Observation

Tremor of the head consists of shaking of the head, with the head usually moving back and forth. The tremor ranges from the very slight with small amplitude to the very pronounced with large amplitude.

Clinical significance

A tremor of the head always indicates internal Wind, which itself stems from the Liver. Liver-Wind may be of the Full or Empty type: the Full type develops from Liver-Yang rising or Liver-Fire while the Empty type develops from Liver- and Kidney-Yin or Liver-Blood deficiency. The tremor of the head is pronounced in the Full type and slight in the Empty type. In a few cases, the cause may be exhaustion of Heart-Yin, in which case the tremor will usually be a fine one.

Observation

‘Rigidity of the neck’ indicates that the patient finds it difficult to bend the head forwards or backwards and to turn the head from side to side.

Clinical significance

In acute situations, rigidity of the neck may indicate an invasion of external Wind, in which case it will be accompanied by all the typical manifestations of an exterior invasion such as aversion to cold, fever, headache and a Floating pulse. Both Wind-Cold and Wind-Heat may cause rigidity of the neck but it is more likely to occur with an invasion of Wind-Cold (in fact, it is one of the chief symptoms of invasion of Wind-Cold as listed in the ‘Discussion of Cold-induced Diseases’ – see Bibliography, p. 1067). Another possible acute condition causing stiffness of the neck occurs when external Cold and Dampness invade the muscles of the neck, in which case there is also pronounced neck pain; this is a case of acute Painful Obstruction Syndrome and it is relatively common.

In chronic cases, stiffness of the neck is due either to a weakness of the Bladder channel in the neck occurring against a background of Kidney deficiency or to internal Wind, both of which are more common in the elderly.

Box 4.1 summarizes patterns underlying neck rigidity.

Observation

Deviation of eyes and mouth consists in the mouth’s being pulled towards the healthy side and an inability to close or open the eye completely; in addition, the patient finds it difficult to grimace, to bulge the cheeks, grin and whistle.

Clinical significance

Deviation of eye and mouth is a consequence of Wind-stroke and is usually seen in middle-aged or elderly people; it always indicates internal Wind affecting the muscles of the face.

When deviation of eyes and mouth follows a stroke, it is called central facial paralysis in Western medicine, as it arises from the central nervous system. In facial paralysis following Wind-stroke, the nerves above the eyes are not affected, that is, the movement of the eyebrows and furrowing of the forehead are normal. By contrast, in peripheral facial paralysis (Bell’s palsy), the patient will be unable to raise the eyebrow or furrow the forehead on the paralysed side. Figure 4.1 shows the deviation of eye and mouth.

Observation

Facial paralysis is characterized by deviation of the mouth, incomplete closure of one eye and inability to grimace, grin, bulge the cheeks, whistle, or raise the eyebrow and furrow the forehead on the affected side (see Plate 4.1 on p. P8).

Clinical significance

Facial paralysis is due to invasion of external Wind in the muscles of the face and primarily in the Bright-Yang channels.

Observation

Tic consists in an involuntary twitching of the face muscles.

Clinical significance

In Chinese medicine a facial tic may be due to various patterns, among which are Liver-Qi stagnation, Liver-Blood deficiency, Liver-Wind, Liver-Wind with Phlegm and external Wind.

When due to Liver-Qi stagnation, facial tic will be accompanied by irritability, depression, tendency to crying, abdominal distension, headache and a Wiry pulse.

Liver-Blood deficiency causes facial paralysis by failing to nourish the muscles of the face and giving rise to Empty-Wind; other symptoms may include dizziness, blurred vision, dull-pale complexion and a Choppy pulse.

Liver-Wind may lead to facial tic because it is in the nature of internal Wind to cause involuntary movements. Facial tic caused by Liver-Wind is more common in the elderly and is accompanied by vertigo, headache, loss of balance and a Wiry pulse.

In the elderly, Liver-Wind frequently combines with Phlegm, both of which may lead to facial tic. Other symptoms include vertigo, nausea, headache, a feeling of oppression of the chest, a tendency to being overweight, a Swollen tongue and a Wiry-Slippery pulse.

External Wind may cause a temporary facial tic.

Box 4.2 summarizes patterns underlying facial tic.

Observation

In paralysis, a weakness of the muscles of the four limbs impedes the proper function of the legs or arms, or both. Paralysis is seen only in chronic, protracted conditions and is usually, but not always, accompanied by flaccidity of the muscles, in which case, in Chinese medicine, it pertains to the disease category of Atrophy (Wei syndrome). In mild cases, paralysis consists in a weakness of arms or legs which creates a slowness of movement, whilst in severe cases movement of the arms or legs, or both, is severly impaired or completely impossible and the patient is confined to a wheelchair.

In Western medicine, this type of paralysis is frequently seen in spinal injuries or neurological diseases such as multiple sclerosis or motor-neurone disease.

Clinical significance

Paralysis may be due to many different patterns depending on the severity of the disease.

Generally speaking, in the beginning stages of paralysis there may be invasion of external Dampness occurring against a background of Deficiency.

In the later stages, paralysis is often due to a general deficiency of Qi and Blood, and in particular a deficiency of Stomach and Spleen, which become unable to transport Qi to the limbs.

In yet later stages, the main pattern emerging in paralysis is a deficiency of Liver and Kidneys, which may manifest with Yin or Yang deficiency. At such a stage, the condition is complicated by the possible development of pathogenic factors such as internal Wind (which may cause spasticity of the limbs), Blood stasis (which may cause pain in the limbs) or Phlegm (which may cause numbness of the limbs).

In acute febrile diseases which progress to the Blood level, Yin deficiency may develop leading to the severe malnourishment of the channels and therefore to paralysis; this is, for example, the pathology of the paralysis deriving from poliomyelitis.

Of course, paralysis deriving from a spinal injury is different as it is due to external trauma and does not fall under any of the above patterns. However, in a patient suffering from a paralysis from spinal injury, this condition itself will, in time, lead to a deficiency of Stomach and Spleen.

Box 4.3 summarizes patterns underlying paralysis.

Multiple sclerosis

Multiple sclerosis is an example of paralysis that is commonly seen in Western, industrialized countries and one can identify clearly the above patterns in its pathological development. There are four stages in the pathological progression of multiple sclerosis (Box 4.4). The very beginning stage is characterized by invasion of external Dampness and the symptoms are purely numbness and tingling. The second stage is characterized by deficiency of the Stomach and Spleen and at this stage the patient begins to experience difficulty in walking. The third stage is characterized by deficiency of Liver and Kidneys, which fail to nourish the sinews and bones, and the patient experiences severe difficulty in walking and urinary incontinence deriving from the Kidney deficiency. The fourth stage is characterized by the development of pathogenic factors, which may be internal Wind, itself deriving from the Liver and Kidney deficiency and causing spasticity of the limbs, or Blood stasis causing pain in the limbs.

Observation

The patient may suffer from contraction, relaxation or tremor of the limbs.

Clinical significance

Spasticity or tremor of the limbs may be due to many different patterns. Liver-Wind is the most likely pattern to cause this condition in its three possible manifestations, that is, Full-Wind deriving from Liver-Yang rising or Liver-Fire, Empty-Wind deriving from Liver-Blood or Liver-Yin deficiency, or Wind combined with Phlegm. In cases of Full-Wind, the spasticity or tremor of the limbs is pronounced and the patient also suffers from pronounced vertigo. In cases of Empty-Wind, the spasticity or tremor is mild and the patient will display the symptoms of Liver-Blood or Liver-Yin deficiency. When Wind combines with Phlegm the patient will also suffer from numbness and heaviness of the limbs, the tongue is Swollen and the pulse is Wiry-Slippery. Epilepsy is an example of a disease usually characterized by internal Wind and Phlegm.

The same symptoms may be caused by a general deficiency of Qi and Blood failing to nourish the sinews and muscles, in which case they are mild.

Spasticity and tremor of the limbs may also appear at the Blood level (of the Four Levels) when the Heat generated by the febrile disease either leads to Liver-Wind or depletes the Yin to such an extent that Empty-Wind is generated.

Box 4.5 summarizes patterns underlying tremor or spacticity of the limbs.

Observation

Twitching of the muscles consists in an involuntary quivering or vibration of the superficial muscles: in Western medicine this is called ‘fasciculation’.

Clinical significance

Twitching of the muscles may be due to Yang deficiency, Water overflowing or Qi and Blood deficiency.

In Yang deficiency, twitching of the muscles is due to the Defensive Qi (which is Yang in nature) not nourishing the superficial muscles. Chapter 3 of the ‘Simple Questions’ says: ‘The refined part of Yang-Qi nourishes the Mind while the soft part nourishes the sinews.’¹

Water overflowing indicates a condition of severe Yang deficiency leading to the accumulation of fluids, which may occur in the Heart, the Lungs or the muscles. The accumulation of Water in the muscles may cause them to twitch.

General Qi and Blood deficiency may also cause twitching of the muscles when Yang Qi fails to nourish the superficial muscles and Blood fails to nourish the muscles and sinews.

Box 4.6 summarizes patterns underlying twitching of the muscles.

Observation

Opisthotonos indicates a spasm in which the head and heel are bent backward and the body bent forward (Fig. 4.2).

Clinical significance

Opisthotonos is always due to Liver-Wind, which develops at the Blood level of a febrile disease. It may also occur after childbirth when the mother suffers from an infection but this is rarely seen in modern Western countries.

Observation

Contraction of the limbs consists in an involuntary clenching of the fists or contraction of the feet accompanied by rigidity of the affected limbs and the inability of the patient to stretch them. Contraction may affect any joint such as fingers, wrist, elbow, ankle and knees. Dupuytren’s contracture, often involving the ring finger or the little finger, is an example of this condition.

Clinical significance

Contraction of the limbs may occur in various diseases such as arthritis, convulsions or Wind-stroke. The patterns causing it are usually general deficiency of Qi and Blood, internal Wind, Cold, Dampness, Phlegm or Blood stasis; in most cases the Liver and Kidney organs are particularly involved because they nourish sinews and bones.

A general deficiency of Qi and Blood may cause a contraction of a particular joint due to Blood not nourishing the sinews. For example, a deficiency of Blood may affect the channels of the elbow and cause a contraction of that joint.

Internal Liver-Wind may cause contraction of any joint and this is frequently seen after an attack of Wind-stroke.

Cold by its very nature has a tendency to contract and may therefore cause a contraction of any joint; frequently seen in Painful Obstruction Syndrome, this often affects the elbow or knee and is accompanied by pain.

Dampness may cause contraction of a joint by obstructing the sinews and muscles; this is also seen in Painful Obstruction Syndrome and it affects particularly the wrist or fingers causing not only contraction but also swelling.

Phlegm may also cause contraction of a joint by obstructing the sinews, muscles and bones; this is seen in the late stages of Painful Obstruction Syndrome from Cold or Dampness complicated by Phlegm and it manifests not only with a contraction of the joint but also with bone deformities.

Blood stasis causes contraction and rigidity of joints because the Blood fails to nourish the sinews and bones and stagnates in the joints; this is seen also in the late stages of Painful Obstruction Syndrome from Dampness or Cold complicated by Blood stasis, which causes intense pain and rigidity.

Box 4.7 summarizes patterns underlying contraction of the limbs.

Observation

Hemiplegia consists in the unilateral paralysis of the arm or leg, or both.

Clinical significance

Hemiplegia is seen in the sequelae stage of Wind-stroke and the main patterns causing it are Liver-Wind and Phlegm. In protracted cases after a Wind-stroke, Blood stasis may also develop, which causes pronounced rigidity and pain of the limbs in addition to the paralysis.

Observation

‘Tremor of the hands’ consists in an involuntary tremor of the hands or of the whole arm. The tremor may be very pronounced and with wide amplitude or very slight with a small amplitude. It may be unilateral or bilateral. The patient has difficulty holding a book, a spoon or a cup.

Clinical significance

Tremor of the hands always indicates internal Wind. Internal Wind may, in turn, develop from Liver-Yang rising, Liver-Fire, Liver-Blood deficiency or Liver- and Kidney-Yin deficiency. When it derives from Liver-Yang or Liver-Fire, the Wind is of a Full nature and the tremor is pronounced; when it derives from Deficiency, the Wind is of an Empty nature and the tremor is slight. In addition to the above patterns, in the elderly internal Wind is frequently complicated by Phlegm.

In alcoholics, a fine tremor of the hands is caused by Phlegm-Heat. In rare cases, retention of Dampness in the muscles and sinews of the hands may also cause a fine tremor.

Observation

‘Tremor of the feet’ consists in an involuntary tremor of the feet or of the whole leg, which may be unilateral or bilateral. The patient has difficulty in walking and there may be atrophy of the lower limb.

Clinical significance

Tremor of the feet or legs is usually due to internal Wind of the Empty type, that is, deriving from Liver-Blood deficiency or Liver- and Kidney-Yin deficiency.

Observation

‘Contraction of the fingers’, which may be unilateral or bilateral, consists in an involuntary contracture of the fingers and permanent bending with inability to stretch the hand. The movement of the muscles and sinews above the wrist is normal.

Clinical significance

Contraction of the fingers is due either to deficiency of Blood or Yin, or both, or to invasion of Cold in the sinews and muscles, as in Painful Obstruction Syndrome. In the former case, the deficient Blood fails to nourish the sinews, which, in time, contract from lack of fluids; in the latter case, external Cold invades the sinews and muscles of the hands causing them to contract.