Chapter contents

INTRODUCTION

The questions regarding reactions to foods, appetite, hunger and taste are aimed primarily at establishing the state of the Stomach and Spleen.

WHY WE ASK

We always need to ask about digestive symptoms because the Stomach and Spleen are the source of Postnatal Qi and therefore a pathology in these two organs eventually affects other organs.

WHEN WE ASK

I always ask about the state of the digestive system before concluding the interrogation of the patient, unless, of course, the presenting problem is a digestive one.

HOW WE ASK

It is important to ask about digestive symptoms in detail. It would not suffice to ask simply “Do you have any digestive complaints?” We need to ask whether the patient ever experiences any distension, bloating, fullness, pain, heaviness, hiccup, nausea, vomiting, belching, loose stools, diarrhoea, etc.

The Stomach and Spleen are the Root of Post-Heaven Qi and their state affects all the other internal organs; for this reason, it is always necessary to ask questions to assess their state. This is all the more important given the frequency of digestive complaints in Western patients. The Stomach controls the rotting and ripening of food and for this reason it is compared to a bubbling cauldron in the Middle Burner. The Spleen controls the transformation and transportation (Yun Hua) of Qi and it therefore affects the transportation and transformation of food essences in the Middle Burner. Thus, the Stomach and Spleen together are responsible for the proper digestion of food. However, in Chinese medicine, the function of the Stomach and Spleen goes beyond that of digesting food as, in the process of doing so, they are the source of Food Qi (Gu Qi), which, in turn, forms the Gathering Qi (Zong Qi) and True Qi (Zhen Qi). Thus, the Stomach and Spleen are the source of Post-Heaven Qi and an enquiry into the state of these two organs is crucial in every case.

The Stomach and Spleen are particularly important also because they are in the Middle Burner with opposing directions of Qi: Stomach-Qi descends while Spleen-Qi ascends. A normal coordination of these two directions of flow is vital for a proper transformation and transportation of Qi, food essences and fluids; these two organs are at a crucial crossroads in the Middle Burner and an impairment of their movement of Qi has immediate repercussions on Qi, Dampness and Phlegm pathology. In every pathology of the Stomach and Spleen there is some derangement of the proper flow of Qi. For example, when Stomach-Qi rebels upwards rather than descending, it causes symptoms such as hiccup, nausea, vomiting and belching; even when Stomach-Qi is deficient it may fail to descend properly and may cause some of the above symptoms but to a much milder degree. When Spleen-Qi descends rather than ascends, it may cause loose stools or diarrhoea.

MAIN PATTERNS OF DIGESTIVE SYMPTOMS

The main patterns causing digestive symptoms are:

FOOD

Especially if the patient complains of digestive symptoms, it is imperative to ask about the effect of eating on pain. If a digestive pain is alleviated by eating it means it is of an Empty nature; if it is aggravated by eating, it is of a Full nature.

Food intolerance or allergies are generally due either to Spleen deficiency or Stomach-Heat, depending on the reaction: if the intolerance or allergy manifests with digestive problems and lethargy it may be due to Spleen-Qi deficiency, while if it manifests with skin reactions it may be due to Stomach-Heat.

A feeling of distension after eating indicates Qi stagnation; a feeling of fullness indicates retention of food or Dampness; a feeling of oppression of the epigastrium indicates Phlegm; a feeling of stuffiness (a mild feeling of fullness but the epigastrium is soft on palpation) indicates Heat or Phlegm occurring against a background of Deficiency. A feeling of heaviness of the epigastrium indicates the retention of Dampness or Phlegm.

Digestive problems alleviated by the ingestion of warm liquids or aggravated by cold liquids indicate Cold in the Stomach and Spleen while if they are aggravated by the ingestion of warm liquids and alleviated by cold liquids it means that they are due to Stomach-Heat.

Inability to digest fats indicates Gall-Bladder Dampness.

Box 30.1 summarizes the patterns underlying digestive symptoms.

APPETITE

Symptoms and Signs, Chapter 69

A normal appetite is an indication that the Stomach and Spleen are healthy. For social and historical reasons, lack of appetite is always considered a bad sign in China and always features as a prominent symptom in the pattern of Spleen-Qi deficiency. In the West, lack of appetite is less common and is not usually considered a very important symptom unless, of course, it leads to anorexia. Another cultural difference between Western countries and China is that when Chinese people are under stress they lose their appetite, whereas in the West patients tend to “pick” constantly, eat more or eat sweets when under stress.

Lack of appetite indicates usually Spleen-Qi deficiency but it may also be due to a Fullness and specifically to Dampness obstructing the Middle Burner; in this case, it will be associated with a feeling of fullness and of mild nausea.

TASTE

Symptoms and Signs, Chapter 69

A normal taste sensation depends primarily on the state of the Stomach and Spleen and it reflects a healthy state of these two organs and a normal state of fluids. Thus, a loss of taste sensation often indicates a deficiency of Spleen and Stomach. Loss of the sense of taste accompanied by oversecretion of saliva indicates a deficiency of Stomach and Spleen with retention of Cold in the Stomach. Loss of taste may also be due to retention of Dampness in the Middle Burner.

In most cases, a particular taste indicates a Full rather than an Empty condition of the relevant organ.

A bitter taste indicates either Liver-Fire or Heart-Fire; in the former case, the bitter taste is more or less constant, whereas in the case of Heart-Fire it will be present only in the morning after a bad night’s sleep. A bitter taste may also indicate Heat or Damp-Heat in the Gall-Bladder.

A sweet taste indicates either Spleen deficiency or Damp-Heat.

A sour taste indicates retention of food in the Stomach, a disharmony of Liver and Stomach, or Liver- and Stomach-Heat.

A salty taste may indicate a Kidney-Yin deficiency or a severe Kidney-Yang deficiency with fluids rising up to the mouth.

A pungent taste indicates Lung-Heat or Stomach-Heat, or both.

A sticky taste indicates Dampness or Phlegm, usually in the digestive system.

Western patients are often unable to describe the kind of taste they experience: very few report a pungent, sour or salty taste for example. Many patients, when asked, are unable to say whether they experience a sticky taste or not but quite a few report experiencing a “metallic” taste; I interpret this as a “sticky” taste. It is due to Dampness.

Box 30.3 summarizes the patterns underlying particular tastes.

NAUSEA AND VOMITING

Hearing, Chapter 53; Symptoms and Signs, Chapter 69

There are several Chinese terms referring to nausea and vomiting, expressing varying characteristics or degrees of severity. The Chinese term E Xin means “nausea”, Ou means vomiting accompanied by a sound, Tu means vomiting without sound, Gan ou indicates short retching with a low sound, and Yue indicates long retching with a loud sound (before the Ming dynasty this term indicated “hiccup”). The two Chinese terms Ou and Tu are usually used together to indicate vomiting.

Stomach-Qi normally descends; if it ascends it may cause nausea or vomiting, or both. Thus, nausea and vomiting are by definition due to rebellious Stomach-Qi ascending; this is not to say, however, that they are always due to a Full condition as nausea and vomiting may also be due to a Stomach deficiency. The pathological mechanism is different in each case: in Full conditions of the Stomach, Stomach-Qi rebels upwards actively, whereas in Empty conditions it fails to descend. Therefore, although nausea and vomiting always involve rebellious Stomach-Qi, this will be combined with various Stomach pathologies of the Full or Empty type such as Stomach-Cold, Stomach-Heat, Stomach-Yin deficiency, etc. This different patho-logical mechanism explains the different action of the two points Ren-13 Shangwan and Ren-10 Xiawan: the former actively subdues rebellious Stomach-Qi, whereas the latter helps Stomach-Qi to descend.

A mild feeling of nausea is usually due to a deficiency of Stomach-Qi, with Stomach-Qi unable to descend. A strong feeling of nausea and vomiting is due to rebellious Stomach-Qi ascending; this may be associated with stagnation, Cold or Heat.

Profuse and loud vomiting of food soon after eating indicates a Full condition of the Stomach; vomiting of fluids with a low sound some time after eating indicates an Empty condition of the Stomach.

Vomiting of sour fluids indicates stagnant Liver-Qi invading the Stomach. Vomiting of bitter fluids indicates Heat in the Liver and Gall-Bladder. Vomiting of thin, watery fluids indicates Cold in the Stomach. Vomiting soon after eating suggests a Heat condition while vomiting some hours after eating suggests a Cold or Empty condition.

Box 30.4 summarizes the patterns underlying nausea and vomiting.

BELCHING

Hearing, Chapter 53; Symptoms and Signs, Chapter 69

Belching always indicates Stomach-Qi rebelling upwards. This may be due to a purely Full condition, in which case the belching is violent and loud, or it may be due to Deficiency, in which case the belching is mild and with a low sound.

The most common cause of belching is Liver-Qi invading the Stomach and causing Stomach-Qi to rebel upwards; this is accompanied by epigastric and hypochondrial distension.

Retention of food (common in children) may also cause belching, in which case it is accompanied by sour regurgitation and epigastric fullness.

Deficient causes of belching include Stomach- and Spleen-Qi deficiency and Stomach-Yin deficiency; in these cases the belching is mild and its sound is weak.

Box 30.5 summarizes the patterns underlying belching.

SOUR REGURGITATION

Symptoms and Signs, Chapter 69

Sour regurgitation describes an acidy feeling in the oesophagus which comes up into the mouth. Like belching, it is also a form of rebellious Stomach-Qi. The most common cause is Liver-Qi invading the Stomach and causing Stomach-Qi to rebel upwards.

Retention of food is another possible cause of sour regurgitation. Other causes include Dampness in the Stomach, which may be associated with Heat or with Cold.

Box 30.6 summarizes the patterns underlying sour regurgitation.

NOTES