A History of Palpation & Percussion
- V. A. Cyr
- Aug 28, 2024
- 10 min read
We will now dive deeper into another aspect of a nursing assessment: palpation and percussion. Just like auscultation, this is done over various parts of the body. Along with observation (inspection) of the patient, these techniques can indicate a lot before diagnosis. I am sure everyone who has been to the doctor has had someone palpate an area of their body that hurts. However, percussion is a technique that is taught but rarely used anymore. Most senses are used during an assessment: sight, touch, sounds, and smell (taste is no longer best practice for obvious reasons). Sight is the visual inspection of the patient, touch is used upon palpation, and sound is used during percussion and auscultation. Where did these techniques originate? What can palpation and percussion indicate? Why is percussion an old technique that is still taught today?
Definitions & Types
Palpation
Palpation is the act of touching or feeling by the sense of touch (Harper, 2024). Palpation is pressing on the body’s surface to feel the tissues underneath the skin. It can be used to palpate the pulse (see the post on Auscultation), thoracic cavity, abdomen, etc. Palpation and percussion are done after inspection and can be done before or after auscultation. The one exception to this is when assessing the abdomen. Auscultation must be done before palpation and percussion to hear accurate bowel sounds. The pressure from palpation can create false movement sounds.
Light Palpation
Light palpation is done to feel abnormalities on the surface, about 1 to 2 centimetres below the skin. For example, a nurse may palpate the skin when looking for a vein to insert an intravenous catheter (IV) or perform venipuncture (blood draw).
Deep Palpation
Deep palpation involves feeling the organs and masses as the skin is pressed down 4 to 5 cm. This could be done on the abdomen to assess for fecal impaction (see below), palpating tumours, etc.
Here is an example of one-handed light and deep palpation (Sogunro, 2021).
Bimanual Palpation
Bimanual palpation or ballotement is using two hands to feel a specific organ. The bimanual technique to palpate an organ is done with one hand supporting the organ into a position the other can palpate. For example, to palpate the kidneys, the hand on the body’s posterior (back) side pushes up while the hand on the anterior (front) palpates down to feel for any deformities.
Diagram of bimanual palpation of the right kidney (Stewart & Finney, 2017).
Percussion
Percussion is a method of striking or tapping the body’s surface to determine the condition of the internal organs (Harper, 2024). Percussion is the technique of tapping on the skin to distinguish different sounds for the tissues below. This is done to differentiate between types of tissues depending on their density. What comes to mind with the word percussion? Percussion instruments like a drum. The idea of using percussion in medicine is similar to that of musicians. We percuss to emit a sound. The sounds heard when percussing the body are much different than musical instruments, which will be discussed below. This is usually done over the thorax and abdomen but can also be done on tendons to assess reflexes.
Direct Percussion
Direct (immediate) percussion is done with one or more fingers to assess for pain and discomfort. This is usually done over the sinuses (on the face) to asses for tenderness.
Here is a diagram of direct (immediate) percussion done over the left frontal sinus (above the eyebrow) (Nurse Key, 2016).
Indirect Percussion
Indirect (mediate) percussion striking the body with hands or a percussor (“hammer”) tool. With one or more hands, the nurse will tap against the body. The technique is placing one hand with a finger on the body (stationary hand) and tapping the finger with your other hand (striking hand). This creates a sound from the tissues. This method is rarely used, and it is challenging to master. A hammer elicits different sounds and reflexes (see below).
Diagram of indirect (mediate) percussion with two hands (stationary hand on bottom and striking hand on top) (Ismaeel, 2022).
Blunt Percussion
Blunt percussion is done with one hand palm down on the body (stationary hand) and the striking hand in a fist “punching” the back of the stationary hand. This can be used to find deep pain, like in the kidneys.
Here is a diagram of blunt percussion over the kidneys (Clay, n.d.).
Origins
Palpation
Medical professionals have been caring for their patients with palpation and therapeutic touch since the beginning of time. Therefore, it is difficult to find an accurate timeline for when palpation will become part of the medical assessment. However, a few noteworthy people began documenting it in their research.
Around 1878, Frantz Glénard researched the liver and abnormalities of the abdominal viscera (organs) (Wikipedia, 2023). His work contained many diagnosis techniques, such as palpation.
Vasily Obraztsov is considered the creator of methodological palpation as a diagnostic technique (Borodulin et al., 2023). In the 1880s, he signified the importance of deep palpation of the abdominal cavity and organs (Borodulin et al., 2023).
Theodor Hausmann worked as a military doctor and a member of the Russian Red Cross (Wikipedia, 2024). In the 1900s, he researched and published methods of palpation diagnostics of the gastrointestinal tract (Wikipedia, 2024).
Percussion
The beginnings of physical diagnosis occurred with the discovery of percussion by Leopold Auenbrugger in 1760 (Walker, 1990). Before this, there were no proper ways to diagnose disorders while the patient lived. They only found out what their symptoms were caused after death by doing a post-mortem dissection (autopsy). Auenbrugger discovered percussion by basing his idea on observing his father tap wine casks to ascertain the wine in the cask (Walker, 1990). This was disseminated and further explored by Jean-Nicolas Corvisart in 1808. Corvisart was a French clinician famous for his research and eventually became Napoléon Bonaparte’s physician (Walker, 1990).
A portrait of Napoléon (Britannica, n.d.).
Pierre Adolphe Piorry made the first percussion tool in 1826 (Walker, 1990). He invented the pleximetre (from the Greek words "to strike" and "to measure") (Walker, 1990). The pleximetre is placed in the palm of the striking hand to improve sound quality.
In 1875, William Erb reported for the first time on the findings and significance of the deep tendon reflexes using a reflex hammer. Between 1879 and 1885, many reflexes were researched and found. Gowers termed the reflex the "knee jerk" in 1879 and found the ankle jerk in 1886 (Walker, 1990). In 1885, Beevor described the jaw jerk (Walker, 1990). These are just a few reflexes as examples.
In 1890, J. Madison Taylor invented the triangular hammer, which is still widely used (Walker, 1990). Below is a timeline of other percussion tools made throughout the years.
Timeline Throughout History: Percussion Tools
Uses in Medicine
Palpation
Palpation determines location (site on the body), size (length and width), shape (oval, round, elongated, or irregular), consistency (soft, firm, or hard), tenderness (pain), and positioning (of a fetus during pregnancy) (Stephan, 2023). This can be done on any body part (e.g., lymph nodes, breast tissue, joints, gingiva, etc.).
Here is a diagram of the areas that can be palpated on the anterior part of the body (Basicmedical Key, 2017).
Normal Palpation Findings
When palpating a patient without pain, palpation should be painless, and no abnormal findings should occur. The muscles and internal organs will feel soft and moveable, while denser tissues (e.g., bones) will feel rigid and immovable. Palpation of the prostate is done through the rectum of a cis-gendered male patient. Fundal palpation is done on cis-gendered female patients to specifically palpate the positioning and size of a fetus in utero (in the uterus) and for the position of the uterus after birth.
Abnormal Palpation Findings
Palpation can reveal pain, broken bones (e.g., ribs, patella or knee cap), masses (abdominal hernias, ascites), and air-filled pockets (crepitus). Areas of known pain should be palpated last to minimize patient discomfort. There are also times when deep palpation would not be recommended, such as if there is a risk of exacerbating an issue (e.g., rupturing the appendix).
Rebound tenderness is pain that occurs when the hand is quickly removed from the body (when the body is “rebounding” back to its original position). For example, rebound tenderness is found in the lower right quadrant of the abdomen when the patient is experiencing appendicitis. This is known as Rovsing’s sign (Ferguson, 1990).
Masses can be many things, such as tumours, and in any location (e.g., intestines, kidneys, skin). An example of a fluid-filled mass is ascites, which can be commonly caused by cirrhosis of the liver.
Broken bones are usually caused by trauma but can occur as part of a disease process (e.g., osteoporosis). These can be visible and palpable on the body. Depending on the severity, there may be signs and symptoms of inflammation (swelling), erythema (redness), ecchymosis (bruising), and pain when touching the area.
Crepitus is an air-filled area where there typically would not be. A joint filled with air can have a popping sound when the joint is cracked (i.e., cracking hand knuckles). This can also occur in diseases such as arthritis in any joint.
Pitting edema is the presence of inflammation caused by too much fluid being trapped in the skin. The four stages of edema rank from grade 1 to 4 (best to worst) depending on the depth it “pits” and the time to return to normal.
Percussion
Percussion can determine what an area of the body is filled with. For example, air-filled cavities (loudest, e.g., lungs), fluid-filled areas (less loud, e.g., bladder), or dense tissue (not loud, e.g., liver) (Lapum et al., 2022).
Here is a diagram of some locations for mediate percussion (Lapum et al., 2022).
Normal Percussion Sounds
Resonance is a hollow sound heard in air-filled cavities (Ismaeel, 2022). This can be heard when percussing adult lungs.
Hyperrosonance is also hollow but louder and “booming” (Ismaeel, 2022). This can usually heard in children’s lungs.
Tympany is a musical or drum-like sound in cavities filled with air and fluid (Ismaeel, 2022). This sound is emitted from organs like the stomach and intestines.
Dullness sounds like a muffled thud (Ismaeel, 2022). This can be found over dense tissues like the (liver (red on the diagram above) or the spleen (purple on the diagram).
Flatness is the noise of a “dead stop” (Ismaeel, 2022). This noise will be percussed over denser tissues like bones (e.g., ribs, clavicle, sternum).
Abnormal Percussion Sounds
Hyperresonnance in adults is abnormal and is caused by emphysema.
Emphysema is a type of chronic obstructive pulmonary disorder (COPD). The physiology of this disease is that the lungs’ alveoli stay open, making it challenging to exchange gases and get oxygen to the body. Chronic cigarette smoking is the leading cause of emphysema.
Dullness in cavities that should sound tympanic, like the bladder or intestines.
Tumours in the abdominal cavity can be caused by various things, like benign masses, ascites (fluid-filled spaces in the abdominal cavity), or cancerous cells. As tumours are made of dense cells, their percussion will give a dull sound rather than the typical sound of that body area.
Fecal impaction is a mass of hard stool stuck in the intestines that causes bowel obstruction. Dehydration, poor diet, medications, or other factors can cause it. Impaction will also produce a dull noise instead of a tympanic sound.
This video gives a good example of thoroughly examining the thoracic cage, including percussion sounds (Geeky Medics, 2022).
I learned a lot about these techniques that I have done for years while researching this post. What is the fact you find most interesting about these techniques?
– V. A. Cyr
References
Banzelyuk, E.N., Borodulin, V. I., Pashkov, K. A. & Topolyanskiy, A.V. (2021). [Methodical abdominal palpation: the history of the development of the method] (Russian). Ter Arkh, 93(8), 999-1002. Russian. 10.26442/00403660.2021.08.200969
Basicmedical Key. (2017). FIG. 51.1 Areas of the chest and abdomen and the Internal Organs [Image]. https://basicmedicalkey.com/palpation-of-parts-of-the-body/
Basicmedical Key. (2017). Palpation of the Parts of the Body. https://basicmedicalkey.com/palpation-of-parts-of-the-body/
Borodulin, V. I., Vasilyev, K. K., Poddubny, M. V. & Topolyanskiy, A. T. (2018). On the history of national medicine: Vasily Parmenovich Obraztsov (1851–1920). History of Medicine, 5(1), 14-27. 10.17720/2409-5834.v5.1.2018.02b Britannica. (n.d.). Napoleon I [Image]. https://www.britannica.com/biography/Napoleon-I
Clay, D. (n.d.). Costovertebral angle [Image]. Pinterest. https://www.pinterest.com/pin/360358407669637564/
Geeky Medics. (29 August, 2022). Percussion & Auscultation of the Lungs - OSCE Guide | Clip | UKMLA | CPSA [Video]. YouTube. https://www.youtube.com/watch?v=E3FW11Mbb0I
Ferguson, C. M. (1990). Chapter 93: Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In Walker H. K., Hall, W. D. and Hurst, J.W. Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). https://www.ncbi.nlm.nih.gov/books/NBK420/
Harper, D. (2024). Palpation (n). Online Etymology Dictionary. https://www.etymonline.com/word/palpation
Harper, D. (2024). Percussion (n). Online Etymology Dictionary. https://www.etymonline.com/word/percussion#etymonline_v_12673
Ismaeel, M. (2022). Physical Assessment Strategies & Techniques [PowerPoint]. https://www.slideshare.net/slideshow/physical-assessment-strategies-techniquepptx/254492860
Lapum, J., Hughes, M., St-Amant, O., Garcia, W., Verkuyl, M., Petrie, P., Dimaranan, F., Pemasani, M. & Savicevic, N. (2022). Figure 1.9: Expected location of percussion sounds [Image].
https://pressbooks.library.torontomu.ca/ippa/chapter/percussion/
Lapum, J., Hughes, M., St-Amant, O., Garcia, W., Verkuyl, M., Petrie, P., Dimaranan, F., Pemasani, M. & Savicevic, N. (2022). Percussion.
https://pressbooks.library.torontomu.ca/ippa/chapter/percussion/
Nurse Key. (2016). Assessment - Reviewing the Techniques: Direct Percussion [Image]. https://nursekey.com/assessmentreviewing-the-techniques/
Performance Health. (n.d.). Taylor Percussion Hammer [Image]. https://www.performancehealth.ca/taylor-percussion-hammers
Sogunro, O. A. (2021). How to palpate the abdomen during an abdominal exam. Med Mastery.
Sogunro, O. A. (2021). Figure 1 [Image]. Med Mastery.
Soiferman, E. & Rackow, E. (n.d.). Flint's Pleximeter made of hard rubber on the left and Flint's Percussor with rubber head and hard rubber handle on the right, circa 1880 [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html Soiferman, E. & Rackow, E. (n.d.). On the left is a typical pleximeter designed after the Piorry model, which was about 2 inches long and 1 inch wide, circa 1826 [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html
Soiferman, E. & Rackow, E. (n.d.). On the left is Curschman's Percussor with Ivorine [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html
Soiferman, E. & Rackow, E. (n.d.). On the right is Seitz's Percussor with ebony handle [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html
Soiferman, E. & Rackow, E. (n.d.). Sibson's percussor-pleximeter, circa 1860 [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html
Soiferman, E. & Rackow, E. (n.d.). Traube's pleximeter made of ivory, marked with a scale and with silver hinges that bend up to allow the physician to hold the pleximeter in place on the patient, circa 1850 [Image]. Medial Antiques Online. https://www.antiquemed.com/percus.html
Stephan, P. (2023). The Role of Palpation in Medicine. Very Well Health. https://www.verywellhealth.com/what-is-palpate-430300
Stewart, L. H. & Finney, S. M. (2017). Fig. 23.1 Bimanual palpation of the right kidney [Image]. https://basicmedicalkey.com/urological-surgery/
The Free Dictionary. Percussion. (def. 1) From Jarvis, 1996 [Image].
https://medical-dictionary.thefreedictionary.com/Percussions
Walker, H. K. (1990). Chapter 1: The Origins of the History and Physical Examination. In Walker H. K., Hall, W. D. and Hurst, J.W. Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). https://www.ncbi.nlm.nih.gov/books/NBK458/
Wikipedia. (2023). Frantz Glénard (Swedish). https://sv.wikipedia.org/wiki/Frantz_Gl%C3%A9nard
Wikipedia. (2024). Theodor Hausmann (German). https://de.wikipedia.org/wiki/Theodor_Hausmann_(Mediziner)
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