OBSERVATION OF THE FOUR LIMBS

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Chapter 18

imageOBSERVATION OF THE FOUR LIMBS

ATROPHY OF THE FOUR LIMBS

Interrogation, Chapter 39; Symptoms and Signs, Chapter 64

Atrophy of the four limbs may range from a very slight thinning of the muscles to a complete wasting of the muscles such as is seen in the advanced stage of some neurological problems (e.g. motor neurone disease). The most common cause of atrophy of the limb muscles is a deficiency of the Stomach and Spleen, which results from the Stomach’s not transporting the Food-Essences there. Another possible cause of atrophy of the four limbs, which usually involves the Heart, Spleen and Liver, is Qi and Blood deficiency. In more advanced stages, atrophy of the four limbs may be caused by Liver- and Kidney-Yin deficiency, or Spleen- and Kidney-Yang deficiency.

In children, atrophy of the four limbs is due either to a deficiency of Stomach and Spleen or to a congenital Kidney-Essence deficiency and it is one of the Five Flaccidities seen in children (see Ch. 90). The Chinese name for the condition that causes a child to have flaccid leg muscles and swollen knees is Crane Knee Wind, which is due to a deficiency of Yin of the three leg channels combined with invasion of Damp-Cold in the knees.

Box 18.1 summarizes the patterns underlying atrophy of the limbs.

BOX 18.1   ATROPHY OF THE FOUR LIMBS

FLACCIDITY OF THE FOUR LIMBS

Interrogation, Chapter 39; Symptoms and Signs, Chapter 64

The term ‘flaccidity’ indicates that the muscles are flaccid, soft and limp but not atrophied (as in atrophy of the muscles).

In acute cases, flaccidity of the four limbs may be due to invasion of Wind-Heat in the Lungs, later becoming interior Heat and injuring the Body Fluids of the Stomach and Spleen. In chronic cases, the flaccidity may result from Damp-Heat affecting the Stomach and Spleen in Full cases, or from a deficiency of the Stomach and Spleen in Empty conditions. In severe, chronic cases, flaccidity of the four limbs is often due to a deficiency of Kidney-Yin.

In children under 5 years, acute cases of flaccidity of the four limbs are due to an invasion of Wind-Heat that quickly progresses to the Interior, turns into interior Heat and damages the Body Fluids, which leads to malnourishment of the channels; this is the pathology of limb flaccidity caused by infectious diseases such as poliomyelitis. In interior conditions, flaccidity of the four limbs in children is due to retention of Damp-Heat or to Qi deficiency with Blood stasis occurring against a background either of poor hereditary constitution or of poor postnatal nutrition.

Box 18.2 summarizes the patterns underlying flaccidity of the limbs.

BOX 18.2   FLACCIDITY OF THE FOUR LIMBS

RIGIDITY OF THE FOUR LIMBS

Symptoms and Signs, Chapter 64

Rigidity of the four limbs means that the patient is unable to flex or extend the wrist, elbow, knee or ankle joints. It has many causes. In acute cases with sudden onset, it is due to invasion of Wind; such a rigidity is obviously of short duration and resolves itself once the Wind has been expelled.

In interior conditions, one common cause of rigidity of the four limbs is Liver-Yang rising or Liver-Wind in the elderly. Another is of course seen in Painful Obstruction (Bi) Syndrome, especially when caused by Dampness complicated by Phlegm in chronic cases, in which case the limb rigidity is accompanied by swelling and pain of the joints.

In the elderly, an inability to flex the joints is often due to retention of Phlegm in the channels together with internal Wind. A rigidity of the limbs accompanied by pain in the joints or muscles, or both, and worsening at night, is due to Blood stasis.

In Empty conditions, rigidity of the limbs may be due to a deficiency of Liver- and Kidney-Yin, or of Spleen- and Kidney-Yang, and this is more common in the elderly.

Box 18.3 summarizes patterns underlying limb rigidity.

BOX 18.3   RIGIDITY OF THE FOUR LIMBS

PARALYSIS OF THE FOUR LIMBS

Symptoms and Signs, Chapter 64

Paralysis of the four limbs may range from a very slight limitation of movement, such as a tendency to drag a foot, to complete paralysis, as is seen in hemiplegia following a fracture of the spine.

The main causes of paralysis of the four limbs are a Stomach and Spleen deficiency, a general deficiency of Qi and Blood and a deficiency of Yin of the Liver and Kidneys. There are also Full causes of paralysis such as retention of Dampness in the muscles and Blood stasis.

The hemiplegia that occurs after a stroke is due to retention of Wind and Phlegm in the channels of the limbs on one side. The underlying pathology leading to a stroke is usually quite complex and includes Phlegm, internal Wind and Heat, usually occurring against a background of deficiency of Qi and Blood or of Yin.

Box 18.4 summarizes the patterns underlying limb paralysis.

BOX 18.4   PARALYSIS OF THE FOUR LIMBS

LIMB MOVEMENTS

Contraction of the four limbs

Symptoms and Signs, Chapter 64

In acute cases with sudden onset, contraction of the four limbs may be caused by invasion of Wind and this is always of short duration and self resolving. In Full conditions, the contractions may be caused by Dampness obstructing the muscles, or by Heat injuring the Body Fluids of the limb channels.

In Empty conditions, the most common cause of contraction of the four limbs is Liver-Blood or Liver-Yin deficiency. In the elderly, a common example usually deriving from Liver-Blood or Liver-Yin deficiency is the Dupuytren contraction, which usually involves either the ring finger or the little finger (see Fig. 14.1 on p. 131).

Box 18.5 summarizes patterns underlying contraction of the four limbs.

BOX 18.5   CONTRACTION OF THE FOUR LIMBS

Convulsions of the four limbs

Symptoms and Signs, Chapter 64

Convulsions of the four limbs always indicate internal Wind. In Chinese medicine, convulsions are considered to be due to the ‘shaking’ of the tendons and this is another reason why the Liver is always involved in this pathology.

In chronic, interior conditions, internal Wind is generated as the end result of a long pathological process, usually involving the Liver. In acute, febrile diseases, internal Wind is generated either directly from extreme Heat or from Yin deficiency, usually at the Blood level of the Four Levels. Whether the origin is internal or external, one can distinguish two types of internal Wind: one Full, characterized by strong convulsions with high amplitude; the other Empty, characterized by weak and infrequent convulsions with small amplitude, such as twitching.

In acute febrile diseases, internal Wind can develop quickly, even in a matter of days, when the Heat reaches the Blood level of the Four Levels. If Heat generates Wind, this causes strong convulsions of the four limbs. If Empty-Wind develops from Yin deficiency (itself caused by the Heat burning up the Body Fluids), the convulsions of the four limbs are less pronounced and may be infrequent.

In interior conditions, convulsions or twitchings of the four limbs are caused by internal Liver-Wind, which may derive either from Liver-Yang rising or from Liver-Blood deficiency.

If a newborn baby suffers from slight, intermittent convulsions but looks completely normal in between the attacks, its convulsions are due to invasion of external Wind combined with prenatal shock and poor hereditary constitution. The convulsions are more likely to occur in spring and autumn and they are due to a deficiency of the Spleen and Kidneys. Because the sinews lack nourishment, they are easily attacked by external Wind.

Convulsions in women after childbirth (now relatively rare) are due to Liver-Blood deficiency generating Liver-Wind.

Epilepsy is of course a type of convulsions of the four limbs due to internal Wind. Called dian xian, according to Chinese medicine it is caused both by internal Wind and by Phlegm obstructing the Mind’s orifices, and the pathology involves Liver, Spleen and Kidneys.

Epileptic attacks during pregnancy or after childbirth are generally due to Liver- and Kidney-Yin deficiency and Blood deficiency giving rise to Liver-Wind.

Box 18.6 summarizes patterns underlying convulsions of the limbs.

BOX 18.6   CONVULSIONS OF THE FOUR LIMBS

Tremor or spasticity of the four limbs

Observation, Chapter 4; Interrogation, Chapter 39; Symptoms and Signs, Chapter 64

Tremor consists in a shaking, trembling or quivering either of the arms or the legs, or both. It ranges from a very pronounced shaking with wide amplitude to a quiver that is so fine and in amplitude so small that it is almost imperceptible. Tremor of the hands is more common than tremor of the legs. The cause is always Liver-Wind; as with convulsions, it may be either the Full or Empty type, the former being characterized by a pronounced shaking of the limbs and the latter by a fine tremor.

The most common cause of tremor of the four limbs, especially in the elderly, is a combination of Liver-Wind and Phlegm affecting the channels and sinews. Liver-Yang rising by itself may also give rise to internal Wind and tremors. Another common cause of tremors is Liver-Wind deriving from Liver-Blood deficiency; this is more common in women and will cause a fine tremor. Liver- and Kidney-Yin deficiency are also a common cause of tremors in the elderly.

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

A general deficiency of Qi and Blood failing to nourish the sinews and muscles may cause a mild, fine tremor of the limbs.

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 so that Empty-Wind is generated.

Box 18.7 summarizes the patterns underlying tremor of the limbs.

BOX 18.7   TREMOR OR SPASTICITY OF THE FOUR LIMBS

OEDEMA OF THE FOUR LIMBS

Observation, Chapter 19; Interrogation, Chapter 39; Symptoms and Signs, Chapters 64, 65, 68

There are two types of oedema, one called ‘water oedema’ (Shui Zhong) and the other ‘Qi oedema’ (Qi Zhong). Water oedema is due to Yang deficiency and is always pitting oedema, that is, the skin pits and it changes colour on pressure. Qi oedema is due to either Qi stagnation or Dampness and the skin does not pit, nor does it change colour on pressure.

Another classification is that of Yang and Yin oedema: the former is of the Full type and is due to invasion of Wind, Dampness or Toxic Heat, whereas the latter is of the Empty type and is due to a deficiency of Spleen- or Kidney-Yang, or both. In Yin oedema there is marked pitting on pressure, whereas in Yang oedema there is little or no pitting. From a Western perspective, absence of pitting indicates oedema due to hypothyroidism.

When observing the limbs for oedema, we should always palpate the oedematous area and check whether or not the skin pits on palpation. If pressing the skin with the thumb leaves a dent that takes a long time to spring back, this indicates the so-called ‘water’ oedema, that is, oedema due to retention of fluids; if pressing the skin with the thumb forms no dent, this indicates ‘Qi oedema’ and it is due to Qi stagnation or Dampness.

True oedema is generally due to deficient Yang; the fluids which it is unable to transform, transport and excrete properly accumulate in the space between the skin and muscles (Cou Li).

Yang deficiency is the most common cause of oedema of the limbs: Lung-Yang deficiency affects primarily the hands, Kidney-Yang deficiency primarily the feet and Spleen-Yang deficiency both. Oedema of the four limbs may also derive from retention of Dampness in the muscles, which may be associated either with Cold or with Heat.

Qi stagnation affecting the muscles may also cause oedema of the limbs, in which case it will be of the non-pitting type. In the elderly, oedema of the limbs may also derive from Qi deficiency and Blood stasis. Finally, acute oedema of the hands and face only may be due to invasion of the Lungs by Wind-Water, which is a type of Wind-Cold.

Box 18.8 summarizes the patterns underlying oedema of the limbs.

BOX 18.8   OEDEMA OF THE LIMBS

SWELLING OF THE JOINTS OF THE FOUR LIMBS

Symptoms and Signs, Chapter 64

A swelling of the joints of the four limbs is always due to Painful Obstruction (Bi) Syndrome, especially that deriving from Dampness. In chronic conditions, Dampness develops into Phlegm, which obstructs the joints and causes further swelling and bone deformities. In adult patients, and especially women, it is very common for Painful Obstruction Syndrome and swelling of the joints of the four limbs to occur against a background of Blood deficiency. If, in addition to being swollen, the joints are also red and hot to the touch, this indicates retention of Damp-Heat.

Box 18.9 summarizes patterns underlying swelling of the joints.

BOX 18.9   SWELLING OF THE JOINTS OF THE FOUR LIMBS

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