The Art of Palpatory Diagnosis in Oriental Medicine

This book provides a step-by-step introduction and practical guide to palpation as a method of assessment, diagnosis and treatment within the context of Oriental medicine, and in particular Japanese acupuncture practice. Leading the reader through the how and what of touch, around the abdomen (or hara) and other key areas of the body, the author also explores key acupuncture points for clearing these areas, as well as Japanese needle techniques. The aim of the book is to allow the reader to have a more vivid and sensitive feel for what lies below acupuncture meridians and points, and to be able to assess and treat a very wide variety of clinical conditions with an understanding of the individual patient - successfully.

The first part of the book outlines the theoretical and clinical basis for palpation. Palpation, particularly on the hara, or abdomen, is a skill that for historical and cultural reasons is insufficiently taught in TCM, whereas in Japanese acupuncture (JA) it has retained its place as a major and essential part of the four examinations. In JA, it is used both for diagnosis and treatment. This treatment is dynamic and effective because the area used primarily, the abdomen, reflects the patient’s root, or core energy. Gardner-Abbate states that “root treatment is the fundamental orientation to Japanese meridian therapy” which allows “the energetic network to return to its most efficient posture, facilitating and allowing healing.”

Palpation is also a more meaningful and more quantifiable feedback mechanism to patient and practitioner than pulse and tongue diagnosis. A painful area on the abdomen can change within seconds when the appropriate distal point is treated. It is also “unsurpassed in establishing mutual rapport and trust.”

The book outlines differences in clinical practice between JA methods and TCM, and presents theoretical explanations for these differences, for example, why JA needling is effective when the insertion depth is barely a few millimetres. Gardner-Abbate does not have an overt intention to compare one system favourably with the other, but instead, seeks to integrate her palpation skills and channel diagnostics with her TCM understanding. Thus the book is full of references to TCM organ and substance differentiation such as damp heat, liver qi stagnation, and stomach yin deficiency, terms less familiar in many JA systems, while at the same time the emphasis of treatment is very much on diagnosis through channel and hara palpation.

The second and third parts of the book present a systematic palpation and treatment procedure. Various abdominal maps and organ correspondences are described, together with distal points to release them with finger pressure when pathological reactions are found. This procedure is called abdominal clearing and is described in impressive detail in chapter 8. When the abdomen has been cleared, the practitioner is free to devise a treatment with needling, hopefully in keeping with the diagnostic findings made through this first step.

A series of subsequent examinations and procedures follow, including palpation and release of the navel, inner thigh compression, scar tissue, sinuses, the neck and back.

The book is well organised, and thorough. Each chapter is introduced and put into context before the material is explored in detail. For example, the chapter on inner thigh compression discusses the anatomy of the thigh, clinical presentation of inner thigh problems, and aetiology before the main material on evaluation and treatment. Clinical signs include anaemia, dizziness, oedema, varicosities, dysmenorrhoea and fibroids. Treatment includes massage on Yongquan KID-1 and Zhongfeng LIV-4, or simply treating the inner thigh area with a rolling pin. This is consistent with tuina treatments I have seen in China for painful periods which used rolling technique on the liver channel on the thighs.

Other useful features are the chapter summaries of new concepts, the learner centred questions at the end of each chapter, and numerous illustrative case studies. There are also many clear and informative diagrams. Forms outlining procedures, diagnoses and possible treatment strategies are provided for readers to photocopy and use in clinical practice. These are good learning aids, and can be used as stationary for patient files.

I particularly valued the section on navel diagnosis, and the many varied photographs of navels to illustrate different pathologies. For example, “if the navel is too tiny, narrow, long or deep, it is indicative of decreased Qi flow to the Lower Jiao…indicative that the Kidney is not grasping Lung Qi.” To my knowledge this is the first compilation of photographs of this kind in an English language acupuncture book, and extremely useful.

Similarly, I found the chapter on the significance and treatment of scars to be thorough and practical, and again, the first time that so much material has been compiled in one place. There is important and useful information here for any acupuncturist, of whatever system of acupuncture. I would have liked more information and diagrams on the use of the “tiger thermie” or tiger warmer, a metal tool used to apply heat and pressure to the acupuncture points in place of moxibustion. Its use is referred to throughout the book but the small section on how to use it was not really clear enough.

Gardner-Abbate acknowledges that writing a book on practical skills such as palpation is “not an easy task”. Inevitably there will be gaps between her intention and the reader’s understanding. I personally found that the chapters focusing on specific areas such as the navel, scars, neck, back, etc., were more appealing than the section on abdomen clearing, her preferred root treatment protocol.

Partly this was because as a reader it is difficult to appreciate how a dynamic and physical system such as the one she describes works in practice. What I was able to appreciate is that some of the clearance points used to treat the abdominal reactions can be painful. For example, when Zhongwan REN-12 is reactive, it is treated by finger pressure at Liangqiu ST-34, Neiting ST-44, or Gongsun SP-4. The sensation elicited by this technique at each point is described as very tender, exquisitely tender and excruciatingly tender, respectively. I am reluctant to take up a system of acupuncture which is described as excruciating. This is the limitation of book writing. You have to see and do before really understanding how something works. From my own practice I am aware that my palpation techniques at the outset caused much more discomfort to my patients than they do now, and I am sure that Gardner-Abbate herself is much more sensitive the descriptions above would suggest.

I was also dissatisfied that after a historical discussion of the evolution of abdominal maps from the nanjing, Gardner-Abbate presents her own modified abdominal map and treatment system. Of course other acupuncturists have also done this, notably Dr. Manaka made abdominal maps for the assessment and treatment of the eight extraordinary vessels, but I would like to know more about the origins of Gardner-Abbate’s system, and specifically, which parts of it are imported from the methods of Kiiko Matsumoto and Dr. Nagano, who she acknowledges as influences, which come from other sources, and which are her own. She refers often to “the Japanese system”, but I am aware of at least four separate Japanese acupuncture systems, and I am sure there are many more. There is no one unified national style of Japanese acupuncture which can be described as such. This criticism also applies to her descriptions of JA point locations, which vary from standard TCM locations. She provides a very informative list of acupuncture point locations and energetics, but again I would have liked to know her sources.

In conclusion, I think this is a very useful book filled with thought-provoking discussions and insights into a different approach to diagnosis and treatment. At the same time it emphasises that the roots of TCM and JA are the same, and attempts to integrate the two. It is particularly informative on the treatment of specific areas in the body and specific conditions such as back pain. For people already practising JA I think it’s a very welcome and helpful addition to our tiny library of English language JA books, especially for the section on navel diagnosis. For people using other systems of acupuncture such as TCM or Leamington Five Elements, there is much that can be imported to your practice: not just the material on the treatment of scars and sinus problems, but also a way of thinking which tilts the emphasis of the four examinations away from asking towards palpation, from thinking to touching.

Oran Kivity