Listening

The listening part of the examination involves listening to the sound of the patient’s voice, breathing, cough (if present), and the sounds that express pain and discomfort. Changes in the voice and breathing sounds are a direct reflection of the state of the lung and original qì. Verbal expression and response to inquiry reflect the state of the spirit.

Voice

Heavy Turbid Voice (语声重浊 shēng yīn zhòng zhuó)

A deep, muffled voice is called heavy turbid voice. It mostly occurs in external contraction of wind-cold or in phlegm-damp obstruction that causes non-diffusion of lung qì and blockage of the nose.

Loud Strident Voice (语声高亢 yǔ shēng gāo kàng):

This is a sign of repletion.

Faint Low Voice (语声低微 yǔ yīn dī wēi)

Sometimes called a timid low voice (语声低怯 yǔ shēng dī qiè). Talking in a faint low voice is a sign of qì vacuity. A faint low voice is usually accompanied by laziness to speak, a lack of energy or inclination to talk.

Hoarse Voice; Loss of Voice (声音嘶哑 shēng yīn sī yǎ, 失音 shī yīn)

Both hoarse voice and loss of voice share the same pathomechanisms. Loss of voice is merely more severe.

• In disease of recent onset, hoarse voice or loss of voice usually forms part of a repletion pattern. It is caused by externally contracted wind-cold or wind-heat preventing the diffusion and downbearing of lung qì and phlegm obstructing the airways. It can also arise when phlegm turbidity congests. This is often called replete metal failing to sound, based on the notion that a bell will not ring when its cavity is filled with matter.
• Persisting for a long time, a hoarse voice or loss of voice usually forms part of a vacuity pattern. Kidney yīn vacuity with vacuity fire scorching the lung can cause damage to liquid and the lung. This is called broken metal failing to sound.
• Shouting as in a sudden rage or speaking in a loud voice for a long time can give rise to hoarse voice and loss of voice when it damages qì and yīn and deprives the throat of moisture.
• Loss of voice in pregnancy can occur when the fetus exerts pressure that obstructs the qì in the vessels and prevents kidney essence from ascending to provide luxuriance for the throat. This usually disappears after delivery.

Groaning (呻吟 shēn yín)

Groaning reflects pain or distension that is difficult for the patient to bear. If the groaning is strident (high and forceful), it forms part of a repletion pattern. If it is low and forceless, it forms part of a vacuity pattern. Groaning accompanied by knitting of the brows indicates headache. Very often the location of the discomfort is indicated by a hand or hands held on the affected area.

Cries of Fright (惊呼 jīng hū)

The sudden letting out of shrill cries is called cries of fright. It is accompanied by a facial expression of fear and fright. It is caused by actual fear and fright or by severe pain.

Infants and children: When children let out cries of fright, it is usually attributable to fright wind. Cries of fright in children during the night are attributable to:

• spleen cold abdominal pain traceable to excessive consumption of raw or cold foods;
• spleen heat;
• food accumulation or worm accumulation;
• actual fear or fright.

Soundless crying in infants and children may indicate stomach pain.

Adults: Cries of fright in adults is usually attributable to acute pain caused by obstruction of qì dynamic. The location may be the joints or the bowels and viscera.

Epilepsy: Squealing like a pig or goat occurs in epileptic seizures and reflects liver wind carrying phlegm upward.

Speech

Abnormalities of speech are associated with disturbances of the spirit and are observed in both externally contracted disease and internal damage and miscellaneous diseases.

Delirious speech (谵言 zhān yán): Talking incoherently in a strident voice in patients with an unclear state of consciousness is called delirious speech. Severe forms are sometimes called delirious raving. This occurs in repletion heat patterns of externally contracted disease, such as intestinal heat bowel repletion occurring in yáng brightness (yáng míng) disease, heat entering the provisioning aspect or the pericardium in warm disease. It also occurs in hyperactive heart fire or phlegm-fire harassing the spirit, but usually only when these are attributable to externally contracted fire. Delirious speech also occurs in qì block patterns. It may also be seen in yīn collapse patterns when the heart is deprived of nourishment, although in such cases the voice is less strident.

Manic raving (狂言 kuáng yán): Senseless, incoherent raving in a patient whose essence-spirit is deranged and who chides and curses regardless of who is present is called manic raving. It occurs in yáng heat repletion patterns that arise when qì is depressed and transforms into fire and when phlegm-fire harasses the heart. It is similar to delirious speech but only occurs in repletion patterns.

Deranged speech (错言妄语 cuò yán wàng yǔ): Speech that makes no sense even to the patient herself is called deranged speech or disordered speech. Also called incoherent speech (语无伦次 yǔ wú lún cì) or talking nonsense (说糊话 shuō hú huà). It occurs in vacuity and repletion patterns. Vacuity patterns are dual vacuity of the heart and spleen depriving the heart spirit of nourishment. Repletion patterns are usually attributable to obstruction of the heart by phlegm turbidity, blood stasis, or depressed qì.

Muttering (郑语 zhèng yǔ), also called mussitation, is mumbling to oneself haltingly and with frequent repetitions. Muttering is a sign of dissipation of essence-spirit in yīn or yáng collapse patterns when the heart spirit is clouded. Muttering is similar to delirious speech but only occurs in severe vacuity patterns.

Incenssant talking (语言不休 yǔ yán bù xiū): Garrulousness. Associated with spirit failing to keep to its abode.

Taciturnity (沉默寡言 chén mò guǎ yán): Disinclination to talk. It is seen in withdrawal disease, feeble-mindedness, and certain conditions occurring in externally contracted disease.

Talking to self (独语 dú yǔ): Also soliloquy. When a person talks to herself incessantly and incoherently but stops when another person appears, this is called talking to self. It may be attributable to insufficiency of heart qì depriving the heart spirit of nourishment or to qì vacuity engendering phlegm that clouds the orifices of the heart, as in withdrawal disease or depression patterns.

Difficult sluggish speech (语言謇涩 yǔ yán jiǎn sè): Halting, unclear speech in a patient whose spirit-mind is lucid and thought is clear, is called difficult sluggish speech or sluggish speech. It is invariably associated with a stiff tongue and caused by wind-phlegm obstructing the network vessels.

Breathing Sounds

A healthy person usually takes about 16–20 breaths per minute when awake and in a relaxed state. The speed accelerates during exertion and certain emotions and decelerates during sleep. The focus of attention is on panting, wheezing, shortness of breath, scantness of breath, faint breathing, rough breathing, and yawning. More information about breathing is given under Inquiry (Inquiry about Chest and Abdomen).

Rough, Faint, Rapid, Slow, Breathing

In externally contracted disease, rough breathing that is faster than normal indicates a heat or repletion pattern. When right qì is insufficient in internal damage, faint breathing that is slower than normal indicates a vacuity pattern or a cold pattern.

Rough Breathing (气粗 qì cū)

Respiration that produces a harsh crackling sound. It is attributable to the presence of phlegm in the lung. It occurs in any pattern involving phlegm congestion. Nevertheless, in enduring illness, when lung and kidney qì are on the verge of expiration, rough halting breathing is a false repletion sign.

Faint Breathing (息微 xī wēi)

Also called faint weak breathing (呼吸微弱 hū xī wēi ruò). Breathing that is not easily detected visually or audibly. It is mostly a sign of lung qì vacuity. Nevertheless, in warm-heat disease, when heat is in the pericardium, faint breathing with clouded spirit is a false vacuity sign.

Panting (气喘 qì chuǎn, 喘 chuǎn)

Panting is often represented in English by the biomedical term dyspnea, but Chinese medicine names this condition by its similarity to the normal phenomenon of panting experienced when running. Panting is the most severe form of labored breathing, characterized by short rapid breaths with discontinuity between breaths (failure to catch the breath), flaring nostrils, inability to lie flat, raised-shoulder breathing (肩息 jiān xī) and open mouth and raised shoulders (张口抬肩 zhāng kǒu tái jiān), which are not seen in other forms of breathing difficulty. Panting is a manifestation of lung qì ascending counterflow. Distinction is made between vacuity and repletion panting.

Vacuity panting: Panting that develops gradually, makes a faint low sound with short hasty breaths, and is relieved only when a long inhalation is achieved is vacuity panting. It varies in severity at different times and is exacerbated by physical exertion. It occurs in patients with kidney failing to absorb qì (lung-kidney qì vacuity) and vacuous qì floating upward. It can also occur in kidney vacuity water flood with water-cold shooting into the lung, a specific form of kidney yáng vacuity.

Repletion panting: Panting that develops suddenly, with rough loud breathing, deep long inbreaths, and relief experienced on exhalation is repletion panting. It is accompanied by oppression in the chest, raised head and protruding eyes (仰首突目 yáng shǒu tú mù), and a replete and forceful pulse. It is usually observed in people with firm bodies. It can be attributed to:

• wind-cold fettering the lung (most common cause);
• intense lung heat;
• phlegm-heat congesting the lung;
• cold-phlegm or phlegm-rheum obstructing the lung;
• depressed liver qì affecting the lung qì depression damaging the lung.

Wheezing (哮 xiāo)

Wheezing is a high-pitched whistling sound made by breathing when the airways are congested with phlegm. The sound is often described as a frog rale in the throat because its sound is similar to the prolonged low croaking sound of a frog, although this term is also used to describe other phlegmy breathing sounds. Wheezing is always associated with hasty panting, and the combined condition is known as wheezing and panting (哮喘 xiāo chuǎn), which corresponds to the Western medical concept of asthma. Wheezing and panting arises when phlegm-rheum is stirred by an external contraction or when externally contracted evils fail to disperse and stagnates in the lung. It thus presents as phlegm-heat congesting the lung, cold phlegm obstructing the lung, or wind-cold fettering the lung. Other factors include living in cold damp surroundings for a long time and excessive consumption of sweet, salty, raw, or fishy-smelling food. It is difficult to treat.

Shortness of Breath (短气 duǎn qì)

This is breathing in short and hasty breaths. The patient feels as though he is not getting enough air and sometimes cannot catch his breath (discontinuity of breathing). However, there is no raising of the shoulders, flaring nostrils, or inability to lie flat as in panting. There is no phlegm rale as in wheezing. Shortness of breath appears in numerous patterns, both vacuity and repletion.

Vacuity patterns are characterized by short faint breaths, with general weakness of the body, lassitude of spirit, dizzy head, and lack of strength. They are caused by insufficiency of lung qì or great vacuity of original qì.

Repletion patterns are characterized by rough short breaths, accompanied by breathing, asphyxiating oppression in the chest, distension of the chest and abdomen. It is caused by phlegm-rheum, stagnant qì, or blood stasis obstructing the chest and abdomen.

Scantness of Breath (少气 shǎo qì)

Faint breathing with a low voice. In scantness of breath, the patient does not have sufficient qì to breathe or speak. In contrast to shortness of breath or panting, there is no discontinuity in breathing (failure to catch the breath). Scantness of breath is attributable to qì vacuity and occurs in all vacuity taxation (severe vacuity) patterns. It does not occur in repletion patterns. Also called scantness of qì (气少 qì shǎo), although this term may also loosely mean qì vacuity.

Differentiation

Scantness of breath (scantness of qì), shortness of breath, and panting can be differentiated with some general rules:

• Scantness of breath is the mildest form. It makes little sound.
• Shortness of breath is more severe; it manifests in short hasty breaths and discontinuity between breaths.
• Panting is a breathing difficulty that in severe cases is associated with hasty rapid breathing with discontinuity between breaths, raised shoulders, flaring nostrils, and inability to lie flat.
• Scantness of breath only occurs in vacuity patterns; shortness of breath and panting occur in both repletion and vacuity patterns.

Yawning (呵欠 hē qiàn)

Opening the mouth wide and taking a deep breath as an involuntary reaction to fatigue or boredom. It is attributable to depressed liver qì, to qì stagnation and blood stasis, or to spleen-kidney yáng vacuity. It often appears in smallpox.

Cough Sounds

Cough (咳嗽 ké sòu)

Cough is a sign of non-diffusion of lung qì or impaired depurative downbearing of the lung and lung qì ascending counterflow. It is often associated with expectoration of phlegm and in some cases with coughing of blood. It is mostly seen in disease of the lung, as when externally contracted evils directly invade the lung. It can also occur when disease of other bowels and viscera affects the lung.

The practitioner should pay attention to the sound of the cough and the quality, volume, and color of the phlegm.

• Cough with a deep turbid sound with thin clear white phlegm and nasal congestion, possibly with aversion to cold, indicates wind-cold fettering the lung.
• Cough with deep turbid sound with copious thick or thin white phlegm that is easily expectorated, panting, phlegm rale in the throat, oppression in the chest, and cold limbs indicates cold phlegm obstructing the lung. Note that phlegm rale is a phlegmy sound in the airways, sometimes called frog rale because it sounds like the prolonged low croaking sound of a frog.
• A cough that is not resonant and that produces thick yellow phlegm that is difficult to cough up usually forms part of a lung heat pattern. This is often caused by heat evil invading the lung and scorching the liquid of the lung.
• Cough with a low faint forceless sound usually forms part of lung qì vacuity or lung yīn vacuity arising when enduring illness damages lung qì causing loss of diffusion or downbearing.
• A dry hacking cough is one with little or no expectorate and is attributable to dryness evil invading the lung or to yīn vacuity with lung dryness.
• A cough that sounds like the bark of a dog, accompanied by hoarse voice and difficult breathing, is a sign of lung-kidney yīn vacuity with fire toxin attacking the throat. It often occurs in diphtheria.
• Whooping cough: In infants, repeated bouts of short hasty continuous coughing that end with the sound of a chicken are a sign of whooping cough. In Chinese medicine, it is also called hundred-day cough. More under Infants’ and Children’s Diseases in Appendix 3.

Vomiting, Hiccup, and Belching Sounds

Vomiting, hiccup, and belching are all manifestations of stomach qì ascending counterflow.

Vomiting (呕吐 ǒu tù)

Vomiting is the expulsion of food or phlegm-drool (mucus from the stomach) out of the mouth. In Chinese, the dual term 呕吐 ǒu tù means retching and vomiting. Ǒu means producing sound without matter (dry retching); tù means producing matter without pronounced sound (vomiting). Vomiting and dry retching are manifestations of stomach qì ascending counterflow. In clinical practice, the loudness of the sound produced, the acuteness of the vomiting, the nature and smell of the vomitus, and the accompanying signs all help to determine the nature of the pattern. Note more information is given about vomiting under inquiry (Inquiry about Chest and Abdomen) and vomitus under inspection (Inspecting Elininated Matter). In general, vomiting in fulminant (sudden and violent) illness is usually attributable to repletion. In enduring illness, it is usually related to vacuity.

• Gentle vomiting, with a faint sound and with clear thin vomitus, is usually attributable to vacuity cold.
• Fierce vomiting that produces a loud sound and that brings up sticky phlegm and yellow water or sour-putrid or bitter matter is usually a repletion heat pattern.
• Projectile vomiting, whereby vomit shoots out of the mouth, is usually a sign of heat harassing the spirit.

Diagnosis of vomiting cannot be based on the sound alone and must be supported by inquiry about the time and circumstances of vomiting.

• Vomiting immediately after eating may indicates intense stomach heat or food poisoning.
• Vomiting and diarrhea with abdominal pain may indicate sudden turmoil (cholera).
• Vomiting in the evening of food ingested in the morning or vomiting in the morning of food ingested the previous evening is a sign of stomach reflux (反胃 fǎn wèi), which is usually attributed to stomach yang vacuity or dual vacuity of the spleen and kidney.
• Dry mouth and desire to drink with immediate vomiting of ingested fluids is called water counterflow (水逆 shuǐ nì), which is due to the clogging action of water-rheum.

Hiccup (呃逆 è nì)

Hiccup is a phenomenon characterized by uncontrollable repeated short sounds in the throat. Like vomiting, it is seen as a manifestation of stomach qì ascending counterflow. A sudden bout of hiccuping with a sound that is neither strident nor low in the absence of other signs of illness is usually attributable to irritation by food, to stress, or to contraction of wind-cold that causes stomach qì to ascend counterflow and stir the diaphragm. It is transient and passes without treatment. However, you should pay attention to hiccup that repeatedly occurs in illness.

• Frequent short forceful strident hiccups usually form part of a repletion or heat pattern.
• Low faint hiccups are normally seen in vacuity patterns.
• In disease of recent onset, loud hiccups are usually attributable to cold evil or heat evil settling in the stomach.
• In enduring or severe illness, persistent low-sounding forceless hiccups are usually a critical sign that stomach qì is vanquished (severely damaged).

Belching (嗳气 ài / ǎi qì)

Also called eructation. Belching is the noisy expulsion of qì (gas) from the stomach. Like vomiting and hiccup, it is a manifestation of stomach qì ascending counterflow. Occasional belching after eating or drinking (especially after fizzy drinks) is normal. Pay attention to belching only when it becomes a recurrent feature in a patient’s illness.

• Belching of sour-putrid qì (gas), accompanied by distension and fullness in the stomach duct and abdomen, is usually attributable to food accumulation, a repletion pattern.
• In a patient with distension in the stomach duct or abdomen, belching that relieves the distension is usually the result of liver qì invading the stomach, which is a repletion pattern. In such cases, the belching is frequent and resounding and tends to vary with mood.
• Discontinuous low-sounding belching without any sour or putrid smell and associated with reduced eating, is usually attributable to stomach vacuity. This is a vacuity pattern mostly occurring in elderly patients and those who have weak constitutions from enduring illness.
• Frequent belching without sour or putrid smell and accompanied by stomach duct pain, is usually attributable to cold evil settling in the stomach, a cold pattern.

Other Sounds

Sighing (太息 tài xī)

Also called frequent sighing (善太息 shàn tài xī). Sighing is an occasional long exhalation. It is a normal sign of emotional relief. When abnormally frequent, it is usually a sign of depressed affect-mind, occurring in patients suffering from depressed liver qì, and bringing relief to oppression and discomfort in the chest. Sighing may also be a sign of qì vacuity.

Sneezing (噴嚏 pēn tì)

Sneezing is a noisy expulsion of air that occurs when lung qì surges up into the nose. Occasional sneezing is attributable to irritation of the nose. Only frequent or persistent sneezing calls for attention.

• Sneezing in a new illness, accompanied by aversion to cold and heat effusion and by runny nose with clear snivel, indicates external contraction of wind-cold, an exterior-cold pattern (wind-cold fettering the exterior).
• Sneezing with cough, sneezing, runny nose with clear snivel, tearing, and heat effusion occurs in the initial stage of measles, which is attributable to seasonal pestilential heat toxin.
• In patients suffering from enduring illness characterized by yáng vacuity, the sudden appearance of sneezing may indicate that yáng qì is returning. This is a sign of favorable change in the patient’s development.

Yawning (欠气 qiàn qì, 呵欠 hē qiàn)

Taking a deep breath with the mouth wide open. As an involuntary reaction to tiredness or boredom, yawning is not pathological. Abnormally frequent yawning may be a sign of depressed liver qì, qì stagnation and blood stasis, or spleen-kidney yáng vacuity. It may also be seen in patients suffering from cold strike (中寒 zhòng hán) in cold damage.

Rumbling Intestines (肠鸣 cháng míng)

A gurgling sound emanating from the intestines is called rumbling intestines. It is called borborygmus in biomedicine. It is normal for the intestines to make occasional low rumbling sounds, but when these are persistent and clearly audible, they call for attention.

• Water-rheum: When the stomach duct feels like a water bag and there is a gurgling sound in the stomach duct area when the patient stands up and walks or when the area is pressed, it indicates water-rheum gathering in the stomach.
• Wind, cold, or dampness: Thunderous rumbling of the intestines, with diarrhea and with glomus (sensation of blockage) and fullness in the stomach duct and intestines, is mostly attributable to wind, cold, or dampness. When there is severe cold, rumbling intestines may be accompanied by abdominal pain, reversal cold of the limbs, and vomiting.
• Insufficiency of center qì: Rumbling in the stomach duct or abdomen like the rumbling of a hungry stomach, that is relieved by warmth or by eating, and exacerbated by cold or hunger, is a sign of insufficiency of center qì (spleen-stomach qì) or of vacuity cold in the stomach and intestines.
• Food stagnation: Rumbling intestines with abdominal pain, passing of flatus, ungratifying defecation, and diarrhea with foul-smelling stool with a sour-putrid odor is a sign of food stagnation affecting the intestines. Food stagnation that manifests only in distension, fullness, and pain in the stomach duct and vomiting of sour putrid matter has not affected the intestines.
• Gastrointestinal qì stagnation: Rumbling intestines with distension and scurrying pain in the stomach duct and intestines, belching, nausea and vomiting, and passing of flatus is attributable to gastrointestinal qì stagnation. If the rumbling sound suddenly disappears completely, this may mean severe stoppage in the intestinal tract.

Smelling

Smelling involves identifying odors on the patient’s body and in the sickroom. Body smells include those of the breath, sweat, phlegm, nasal mucus, vomitus, stool, urine, menstrual discharge, vaginal discharge, and lochia. Generally, foul, sour, putrid smells indicate heat. Smells that are unpronounced or slightly fishy indicate vacuity cold.

Mouth Odor

Mouth odor is the odor that can be smelled when a person opens her mouth to breathe or talk. Healthy people usually have no noticeable mouth odor. An unpleasant mouth odor is called fetid mouth odor (口臭 kǒu chòu), that is bad breath or halitosis.

• Fetid mouth odor is usually attributable to poor oral hygiene, tooth decay, periodontal disease, throat diseases, or poor digestion.
• A pronounced foul smell (a highly offensive odor) is usually attributable to stomach heat.
• A sour mouth odor is usually attributable to food accumulating in the stomach and intestines or stomach heat. This tends to be noticeable because patients suffering from food damage often suffer from belching.

Odors of Sweat, Body Odor

Odors of Excreta

Odor of Phlegm and Nasal Mucus

• Coughing of thick yellow phlegm that has a foul odor is a sign of lung heat congestion.
• Coughing of fishy-smelling turbid phlegm with pus and blood indicate a pulmonary welling-abscess (i.e., a suppurative lesion of the lung), which arises when phlegm-heat congests the lung and blood putrefies and transforms into pus.
• Coughing of copious clear thin phlegm that has no noticeable smell is attributable to cold rheum collecting in the lung.
• Nasal mucus that is turbid and malodorous is usually a sign of deep-source nasal congestion, a traditional disease category that corresponds to paranasal sinusitis or to chronic rhinitis. It is mostly attributable to damp-heat steaming upward.
• Runny nose with thin clear nasal mucus without any abnormal smell is attributable to externally contracted wind-cold exterior patterns (wind-cold fettering the exterior).

Odor of Vomitus

• Putrid-smelling vomitus is usually attributable to stomach heat.
• When it is also sour-smelling, it indicates food accumulation.
• Vomitus without any sour-putrid smell is usually attributable to qì stagnation.
• Thin clear vomitus that is not fetid is attributable to stomach cold.

Odor of Stool and Urine

Sour-smelling stool is usually attributable to depressed heat in the large intestine. Fishy-smelling sloppy stool or diarrhea usually indicates spleen-stomach vacuity cold. Diarrhea with stool smelling like rotten eggs, which in severe cases contains undigested food, and with sour-smelling flatus is indicative of food accumulation.

Urine that has a powerful smell and is reddish and murky is usually attributable to lower-burner damp-heat. Urine with the sweet smell of apples and a sweet taste is a sign of dispersion-thirst, which mostly corresponds to diabetes mellitus. (Note that mellitus means honey-sweet, reflecting the taste of the urine).

Odor of Menstrual Discharge, Vaginal Discharge, and Lochia

The odor of the menstrual discharge, vaginal discharge (leukorrhea), and lochia (the fluid discharged from the uterus after childbirth) help to differentiate between cold or damp-heat conditions. Such odors should be correlated with other signs. See inquiry(Inquiry about Men and Women).

• Menstrual discharge: Foul-smelling menstrual discharge usually forms part of a damp-heat pattern. Fishy-smelling menstrual discharge is usually attributable to cold.
• Vaginal discharge: Foul-smelling vaginal discharge that is thick and yellow usually forms part of a damp-heat pattern. Fishy-smelling vaginal discharge that is thin and white is usually attributable to cold-damp or vacuity cold.
• Flooding or spotting or vaginal discharge with strange smells and colors, according to modern clinical knowledge, may indicate cancer.
• Lochia that is foul-smelling is usually attributable to damp-heat pouring downward.

Sickroom Odors

Sickroom odors are odors given off by patients that pervade the entire sickroom.

• Strong odors in the sickroom are associated with warm disease.
• A fishy smell of blood is usually a sign of bleeding.
• Putrid smells are associated with ruptured and putrescent sores.
• A cadaverine odor indicates a critical condition due to vanquishing of the bowels and viscera (organ failure).
• An ammonia or urine smell indicates advanced stage water swelling (uremia).
• A smell of rotten apples is usually a sign of severe dispersion-thirst (ketoacidosis in diabetes).