumb and forefinger, evinces a normal springiness. If it is tight it will be difficult to pinch the skin, if it is loose it will be easy to pinch it. In extreme vacancy, when the skin is pinched it remains pinched and will not return to flatness.
The skin pinching technique can reveal various sensations including tightness, tension, small lumps and sometimes vague symptoms of “something there.” It is a way of diagnosing the most reactive points and those points where a patient is under-sensitive. It is the most useful method for determining sensitivity. Some Japanese practitioners use the pinching with great dexterity and skill, being able to diagnose the entire hara and the lengths of meridians in just a few minutes.
Skin texture is also very important:
- Dry skin represents vacancy
- If the skin is too moist it is generally not a good sign
- Some skin moisture, but not too much is normal.
- Roughness, smoothness, color tones, paleness or redness may all have some significance.
Swellings and Indentations
Swollen or indented areas are usually palpable. Swelling is a sign of repletion while an indentation is a sign of vacancy. In general, when we speak of signs of repletion such as tension, tightness or swelling it is generally a sign of vacancy so that these signs are to be considered a kind of false repletion (yin deficiency).