MingLang

Tremors are involuntary muscular quivering or rhythmic movements of the extremities or head. In traditional Chinese Medicine, all such movement is due to the stirring of internal Wind. There are three main ways the internal Wind can be generated – Blood deficiency, yin deficiency and Heat.

Aetiology

Liver and Kidney Yin Deficiency

Liver and Kidney yin are damaged through aging, excessive sexual activity, overwork (especially while under stress), insufficient sleep and febrile diseases. Another common cause of yin depletion, especially in younger people, is abuse of recreational drugs. Liver yin deficiency can also be an extension of Liver Blood deficiency, or follow any Liver Heat pattern, especially Liver fire. Prolonged Liver qi stagnation can also damage Liver yin by generating stagnant Heat. In tremor patterns, there are often mixtures of Phlegm Heat and yin deficiency.

Yin and Blood deficiency generated Wind in a similar way. Yin and Blood are the anchor that secures yang and provide a counterweight to its active and rising nature. When these stabilising elements reach a critical point of deficiency, yang (or qi) loses its mooring and becomes excessively mobile. This mobile and uncontrolled yang is Wind. Blood deficiency is relatively less server than yin deficiency, and the resulting Wind tends to be milder and the tremors finer.


Yin deficiency can give rise to two degrees of Wind, the first milder and associated with the rhythmic tremors and spasms of diseases like Parkinson’s disease pr hyperthyroidism. The second, more severe, occurs when Liver yang suddenly (and disastrously) slips its mooring and becomes Wind, rushing towards the head to cause Wind stroke.

Phlegm Heat

Phlegm Heat can be generated in several ways. Excessive consumption of rich spicy foods and alcohol can directly generate Phlegm Heat. Any pre-exisiting Heat in the body (from Liver qi stagnation with stagnant Heat or Fire, yin deficiency or external invasion, etc), can thicken and congeal fluids into phlegm, and subsequently Phlegm Heat. A weakness of Spleen qi or innappropriate consumption of cold natured foods can allow accumulation of Dampness and Phlegm, which can eventually become hot.

Phlegm Heat, at a certain point of intensity, can generate sufficient movement to be redefined as Wind. The variety of Wind associated with Phlegm Heat type tremor is not severe enough to cause the convulsive Wind of extreme Heat or Fire. In this case the yin nature of the Phlegm restrains and modifies the intensity of the Heat’s expression, and milder form of Wind occurs. The Heat smoulders at just the right intensity to promote ongoing Wind, but is not severe enough to cause convulsions.

Qi and Blood Deficiency

Overwork, excessive worry or mental activity, irregular dietary habits, excessive consumption of cold, raw foods or prolonged illness can weaken Spleen qi. As the Spleen (and Lungs) are the source of the qi and Blood of the body, weakness in these organs will inevitably lead to a decrease in production of qi and Blood. Other causes are acute or chronic hemorrhage, prolonged breast feeding and malnutrition (seen, for example in vegetarians who eat insufficient protein). Qi and Blood are so closely related that deficiency of one usually leads to deficiency of the other.

As noted previously, Blood deficiency can give rise to a mild form of Wind by failing to anchor yang qi securely. Qi (yang) deficiency may also contribute to the development of a type of Wind, one generated by the movement of qi to fill the vacuum formed by chronic deficiency. In the case of predominant qi deficiency, the Wind is more likely to manifest as chronic childhood convulsion.

Treatment

After a diagnosis from a qualified practitioner has been given, acupuncture is the treatment of choice and herbal medicines are recommended to support correcting any systemic imbalances that may be present.

Weakness of Anti-Pathogenic Qi, Weakness of Lung, Spleen and Kidney Qi, Weak Constitution

Any pre-existing constitutional or acquired weakness can predispose patient to a pathogenic invasion, which they cannot repel. Weakness of Lung and Spleen qi can enable a pathogen to penetrate into the qi level. Patients presenting with ying and blood level heat pathogens are often found to have a constitutional predisposition to Kidney weakness, and a family history of related conditions may be seen.

Overwork

One of the most common contributing factors is failure to rest and look after oneself during an acute illness. Patients who try to ‘sweat it out’ and soldier on, or simply ignore the illness and continue to work through it, are especially likely to end up with a lingering pathogen. The diversion of resources away from the fight leads to an incomplete response from the anti-pathogenic qi.

Overwork in general, both physical and mental, drains the basic reserves of yuan qi and weakens the Kidneys. This weakness enables a pathogen to easily enter, and once in to linger, especially at the deep levels, ying, blood and shaoyin. The anti-pathogenic qi is unable to mount a robust defense. Prolonged ‘burning the candles at both ends’ is a common finding in patients who go on to develop chronic fatigue syndrome and other persistent fatigue patterns. Shift workers and those working long hours in stressful situations are particularly vulnerable. These patients tend to develop very prolonged illnesses because the acquired weakness of yuan qi and jing essence complicates removal pf the pathogen and restoration of normal function and recovery.

Immunization

Immunizations may cause a lingering pathogen in some circumstances. Patients who are weak to start with, or who are vaccinated during an acute illness, are especially vulnerable. The use of antipyretic drugs such as paracetamol and aspirin, directly after and immunization can transmit a pathogen directly into the qi, shaoyang, ying or blood levels.

Antibiotics During Acute Viral Illness

Antibiotics are bitter and cold, and can weaken Spleen yang qi. They act like a bitter cold purge, often causing diarrhea. They effectively clear heat, but are unable to completely disperse the pathogen, so a residue, often in the form of damp, is left behind, creating a medium for repeated infection. The weakened Spleen yang leads to poor resistance and enables pathogens to gain easy access deep into the qi level.

Wrong Treatment

Wrong or poorly administered treatment for the type and location of the pathogen ca weaken anti-pathogenic qi, trap a pathogen or drag it deeper into the body. Wrong treatments include diaphoresis when a pathogen is alread beyond the surface, excessive purging, and prescriptions of bitter cold herbs or antibiotics when a pathogen is still on the surface. Supplementing inappropriately (can occur when mistaking fatigue for deficiency) with qi and yin supplements is another common trap, which can lock the pathogen in rather than disperse it. Repeated use of antipyretic drugs during mild childhood fevers is also implicated.

Environmental Exposure

Repeated exposure to certain climates or toxins can lead to lingering pathogen pattern. The climactic factors are the most common, with prolonged exposure to hot humid weather, a damp house or frequent contact with water, especially when tired or vulnerable, enabling dampness and damp heat to seep into the body.

Exposure to farm and industrial chemicals, pesticides, volatile fumes and pollutants can induce a lingering pathogen reaction in some people, especially those already weakened or vulnerable due to constitution, age or pre-existing illness. This may be seen in rural workers, the residents of badly polluted cities, in the inhabitants of new and hermetically sealed buildings (‘sick building syndrome’) and in those working with volatile substances, such as perfumes, paints, varnishes, solvents and gasoline.

Strong Pathogen

A strong or epidemic pathogen can overwhelm even the most robust of defenses, deplete qi and damage yin, and become persistent. This is seen in certain new strains of flu and other viral and bacterial illness that sweep through populations affecting many regardless of health. A strong pathogen may also be something other than and infectious agent, such as a chemical, poison or radiation, that is able to create a persistent immune response regardless of how robust the patient.

Drugs (Pharmaceutical, recreational)

Some drugs weaken the Spleen and can damage qi, for example, laxatives and antibiotics. some drugs deplete yin, weaken Kidneys and open the shaoyin to invasion. These stimulants such as amphetamines and cocaine, antidepressants, steroids and cytotoxic agents.

Emotional Factors

Any emotional factor that leads to depletion of Spleen, Lung or Kidney qi can enable a pathogen to get past the body’s defenses and into the deeper levels where the weak qi is unable to adequately expel it. Chronic Liver qi constraints will eventually weaken Spleen qi, whereas a sudden or severe fright or shock can damage Kidney qi, or disrupt the Heart Kidney axis and leave the ying and blood levels vulnerable.

Treatment

After a diagnosis from a qualified practitioner has been given, acupuncture is the treatment of choice and herbal medicines are recommended to support correcting any systemic imbalances that may be present.

Key Signs of a lingering pathogen:

> History
> Fever pattern / abnormal heat
> Abnormal sweating
> Muscle aches and weakness
> Fatigue, low energy levels
> Swollen lymph nodes
> Tongue thrones
> Skin lesions

Low Grade Fever and Abnormal Heat Sensations

A fever is an abnormal elevation, or the perception of an elevation in the body temperature, that may be either systemic or localized. The fever type most typical of a lingering pathogen is a low grade fever, but depending on the duration of the condition, the degree of dampness and any complicating deficiency, the heat sensation can vary considerably. Abnormal heat sensations in the body may also point to the possibility of a lingering pathogen, and these may be subjective or objective.

When subjective, the patient feels hot or heat intolerant in one part of the body – the hands and feet, head or chest are common. The heat may be suggested by symptoms such as night sweats, flushing, light or inadequate dressing for the weather, or throwing the bedding off of the feet at night.

When objective, the patient is generally unaware of any heat, and it is detected by the practitioner during the course of the physical examination, usually as a region of the body (commonly the chest, upper back, abdomen, hands and feet or head) that is distinctly warmer than the surrounding area.

The more heat, or heat related damp, the more distinct the heat sensation or fever is likely to be. In cases with relatively little heat, with damp predominance or significant complicating deficiency, heat sensations may be muted or absent. In this case a ‘contained fever’ may be detected, Low grade fevers cyclical, appearing daily at specific times. Periods of fever may come and go, occurring for a few weeks, the abating for a variable time before beginning again.

A common variant is alternating fever and chills. These are characterized by distinct episodes of fever alternating with distinct chills, shivering, cold intolerance or goose bumps. In acute cases the fever and chill pattern is clear and unmistakable, but when prolonged and in patients with underlying deficiency, the fever and chill episodes can be muted to point that they may only appear sporadically when the patient is run down, and then often described vaguely as ‘flu like symptoms’ or ‘getting hot and cold’. In some patterns, the fever and chill episodes may appear every few days for a few hours, or just in the afternoon.

Swollen Lymph Nodes and Tonsils

Palpable lymph nodes in the neck are a common finding, and often the initial clue that points towards a lingering pathogen diagnosis. The nodes have a very specific feel. Lymph nodes suggestive of a lingering pathogen are non tender or slightly tender, well defined, round, soft or slightly rubbery and yielding. They feel just like small peas under the skin, and are able to move slightly over the subcutaneous tissue. Lymph node swelling can come and go during the course of a prolonged lingering pathogenic illness.

Abnormal Sweating

Abnormal sweating is a common finding in patients with a lingering pathogen, and one that is easy to overlook. Troublesome, debilitating or embarrassing sweating (usually night sweats or sweating palms) will be reported, but patients are often insensible to sweating, or it is considered normal and thus disregarded. A thorough physical examination is essential in assessing the presence or absence of moisture on the skin. Particular attention should be paid to the hands and feet, forearms and shins, back of the neck and chest and upper abdomen. Be aware of influences of anxiety, the warmth of the environment, and whether or not the patient has rushed to the appointment.

Muscle and Joint Aches

The aching is felt deep in the muscles and tends to be diffuse. It can be associated with a distinct feeling of heaviness or weakness, and most commonly affects the large proximal muscles. The thighs and hips, buttocks and waist, and upper arms are common locations. The more damp there is, the more aching; the more heat there is, the weaker the muscles feel. Soft tissue around joints can be affected as well, so both muscle and joints may ache.

Energy Levels

Persistent fatigue since a previous illness, or a sudden and otherwise inexplicable drop in energy lasting from a few hours to days or longer, may suggest a lingering pathogen, when accompanied by abnormal heat, sweating or lymph node swelling. Most lingering pathogens are accompanied by significant to debilitating fatigue, which bears little relationship to the energy expenditure of the individual.

Tongue

Certain features of the tongue, in particular the prominent red protrusions (thorns) that appear anteriorly, around the edges of the tongue and on the root of the tongue, are suggestive of a lingering pathogen. The distribution of the thorns can give clues as to the depth of the pathogen. The other main benefit of the tongue is as a prognostic indicator and a measure of how well a treatment is progressing.

Skin Lesions and Rashes

Skin lesions and rashes characteristic of lingering pathogens include macules, papules and vasicles. Macules and papules often appear together as a maculopapular rash. Depending on their nature and when they appear, their appearance can be encouraging, or a sign that something is going wrong. In general however, if other symptoms are improving when a rash appears, it is a good sign.

Lingering Pathogens Part Three: Etiology and Treatment

Lingering pathogens are pathogenic influences that remain in the body and provoke a persistent immune response that produces characteristic signs and symptoms. Pathogenic influences in this context include living organisms (viruses, bacteria, fungi and parasites) as well as allergens, chemicals, drugs and environmental toxins.

Lingering pathogens manifest in a number of ways. An infection from the past may still be making its presence felt with recurrent symptoms (often arising when the patient is stressed or run down), or is perhaps detectable as persistent antibodies or other markers, in blood tests. Examples include glandular fever (Epstein Barr virus), cytomegalovirus, toxoplasmosis, brucellosis, aspergillus, malaria, viral hepatitis, and the active factors in immunizations. Some natural fauna can also manifest as lingering pathogens if they are not maintained in proper balance.

In clinic we often suspect a lingering pathogen when the patient presents with a history that begins “I have never been well since…”. They are usually referring to an acute infection they suffered some time ago, and occasionally an immunization. Alternatively, the initial insult which has left the patient with chronic or recurrent symptoms may have been exposed to environmental toxins such as volatile gases, fumes or heavy metals, or in some cases drugs or substances causing an allergic reaction.

In some cases, the initial infection or injury is not recalled or apparent, however the pattern of recurrent symptoms fits the picture of a lingering pathogen and will be treated as such.

There are a number of signs and symptoms that point to the presence of a lingering pathogen. Not all will be present in any particular individual, and their appearance can vary depending on any complicating pathology or deficiency, the duration of the condition, the age of the patient and any medications the patient may be taking.

A thorough physical examination is essential in the discovery of lingering pathogens, as signs like abnormal heat distribution or isolated sweating may be quite subtle and not obvious to the patient. The golden rule is that while patients are often unreliable witnesses, the body never lies. A good physical examination, in the context of lingering pathogens, requires systematic assessment of the neck for lymphadenopathy, observation of the tonsils for swelling, and palpation of the skin of the arms and hand, chest, head and feet for abnormal temperature sensations and moisture.

A positive history of infection or other event (immunization, chemotherapy) from which the patient has never completely recovered, or following which has been ‘never well since’ is the strongest indicator that a lingering pathogen is in situ. In such cases, the lingering pathogen may be present as a persistent illness after the initial episode has passed, or as an ‘echo’ of the initial illness that appears from time to time, recurring in much the same fashion as the first episode, although generally less severe, and usually when the patient is run down or stressed.

The sudden onset of an uncharacteristic symptom, in some absence of any clear etiology, may suggest a possible pathogenic influence. This is seen most commonly in middle aged people who suddenly develop an uncharacteristic problem, such as insomnia, headaches, asthma or allergies, with no identifiable changes in diet, habits, environment, routine or relationships to explain it. In such cases, a lingering pathogen should be part of the differential diagnosis.

Lingering Pathogens Part Two: Signs and Symptoms

The term xuan yun is used in Traditional Chinese Medicine to describe both dizziness and vertigo and is characterised by symptoms ranging from mild light-headedness or giddiness, to severe loss of balance and equilibrium disturbance.

The mild end of range, termed dizziness, may only occur on moving and last a few seconds. Occasionally, fainting may occur. It is frequently accompanied by blurring vision or spots in the visual field.

Vertigo is generally more severe, and is characterised by a sudden sensation of spinning, or the surroundings rotating. It may be described as ‘head spinning’, ‘the room spinning’, ‘bed spins’ or ‘everything rocking and swaying’. Vertigo may or may not be precipitated by movement of the head, and may last for minutes or hours. Patients occasionally awake from sleep with vertigo. During episodes they usually become frightened and tend to remain immobile. Nausea, vomiting and tinnitus are often associated with vertigo.

In Traditional Chinese Medicine, dizziness and vertigo are primarily due to either excess or deficiency affecting the head. In excess patterns, there is too much of some pathological entity in the head which hinders the normal flow of yin, yang, qi and blood. In the deficient patterns, there is too little of some physiological substance (Blood, qi, yang, jing) getting to the head.

Aetiology

Liver Qi Stagnation, Liver Qi Stagnation with Stagnant Heat, Liver Fire and Liver Yin Deficiency with Yang Rising:

Frustration, anger, resentment, prolonged emotional turmoil, repressed emotions and stress disrupts the circulation of Liver qi. When qi stagnates for any length of time, the resulting pressure can generate Heat. Depending on the intensity of the condition, this can cause stagnant Heat, and the more server Fire or the eventual generation of internal Wind. Qi stagnation can give rise to Phlegm by damaging the Spleen and retarding the movement of fluids.

Qi stagnation, stagnant Heat and Fire are excess patterns. Once there is Heat, it can deplete and scorch the yin, giving rise to the more chronic yin deficiency with yang rising, or Liver Wind. The Wind that gives rise to dizziness is most frequently associated with Liver yin deficiency, although dizziness may be a symptom of all the patterns that can be caused by internal Wind. The dizziness associated with Liver qi stagnation is generally quite mild (may be described as ‘light-headedness’) and due to poor distribution of qi and Blood. Dizziness severe enough to cause loss of balance or collapse is associated with rising Liver yang or Wind.

Phlegm Damp:

Phlegm Damp is generated by overindulgence in Phlegm or Damp producing foods and are associated with eating habits that weaken Spleen qi. Repeated courses of antibiotics can also damage Spleen qi, allowing the generation and accumulation of Dampness. Foods that can weaken the Spleen if consumed in excess include dairy products. fatty, sweet or raw foods, and alcohol. Once the Spleen is weak, inefficient digestion allows accumulation of Dampness, which over time congeals into Phlegm. In the presence of Heat, Damp may be condensed to from Phlegm in a shorter time.

Poor fluid metabolism (due to Spleen, Lung or Kidney dysfunction) may cause stagnation, accumulation and thickening of physiological fluids into Phlegm. In addition, prolonged Liver qi stagnation can contribute, by weakening the Spleen and by retarding the movement of fluids, which gradually condense into Phlegm. Phlegm can fill the head, obstructing the ‘clear yang’ of the senses, and also obstruct the passage of qi and Blood to the head, causing relatively server dizziness.

Stagnant Blood:

Stagnant Blood type dizziness usually follows an injury to the head. It can also follow other long term pathologies, particularly stagnant qi, yin deficiency or Phlegm, all of which obstruct the circulation of qi and Blood.

Stagnant Blood type dizziness also appears to occur post-partum if the birth products and lochia are not completely expelled. If the complete downward discharge of chong mai is obstructed by stagnant Blood, chong mai qi will accumulate and rebel upwards to the head.

Qi and Blood Deficiency

Overwork, excessive worry or mental activity, irregular dietary habits, excessive consumption of cold raw foods or prolonged illness can weaken Spleen qi.

The Spleen (and Lungs) are the source of the body’s qi and Blood, so weakness of these organs will inevitably lead to a decrease in production of qi and Blood. Other causes are acute or chronic haemorrhage, extended breast feeding and malnutrition (seen for example in vegetarians who consume too little protein). Qi and Blood are so closely related that deficiency of one often leads to deficiency of the other.

Kidney Deficiency:

Kidney deficiency can be either jing, yang or yin deficiency. Kidney deficiency may be inherited or may develop as a result of age, chronic illness or excessive sexual activity. Kidney yang or qi is particularly affected by prolonged exposure to cold conditions or excessive lifting or standing (particularly if this occurs in a cold environment). In younger people, Kidney qi may be weakened while Kidney yang remains intact, in which case the cold symptoms are not seen.

Kidney yin is damaged through overwork (especially while under stress), insufficient sleep, febrile disease, insufficient fluid replacement and by the use of some prescription and recreational drugs. Kidney yin may also be damaged by pregnancy or haemorrhage following childbirth.

Treatment

After a diagnosis from a qualified practitioner has been given, acupuncture is the treatment of choice and herbal medicines are recommended to support correcting any systemic imbalances that may be present.

Guided by the concept of wholism of man to nature, the subject of health preservation in Traditional Chinese Medicine holds that all the life activities of the human body must comply with the objective law of the relative wax and wane and transformation of yin and yang throughout the four seasons; otherwise, diseases will occur, which may even endanger man’s life.

The History of the Han Dynasty says “It is a universal law to sprout in spring, grow in summer, to harvest in autumn and to store in winter; if it is not conformed to, there will be no law and discipline to be followed.” Therefore, this requires that people properly adjust their mental activities, their work and rest in daily life and the five flavors in their diet in accordance with the changes of the four seasons. For instance, of the four seasons of the year, spring and summer are of yang nature while autumn and winter are of yin nature, the natural phenomena will present, with the changing of the climate, sprouting in spring, growing in summer, harvesting in autumn and storing in winter. Thus , people should cultivate yang-qi in spring and summer to cultivate the vital energy for sprouting and the vital energy for growing; and in autumn and winter, cultivate yin-qi to harvest and store the vital essence.

The three months of spring are a season of resuscitation of all things on earth. Grasses and trees are sprouting, which makes the natural world look brand-new and full of vitality. People should retire to bed early at night and rise early in the morning. You should also take a stroll in your yard after waking, while letting your hair hang down loosely so that you feel relaxed all over. Newborn things should not be stripped of their energy of growth. They should be appreciated instead of being killed. All these constitute the ways of health preservation in spring. Those who disobey them will incur impairment of the liver and, when summer comes, contract cold syndromes.

Nausea and vomiting are symptoms of rising stomach qi. Normally, stomach qi descends, taking the waste products of digestion to the intestines. However, stomach qi can be blocked by a pathogen, or it can simply be too weak to descend. In either case, raising stomach qi is a form of ‘rebellious’ qi.

In adults, nausea and vomiting can be caused by dysfunction of almost any organ system, reflecting a large range of different disorders, ranging from simple acute viral infections to emotional stress to cancer.

In children, vomiting may be the first sign of an infection. All children with vomiting accompanied by fever, should, in addition to the obvious gastrointestinal infection, be checked for middle ear, urinary tract, upper respiratory tract or central nervous system infection.

Aetiology

External Pathogens
Invasion by external pathogens into the Stomach is a common cause of both nausea and vomiting, and is typically associated with a seasonal pathogens, or with eating spoiled food. The most frequent cause is Dampness, either alone or in combination with another pathogen. Nausea and vomiting of this type is most commonly to occur during the humid months of Summer and Autumn, but may occur at any time of the year. External invasion usually cause acute, self limiting illness. However, in some cases, the illness can drag on and become entrenched. Chemotherapy for cancer, a frequent cause of nausea and vomiting, often resembles an external pathogen, and may be treated as such.

Diet
The type of food consumed, and the way it is consumed, are important aetiological factors in the generation of nausea and vomiting. Eating spoiled or contaminated food can produce acute vomiting, which, in traditional Chinese medicine terms, may resemble the invasion of an external pathogen, such as Summerheat or Summerdamp.

Too much cold natured or raw food can introduce Cold into the Stomach and weaken Spleen qi and yang. Over consumption in general, and excessive consumption of rich heating or supplementing foods in particular, can lead to the accumulation of food, and Heat or Damp Heat in the Stomach and Intestines. An excess of heating foods can create Stomach Heat or damage Stomach yin. Sugar, dairy products and some medications, such as antibiotics, create Dampness and Phlegm. All these pathogens can obstruct the qi mechanism and cause Stomach qi to rise.

The way food is eaten is as important as the type of food that is cinsumed. Irregular eating times, eating late at night, or while stressed, or in excessive quantities can all tax the capacity of the Stomach and Spleen to digest and distribute food. These habits can contribute to excess, deficiency and mixed pathologies.

In addition, the manipulations of modern agriculture business have added a raft of new and potentially disruptive substances to many of our foods. Pesticides, fertilisers, hormones and antibiotics find their way into our daily foods as residues of the production process. Artificial colouring and flavouring agents, preservatives and stabilisers are added to enhance shelf life and taste. It seems that some people are unable to metabolise these compounds adequately; they become sensitised and ingestion of the offending agents produced symptoms of nausea, vomiting, abdominal distension, flatulence and pain.

Emotion
Frustration, anger, resentment, prolonged emotional turmoil, repressed emotions and stress disrupt the circulation of Liver qi. These emotions cause a low grade spasm and tension in the smooth muscle of the digestive tract. Nausea or vomiting associated with Liver qi stagnation is generally intermitted and related to the patient’s emotional state.

When the smooth movement of Liver qi is impeded, it finds alternative pathways. In this case, the stagnant qi is discharged sideways, overcontrolling the Stomach through the controlling cycle, disrupting the descent of Stomach qi and causing nausea and vomiting.

There are several consequences of Liver qi invading the Stomach. When qi stagnates for any length of time, the resulting pressure can generate Heat. Chronic Heat in the Stomach will eventually consume Stomach yin. Stagnant qi can disrupt the Spleen, weakening it and contributing to the development of Dampness and Phlegm, which block the descent of Stomach qi.

Liver qi invading the Stomach can be a long term, or even lifetime disorders, and may have a constitutional component. Liver qi stagnation can run in families, with several members prone to emotional gastrointestinal upset.

Phlegm Damp
Phlegm Damp is generated by overindulgence in Phlegm or Damp producing foods and by eating habits that weaken Spleen qi. Repeated courses of antibiotics can damage Spleen qi, allowing the generation and accumulation of Dampness. Foods that can weaken the Spleen if consumed to excess including dairy products, fatty, rich, sweet or raw foods, and alcohol. Once the Spleen is weak, inefficient digestion allows accumulation of Dampness, which over time congeals into Phlegm. In the presence of Heat, Damp may be condensed to form Phlegm in a shorter time.

Poor fluid metabolism, due to Spleen, Lung or Kidney dysfunction, may cause accumulation and thickening of physiological fluids into Phlegm. In addition, prolonged Liver qi stagnation can contribute to the condition by weakening the Spleen and by retarding the movement of fluids, which gradually condense into Phlegm.

Phlegm may also arise following a serious acute febrile illness. the pathogenic Heat cooks and congeals fluid into Phlegm Heat. Once present, Phlegm or Phlegm Heat blocks the qi mechanism and the descent of Stomach qi, provoking nausea and vomiting.

Spleen and Stomach Deficiency
This refers to qi, yang or yin deficiency. The most common cause of Spleen yang qi deficiency nausea or vomiting is prolonged or excessive consumption of cold raw foods and irregular eating habits, or inappropriate use of cold natured herbs or antibiotics in the treatment of a febrile disease. Prolonged insult to the Stomach or severely limited food intake, such as occurs in patients with bulimia and anorexia nervosa, can seriously damage Spleen and Stomach yang qi. Excessive mental strain or prolonged concentration may deplete Spleen qi. The damage is aggravated when an irregular diet is combined with sustained mental activity and too much sitting. The Spleen and Stomach can also be weakened following an acute invasion of Cold and/or Dampness. Gastric surgery can deplete Spleen yang and cause Blood stagnation. When stomach qi is weakened, it can become too feeble to descend properly. The qi mechanism is disordered, qi accumulates and eventually rises causing nausea and vomiting.

Stomach yin deficiency may follow a febrile disease, long term consumption of spicy heating foods, or excessive consumption of drugs such as steroids, illicit stimulants and yang supplementing substances. It also may result from prolonged or excessive vomiting from an excess pathogen, or another chronic Stomach pathology, especially one characterised by Heat or dryness.

Spleen and Stomach deficiency may also be constitutional, and in patients with a component of inherited weakness, there will often be a history of recurrent nausea or vomiting since childhood.

Treatment

After a diagnosis with a qualified practitioner, acupuncture is the treatment of choice and herbal medicines are recommended to support correcting any systemic imbalances that may be present. In some cases, massage can also be effective.

Epigastric pain is pain in the area defined as epigastrium. The epigastric region is the area medial to the nipples, above the umbilicus and beneath the ribs. Most commonly, epigastric pain is experienced in a fist sized area beneath the notch of the ribs. The pain may radiate to the hypochondriac region or back, and may associate with symptoms such as intergestion, flatulence, nausea, vomiting, acid reflux, indeterminate gnawing hunger, coldness in the body, black sticky stools or constipation and diarrhoea.

The epigastric region is under the control of the Stomach, Spleen and Liver. Most epigastric pain is associated with Stomach and/or Liver pathology. The most common patterns clinically are Liver and Stomach disharmony, stomach qi or yang deficiency, and Stomach Heat or yin deficiency.

Epigastric pain can be acute or chronic, or chronic with acute exacerbations. When acute and severe, possible surgical emergencies, such as perforated peptic ulcer, should be kept in mind. In general, it is chronic or recurrent epigastric pain that brings patients to seek Traditional Chinese Medicine treatment, and for which is usually quite successful.

Aetiology

Cold

External Cold: External cold can be introduced into the body in association with Wind, or directly, by ingestion of large quantities of cold natured or physically cold foods, drinks or medications. Enviromental Cold can invade the gastro-intestinal system directly through the mouth, bypassing the surface altogether. Invasion of external Cold is facilitated by pre-existing weakness of Spleen and Stomach qi and/or yang. Cold invasion usually causes acute epigastric pain.

Internal Cold: Internal Cold is the product of a deficiency of Spleen and/or Kidney yang, whereby yin Cold becomes predominant relative to warming active yang. Depending on the degree of deficiency and the degree of Cold, the pain produced can vary. When the deficiency elements are primary, the pain tends to be mild and dull, relieved by both warmth and pressure. When yin Cold excess is predominant, the pain tends to be fairly severe and cramping, relieved by warmth but made worse by pressure.

Heat

External Heat: External Heat can invade the gastro-intestinal system directly, or follow a virulent, or unresolved, acute exterior disorder. Heat, or Cold which transforms into Heat as it penetrates deeper into the body, pushes through the surface, the shao yang level, and lodges in the yang ming level, the Stomach and Intestines. Occasionally, febrile illness can leave a residue of phlegm Heat in the Stomach, causing pain and discomfort. External Heat type epigastric pain is mostly acute.

Internal Heat: Consumption of heating foods introduces Heat directly into the Stomach. Internally generated Heat that affects the Stomach may also be the product of chronic Liver qi stagnation that generates stagnant Heat or Fire. Once stagnant Heat is present in the Liver system, it can be introduced into the Stomach via the controlling cycles, similarly, but less commonly, prolonged worry, anxiety and depression, or a sudden shock can retard the movement of Heart qi. The resulting accumulation of qi creates a focus of pressure in the chest, which can result in Heart Fire. Heart Fire can be transmitted via the generating cycle to influence and heat the Stomach. Internal Heat can also be created by yin deficiency. The Stomach needs a degree of moisture for efficient operation, and is thus easily dried out and heated up by a systemic increase in Heat from yin deficiency.

Diet

The type of food consumed and the way it is consumed are important factors in the genesis of epigastric pain. Eating spoiled or contaminated food can produce acute pain, which in TCM terms may resemble an attack of Cold or Damp Heat.

To much cold natured food can introduce Cold and weaken Spleen and Stomach qi and yang. Some drugs weaken the middle jiao and deplete Spleen and Stomach qi and yang. Reduced food intake as a result of strict dieting, or prolonged starvation or digestive insult, such as occurs in patients with a history of anorexia nervosa, bulimia or during famine, serious damages Spleen yang.

Over consumption in general, and excessive consumption of rich, heating or supplementing foods in particular, can lead to the accumulation of stagnant food and Heat or Damp in the Stomach. Food stagnation is a common precursor to a host of pathologies that may give rise to epigastric pain. Eating large quantities of foods that heat the Stomach and Liver, specifically substances like chilli and spices, alcohol, coffee and chocolate cause Heat to accumulate. Once Heat is resident in the Stomach it easily damages Stomach yin. The natural tendency of Heat to rise can contribute to acid reflux which may damage the lining of the oesophagus and cause pain. Some specific foods are notorious for being indigestible to some people, and easily cause acid and pain. These include acid foods like the citrus family, tomatoes, uncooked peppers and capsicums, radishes, onions and garlic. Sugar and dairy products create Dampness and Phlegm.

Drugs

Numerous therapeutic agents, both herbal and pharmaceutical, legal or illicit, can cause epigastric pain. Probably most common are those that are cold in nature, such as non steroidal anti-inflammatory agents (NSAIDs), purgative laxatives and occasionally antibiotics. Non steroidal anti-inflammatory agents are well known for physically damaging the lining of the Stomach. Drugs that are heating can also damage the Stomach, consume yin and cause pain. These include corticosteroids, alcohol, inappropriate yang supplementing medicines, and stimulants such as cocaine and speed.

Emotion

Emotional factors, particularly those that contribute to stagnant Liver qi, are a major factor in the development of epigastric pain. Liver qi stagnation is most commonly produced by repression of emotions, the buried frustrations of everyday life, the suppressed anger and resentments. It also arises from exposure to ongoing stress or emotional tension, whether at work, at home or at school.

Prolonged qi stagnation can contribute to several complications which also cause pain, such as Blood stagnation, stagnant Heat and Spleen deficiency with the eventual generation of internal Cold or Dampness. In addition, qi stagnation leads to a generalised hypertonicity of both skeletal and smooth muscle, further restricting the circulation of qi and Blood to the tissues.

In addition to the emotional factors that upset the Liver, worry, obsessive thinking and prolonged concentration in combination with a sedentary or studious lifestyle and poor diet, will weaken Spleen and Stomach qi. When weak, the Stomach is predisposed to invasion by Liver qi resulting in further damage.

Some Biomedical Causes of Epigastric Pain

Gastro-intestional
> Acute and chronic gastritis
> Peptic ulcers
> Acute and chronic pancreatitis
> Oesophagitis/reflux
> Cholecystitis
> Chloelithiasis
> Gastrospasm
> Carcinoma – stomach oesophagus, pancreas
> ‘Nervous’ stomach
> Irritable bowel syndrome
> Dyspepsia

Cardiac
> Referred myocardial infarction

Respiratory
> Referred lower lobe pneumonia

Medications
> Aspirin/NSAIDS
> Cortisone
> Alcohol abuse

Other
> Poisoning

Treatment

Treatment of epigastric pain is generally quite successful with TCM, especially when combined with dietary and life habit modifications. Acupuncture is effective for relieving acute pain and for gradual removal of the stagnation which contributes to chronic epigastric pain. Herbs are usually required to replenish Blood and yin.