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

A 44-year-old woman had been suffering from palpitations for 8 years. ‘Palpitations’ was just a subjective symptom of a feeling of her heart thumping in her chest and was not associated with tachycardia. The palpitations were always worse before her period. She also complained of nausea and an epigastric pain, which was experienced just under the sternum, a sticky taste and a feeling of lump in the throat. She experienced a dry mouth occasionally, and occasionally suffered from tinnitus.

Her periods were basically normal, coming every 4 weeks, lasting 6 days and they were not painful. The only problem associated with the periods was premenstrual tension.

Her complexion was dull and sallow without lustre and her eyes were very dull and lacked lustre to an extreme degree.

Her tongue was of a normal colour, except for a Red tip. It had a Heart crack and, although it could not be defined as being peeled, the coating was not sufficient. Her pulse was Fine on the right and Floating-Empty on the left.

Diagnosis:

The aggravation of the palpitations before the period, together with the nausea, epigastric pain under the sternum and the feeling of lump in the throat, indicate a condition of rebellious Qi in the Penetrating Vessel, as this vessel flows through the stomach, connects with the heart, traverses the chest and goes over the throat (on its way to the face).

However, the pulse, being Fine on the right, and the dull-sallow complexion clearly show a condition of Blood deficiency, while the Floating-Empty nature of the pulse on the left side and the insufficient coating on the tongue show the beginning of Yin deficiency (of the Liver, Kidneys and Heart). In this case, therefore, the condition of rebellious Qi in the Penetrating Vessel is secondary to the condition of Blood and Yin deficiency; in other words, the Qi of the Penetrating Vessel rebels upward because there is a deficiency of Blood and Yin. In fact, the Penetrating Vessel is the Sea of Blood and it is therefore easily affected by Blood deficiency. The treatment principle in this case, therefore, should be to nourish Blood and Yin (of the Heart and Liver) primarily and to subdue rebellious Qi in the Penetrating Vessel secondarily.

The Heart crack and the very dull appearance of the eyes indicate a disturbed Mind and a strong propensity to emotional problems.

HOW WE ASK

It is important to be clear about the area involved because patients are often vague about the location of their abdominal symptoms. For example, someone might refer to the whole abdomen as the ‘stomach’. We should therefore always make sure we ask the patient to point to the area involved.

In the case of pain, we should first let patients describe the abdominal pain in their own words; only then can we ask systematically about the reaction of pain to pressure, application of heat and food or drinks in order to establish the Full or Empty and the Hot or Cold character of the pain. When asking about the reaction of their abdominal pain to ‘pressure’, instead of simply asking ‘Is it better with pressure or not?’, which the patient would not really understand, we should ask, ‘When you have the pain, do you like to press the area of pain with your hands, or do you dislike being touched?’ We should then ask about the reaction of the abdominal pain to exposure to heat or cold and to ingestion of hot or cold drinks.

Besides this, there is also a terminology problem since few patients will actually use the term ‘distension’ (often described as ‘bloating’ in English), and even fewer the term ‘stuffiness’. The exact meaning of these symptoms is described below.

The discussion of abdominal symptoms will be centred first on the four most common sensations experienced in the abdomen, which are:

After this, the various abdominal symptoms will be discussed according to areas (see Fig 16.7 on p. 145), which are:

Sensations

Pain

Symptoms and Signs, Chapter 71

Abdominal pain can be due to a very wide variety of conditions, some Full and some Empty. By definition, the abdominal pain from a Full condition is severe, whereas that from an Empty condition is mild. Among the Full conditions that may cause abdominal pain are:

Among the Empty conditions are:

(For a detailed discussion of the patterns causing abdominal pain in its various areas, see Part 5, Chapter 71.)

Abdominal pain is one of the most common presenting symptoms in practice. When diagnosing such pain, it is important to refer to the basic principles, which allow us to differentiate Fullness from Emptiness and Heat from Cold. Abdominal pain that is alleviated by pressure indicates Deficiency, whereas if it is aggravated by pressure or if the patient dislikes being touched in the area this indicates Fullness. Abdominal pain that is alleviated by the application of heat (such as a hot-water bottle) or by the ingestion of warm drinks indicates a Cold condition, and the same if it is aggravated by exposure to cold or ingestion of cold drinks. Abdominal pain that is aggravated by exposure to heat or by the ingestion of warm drinks indicates a Heat condition, and the same if it is alleviated by exposure to cold (which is very rare even in Heat conditions) or by the ingestion of cold drinks.

Areas of abdominal pain

Before establishing the Full or Empty and Hot or Cold nature of the condition according to the abdominal symptoms, it is important to ask the patient to identify clearly the location of the problem, which is most commonly pain. Patients are often vague about the location of the pain and we should ask them to pay attention and be exact. This difficulty is particularly evident in children who are often unable to identify the exact location of the abdominal pain.

The regions of the abdomen in Chinese medicine are as follows (see Fig 16.7 on p. 145):

• Area under the xyphoid process: this is the small area immediately below the xyphoid process extending approximately 50 mm (2 inches) and bordered by the ribs. It is influenced by the Heart and Stomach channels and the Penetrating Vessel.

• Epigastric: this is the area between the xyphoid process and the umbilicus but excluding the hypochondrial area. It is related to the Stomach and Spleen channels.

• Hypochondrial: these are the two areas below the rib cage. This area is influenced by the Liver and Gall-Bladder channels.

• Umbilical: this is the area around the umbilicus. It is influenced by the Spleen, Liver, Kidney and Small Intestine channels.

• Central-lower abdominal (Xiao Fu): this is the area between the umbilicus and the symphysis pubis. This area is influenced by the Liver, Kidney, Bladder and Large Intestine channels and by the Directing Vessel; in women, it is also influenced by the Uterus.

• Right-lateral-lower abdominal and left-lateral-lower abdominal (Shao Fu): these are the lateral areas of the lower abdomen. This area is influenced by the Liver and Large Intestine channels, and by the Penetrating Vessel.

The diagnosis of abdominal problems, and especially abdominal pain, is much more complex than with those of the epigastric region because of the large number of channels involved. In women, it is even more complex because the lower abdomen can reflect problems of all the above channels as well as those of the Uterus and gynaecological system. In practice it is therefore often difficult in women to differentiate whether an abdominal pain is of intestinal or gynaecological origin. This difficulty exists also in Western medicine. In Chinese medicine, however, the distinction is less important than it is in Western medicine as there is often an overlap between a pathology of the Intestines and one of the gynaecological system. For example, in women stasis of Blood in the lower abdomen may cause painful periods and an abdominal pain of intestinal origin at the same time.

Here I will discuss the most common patterns and conditions differentiated according to their location (i.e. the area under the xyphoid process, epigastrium, hypochondrium, umbilical area, central-lower abdomen, right-lateral lower abdomen and left-lateral lower abdomen). (For the differentiation of various abdominal symptoms, see Part 5, Chapter 71.)

Area under the xyphoid process

Symptoms and Signs, Chapter 71

The area under the xyphoid process extends approximately 50 mm (2 inches) from the xyphoid process and is bordered by the ribs. It is influenced by the Stomach, Heart and Penetrating Vessel channels and its symptomatology often reflects emotional problems. In fact, this is an area that is very easily and frequently affected by emotional problems due to worry, fear, sadness or grief. The symptoms related to this area may include a feeling of tightness, distension, oppression, stuffiness and palpitations depending on the channel and pathology involved.

The Penetrating Vessel has a strong influence on this area causing a feeling of tightness; however, a pathology of the Penetrating Vessel can be diagnosed only if the feeling of tightness in this area is associated with other abdominal or chest sensations, such as lower abdominal fullness or pain, epigastric distension or pain and chest oppression or tightness. A typical symptom of the Penetrating Vessel in the area below the xyphoid is characterized by a feeling of ‘urgency’, anxiety and palpitations in that area. Occasionally, Western patients will describe this Penetrating Vessel symptomatology in different and unusual ways; for example, in England, a patient may describe a feeling of ‘butterflies’ in this area, of ‘heart cascading’, ‘as if the stomach was having an argument with itself’ or ‘adrenaline rushing up and down the chest’. All these are symptoms related to rebellious Qi in the Penetrating Vessel along its course in the abdomen and chest and affecting the Heart and the region under the xyphoid process.

In the absence of other Penetrating Vessel symptoms along its course, symptoms in the area under the xyphoid are usually related to the Stomach or Heart. The symptoms in this area should be closely integrated with palpation: a hardness on palpation indicates a Full condition whereas a softness indicates an Empty condition.

A feeling of oppression in the area under the xyphoid process usually indicates Phlegm or severe stagnation of Qi in the Heart and Stomach channel. A feeling of fullness in this area indicates retention of food in the Stomach affecting the Heart; a feeling of stuffiness in this area (i.e. the patient feels full but the area is soft on palpation) indicates Stomach and Spleen deficiency with Heart-Heat. A feeling of distension in this area indicates stagnation of Qi in the Stomach.

On the pulse, this area can be felt on the distal end of the right Middle position, by placing the finger on the Stomach position and rolling it distally very slightly.

Box 38.6 summarizes patterns underlying pain in the area under the xyphoid process.

BOX 38.6   AREA UNDER THE XYPHOID PROCESS

Epigastrium

Symptoms and Signs, Chapter 71

This refers to the area between the xyphoid process and the umbilicus, but excluding the hypochondrial area. The epigastrium is closely related to the Stomach and Spleen channels and it reflects primarily Stomach patterns, such as Cold in the Stomach, Stomach-Heat, Stomach-Fire, Damp-Heat in the Stomach, Stomach deficient and cold, Stomach-Yin deficiency, etc.

In a patient presenting with an epigastric problem (which is usually pain or distension) it is important to integrate questions about the character of the epigastric pain with those about thirst, taste, nausea, belching and sour regurgitation.

The upper part of the epigastrium (i.e. the area just below the xyphoid process) is influenced also by the Heart channel and in Chinese medicine there is often an overlap and an interaction between the Stomach and the Heart channels in certain patterns. For example, rebellious Stomach-Qi causing nausea and vomiting is often associated with rebellious Heart-Qi, that is, Heart-Qi not descending so that the patient may have epigastric pain, nausea, vomiting, belching, sour regurgitation but also palpitations and a discomfort that extends from the epigastrium to the sternum area.

However, epigastric pain is not always related to the Stomach channel and in some cases the Chinese diagnosis of epigastric pain should be integrated with a Western diagnosis. For example, when the Large Intestine is affected by stagnation of Qi and there is severe flatulence in the transverse colon, this may cause an epigastric pain; in this case it would be wrong to attribute the problem to the Stomach channel simply because it occurs in the epigastric area. Of course, in such a case there would be other symptoms such as lower abdominal pain, constipation and small stools, which would point to the Large Intestine.

There are many types of epigastric pain, as follows:

• A spastic epigastric pain that is ameliorated by the application of heat and the ingestion of warm drinks indicates Full-Cold in the Stomach.

• Epigastric pain with a pronounced feeling of fullness indicates retention of food, which is more common in children.

• A distending epigastric pain radiating to the right or left hypochondrium indicates rebellious Liver-Qi invading the Stomach; this is a very common type of epigastric pain.

• Burning epigastric pain denotes Stomach-Heat.

• Burning epigastric pain with a feeling of heaviness, nausea and a feeling of oppression of the chest indicates Phlegm-Heat in the Stomach.

• Burning epigastric pain with a feeling of heaviness, a sticky taste and a sticky yellow tongue coating denotes Damp-Heat in the Stomach.

• A severe, stabbing epigastric pain indicates Blood stasis in the Stomach.

• A chronic, intermittent, dull ache that is ameliorated by the application of heat and the ingestion of warm drinks, and is aggravated by overwork, indicates Stomach deficient and cold.

• A chronic, intermittent, dull, slightly burning epigastric pain with a dry mouth indicates Stomach-Yin deficiency.

Feelings of pain, distension, tightness or oppression of the epigastrium may also be caused by rebellious Qi in the Penetrating Vessel. However, such epigastric sensations point to a Penetrating Vessel pathology only when they are associated with other abdominal symptoms such as pain or distension in the lower abdomen or umbilical pain.

Interrogation about epigastric symptoms should be closely integrated with investigation of the tongue and pulse.

Epigastrium manifestation on the tongue

On the tongue, the epigastric area is reflected either in the centre or on the sides around the centre (see Fig 23.3 on p. 205). An examination of the coating in this area is essential to distinguish Full from Empty conditions as a Full condition will be reflected by a thick coating in this area and an Empty condition by a rootless coating or the absence of coating. The coating in this area also closely reflects the Hot or Cold nature of Stomach problems: a white coating indicates Cold while a yellow (including brown) coating indicates Heat. The thickness of the coating reflects the intensity of the pathogenic factor: the thicker the coating, the more intense is the pathogenic factor.

To summarize, when examining the coating in the Stomach area of the tongue, we should establish systematically first whether there is a coating or not, secondly the colour of the coating and thirdly the thickness of the coating. Some Stomach pathologies are reflected in the central section of the tongue on the sides; for example, Stomach-Heat often manifests with a redness in these areas. Cracks in the central area are a very clear reflection of Stomach-Yin deficiency; these may be small horizontal or vertical cracks or a wide, midline crack in the central area. While small cracks in this area develop gradually from dietary irregularities, a wide central midline Stomach crack may be hereditary and indicate a tendency to develop Stomach-Yin deficiency.

Epigastrium manifestation on the pulse

With regard to the pulse, the right Middle position of course reflects closely Stomach disharmonies. The most common pulse qualities in this position are Slippery, Soggy, Floating-Empty and Wiry. A Slippery pulse in the Stomach/Spleen position indicates retention of Dampness in the Stomach and Spleen; a Soggy quality indicates Dampness occurring against a background of Stomach and Spleen deficiency; a Floating-Empty pulse in this position indicates Stomach-Yin deficiency; a Wiry pulse in this position denotes Stomach-Qi stagnation, which may occur by itself or as a consequence of Liver-Qi stagnation in which case the pulse would be Wiry in both Middle positions. An interesting aspect of the Stomach pulse is its upper part, which is felt by rolling the finger distally (towards the fingers) very slightly. This corresponds to the oesophagus and if the pulse is Tight in this area it indicates rebellious Stomach-Qi or stagnation of food in the upper part of the Stomach, which is often due to eating too fast or eating when under pressure at work.

Case history 38.3 illustrates a case of deficiency and rebellious Liver-Qi causing epigastric pain.

Case history 38.3

A 42-year-old woman complained of indigestion, belching, acidity, sour regurgitation and epigastric distension. She had been suffering from this problem for several years. Her appetite was normal, there was no nausea and her stools were normal. Her complexion was dull and pale.

Her tongue was Pale on the sides, slightly Swollen and very slightly lacking a coating in the centre. Her pulse was Weak and Choppy.

Diagnosis:

The digestive symptoms clearly suggest the condition of rebellious Liver-Qi invading the Stomach and preventing Stomach-Qi from descending, which causes the belching and sour regurgitation. However, the tongue and pulse show predominantly Deficiency and in particular, deficiency of Spleen-Qi (Weak pulse), a slight Stomach-Yin deficiency (lack of coating in the centre) and a Liver-Blood deficiency (Pale sides and Choppy pulse). In conditions of rebellious Liver-Qi invading the Stomach and Spleen, one can distinguish two situations: one when the primary problem is a disharmony of the Liver channel caused by emotional problems and the other when the primary problem is a weakness of the Stomach and Spleen, which ‘allow’ themselves to be invaded by the Liver. In this case, the latter situation clearly applies. This distinction is important to determine the appropriate treatment principle because, in the first situation, the primary aim is to subdue rebellious Liver-Qi and the secondary one to tonify the Stomach and Spleen; in the second situation, the primary aim is to tonify the Stomach and Spleen and the secondary one to subdue rebellious Liver-Qi.

Box 38.7 summarizes the patterns underlying epigastric pain.

BOX 38.7   EPIGASTRIC PAIN

• Cold in the Stomach: spastic pain ameliorated by heat

• Retention of food: pain with feeling of fullness

• Rebellious Liver-Qi invading the Stomach: Distending pain radiating to the right or left hypochondrium

• Stomach-Heat: burning, redness in centre of tongue

• Phlegm-Heat in the Stomach: burning pain with feeling of heaviness and feeling of oppression of chest

• Damp-Heat in the Stomach: pain with feeling of heaviness and sticky taste, sticky yellow tongue coating

• Blood stasis in the Stomach: severe, stabbing pain

• Stomach deficient and cold: chronic, intermittent, dull ache ameliorated by heat and warm drinks, aggravated by cold

• Stomach-Yin deficiency: chronic, intermittent burning pain, dry mouth

• Rebellious Qi in the Penetrating Vessel: distension, tightness and pain radiating to abdomen/umbilicus/chest, anxiety

Hypochondrium

Symptoms and Signs, Chapter 71

Most patients are not familiar with the word ‘hypochondrium’. Therefore when I ask patients about symptoms in this area, I simply point to it. The hypochondrial area includes the ribs and the area immediately below them on both sides; this area is influenced by the Liver and Gall-Bladder channels and it is important to note that the left hypochondrial area may also reflect Liver disharmonies. Again, when patients report abdominal problems in this area, it is important to identify the location exactly. If any pain is located only in the hypochondrial region, it is definitely related to the Liver or Gall-Bladder channels, or both; if the pain starts in the hypochondrial region and radiates towards the centre of the epigastrium, it indicates rebellious Liver-Qi invading the Stomach; if the pain starts in the centre of the epigastrium and radiates towards either the right or left hypochondrium, it indicates a primary deficiency of the Stomach with a secondary stagnation of Liver-Qi.

Case history 38.4 illustrates a pattern underlying hypochondrial pain.

Case history 38.4

A 49-year-old woman had been suffering from recurrent bouts of pain and discomfort in the right hypochondrium for the past 7 years. The pain was sometimes sharp in nature and radiated to her shoulder.

The patient also suffered from a feeling of muzziness in her head, lacked concentration and sometimes had difficulty finding her words. She had occasional dizzy spells in the mornings and also suffered from blurred vision and floaters. She often felt tired and her joints would ache, especially her left hip where she had had pain for a long time.

The patient suffered from insomnia and often woke up between 3 am and 4 am. She used to suffer from colitis, with abdominal pain, mucus and blood in the stools and diarrhoea. This had been helped by acupuncture although she still had loose stools.

She suffered from premenstrual breast distension and irritability. Her periods were becoming scantier and her left breast hurt after her period. She had several breast lumps.

The tongue body was slightly Pale-Purple, with Red points and slightly Red sides. It was Swollen with teethmarks and had a sticky coating. Her pulse was Deep-Weak-Choppy and the left Front position was relatively Overflowing.

Diagnosis:

The hypochondrial pain is caused by Liver-Qi stagnation. Other symptoms of Liver-Qi stagnation are the premenstrual breast distension and irritability. Evidence of the long-standing and severe nature of the stagnation is shown by the tongue having a slightly Purple colour.

The feeling of muzziness in the head, lack of concentration, difficulty in finding words, breast lumps and dizzy spells in the morning point towards the presence of Phlegm. This is confirmed by the Swollen tongue body and the sticky tongue coating.

The underlying Deficiency which has led to the development of Phlegm is predominantly one of Spleen- and Kidney-Yang. This is causing the loose stools and tiredness and is reflected in the pulse, which is Deep and Weak, and on the tongue, which is Swollen with teethmarks.

There is also a deficiency of Liver-Blood, manifesting with blurred vision, floaters, the periods becoming scantier, the Choppy quality of the pulse and the Pale colour of the tongue. The pain in the left breast occurring after the period indicates that, although it is due to Liver-Qi stagnation, there is an underlying Blood deficiency. Ache in the joints is normally due to Painful Obstruction Syndrome with Wind, Dampness or Cold; however, in women, ache in the joints without swelling is often caused simply by deficient Blood failing to nourish the sinews, as is the case in this patient.

Box 38.8 summarizes the patterns underlying hypochondrial pain.

BOX 38.8   HYPOCHONDRIAL PAIN

Central-lower abdominal area

Symptoms and Signs, Chapter 71

The central-lower abdominal area is influenced by many different channels: the Kidney, Liver, Bladder, Small Intestine, Directing Vessel, Penetrating Vessel and the Uterus itself. Pain in this area is therefore often difficult to diagnose because of the involvement of so many different channels; and the difficulties are compounded in women because of the influence of the Uterus on this area.

The most common patterns causing problems in this area are:

Apart from identifying the pattern, it is of course necessary to identify the channel involved and this is done according to the accompanying symptoms. In the case of the Bladder, there will be some urinary symptoms; in the case of the Uterus, there will be some menstrual irregularities; in the case of the Small Intestine, there will be borborygmi, loose stools or constipation; in the case of the Liver, there will be a pronounced distension and a clear correlation of the abdominal problem with the emotional state.

Case history 38.5 illustrates a pattern of Blood stasis and Deficiency causing central-lower abdominal pain.

Case history 38.5

A 31-year-old woman complained of abdominal pain following a dilatation and curettage operation on her uterus. Ten months previously she had had an exploratory laparoscopy for a suspected ovarian cyst; she developed complications after this operation with an infection of the scar and a haematoma in the abdomen. Three months after that she had a termination of pregnancy; as she developed complications, she was advised to have a dilatation and curettage of her womb. Following these procedures she developed a constant, sharp lower abdominal pain, pain on intercourse and mid-cycle bleeding, and her menstrual blood became dark with clots. Before all this happened, her periods were painful but not dark and without any mid-cycle bleeding.

Apart from the above problem, she also complained of a pronounced tiredness and, on interrogation, it transpired that she suffered from floaters in the afternoon, tingling of her limbs, poor memory and dizziness. She also complained of lower backache, which she attributed to riding, and the occasional tinnitus. She felt cold in general and suffered from cold hands and feet. She occasionally also suffered from a slight pain in the chest with a feeling of palpitations and breathlessness, for which she used an inhaler.

Her complexion was rather pale and the shen of her eyes was bright. Her voice sounded clear but with a very subtle tone of sadness to it. Her tongue was Pale in general with paler sides, Swollen, with a Stomach crack and a rootless coating on the root. Her pulse was Weak and Choppy and particularly Weak on both Rear positions; the Heart position was also particularly Choppy.

Diagnosis:

In diagnosis, we must differentiate the diagnosis of her present, acute problem (abdominal pain, dyspareunia and mid-cycle bleeding following the dilatation and curettage) from that of her underlying condition. The present problem of abdominal pain is clearly due to Blood stasis; this is clearly shown by the sharpness of the pain and the darkness of the menstrual blood with clots. The tongue does not show any Blood stasis (as it is not Purple) owing to the relatively short duration of this problem.

The underlying condition is characterized primarily by three problems:

1. Blood deficiency (Pale tongue, floaters, tiredness, tingling, poor memory and dizziness): there is Blood deficiency of the Liver but also of the Heart, as is evidenced by the palpitations, breathlessness and the Choppy pulse on the Heart position.

2. Stomach and Spleen deficiency with some affliction of the Intestines: the Spleen deficiency is manifested clearly by the swelling of the sides of the tongue and the tiredness. The Stomach deficiency is manifested by the Stomach crack and the rootless coating: the fact that the rootless coating is on the root of the tongue shows that there is an intestinal pathology. It was only after I pointed this out to her that she told that she had also just been diagnosed as suffering from intestinal parasites.

3. Kidney-Yang deficiency: this is manifested by lower backache, feeling cold, cold feet and hands and occasional tinnitus.

As for possible aetiology, I ventured to say that in my opinion the main origin of the problem was emotional. I based this primarily on the Choppiness of the pulse (especially on the Heart pulse) and its lack of wave, which is usually due to sadness. As I told her that I thought sadness was the main origin of the problem, she confirmed this by saying that she had been repeatedly sexually abused as a child. I think this was the emotional cause for the Blood deficiency (especially of the Heart) and also of the Kidney deficiency as the sexual abuse was obviously accompanied by fear, which injured the Kidneys. Besides being sexually abused she was also frequently beaten across the lower back; I think that that, rather than riding, was the cause of the lower backache.

Treatment:

In treatment, one must concentrate on the present, acute problem of Blood stasis in the abdomen with a formula to invigorate Blood and eliminate stasis such as Sheng Hua Tang Generating and Transforming Decoction; this is a formula for abdominal pain from Blood stasis after childbirth. The termination and dilatation and curettage are somewhat energetically equivalent to childbirth (without, of course, the pronounced depletion of Qi and Blood that follows childbirth).

Box 38.9 summarizes the patterns underlying pain in this area.

BOX 38.9   CENTRAL-LOWER ABDOMINAL PAIN

Left-lateral lower abdominal area

Symptoms and Signs, Chapter 71

This area is influenced by the Large Intestine, Liver and Spleen channels and by the Penetrating Vessel. As a rule of thumb, compared with the right-lower abdominal region, problems in this area are often caused by the pathology of the Large Intestine. The most common patterns causing problems in this area are the same as those of the right-lateral lower abdominal area, that is:

Figure 38.1 summarizes the most common patterns affecting each area of the chest and abdomen.

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