OBSERVATION OF THE CHEST AND ABDOMEN

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OBSERVATION OF THE CHEST AND ABDOMEN

Chapter contents

Protruding chest

Protruding sternum

Chest sunken on one side

Chest protruding on one side

Abdominal masses

Umbilicus signs

CHEST

The front of the chest is influenced by the Lung and Heart channel and by the Directing and Penetrating Vessels; the sides of the chest are influenced by the Gall-Bladder and Liver channels (Fig. 16.1).

Fig. 16.1 Chest areas

For a more detailed description of the patterns causing chest signs, see Part 5, Chapter 63.

Box 16.1 summarizes the channels influencing the chest.

BOX 16.1 CHANNELS INFLUENCING THE CHEST

• Directing Vessel

• Penetrating Vessel

• Gall-Bladder (sides of chest)

• Liver (sides of chest)

Protruding chest

Symptoms and Signs, Chapter 63

The most common cause of a protruding chest (Fig. 16.2) is chronic retention of Phlegm in the Lungs. Other causes include severe, chronic Liver-Qi stagnation or Blood stasis in the chest.

Fig. 16.2 Protruding chest

Sunken chest

Symptoms and Signs, Chapter 63

The most common cause of a sunken chest (Fig. 16.3) is a deficiency of Qi or Yin of the Lungs. A Kidney deficiency may also cause a sunken chest.

Fig. 16.3 Sunken chest

Protruding sternum

Symptoms and Signs, Chapter 63

The protruding sternum (Fig. 16.4) is either hereditary, in which case it is due to a constitutional deficiency of the Lungs and Kidneys, or it is caused by retention of Phlegm in the Lungs.

Fig. 16.4 Protruding sternum

Chest sunken on one side

Symptoms and Signs, Chapter 63

The chest can become sunken on one side (Fig. 16.5) either because of a deficiency of the Lungs, specifically affecting one lung, or because of retention of Phlegm-Fluids, often with Blood stasis.

Fig. 16.5 Chest sunken on one side

Chest protruding on one side

Symptoms and Signs, Chapter 63

The chest can become protruding on one side (Fig. 16.6) from Phlegm-Fluids in the Lungs, severe Liver-Qi stagnation or Heart-Qi deficiency with Blood stasis.

Fig. 16.6 Chest protruding on one side

Gynaecomastia

Symptoms and Signs, Chapter 63

Gynaecomastia indicates a swelling of the breast in males. It may be due to either Liver-Blood stasis or Damp-Heat in the Penetrating Vessel.

ABDOMEN

The regions of the abdomen in Chinese medicine are shown in Figure 16.7.

Fig. 16.7 Abdominal areas

The area under the heart is the small area immediately below the xyphoid process extending approximately 2 inches (5 cm) and bordered by the ribs. It is influenced both by the Heart and the Stomach channels and by the Penetrating Vessel.

The epigastrium is the area between the xyphoid process and the umbilicus but excluding the hypochondrial area. It is related to the Stomach and Spleen channels.

The hypochondrium includes the two areas below the rib cage and its edges which are influenced by the Liver and Gall-Bladder channels.

The area around the umbilicus is influenced by the Spleen, Liver, Kidney and Small Intestine channels.

The central-lower abdominal area (Xiao Fu) is 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.

The lateral-lower abdominal areas (Shao Fu) are influenced by the Liver and Large Intestine channels, and by the Penetrating Vessel.

Observation of the abdomen is an important part of observation in the clinic and one that should always be carried out in conjunction with palpation of the abdomen. In particular, observation of the abdomen is important because the epigastrium reflects the state of Stomach and Spleen (the Root of Postnatal Qi) and the lower abdomen that of the Kidneys (the Root of Prenatal Qi).

For a more detailed discussion of the patterns involved in abdominal signs, see Part 5 Symptoms and Signs, Chapter 71.

Abdominal size

Abdominal distension

Interrogation, Chapter 38; Symptoms and Signs, Chapter 71

Abdominal distension is both a symptom and a sign, that is, it is a subjective feeling of bloating but also an objective, distended feeling of the abdomen like a drum on palpation. The distended abdomen looks swollen and on palpation it is hard but relatively elastic, like an inflated balloon. In severe cases, the whole abdomen can be distended like a ball or a frog’s belly. By far the most common cause of abdominal distension is Qi stagnation, which is usually related to the Liver, Spleen or the Intestines. Liver-Qi stagnation is the most common cause of abdominal distension, which may involve both the epigastrium and the lower abdomen. Stagnation of Qi in the Intestines will also cause abdominal distension and in this case there will be other symptoms such as loose stools or constipation. Spleen-Qi deficiency may cause slight abdominal distension.

In severe cases, when the whole abdomen may look like a ball or a frog’s belly, this may be due to Damp-Phlegm in the Lower Burner or oedema of the abdomen.

Box 16.2 summarizes the patterns underlying abdominal distension.

BOX 16.2 ABDOMINAL DISTENSION

• Distension of epigastrium and the lower abdomen: Liver-Qi stagnation

• Distension with loose stools or constipation: Qi stagnation in Intestines

• Slight distension: Spleen-Qi deficiency

• Severe distension: Damp-Phlegm in the Lower Burner, oedema of the abdomen

Large abdomen

Symptoms and Signs, Chapter 71

A large, fat abdomen indicates Phlegm occurring against a background of Spleen deficiency. Again, allowance should be made for the Elemental type body structure: for example, a large abdomen is relatively normal in an Earth type but not in a Metal type.

Oedema of the abdomen

Symptoms and Signs, Chapter 71

Oedema of the abdomen is always due to a deficiency of Yang, which may be of the Spleen or of the Kidneys, in which case the ankles will be swollen as well.

Sagging lower abdomen

Symptoms and Signs, Chapter 71

The sagging abdomen is usually seen in obese people; it is swollen but soft and hangs down. If not due to obesity, the sagging abdomen is usually seen only in the elderly and it may be due to Damp-Phlegm in the lower abdomen or to a severe deficiency of Spleen- and Kidney-Yang associated with Damp-Phlegm. A sagging abdomen always involves a deficiency of the Directing and Penetrating Vessels and a slackening of the Membranes (Huang) and the Ancestral Muscles (Zong Jin), which are controlled by the Penetrating Vessel.

Thin abdomen

Symptoms and Signs, Chapter 71

A thin and emaciated abdomen may indicate a severe deficiency of Qi and Blood, which is often seen in serious diseases such as cancer; however, it may also simply indicate the condition of Yin deficiency. When observing the abdomen, allowance should be made for the Elemental type body structure; for example, a thin abdomen is relatively normal in a Metal type but not in an Earth type.

Abdominal masses

Symptoms and Signs, Chapters 71 and 89

Abdominal masses are called Ji Ju. Ji indicates actual abdominal masses which are fixed and immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood and I call them ‘Blood masses’. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable. If there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi and I call them ‘Qi masses’.

Actual abdominal lumps therefore pertain to the category of abdominal masses and specifically Ji masses, that is, Blood masses.

Another name for abdominal masses was Zheng Jia, Zheng being equivalent to Ji, that is, acute, fixed masses, and Jia being equivalent to Ju, that is, non-substantial masses from stagnation of Qi. The term Zheng Jia normally referred to abdominal masses occurring only in women; but although these masses are more frequent in women, they do occur in men as well.

Visible lumps in the lower abdomen are usually due to Qi stagnation, Blood stasis, Damp-Phlegm or Damp-Heat in the lower abdomen. As in the case of epigastric lumps, abdominal lumps visible on observation indicate an advanced stage which is usually seen in cancer of the uterus, large ovarian cysts or large myomas.

If due to Qi stagnation, abdominal lumps normally feel soft and come and go with emotional moods; if due to Blood stasis they feel hard on palpation and are usually associated with pain; if from Damp-Heat they may also be painful and, when palpated, very tender; if from Damp-Phlegm they feel softer than do lumps from Blood stasis or Damp-Heat. A typical example of an abdominal lump from Blood stasis is a myoma, while an example of that from Damp-Phlegm or Damp-Heat is an ovarian cyst.

Box 16.3 summarizes the two types of abdominal masses.

BOX 16.3 TYPES OF ABDOMINAL MASSES

• Qi (Ju or Jia): relatively soft masses that come and go

• Blood (Ji or Zheng): hard, fixed masses

Lumps in the epigastrium

Symptoms and Signs, Chapter 71

Visible epigastric lumps are usually due to Damp-Phlegm, Blood stasis or Phlegm and Blood stasis in the Middle Burner. Obviously, when a lump is visible on observation (rather than palpation), it is quite advanced and is seen in serious diseases such as stomach cancer, liver cancer, cancer of the oesophagus or enlargement of the liver or spleen.

Small hypochondrial lumps

Symptoms and Signs, Chapter 71

Small hypochondrial lumps resembling a string of pearls indicate Liver-Blood stasis.

Umbilicus signs

Protruding umbilicus

Symptoms and Signs, Chapter 71

A protruding umbilicus may be due to Empty-Cold with Qi stagnation, to Blood stasis with oedema in the abdomen, or to severe Spleen and Kidney deficiency. Empty-Cold with Qi stagnation is seen more frequently in children, whereas the pattern of Blood stasis with oedema is seen more frequently in the elderly.

Sunken umbilicus

Symptoms and Signs, Chapter 71

A sunken umbilicus may be due to Blood stasis with sinking of Qi, or to Damp-Heat in the abdomen.

Skin signs

Distended abdominal veins

Symptoms and Signs, Chapter 71

From a Chinese perspective, distended abdominal veins represent the Blood Connecting channels, which are a network of secondary Connecting channels where the blood pools. Thus, by definition, visible distended veins in the abdomen indicate a pathology of the Blood Connecting channels and, being in the abdomen, a pathology of the Penetrating Vessel. The Penetrating Vessel is the Sea of Blood and controls all the Blood Connecting channels, in particular those of the abdomen, and of the medial sides of the legs. If the distended veins are purple they indicate Blood stasis, if red Blood-Heat, and if bluish Cold.

Lines on the abdomen

Symptoms and Signs, Chapter 71

Lines on the abdomen are wide streaks which look like stretch marks (indeed, stretch marks are one type of such ‘lines’). They may be blue or purple – blue indicating Blood stasis from Cold associated with Yang deficiency, and purple indicating Blood stasis with Blood-Heat associated with Yin deficiency. Such lines are frequently seen in patients who have been on oral corticosteroids for a long time.

Maculae on the abdomen

Symptoms and Signs, Chapter 71

Maculae on the abdomen always indicate a Blood pathology, which is Blood-Heat if they are red, Blood stasis if they are purple and Blood-Heat with Yin deficiency if they are scarlet red.

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