The ART of PALPATION
Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided. — Paracelsus
Although it might be considered a relatively minor aspect of the clinical examination, the art of palpation — using human touch to assess the patient—is, in fact, one of the most useful skills a physician can develop. It was certainly an important part of the old British system of training. We were well tutored in the art. This included learning how to feel for the shape, size, firmness and location of key organs and their spatial relationships to other organs.
And not only organs. There is great deal to be learned from any mass that might develop. Is it smooth or rough? Is it hard or soft? Does it move with breathing or is it fixed? Is there lymph node involvement? Does it pulsate? The answers to these questions can tell you a great deal about whether the mass is benign or malignant and, if the latter, how far it has progressed.
In most cases, palpation will be just one of many tools used for diagnosis. But there are times where touch alone can tell you everything you initially need to know. I had occasion to learn this lesson very early in my career. And the patient, as it turned out, was my own father, Percy Ho Ping Kong.
I was in the middle of internship in Jamaica in 1966. My father, only 49 years old and in seemingly good health, complained to me one day about having found dry red blood in his stool. I mentioned this to my good friends, Karl Massiah, a gold medallist in surgery from Barbados who became an orthopedic surgeon, and his wife, Pamela DaCamera, a gold medallist in pathology. Almost in unison, they said my father needed to have a colonoscopy, to rule out bowel cancer. We were fortunate to have Dr. David Atkinson, a fully trained surgeon from Britain working as senior registrar of the hospital. I went to see him.
"David " I said, "my father is experiencing some rectal bleeding... There's no history of colon cancer in the family, but we want to rule it out. He had been diabetic, but he lost weight and is now in generally good health, though he had a sore throat last week."
Atkinson readily consented and in due course arranged for my father to be physically examined. The doctor went through the conventional physical exam and, using his hands, found a lymph node in my father's neck. Later, he performed the colonoscopy, which revealed that my father's bleeding was being caused by inflamed hemorrhoids, more commonly known as piles. Happily, there were no colon polyps and no cancer.
So we were left with the node, discovered in a routine palpation preparatory to the procedure for which my father was being examined, and the week-old sore throat. My two friends were. with me to receive Atkinson's report.
"Your dad is from China," they correctly noted. "He could have nasopharyngeal carcinoma." A cancer of the upper throat, the disease is common in South China, with average rates of 25 cases in a population of 100,000 (compared to 1 in 100,000 among North Americans). I would later make this diagnosis on half a dozen of my own patients, all with southern Chinese roots.
It's a disease triggered by the Epstein-Barr virus, the same one that produced lymphoma in Africans.
The next day, my father saw Dr. Wright, a British ear, nose and throat surgeon, who performed a biopsy of the pharynx. It confirmed the diagnosis of nasopharyngeal cancer, a potentially lethal disease. Indeed, in Jamaica, the average patient with this condition lived only six months. Another colleague, neurosurgeon Dr. Andrew Masson, urged me to immediately take my father to London's Royal Marsden Hospital for treatment, and to see Dr. M. Lederman, the world's ranking expert on this particular cancer.
Within 72 hours, my wife, then 32 weeks pregnant, and my father and I were on a plane to London, carrying the various test results. When we met Lederman the next day, he told us my father would have a 25 percent chance of survival. And for every year of survival, his odds would improve by 25 percent. Even though the malignant node had been found on only one side of my father's neck, Lederman believed in radiating both sides. My father spent six weeks in London receiving treatment. As it happened, we knew another Chinese man in Jamaica who developed the same disease; he was radiated on only one side of the neck and died within six months. My father survived his cancer ordeal and lived another 30 years, before succumbing to a heart attack. All of this, remember, was the result of simple palpation procedure performed by a physician who did not automatically assume that because my father was in need a colonoscopy, the lymph node examination was unnecessary.
EXCEPT FOR OBSTETRICIANS AND MIDWIVES, palpation has become a somewhat neglected art. But a good pair of hands can help clinicians reach conclusions and diagnoses much faster and more accurately.
I recall one particularly instructive example. I had been treating a young woman for a condition known as paroxysmal atrial tachycardia (PAT), a particular form of arrhythmia. Not uncommon in young women, and usually caused by some aberration in the heart's electrical conduction system, it yields pulse rates of up to 200 beats per minute. One day, she came to see me with her husband, Howard, a 40-year-old businessman who was on his way to Asia via Los Angeles for a buying trip. In fact, he was planning to leave for the airport in a few hours. He, too, had been my patient.
In passing, he mentioned to me that he had found something suspicious on his private parts, but intended to deal with it when he returned in six weeks.
I said, "This will only take five minutes. Please undress." I conducted the examination and quickly found a hard lump on his testes.
"You probably won't be going to Los Angeles," I said.
The next day, he saw an urologist who surgically removed the lump. It proved to be malignant. He had lymphoma. We immediately started a course of chemotherapy. Howard survived for 10 years, before succumbing to a treatment-related lymphoma. This is a common and tragic consequence of radiation and chemotherapy — the malignancy recurs, often in a more lethal form. Again, I can't stress enough the importance of these simple examination procedures. I can't say whether palpation at an earlier stage would have saved Howard's life, but I do think it's a skill that is too often neglected in routine medical examinations.
Sometimes it is interesting to compare notes with patients — to see how they remember the story of their illness versus how I remember it. Quite frequently, it illuminates the truth reflected in the great Japanese film Rashomon, by director Akira Kurosawa, which tells the same narrative through characters' different points of view.
Arthur G., whom you will meet below, represents a small version of the Rashomon idea. I will let Arthur tell his story first and then provide my own recollections.
A patient's perspective —Arthur G.
I was raised in a small town in Saskatchewan—population 800 people—halfway between Regina and Saskatoon. My family, the local entrepreneurs, ran the town's hotel and restaurant, the movie theatre, the newspaper. My father died of pancreatitis at the age of 37.1 was eight years old. My mother, as he was dying, was coming out of the hospital with my new baby sister.
I worked in the hotel growing up. I was encouraged to go to university, earned a degree in sociology and psychology at the University of Saskatchewan, went to Europe, got a teaching certificate in Alberta, taught elementary school there and then moved to Vancouver. By then I was married, but gay — and eventually I could not avoid coming to terms with that. My wife and I divorced, and I went to back to school to study marketing and corporate communications.
In 1983,1 arrived in Toronto just as the aids crisis was gathering steam. But I did reasonably well as a producer of sales videos and corporate events. I am today 61. And I met Gilles, my partner, who's in the corporate travel business. We've been together 23 years. We recently sold our house and moved into a condo because of my arthritis. Some days, I can barely walk. I started drinking when I was 12, stealing liquor from my parents. A nip of this, a nip of that. In high school, bootleggers would buy beer or whatever for us and we'd drink at parties. University was party central and I could party with the best of them. I was not a troubled drunk. I held it very well. Later, when I joined the work force, Pd get home from work, and have a scotch or a few scotches. I just liked the taste. Booze was nice. It would loosen you up. But people would be surprised to know that I had a drinking problem. It wasn't until the last 10 or 12 years that I recognized it. I knew I was drinking too much. My partner occasionally suggested I cut back. A manager at work once summoned me to her office; another colleague had mentioned I smelled of alcohol. I guess I was a functioning alcoholic.
The drink of choice for years was vodka. One drink to start and then free pour and mix. Then some wine with dinner, then smoke a joint. But apart from pot, coffee and alcohol, no other hard drugs. By the time I was diagnosed, I was close to the point where I needed to buy a bottle of vodka every two days.
I developed what I thought was a skin rash and went to see my GP. It looked like red pimples that were spreading. My GP gave me anti-fungal ointment, but that didn't work, so I went back, because it was getting worse. So he sent me to see a dermatologist, Dr. Barbara Ho Ping Kong, who turned out to be Herbert's wife. This was 2010.
She looked at the spots and said, "Do you know what cirrhosis is?"
I said, "What do red spots have to do with cirrhosis?" Stupid question of the day.
"Do you drink a lot?" she asked me. "What's a lot?" A standard line I used.
She said, "These are spider veins."
Apparently, the fine ends of your blood vessels are exploding and leave a little scar where the blood has drained. They are an indicator of liver disease. She suggested that I see her husband. So I came here a week or two later to see Herbert and his retinue of interns, humble servants of the wise doctor. And they tap and feel and pluck. I recall no pain, except for my lower back, which is an arthritic condition I have had all my life. Although I was a good swimmer as a youth and worked as a lifeguard, I would throw my back out every once in a while. Now, there are issues with both the cervical and lumbar spine, plus scoliosis, plus degenerative disc disease. On an MM, my lumbar spine looks like the letter C. I treated it with a lot of opioids. I used to take over-the-counter anti-inflammatories, two or three every morning. I wonder how much damage that did to my liver, long-term.
So by the time I saw HPK, I already had a preliminary diagnosis. One test had showed what they call a grey liver —a sign of damage. My GP had lectured me. I ignored his advice not to drink. I knew that it would turn up eventually, but never thought I'd be exposed by asking about red spots. HPK confirmed the diagnosis. It was definitive, very firm. I totally got it. But it was delivered in a non-combative way. I did not feel I had been slapped down — "You stupid man. You should know better." He just made it clear that this was the reality. "You have to stop and can't drink, ever again. Or you will kill yourself."
One of his interns said afterward that while that may seem pretty tough, it's easier to quit drinking than quit smoking. And I had already quit smoking. Sol quit. I gave myself permission to finish the last bottle of vodka and to take as much time finishing it as I wanted. I finished it that week, and have not had a drink since. Today, my liver has some scarring, which is likely permanent, but my spleen has gone down in size. HPK says he can still feel cirrhosis on the liver, but no fluids, which is good. My blood is fine. If I needed surgery for my back, Fd be okay. My right hip is arthritic and I'm wait-listed for hip replacement. But I'm in pain all the time.
Quitting drinking was not hard. No DTS, no trauma, no shaking. I got the shakes when I was drinking, every morning when I woke up, when my body was telling me it needed alcohol. HPK wanted me to go to AA, and I said no, it's just not for me. It's about God and God's powers, and I don't believe in that, though I see the value in having someone to run to for help. I knew if I were in trouble, I could call HPK and he'd be on my side. Gilles, my partner, still drinks, but moderately. I used to drink my vodka with lemonade and soda water. Now, at parties, I just have the lemonade and soda water. It lacks a bit of bite.
An interesting thing. The last time I was in Saskatchewan, the fellow who had bought my grandparents' house in town tells me my grandmother left a box behind. He could never bring himself to throw it out. "Would you please come and get it?" So I open it up and what do I find included among the artifacts? This buckle-like thing, etched with the words, "Easy does it. First things first." And the date, 1947. It belonged to my grandfather. The phrases are used by Alcoholics Anonymous. So I brought it home and, while I don't go to AA meetings, I use it as my talisman. Now, it's not just about not drinking. I carry it with me whenever I go out. It's like carrying keys. I told HPK about it and he said, "Whatever works."
Truth be told, I never would have thought that quitting would be so easy. I think part of what kept me drinking is the fear that quitting would be too hard, that I'd be a failure. My view is, "moderation in all things, including moderation." It's useless without the other part, the ability not to be moderate. But you need the wherewithal to control it. Some alcoholics can.
I think HPK saw that this was my way of fighting my addiction and he was very accepting. I was right up his alley, because he believes in listening to the patient. He doesn't talk much philosophy with me, but he's such a gentle soul that you can't help but be straight with him. You don't find people like him that much anymore. He was just so understanding, yet I knew he was totally serious and would not give me the time of day if I came in here with alcohol on my breath, or if he saw something in the blood work. And who could blame him?
Arthur had been sent to me by my wife, Barbara, who had examined him in her dermatology clinic. Her report said he had spider naevi (broken blood vessels) and thrombocytopenia, a low platelet count. These are well-recognized characteristics of cirrhosis patients. A low platelet count can be caused by other conditions such as idiopathic thrombocytopenic purpura (ITP). I had no idea initially that he was a serious drinker. Nor did Barbara, in my recollection. She sent him because of the low platelet count, which was about 60,000, instead of the normal 200,000.
However, when I took his personal history, he readily acknowledged that he was a drinker. And when I performed the physical examination, I quickly established that his liver was enlarged. It felt firm and cirrhotic. He also had an enlarged spleen. All of these indicators taken together—the spidery veins, the low platelets and what I had learned from palpation, the firmness of an enlarged liver and the enlarged spleen — made the diagnosis relatively simple. Ultrasound tests later confirmed it. With practice, you can actually feel the irregular surface of the organ through skin, subcutaneous tissue and muscle. Still, feeling the liver is a sophisticated procedure. One of the finest physicians I ever saw perform this procedure was Toronto Western Hospital's Dr. Ken Robb. He examined a patient that had been feeling unwell, with weight loss and sweating. "The liver has a ground glass feeling to me," he said, after palpating the organ. "This is likely going to be amyloidoisis." And so it proved to be. Amyloid is a very difficult diagnosis to make, but Robb did it merely by palpating the liver.
The art of palpation can be important in diagnosing any number of conditions. I recall being summoned to the emergency room one night to examine a 70-year-old woman who was feeling generally unwell — not eating and losing weight. The attending ER residents weren't sure what was wrong. Her physical exam looked normal. She appeared mildly anemic, but there was no evidence of enlarged lymph nodes in the neck or elsewhere. The challenge in the emergency room is to develop a reasonable clinical diagnosis and do tests to confirm it. You need to do this well, or else you can waste time pursuing the wrong track, putting the patient at risk. Some medical residents surmised that she might have a neoplastic condition — a tumour somewhere in the body Others thought it might be tuberculosis.
I then conducted the examination, palpating the liver, stomach, spleen and lymph nodes. There's also a palpation test one can perform for a patient with a thin habitus, or body type, in which you feel the retroperitoneum, the anatomical space in the abdominal cavity, behind the peritoneum. With experience, you can sometimes feel through the skin, fat and subcutaneous tissue for lymph node swelling or Hodgkin's disease. I palpated the area and felt no retroperitoneal lymph nodes, but detected a small, hard nodule at the umbilicus. I turned to my colleagues.
"This person has Sister Marie Joseph's nodule," I said, "and it is evidence of an abdominal carcinoma."
Named for Sister Mary Joseph Dempsey, a surgical assistant of Dr. William Mayo at St. Mary's Hospital in Rochester, Minnesota, in the late 19th century, the nodule protrudes into the umbilicus as a result of metastasis. It is typically a grave diagnosis. The patient I examined likely had an advanced form of ovarian cancer.
So palpation can be a critical tool for diagnosis, although before disclosing it to the patient, you should further test your theory using CT scan and then confirm the diagnosis by biopsy.
One relatively common condition that lends itself to diagnosis by palpation is the abdominal aneurysm, particularly in older patients. You can actually feel its pulsation. The key objective is to accurately measure the dimensions of the aneurysm, which is effectively a bulge in the arterial wall. Three centimetres is considered normal; anything in the vicinity of six centimetres will require surgical repair. Again, ultrasound and, if necessary, the CT scan are invaluable tools for determining the precise dimensions. Palpation can lead you to doing the appropriate tests.
Some 30 years ago, I had a patient with a moderately enlarged goiter, a swelling in the neck usually associated with iodine deficiency. Curiously, she felt no pain at the site of the goiter itself. Instead, the pain was localized in her left arm. It is very, very painful," she told me. "It feels like it's beating, doctor." I put my hand on the arm and could feel the pulsation. It felt deep to me, deeper than the muscle. It was the bone itself that was throbbing. I feared that its depth suggested cancer, which unfortunately proved to be the case. The formal diagnosis was follicular thyroid cancer, a very vascular cancer that has a propensity to metastasize to bones and the lungs. We tried to reverse its course with radioactive iodine treatments, but unfortunately it was too late.
Palpation was the origin of another diagnosis that did not lend itself to treatment. The patient was Walter, a 42-year-old man who, 25 years earlier, had been successfully given radiation and chemotherapy for Hodgkin's disease. Effectively cured, he was carefully followed for many years. He came to see me complaining about a lump he had found in his lower, anterior chest, just below the breastbone. His family doctor thought it was likely a sebaceous cyst, but wanted another opinion.
The lump was visible — the size of a golf ball — and it was hard. Just feeling it, I thought it was likely a cancer. As it turned out, it was — a treatment-related sarcoma, induced by the radiation Walter had received a quarter century earlier. It was located precisely at the junction of the protective shield worn during treatment and the rest of his body. Sadly, this is a not uncommon legacy of radiation therapy.
Before making a formal diagnosis, I spoke to a hematology colleague.
"I think I have a patient with treatment-related cancer," I said. "Where's the tumour?" "Just below the breastbone."
"That's exactly where they occur," he said. "The area near the edge of the protective mantle also gets radiated."
The popular press these days often carries stories about the corning wave of a diabetes crisis. I wish I could say that these reports are exaggerated, but I suspect they are not. More and more, we are seeing evidence of what physicians call insulin resistance, which is a precursor to full-blown type 2 diabetes, the kind that strikes adults. Such patients have a propensity not only to become diabetic, but to develop lipid disease, coronary heart disease, hypertension and stroke. It's called Syndrome X and it's a major problem. If there is no intervention and change in dietary and exercise habits, a high percentage will develop one or more of these conditions.
One of the clinical features of insulin resistance is a condition known as Acanthosis nigricans (AN), which is characterized by blotches of darkly pigmented skin under the arms, the breasts, in the groin and other folds of the skin. Because of the discolouration, it is not difficult to diagnose. The question is — does the condition suggest that something else might be going on?
I recently saw a 42-year-old Middle Eastern woman with AN. Her endocrinologist had made the initial diagnosis and was concerned about an underlying ailment. That's because the disease is frequently associated with paraneoplastic condition — i.e., a cancer. It's one of those dermatological manifestations of internal malignancies, in the same group as intractable itching.
However, the endocrinologist found no evidence of insulin resistance—the woman had been a competitive skier in her youth and was still fit—and thus sent her to see a gastroenterologist, to look for cancer. "When both the gastroscopy and a colonoscopy proved negative, she was sent to see me. I took a full history, as I usually do, and a complete physical exam.
In addition to the Acanthosis nigricans, the skin on the palm of her hands had become coarse and roughened — this is known as tripe palms — and her lips deeply furrowed, known as ruga. Dr. Sanjay Siddha, a dermatological colleague of mine at Toronto Western, later said these were simply other expressions of the same ailment, the most severe he had ever seen.
More ominously, using palpation, I found a series of four or five masses in her abdomen, each as large as a small orange. So her AN was indeed a secondary consequence of an internal malignancy, probably ovarian cancer. The diagnosis of borderline ovarian malignancy was confirmed later by biopsy. The prognosis is uncertain. Some patients can survive for many years, although the skin conditions are intractable.
Obviously, clinicians conducting abdominal examinations of women must be vigilant about protecting the patient's privacy, but it can and should be done. A physician's hands constitute a powerful diagnostic tool. With practice, you can feel and assess the spleen, the liver and the retroperitoneal nodes. In most cases, palpation will be just one of many skills needed to make a proper diagnosis, but I hope these cases demonstrate how pivotal and valuable that art can be.