Differentiation of pain (Treatment of Pain with Chinese Herbs and Acupuncture) Part 1

Differentiation of the location of pain

Pain generally occurs at only certain locations, and it is very important to find out where these are in order to determine which Zang-Fu organs or channels are involved, as this may help greatly in determining treatment accurately.

The Zang-Fu organs

The locations of the Zang-Fu organs are as follows:

•    Upper Jiao (or Upper Burner): Heart and Lung

•    Middle Jiao (Middle Burner): Spleen, Stomach, Liver and Gall Bladder

•    Lower Jiao (Lower Burner): Kidney, Bladder, Uterus, Small and Large Intestine.

However, since the Internal Zang-Fu organs are closely related to each other through the channels and collaterals, it is very possible to see pain occurring in a certain place that is caused by a problem in other place, so attention also has to be paid to clinical manifestations. For instance, in a case of stagnation of Liver-Qi with invasion of the Lung by Liver-Fire, there would be chest pain, fullness of the chest, cough, blood in the phlegm, a red tip and edge of the tongue, and a thin and yellow tongue coating, and in addition hypochondriac pain, restlessness, nervousness and headache. In this case, the chest pain is nothing to do with the External invasion to the Lung, but rather with the Liver disorder. The correct treatment should be to calm the Liver, reduce the Liver-Fire, and make the Lung-Qi descend.


The channels

As to the distribution of the 14 channels, the 12 regular channels are distributed symmetrically on the left and right sides of the body. The other two major channels, the Governing Vessel (abbreviated GV, the DuMai) and the Directing (or Conception) Vessel (abbreviated CV, the Ren Mai), emerge from the perineum, and ascend respectively along the middle line of the front and back of the body.

CHANNEL DISTRIBUTION IN THE LIMBS

On the upper limbs the distribution is as follows:

•    The anterior border of the medial aspect and radial end of the thumb are supplied by the Greater Yxn (Tai Yin) channel of the hand.

•    The middle of the medial aspect and the radial end of the middle finger are supplied by the Terminal Ym (Jue Yin) channel of the hand.

•    The posterior border of the medial aspect and the radial end of the small finger are supplied by the Lesser Yin (Shao Yin) channel of the hand.

•    The Bright Yang (Yang Ming) channel of the hand goes from the radial end of the index finger to the anterior border of the lateral aspect.

•    The Lesser Yang (Shao Yang) channel of the hand goes from the end of the index finger to the middle of the lateral aspect.

•    The Greater Yang (Tai Yang) channel of the hand goes from the ulnar end of the small finger to the posterior border of the lateral aspect.

On the lower limbs the distribution is as follows:

•    The anterior border of the lateral aspect and the lateral end of the second toe are supplied by the Bright Yang (Yang Ming) channel of the foot.

•    The middle of the lateral side and the lateral end of the fourth toe by the Lesser Yang (Shao Yang) channel of the foot.

•    The posterior border of the lateral aspect and the lateral end of the little toe are supplied by the Greater Yang (Tai Yang) channel of the foot.

•    The Greater Ym (Tai Yin) channel of the foot runs from the medial end of the great toe to the middle of the medial aspect of the lower limb and then goes round to its anterior border.

•    The Terminal Yin (Jue Yin) channel of the foot goes from the lateral end of the great toe to the anterior border of the medial aspect of the lower limb and then shifts to the middle.

•    The Lesser Yin (Shao Yin) channel of the foot starts under the little toe, crosses the sole and then goes along the posterior border of the medial aspect of the lower limb.

CHANNEL DISTRIBUTION IN THE TRUNK

In the thoracic and abdominal regions the Directing Vessel is situated on the middle line. The first line lateral to it is the Kidney channel-Lesser Yin channel of the foot, the second lateral line is the Stomach channel-Bright Yang channel of the foot, and the Lung channel-Greater Yin channel of the hand and the Spleen channel-Greater Yin channel of the foot correspond to the third line. The Gall Bladder channel-Lesser Yang channel of the foot is located at the lateral side of the hypochondria and the lumbar region, while the Liver channel-Terminal Yin channel of the foot is in the region of the anterior external genitalia and hypochondria.

On the back, the Governing Vessel is in the midline, while both the first and second lines lateral to it are the Bladder channel-Greater Yang channel of the foot.

CHANNEL DISTRIBUTION IN THE HEAD, FACE AND NECK

The Bright Yang channels of the hand and foot run in the facial region; and the Lesser Yang channels of the hand and foot travel in the lateral sides of the head. The Governing Vessel goes along the middle line of the neck and head, while the Bladder channel-Greater Yang channel of the foot runs on both sides of this channel.

Differentiation of the level of pain

Differentiation of the level of pain is a TCM method of recognising and diagnosing pain that is also a way of making a comprehensive analysis of the symptoms and signs obtained when applying four diagnostic methods. This method enables the clinician to differentiate whether the cause of the pain is due to invasion of external factors or to internal disorders, to Cold or Heat, to Excess or Deficiency, to Qi disorder or Blood disorder, as well as to Wind, Cold, Damp, Heat or Dryness, and so on.

Exogenous invasion or internal disorder

The categories of Exogenous invasion and Internal disorder are two principles that are used to determine the depth of the pain and to generalise the direction of its development (Table 5.1).

Generally, treatment will be relatively easy and have relatively good therapeutic results if the pain is caused by Exogenous invasion. The principles of treatment in this case are to induce sweating so as to dispel Exogenous factors, promote Qi and Blood circulation and so sedate the pain.

Table 5.1 Differentiation of pain into Exogenous and Internal types

Exogenous

Internal

Onset

acute

gradual

Duration

short

long

Symptoms

yes

no

Tongue

normal, or no change

much change

Pulse

superficial (floating)

deep

If the pain is caused by Internal disorders, however, its treatment will be not so easy, since such disorders are often caused by factors such as emotional disturbance, bad diet, overstrain, and as a result the level of the sickness tends to be deeper than that caused by exogenous invasion. Furthermore, if the Externally derived pathogenic factors are not expelled from the Exterior of the body, they will affect the Interior, giving rise to pain due to Interior disorders. The main principles of treatment in this instance are to harmonise the Zang-Fu organs, tonify the Deficiency, eliminate the Excess, circulate Qi and Blood and so stop the pain.

Cold and Heat

Cold and Heat are the two principles used to differentiate the nature of the pain (Table 5.2).

If the pain is caused by Cold, it is usually a result of invasion of Exogenous Cold, or deficiency of Yang of the body, leading to hypofunction of Internal Zang-Fu organs. Its manifestations include aversion to cold and chills, a pale complexion, cold hands and feet, a preference for warmth, an absence of thirst, clear urine, loose stools, a white or wet tongue coating, and a slow pulse. The main principles of treatment here are to dispel the Cold, warm the Yang and stop the pain; cupping and moxibustion are the best ways to relieve pain due to Cold.

Table 5.2

Differentiation of pain into Cold and Hot types

Cold

Hot

Hands

cold

warm

and feet

Face

pale, or blue

red

Thirst

absent

present

Stiffness

yes

no

Urine

clear

turbid and deep yellow

Stool

mostly diarrhoea

mostly constipation

longue

pale tongue, white

red tongue, yellow

coating

coating

Pulse

slow

rapid

If the pain is due to Heat, it is usually caused by invasion of Exogenous Heat, or conversion of Cold into Heat because of overlong Cold accumulation, or Excessive-Yang in the body, or the formation of Deficient-Heat resulting from Yin deficiency. Its manifestations are fever, aversion to heat, headache, thirst, deep yellow urine, a red face, warm hands and feet, restlessness, insomnia, constipation, a red tongue with yellow coating and a rapid pulse. The principles of treatment in this case are to clear the Heat, reduce the fever, cool the Blood and stop the pain.

Excess and Deficiency

Excess and Deficiency are the two principles that are used to generalise and distinguish the relative strength of the Defensive Qi and pathogenic factors (Table 5.3).This differentiation determines whether treatment aims at eliminating the pathogenic factors or tonifying the Defensive Qi.

Table 5.3 Differentiation of pain into Excess and Deficiency types

Excess

Deficiency

Onset

acute

gradual

Duration

short

long

Location

fixed

moving

Response

dislike of

preference for pressure

to touch

pressure and massage

and massage

Intensity

constant

intermittent

Pulse

excessive (full)

deficient (empty)

Qi stagnation and Blood stagnation

The main pathogenic change in pain is stagnation of Qi and Blood. However, it is very important to find out whether the situation is predominantly one of Qi stagnation, or Blood stagnation, or Qi and Blood stagnation in equal proportion. This differentiation determines whether treatment is geared towards circulating the Qi, or circulating the Blood, or circulating both Qi and Blcxid together (Table 5.4).

Table 5.4 Differentiation of pain into Qi stagnation and Blood stagnation types

Qi stagnation

Blood stagnation

Location

moving

fixed

Nature

distending

stabbing

Hardness

soft

hard

Fullness

yes

no

Time of attack

daytime

night-time

Emotion

aggravating pain

no direct influence

Tongue

not purplish

purplish

Pulse

wiry

choppy

Damp and Dryness

Damp and Dryness are the two principles that are used to determine the condition of the Body Fluids (Table 5.5).

Damp, whether caused by Exogenous invasion or by disorder of Zang-Fu organs, is a pathogenic factor that easily blocks the channels, muscles and Zang-Fu organs, causing pain of the Excess type to occur. The main principles of treatment in this case are to eliminate Damp, activate the Spleen and Stomach, circulate Qi and Blood in the channels, relieve the blockage and so stop the pain.

Dryness is usually caused by Exogenous invasion, or deficiency of Yin due to Yang Excess, or excessive vomiting, diarrhoea, sweating or bleeding, or weakness of Zang-Fu organs. The pain caused by Ehyness is usually due to undernourishment of the body, leading to contraction of the channels, Blood Vessels, muscles and Zang-Fu organs. The principles of treatment in this situation are to nourish Yin and Blood, promote the secretion of Body Fluids, moisten the Dryness and relieve spasm so as to stop the pain.

Table 5.5 Differentiation of pain into Damp and Dryness types

Damp

Dryness

Lassitude

yes

no

Heaviness

yes

no

Fullness

yes

no

Appetite

disturbed

not disturbed

Mouth

watery feeling

dry mouth

Nose

nasal discharge

dry nose

Throat

phlegm in the throat

dry throat

Stool

loose, or diarrhoea

hard, or constipation

Tongue

greasy, or wet coating

dry, or peeled coating

Pulse

slippery

thready, or choppy

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