All about pain in tcm

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

Wind, Cold, Damp and Heat

Where the pain is caused by Wind, Cold, Damp or Heat due to either Exogenous invasion or Internal disorders, there is often seen to be a predominance of one or two of these pathogenic factors. The differentiation of Wind, Cold, Damp and Heat is the way to distinguish whether treatment should be based on dispelling Wind, warming the Cold, eliminating Damp or clearing Heat.

PAIN DUE TO PREDOMINANCE OF WIND

Pain due to invasion of Exogenous Wind usually is not very heavy nor constant, but if the pain is caused by internal disorders, it tends to be more severe. Internal Wind can be caused by hyperactivity of Liver-Yang, formation of VWnd resulting from Excessive-Heat, and formation of Wind due to deficiency of Blood. The principles of treatment for Exogenous Wnd are to dispel the Mnd and relieve External symptoms; for Internal disorders they are to calm the Liver, suppress the Wind, reduce the Heat and moisten the Blood Dryness.

The symptoms of Wind include the following.

•    It is basically moving, wandering, erratic or migratory, coming and going like the wind. The pain is moving continuously—for instance, rheumatic pain occurs first in one joint and then in another, and a headache may occur on the left side one day and on the right the next.

•    The type of symptom changes—for example, the quality of pain may sometimes be sharp, sometimes there is soreness, at another time there is numbness, later on there will be distending pain. Different sensations occur, or the sensibility varies.

•    Symptoms are often abrupt, appear suddenly, and are acute or paroxysmal—for example, in migraine the headache is acute and very heavy. Wind symptoms can occur suddenly and disappear as rapidly as well.

•    There is an aversion to wind and a slight fever where the pain is due to invasion of exogenous Wind.

If the pain is due to Internal Wind resulting from hyperactivity of Liver-Yang, there is restlessness, headache, thirst, nervousness, a red tongue with yellow coating and a wiry and rapid pulse. If the pain is due to accumulation of Excessive-Heat, there is a high fever, headache, much thirst, restlessness, constipation, a deep red tongue with no coating and a rapid and forceful pulse. In case the pain is due to deficiency of Blood in the Liver, there is trembling of the head and limbs, tiredness, a pale complexion, dry eyes and skin, numbness in the limbs, scanty menstruation or amenorrhoea, a pale tongue with a thin coating and a thready and weak pulse.

Besides the above characteristics, other general symptoms of Wind can occur, such as:

•    fear of Wind, fear of draught, aggravation when the weather is Windy

•    sweating, which is due to opening of the pores by the invasion of the Wind factor.

PAIN DUE TO PREDOMINANCE OF COLD

Pain can be caused by either invasion of Exogenous Cold or deficiency of Yang Qi in the body; the latter situation is usually a deficiency of Yang of the Heart, Spleen or Kidney. If there is Exogenous Cold invasion then the principles of treatment are to dispel the Cold and relieve the External symptoms; for Internal disorders treatment aims to warm the Interior, strengthen the Heart, activate the Spleen and tonify the Kidney.

The symptoms of Cold include the following.

•    Unlike pain that is due to Wind, Coldness freezes Qi and Blood locally, so the pain is fixed, seldom moves and is well localised.

•    Since Cold is contracting and blocking, it slows down any movement. If the pain is caused by Cold, then it is rather severe, and very sharp or stabbing as the Cold causes Blood stagnation.

•    Another possible symptom accompanying the pain is stiffness due to the freezing effect of the Cold, as in 'frozen shoulder'.

•    The pain is improved by warmth and movement, but is aggravated by cold and rest. It is also aggravated in cold weather or by using cold therapy.

•    There is aversion to cold and occasionally a slight fever in cases of invasion of Exogenous Cold.

The Exogenous Cold pathogenic factor has Yin characteristics. However, invasion of the body by Exogenous Cold may cause a Yang reaction in the superficial layers of the body as the skin pores are closed, so the body is not able to sweat. Due to this, the Body Fiuids try to escape out of the body through the urine, thus there is frequent discharge of large quantities of clear urine.

Besides a lack of perspiration, the person shivers to help the body maintain its temperature at a normal level. Muscular fibrillation also produces some warmth, so there can be a degree of fever, but chills and a cold feeling are predominant.

If the Heart-Yang is deficient, there is pain in the chest, an aversion to cold, cold limbs, palpitations, the spirits are low, there is a pale tongue with a thin coating and deep, slow and thready pulse.

If the Spleen-Yang is deficient, there are loose stools, or diarrhoea, abdominal pain, an aversion to cold, cold in the limbs, a feeling of tiredness, a thin and white coating, or even greasy coating, to the tongue and a thready, slow and weak pulse.

If the Kidney-Yang is deficient, there is lower back pain, weakness of the knees, frequent urination, nycturia, a feeling of tiredness, cold hands and feet, low potency, a thin and white tongue coating and a thready, slow and weak pulse.

In summary, generally, in Cold syndromes the following are noted:

•    tongue: a thin and white coating, or a pale tongue

•    pulse: a tight and superficial pulse if there is exogenous invasion, or a wiry and slow pulse if Yang of the Zang-Fu organs is deficient.

PAIN DUE TO PREDOMINANCE OF DAMP

Pain can be caused either by invasion of Exogenous Damp or by disorder of the Internal Zang-Fu organs, especially the Lung, Spleen or Kidney. The principles of treatment for the former are to dispel the Damp and relieve External symptoms; for the latter the aim is to restore the Zang-Fu organ function, eliminate the Damp and promote urination.

The symptoms of Damp include the following.

•    The pain is very localised, and never moves as Damp, which is of the same nature as water, is characterised by heaviness and inertia, therefore there is no movement.

•    There is a feeling of heaviness, tiredness and numbness, especially in the lower limbs and lower parts of the body.

•    The affected parts are swollen; this swelling may be in the body or in the joints, and there may be an accumulation of liquid under the skin.

•    Pain that is due to Damp is never sharp or acute; rather, it is deep, heavy and dull. Also it never appears suddenly, but slowly, gradually and chronically.

•    Pain that is due to invasion of Exogenous Damp is aggravated in damp climatic conditions, such as when the weather is foggy, humid, wet or overcast. Wet places, moist walls or houses built on swamps usually also make the pain more severe (this can be compared to miasmatic symptoms in homeopathy). Moreover, this kind of pain is mostly aggravated if it becomes complicated by Wind or Cold factors, as happens in Damp-Bi Syndrome.

•    Pain that is due to Damp resulting from Internal disorder is usually aggravated by eating too-fatty and greasy food as well as by eating cold food.

In general, in Damp conditions the following are noted:

•    tongue: the coating is thick, sticky, whitish and wet; also it is very wet and never dry, even watery

•    pulse: this is weak-floating soft (Ru), or slippery (Hua) and a little slowed down (Huan).

PAIN DUE TO PREDOMINANCE OF HEAT

Heat can be caused either by invasion of ExogenousHeat or by accumulation of Internal Heat resulting from Yang Excess or Yin Deficiency. The principles of treatment for invasion of Exogenous Heat are to dispel the Heat, reduce the fever and relieve the External symptoms. For Yang Excess the aim is to clear the Heat, reduce the Fire and promote defecation in order to induce the Heat out of the body. For Yin Deficiency, it is to nourish Yin, clear the Heat and promote the secretion of Body Fluids.

The symptoms of Heat include the following.

•    Heat, like Fire, is a Yang pathogenic factor, which may cause pain accompanied by redness and swelling of the joints and muscles.

•    The joints are painful, with a feeling of warmth, and are difficult to move (as seen in acute inflammatory arthritis).

Besides these characteristics of any joint or muscle pain, the following general symptoms of Heat may be observed:

•    fever, sometimes with a slight chill, although the fever and hot sensation predominate

•    aversion to Heat

•    thirst, dryness of the mouth

•    irritability, nervousness or restlessness

•    tongue: a red tip to the tongue, or the whole body of the tongue, and a yellowish coating; if there is Yin Deficiency a peeled or scanty coating

•    pulse: a rapid and superficial pulse if there is invasion of exogenous Heat, rapid and forceful in Yang Excess, and rapid, thready and weak in Yin Deficiency.

At least two circumstances are required for a diagnosis of invasion of Exogenous Heat:

•    predominance of Heat among Wind-Heat and Damp;

•    the pre-existence of Excessive-Heat or Deficient-Heat in the body, which is usually caused by bad dietary habits, such as eating too much greasy, fatty or hot foods, or too many sweets, or drinking too much alcohol.

Emotional disturbances such as stress, frustration, excessive meditation, pent-up emotions and so on produce Liver-Qi stagnation and hyperactive Liver-Fire, which are manifested as irritability, nervousness, anger, insomnia, hot flushing, etc. Overwork, and infectious or chronic diseases, amongst other things, cause Yin deficiency with Deficient-Heat.

Invasive pathogenic factors can also be transformed into Heat (Huo Hua) if they are of prolonged duration. This transformation is generally incomplete at the beginning of the process, so a mixture of Heat, Wind, Cold and Damp are generally seen, but the Heat predominates.

Differentiation of the characteristics of pain

Sore pain

This kind of pain often occurs in all four limbs and the trunk, especially the lower back and places where there are a lot of soft muscles. It is not very severe, and is accompanied by weakness, soreness, lightness and emptiness. It is mostly caused by deficiency of Qi and Blood.

Distending pain

This type of pain often occurs in the chest and abdomen, and is mostly caused by stagnation of Qi. Because of the stagnation, it fluctuates in intensity and location, and is rather obviously influenced by emotional changes, especially by stress, anger, irritation, nervousness.

Stabbing pain

This is commonly seen in daily practice, and characteristically feels as if a needle or knife were pricking the skin or muscles. The pain occurs always in the same place, but can be worsened during the night or by lying/sitting in a still position; it is better after movement, and is accompanied by swelling or petechiae on the skin, a dislike of pressure, a purplish tongue, and sometimes petechiae on the tongue, and a choppy pulse. This type of pain is typically seen in patients with stagnation of Blood, and after physical trauma, thus to promote Blood circulation can quickly relieve the pain.

Sharp pain

This kind of pain is mostly seen to be caused by acute Qi and Blood stagnation, and especially Qi stagnation, and is due to various factors. It is greatly diminished by treating with methods that circulate the Qi and Blood; however, it is very important to discover and treat the real cause, otherwise the pain will always return.

Throbbing pain

This type of pain is characterised by its rhythmic quality similar to beating of the pulse. It is often seen in patients with migraine, which is normally caused by hyperactivity of Liver-Yang. A throbbing pain is also found in patients with a carbuncle or furuncle of the Yang type, which is caused by invasion or accumulation of Toxic Heat in the body, and is accompanied by a feeling of heat, redness and swelling.

Burning pain

This kind of pain is characterised by pain with very hot feeling, as though the skin were burned, and is typically caused by Heat, either from invasion of exogenous Wind-Heat, Damp-Heat, Dryness-Heat or Toxic Heat, or Internal Heat from dysfunction of the Zang-Fu organs. In most cases, local redness and swelling can be observed.

Prolonged stagnation of Cold, or Qi and Blood, also may gradually produce Heat.

In contrast, in some patients who complain of a subjective burning feeling, nothing can be found physically. In this case, the burning pain is mostly caused by generation of Heat from the interior.

Colic pain

This kind of pain is usually very severe, often occurring in the internal Zang-Fu organs, such as the Small Intestine, Gall Bladder or Uterus. It is caused either by invasion of Exogenous Cold, or by accumulation of Cold, stagnation of Qi, or some substantial blockage such as stones, sand, stagnant Blood or Phlegm.

Hemialgia

This is pain that develops gradually and is confined to either the right or left side of the body. This type of pain often fluctuates in its intensity. Its causes include disharmony of the Nutritive Qi and Defensive Qi system, slowing of the Qi and Blood circulation, and disorder of Yin and Yang—for instance, it can often be seen on those who suffer from the sequelae of a cerebrovascular accident (Zhongfeng).

Pantalgia

This is pain that is experienced over the general body, but mainly in the joints and muscles. It can be caused either by Excessive factors, such as Qi and Blood stagnation or accumulation of Damp, or by deficient factors, for instance a deficiency of Qi and Blood.

Wandering pain

This is pain in the muscles and the joints that comes and goes, and fluctuates in its location. This type of pain is often seen in people suffering from Painful Obstruction Syndrome (Bi Zheng) due primarily to invasion of Wind.

Wandering pain can also be seen in the internal Zang-Fu organs, mostly in the abdomen and chest, and is caused by stagnation of Qi; it is closely related to emotional changes, which means that under conditions of stress, nervousness or anger the pain will be aggravated.

Pain with fixed location

This type of pain can be caused either by stagnation of Blood, or by invasion of Exogenous Damp, or by accumulation of Damp in the body.

If the pain is due to stagnation of Blood there is a stabbing pain, aggravation of the pain at night and when the person remains in a still position. If it is caused by invasion of Exogenous Damp there is an aversion to cold, slight sweating, a feeling of heaviness in the limbs and trunk, and headache. If it is caused by accumulation of Damp in the body there is nausea, poor appetite, loose stool or diarrhoea, a feeling of lassitude, fullness of the chest and abdomen, a greasy coating to the tongue and a slippery pulse.

Pain with spasm

This kind of pain can be caused either by invasion of Exogenous Cold, by deficient Blood in the Liver, by retardation of Blood circulation, or by formation of Deficient-Cold. For instance, acute facial paralysis is often caused by invasion of Wind-Cold, since Cold is characterised by contraction and stagnation.

Deficiency of Blood in the Liver often causes headache with a feeling of spasm. Spasm in the legs, especially in the gastrocnemius muscle, during the night, could be caused by deficiency of Blood in the Liver accompanied by poor Blood circulation, leading to undernourishment of the tendons. This condition is often seen in elderly people.

Pain with a suffocating feeling

This kind of pain is caused by blockage of the Qi circulation due to Qi stagnation or Damp-Phlegm accumulation, often occurring in the chest or abdominal region. For example, Painful Obstruction Syndrome in the chest is usually due to mixture of Qi stagnation and Phlegm accumulation.

Pain with radiation

This kind of pain refers to conditions characterised by pain occurring mainly in one location and radiating to another. It is usually caused either by stagnation of Qi and Blood or by accumulation of stone or sand in the Zang-Fu organs. For instance, stagnation of Qi in the Liver and Gall Bladder often causes hypochondriac pain with radiation of the pain to one shoulder or the upper back. Again, stagnation of Blood in the Heart may cause chest pain radiating to the arms and neck.

Pain with contraction

Since Cold is characterised by contraction, this kind of pain is usually caused by invasion of Exogenous Cold or formation of Deficient-Cold due to deficiency of Yang.

If the pain is caused by invasion of Exogenous Cold, the pain is severe, and accompanied by an aversion to cold, slight fever, headache, anhidrosis, a runny nose with a whitish nose and throat discharge, a thin and white coating to the tongue and a superficial and tight pulse. If it is caused by formation of Deficient-Cold due to deficiency of Yang, the pain tends to be slight and intermittent, and is accompanied by an aversion to cold, a feeling of tiredness, a pale complexion, shortness of breath, cold hands and feet, a pale tongue with a thin coating and a slow and deep pulse.

Pain with heaviness

This kind of pain is normally not very severe, it often occurs in the limbs, chest, epigastric region, abdomen or head, and there is a feeling as if the limbs and the head are bound by a piece of band, or as if the person is suffocating. It is a sign of invasion of Damp or accumulation of Damp in the body.

Pain with swelling

This kind of pain often occurs in the joints and muscles, and is usually caused by stagnation of Blood after trauma, or accumulation of Damp, or of Toxic Heat.

If the cause is stagnation of Blood due to trauma,there is severe pain, limitation of joint movement, a hard swelling with distinct edges, and blue spots on the skin. If it is accumulation of Damp in the joints and muscles, the joints are painful and the muscles have a heavy feeling, there is a soft swelling with indistinct edges, and a feeling of vibration can be obtained under the skin, the tongue has a greasy coating and there is a slippery pulse. If it is accumulation of Toxic Heat, the joints and muscles are swollen and there is redness, heat and severe pain, accompanied by fever, thirst, a feeling of restlessness, a red tongue with yellow coating and a rapid and forceful pulse.

Pain with dislike of pressure and massage

This kind of pain is usually severe and constant, and is caused by Excessive factors such as Qi and Blood stagnation, accumulation of Cold, or stagnation of food. It is accompanied by aggravation of the pain according to emotional changes, or food intake, and there is also rough breathing, constipation and a wiry pulse.

Pain with preference for pressure and massage

This kind of pain is usually slight and intermittent, and is caused by Deficient factors such as deficiency of Qi and Blood, deficiency of Yin or Yang. It is accompanied by a feeling of tiredness, or a weak feeling, it is aggravated by exertion, and there is a weak and thready pulse. After pressure and massage, the pain will disappear for a bit, but then gradually returns.

In addition, in some patients a pain caused by excessive factors may also be alleviated by pressure and massage; this is because pressure and massage disperse the Qi and Blood circulation temporarily so the pain diminishes; however, it quickly returns.

Pain with preference for warmth

When this kind of pain occurs it means that there is too much Yin and Cold in the body. This is caused either by invasion of Exogenous Cold, or by formation of Deficient-Cold due to Yang deficiency. Because warmth can counteract and diminish Tm and Cold, the person prefers warmth.

If the pain is caused by invasion of Exogenous Cold,the onset is usually acute and relatively severe, and is accompanied by an aversion to cold, fever, headache, muscle pain with a contracting feeling, a runny nose with a whitish discharge, cough, a thin and white coating to the tongue and superficial and tight pulse. If it is caused by development of Deficient-Cold due to Yang deficiency, the onset is usually gradual, and is accompanied by an aversion to cold, a feeling of tiredness, a pale complexion, a poor appetite, there is intermittent occurrence of pain, the tongue is pale with a thin coating and there is a deep, thready and slow pulse.

Pain with preference for cold

Cold can clear Heat and reduce fever, so this kind of pain is usually caused either by invasion of Exogenous Heat, or by accumulation of Heat in the body.

If the pain is caused by invasion of Exogenous Heat, there is fever, a slight aversion to cold, a runny nose with a yellow discharge, throat pain with redness and thirst, a thin and yellow tongue coating and superficial and rapid pulse. If it is caused by accumulation of Heat in the body, there would be no External symptoms, but fever, thirst, restlessness, constipation, insomnia, yellow and dry coating, wiry and rapid pulse.

Constant pain

This kind of pain can be caused by all kinds of Excessive factors. It implies that the battle between the Defensive Qi and the pathogenic Qi is still very active and when the Defensive Qi is the stronger one, the pain level diminishes, and when it is the reverse level the pain increases. Treatment is mainly aimed at helping the Defensive Qi to eliminate the pathogenic Qi.

Intermittent pain

This kind of pain is usually caused by a deficiency of Qi, Blood, Yin or Yang, and this implies that the Defensive Qi is weak, so the battle between the Defensive Qi and the pathogenic Qi is not very active. Treatment is mainly aimed at nourishing the Defensive Qi so as to relieve the pain.

Intermittent pain, specially intermittent pain around the navel, can also be caused by accumulation of worms, and is often accompanied by vomiting, even vomiting of worms, and intermittent abdominal pain with sudden aggravation. If the worms are in the Gall Bladder, there is hypochondriac pain, nausea, vomiting, jaundice and fever.

Aetiology of pain

Exogenous factors

WIND

Wind is one of six exogenous factors, which is predominant in the spring but may also occur in any of the four seasons. When attacking the body, Wind is likely to combine with another of the pathogenic factors, such as Cold, Damp or Heat, etc., leading to retardation of Qi and Blood circulation. This causes blockage in the Zang-Fu organs, muscles, tendons, joints and channels, and pain follows.

Wind is classified as a Yang pathogenic factor because it has the characteristic of upward and outward movement. Because of this quality, it may easily invade the upper and superficial areas of the body, for instance the face, head, neck, shoulders, arms, chest, upper back, etc. So pain that is caused by Wind is found mostly in the top half of the body.

In nature Wind blows in gusts and is subject to rapid changes. Similarly, in the body it causes symptoms that are characterised by their migratory appearance. When a pain has no fixed location, but rather tends to wander around, this implies that its primary causative factor is Wind.

COLD

Cold is the predominant factor in winter. Although it can be seen in other seasons, in these its nature is not so severe. Cold invasion normally results from wearing too little clothing, exposure to Cold after sweating, being caught in rain, or wading through water in cold weather.

Cold is a Yin pathogenic factor and is likely to damage the Yang Qi of the Heart, Stomach, Spleen or Kidney. Cold includes both Exogenous and Internal Cold pathogenic factors; the former refers to Cold due to External invasion, and the latter to Cold due to Deficiency of Yang Qi. Exogenous Cold and Internal Cold may mutually influence and transform each other. For instance, Exogenous Cold may change into Internal Cold where there is prolonged persistence of the condition, resulting in damage to the Internal Yang Qi; conversely, a state of Internal Cold may easily induce invasion of Exogenous Cold.

Cold is characterised by stagnation and contraction,so Cold can easily slow the circulation of Qi and Blood. Thus, pain accompanied by a sensation of contraction, limitation of joint movement, aversion to cold and anhidrosis will be classified as being caused by Cold.

Cold may invade the body not only through the skin, mouth and nose, and drinking of cold liquids, but also through the uterus (e.g. after walking in the rain, or swimming or sex during menstruation). Moreover it can directly invade the muscles and joints, or even the Internal Zang-Fu organs if the Cold is very extreme, or the body very weak. The other opportunity for External Cold to invade is through the practice of walking barefoot. In Western countries, many people often do this inside the house, even on a cold floor, and in winter. Since the Kidney, Liver and Spleen channels all begin on the foot, External Cold may easily invade the Spleen, Kidney and Liver through these channels, especially the Kidney channel, which begins on the soles, in people who too frequently walk around barefoot on a cold floor.

Nowadays more and more homes and other buildings have air-conditioning to cool the place in the heat of summer. Consequently, many people now suffer from pain that becomes worse when they are sitting in their office equipped with air-conditioning, and they improve spontaneously once they leave the office and go out in sun. Thus they form a clear impression that cold places are bad and warm places are good for them, which is true. This is because our skin pores stay relatively open in the summer in order that we may sweat and keep our body temperature down. However, this also provides a very good opportunity for invasion of Cold, as the artificially cooled air can enter the body through the opened pores. Being characterised by contraction and stagnation, Cold may cause closure of the skin pores; this results in accumulation of Cold in the joints and muscles, so leading to pain due to Qi and Blood stagnation. Moreover, since the skin pores are now closed, Internal Heat cannot easily leave the body in sweat evaporation. So accumulated Cold can soon change into Heat, leading to symptoms of that aggravation, including redness, hotness, pain and swollen joints and muscles.

DAMP

Invasion of Exogenous Damp is usually induced by humid weather, walking in the rain, living and working too long in humid places, or not changing out of one's wet clothing after sweating. There is also a condition of Internal Damp, which is normally caused by disorder of the transportation and transformation functions of the Spleen and Stomach leading to formation of excessive water in the body. Exogenous Damp and Internal Damp often mutually influence each other in the causation of pain—that is to say, invasion of Exogenous Damp often attacks the Spleen and Stomach, while weakness of the Spleen and Stomach with formation of Damp may easily induce invasion of External Damp.

Damp is similar to water, which is characterised by heaviness. When it attacks the body, it causes pain accompanied by a feeling of heaviness of the head, limbs and body, together with a sense as though the body is bound. Where there is invasion of the skin and muscles by External Damp, this results in a blockage of the Clear Yang and disharmony of the Nutritive and Defensive Qi, which manifests as symptoms such as soreness of the limbs and joints, numbness of the limbs and muscles, and lassitude.

Damp is also characterised by viscosity and stagnation. Following on from this principle, pain that is caused by Damp is, generally speaking, stubborn and tends to be prolonged and intractable, compared with that caused by other pathogenic factors.

Damp is a Yin pathogenic factor and easily blocks Qi circulation and impairs Yang. When Damp accumulates in the Zang-Fu organs, joints, muscles or channels it may affect the ascending and descending of the Qi, leading to symptoms such as numbness of the skin and joints, and limitation of movement.

DRYNESS

Dryness is predominant in autumn, and tends most often to impair the Lung, impeding the dispersal of Lung-Qi and causing stagnation, leading to symptoms such as throat and chest pain.

Dryness can also damage the Body Fluids, causing dryness of the skin, nose and throat. Furthermore, it may disturb and consume the Blood; then the blood vessels are not properly nourished resulting in narrowed vessels, and then the Qi and Blood stagnate, leading to painful skin.

HEAT (FIRE, WARMTH)

Fire and Heat both indicate excessive Yang Qi, thus in most cases they are interchangeable, but there is still some slight difference between them. In terms of pathology. Heat is usually caused by Exogenous invasion, for instance Wind-Heat or Damp-Heat, whereas Fire is often caused by Internal disorders, for example flaming up of Heart-Fire or hyperactivity of Liver-Fire. In terms of the physiology, Fire has a proper function, which is to warm the Zang-Fu organs and promote Qi transformation and energy production; only if it becomes excessive does it become a kind of pathogenic factor causing overconsumption of energy in the body. Heat, in contrast, is simply a pathogenic factor.

Warmth is like Fire, with a physiological role but potentially pathogenic, and is also a kind of Heat, but milder. Of the three, Fire is the most severe, and Warmth the least severe, yet they all share similar characteristics. In practice, the terms Fire-Heat and Warmth-Heat are often used interchangeably.

Heat, a Yang pathogenic factor, is characterised by flaming up, burning and hotness. When it attacks the body, it may cause abnormal Qi and Blood circulation as well as injury to the Blood Vessels, causing pain accompanied by a burning feeling, a hot sensation, or redness. When Heat disturbs the Blood, the Blood circulation will be accelerated and the Blood Vessels can be damaged, causing swelling of the joints, muscles, or even bleeding, such as epistaxis, etc. Heat may also often disturb the Heart, which houses the Mind, causing restlessness and insomnia.

Like pathogenic Wind, Heat often attacks the top half of the body because of its characteristics of flaming up and moving in an upward direction, thus a combination of Wind and Heat causation is often seen. In most case of acute inflammatory joints and muscles in the upper parts of the body, Wind-Heat is the chief causative factor, thus the main treatment principle will be to dispel Wind and clear Heat.

Emotional factors

Pain is an indication of human suffering. This suffering may frequently be rooted in emotional distress as well as physical trauma.

Mental activities relating to emotion in TCM are classified into joy, anger, melancholy, meditation, grief, fear and fright, and are known as the seven emotional factors. The seven emotional factors differ from the six Exogenous factors in that they affect the Zang-Fu organs and the circulation of Qi and Blood, directly. For this reason, they are considered to be the chief causative factors for various kinds of pain. It is believed traditionally that different emotional factors tend to affect the circulation of Qi and Blood of various individual internal organs, resulting in retardation of Qi and Blood circulation, causing blockage to follow, and pain as the main clinical manifestation. The saying 'anger injures the Liver, joy injures the Heart, grief and melancholy injure the Lung, meditation injures the Spleen, and fear and fright injure the Kidney' (Yellow Emperor's Classic of Internal Medicine: Simple Questions 1956, p. 17) is an expression of relationship between the different emotional factors and each of the internal Zang-Fu organs.

Another saying from ancient medical texts is: 'anger causes the Qi to rise, joy causes it to move slowly, grief drastically consumes it, fear causes it to decline, fright causes it to be deranged, and worry causes it to stagnate' (Yellow Emperor's Classic of Internal Medicine: Simple Questions 1956, pp. 80-81). From this it can be seen clearly that abnormal Qi and Blood circulation is one explanation for the occurrence of pain.

In clinical practice, it has often been observed that in some patients suffering with pain their pain is aggravated or alleviated by their emotional state. Take shoulder pain, for instance: if the biceps muscle (which is in the area of the Lung channel) is involved, it is sometimes found that such patients either have suffered much grief in the past or do so at present and usually admit that when their feelings of grief recur their shoulder pain worsens. Since the Lung and Large Intestine share a pair of channels and collaterals, if the Lung channel is blocked the Large Intestine channel can also become impaired, leading to shoulder or arm pain. In this case, the points nearby (such as LU-2 Yunmen, LU-3 Tianfu, LU-5 Chize or LU-6 Kongzui) are usually found to be tender. There may also be tenderness found around LI-4 Hegu, LI-9 Shanglian and LI-10 Shousanli, as well as LI-Il Quchi. Another example is patients suffering from lower back pain, some of whom may have aggravation of pain with particular emotional states, especially anger and stress. This kind of pain can also radiate to the inguinal region, and even to the interior aspect of the leg along the Liver channel, and consequently along the Gall Bladder channel also. Conversely, if the Gall Bladder channel is primarily affected, there could be impairment of the Liver channel as well. For instance, disc herniation between L4 and L5 often manifests as pain along the Gall Bladder channel, which sometimes refers to the inguinal region. In this case, anger or stress may play a very important role in the aggravation of the low back pain.

The causation of pain by excessive emotional activities is basically described in following sections.

EXCESSIVE JOY, FEAR OR ANXIETY

These often disturb the physiological functions of the Heart, leading to retardation of Qi and Blood circulation in the Heart, causing chest pain, heart pain, and pain in the shoulder along the Heart channel; palpitation and insomnia also occur. A point of distinct tenderness is typically found along the Heart channel, especially at HT-3 Shaohai. Needling or even simple massage at this point can greatly relieve the chest, heart or shoulder pain.

Anger may cause dysfunction of the Liver, impeding its free flow of Qi, and leading to a condition of stagnation of Liver-Qi. In TCM anger in fact includes other emotions such as frustration and irritation, which also may cause disharmony of the Liver leading to stagnation of Liver-Qi. Liver-Qi stagnation gives rise to symptoms such as headache, hypochondriac pain and distension, depression, abdominal pain and distension, and low back pain. Such pain is characterised by being wandering and distending in nature, or intermittent, or fluctuating in intensity and location. Another characteristic is that the pain often occurs at times of strong emotion, especially anger, stress, nervousness or irritability.

Stagnation of Liver-Qi can also be traced to emotions arising from being mistreated during childhood (e.g. from being beaten, lack of love, limitation of freedom, sexual abuse, or difficulties with friends, parents, brothers or sisters). Stagnation of Liver-Qi originating in childhood may cause either conscious or subconscious blockage in the Liver, bringing on pain at a later date due to severe psychological and physiological problems.

The Liver is in charge of promoting Qi circulation both in the Liver itself and generally in the body. If there is Liver Qi stagnation, the Liver fails to maintain the free flow of Qi in the channels, muscles, and Zang-Fu organs as well. The consequences can be summarised as follows.

BLOOD STAGNATION

Because Qi is the commander of the Blood, Qi circulation leads to Blood circulation, and Qi stagnation causes Blood stagnation. Hence, Liver-Qi stagnation may finally bring about Blood stagnation, which results in a more severe pain, stabbing pain, or a constant pain with fixed location.

GENERATION OF LIVER-FIRE

Prolonged Liver-Qi stagnation may also generate Fire, leading to flaming up of Liver-Fire, and symptoms such as headache, painful ears or painful eyes. A further development of this is hyperactivity of Liver-Yang, which can develop into internal stirring of Liver-Wind which causes severe headache, facial pain, neck pain, or stiffness of the neck.

If Liver-Fire persists it eventually can consume the Yin of the Liver, and even the Yin of the Kidney, resulting in failure of the Liver and the tendons to be nourished, and consequently in hypochondriac pain, tiredness, headache, muscle pain with cramp, dizziness, constipation, or abdominal pain.

When there is Liver-Yin deficiency, the Yang of the Liver will not be properly controlled, leading to hyperactivity of Liver-Yang; thus a mixture of Deficiency and Excess appears, which is not easy to deal with.

ABNORMAL BILE CIRCULATION

Bile is stored in the Gall Bladder, but its formation depends on the normal circulation of Liver-Qi. Once Bile is formed it must be distributed, with the help of Liver-Qi, into the Stomach and Intestines in order to help the digestion. However, if there is Liver-Qi stagnation there is either insufficient Bile secretion or abnormal bile distribution, so the digestion is disturbed, leading to stomach pain, belching, abdominal pain and distension, or constipation, etc. resulting from the dysfunction of the the digestive action of the Stomach and Intestine.

DYSFUNCTION OF SPLEEN

To produce Qi and Blood, the Spleen also needs the help from the Liver, as the latter maintains the free circulation of Qi not only in the Liver itself, but also over the whole body. Without Liver-Qi circulation, the Spleen would find it impossible to maintain its physiological function of transportation and transformation. Where there is stagnation of Liver-Qi, there could also be stagnation of Spleen-Qi. In this situation the Spleen cannot transport and transform food and water, and excessive water forms in the body, causing pain resulting from blockage of the Zang-Fu organs, channels, joints and muscles by Damp-Phlegm. Moreover, Liver-Qi stagnation often attacks the Spleen, leading to formation of so-called disharmony between the Liver and Spleen; this manifests in symptoms such as abdominal pain, loose stool or diarrhoea when nervous, or flatulence.

BLOCKAGE OF THE CHANNELS

Liver-Qi stagnation is one of the direct causes of stagnation of circulation in the channels generally. In addition, stagnation of Blood and formation of Damp-Phlegm may also impede circulation in the channels; in such cases blockage occurs in the channels, followed by numbness, pain, diminished skin and muscle sensitivity, joint pain, etc.

EXCESSIVE GRIEF AND MELANCHOLY

These may cause dysfunction of the Lung, leading to Qi and Blood stagnation in the Lung and its channel. The symptoms of this include: chest pain, shoulder pain and throat pain, accompanied by cough, difficulty in breathing out, and a sensation of oppression across the chest area.

Dysfunction of the Lung may also cause shoulder pain, which occurs in the interior aspect of the shoulder, down the biceps muscle. Patients with such pain often admit that they might have experienced enormous grief prior to the onset of the pain. Points of tenderness along the Lung channel may be found at LU-I Zhongfu, LU-2 Yunmen, LU-3 Tianfu, LU-4 Xiabai, LU-5 Chize and LU-6 Kongzui.

EXCESSIVE MEDITATION

This brings about Qi stagnation in the Spleen and Stomach, leading to dysfunction in the functions of transportation and transformation. This may cause the following four kinds of pathological changes.

PAIN

Types of pain include epigastric pain, abdominal pain and distension with fullness, and pain that is worsened after eating.

DEFICIENCY OF Ql AND BLOOD

This may cause failure to nourish the Zang-Fu organs, muscles, joints and channels.

FORMATION OF DAMP-PHLEGM

Damp-Phlegm may block the Zang-Fu organs, joints, muscles and channels. Slowing the circulation of Qi and Blood, and causing pain, swelling and numbness of muscles and joints accompanied by a heavy feeling, limitation of movement and lassitude.

ATTRACTION OF EXOGENOUS DAMP INVASION

If Damp-Phlegm accumulates in the body then it is vulnerable to External Damp invasion, leading to aggravation of the pain, and complications in treatment.

EXCESSIVE FRIGHT MAY CAUSE SUNKEN QI OF THE KIDNEY

Fright or shock gives rising to a failure of the Kidney to distribute the Kidney-Essence, which in normal circumstances produces the Marrow and nourishes the Bones. Weakness of the knees and lower back, dizziness, tinnitus and other symptoms can be the result. Of course, this type of lower back pain is not often seen in practice.

From the above account, it can be concluded that it is insufficient simply to use the method of circulating the channels to treat the various kinds of pain associated with certain emotions. It is also necessary to use the method of smoothing the emotions and regulating the organs.

Miscellaneous pathogenic factors

INAPPROPRIATE FOOD INTAKE

Food is the main material from which human beings receive energy, Qi and Blood; even Kidney-Essence needs to be nourished continuously from food. Inappropriate food intake comprises three aspects: overindulgence, insufficiency and intake of unsanitary food.

In industrialised countries, insufficient food intake normally is now seldom seen; overindulgence or intake of unsuitable or unsanitary food, however, is much more common. Generally speaking, insufficient food intake causes pain of the Deficient type resulting from failure to nourish the body, joints, muscles or Zang-Fu organs. In contrast, overindulgence and intake of unsanitary food often cause pain of the Excessive type resulting from blockage of the Zang-Fu organs, meridians, joints and muscles from Qi and Blood stagnation or Phlegm and Damp accumulation.

OVEREATING OF RAW AND COLD FOOD, OR DRINKING ICE-COLD DRINKS

Raw food, cold food and cold water are Yin in nature. Generally speaking, Westerners eat far fewer vegetables than do Chinese people; moreover, many like to eat them raw, whereas Chinese people usually don't like to eat their vegetables uncooked, but rather steamed or oil-baked, for instance. In addition, in hot weather Westerners prefer to drink cooled water from the refrigerator, or even with a few pieces of ice in the glass. This is not good for the health, according to TCM, because the Spleen organ 'dislikes' cold and raw food, as it needs to spend more energy to first warm it before digesting it, compared with warm or cooked food. If Spleen, day after day, year after year, has to do this extra work, the Spleen-Yang eventually becomes impaired, causing inhibition of its functions of transportation and transformation, and Phlegm-Damp develops as a consequence. Once this is formed, it may spread throughout the body together with the Qi and Blood, causing, for instance, blockage in one of the Zang-Fu organs, or the joints, muscles or channels; Qi and Blood circulation are impeded and, as a result, pain occurs. Overeating of raw or cold food and drinking cold water is a common cause of the formation of Cold-Damp, or Cold-Phlegm.

One more fact that needs to be mentioned is that inappropriate use of some medicinal drugs or herbs may also sometimes cause damage of the Spleen and Stomach leading to formation of Cold Damp-Phlegm. In clinical practice it is often seen that some patients, and especially children, suffering from Spleen-Yang deficiency have been taking antibiotics for too long or too often frequently. People who often use Heat-clearing herbs for their Heat syndromes may also eventually damage their Spleen and Stomach-Yang. AU these habits finally bring about dysfunction of the processes of digestion, transportation and transformation of the Spleen and Stomach, resulting in the development of Cold-Damp.

Addition of too much salt to food is another important pathogenic factor. This practice damages the Kidney. A certain amount of salt intake in the food is necessary for the functioning body, especially for the Kidney, because according to TCM a salty taste goes into the Kidney and can disperse Qi and promote defecation. However, overuse of salt will impair the physiological function of the Kidney—that of Qi transformation and water metabolism. As a result, Excessive Water accumulates in the body, leading to pain in the limbs and body, oedema, and a feeling of heaviness in the body generally.

OVEREATING OF FATTY AND FIERY FOOD AS WELL AS DRINKING HEATING BEVERAGES

In the West, many people have a tendency to be too Yang, probably because of the following factors:

•    constitutional Yang excess or Yin deficiency from the parents

•    depletion of Liver-Yin and Kidney-Yin due to too much sex, overworking, too much excitement or too much stress

•    too much consumption of warming meats (e.g. pork, lamb, beef or rabbit)

•    too much drinking of milk and eating milk products, such as cheese

•    eating of too much sweet food (e.g. sweets, biscuits and chocolate)

•    too-frequent consumption of fiery food (e.g. too much application of pepper in the cooking)

•    too-frequent consumption of wine or other warming alcohol.

According to TCM theory, the constitution of the parents is largely passed on to the next generation. Constitutional Yang Excess leads to a predisposition to many diseases, and can also predispose to the invasion of External Heat, leading to the development of a mixture of Internal Heat and Exogenous Heat.

Alcohol that is warm or hot in nature can overload the Spleen and Stomach, leading to impedance of their functions of transportation and transformation, and a condition of Phlegm-Heat subsequently develops. Both white wine and red wine are equally warming by nature. However, drinking a certain amount of rice wine from time to time is healthy for the Qi, and specially the Blood, circulation—which is why there are a lot of herbal formulas to be taken at the beginning of winter that need to be decocted in a little wine, or soaked in wine. Rice wine, according to TCM, warms the interiors, dispels Cold, resolves stagnant Blood, smoothes the channels and circulates the collaterals. Many diet therapists also prescribe 10 to 20 ml of wine every day for people suffering from Qi and Yang deficiency. However, it is not advisable to give wine to people with Yin deficiency, Yang Excess, Damp-Heat accumulation, etc.

In addition, prolonged use of some pharmaceutical drugs, such as corticosteroids, may also deplete the Yin of the body, specially that of the Lung, Spleen, Liver and Kidney, leading to the concentration of Body Fluids, and the development of sticky Phlegm, which in turn would cause stagnation of Blood in the body.

INADEQUATE FOOD INTAKE

An adequate amount of food is necessary to maintain health. Eating too little food may cause malnutrition, causing pain due to undernourishment of the body. Inadequate nourishment can be caused by dysfunction of the Spleen and Stomach; this may be the result of prolonged sickness, or of undereating because of financial shortage or being on a weight-reducing diet. Of course, if it is due to prolonged sickness, different methods should be used to treat the sickness. People who have a financial shortage may need to be helped or given advice to enable them to get enough food. However, nowadays more and more people in the West, specially women, desire to become or remain slim merely by following a strict diet, ignoring inherited differences. Of course, if the overweight were purely caused by overconsumption of food and drink then a fairly strict diet would be one of the best methods to reduce the weight. However, if the cause is Spleen-Qi deficiency, causing weakness of transportation and transformation, such diets can only aggravate this deficiency, as a Damp condition would constantly be precipitated, tending to increase the weight. Once Damp blocks the channels, joints, muscles and Zang-Fu organs, pain also occurs.

INTAKE OF UNHYGIENIC FOOD

Unhygienic food includes not only poisonous food, food that has deteriorated and allergenic food, but also other contaminated food. Although it is not so difficult to avoid the first of these, it is not easy to avoid all contamination. Indeed, with industrial development, these days one can say that pollution exists everywhere—in the air, water and earth. Pollution can also be caused by nuclear weapon testing and use. So the food we eat naturally will sometimes be contaminated. Eating food with traces of contaminants disturbs the physiological functions of the Spleen and Stomach, leading to the development of Damp and Toxin accumulation, which may spread with the Qi and Blood circulation everywhere in the body, causing disorders in other Zang-Fu organs, and in the channels, joints and muscles. Generally speaking, food poisons and pollution first attack the Spleen and Stomach, and because the Spleen dominates the muscles and the limbs, pain from this cause usually occurs in the muscles and the limbs.

Drugs and hormones may be given to farm animalsso as to promote their growth and shorten their developmental period. Eating the meat from such animals can, of course, disturb the person's Spleen, Stomach and especially the Kidney. So this inhibits the physiological function of these organs in transportation and transformation of water, and as a consequence Damp-Phlegm develops. That is why people who frequently eat such meats tend to suffer from body swelling, overweight, body pain, and so on.

OVERSTRESS, OVERSTRAIN OR LACK OF PHYSICAL EXERTION STRESS

In addition to the emotions mentioned earlier, too much stress is also a causative factor in many diseases. In the industrialised countries many people work and live under enormous stress. This could include stress in any of the areas of social and work relationships, sexual relationships, family relationships, living conditions, finances, etc. According to TCM, stress may cause the following disorders:

•    stagnation of the Qi of the Heart, Lung, Liver and Spleen, eventually leading to stagnation of Blood, which is a common causative factor in various kinds of pain

•    depletion of the Qi and Yin, specially the Yin of the Liver and Kidney and the Qi of the Kidney.

This is the causative factor that can cause pain due to deficiency of Qi and Yin, leading to undernourishment of the body.

PHYSICAL EXERTION AND EXERCISE

According to TCM theory, normal and regular physical exercises, combined with adequate rest, are very important for health, because they build up the constitution and help prevent disease. However, overstrain or excessive exercise, or indeed any excessive physical or mental activity, may deplete the energy generally, including the Qi, Blood, Yin and Yang, leading to weakening of the body's Defensive Qi. This leaves the body more vulnerable to the invasion of Exogenous factors, and to dysfunction of the Zang-Fu organs. For instance, overstudy will deplete the energy in the brain. Since according to TCM the brain substance is formed from the Marrow, which derives from the Kidney-Essence, if there is mental exhaustion then the Kidney-Essence will in turn gradually be depleted, leading to lack of nourishment of the brain and lower back and symptoms such as headache and lower back pain follow. This is the reason why many intellectuals and students suffer from chronic headaches and lower back pain even if they are very conscientious about the degree of physical exertion and sexual activity they undertake. In addition, overheavy labour or making the same physical movements for long periods may lead to weakness and strain of the muscles and tendons in the locality; Qi and Blood circulation will also be impaired. For example, builders often suffer from low back pain due to frequent lifting of too-heavy loads, and players of some sports suffer overexertion of their elbows, causing 'tennis elbow'.

The other extreme, of too little exertion, or living an excessively comfortable life with lack of physical exercise, can also be a causative factor in pain. According to TCM, this is because these habits may:

•    slow down the Qi and Blood circulation

•    weaken the functions of the Spleen and Stomach

•    soften the muscles, tendons and bones.

All these effects may eventually cause Qi and Blood to stagnate, leading to the development of Damp, weakness in the tendon and bones, etc., and finally the appearance of pain. This situation can be seen in, for example, some people on benefits and old people who may suffer from general body pain that is made worse by more rest and sleep. Once they are advised to take some moderate physical exercise (such as slow walking, running, swimming, as well as light physical work) their pain tends to improve. The reason for this is that once they start to exercise, their Qi and Blood circulation improves, which stimulates the physiological function of the Zang-Fu organs, and the pain then diminishes. Pain caused by too little exertion can typically be seen in patients who lie for too long in bed without enough movement; their limbs can become swollen and purplish in colour, and stiff and painful as muscular atrophy occurs, accompanied by stabbing or contracting pain. As soon as they begin to walk, or even do some physical movements while seated, the muscular atrophy gradually disappears, the stiff joints becomes freer and flexible, and the pain often vanishes by itself, or with the help of some simple treatment.

TRAUMATIC INJURIES

Traumatic injuries include gunshots, penetrating knife wounds, beating, falling, accidents, scalds, bums, frostbite, muscular sprain caused by sudden or frequent lifting or carrying too-heavy loads, bites by animals or insects, and so on.

WOUNDS AND JOINT INJURIES

Gunshots, incision by knives, beating, falling, accidents, etc., may directly result in muscular swelling, bleeding and haematoma, or joint dislocation or fracture involving the tendons, muscles and bones. There may also be damage to the internal Zang-Fu organs, and shock following on from sudden and severe pain.

BURNS, SCALDS AND FREEZING CONDITIONS

Scalds and bums may result from industrial chemicals, boiling water or oil, or fires. If only the superficial layer of the skin is affected then tissue damage may be confined to redness, swelling, heat and blisters, and pain will be severe. However, if scalds or bums are severe, the tendons, deep muscles and even the bones can be damaged, the pain will not necessarily be worse: once the nervous tissue is burned as well, the patient will not feel any pain.

Frostbite may also cause damage of the skin, muscles and even tendons, leading to severe pain. This often occurs in locations where the winter temperatures are very low. Frostbite may affect only the limbs, or the body generally, often attacking those who tend to have deficiency of Yang Qi with poor Blood circulation. In consequence, the body is not sufficiently warmed and protected, and Qi and Blood stagnation develop, causing contraction of the tendons, blood vessels and muscles, and pain develops.

SPRAINS

Muscle contraction or sprain due to sudden or quite frequent lifting or carrying too-heavy loads is also a common cause of pain, especially in the limbs and lower back. It leads to disorder of Qi and Blood circulation, damage to the tendons and muscles, abnormal joint movement, and hence to an alteration in the body's physical structure; this causes Qi and Blood stagnation, and pain follows. The longer stagnation of Qi and Blood persists, the more complications are seen.

OPERATIONS

Operations can be also be causative factors in pain. In the West, operations are carried out in all hospital departments, most of the time they have positive results, but sometimes the operation is a failure, or may even aggravate the problem. In any event, the operation often necessitates cutting through tissues, so almost inevitably there is some bleeding during the operation, and some blood may be left behind in the body, leading to the development of Blood stagnation.

According to the TCM viewpoint, pain after an operation can be caused by:

•    disturbance of the Qi and Blood circulation

•    a deleterious effect on the physiological functions of the Zang-Fu organs

•    damage to or even complete blockage of channel circulation

•    the persistence of excessive amounts of blood in the body from bleeding during the operation, which then becomes stagnant

•    scar formation.

Pathology of pain

The main pathology: disorder of Qi and Blood circulation

From the above discussion, it can be clearly seen that there are various kinds of causative factors bringing about pain, but the main pathology is either due to blockage and obstruction, or to deficiency. The basic statement about pain, formed almost two thousand years ago, is: if there is free flow, there is no pain; however, if there is a disruption of this free flow then pain occurs. Here 'free flow' refers to the free flow of Qi and Blood. The circulation of Qi and Blood in the body should be constant, just like the continual courses of the sun and moon. According to TCM, this circulation depends upon the correct, interdependent functioning of the Ziang-Fu organs, including the Lung, Heart, Liver and Kidney. The Lung disperses Qi to every part of the body, and also connects to the blood vessels, thus keeping the Qi and Blood circulating freely in the body. The Heart is in charge of promoting the circulation of Blcxxi in their Vessels. The Liver is in charge of keeping the Qi circulating freely, which in turn keeps the Blood circulating freely. The circulation of Liver-Qi also promotes the digestive functions of the Spleen and Stomach, and this keeps the water passages clear, so preventing the accumulation of Damp in the body. The Kidney is the root of Yang Qi, which warms the Qi and Blood to maintain their free circulation. Moreover, the Kidney also produces Yuan Qi or Original Qi, which is the root energy for all the Zang-Fu organs. Where there is dysfunction of any of these organs, due to the various kinds of pathogenic factors discussed earlier, there will be retardation of the Qi and Blood circulation, eventually causing pain.

Mechanisms in the disorder of Qi and Blood circulation

DISORDER OF QI AND BLOOD CIRCULATION DUE TO EXOGENOUS FACTORS

The mechanisms causation of the disorder of Qi and Blood circulation vary according to the nature of the pathogenic factor.

When Wind, Heat and Fire, the Yang pathogenic factors, invade the body they accelerate the circulation of Qi and Blood creating an abnormal circulation and local congestion of Qi and Blood. This may cause blockage in the Qi and Blood circulation, and so pain develops.

Cold, a Yin pathogenic factor, may damage the Yang of the body, so that Excess of Yin and Cold develop in the body. Cold is characterised by Stagnation and contraction, so when Cold and Excess Cold invade the body there is a decreased Qi and Blood circulation and also spasm of the channels and Blood Vessels. This slows the circulation of Qi and Blood, and pain eventually results.

Damp is characterised by stagnation and viscosity. The presence of Damp, whether caused by Exogenous invasion or by dysfunction of the Internal Zang-Fu organs, may slow the Qi and Blood circulation because the channels and Blood Vessels become narrowed, or there may even be Qi and Blood stagnation.

Dryness may damage the Lung causing failure of the Lung to disperse the Qi and Body Fluids. As a consequence the channels and blood vessels are not properly nourished, the Qi and Blood circulation slows, and so pain follows.

DISORDER OF THE QI AND BLOOD CIRCULATION DUE TO EMOTIONAL DISTURBANCE

Emotional disorder may cause direct dysfunction in the Zang-Fu organs, disturbing in turn the Qi and Blood circulation, so that the Qi and Blood stagnate, and pain follows.

Excessive grief may slow the Qi circulation in the Lung, so the Lung cannot properly disperse the Qi and Body Fluids; this causes both stagnation of Qi and Blood and formation of Damp, and pain develops.

Too much anger, frustration, anxiety and stress may prevent the Liver from maintaining a free Qi circulation through the body, and stagnation of Qi as well as of Blood occur, as a consequence. In addition, Qi stagnation in the Liver may cause stagnation of Qi in other organs such as Lung, Heart and Spleen, leading to Blood stagnation and accumulation of Damp as well. AU these situations bring about pain.

Too much meditation may cause the Qi in the Spleen to stagnate, disturbing the transportational and transformative functions of the organ, and so Damp accumulates, or Qi and Blood become deficient, any of which which may result in pain.

Fear and fright may impair the Kidney, leading to sinking of the Qi there; as a consequence the original Qi becomes weak, so it cannot properly promote Qi and Blood circulation in the body, and the Qi and Blood circulation slows.

TCM also holds that the Heart stores the Mind, and a person's emotional states are a reflection of mental stimulation caused by the External environment, thus the Heart will be affected by all kinds of emotional activities.

DISORDER OF QI AND BLOOD CIRCULATION DUE TO BAD DIET, PHYSIC TRAUMA AND ANIMAL BITES

Bad diet may disrupt the ascending and descending of Qi in the Middle Jiao, or Middle Burner. This can lead to a slowing down in the Qi circulation, thus Qi stagnates, and pain will be the result. A bad diet may also make the Qi and Blood deficient, or cause Damp to develop in the body. The former may cause undernourishment of the Zang-Fu organs, channels, muscles, tendons, bones and Blood Vessels, and as a result pain of a deficient type may occur. The latter may cause the channels and Blood Vessels to narrow, leading in turn to stagnation of the Qi and Blood. Physic trauma and bites by animals may cause direct injury to the muscles, tendons, bones, channels, and even Internal Zang-Fu organs, also leading to stagnation of Qi and Blood, or damage to body tissues.

DISORDER OF QI AND BLOOD CIRCULATION DUE TO IMPROPER EXERTION

Overstrain, overindulgence in sex and excessive study may all exhaust the Qi and Blood, leading to their deficiency; thus pain occurs caused by undernourishment of the body. Too little physical exertion and living too luxuriously may also slow the Qi and Blood circulation, leading to pain resulting from a gradual stagnation of the Qi and Blood.

An explanation for pain resulting from disordered Qi and Blood circulation

It should now be clear that pain is mainly a result of disturbances in the Qi and Blood circulation, and may be caused by stagnation of Qi and Blood, or deficiency of Qi and Blood—but why does this disturbance of Qi and Blood flow cause pain? Which organ is in charge of pain? The reason was stated clearly, two thousand years ago, in the Simple question: 'all kinds of pain, itching and sores are due to Heart disorder' (Yellow Emperor's Classic of Internal Medicine: Simple Questions 1956, p. 190). Why did the ancient texts attribute pain to the Heart? This can be explained as follows.

THE HEART DOMINATES THE BLOOD AND BLOOD VESSELS

The Heart promotes normal Blood circulation in the Zang-Fu organs, Blood Vessels, channels and the tissues. Where the Qi and Blood circulation are disordered, a disturbed feedback will be sent to the Heart. In other words, one can say that the Heart is constantly sensitive to the condition of the Qi and Blood circulation.

THE HEART IS THE CONTROLLER OF THE MIND

Modem medicine considers that pain is the body'sway of responding to damaged tissue. For instance, when a bone breaks, nerves send pain messages through the spinal cord to the brain, where they are interpreted. TTie TCM viewpoint is that pain is the reflection of the Mind (Shen) to the stimulation from the environment, and the activity of the Mind is considered to be the result of physiological function of the Heart. When the Qi and Blood circulation are disturbed, this situation will be conveyed to the Heart, and the pain that follows is a response from the Mind to this situation. According to this viewpoint, pain is closely related to the Heart.

THE HEART IS THE ROOT CONTROLLER OF THE OTHER ZANG-FU ORGANS

How a person responds to pain is determined by many factors, of which emotional states are very important. For example, depression seems to increase a person's perception of pain and to decrease the ability to cope with both the pain and the treatment. Thus treating the depression treats the pain as well. If pain is not adequately treated, then pain impulses are more readily transmitted to the brain. Therefore, in TCM it is considered that it is more effective to prevent pain than to treat it after it occurs.

In terms of the relationship between the emotions, the interior organs and the Heart, TCM holds that the Heart dominates the emotions and is the root controller of other Zang-Fu organs. For instance, Ling Shu (1963) states: 'the Heart is the root controller for five Zang organs and six Fu organs, therefore the Heart will be disturbed by grief and meditation' (p. 69). The same topic points out that: 'the Heart has the responsibility to all kinds of emotional stimulation' (p. 23). AU these statements clearly mention that the Heart can be influenced by the dysfunction of other Zang-Fu organs as well the difference emotions, and this may lead to the development of pain.

Selection of acupuncture points

Acupuncture treatment consists of the application of a few points at specific places on the body. Thus, the selection and combination of points in an acupuncture treatment is most important. Since selection of points along the channels is guided by the theory of Zang-Fu organs and channels, it is essential for practitioners to have a full understanding of the following so as to be able to choose the correct points:

•    physiology and pathology

•    the course of the channels

•    the Exterior-Interior relationship of Yin and Yang

•    the function, and difference and characteristics of the points.

Selection of points along the course of the channelsis one of the basic principles of acupuncture treatment, and is performed according to the theory that disease is related to channels. In practice the points are selected from the channel to which the affected organ is related; or from related channels according to the relations between the Zang-Fu organs and channels; or from several channels.

There are three principles for point selection: local point selection in the vicinity of the pain, distal point selection and symptomatic point selection. Each may be used in combination, or independently of the others.

Local point selection

This is the selection of points in the locality of the pain—for instance, pain in the head, forehead, neck or arm can be treated by using the points in the vicinity. In cases of elbow pain, LI-Il Quchi and LU-5 Chize can be selected to promote the circulation of Qi and Blood in that region; CV-12 Zhongwan can be selected to treat epigastric pain; GB-20 Fengchi can be chosen to treat headache and neck pain in the occipital region.

This method also includes selection of adjacent points close to the pain. For instance, ST-21 Liangmen can be used as an adjacent point to CV-12 Zhongwan to treat stomach pain; Ll-IO Shousanli can be used as an adjacent point to LI-Il Quchi to treat painful elbow. Adjacent points may be applied independently or in combination with the local points.

Distal point selection

This is the selection of points far from the sides of pain, and usually below the elbow and knees. This method is often used to treat pain caused by disorder of Internal Zang-Fu organs; for instance, ST-44 Neiting and LI-4 Hegu are used to treat toothache due to Stomach-Heat.

Special point selection Stream points

It was stated two thousand years ago in the Neijing that Stream (Shu) points can be used to joint and limb problems. These points are indicated in painful joints, stiff joints, joint deformity, joint swelling as well as injury in the joints. Also, these points can also be used as inducing points to conduct the treatment to the affected parts of the limbs.

Source points

As the name implies, Source (Yuan) points are the points where the Original Qi resides. On the Yang channels, the Source points are the points just proximal to the Stream points. On the Yin channels, they are the same as the Stream points.

The Source points are said to be responsible for regulation of the Original Qi in both the interior organs and the channels, so they are used for the treatment of diseases that affect the organs, and problems in those channels. Generally speaking, Source points are really good only for blockage of the channels resulting from Excessive pathogenic factors. In this treatment, they are often applied together with the Connecting points. This is because the channels are subdivided into channels and collaterals, and whereas the Source points can regulate the channels, the Connecting points can harmonise the collaterals, thus both channels and collaterals are treated together.

Connecting points

The place where a Connecting Vessel splits from a main channel is called Connecting (Luo) point. Each channel has its own Connecting point—the 12 regular channels and two of the extraordinary channels, the Governing Vessel and the Directing Vessel—and there is in addition a Connecting point from the Spleen: the Spleen Connecting vessel. So, in total, there are 15 Connecting points.

Classically speaking, the Connecting points have two major applications:

•    they can be used in the treatment of Interior-Exterior coupled organ problems

•    they can also be used in the treatment of Connecting Vessel symptoms.

Since these points directly connect to the collateral,in fact they have a third function, which is to harmonise and promote the circulation in the collateral. It is true that not all diseases affect the channels and Interior organs. In a lot of cases, pathogenic factors may attack only the collaterals, especially in cases of pain at the superficial levels.

As was mentioned in Source points, when treating pain the Source points and Connecting points are often combined so as to regulate both the channels and collaterals.

Accumulation points

Accumulation (Xi) points (or Cleft points) are the place where Qi and Blood accumulate in the channels. These points are very important in dealing with pain, both in diagnosis and in treatment.

In terms of diagnosis, a sharp or intense pain on pressure, or redness, swelling, hardening, a tingling 'electric' feeling or the formation of nodulations indicate Excess, whereas a dull, mild, slight or intermittent pain indicates Deficiency.

In terms of treatment, these points are often used to treat stubborn and acute cases. In treating pain, these points are very effective in relieving pain involving the organs, channels or collaterals. Therefore, in some cases they can be punctured first of all, so as to sedate the pain as soon as possible. However, such treatment can only be considered as symptomatic—that is to say, it doesn't deal with the cause of the pain. A root treatment should be followed immediately after application of these points.

Eight Gathering points

The following eight points have special functions on the organ or substance for which they are named. They can be applied for pain originating from either Excess or Deficiency. They can in addition be used as the inducing points to lead the treatment to the affected areas.

BL-Il Dashu

This is the Gathering point for the Bones. In case of pain related to bone disorder, use of this point is advisable. For instance, in rheumatoid arthritis there is stabbing finger pain, bone deformity and swelling of the hand. Points should be used that promote circulation of the Blood, smooth the channels and sedate the pain. However, BL-Il should be added simultaneously in order to strengthen the bones.

GB-39 Xuanzhong

This is the Gathering point for the Marrow. This point is often applied to treat pain due to deficiency of Blood, since the Marrow produces Blood. Moreover, since the Marrow nourishes the Bones, thus this point is often combined with some other points to treat bone problems due to deficiency. For instance, lower back pain in senile people is commonly due to weakness of the Liver and Kidney, thus the points to tonify the Liver and Kidney should be used together with GB-39 in order to strengthen the bones. It is clear to see that this point is indicated only in chronic cases.

GB-34 Yanglingquan

This is the Gathering point for the Tendons. It is effective for treating pain in the Tendons originating from both Excessive and Deficient causes. For instance, in the treatment of sciatica, no matter the cause, this point should be coupled with the local point and distal points to eliminate pathogenic factors and relieve the pain. In treating acute ankle sprain, which is usually caused by stagnation of Blood in the channels, this point should be punctured first to relieve the pain, followed by needling at local and distal points to eliminate Blood stasis.

CV-17 Tattzhong

This is the Gathering point for the Qi. This point is mostly used to treat general stagnation of Qi or stagnation of Qi in the chest, Lung, Heart or Liver. So it is clear to see that this point is usually not indicated in deficiency of Qi.

BL-17 Geshu

This is the Gathering point for the Blood. It is indicated in both deficiency of Blood and stagnation of Blood. Also this point is very effective for clearing Heat in the Blood, and is indicated in the generation of Heat caused by over-to-long Blood stagnation, or invasion of Blood by Excess-Heat or Deficient-Heat.

LU-9 Taiyuan

This is the Gathering point for the vessels. Generally speaking, this point is often indicated in pain due to stagnation of Blood in the vessels.

LR-73 Zhangmen

This is the Gathering point for the Zang organs. It is indicated in pain due to disorder of the Zang organs. Of course, it should be be used together with other points to treat the affected organs. For instance, in treating pain due to Damp resulting from weakness of the Spleen, LR-13 can be applied in combination with SP-3, SP-9 and ST-40 to activate the Spleen and resolve the Damp.

CV-12 Zhongwan

This is the Gathering point for the Fu organs. This point has the function of promoting the digestion and transportation functions in the Fu organs. However, it is particularly indicated in pain due to disorder of Stomach and Large Intestine.

Front Collecting points

The Front Collecting (Mu) points are those points that are located on the chest and abdomen where the channel Qi collects. Each Zang-Fu organ has a Front Collecting point. These points can be found directly above or near to the organ to which they are related. Generally speaking, when there is disorder of the organ, there can be found some pathogenic reaction at these points, including tenderness, lumps, hardening, redness, blistering, a hot feeling, depression and swelling. Thus the Front Collecting points can be used for diagnostic purpose to determine whether there is disorder of the interior Zang-Fu organ, or of the channels.

The Front Collecting points can also be used as therapeutic points. In this case, they should be combined with other points to treat the root causes.

Mother-Son points

This is the method expounded in the Nanjing (c. ad 198, new edition Nanjing College of Traditional Chinese Medicine, 1979) based on the combination of the theory of the Five Elements and the nature of internal Zang-Fu organs. In the treatment, the Mother points should be tonified in cases of deficiency of the interior organs, and the Son points should be reduced in cases of Excess in the Interior organs. For instance, the Lung corresponds to Metal. According to Five Element theory, Metal produces Water, so the Water point from the Lung channel is the Son point; this is LU-5 Chize. Thus, in cases of Excess in the Lung, LU-5 should be needled using the reducing method. Furthermore, according to the Five Elements, Earth is the mother of Metal, so LlJ-9 (the Earth point) is the Mother point. In cases of deficiency, LU-9 Taiyuan should be needled using the tonifying method.

Back Transportingpoints

Although the Back Transporting (Shu) points are located on the Bladder channel, they are also the places where Qi passes through all named organs. These points can be used to diagnose and to treat the organ with which they are associated. Disorder of an Interior organ can be detected by finding tenderness, swelling, hardening, blister, or some other abnormality when palpating on the corresponding point. For instance, Liver disorder can often be detected by palpating at BL-18 Ganshu; in most cases, there is tenderness, hardening or discoloration. This point can also be needled to treat disorder of Liver. The Back Transporting points are indicated in pain due to disorder of Interior organs rather than superficial complaints on the channels, skins, muscles and tendons resulting from invasion of External factors.

The four Command points

The Command points govern particular parts of the body. They include the following:

•    ST-36 Zusanli commands the abdomen

•    LI-4 Hegu commands the head, face and mouth

•    LU-7 Lieque commands the head and neck

•    BL-40 Weizhong commands the back of the body.

These points are selected when the parts of the body they command are involved in the problem. Thus they can be leading points to bring the treatment to certain parts of the body. However, they can only be applied together with other points to treat the root causes.

Eight Confluence points

The eight Confluence points are located on the limbs; each is linked with one of the eight extraordinary channels. They are: PC-6, SP-4, TE-5, GB-41, LU-7, KI-6, SI-3 and BL-62. These eight points are very important in the treatment of pain. These eight Confluence points can also be considered as the opening points and leading points of the extraordinary channels. In practice, they can be subdivided into four groups:

PC-6 Neiguan and SP-4 Gongsun. These are indicated in Heart pain, Stomach pain and chest pain. When these two points are combined, they can regulate Qi and Blood in the Heart, Stomach and chest. They can also regulate the Penetrating Vessel (Chong Mai) and cause the Qi to descend, and are indicated in belching, acid regurgitation, nausea, vomiting, and uprising of Qi from the abdomen to the chest.

SI-3 Houxi and BL-62 Shenmai. These are indicated in pain at the inner canthus, pain at the back of the neck, ear pain, shoulder pain and back pain caused either by invasion of External factors, or disorder of the Internal Zang-Fu organs. They are used only to treat pain at places where covered by the Greater Yang channels.

Since this combination can open the Governing Vessel, it is widely used to treat all kinds of back pain due to blockage of this channel.

TE-5 Watguan and GB-41 Zulinqi. These are indicated in pain at the outer canthus, pain behind the ear, cheek pain, and pain at the side of the neck or shoulder. This combination is specially indicated in pain on the sides of the body due to invasion of external factors or stagnation of Liver-Qi and disharmony of the Gall Bladder.

LU-7 Lieque and KI-6 Zhaohai. These are indicated in chest pain, throat pain and pain at the epigastric regions. Generally speaking, this combination is very effective for treating chronic pain above the waist resulting from deficiency of the Yin of Lung and Kidney.

Six Lower Sea points

Each of the three Yang channels of hand and three Yang channels of the foot has a Lower Sea (He) point around the knee. They are:

•    ST-36 Zusanli for the Stomach

•    ST-37 Shangjuxu for the Large Intestine

•    ST-39 Xiajuxu for the Small Intestine

•    GB-34 Yanglingquan for the Gall Bladder

•    BL-40 Weizhong for the Bladder

•    BL-39 Weiyang for the Triple Burner.

Actually, these six Lower Sea points are a kind of symptomatic treatment points. They are usually used in combination with the corresponding Front Collecting or Back Transporting points. For instance, in cases of abdominal pain due to accumulation of Excess-Heat in the Bright Yang Fu organs manifesting as abdominal pain, constipation, thirst, a large appetite, a foul smell in the mouth, a red tongue with a yellow and dry coating and a rapid and forceful pulse, ST-37 should be applied together with ST-25 Tianshu, ST-40 Fenglong, ST-44 Neiting and LI-Il in order to clear the Heat, drain the Stomach and Large Intestine and sedate the pain.

Ah Shi points

Since these points are especially sensitive to palpation and pressing, they usually reveal blockage or disorder of channels or Interior organs. However, the practitioner should remember that a discovery of a sensitive Ah Shi point doesn't mean the problem is only in the locality, as it can also reflect some disturbance at a distal place or an Interior organ. Moreover, Ah Shi points can be used only as the symptomatic treatment. They have to be used in combination with other points that treat the root causes.

Symptomatic point selection

Selecticm of local and distal point is based upon the distance of the points from the site of the pain; however, some diseases are not local but systemic in nature, and can be treated at those points that have long been associated with relieving a particular disease. Such points include the eight Confluence points and the six Lower Sea points.

Certain individual points have also traditionally been found useful for treating specific symptoms. For instance. GV-14 Dazhui is used for reducing fever, GV-26 Renzhong for reviving unconscious patients, PC-6 Neiguan for relieving nausea and vomiting, ST-40 Fenglong for eliminating Damp-Phlegm in the body and ST-36 Zusanli for activating the Spleen and tonifying the Qi and Blood.

Combination of points

In addition to the method of individual point selection outlined above, there are several traditional methods of combining one point with another in an acupuncture prescription. These techniques are flexible, permitting much variation according to the particular needs of the case.

Combining local points and distal points

This method is the most popular in everyday practice. In this, a point (or points) at or near the place of the diseases (the local point(s)) would be combined with distal points that are traditionally considered to have an effect on the disordered area. For example, in Stomach disease, the local points CV-12 Zhongwan and ST-21 Liangmen, and the distal points PC-6 Neiguan and ST-36 Zusanli could be used together.

When treating pain, the practitioner is advised to use a greater number of distal points to treat acute pain, and a greater number of local points to treat chronic pain.

Combining points on the front with points on the back

The front includes both the chest and abdomen, and the back includes both the back and waist. In this method, points on both the front and back appropriate to a particular disease are used in combination. It employs simultaneous use of the Front Collecting points and Back Transporting points to increase the therapeutic effect of both. For instance, in Spleen disease, both LR-13 Zhangmen on the front and BL-20 Pishu on the back can be needled in tandem. This method of point selection is often used to treat pain due to Internal Zang-Fu organs. If, in contrast, pain is caused by channel problems, for instance channels blockage, symptomatic point selection is more often carried out.

Combining points on the Yang channels and the points on the Yin channels

Each of the channels has a paired channel, and they form a Yin and Yang relationship. By combining a point on a Yang channel with another on its paired Yin channel, the practitioner can obtain a greater effect than if needling either point separately. Examples include: combining ST-36 Zusanli on the Stomach channel with SP-4 Gongsun on the Spleen channel for Stomach disease, or combining LU-9 Taiyuan on the Lung channel with LI-4 Hegu on the Large Intestine channel for cough. The most well-known combination of this kind is between the Source point on the channel primarily affected by a disease, and the Connecting point on the channel with which the first has a Yin-Yang relationship. In this combination, the Source point is called the 'host', and the Connecting point is called the 'guest'. For example, a disease affecting the Lung channel may be treated through that channel's Source point, LU-9 Taiyuan, in combination with the Connecting point of its Yang partner the Large Intestine channel, LI-6 Pianli. Conversely, a disease affecting the Large Intestine channel could be treated by that channel's Source point, LI-4 Hegu, together with the Connecting point of the Lung channel, LU-7 Lieque.

Combining points above with points below

'Above' refers to points on the arms and above the waist, and 'below' to points on the legs and below the waist. However, this method of point combination is mostly commonly practised on the limbs. For instance, in cases of Stomach disease, PC-6 Neiguan on the arm may be combined with ST-36 Zusanli on the leg. For sore throat or toothache, LI-4 Hegu on the hand can be combined with ST-44 Neiting on the foot.

Traditionally, a distinctive use of the above-below combination was made with respect to the confluence points of the eight extraordinary channels. A confluence point on one of these channels affected by a disease above would be combined with a confluence point on another extraordinary channel below. For example, diseases of the Heart, chest and abdomen are related to the Yin Linking channel and the Penetrating channel; therefore, PC-6 Neiguan, the Confluence point of the former on the arm (above), and SP-4 Gongsun, the Confluence point of the latter on the foot (below), are selected as a combination for needling.

Combining points on the left with the diseases on the right

Because channel points are bilateral, it is common to treat diseases of the internal organs by manipulating the same points on both sides in order to strengthen the effect. For example, ST-36 Zusanli on both legs can be needled to treat diseases of the Stomach. Furthermore, because the channels on the right side intersect with those on the left, a point on the right may be chosen to treat disease or pain on the left side of the body, and vice versa. For instance, in the case of hemiplegia, the practitioner may select not only a point on the side affected by the paralysis, but also the same point on the healthyjside.

Combining corresponding points

If the body is subdivided into upper and lower parts, it is clear to see that there is a correspondence between the upper and lower limbs. This implies that, for points on the shoulders, elbows, wrists and fingers in the upper limbs, there are corresponding points on the hips, knees, ankles and toes in the lower limbs— that is, there are points on the shoulders corresponding to points on the hips, elbows to knees, wrists to ankles and finally fingers to toes. Meridians in these corresponding places bear the same names, as Qi and Blood in these places can mutually influence each other.

By combining corresponding points the practitionercan treat painful areas by using points in the corresponding areas rather than in the painful area itself. For instance, in the treatment of shoulder pain along the Large Intestine channel, the practitioner can use the corresponding point from the channel that bears the same name on the hip (i.e. ST-30 Qichong), and vice versa. This method is especially indicated for treating most acute pain syndromes, and gives very good results. In some cases, if the pain is very localised and very acute, needling only one point can sedate pain. Attention should be paid here to diagnosis, as some cases of pain may have ruptured tendons or bone that are fractured or even broken. The following is a list of suggested corresponding points:

•    Shoulder to hip: HT-I Jiquan to KI-Il Henggu, PC-2 Tlanquan to LR-12 Jimai, LU-2 Yunmen to SP-12 Chongmen; LI-15 Jianyu to ST-30 Qichong, TE-14 Jianliao to GB-30 Huantiao, SI-IO Naoshu to BL-36 Chengfu.

•    Elbow to knee: HT-3 Shaohai to KI-10 Yingu, PC-3 Quze to LR-8 Ququan, LU-5 Chize to SP-9 Yinlingquan; LI-Il Quchi to ST-35 Dubi, TE-IO Tianjing to GB-34 Yanglingquan, SI-8 Xiaohai to BL-40 Weizhong.

•    Wrist to ankle: HT-7 Shenmen to KI-3 Taixi, PC-7 Daling to LR-4 Zhongfeng, LU-9 Taiyuan to SP-5 Shangqiu; LI-5 Yangxi to ST-41 Jiexi, TE-4 Yangchi to GB-40 Qiuxu, SI-4 Wangu to BL-62 Shenmai.

Point prescriptions

When selecting points for a prescription, the number of points in prescription should be as few as possible. In practice, four to six points are selected to treat acute pain, or mild pain, or with persons of weak constitution. For treating severe pain, or chronic pain, since they are complicated in pathology, the practitioner should use a larger number of points (eight to ten) to produce stronger stimulation. After a few initial treatments, points may be added or subtracted as the condition requires.

When treating a nervous patient for the first time, the practitioner should needle fewer points, increasing the number in later treatment when the patient feels more accustomed to acupuncture.

Each acupuncture point has its own distinctive characteristics, yet those on the same channel or in the same locality can produce certain effects in common. It is wrong to needle the same point for too many times in the same treatment series, as the efficacy of these points will diminish. Rather, other points with similar characteristics should be substituted, or a similar prescription made up of different points should be used instead.

Frequency of treatment

A small number of cases of acute pain require more than one treatment in a single day. Most cases of chronic pain are treated once every I to 3 days, or even once a week. After giving acupuncture treatment for a period of weeks, treatment should be suspended temporarily to rest the patient.

Hr. deepak raj mirdha
yog teacher , Acupressure therapist and blogger
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