The widespread and moving joint pain, which is aggravated by exposure to damp and cold weather, indicates Painful Obstruction Syndrome from Wind and Cold. Wind is indicated by the moving pain, while Cold is indicated by the intensity of the pain and its aggravation from exposure to cold. The absence of swelling of the joints indicates that there is no pronounced Dampness.

The stabbing joint pain is caused by Blood stasis in the channels which was brought on by the sudden shock the patient experienced just prior to the onset of the symptoms. Being put in neck traction, with the consequent restriction of movement, would have only exacerbated the Blood stasis. Blood stasis is obvious from the Purple colour of the tongue body and the stabbing nature of the joint pain. The hypertension is caused by Kidney deficiency and retention of Phlegm, which itself has come about as a result of the long-standing Kidney deficiency and which is evidenced by the Swollen tongue and Slippery pulse.

There is an underlying Kidney deficiency, which is predominantly a deficiency of Kidney-Yin. This probably originated during her first pregnancy at the age of 16 when she suffered from kidney problems, and was exacerbated by her third pregnancy which was when she developed asthma, and further aggravated during the fourth pregnancy when she developed a pre-eclampsia condition. Other signs and symptoms of Kidney-Yin deficiency are the hot flushes the patient suffered before going on HRT, the tendency towards constipation, and the lack of tongue coating.

I interpreted the expression she used ‘feeling like being crushed inside’ as strongly suggestive of the emotional origin (shock) of her problem.

Box 39.5 summarizes the patterns underlying generalized joint pain.

BOX 39.5 GENERALIZED JOINT PAIN

• Wind: pain moving from joint to joint

• Cold: severe pain

• Dampness: dull ache with swelling of joints

• Damp-heat: chronic ache and swelling of joints

• Qi stagnation: pain in the joints that is alleviated by exercise

• Blood stasis: severe pain, often worse at night

• Qi and Blood deficiency: generalized mild ache that is better with rest

TREMOR OF THE LIMBS

Observation, Chapters 4 and 18; Symptoms and Signs, Chapter 64

A tremor of the limbs always indicates Liver-Wind; we should therefore establish the source of Liver-Wind and whether it is Full- or Empty-Wind. The root cause of Liver-Wind may be Heat during an acute febrile disease, Liver-Fire, Liver-Yang rising, a deficiency of Yin of the Liver or Kidneys, or both, and Liver-Blood deficiency. The last two types of Wind are of the Empty type, whereas all the others are of the Full type.

Full Wind is characterized by pronounced tremors or convulsions (during an acute febrile disease), vertigo, unilateral numbness and a Wiry pulse. Empty -Wind is characterized by fine tremors or tics, mild dizziness, tingling and a Choppy or Fine and slightly Wiry pulse.

The tongue indicating Liver-Wind may be Moving, Deviated or Stiff.

Case histories 39.2 and 39.3 illustrate tremor caused by Liver-Wind.

Case history 39.2

A 45-year-old man had been suffering from a fine tremor of his right arm for 3 years. He had seen a neurologist who excluded the diagnosis of Parkinson’s disease. This patient had very few other symptoms, complaining only of a feeling of heat in the head, cold hands and feet, floaters, an occasional itch in the left eye and occasional heat and dryness in both eyes. His skin was also rather dry and he had been suffering from myopia from the age of 8.

His body type was a mixture of Metal and Wood. His tongue was slightly Thin, Red on the sides and not enough coating in the centre. His pulse was slightly Wiry on the left and Weak on the right, most of all on the Lung position.

Diagnosis:

The tremor of the arm is an unmistakable sign of Liver-Wind and we should establish the root pattern giving rise to Wind. In this case, it is Liver-Blood and Liver-Yin deficiency. The symptoms of Liver-Blood deficiency are floaters, itch of the left eye, dry skin, myopia from childhood, Weak pulse on the right, while dryness of the eyes and the lack of coating on the tongue indicate Liver-Yin deficiency. There are also some symptoms of Liver-Yang rising (feeling of heat in the head and eyes, Red sides of the tongue) and of Liver-Qi stagnation (cold hands and feet). The Wiry pulse may be related to any of the Full Liver patterns. In Liver disharmonies, it is not unusual to have a combination of several different patterns.

There are no symptoms or signs corresponding to the weakness of the Lung pulse, which is not unusual for this organ. When the Lung pulse is the weakest of all the pulse positions, I usually relate this to emotional problems due to sadness and grief.

Case history 39.3

A 45-year-old woman had been suffering from a fine tremor of the left arm for 1 year. She also experienced numbness and tingling of the left arm. She had very few other symptoms, except for her periods being quite scanty.

Her tongue was Pale and slightly Thin and her pulse was Fine and Wiry.

Diagnosis:

This is a clear example of Empty-Wind deriving from Blood deficiency. The Blood deficiency is evident from the Pale and Thin tongue and Fine pulse, while the Wind is evident from the Wiry pulse and obviously the tremor of the arm.

Box 39.6 summarizes the patterns of Liver-Wind.

BOX 39.6 LIVER-WIND

• Full type: pronounced tremors, convulsions, vertigo, unilateral numbness of a limb, Wiry pulse

• Empty type: fine tremors, tics, mild dizziness, tingling of limbs, Choppy or Fine and slightly Wiry pulse

UPPER LIMBS

Pain and inability to raise the shoulder

Symptoms and Signs, Chapter 65

Inability to raise the shoulder, which is nearly always accompanied by pain in the shoulder, is a very common complaint, especially after the age of 40.

The most common cause of inability to raise the shoulder is chronic retention of Cold in the joint owing to successive exposures to cold and damp weather; this syndrome falls under the category of Painful Obstruction Syndrome. In this case the pain is worse with rest and better with exercise, aggravated by exposure to cold and alleviated by exposure to heat and by wearing warm clothes.

Another common cause of this problem is sprain of the shoulder joint, which leads to local stagnation of Qi and Blood; in this case the pain is better with gentle exercise and worse with rest.

In old people, chronic inability to raise the shoulder is often due to local Blood stasis and this may be a consequence of chronic retention of Cold or repetitive strain. In this case, the inability to raise the shoulder is very pronounced and there is severe pain and stiffness that are worse at night.

In rare cases, an inability to raise the shoulder accompanies Chest Painful Obstruction Syndrome, in which case the patient suffers from chest pain, breathlessness and palpitations.

Box 39.7 summarizes the patterns underlying pain and inability to raise the shoulder.

BOX 39.7 PAIN AND INABILITY TO RAISE THE SHOULDER

• Cold in the joint: Painful Obstruction Syndrome pain better with exercise, worse with rest, aggravated by cold, ameliorated by warmth

• Stagnation of Qi and Blood: pain better with exercise, worse with rest

• Local Blood stasis: severe pain and stiffness, worse at night

• General Blood stasis: Chest Painful Obstruction Syndrome (Chest Bi) with breathlessness, palpitations

Pain in the elbow

Symptoms and Signs, Chapter 65

Pain in the elbow is usually due either to retention of Cold or to local stagnation of Qi and Blood due to repetitive strain injury. In the case of retention of Cold, the pain is severe and is aggravated by exposure to cold and alleviated by the application of heat. In the case of stagnation of Qi and Blood, the pain is aggravated by rest and slightly ameliorated by movement.

Box 39.8 summarizes patterns underlying elbow pain.

BOX 39.8 PAIN IN THE ELBOW

• Retention of Cold: severe pain aggravated by cold and ameliorated by warmth

• Stagnation of Qi and Blood: pain ameliorated by exercise

Pain in the hands

Symptoms and Signs, Chapter 65

Pain in the hands may be of a Full or Empty nature: in Full conditions the pain is severe, whereas in Empty conditions it is dull.

The three most common causes are retention of Cold, Dampness or Wind (or a combination of these) in the hands; this falls under the category of Painful Obstruction Syndrome. When the hand pain is due to Cold, it is intense, aggravated by exposure to cold and alleviated by application of heat. When it is due to Dampness, there is swelling of the fingers. When due to Wind, the pain in the hands is usually associated with pain in other joints.

Pain in the hands may also be due to Liver-Qi stagnation, in which case it may be accompanied by pain in the feet. In chronic cases, Qi stagnation will lead to Blood stasis and this may cause a severe pain in the fingers, which is worse at night, and a pronounced stiffness in them.

Blood deficiency may cause a dull ache in the hands. This is due to deficient Blood not reaching the hands and causing a minor local stagnation; it is more common in women. Yang deficiency may also cause a dull ache in the hands, similar to Blood deficiency, and, in addition, the hands have a pronounced cold feeling.

Box 39.9 summarizes the patterns underlying hand pain.

Cold hands

Symptoms and Signs, Chapter 65

Cold hands are due to three possible causes: Yang deficiency (the most common one), Blood deficiency and Qi stagnation.

Yang deficiency causing cold hands is most commonly of the Spleen, Lungs or Heart; it is ameliorated by the application of heat. Blood deficiency, especially of the Heart, may also cause cold hands; it is accompanied by palpitations and dizziness, and is more frequent in women. Liver-Qi stagnation may also cause cold hands but in conjunction with cold feet; this is called the ‘Four Rebellious Syndrome’ in which the ‘four rebellious’ indicate cold hands and feet. The famous formula Si Ni San Four Rebellious Powder is used for this pattern. An important difference between cold limbs due to Yang deficiency and cold limbs due to Qi stagnation is that in the former case the whole limb will be cold, whereas in the latter case only the hands and feet, particularly the fingers and toes, are cold.

In the case of deficiency of Yang or Blood, the cold feeling is due to deficient Yang-Qi or Blood not reaching the extremities; in the case of Liver-Qi stagnation, Qi does not reach the extremities because it stagnates in the body.

Box 39.10 summarizes the patterns underlying cold hands.

BOX 39.10 COLD HANDS

• Dull ache in the hands ameliorated by heat, cold hands: Yang deficiency

• Cold hands with palpitations and dizziness: Heart-Blood deficiency

• Cold fingers and toes: Liver-Qi stagnation

Hot hands

Symptoms and Signs, Chapter 65

To diagnose the significance of hot hands, we must first of all differentiate between exterior and interior syndromes. In exterior syndromes due to invasion of Wind, the dorsum of the hands feels hot to the touch while the patient feels cold, and an aversion to cold, in general. The acute onset, simultaneous subjective cold feeling of the patient (to the point of shivering) and the objective feeling of heat in the dorsum of the hands characterize the initial stages of an invasion of Wind.

In interior conditions, hot hands are due to either Full- or Empty-Heat usually of the Lungs, Heart or Stomach. In Full-Heat the whole hand feels hot, whereas in Empty-Heat especially the palms feel hot.

Box 39.11 summarizes the patterns underlying hot hands.

BOX 39.11 HOT HANDS

• Hot dorsum of the hands with acute onset and aversion to cold: invasion of external Wind

• Chronic hot dorsum of the hands: Full-Heat (Lungs, Heart or Stomach)

• Chronic hot palms: Empty-Heat (Lungs or Heart)

Itchy hands

Symptoms and Signs, Chapter 64

A common cause of itchiness of the hands is Dampness, which may be associated with Heat. With Dampness, the itchiness of the hands is associated with a swelling of the fingers and often small, white vesicles; with Damp-Heat the itching is more intense and is associated with swelling and redness of the fingers.

Another possible cause of itchiness of the hands is Blood deficiency leading to Wind in the skin.

Box 39.12 summarizes the patterns underlying itchy hands.

BOX 39.12 ITCHY HANDS

• Dampness: with white vesicles

• Damp-Heat: intense itching

• Blood deficiency with Wind in the skin: mild itching

Numbness/tingling of the hands

Symptoms and Signs, Chapter 65

When asking patients about numbness, it is important to explain to them that this includes any feeling of tingling (in Britain often called ‘pins and needles’).

Causes of numbness or tingling of the hands include:

• Blood deficiency

• Phlegm

• Qi and Blood stagnation

• Wind.

Blood deficiency is a common cause of numbness/tingling of the hands, especially tingling. Phlegm may also cause numbness/tingling of the hands and especially numbness. Another less common cause of numbness/tingling of the hands is chronic Qi and Blood stagnation. Unilateral numbness or tingling of the first three fingers in an old person may indicate the possibility of impending Wind-stroke.

Oedema of the hands

Observation, Chapter 18; Symptoms and Signs, Chapters 64 and 65

Oedema of the hands may be due to Lung-Yang deficiency or Spleen-Yang deficiency; in this case the oedema is pitting. If the oedema is not pitting it is due to Qi stagnation.

LOWER LIMBS

Box 39.13 summarizes the patterns underlying knee pain.

BOX 39.13 PAIN IN THE KNEES

• Invasion of Cold: severe pain with rigidity, usually unilateral

• Damp-Cold: pain and swelling

• Damp-Heat: pain, swelling and hot to the touch

• Stagnation of Qi and Blood: better with exercise

• Kidney deficiency: chronic ache of gradual onset, better with rest

Weak knees

Symptoms and Signs, Chapter 66

The most common cause of weak knees is a deficiency of the Kidneys. A chronic deficiency of Stomach and Spleen may also cause a weakness of the knees.

Cramps in the calves

Symptoms and Signs, Chapter 66

The most common cause of cramps in the calves is Liver-Blood deficiency. This symptom is more common in the elderly and it frequently occurs at night. If the cramps are very severe and are accompanied by numbness of the legs, this may indicate the presence of Empty-Wind stemming from Liver-Blood deficiency.

Cramps in the calves may also be caused by a combination of Wind and Phlegm in the limbs and this generally occurs only in patients over 70 years of age. If cramps in the calves are accompanied by pain, this indicates that, in addition to Liver-Blood deficiency, there is also Liver-Blood stasis.

Cold feet

Symptoms and Signs, Chapter 66

The most common cause of cold feet is Kidney-Yang deficiency; indeed, this symptom is a relatively important one to diagnose a Kidney-Yang deficiency. Another possible cause of cold feet, especially in women, is Liver-Blood deficiency.

Obstruction of Phlegm in the Lower Burner may also cause the feet to be cold.

Pain in the feet

Symptoms and Signs, Chapter 66

By ‘pain in the foot’, we mean a localized pain, usually unilateral, without swelling or redness. It is therefore different from the pain in the joints due to invasion of Wind, Cold or Dampness causing Painful Obstruction Syndrome. Pain in the foot may occur on the dorsum, the sides or the soles and the three most common causes of it are a Kidney deficiency (which may be of Yin or Yang), Blood deficiency and Dampness or Phlegm.

Dampness produces pain with swelling, and in Damp-Heat there is also redness and Heat. Phlegm causes a pain with numbness and tingling. A pain in the ball of the foot which is aggravated by walking if the patient is overweight is due to Damp-Phlegm.

Pain that is due to Blood deficiency is a chronic pain with tingling.

When the pain extends from the side of the foot towards the sole, it is usually due to Kidney-Yang deficiency; if due to Kidney-Yin deficiency it is accompanied by a feeling of heat of the soles, and is worse at night.

In addition, a severe pain may be due to Cold.

Box 39.14 summarizes the patterns underlying foot pain.

Oedema of the feet

Observation, Chapters 18 and 19; Symptoms and Signs, Chapters 64, 66, 68

Oedema of the feet is usually due to Kidney-Yang deficiency; in this case the oedema is pitting. If the oedema is not pitting, it is due to Qi stagnation. Oedema is discussed in more detail in Chapter 18.

Pain in the soles

Symptoms and Signs, Chapter 66

We can differentiate three distinct areas of the sole (Fig 39.1): the ball of the foot, which pertains to the Stomach channel; the area under the big toe, which pertains to the Liver and Spleen channels, and the rest of the sole, which pertains to the Kidney channel. Therefore a pain in the ball of the foot is often due to a Stomach-Qi deficiency with invasion of Dampness in the limbs or to Stomach-Heat, while a pain below thebig toe is often due to Liver-Fire or Dampness in the Spleen.