CHEST AND ABDOMEN

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Chapter 38

imageCHEST AND ABDOMEN

Interrogations in relation to diagnoses of the chest and abdomen are discussed separately below.

HOW WE ASK

It is important to be sensitive when asking questions regarding the chest because people often fear that if we ask about the chest we suspect a heart pathology. Besides this, some typical Chinese expressions are not used by Western patients and we should therefore phrase the question in a way that is understandable to the patient. For example, few patients will actually use the expression ‘feeling of oppression of the chest’; they will probably describe a ‘feeling of tightness of the chest’ or say a feeling was ‘like having a weight on the chest’.

‘Palpitations’ is another example of the importance of asking questions in a way that the patient can understand. Most people think that palpitations are synonymous with tachycardia, that is, the heart beating faster than normal. We should therefore explain to the patient that ‘palpitations’ simply means an uncomfortable sensation of being aware of one’s heartbeat.

Cough

Observation, Chapter 20; Hearing, Chapter 53; Symptoms and Signs, Chapter 63

When a patient presents with a cough, we must first of all establish whether it is an acute or a chronic cough. By ‘acute’ we mean a cough that had a sudden onset and may continue for a few days or weeks. By ‘chronic’, we mean either a cough that began insidiously without a previous invasion of Wind and persisted for months or years, or one that began with an exterior invasion of Wind and persisted for months or years.

An acute cough may have any of three causes. First, it may be an acute cough in the very beginning stages of an invasion of Wind, when the pathogenic factor is still on the Exterior. Secondly, it may be an acute cough with the pathogenic factor (such as Heat or Phlegm-Heat) in the Interior following an external invasion. Thirdly, it may be an acute cough caused by a residual pathogenic factor (such as Dryness or Phlegm) following an external invasion. In the first case the cough will be accompanied by signs of the external invasion such as aversion to cold, fever, sore throat, a runny nose and a Floating pulse. Heat or Phlegm-Heat in the Lungs produces a barking cough with yellow mucus, feelings of heat and thirst, and an Overflowing-Rapid pulse. In residual Dryness with Phlegm in the Lungs, the cough is dry with difficult expectoration of scanty sputum after repeated bouts of coughing, and a tickling sensation in the throat.

A chronic cough is generally due either to chronic retention of Phlegm in the Lungs (which may be combined with Dampness, Heat or Dryness), or to deficiency of Qi or Yin, or both, of the Lungs.

A very common type of chronic cough is one due to Damp-Phlegm in the Lungs, which is characterized by the expectoration of profuse, white sputum which is easy to expectorate, a feeling of oppression of the chest, a Swollen tongue with a sticky coating and a very Slippery pulse. When Phlegm combines with Heat in the Lungs the cough has a louder sound and is characterized by the expectoration of yellow sputum, a feeling of oppression of the chest, a feeling of heat and a Red and Swollen tongue with a sticky yellow coating and a Slippery-Rapid pulse.

A common type of chronic cough in the elderly is that due to Dry-Phlegm in the Lungs which is characterized by a chronic, dry cough with a weak sound and the occasional, difficult expectoration of scanty sputum, a dry throat and a Swollen tongue with a dry coating.

A chronic cough due to a deficiency of Lung-Qi or Lung-Yin is characterized by a slight, dry cough with a weak sound, dry throat in the evening accompanied by the signs of Qi or Yin deficiency, such as night sweating, and a tongue without coating.

Case history 38.1 illustrates a pattern underlying chronic cough.

Case history 38.1

A 48-year-old woman had been suffering from a persistent cough for 6 months: she felt she had some phlegm in the throat but this was difficult to expectorate so that the cough was often dry. When she did expectorate some sputum, this was thick, sticky and white. She also complained of breathlessness and a feeling of tightness and oppression of the chest. A chest specialist had diagnosed bronchiectasis.

She was thin and slightly built and she had experienced loss of weight for the past 2 years. Her complexion was very dull and sallow. She also suffered from a general cold feeling, cold hands and feet, constipation and a yellow vaginal dis-charge.

Her tongue-body colour was normal but the tongue body was Swollen; the back of the tongue had a rootless, yellow coating but no ‘spirit’. Her pulse was Weak in general, especially in both the Rear positions, but also slightly Slippery.

Diagnosis:

The cough with expectoration of thick, sticky white sputum, together with the breathlessness and feeling of tightness and oppression of the chest, indicate the presence of Damp-Phlegm in the Lungs, which is confirmed by the swelling of the tongue body and the Slippery pulse. The general cold feeling, cold hands and feet, constipation and Weak Rear pulse positions also indicate Kidney-Yang deficiency, which obviously contributed to the formation of Phlegm. The Kidney deficiency is also evidenced by the absence of ‘spirit’ on the root of the tongue. Besides Damp-Phlegm in the Lungs, there is also Damp-Heat in the Lower Burner, which causes the yellow vaginal discharge.

The loss of weight which occurred in the previous 2 years and the rootless tongue coating point to the beginning of a situation of Kidney-Yin deficiency, which may sometimes develop from Kidney-Yang deficiency.

The treatment should concentrate first on resolving Damp-Phlegm and stimulating the descending of Lung-Qi and secondly on tonifying the Kidneys.

Box 38.1 summarizes the patterns underlying cough.

BOX 38.1   COUGH

Chest pain

Observation, Chapter 16; Symptoms and Signs, Chapter 63

Here ‘chest’ indicates the front of the chest. A pain in this area is usually due to either the Heart or Lung channel and it always denotes a Full condition (even though this may itself derive from an underlying Empty condition).

Chest pain can be differentiated according to its character. A fixed, pricking, stabbing or needle-like pain indicates Blood stasis. Chest pain accompanied by a feeling of distension of the chest itself and the hypochondrium indicates Qi stagnation and is usually accompanied by sighing and irritability. An intermittent, chronic chest pain that comes and goes also indicates Blood stasis but suggests an underlying Empty condition of Qi or Yang deficiency.

A stabbing or pricking chest pain indicates Blood stasis affecting the Heart channel (especially if it radiates down the left arm) and this often occurs against a background of Heart-Yang deficiency; it falls into the category of Chest Painful Obstruction Syndrome.

Chest pain accompanied by cough with expectoration of profuse yellow sputum is due to Phlegm-Heat in the Lungs and this may be seen in acute lung conditions, such as bronchitis, pneumonia or pleuritis.

A chest pain in a large area of the chest together with a cough, breathlessness and a red face indicates Lung-Heat. Chest pain extending to the hypochondrial region may be due to Damp-Heat in the Liver and Gall-Bladder channel, in which case it may be accompanied by feeling of heaviness and a sticky taste.

Pain in the heart region on the left side of the chest indicates either Heart-Blood stasis or Phlegm obstructing the Heart channel.

Chest pain extending to the upper back is usually due to Phlegm or Blood stasis.

Box 38.2 summarizes the patterns underlying chest pain.

BOX 38.2   CHEST PAIN

Feeling of oppression of the chest

Symptoms and Signs, Chapter 63

A feeling of oppression of the chest is the translation of the Chinese term Xiong Men. Western patients, at least in Anglo-Saxon countries, would seldom use this term and report this symptom as a feeling of tightness, discomfort in the chest, or the sensation of having a weight on the chest.

A feeling of oppression of the chest accompanied by slight breathlessness, sighing, a cough and expectoration of phlegm indicates retention of Phlegm in the Lungs, which is the most common cause of this symptom. A feeling of oppression of the chest without a cough and without expectoration of phlegm, and accompanied by slight breathlessness, sighing and a feeling of a lump in the throat, indicates stagnation of Lung-Qi with Lung-Qi failing to descend; this is usually caused by emotional problems such as sadness or worry. Although a feeling of a lump in the throat is usually related to Liver-Qi stagnation, stagnation of Lung-Qi caused by emotional problems is a very frequent cause of this symptom together with a feeling of oppression of the chest.

Another very common cause of a feeling of oppression of the chest is rebellious Qi of the Penetrating Vessel, which is more common in women. However, before diagnosing rebellious Qi of the Penetrating Vessel, we should check whether the feeling of oppression of the chest is accompanied by other relevant symptoms such as abdominal distension or fullness, pain or fullness around the umbilicus, or epigastric tightness.

In a few cases, a severe stagnation of Liver-Qi from emotional problems may also cause a feeling of oppression of the chest.

Box 38.4 summarizes the patterns underlying a feeling of oppression of the chest.

BOX 38.4   FEELING OF OPPRESSION OF THE CHEST

Feeling of heat in the chest

Symptoms and Signs, Chapter 63

Excluding external invasions of Wind-Heat, a feeling of heat in the chest is due to Full- or Empty-Heat of the Lung or Heart channels. If there is a feeling of heat in the chest, accompanied by thirst, insomnia, palpitations, agitation and a Red tip of the tongue, this indicates Heart-Fire; if there is a feeling of heat in the evening, dry mouth at night, insomnia, night sweating and five-palm heat, it is due to Heart Empty-Heat.

A feeling of heat in the chest accompanied by a cough, hot hands, a red face and expectoration of yellow mucus is due to Lung-Heat; if it is accompanied by night sweating, a feeling of heat in the afternoon, five-palm heat, a dry throat at night and a dry cough it indicates Lung Empty-Heat.

Box 38.5 summarizes the patterns underlying a feeling of heat in the chest.

BOX 38.5   FEELING OF HEAT IN THE CHEST

Palpitations

Symptoms and Signs, Chapter 63

When we ask patients about palpitations it is important to explain to them the meaning of this symptom, as most patients mistakenly identify ‘palpitations’ with tachycardia, that is, the pulse beating faster than normal. In reality, palpitations are not related to the rate or speed of the pulse but simply indicate a subjective and uncomfortable sensation of being aware of one’s heartbeat.

Palpitations are a symptom that is always related to the Heart and may appear in any of the Heart patterns.

Palpitations with an acute onset may be due to external stimuli such as a fright or an overwhelming emotional upset, in which case they are called ‘fright palpitations’ (Jing Ji).

Palpitations that extend upwards towards the chest and throat and downwards towards the umbilicus and abdomen are called Zheng Chong, which I translate as ‘panic palpitations’ (literally it means ‘panic and anxiety’). This type of palpitations is due to rebellious Qi in the Penetrating Vessel affecting the Heart and is considered more severe than ordinary palpitations.

Case history 38.2 illustrates a pattern underlying palpitations.

Case history 38.2

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