Chip on Palpation as Practice

Palpation as Practice: Part I

Learning to palpate is a lot like learning to meditate. The two skills are similar enough that the road signs commonly used to navigate the meditation landscape are also useful on the path to palpatory competency.  I want to talk about palpation from this perspective. We should be clear at the beginning that they are different things, although there is most probably some cross over benefit in practicing both meditation and palpatory awareness. Most importantly you don’t have to be in a deep meditative state to palpate effectively.

Perhaps the most significant commonality between meditation, palpation and for that matter, medicine is that they are all practices. At the beginning, the expectation is not so much that we will be good at these disciplines as that we know how to practice them. They are skills that are cultivated over time. At least in terms of meditation and palpation, we don’t really know the limit to what it is possible for us to experience. 

In learning to meditate, sooner or later we will have a fleeting experience of open awareness. At this point, we can’t really say anything about it. Even acknowledging that it is happening, “hey, look at that, my mind is quiet,” is enough to derail the experience. The early stages of cultivating any form of palpatory awareness can be very much like this as well. It too, may be very fleeting, and just as you think you’ve caught it, it may be gone. Even once you are consistently feeling something, the experience will initially be pre-verbal. It is new and vague enough we have no words for it. Nevertheless, the process of progressively fine-grained articulation builds from this fundamental binary apprehension. I feel something or I don’t. 

After a while perception stabilizes, and we start to be able to look around. As we more consciously experience our experience, we are increasingly able to say things about what we are experiencing. In meditation we may simply witness the moment- to-moment play of our emotions. A common observation for palpators at a similar stage is “well definitely I feel something, but is that me or my patient?”  In more general terms, we might ask whether this input is self or other. Meditators spend a lot of time on the cushion trying to break down the bounds of self and other, just as we are cultivating a capacity to appreciate qi beyond the perimeter of our own skin. Yet, in both cases, no matter how effectively we extend our perception into our environment, we cannot really function without simultaneously being able to distinguish between what is outside and what is inside. 

Mindfulness meditation practices concern themselves with an examination of our internal environment and our responses to external stimuli of one sort or another. 

In learning any new palpatory technique, it similarly helpful to identify that phenomena in oneself. If you know what it feels like in your own body, it is easier to identify it someone else. It is also easier to tell whether that palpatory information is coming from you or your patient. For instance, what does your own yang rhythm feel like? Knowing that will help you to differentiate it from your patient’s yang rhythm.  You can also palpate an inanimate object. If you find that the treatment table has a yang rhythm then you either have a very special treatment table or you are feeling your own qi?” All this can take some time and experimentation to sort out for oneself.  The good news is that the difficulty in distinguishing between self and other fades with experience and generally becomes less of an issue with every new palpation technique you learn. 

Meditation is about learning how our mind in particular works and in using that insight to exert some productive control over that process. Although we all share a human nervous system, each of us is wired a little differently. No one’s palpatory antenna is without a few unique bends and kinks. Learning the quirks of our particular apparatus is an essential part of learning to appreciate qi. For instance, is one hand more sensitive than the other when listening to the yang rhythm or doing channel listening? Does it help cross-reference your findings by switching hands? Which hand is best for manual thermal evaluation and which for local listening. Our own acute or chronic injuries may influence the accuracy of our listening. Even problems in our ankle may influence how we stand, subtly influencing the way our hands receive information.  

Some days we may be able to sustain our attention and awareness on the cushion better than others. Its best not to label our meditation sessions as good or bad, we just practice. Just as it is counterproductive to beat yourself up when you catch your mind wandering, it is also unhelpful to fret over the fact that you’re not feeling anything. Just move on and keep practicing. 

Most experienced clinicians will acknowledge that their palpatory capacities vary from day to day, and even over the course of a single day. In meditation, pulse diagnosis, yang rhythm or general listening, our baseline competencies generally improve as we gain experience. We gradually get to the point where our palpatory input is clinically useful even on our off days. Some days we may be more confident in our local listening than in our channel listening. At other times the opposite may be true. We simply do our best to make use of whatever information we can glean at any given moment. Our receptivity is inherently variable for reasons including but by no means limited to our own competency. Sometimes our patients are just not communicating with us on a particular palpatory wavelength.  Cultivating our comfort in working with whatever information we have is a skill in itself. A key to all of this is to try with just the right amount of effort. If we don’t try seriously enough or often enough, we will never learn the skill. Yet working too hard will just as surely subvert the learning process. 

Once we are reasonably confident that we are feeling something, and that what we are feeling is coming from the patient and not ourselves, the issue is no longer whether we can feel qi but what specifically we should be filtering for. 

We will pick up this thread in a subsequent blog. 

Clinical Case #1 by Chip Chace

The Engaging Vitality approach is based  on the idea that enhancing engagement with our patients’ qi enhances clinical efficacy. Part of this comes about from expanding our repertoire of techniques for appreciating the qi while another important aspect is to learn how to weigh and cross-reference this input.  This is central to the diagnostic process whether we are working exclusively with the familiar TEAM methods of tongue, pulse, abdomen, and symptoms, or incorporating a broader range of assessment methods. 

I have used the following case in a few Module IV trainings to illustrate the application of the listening to the fluids in Chinese herbal prescribing. Here, fluid-body palpation worked for me as a sort of diagnostic tiebreaker. I think the case works pretty well on that level. In the course of presenting the case again, however, it recently struck me that it also exemplifies the more general process by which we creatively apply and cross-reference a variety of diagnostic input. The case may actually be more informative in this regard, as it speaks to the challenges of dealing with vague, ambiguous, and even irrelevant information. 

IW, a petite, female yoga teacher in her late 40’s experienced what she described as an “asthmatic cough” subsequent to a bout of bronchitis she had contracted after a trip to India three month’s previously. The cough was predominantly dry and unproductive. It was worse in the morning and evening, or when teaching or speaking, and drinking water helped to soothe it. She also complained of a burning, inflamed sensation in her chest. 

Prior to her trip to India, we had briefly worked together in treating some perimenopausal symptoms, addressing them with at least partial success in the context of a liver and kidney deficiency. She now only had night sweats once a week, though she remarked that her recent menstruation was preceded by an outbreak of acne. She was also prone to joint pain. IW mentioned that she had been very busy since her return from India made a point of reminding me that she was very sensitive to stimulants. 

General Listening localized to her posterior left diaphragm with a confidence level of +++ out of ++++ . Her tongue was slightly red and dry (+++),  and her pulse was rapid and fine  (++++). Pulmonary auscultation revealed clear but slightly tight lungs (++++). I was confident that her yang rhythm felt unremarkable (+++).  Here I had a fairly high confidence level in my palpatory findings. 

IW’s dry cough, burning sensation in her chest, dry tongue, and fine rapid pulse suggested a straightforward though fairly entrenched case of dry heat in the lungs. I didn’t think that there was sufficient evidence to consider her background liver and kidney pattern a significant factor in her present situation. My plan was to drain deficiency heat/fire with bitter and sweet flavors, secondarily moisten the lungs, and downbear the lung qi to stop cough. I gave her 3 packets of the following prescription. 

• Mori Cortex (sāng bái pí) 15

• Lycii Cortex (dì gǔ pí) 9

• Anemarrhenae Rhizoma (zhī mǔ) 12

• Lilii Bulbus (bǎi hé) 9

• Trichosanthis Pericarpium (guā lóu pí) 6

• Stemonae Radix (bǎi bù) 9

• Armeniacae Semen (xìng rén) 9

• dry fried Scutellariae Radix (huáng qín) 4.5

• Glycyrrhizae Radix (gān cǎo) 6

She was instructed to sip 1 ½ cups of this in decoction over the course of each day. 

IW e-mailed me 6 days later and reported that she was 60% improved after taking the first packet of the prescription and 75% improved after taking all three packets over the course of 6 days. Although she was happy with her rapid response, she now complained of mild jaw pain she described as “TMJ” (temporomandibular joint syndrome). Unable to actually see her, as I was in Europe at the time, I had to rely on her short written report. The most likely pathodynamic involved in the jaw discomfort seemed to be a counterflow of yang, though I was unsure precisely where it was coming from or why it was happening. I asked her to take another 2 packets of the same prescription with the addition of 12 grams of Ostreae Concha (mǔ lì) to more aggressively downbear this counterflow. 

IW returned for an office visit 4 days later and reported that her lungs were now 90% improved. She mentioned that she had experienced a tight cough and a slight tightness in her chest for one day though this was now gone. Thinking that this might be a sign of constrained qi I asked her about her moods but she reported that if anything, she was less irritable than usual. On the other hand, Spring had sprung and her usual seasonal allergies were bothering her. IW’s eustacian tubes felt blocked and there was no change in her jaw discomfort.

IW’s lungs were clear upon auscultation with no sign of the tightness I had heard previously (++++). Her pulse when sitting was soft (+++) and possibly slippery (+). When prone, her pulse was wiry on the left, esp. in guan and proximal positions (++++). Her tongue was significantly better overall, but I could imagine that there might be a hint of blueness in the center (+). Her yang rhythm was again unremarkable but again, I could imagine that there was a slight restriction in the cranium (+)

None of this suggested a definitive course of action. Was her jaw pain actually linked to her seasonal allergies, an external pathogenic factor complicating a pre-existing condition? Her pulse when sitting suggested the presence of dampness and possibly phlegm, presumably attributable to the allergies, though the pulse was clearly not superficial. Was there a deeper counterflow phenomena at play arising from her underlying liver and kidney yin deficiency? It was certainly possible to read her prone pulse presentation in this way. Yet it was equally plausible that her wiry pulse reflected an element of qi constraint. Moreover, she complained of no tightness in her chest, no irritability and her tongue only “possibly” (+) blue. The restriction in the yang rhythm in her head, if it was there at all, did not contribute to a differential diagnosis.  Did I need to nourish her fluids at a deeper level, relieve constraint, or perhaps even open the exterior and clear her sensorium?  Some other diagnostic criteria was needed, so I listened to her fluids. 

Based on the prominence of the left guan and proximal pulse findings, I needled left Ki 2 and right Liv 8, the side determined by channel listening and the points themselves determined by manual thermal evaluation. Since her current chief complaint were in her head, and though vague, her cranium was the most prominent listening post, I found GV 23 using manual thermal evaluation and also needled that. This settled her system sufficiently to allow me to listen to her fluid body. 

I could imagine that fluids felt somewhat dry (+) . More significant, however, was a slight but clear tightness on the outside(+++). This suggested a significant element of superficial constraint, though I remained unconvinced that an exterior pathogen was anything more that an adjunctive concern. I decided to continue clearing deficiency heat and moistening the lungs but to more directly open the chest and relieve constraint there. In retrospect, perhaps she could have done with a little more lung diffusion from the very start. Because her pulse as a little soft I included an adjunctive component for awaken the spleen and opening the sensorium, if only to mitigate the potentially cloying nature of the sweet moistening flavors. 

• Anemarrhenae Rhizoma (zhī mǔ) 9

• Glehniae/Adenophorae Radix (shā shēn) 9

• Platycodi Radix (jié gěng) 6

• Curcumae Radix (yù jīn) 4.5

• Acori tatarinowii Rhizoma (shí chāng pǔ) 3

IW took 1 packet of this preparation in decoction over two days and all of her symptoms disappeared. 

Vague and ambiguous information is often all we have to work with. Dan, Marguerite and I typically use some form of confidence level scale to help us weigh the influence of of each diagnostic parameter. Here, I used a scale of 1+ to 4+. Of course, any bit of information can have multiple meanings. Here, even the most unambiguous aspects of the pulse image could plausibly have been interpreted in a few very different ways.  Cross referencing those possible pulse interpretations with the tongue, auscultation and patient history helped to narrow the differential diagnosis though not sufficiently to make a definitive diagnosis.  Although listening to the fluids was the diagnostic tie-breaker even this metric was somewhat ambiguous. The fluids did “perhaps” (+) feel a bit dry, but I was more confident (+++) that they felt tight and that distinction was the difference that made the difference, leading to an effective course of action. 

As we are learning the Engaging Vitality palpatory techniques, our findings will almost certainly feel vague and ambiguous, particularly when compared with diagnostic parameters we may be more familiar with such as the pulse and tongue. This is even more the case, if we gravitate towards a particular style of diagnosis or treatment where a particular finding yields an “if X then treat Y” answer. More often than not, however, the diagnostic process is characterized by some degree of ambiguity, regardless of the system we may be orienting to. When applied carefully and critically, low confidence findings can nevertheless help to clarify these situations and guide us to effective clinical outcomes.

Connecting to the Whole: The Role of Tong in the Engagement of Qi by Chip Chace & Dan Bensky

Here is an excerpt from an article in The Lantern Dan and Chip wrote about the Chinese concept of tong and its relation to East Asian medicine.

Now published 2018 Feb. Available for $5AU

To Order from The Lantern Volume: XV, Issue: 1, 2018

For more information, go to www.thelantern.com.au

[O]penness, denotes in this context our translation of tong 通. For us, tong is the fundamental thing that acupuncture accomplishes. As we will demonstrate in this essay, we understand tong as far more than a synonym for moving the qi. We are not in any way proposing an orientation to practice based on drainage as opposed to tonification. Tong is a principle that lies even deeper than the elementary ideas of excess and deficiency, tonification and drainage. If the system is tong, a great many of the issues regarding when and where to tonify and drain become moot. This is because once the body is tong it can fully utilize its inherent capacity for self regulation.

To us, tong is a synonym for one aspect the body’s own self-healing abilities, that is for health. As A.T. Still, the founder of osteopathy put it, “To find health should be the object of the doctor. Anyone can find disease.” A tong body knows better than any physician how best to rid itself of a surplus or pathogenic qi, and to replenish regions of insufficiency. A crucial aspect of our job as physicians is simply to help the human system express its inherent tong-ness. This article explores the concept of tong and how it can be applied to the practice of medicine.