Section One Basic Theories

Transcription

1 Section One Basic Theories Chapter One Introduction Traditional Chinese Medicine (TCM) is a medical system gained from the experiences of Chinese people over thousands of years in their struggle against diseases. Through thousands of years of medical practice the unique system and theories of TCM were developed. TCM plays a major role in maintaining the health of Chinese citizens and is an outstanding development in our national history. 1.1 The Initiation and Development of TCM TCM is a science which encompasses both physiology and pathology to diagnose, prevent and treat disease. Influenced by Chinese ancient philosophy, yin-yang and the five elements theories soon developed into a medical theoretical system (TCM) characterized by the physiological and pathological functions of the viscera, and meridians. The diagnostic and therapeutic features of treatment are based upon syndrome differentiation and interaction of these systems. TCM theory developed and expanded mainly from practice and experience. As early as 4000 years ago, the ancient Chinese created primitive medicine in their struggle with nature and disease. In finding food, they soon understood that some foods could relieve or even eliminate some diseases. Thus, this was the origin of development and application of Chinese herbal medicine. In utilizing fire for warmth, they found applying stones or sand wrapped with leather or certain types of bark could relieve some diseases. Gradually they developed the method of using hot compresses and moxibustion. In using stones as production tools, they found that when a portion of the body is injured, the disorder in another portion of the body can be relieved, hence, they created the method of using stone or bone needles for treatment. Through these experiences, acupuncture therapy was developed, which in turn further developed the theory of meridians. Two thousand years ago, the earliest known TCM book,"huangdi Neijing"(Huangdi s Classic of Internal Medicine), was written. It is consists of two parts- "ShuWen" (Plain Questions) and "Ling Shu" (Miraculous Pivot). The book summarizes the therapeutic experiences and medical theories of that time period. Assimilating achievements of other natural sciences at that time, it comprehensively examines the physiology and pathology of the body, along with diagnosis, prevention and treatment of diseases. It remains the theoretical foundation TCM. "Shennong Bencao Jing (Shennong's Herbal Classic)" is a pharmaceutical monograph compiled during the Han Dynasty. 365 kinds of herbs were recorded in the book concerning pharmaceutical theories of the "chief, deputy, assistant, and envoy," the "seven conditions," "four natures" and "five flavors." 1

2 A famous medical expert named Zhang Ji who practiced during the Han Dynasty completed a book entitled "Shanghan Zabing Lun" (Treatise on Exogenous Febrile and Miscellaneous Diseases). It utilizes the six meridian principles to differentiate exogenous febrile diseases, along with theories of the viscera to differentiate miscellaneous diseases. The book outlines a system of treatment determination based on syndrome differentiation, and is regarded as a very important text in the development of clinical TCM. Li Shizhen, a famous TCM doctor of the Ming dynasty, went to various mountains to collect medical herbs and investigated the growth and morphology of medical plants. He also dissected and carried out studies on animals, and compared minerals used for medical purposes. He also referred to more than 800 kinds of literature and took 27 years to complete Bencao Gangmu (Compendium of Materia Medica). The book recorded kinds of herbs with more than l0 000 prescriptions. It made a great contribution to the development of pharmacy and herbal medicine in both China and worldwide. The Doctrine of Warm Diseases is a summary of experiences of TCM doctors and their long history of treating exogenous febrile diseases. One such practitioner, Wu Youke of the Ming Dynasty advanced the theory in his book "Wenyi Lun" (Treatise on Pestilence) that pathogens are "not wind, not cold, not summer-heat, not dampness, but a pestilent-qi between the Heaven and the Earth," and that "infections enter by way of the mouth and the nose, not from the skin." After the founding of new China, TCM advanced to a new stage. Medical works have been systematized, historical medical texts have been researched, basic TCM theories have been studied by modern scientific means. Furthermore, studies have advanced theories and understanding of the essence of the meridians and the viscera, and have furthered research in treatment of both common and chronic of diseases. 1.2 The Essential Characteristics of TCM The theoretical system of TCM mainly embodies the following two essential characteristics The Concept of Wholism Wholeness means unity and integrity. TCM pays attention to the unity and integrity of the body, and interrelation between the human body and nature. The human body itself is seen an organic whole. Every part composing the body is inter-cooperative, interactive and inter-influenced. The human body is also closely related to external natural surroundings. This idea of unity between interior and exterior conditions, and wholeness of the body itself is called the "concept of whole." (1) The Human Body as an Organic Whole The human body is composed of a number of viscera, organs and tissues, which have their own respective functions. Every function, however, is a component of the general activity and thus effects the unity of the whole body. So, they interrelate physiologically, and inter-influence pathologically. The unity of 2

3 the body is formed through communication of the meridian system, with the five zang viscera as the center, which associate with the six fu-viscera. It embodies various aspects both physiologically and pathologically among the viscera, and between the viscera and the body s constitution. For example, the heart corresponds with the small intestine, governs the blood vessels, and opens on the tongue. The lung corresponds with the large intestine, governs the skin and hair, and opens in the nose. The spleen corresponds with the stomach, governs the muscles and four limbs, and opens in the mouth. The liver corresponds with the gallbladder, governs the tendons, and opens to the eyes. The kidney corresponds with the bladder, governs the hones, and opens to the ears. As one can see, dysfunctions of the viscera may be reflected in the body surface through the meridians; while disorders of the tissues and organs in the body surface may involve the related viscera through the meridians. Relatedly, the zang-viscera and the fu-viscera may also influence each other through the meridians. Therefore, in diagnosis and treatment of disease, the deficiency or excess of internal viscera, exuberance or decline of qi and blood, and relative strength or weakness of the vital or the evil may be detected through the external changes in five sense organs, body constitution, complexion and pulse. For instance, clearing liver-fire to treat epidemic conjunctivitis, clearing heart-fire and small intestine-fire to treat stomatitis, clearing of stomach-fire to treat toothache caused by excess-fire, dispersing the lung to treat cold and cough, and expelling of internal toxin to treat skin diseases and sores. All these examples reveal that the human body is an inseparable and related organic whole. Thus, the practitioner should carefully and skillfully study the relationship between the part and the whole. In this manner one can correctly recognize, diagnose and treat disease. (2) The Relationship Between Humans and Nature Humans are tied to nature, and there is in nature an essential condition for people to live. Changes in nature, therefore, may directly or indirectly influence the body, and accordingly cause physiological or pathological reactions. For instance, there are regular seasonal changes or cycles such as spring-warm, summer-hot, autumn-dryness and winter-cold. To adapt to such weather there are physiological changes in the body which take place. If it is hot, the body will sweat for thermolysis; if it is cold, in order to keep warm, the striae of the body will become compact, hence hypohidrosis, and more fluid will be excreted in the urine. The adaptability of human body also is present in geographic and living conditions. Once climatic or living conditions change beyond the adaptive or regulating functions of the body, health disorders and disease ensue. In particular, seasonal epidemic diseases are often directly influenced by and arise from natural conditions. Finally, some diseases may also change according to day or night, e. g. some diseases are mild in the morning and get become worse from afternoon to night. On the other hand, TCM theories also recognize that humans can do physical training, reform nature, adapt to natural conditions, and by such means and ways can effectively prevent and treat diseases. 3

4 1.2.2 Treatment Determination Based on Syndrome Differentiation Treatment determination based on syndrome differentiation is an essential principle in TCM in understanding and treating disease. It is a specific research and treatment method of disease in TCM, and also one of the essential characteristics of TCM. "Syndrome differentiation" includes analyzing, differentiating and recognizing syndromes of disease. "Treatment determination" includes deciding on an appropriate therapeutic measure according to syndrome differentiation. Syndrome differentiation is the prerequisite and basis for determining treatment. Treatment determination is the means to treat disease, and also involves examination of whether syndrome differentiation is correct or not. Syndrome differentiation and treatment determination are inseparable in the process of diagnosis and treatment of disease, and embody the combination of theory and practice. In different stages of a disease, there may appear different syndromes; and in different diseases, the same syndrome may appear. So, different syndromes in one disease should be treated by different treatments; while different diseases, as long as they express the same syndrome, can be treated with the same treatment. It should be noted that "syndrome" is a summary of the cause, place and nature of a disease, and a situation of mutual conflict between pathogenic factors and residence. For example, in dysentery there are symptoms of abdominal pain, diarrhea, and bloody, purulent stool. In onset and development different syndromes may appear in the qi or blood phase, with more heat or cold, or with more or less damp. So, in treatment, different therapeutic methods should be utilized according to different syndromes. Another example is seen in chronic nephritis patients with edema or chronic heart failure patients-both suffer from heart yang deficiency and can be treated by warming yang and promoting qi transformation to excrete water. This principle is called "treating the same disease with different methods" and "treating different diseases with the same method." It follows that in treatment TCM pays more attention to differences of "syndromes" rather than "diseases." The principle that at different times in the course of one disease different methods of treatment are utilized relates to syndrome differentiation in TCM diagnosis. ( 李宝丽 ) 4

5 Chapter Two Yin-yang and the Five Elements Doctrines Yin-yang and the five elements can be traced to ancient Chinese philosophy. Yin and yang are two aspects of the unity of opposite things. The five elements include the most basic elements in nature and include wood, fire, earth, metal and water. Each has its own properties, and yet promote and restrict one other. In ancient China TCM doctors applied yin-yang and the five elements doctrines to physiological functions, pathological changes of the human body, diagnosis and treatment Yin-yang Theory The Formation and Concepts of Yin-yang Theory Initially, yin and yang refer to the light and darkness of the sun light, i.e., anything that is exposed to the sun belongs to yang, and that which is unexposed to the sun belongs to yin. For example, the south side of a mountain belongs to yang and the north side of the mountain to yin. Later, through a long period of study, practice and investigation of various natural phenomena, the theory of yin and yang gradually developed into the two opposite sides of yin and yang, and it was further recognized that interaction between the two promote the origination, development and transformation of things. So, yin-yang were used as a tool to reason things out and explain various phenomena in nature. Yin and yang symbolize two opposite and related sides, and are not confined to a specific thing. Generally speaking, anything that is active, ascending, bright, progressive, hyper functioning or functional aspect is yang; while anything that is static, descending, dim, degenerate, hypo-functioning, or organic aspect is yin. For example, in viewing the attributes of things, heaven being in the upper is attributed to yang, and the earth being in the lower is attributed to yin; water being characterized by cold and downward-flowing is attributed to yin, and fire being characterized by hotness and flaring-up is attributed to yang. When speaking of changes and motion of things, motion lessness belongs to yin and motion to yang, as a thing is in a static state, it is attributed to yin, and if a thing is in excited state, it is attributed to yang. If there is transformation or qi, it is attributed to yang, and as it becomes visible or tangible, it is attributed to yin. Yin or yang attribute of a thing is by no means absolute, but relative. The relativity of yin and yang embodies inter transformation of yin and yang under a given condition. Also, yin may transform into yang and yang into yin. On the other hand, within yin or yang there still might be further subdivided yin and yang. For example, day belongs to yang and night to yin, and morning is yang within yang and afternoon is yin within yang. As one might note, things in the universe may be summarized or categorized as either yin or yang, and a thing itself may be further subdivided into two aspects of yin and yang. Also, any aspect of yin or yang in a thing may be further divided into yin and yang. This phenomenon that things are both mutually opposite and related is infinite in nature. 5

6 2.1.2 Major concepts of Yin-yang Theory The major concepts of yin-yang doctrine may be summarized by the following four aspects: Opposition of Yin-yang Opposition of yin and yang means that in nature two opposite aspects exist for all things and phenomena, such as the heaven and the earth, inside and outside, motion and motionlessness, exit and entrance, day and night, cold and heat, and ascent and descent. Yin-yang doctrine further postulates that heaven belongs to yang, the earth to yin; outside belongs to yang, inside to yin; motion belongs to yang, and motionlessness to yin; exit belongs to yang, and entrance to yin; day belongs to yang, and night to yin; heat belongs to yang, and cold to yin; ascent belongs to yang, and descent to yin. All of these examples indicate that there is a general opposition of yin and yang in all things and phenomena Interdependence of Yin-Yang The two sides of yin and yang are both opposite and interdependent, and neither of them can exist by its own without the other. For example, without heaven there would be no the earth, and vice versa; without outside there would be no inside, and vice versa. This relationship of relying on each other is called interdependence of yin and yang. TCM holds that "functional activity" belongs to yang, and "nutritive substance" to yin. Neither of the two can exist without the other. For example, if the spleen and stomach function in a weak manner, digestion and absorption of nutritive substances will be deficient. On the contrary, if nutritive substances are long under supplied, the function of the spleen and stomach will decrease Wax-wane of Yin-yang The two inter-opposite and interdependent sides of yin and yang are not in a state of stillness, but in a state of constant change, or in a state of "yin wane with yang wax" and "yang wane with yin wax. "This dynamic change of wane and wax between yin and yang is called "wane-wax of yin and yang. "The climatic changes of the four seasons such as winter to spring to summer, changes gradually from cold to warm and to hot and is a process of "yin wane with yang wax." Summer to autumn to winter changes gradually from hot to cool to cold and is a process of "yang wane with yin wax. "Of course, if the wane or wax of yin and yang occur within a certain limit and within a given time, a relative balance is maintained Transformation of Yin-yang This relates to two sides of yin and yang under certain conditions transforming themselves into each other, such as yin may turning into yang, and yang into yin. Concerning the movement and change of things, the "wane-wax of yin and yang" is a process of quantitative change, and the "transformation of yin and yang" is a process of qualitative change. In the progress of a disease, a change from yin to yang or from yang to yin frequently occurs. For example, in some acute infectious diseases such as toxic 6

7 pneumonia, or dysentery, the heat-toxin is extremely strong and the anti-pathogenic qi of the body is greatly injured. As a result, there is a lowering of body temperature, pallor, and cold extremities with a faint pulse that is hard to feel. Thus the disease changes from yang to yin. If emergency treatment is given in a timely and proper manner, the extremities will become warm, the complexion and pulse return to normal and yang qi will recover. The patient is then out of danger and yin and yang are again balanced. In addition, clinically some syndromes change caused by various factors such as a change from excess to deficiency, deficiency to excess, exterior to the interior, or interior to the exterior. The previous are also examples of the transformation of yin and yang. The previous relations of interdependence, opposition, wane-wax and transformation of yin and yang are the major components of the theory of yin-yang. These aspects are not isolated, but inter-related, inter-influenced and inter-causal Application of Yin-yang Theory in TCM Yin-yang and the Structure of the Body When examining the structure of the body, the theory of yin-yang holds that the body is an organic whole. Furthermore, all organic structures are closely related and divided into two mutually opposite parts of yin and yang. When looking at the body in general terms, the upper part belongs to yang, and the lower part to yin; the superficial part belongs to yang, and the internal part to yin; for the body surface, the back belongs to yang, and the abdomen to yin; the lateral aspect belongs to yang, and the medial aspect to yin. In terms of the viscera, the six fu-viscera belong to yang, and the five zang-viscera to yin. Among the five zang-viscera, the heart and the lung belong to yang, and the liver, the spleen and the belong to kidney to yin. For each organ there is also a difference of yin and yang. For example in the heart there is heart-yin and heart-yang; in the kidney there is kidney yin and kidney yang. In short, the interaction between all of the organs and even within an organ itself are complicated, but they all may be summarized and explained in terms of yin and yang Yin-yang and the Physiological Functions of the Body TCM also uses the theory of yin-yang to summarize and explain the body's physiological functions, claiming that the normal life activity of the human body is an outcome of the relation of yin and yang in their unity of opposites. For example, the relation of functions belonging to yang and substances belonging to yin embodies this relation of unity of opposites. The physiological activity of the human body takes substance as the basis, and without yin-essence, there would be no production of yang-qi. The outcome of the physiological, because of action of yang-qi, constantly produces yin-essence. If yin and yang cannot promote each other and become separated, the vital activities of the body will come to an end Yin-yang and Pathological Changes in the Body The theory of yin and yang indicates that the onset of a disease is the outcome of a 7

8 relative imbalance between yin and yang with a consequent excess or deficiency of one or the other. The onset and development of a disease relate to the vital and the evil. The resistance against disease by anti pathogenic-qi, pathogenic evil-qi, and the struggle between them may all be summarized and explained by yin and yang. Pathogenic evils may be divided into yin or yang-evils. The anti-pathogenic-qi includes yin-essence and yang-qi. The invading yang-evil may lead to an excess of yang and injure yin, causing a heat syndrome. The invading yin-evil may lead to an excess of yin and injure yang, causing a cold syndrome. Deficient yang-qi can not check yin, and will lead to a deficient-cold syndrome due to yang deficiency with yin exuberance. Deficient yin-fluids cannot check yang, and will lead to deficient-heat syndrome due to yin deficiency with yang hyperactivity. In summation, pathological changes are complicated but can all be summarized and explained by an "imbalance between yin and yang." The Application of Yin-yang in Diagnosis of Disease The root cause of onset and development of a disease lies in a relative imbalance between yin and yang. Thus in all diseases, no matter how changeable or intricate their clinical manifestations, they all come under the two categories of a "yin syndrome" or a "yang syndrome." The "eight principles for syndrome differentiation" are a framework for various syndrome differentiations clinically, and among then, yin and yang are the most general and fundamental principles. For example, the exterior, heat and excess belong to yang, and interior, cold and deficient belong to yin. A right diagnosis should first distinguish between yin and yang. Then, the essence of the disease can be examined. For instance in inspection, a bright color belongs to yang, and a dark and gloomy color to yin. In auscultation, a voice with a high tone belongs to yang, and a feeble voice with a low tone to yin. In the pulse, floating, rapid, large, smooth, or excess pulses belong to yang, and deep, slow, small, unsmooth, or deficient pulses belong to yin The Application of Yin-yang in Treatment of Disease Since an excess or deficiency of yin or yang is the root cause for onset and development of disease, regulating yin and yang to restore its relative balance is the guiding principle in treatment. For example, in a case in which yang-heat is exuberant and injures yin-fluids (excess yang injures yin), the method of "cooling what is heat" may be used to reduce the surplus yang. For a case of yin-cold excess and injuring yang-qi the method of "heating what is cold" can be used to reduce the surplus yin. For a case of hyperactivity of yang due to the failure of yin-fluids in checking yang, or a case of exuberance of yin due to a failure of deficient yang-qi checking yin, the treatment must include reinforcing the deficiency of yin or yang. The therapeutic treatment principle of restoring a relative balance between yin and yang is "treating yin for a yang illness and treating yang for a yin illness." 8

9 2.2 The Five Elements Formation and Concepts of the Five Elements Over thousands of years people in ancient China recognized that wood, fire, earth, metal and water are the five indispensable materials in human life. Later, people looked to the properties of these five materials to explain the whole physical world. They also believed that the five materials not only inter-promotion and inter-restriction, but are also in a constant state of motion and change. This soon be came what is now known as "the five-element doctrine" or theory. The five-element doctrine has been used in TCM to explain physiological and pathological changes in the human body, and the relation of the body to the external environment.thus, treatment determination based on syndrome differentiation can be carried out to prevent or treat disease Major Concepts of the Five Elements Characteristics of the Five Elements Ancient TCM practitioners used the five elements to study and classify tissue structure, physiology and pathology of the human body, and nature. They also categorized things into wood, fire, earth, metal, water and fire elements according to their different natures, actions, shapes or forms. This is known as the method of "categorization according to picture." Studies and explanation of the complex relations among the viscera and tissues of the human body physiologically and pathologically, and the relation between the human body and its external environment were also developed. The following table-1 examines the relationship between the human body and the five elements. The table displays the attributes and character of each of the five elements. For example, wood flourishes and grows freely, and anything that possesses this nature is attributed to wood. Fire is characterized by warmth, heat and flares up, and accordingly anything that possesses this nature is attributed to fire. Earth is characterized by holding and producing, thus anything that possesses this nature is attributed to earth. Metal is characterized by solidity and clarity and anything possessing this nature is attributed to metal. Water is characterized as cold moist and flowing in a downward direction, so anything that possesses these characteristics is attributed to water. As one can see, the five elements in TCM contain the abstract nature and character of each element Promotion, Restriction, Subjugation and Violation of the Five Elements (1) Promotion and Restriction Promotion indicates promoting and improving the orderly function among the five elements. The order of promotion is as follows: wood promotes fire, fire promotes earth, earth promotes metal, metal promotes water, and water in turn promotes wood. In the promotion of the five elements, each element has two aspects of "being promoted" and "promoting. "The promoting element is the 9

10 HUMAN BODY NATURE Table 1. Characteristics of the Five-Elements 5 flavors sour bitter sweet pungent salty 5 colors green red yellow white Black 5changes germination growth alteration reaping Storing 5 climates wind summer-heat dampness dryness cold 5 directions east south middle west north 5 seasons spring summer Late-summer autumn winter Five elements wood fire earth metal water 5 zang-viscera liver heart spleen lung kidney 5 fu- viscera large urinary gall bladder small intestine stomach intestine bladder 5 sense organs eye tongue mouth nose ear 5body constituents tendon vessel muscle skin bone 5 emotions anger joy thinking sorrow fear 5 voices shout laugh sing cry groan 5 secretions tear sweat slobber snivel spittle "mother,"and the promoted element is the "child." The promotion relationship is thus called the "mother-child relationship." As an example, because wood promotes fire, wood is the mother of fire; and wood is promoted by water, thus it is the child of water. Restriction implies checking and bringing under control among the five elements. The order of restriction is: wood restricts earth, earth restricts water, water restricts fire, fire restricts metal, and metal restricts wood. In the restriction of the five elements, each element possesses two aspects of "being restricted" and "restricting." The restricting element is the "dominator," and the promoted element is the "subordinate. "With wood as an example, the element that restricts wood is metal, so metal is the dominator of wood. The element that is restricted by wood is earth, thus earth is the subordinate of wood. In the relationship of the five elements, neither promotion nor restriction is separated. Without promotion, there would be no birth and growth of things; without restriction, there would be abnormal changes. For example, wood promotes fire and fire is restricted by water; water is restricted by earth and metal promotes water. Thus, promotion continues there is restriction, while restriction continues there is promotion. Promotion and restriction oppose each other yet also complement each other, keeping a relative balance for normal generation and development. (2) Invasion by Another Element Invasion indicates "encroaching on that which is weak." It is an abnormal manifestation in the normal co-ordinative relationship of elements. For example, when wood is excessive, and metal fails to check wood, then the excessive wood will invade earth and make the latter even more deficient. Violation in relation to the elements is "using one s strength to bully another one. 10

11 wood water fire generation restriction metal earth "That is, one of the five elements becomes too excessive, thus the element that originally restricts it can not restrict it any more, and is restricted by it. This is called "counter-restriction. "For example, in normal restriction relations, metal restricts wood, if wood becomes excessive or metal becomes deficient, then wood will reverse and violate metal. The order of violation is just opposite to the order of restriction in the five elements. Violation in the five elements is an abnormal relation Application of the Five Elements in TCM Physiological Functions of the Five Zang-viscera and Their Relationships Promotion in the five elements may be used to explain the inter-promotion relationships among the five zang-viscera. For example, kidney (water) -essence nourishes liver (wood) and water promotes wood. The liver (wood) stores blood to assist the heart (fire), thus wood promotes fire. Heart (fire) -yang warms the spleen (earth), so fire promotes earth. Spleen (earth) transforms food and water into essence and nourishes lung (metal), thus earth promotes metal. The lung regulates water passage to support the kidney (water) so metal promotes water. Restriction in the five elements may be used to expound the inter-restriction relationships among the five zang-viscera. For example, the purifying and descending function of lung qi (metal) can check the hyperactivity of liver-yang (wood), so metal restricts wood. The flow of liver qi (wood) can smooth and resolve the stasis of the spleen qi (earth) and so wood restricts earth while the transformation and transportation of the spleen (earth) can prevent edema caused by failure of the kidney (water). In dominating water metabolism the earth restricts water and kidney yin (water) can prevent the raging of heart fire, thus water restricts fire Inter-affection Disorders of the Five Zang-Viscera The five elements not only can be used to explain the relationships among the viscera physiologically, but also may be used to explain inter-affection of the viscera pathologically. This relates to the laws of promotion, restriction, subjugation and violation of the five elements. For example, liver disease may affect the spleen, and is wood subjugating earth; a spleen disease also may involve the liver, and would be earth violating wood. As one can see when the liver and the spleen are both in disharmony, 11

12 both are affected. Wood stagnation can lead to earth deficiency or earth stagnation can lead to wood stagnation. A liver disease may also affect the heart, and would be considered a child disease involving the mother. Disease of the other viscera can all be explained according to the laws of promotion, restriction, subjugation and violation by using the five elements inter-affection and pathology Diagnosis and Treatment Application Abnormal changes in functional activities of the viscera and their relationships can all be reflected in the complexion, voice, taste, and pulse. That is, a diagnosis can be made from a patient s complexion, voice, taste, and pulse. However, the five zang-viscera have a specific connection to the five elements with color, voice, flavor and corresponding pulse. In clinical diagnosis, the state of illness may be deduced through information gained by using the four diagnostic methods in relation to the five elements and five-element laws dealing with promotion, restriction, subjugation and violation. For example, a patient whose complexion is greenish with a preference for sour food and a wiry pulse may be diagnosed as having a liver disease. A patient with a reddish complexion, bitter taste in the mouth, and a surging pulse maybe diagnosed as having a heart disease. A disorder of spleen deficiency accompanied with a greenish complexion implies that wood (liver) has invaded earth (spleen). A patient of heart disease with darkish appearance suggests that water (kidney) has invaded fire (heart). In addition, the onset and development of some diseases are related to the promotion and restriction relationships among the viscera. Thus in treatment while treating the diseased viscus, one should also consider the other related viscera in order to stop the transmission of disease. Examples might include treatment principles such as reinforcing earth to strengthen metal, replenishing water to nourish wood, checking wood to assist earth, or replenishing water to reduce fire. These principles are based on the five element laws of promotion, restriction, subjugation and violation. 2.3 Combined Application of Yin-yang and the Five Elements Yin-yang and the Relation of Two Opposite Aspects Yin-yang mainly deals with and relates to opposition, dependence, wax-wane and the transformation of the two aspects of a given thing. When explaining the universe, yin-yang theory claims that the whole universe is but a unity of opposites. When explaining the human body, it looks at the body as an integrated whole which has various opposite tissue structures and functional activities. When explaining the relation between man and nature, it holds that people and nature are entities of opposites Aspects of the Five Elements Five element theory is a major concept dealing with and explaining the multiple relationships of promotion and restriction, and control-generation cycles. In terms of the universe, five element theory holds that the whole universe is an entity consisting of the 12

13 promotion, restriction, control and generation of the five essential elements of wood, fire, earth, metal and water. In terms of the human body, it applies the character of the five elements to each of the five zang-viscera, five sense organs, five body constituents, five emotions, et. In examining the organic whole of the body there is promotion and restriction, control and generation. Five element theory holds that the relationship between humans and nature contains five phases, six climates, five directions, five seasons, and five changes which all correspond internally to the viscera, their physiological activities in the body and the natural environment. All of which examples are related to promotion and restriction, control and generation. While both the yin-yang and five elements theories have their own areas of focus, emphasis and characteristics, they are mutually related. By combining these theories in TCM, one can comprehensively understand the human physiology and pathology. ( 李宝丽 ) Chapter Three Visceral Theory TCM classifies the internal organs of the body into three kinds: the five zang-viscera, or the heart, liver, spleen, lung and kidney, all of which have the common physiological function of producing and storing essential qi. The six fu-viscera, or the gallbladder, stomach, small intestine, large intestine, urinary bladder and san-jiao, which have the common physiological functions of receiving, transforming, and transporting food and water. The extraordinary fu-viscera include the brain, marrow, bone, vessel, gallbladder and uterus, and are distinct from the fu-viscera in function, and are thus known as the extraordinary fu-viscera. 3.1 The Five Zang-viscera Heart The heart is located in the thorax and guarded externally by the pericardium. Its physiological function is governing blood and the vessels, and giving motive power for blood circulation. The heart also governs spiritual activities, and opens to the tongue Governs Blood and the Vessels The heart has the function of circulating blood through the vessels to nourish the whole body. The vessels are the passage of blood circulation. While the circulation of blood in the vessels depends upon both the heart and vessels, the heart plays the major role. The function of the heart in governing blood and the vessels is carried out by heart qi. Only with strong heart qi can blood incessantly circulate through the vessels, filling the demand of tissues and organs for nutrients and blood Governs Spiritual Activities Spiritual activities embody mental aspects, consciousness and thought. According to modern physiology, mental, conscious and activities of thought are the function of the cerebrum, or the cerebrum's reflection, relation to, and experiences with objective things, 13

14 In TCM however, they are related to the five zang-viscera, and in particular, the heart. The material basis of spiritual activities, the blood, is governed by the heart. So, the functions of the heart in governing spiritual activities, blood and vessels are closely related. If the heart is functioning well in governing spiritual activities, one will be full of vitality, have a clear head, and be quick in both thought and response. Should imbalance or disorder appear in the heart one will notice the patient being upset, having an abnormal spiritual or mental state such as depressive psychosis and mania caused by phlegm-fire disturbing the heart, insomnia, frequent dreaming, or palpitations if there is a designs and symptoms appear, the heart should be considered in the treatment principle Sweat and the Heart In TCM, sweat is derived from a body fluid which is a related and important component part of blood. As blood is governed by the heart it is said that "blood and sweat share a common source" and "sweat is the fluid from the heart." In TCM it is thought that too much sweating can injure heart-blood and heart qi, manifesting with palpitations or with a feeling or fear. Profuse sweating can injure heart yang, leading to a critical condition known as " depletion of yang resulting from profuse sweat. " While deficiency of heart yang is apt to likely to cause night sweating The Heart Opens to the Tongue and Manifests on the Face The large divergent collateral of the heart meridian goes up to the tongue and the face which are both rich in blood vessels. Therefore, TCM practitioners often look at the tongue and face to examine the underlying condition of the heart and blood. As a result it is said that "the tongue is the sprout of the heart. When the heart functions well and heart-blood is abundant, the face will be ruddy and lustrous, and the tongue will be light red and free in motion. If heart-blood is deficient, there will be a pallor complexion and pale tongue. In the case of stagnation of heart-blood, the complexion will be purplish and dark, or have echymoses or petechiae. If there is a dysfunction of the heart in governing mental activities or the spirit, the tongue will be stiff, there will be difficult speech, or aphasis. In addition, hair is dependent upon the nourishment of blood, and thus it is said that "hair is the extension of blood." In the case of a deficiency of heart blood, the hair will be withered. Appendix: Pericardium The pericardium is a membrane surrounding the heart, and has the function of protecting the heart. Exopathic factors invading the heart often first attack the pericardium. For instance, in the course of a febrile disease with symptoms of high fever, coma, and deep red tongue, it is known in TCM as "heat invading the pericardium." The manifestations of a disease caused by an invasion of the pericardium by pathogenic factors are the same as those of the heart Lungs 14

15 The lungs are situated in the thorax. They communicate with the heart, and open to the nose. The major functions of the lungs include governing qi, controlling respiration, dispersing and descending, and smoothing water passages Governs Qi The lungs have the function of governing the qi of the whole body and air breathing. (1) Governs Air Breath The lungs have the function are the place where gas is exchanged between the interior and the exterior of the body. Through respiration, the lungs inhales fresh air (oxygen), and exhales the waste(carbon dioxide). This process in TCM is called getting rid of the state and taking in the fresh, thus continuing to the body s metabolism. (2) Governs Qi of the Whole Body The lung function of governing qi in the whole body is reflected in two ways. The lungs play an integral role in the production of "pectoral qi. "Pectoral qi is made up from a combination of fresh air from nature inhaled by the lungs and essential qi from food, water, and stored in the thorax. It goes up to the throat to promote the respiratory movements of the lungs. It also permeates into the heart and the vessels to help the heart and the lungs circulate blood and qi through the whole body to warm and nourish the viscera and tissues and maintain their normal physiological functions. The lung can also regulate qi movement in ascent, descent, exit and entrance. Thus, the function of the lungs in governing qi of the body influences the production of pectoral qi and qi movements (ascent, descent, exit and entrance) of the whole body. Any disruption in the qi dynamics of the lungs will result in shortage of breath, a low voice, lassitude, and general weakness In Charge of Dispersing and Descending Dispersing means spreading out. The lungs are in charge of dispersing through the driving action of lung qi, qi, blood and body fluids can go everywhere in the body such as internally to the viscera and meridians, and externally to the muscles and skin. Descending in terms of qi includes cleaning and going down. The lungs are located in the thorax and upper-jiao, and the lung qi functions to send the fails to descend, cough, asthma, and chest distress will appear Smoothes the Water Passages Lung qi has the action of promoting and maintaining water metabolism equilibrium. This function is carried out through the dispersing and descending actions of lung qi. Discharge of metabolized water in the body mainly includes four processes: urine, sweat, respiration, and feces. Of the four, sweat and urine in particular are the major means through which water is released by the body. The body fluids absorbed from food and water go to the whole body to nourish and moisten it through the dispersing action of lung qi. Through the descending action of lung qi, the body fluids go down to the kidneys. The turbid or useless part of the fluid is then turned into urine, which then goes into the urinary bladder 15

16 to be discharged out of the body. This function of the lungs promotes water metabolism is the reason why "the lung is the upper source of water." Governs the Skin and Hair The lungs govern the skin and hair (in addition to the sweat glands), distribute body fluids and spread out defensive, or "wei" qi over the skin and hair. As a result the lungs moisten and nourish the skin and hair, making the series of the muscles and skin compact with strong resistance against exogenous evils. If lung qi becomes deficient and can not disperse defensive qi or distribute the essence to the skin and hair, then the patient might present with sallow skin and white hair with a withered look. In addition, the body might be subject to invasion of exogenous evils because of weak defense qi Opens to the Nose The nose is the gate of the lungs, and the passage for air enter and exit. The function of the nose in receiving air and sense of smell is mainly dependent on lung qi. When lung qi is smooth respiration will be even and normal and the sense of smell will be sharp. However, when the lungs are invaded by exogenous evils, lung qi will not flow smoothly and might cause nasal obstruction, runny nose, and hyposmia. If a heat-evil stagnates in the lungs, nasal flaring will occur. As the nose is the orifice of the lungs, it also serves as the passage for the evils to invade the lungs. For instance, warm-evil mostly invades the lungs through the way of the mouth and nose Spleen The spleen is located in the middle-jiao. Its major physiological functions include governing transformation and transportation, controlling blood, and ascending essence. It dominates the muscles and limbs, opens to the mouth, and manifests on the lips Governs Transformation and Transportation The spleen transforms and transports essential substances from food. The spleen has the function of digesting, absorbing and transporting nutritive substances. After digestion, the essential substances from food and fluids are absorbed by the spleen and be transported upward to the lung and heart to then be distributed to through out the body to nourish the viscera, limbs, bones, skin and hair, tendons. Therefore, transformation and transportation of essential substances from food encompasses the actions of digesting, absorbing and transporting nutrients. If spleen transformation and transportation functions are weakened, poor appetite, abdominal distention, diarrhea, lassitude, and emaciation will become evident. Transformation and transportation of water. The spleen promotes water metabolism, and at the same time transforms and transports essential substances from food. The spleen also absorbs and transports water required to moisten and nourish various tissues of the body. The metabolized water is then transported downward to the kidneys where it is turned into urine and moves through the urinary bladder to be discharged out of the 16

17 body. This process of water distribution and transportation is performed together by the lung qi's dispersing and descending actions and the spleen qi's transforming and transporting actions. The spleen nourishes and moistens tissues, and acts to avoid retention of water, thus maintaining water metabolism balance in the body. If this function becomes weakened, diseases such as edema, phlegm-dampness syndrome, and diarrhea might soon follow Controls Blood The spleen has the function of controlling blood and circulating it within the vessels and prevents blood from extravasating. If spleen qi is deficient and fails to control blood, the blood will no longer circulate inside the vessels and extravasate. Then, in addition to the symptoms of spleen qi deficiency, bleeding, such as hemafecia, hematohidrosis, and metrorrhagia may appear. The treatment principle should include strengthening the spleen to tonify qi in order to control blood Sends up Essence Spleen qi has an upward, ascending nature. Thus there is a saying "spleen qi is in charge of ascending. "Essence implies the essential substances derived from food and fluids. Sending up the essence means that the spleen absorbs and transports the nourishment of essential substances derived from food and fluids up to the heart, lung, head and eyes. The actions of the heart and lung then convert this nourishment into qi and blood which in turn nourishes the entire body. In TCM it is thus said that "the spleen functions well when its qi ascends." If the spleen fails to ascend the essence, its qi sinks, which is known in TCM as "sinking of the middle-jiao. "Chronic diarrhea with proctoptosis, and uterine prolapse are but a few examples of spleen qi sinking Dominates Muscles and Limbs The spleen dominates the muscles and limbs. When spleen qi is strong it transports As a result the muscles will be thick and strong, with the four limbs nimble and forceful in movement. If the spleen weakens in transportation and transformation, nourishment will decrease and the muscles become thin, the limbs forceless, flaccid and or atrophied Opens to the Mouth, Manifests on the Lips The spleen opens to the mouth. Appetite and taste are closely related to the transformation and transportation functions of the spleen. When spleen qi is strong, there will be a good appetite and a normal taste. If the spleen weakens in transformation and transportation, abnormal changes in appetite and taste, such as anorexia, tastelessness, or a sweet or sticky taste in the mouth will be evident. The spleen dominates the muscles, and opens to the mouth. So, any change in the spleen function of transformation and transportation of essential substances from food and fluids may be reflected in the lips. If spleen qi is strong, the muscles will be properly nourished and the lips will be reddish and lustrous. However, if spleen qi weakens in transformation and transportation, the lips will appear sallow and lackluster. 17

18 Liver The liver is located in the right hypochondrium. It is responsible for regulating the smooth flow of qi, storage of blood, and dominates the tendons. The liver opens to the eyes, and manifests on the nails Regulates the Smooth Flow of Qi The smooth flow of qi refers to an unobstructed, consistent, and even flow of qi. The smooth flow of liver qi plays a role in three important areas. (1) Emotions A person's spirit and mental activities, while being controlled by the heart, are also related to the liver function of smoothing the flow of qi. This function of liver can harmonize the spirit, mental activities, and emotions and will result in a good mood, relaxed mind, and quick thought. If the smoothing action of liver qi is hypoactive, the moods will be ones of depression, sorrow, suspicion, sighing, and hypochondriac distress. If the smoothing action is hyperactive, the manifestations will include states of mind such as over excitement, irritability, dizziness, vertigo, insomnia, and dream disturbed sleep. (2) Digestion and Absorption The smoothing action of the liver plays a major role in the ascent and descent of spleen and stomach qi, and the normal secretion of bile, which in turn maintains normal digestion and absorption. If liver qi does not flow smoothly, the ascent and descent of spleen and stomach qi and secretion of the bile will be in a state of disharmony. This condition will manifest with such symptoms as abnormal digestion, poor appetite, indigestion, belching, acid regurgitation, abdominal fullness, and diarrhea. (3) The Smooth Flow of Qi and Blood The smooth flow of liver qi is very important in maintaining normal circulation of qi and blood. Should liver qi not flow in a smooth manner, qi will become obstructed with such signs and symptoms as a distending pain in the hypochondrium, breast, or lower abdomen. Qi is the commander of blood, and if qi stagnates blood stagnates. If liver qi does not flow smoothly, qi stagnation will be followed by blood stagnation, with such signs and symptoms as a stabbing pain in the hypochondrium, abdominal masses, irregular menstruation, dysmenorrhea, and amenorrhea. In addition, the smoothing function of the liver can also smooth the flow of qi in the san-jiao to regulate water passages. Thus, when the liver qi fails to flow smoothly edema or ascites may appear. The smooth flow of liver qi plays a part in sexual function, and smooth flow of liver qi results in normal sexual function. However, if liver qi should become hypoactive, low sex drive will result in impotence and premature ejaculation, or amenorrhea or dysmenorrhea.hyperactive liver qi may result in males having over indulgence in sexual activities, and spermatorrhea. In females the signs and symptoms include dreams of sexual fantasies, an early menstrual cycle, or metrorrhagia Stores Blood 18

19 The liver has the function of storing blood and regulating the volume of blood in circulation. The circulation of blood in different parts of the body differs according to various physiological states. When a person is at rest or in a sleep state, the body's demand for blood is relatively low and any surplus blood returns to and is stored in the liver. If an individual is at work for example, the body's demand for blood increases, and the liver will release blood to meet the requisite demand. Therefore when the liver fails to store blood, it will influence the normal activities of the body, and cause disorders of blood. Conditions often seen in the case of liver blood deficiency include blurred vision, night blindness, contracture of muscles and tendons, and motor impairment. In women, scanty flow of menstrual blood, or amenorrhea will be evident Dominates Tendons and Manifests on the Nails The tendons and fasciae are types of tissue linked with joints and muscles, and control movement. The liver dominates the tendons, which means the fasciae depend upon liver blood for nourishment. If liver-blood is deficient, the tendons will lack nourishment. Liver blood deficiency manifests with numb and or impaired movement of limbs, tremor or spasm. If a heat-evil consumes body fluids, blood too will be consumed and thus will fail to properly nourish tendons. may even be deformed. The loss of fluids due to a heat evil with such signs and symptoms as convulsion, opisthotonos, and clenched jaw are called "liver-wind." The nails are nourished by liver blood, and it is said that the nails are the excretion of the tendons. With abundant liver blood, nails will be firm, thin, withered, lackluster, or may even be deformed Opens to the Eyes The essential qi of the viscera ascends to the eye and thus has and internal relationship with viscera. Of the viscera however, the liver is the major viscus involving the eyes due to the fact that the liver stores blood. Additionally, the liver meridian connects to the eyes. As a result the state of the liver is often manifested in the eyes. One example is liver yin and blood deficiency, with such signs and symptoms of an "uncomfortable feeling" in the eyes, blurred vision or night blindness. When wind-heat evils invade the liver meridian, congested eyes with itching pain may appear. When liver-fire flares up, congested eyes with nebula may appear. If liver-yang becomes hyperactive, common signs and symptoms include dizziness and vertigo. The internal stirring of liver-wind manifests with upward staring of the eyes Kidneys The kidneys are located in the lumber region. The kidneys store vital essence, manufacture marrow, dominate bones, and are the source for growth, development, and reproduction. They also govern water metabolism and the reception of qi. The kidneys open to the ears and manifest in the hair. 19

20 The kidneys store vital essence, and are in charge of growth, development and reproduction. The vital essences stored in the kidney include both congenital and acquired essence. Congenital essence is inherited from ones parents, while acquired essence is derived from food and fluids. Essence can be transformed into qi and qi transformed from kidney-essence is called "the kidney qi." Kidney essence qi is the material base for development and reproduction in the body. At the age seven or eight, because of gradually developing kidney qi, changes appear in growth of both teeth and hair. During the puberty, kidney essence qi becomes even more abundant and an energetic substance relating to sexual development (tian gui) is generated. In males sperm is generated, in females menarche arrives, and sexual function and organs gradually mature. Later in life kidney essence qi gradually declines and along with it so do sexual function and the ability to reproduce, until they finally disappear. As one can see, kidney essence qi plays a major role in growth, development, reproduction and sexual function. Acquired essence is also called visceral essence. It originates from essential substances derived from food and fluids. It is transformed by the spleen and stomach, transported to the viscera, and then becomes visceral essence. When the visceral essence is abundant, it first provides for the body's physiological activities, with any surplus being stored in the kidneys. When viscera need essence, the kidneys supply the essence to them. Therefore, an increase or decline of kidney essence can have a great impact on functions of the viscera Governs Water Metabolism The kidneys preside over and regulate water metabolism in the body. In two ways kidneys play a role in water metabolism. First, in distributing body to nourish and moisten tissue. Secondly, the discharge of utilized water by the tissues(waste). The process of water metabolism is as follows. Water is received by the stomach, is transported by spleen up to the lung, where through the descending action of the lung qi the utilized water and surplus water go into the kidney. Therefore the water arriving to the kidneys is both clear and turbid. Through kidney qi transformation, clear fluid is turned into urine and is then transported into the urinary bladder to be excreted out of the body. Through this cycle the balance of water metabolism in the body is maintained. If kidney qi transformation becomes weak, it will lead to a disturbance of water metabolism and cause disease Governs the Reception of Qi While respiration in the body is governed by the lung, the air inhaled by the lung is sent down and grasped by the kidney. In TCM it is said that "the lungs govern respiration and the kidneys govern reception of qi. "This function of the kidneys plays an important role in respiration. When kidney qi is healthy there will be normal reception of qi, even 20

21 respiration, and the qi passages of the lungs will be unobstructed. If the kidney qi is deficient, the air inhaled can not be grasped by the kidneys, and prolonged expiration or dyspnea will occur Kidneys dominate bone and manufacture marrow, which forms the brain and manifests in the hair The kidneys store vital essence which is then transformed into marrow. The marrow is within the bones and nourishes them. If kidney essence is deficient, there will be a shortage of original marrow. As a result the bones won't get enough nourishment and may become weak or even underdeveloped. For instance, delayed closure of the fontanel and weak bones in children are often caused by deficiency of kidney essence. Teeth are an extension of bone. The teeth also depend upon the nourishment of kidney essence. When kidney essence is abundant, the teeth will be firm. However, when the kidney essence is deficient, teeth will become loose, develop cavities or even fall out. The kidneys manufacture marrow, and the brain is the sea of marrow. So, the brain marrow also depends upon kidney essence for replenishment. When kidney essence is abundant, the brain will soundly develop and the individual will have clear thoughts, sharp vision and keen hearing. When kidney essence is deficient, in addition to lumbar pain and with weak knees, there may also be dizziness, amnesia, insomnia, and slow thought. The nourishment of blood comes from blood. The kidney stores vital essence which can be transformed into blood. When the vital essence and blood are abundant, hair will flourish and be lustrous. Thus it is said that "the kidney manifests in the hair." If hair is sparse, withered, or falling out, it is a chronic condition. If hair is white or falling out early, it is mostly due to a deficiency of kidney essence or blood The kidneys open to the ears and have two yin parts. The hearing function of the ear depends upon nourishment from kidney essence qi. When kidney essence qi is abundant, the hearing will be sharp and when the kidneys are deficient, tinnitus, and a decline hearing will occur. The two yin parts of the kidneys are the anterior and posterior yin (or the genitals and the anus). The anterior yin is in charge of urination and reproduction. The posterior yin discharges feces. The discharge of urine is performed by the urinary bladder, but it relies on the qi transformation of the kidney. Reproduction is controlled by the kidneys. Thus, frequent urination and impotence may be caused by a deficiency of kidney yang. While the discharge of feces is through the posterior yin (anus), it is influenced by the warming action of kidney yang. Clinically, when kidney yang is deficient, constipation and diarrhea occur and are due to the decline and deficiency of spleen and kidney yang. As a result in TCM it is said that "the kidneys controls urine and feces." Appendix: Vital Gate The term vital gate was first recorded in the Nei Jing in reference to the eyes and point 21

22 lingming. The Nan ling was the first text to mention the vital gate as an internal organ. TCM practitioners over the ages have had different opinions about the location and function of the vital gate. In TCM clinical practice, the symptoms resulting from the decline of fire in the vital gate are consistent with those caused by a deficiency of kidney yang. In treatment, the herbs which reinforce fire in the vital gate often have the dual action of reinforcing kidney yang. Through experience and treatment over thousands of years it has been understood and agreed that kidney yang is the fire in vital gate. ( 姚凯 ) 3.2 Six Fu-viscera Gallbladder The gallbladder is attached to the liver The major physiological functions of the gallbladder include storing essential fluid (bile) and discharging bile. Bile originating from the liver is excreted into the intestine and has the action of promoting digestion of food and fluids. Bile is discharged normally is one of the important conditions for the normal spleen and stomach transformation and transportation function. Since the bile helps digestion of food and fluids, the gallbladder is considered as one of the six fu-viscera. However, the gallbladder itself has no physiological function of transmitting food and drink,and in storing the essential fluid it is different from the stomach and intestines. It is also referred to as one of the extraordinary fu viscera. In addition, TCM theory holds that one s courage is related to the gallbladder, and it is the gallbladder that has the function of making decisions Stomach The stomach is located under the diaphragm and in the epigastrium. Its upper opening is the cardia and its lower opening is in the pylorus. The stomach in TCM is know as wei wan (gastric cavity) and its divided into the upper part (including the cardia) know as shang wan, the middle part is referred to as zhong wan, and the lower part including the pylorus is known as the xia wan. The major of the stomach include receiving and digestion food and fluids. The food and drink held in the stomach, through the digestion of the stomach, are transformed into chyme, which then goes down into the small intestine. If this function of the stomach becomes weakened, the result will be poor appetite, indigestion and epigastric. In TCM the physiological functions of the stomach is named stomach qi, it also reflects the functions of the spleen and stomach in the pulse. Stomach qi is thought to be of great importance. In clinical TCM it is said the patient will survive when there is stomach-qi in the pulse; if not, death will soon follow. The direction of the stomach qi is downward. If it does not descend and rebels upward, belching, hiccup, nausea, and vomiting may result. 22

23 Small Intestine The small intestine is located in the abdomen. The major function of the small intestine are transforming chyme and separating the clear (essential substances) from the turbid (waste). The small intestine receives chyme from the stomach and digests and further transforms it, then separates the digested food into two parts. The essential substances are absorbed by the small intestine, then transported by the spleen to the entire body and the waste is sent down through the ileocecal junction to the large intestine. The small intestine absorbs not only the essential substances, but also the water in the small intestine. Through the functions of separating the clear from the turbid of the small intestine, the useless water is poured into the urinary bladder Large Intestine The large intestine connects to the small intestine through the ileocecal junction, and its lower outlet is the anus. The large intestine receives waste material sent down from the small intestine, and after the remained water it still contains absorbed stool is formed and finally it discharges the stool through the anus. The large intestine is the passage way of transmitting waste. If the large intestine is dysfunctioned in transmitting waste, diarrhea or constipation may occur Urinary Bladder The urinary bladder is located in the middle part of the lower abdomen. Its upper outlet communicates with the kidneys through the ureters and its lower outlet connects with the urethra. The major functions of the urinary bladder include storing and discharging urine. In the process of water metabolism in the body, water nourishes and moistens the entire body through the functions of the lung, spleen and kidneys. The used water by the body is sent down to the kidneys where, through qi transformation, the clear part flows back into the body, and the turbid is changed into urine and sent down to the urinary bladder. Went the urine reaches a certain volume, it is discharged out of the body through the qi transformation of both the kidneys and urinary bladder. In TCM it is though that the functions of the bladder in storing and discharging urine depends on kidney qi transformation San-jiao The san-jiao is a collective term including the upper-jiao, middle-jiao and lower-jiao. The upper-jiao is in above the diaphragm; the middle-jiao is in the epigastrium, and the lower-jiao is in the below umbilicus. Regarding the viscera, the upper-jiao includes the heart and lungs, the middle-jiao includes the spleen and stomach, and the lower-jiao includes the liver, kidney, intestines and urinary bladder. The physiological functions of the san-jiao includes controlling the qi transformation of the entire body, transforming essential substances form food and drink, and water metabolism. The reception, digestion and absorption of food and fluids, distribution of essential qi, and discharge of metabolism materials are related to the san-jiao. 23

24 The major functions of the upper-jiao are controlling inspiration, and the governing of blood vessels. It spreads the essential qi from food and fluids over the entire body to warm and nourish tissue and organs of the body. The major functions of the middle-jiao are digesting food and fluids, and transporting essential substances up to the lungs and heart so they can be transformed into qi and blood. The major functions of the lower-jiao are separating the clear from the turbid and discharging waste and metabolized water out of the body.in summation, the san-jiao generally is though to control the qi transformation of the body. 3.3 Extraodinary fu-organs The extraordinary organs refer to the brain, the medulla, the bone, the blood vessel, the gallbladder and the woman s uterus-six organs or tissues. Their form is similar to the six fu-organs, but their functions are different from those of the six fu-organs storing essence. So they are named extraordinary organs. The medulla, the bone, the blood vessel and the gallbladder were mentioned above. There only the woman s uterus and the brain are introduced Brain The brain that lies in the skull, is an accumulation of marrow. The function of the brain relates to mental activity. In theory of Viscera and Bowels, the physiological and pathological functions of the brain belong to the heart and attach to the five fu-organs Uterus The uterus lies in the lower abdomen, in behind of the urinary bladder. Its physiological functions include in taking charge of menstruation and development of the fetus. Menstruation and development of the fetus are complex physiological process. In TCM it is hold that the physiological functions of uterus is depended on the healthy kidney essence, rich qi and blood in the thoroughfare vessel and conception vessel and the physiological function of liver, spleen and heart in regulating qi and blood. 3.4 Relations Among the Five Zang Viscera Heart and Lungs The relationship between the heart and lung is referred mainly to the relation of the heart to control blood circulation and the lung to take charge of the respiration. This relation is embodied in mutual support of qi and blood. (Be discussed in chapter four) Normal blood circulation depends on the function of lung regulating the qi of the whole body to ascend or descend. On the other hand, the respiration of the lung replies on the normal blood circulation. It is the Zong qi (pectoral qi) that relate to the respiration of the lung and blood circulation. Pathologically, when lung qi is deficient, blood stagnation will occur with chest distress, palpitation, and cyanosis of lips etc. On 24

25 the contrary, the heart qi is insufficient that can t propel the blood circulate, the respiration of the lung will be reflect with cough and asthma etc Heart and Spleen The heart control blood circulation, and the spleen keeping blood circulating within the vessels is the source of producing the qi and blood. The relationship between the heart and spleen is embodied in the relation between blood circulation and blood produced. Pathologically, excessive anxiety consuming heart blood can reflect the function of spleen to produce qi and blood. If the spleen qi is deficient and can t govern blood, heart blood weak will occur. The manifestations of the heart and spleen deficiency include in palpitation, amnesia, dreaminess, reduced appetite etc Heart and Liver The heart control blood circulation, and the liver store and regulate blood. The blood, produced by the spleen, stored in the liver, circulate over the body depending on the heart. The heart and liver guarantee normal blood circulation together. Pathologically, asthenia of heart blood is accompanied always with asthenia of liver blood. TCM hold that the heart controls the mental activities, but the mental activities keep nearly relationship with the function of the liver smoothing and regulating the flow of qi and blood. Pathologically, impairment by emotional changes can result in transformation of fire and producing wind. So deficiency of heart and liver yin and hyperactivity of heart and liver fire will reflect to each other Heart and Kidney The heart is associated with the element of fire, and the kidneys are associated with the element of water. TCM hold that heart fire must descend to the kidney, process the cold nature of kidney yin. At the same time kidney water must ascend to the heart and check heart yang. This is named as harmony between heart and kidney. If heart fire can t descend to the kidney and kidney can t ascend to the heart, the manifestations with vexation, insomnia and dreamy sleep will be occurred. This kind of clinical manifestations are referred to as disharmony between heart and kidney Lung and Spleen The lung and spleen are closely related in two aspects. First is the forming of the qi. The fresh air (oxygen) taken by the respiratory function of the lung and the cereal nutrients produced by the functions of spleen in transportation and transformation are mainly material of the qi. The second is the metabolism of water. The spleen transports the water and dampness, and transports essential substances to the lungs to maintain the normal functions of them. The dispersing and descending functions of the lung can improve the water and dampness transportation. Pathologically, if the spleen can t transport the water and damp, it will accumulate into 25

26 phlegm manifesting with cough and asthma Lung and Liver The relationship between the lung and liver is embodied in the regulation of the qi activity. Lung qi descending and liver qi ascending sound keep balance to each other. Insufficient descent of pulmonary qi or rebelling of liver-qi will result in cough and hemoptysis, that is named as liver-fire attacking lung Lung and Kidney The relation between the lung and kidney are mainly manifested in two points: the metabolism of water and respiration. The functions of lung to disperse and descend and regulate the metabolism of water and the transformation of qi of the kidney mutual depend on. The lungs take charge of the respiration, which relies on the kidney to receive of qi. In addition, lung yin and kidney yin nourish each other Liver and Spleen The liver storing blood smoothes the flow of qi. The spleen keeping blood circulating within the vessels controls transformation and transportation. Normal transformation and transportation of spleen need the help of the liver smoothing the flow of qi. The liver regulates the discharging of bile and harmonizes functional activities of qi, which is important to the transformation and transportation of spleen. The liver qi failure to smooth the flow of qi will result in distention and fullness in chest and hypochondriac, abdominal distention and abscess and diarrhea, that is named as disharmony between liver and spleen. Conversely, failure of spleen in transformation will result in qi and blood deficiency, so a deficiency of liver blood will occur Liver and Kidney The liver storing blood smoothes the flow of qi, and the kidneys store vital essence. TCM hold that liver blood and kidney essence nourish each other, it is named the liver and kidney share the same origin. Pathologically, the deficiency of kidney essence and deficiency of liver blood can mutually reflect. The deficiency of kidney yin can lead a deficiency of liver yin and hyperactivity of liver-yang, which is referred to water failing to moisten wood. The deficiency of liver yin lead a deficiency of kidney yin is called hyperactivity of xianghuo(kidney-fire). On the other hand, the liver smoothing the flow of qi and the storage of kidneys regulate the menstruation of woman and the ejaculation of man Spleen and Kidney The spleen is congenital base of life and the kidney is postnatal base of life. The function of spleen in transformation and transportation depend on the warming of kidney yang. Kidney essence needs continual nourishing of cereal nutrients. If the kidney yang fails to warm spleen yang, cold abdominal pain, diarrhea with undigested food or edema will be result in. 26

27 3.5 Relations Among Zang-Viscera and Fu-Viscera Heart and Small intestine The channels of heart and small intestine connect to each other. So the heart and the small intestine are exterior-interiorly related to each other. Pathologically, heart excess-fire can descend to small intestine, lead to reddish urine, scanty urine and pain in urination. On the contrary, small intestine fire can ascend to the heart though channels, result in dysphoria and orolingual sore Lung and Large intestine The channels of lungs and large intestine connect to each other. So the lung and the large intestine are exterior-interiorly related to each other. Lung qi depurating and descending helps the transmission of the large intestine, and the normal transmission of the large intestine can promote the lung qi depurating and descending. Pathologically, if the lung qi fails to depurate and descend, it will lead to constipation. Large intestine excess-fire may also result in failure of lung qi to descend manifesting with cough and asthma Spleen and Stomach The channels of spleen and stomach connect to each other. So the spleen and the stomach are exterior-interiorly related to each other. The stomach receives food and water, and the spleen governs transformation and transportation. The spleen qi ascends and the stomach qi descends. The spleen and stomach take charge of the digesting and absorbing of food and water together. Pathologically, the failure of spleen to transform and transport can reflect the reception of stomach manifesting with poor appetite and nausea. The failure of stomach qi descending may result in abdominal distention and diarrhea Liver and Gallbladder The gallbladder is attached to the liver, and its channels connect to the liver. The gallbladder and liver have exterior-interior relation each other. The bile originates from the liver qi. If the liver qi doesn t flow smoothly, the normal production and excretion of bile will be affected. When the bile can t be discharged smoothly, the function of liver to smooth the flow of qi will be affected. So the diseases of the liver and gallbladder always occur at the same time Kidney and Urinary Bladder The channels of kidney and urinary bladder connect to each other. They are exterior-interiorly related to each other. The functions of the urinary bladder in storing and discharging urine depend on the qi transformation of the kidney. If kidney qi is insufficiency and can t control the closing and opening of the urinary bladder, urinary incontinence and enuresis will occur. ( 王欣 ) 27

28 Chapter Four Qi, Blood and Body Fluids Qi, Blood and body fluids are the basic substances constituting the body and are the material base for the organs and meridians in carring out their respective physiological activities. 4.1 Qi The Concept of Qi Qi was then looked upon as the essential substance constituting the body and maintaining the life activities of the body Generation of Qi The kidney store essential qi, and the congenital essence-qi stored in the kidney is the root of all qi of the body. The spleen and stomach govern transformation and transportation of food and drink, constantly producing essential qi from food and drink. The lungs control respiration, inhale clear qi from nature to combine with the functions of the kidneys, spleen and stomach generate various forms of qi in the body Functions of Qi Driving Action It plays a major role in activating and driving physiological activities of various viscera and meridians, the generation and circulation of blood, generation, and the distribution and excretion of body fluid Warming Action Qi is the source of thermal energy of the body. The constancy of temperature of the body also depends upon qi level of warmth. The warming action of qi is also closely related to the physiological activities of such organs and tissues as the viscera and meridians, and normal circulation of blood and qi as well Defending Action The defending action of qi mainly embodies protecting the body surface and defending attack of exopathic evils Containing Action The containing action of qi mainly embodies preventing losses of blood and body fluids Qi Transformation Qi transformation means changes as a consequence of the movements of qi. It implies the metabolism of qi, blood, body fluids, essence and intertransformation resulting from the action of qi. For example, production of qi, blood and body fluids depend upon the transformation of food and drink into essential substances which then transform into qi, blood and body fluids. Body fluids, after metabolism, transform into sweat and urine; food, after digestion and absorption, has its waste transformed into feces. All of the 28

29 previous are examples of transformation. The process of qi transformation, therefore, is actually a process of substance metabolism and a process of substance and energy conversion Circulation of Qi Circulation of qi is called qi movement. The form of qi circulation includes four basic type : ascent, descent, exit and entrance. The ascending, descending, exiting and entering of qi can activate and drive various physiological activities of the body. On the other hand, only in the physiological activities of the viscera and meridians can they be embodied. For example, the function of lung qi movement include inhalation in entering, exhalation in exiting, dispersion is ascending, and descending is descending. The coordinative balance of qi movement in ascent, descent, exit and entrance is called free qi movement. A disturbance in the balance of ascent, descent, exit and entrance of qi is a pathological state known as the disturbance of qi movement and has the following forms. Unsmooth qi movement is a condition of blocked movement of qi in ascent, descent, exit and entrance due to various factors, qi stagnancy is a case of blocked movement in a local area ; qi regurgitation is a case of hyper ascending or hypo-descending of qi ; qi collapse is a case of outside loss of qi due to a failure in retaining itself inside ; qi depressing and qi block are a case of a failure of qi in exiting and the accumulation of qi in the interior Classification of Qi Based on the component, distribution area, and functional features, there are the following major kinds of qi Primordial qi or original qi,or genuine qi is the most fundamental and important type of qi in the body.it is the motive force of the body s life activities. (1) Formation and Distribution primordial qi is mainly composed of essential qi stored in the kidneys. primordial qi is originate from the lower-jiao, and through the san-jiao it spreads over the whole body. (2) Major Function The major function of primordial qi is to promote growth and development of the body, and warm and boost the functions of various tissues and organs including the viscera and meridians Pectoral Qi This qi exists in the thorax. The place where pectoral qi is gathering is called the sea of qi, or shan zhong. (1) Formation and Distribution pectoral qi is formed by a combination of the clear qi inhaled by the lung and essential qi from food and drinks obtained by the spleen and stomach. After its formation, pectoral qi distributes in the thorax. Follows the respiration, it spreads upward to the throat, and then downward to the elixir field. (2) Major Function There are two major function of pectoral qi: first, it spreads upward along the throat to help respiration. Therefore, the strength of voice and 29

30 respiration are related to the strength of pectoral qi. Second, it permeates into the heart vessels to move qi and blood, coordinates the heart and lungs in carrying out blood circulation, has an effect on the beat of the heart, and regulates the heart rhythm and rate Nutritive Qi Nutritive qi circulates with blood and is a component of blood. (1) Formation and Distrbution Nutritive qi mainly originates from the refined part of the essential qi of food and water. It is formed in the thorax, distributes in the vessels as a component of blood, and flows through the vessels to nourish the whole body. (2) Major Function The major function of nutritive qi includes nourishing the body and producing blood Defensive Qi Defensive qi circulating outside the vessels. (1) Formation and Distrbution Defensive qi is transformed from the essential qi of food and drink obtained by the spleen and stomach. After formation, it mainly circulates outside the vessels, between the skin and the muscles, is distributed to and by the lungs, and spreads among the viscera. (2) Major Function There are three function of defensive qi : firstly, guarding the body surface and resisting invasion of the exopathic factors; secondly, warming the body; thirdly, controlling the opening and of the striae and regulating sweat secretion to maintain proper body temperature. 4.2 Blood The concept of blood Blood is a red liquid circulating within the vessels, being one of the basic substances constituting the body and maintaining its vital activities Generation of Blood Blood is mainly composed of nutritive qi and body fluids. Kidney-essence is abundant, it may transform into blood; when blood is abundant, it may also transform into essence. Accoringly there is a saying that essence and blood share the common source Function of Blood Blood has the function of nourishing and moistening the whole body. Blood is also the major base of material for the spiritual activities of the body. Consciousness, sharp senses, and well developed motor skills all upon an abundance of blood and its smooth circulation Circulation of Blood Blood circulation endlessly within the vessels throughout the whole body. Circulation of blood is closely related with the functions of heart, lungs, liver and spleen. The heart governs blood. The beat of the heart drives blood to circulate. The lungs govern qi, and all vessels meet in the lungs. Circulation of blood depends on the dispersion and regulation of lung qi. The liver, in charge of smoothing, guarantees free movement of qi and a smooth flow of blood, while at the same time stores blood so as to 30

31 regulate blood volume in circulation. The spleen controls blood to keep it within the vessels. Of these, the function of the heart, lungs and liver mainly make up the driving force; while the storing action of the liver and containing action of the spleen form a controlling force. It is the coordinative balance between these two force that maintain the normal circulation of blood. If this balance is upset, it may lead to bleeding that is due to hyper-driving action or hypo-controlling action, or might result in blood stasis due to hypo-driving action. 4.3 Body Fluids The Concept of Body Fluids Body fluid is a general term for all normal liquids in the body, including interstitial fluid in the viscera and other tissues and organs, and normal secretions such as gastric juice, intestinal juice, nasal discharge, tears, etc..body fluid, like qi and blood, is a basic substance constituting the body and plays an important in maintaining its normal life activitives. Because of differences in quality, function and distribution, body fluid is again divided into two types: generally, what is clear, thin and distributing to the skin, muscles, orifices, fluid infiltrating into the blood vessels, and moistening is calling jin ; while that which is nourishing, turbid, thick and distributed to the joints, viscera, and brain marrow is called ye. jin and ye are both liquids, come from drinks and food and are dependent upon the tranformation and transportation of the spleen and stomach. As they can transform each other, they are commonly collectively included as body fluids Production, Distribution and Discharge of Body Fluids These processes involve many viscera, and depend mainly on the function of the stomach, spleen, lungs, kidneys and san-jiao. Body fluids are produced through the digestion and absorption of drink and food by the stomach, separation of the clear from the turbid by the small intestine, and then transportation of body fluids by the small intestine to the spleen. The spleen again transports the body fluids to the entire body and to the lungs. By dispersion, the lungs spread body fluids over the entire body to nourish and moisten, and a portion of the body fluids in the body surface is turned into sweat which is discharge out of the body. Through its descending action, the lungs send body fluids down to the kidneys and the urinary bladder where metabolized fluids are changed into urine to be discharged. Additionally inhalation by the lungs also discharge water. In the process of body fluid metabolism, the kidneys play a decisive role. The functions of the lungs, stomach, spleen, small intestine and san-jiao all depend on the boosting action of kidney qi. In addition, the fluids of the body need the qi transformation and steaming action of the kidneys so the clear can go back to the body to be reused, and the turbid changed into urine can be discharged out of the body. 31

32 Function of Body Fluids Body fluids have the physiological functions of moistening and nourishing. For example, the fluid distributing onto the body surface moistens the skin and hairs; the fluid flowing into the orifices moisten and safeguards the eyes, mouth, and nose. 4.4 Qi, Blood and Body Fluids The three are the most fundamental substances constituting the body and maintain its vital activities. They all rely on the essential substance from food and drink obtained by the spleen and stomach. Functionally, they are inter-dependent and interactive. Therefore, there are very close relationship among qi, blood and body fluids, in both physiological and pathological terms The Relationship Between Qi and Blood Qi Produce Blood The component and production processes of blood can not occur without qi and qi transformation. Body fluids and nutritive qi are the major components of blood, all derived from the essential qi of food and drink obtained by the spleen and stomach. Food and drinks are ingested and transformed into essential qi, from there they are turned into nutritive qi and body fluids, and finally become blood. The entire process depends upon qi transformation Qi Circulates Blood Blood belongs to yin and is characterized by stillness. Blood can not move itself and relies on the driving action of qi. As qi moves, blood follows. Qi deficiency or qi stagnancy may cause sluggish flow of blood, and qi deficiency failing to drive while qi stagnancy may cause blood stasis Qi Contains Blood Containing blood is the main aspect of the containing action of qi. Blood circulating within the vessels and without extravasating out of them depends mainly upon the containing action qi has on blood. The above there action of qi on blood are summarized by the quote qi is the commander of blood Blood, the Mother of Qi This means blood is the carrier of qi, and provides qi with ample nourishment. Owing to its strong activity, qi is apt to escape and it must attach itself to blood or body fluids so as to exist within the body The Relationship Between Qi and Body Fluids Qi produces Body Fluids Body fluids come from ingested food and fluids, dependent on the transformation and transportation qi in the spleen and stomach Qi Circulates Body Fluids The flow and distribution of body fluids rely on qi movement in ascent, descent, exit 32

33 and entrance, such as, dispersion and descending of lung qi, sending up the clear of the spleen and sending down the turbid of the stomach qi, transformation and steaming action of the kidney qi Qi Contains Fluid, and Fluids Convey Qi The discharge of qi depends on the driving and transformation action of qi. Maintenance of the normal balance of body fluid metabolism also depends upon the containing action of qi. Conversely, body fluids can convey qi The Relationship Between Body Fluids and Blood Both blood and body fluids come from the essential substances of food and drink, from which they are produced. Thus, there is a saying that fluid and blood share the same source. Generally speaking, body fluids are the major component of blood while blood includes body fluids and nutritive qi. ( 王晓红 ) Chapter Five Etiology and Pathology TCM holds that the human body maintains a relative dynamic Balance among viscera and tissues, and between the body and its external environment, in which contradictions constantly occur and are then resolved. In such a manner the body maintains normal physiological activities. Whenever this dynamic balance is disharmonious due to some factors and cannot be recovered by self-regulation, illness will immediately ensue. Factors that cause disharmony of the relative balance and lead to disease are the causes of disease, or are known as pathogenic factors. Pathogenic factors resulting in disease are many and varied, such as abnormal climatic changes, pestilence infection, emotional stimulation, an improper diet, overstrain and stress, traumatic injuries, and insect or animal bites. In the course of a disease, cause and effect are often inter-active. An effect in a pathological stage may be a cause in another pathological stage. Examples are phlegm-stagnant-fluid and stagnant blood, which is pathological outcomes of a disturbance of the functions of viscera, qi and blood and may become to pathological factors in causing disease. The pathological mechanisms allowing pathogenic factors to invade the body are many and varied, and the pathological mechanisms involved are complicated. Different diseases have their own pathological character. However in different pathological changes caused by quite different diseases involving various pathogenic factors general laws exist. These general laws can effectively guide syndrome differentiation, treatment, and allow the practitioner to recognize the nature of a disease. 5.1 Etiology There are many factors that can cause diseases, including six exopathic factors, seven emotional factors, an improper diet, overstrain and overease. TCM holds that there is no syndrome without cause. Any syndrome is a 33

34 disharmonious reflection of the body under the influence and action of some factors. TCM studies the cause of a disease, by understanding objective conditions that may become pathogenic factors according to the clinical manifestations of the disease and through analysis of symptoms and signs of the disease to infer its cause. This process or method gives a basis for treatment and prescription and is called "seeking the cause by syndrome differentiation." Therefore, etiology in TCM not only studies the nature and pathogenic character of pathogenic factors, but also probes into clinical manifestations of syndromes they cause. Thus it can play a role in clinical diagnosis and treatment The Six Exopathic Factors Six exopathic factors are a collective term used for six kinds of exogenous pathogenic factors including wind, cold, summer-heat, dampness, dryness and fire. Under normal conditions, wind, cold, summer heat, dampness, dryness and fire are called "six climatic factors," being normal climatic changes in nature. As humans have developed certain adaptive powers in life the six climatic factors do not normally cause disease. Only when the climatic change is sharp or the resistance of the body becomes weak, the six climatic factors will become pathogenic factors, thus causing the body to fail ill. The six climatic factors are then called six exopathic factors. Since six exopathic factors are abnormal, they are also referred to as the "six evils," and are causes of exogenous diseases Wind Wind prevails in spring, but it may occur in any season. While invasion by wind evil may often occur in spring, it is not limited to spring. Wind evil mostly invades the body from the surface to cause exogenous diseases. In TCM it is thought that wind evil is a very important pathogenic factor in causing exogenous diseases. The nature and pathogenic character of wind evil are as follows: (1) Wind is a yang evil, and is characterized by dispersing. Wind evil tends to move constantly, possessing a nature of dispersal, upward and outward movement, and thus belongs to yang. The dispersal means that when it invades the body, it tends to loosen the striae of the skin and muscles, and open the pores. Wind evil is apt to invade the upper portion of the body (head and face) and body surface, resulting in headache, sweating, and aversion to wind. (2) Wind is characterized with constant movement and rapid change. "Constant movement" implies that the diseases caused by wind evil possess the feature of migration. For example, in a bi (arthralgia) syndrome caused by invasion of wind, cold and dampness, if the arthralgia is migratory, and on and off, it is a case in which wind evil prevails. It is thus called "xing bi" (migratory arthralgia) or "feng bi" (wind arthralgia). "Rapid change" denotes that disease caused by wind evil is characterized by sudden attack and quick transformation. For instance, the urticaria is changeable in location and rising one after another, with cutaneous pruritus. In addition, exogenous 34

35 diseases caused mainly by wind evil are generally abrupt in onset and rapid changing. (3) Wind is characterized by sway. This means that the symptoms and signs of a disease caused by wind evil have the character of constant moving, including tremor, convulsion, and vertigo. (4) Wind is the first and foremost factor in the cause of disease. Wind, a leading exopathic factor, is the precursor of exogenous evils causing disease and other evils usually follow wind to invade the body. For example, wind-cold, wind-heat, and wind-dampness may attack to the body exogenously Cold Cold is prevalent in winter. There is a difference between exogenous cold and endogenous cold in disease. Exogenous cold means that cold evil attacks the body from outside. In diseases caused by exogenous cold there is a difference between cold-attack and cold stroke. A case in which cold evil attacks the body surface and depresses the defensive yang is known as a "cold-attack, while a case in which cold evil directly invades the interior and damages the visceral yang-qi is called "cold-stroke. "Endogenous cold is the pathological state resulting from the failure of yang-qi to warm the body due to its deficiency. While exogenous cold and endogenous cold are different, they are mutually related and influence each other. A patient with endogenous cold due to deficiency of yang is predisposed to an invasion of an exogenous cold evil; whereas exogenous cold evil invading and staying in the body for a long period of time is likely to damage yang-qi, and can lead to endogenous cold. The Nature and Pathogenic Character of Cold Evil (1) Cold is a yin evil, and apt to damage yang-qi. Cold is an expression of excessive yin-qi, belonging to yin. Invasion of cold evil is thus apt to damage yang-qi in the body. For example, as cold evil attacks the exterior, defensive-yang will be depressed, and can cause aversion to cold. Cold evil which directly invades the spleen and stomach damages spleen-yang and can result in epigastric pain with a cold feeling, vomiting, and diarrhea. (2) Cold is characterized by stagnation, condensation, and obstruction. Invasion of the body by cold evil may cause stagnation of qi and blood in the meridians, thus giving rise to various kinds of pain. (3) Cold is characterized by contraction, traction, and constriction. When cold evil invades the body it may depress qi movement, and constrict and tighten the striae, meridians and tendons. If cold evil attacks the body surface, the pores and striae may close up and resulting in a depression of defensive yang, and chills, fever, and anhidrosis might follow. If cold evil invades and stays at the blood vessel level, the flow of qi and blood will stagnate, the vessels will contract, and pain might appear in the head and trunk, along with a tense pulse. If cold evil invades the meridians and joints, the meridians and tendons will tighten and contract, with spasm and pain of the limbs 35

36 and joints and impaired movement Summer-heat Summer- heat prevails in summer, being derived from fire and beat. It is remarkable in that it only appears in summer. Summer-heat is a pure exogenous evil, and there is no such thing as endogenous summer heat. The nature and pathogenic character of summer-heat evil are as follows: (1) Summer-heat is a yang evil characterized by burning heat. Summer heat is transformed from the fiery hotness of summer. As fiery hotness belongs to yang, summer heat is a yang evil. Invasion of the body by summer heat evil often results in high fever, fidgets and thirst, flushed face, and a surging pulse. (2) Summer-heat is characterized by rising and dispersion, and apt to consume qi and body fluids. Invasion of the body by summer heat tends to make the striae of the skin and the muscles open, resulting in heavy sweating. Too much sweating consumes body fluids, and a shortage of body fluids may in turn lead to thirst, deep yellow and scanty urine. When heavy sweating occurs, qi escapes with release of body fluids, resulting in qi deficiency. This may then lead to shortness of breath, lassitude, sudden collapse, or loss of consciousness. (3) Summer-heat often combines with dampness. In summer, it is often rainy and is moist. Heat evaporates damp, increasing the level of humidity. Invasion of summer-heat, therefore, often combines with damp evil to attack the body. In addition to fidget and thirst, lassitude with a heavy sensation of the limbs, chest distress, nausea, vomiting, and sticky and loose stools usually appear Dampness Dampness is prevalent in late summer. The period when summer is changing into autumn is the time of the year with the most humidity. There is a difference between exogenous damp and endogenous damp in disease. Exogenous damp is a pathogenic factor invading the body from outside when the climate is damp; for example being caught in rain, or living in a damp condition. Endogenous damp is a pathological state when water-damp accumulates internally, which is usually caused by failure of the spleen in transportation. Exogenous damp and endogenous damp are different, but they often influence each other in the onset of disease. Exogenous damp that invades the body from outside usually affects the spleen, making the spleen fail in transportation, and thus causes formation of damp internally. However, a patient with retention of water-damp internally due to deficiency of spleen-yang is predisposed to invasion of exogenous damp. The nature and pathogenic character of damp evil are as follows: (1) Dampness is a yin evil, apt to damage yang-qi and hinder the movement of qi. The nature of damp is similar to that of water, and thus it is a yin evil. When invading the body, a damp evil is most likely to damage yang qi. Damp evil weakens the spleen 36

37 and makes the spleen yang hypoactive, fail in transformation and transportation, and give rise to diarrhea, oliguria, and edema. When attacking the body and staying in the viscera and meridians, a damp evil is apt to depress the movement of qi, leading to disharmony of qi in ascending and descending, and obstruction of the meridians with chest distress, epigastric distention, dysuria with scanty urine, and dyschesia with mucous in the stool. (2) Dampness is characterized by heaviness and turbidity, and tends to sink downward. Heaviness caused by damp evil usually has symptoms such as a heavy sensation in the head, general lassitude, aching and a heavy feeling in the limbs. Turbidity means that diseases caused by damp evils are represented by filthy and foul discharges or secretions, such as a dirty complexion with hyper-secretion in the eyes, pus, bloody stools, turbid urine massive leukorrhea in female, or eczema with filthy purulent fluid. Sinking downward means the symptoms of diseases caused by damp evil mostly appear in the lower part of the body, such as leukorrhea, stranguria with turbid urine, and diarrhea or dysentery. (3) Dampness is characterized by viscosity and stagnation and appears in two ways. First, in symptoms, such as an invasion by damp evil leading to sticky, greasy discharges and secretions. The other is in the course of a disease-damp evils usually have a long course, relapse repeatedly, and are lingering and difficult to cure. Damp bi (arthralgia), eczema, and damp-warm disease are but a few examples Dryness Dryness is prevalent in autumn. The climate in autumn is dry, and the atmosphere is lacking in moisture. As a result, dry diseases often occur. Dryness invades the body mostly via the mouth and nose to attack the lung defense. There are differences between warm dryness and cool-dryness diseases. In early autumn summer heat lingers, and dryness combines with warm-heat to invade the body, leading to a warm-dryness disease. In late autumn, early winter cold appears, dryness and cold usually associate with each other to attack the body, and thus cool-dryness disease. The nature and pathogenic character of dryness evil are as follows: (1) Dryness is characterized by aridity. Exogenous dryness evils invading the body are most likely to consume body fluids, resulting in various dry symptoms and signs, such as dry mouth and nose, thirst, dry, rough and chapped skin, dry hair, scanty urine, and constipation. (2) Dryness is prone to impair the lung. The lung is a "delicate organ," desiring moisture and has an aversion to dryness. Lungs govern qi and control respiration, are related externally to the skin and hair, and open to the nose. Therefore, a dry evil invading the body via the mouth and nose is most likely to consume lung fluids, making the lungs fail in dispersing and descending with such symptoms as a dry cough with 37

38 little sputum, or sticky sputum that is difficult to be coughed out, blood tinged sputum, asthma, and chest pain Fire Fire and heat are both yang in nature and may be collectively looked upon as fire-heat. Though they are similar, yet there are still differences. Heat is the lesser stage of fire, and strong heat results in fire. Heat is mostly from the outside, such as wind-heat, summer heat, and damp-heat, while fire is usually generated from the inside, such as flaring up of the heat-fire, hyperactivity of liver-fire, and gallbladder-fire. Both exogenous and endogenous diseases are caused by fire and heat. Exogenous diseases mainly originate from a direct invasion of a warm-heat evil exogenously. Endogenous diseases often develop from hyperactivity of yang-qi due to disturbance of visceral yin-yang and qi blood. In addition, invasion of the body by wind, cold, summer heat, dampness, dryness, or emotional stimulation may all give rises to fire under certain conditions. It is thus said that the "five climatic factors generate fire" and "five emotional factors generate fire." The nature and pathogenic character of fire evil are as follows: (1) Fire is a yang evil characterized by burning heat. Yang is characterized by restlessness and an upward direction. Fire (heat) burns and leaps up, and thus fire is a yang evil. Therefore, invasion of the body by fire often leads to high fever, aversion to heat, fidgets, thirst, sweating, and a surging and rapid pulse. (2) Fire is characterized by flaring up. Diseases caused by fire evil mostly have symptoms in the upper part of the body, such as in the head and face. Fire evil invading the body often goes upward to disturb the heart spirit, marked by fidgets with insomnia, mania, and even coma and delirium. If heart-fire flares up, it will lead to a red tongue tip and mouth or tongue ulcers. If stomach fire is flourishing, it will cause toothache with swelling gums. If liver fire flares up, it will result in red eyes with swelling and pain. (3) Fire is likely to consume qi and fluids. Fire evil invading the body is most likely to result in a loss of fluids and consumption of yin-fluids, thus symptoms of thirst with a desire for drink, dryness in the throat and tongue, deep yellow urine scanty in volume, and constipation appear. Fire evil consumes anti pathogenic-qi. So, diseases caused by fire evil may have the symptoms of shortness of breath, reluctance to talk, and general weakness. (4) Fire is apt to stir up wind and cause bleeding. Fire evil invading the body often heats the liver meridian to consume yin-fluids, which in turn deprives the tendons of nourishment. As a result, it leads to an internal stirring of liver-wind, called "wind resulting from extreme heat," marked by high fever, coma, delirium, convulsive limbs, upward starting of the eyes, rigid neck, and opisthotonos. At the same time, fire evil may accelerate blood circulation, burn the vessels, force blood to flow out of the vessels 38

39 and lead to bleeding such as hematemesis, epistaxis, hemafecia, hematuria, ecchymosis, and uterine bleeding. (5) Fire is likely to cause pyogenic infection. Invasion of a fire evil into the blood level may accumulate in a local area, weakening muscles and thinning blood. It will also result in carbuncles and abscesses marked by redness, swelling, hotness and pain, pyogenesis, and ulceration. In addition, fire corresponds with the heart. The heart governs blood and vessels, and houses spirit. Flaring fire in addition to the symptoms of blood-heat bleeding, may Rive rise to restlessness, fidgets, delirium, mania or coma syndromes of fire evil disturbing the heart Pestilent Factors Pestilent factors are very infectious pathogenic factors. In TCM literature pestilent factors have been recorded and include pathogenic agents, toxic qi, and special evils. Invasion of pestilent factors have the features of abrupt attack, a serious condition, similar symptoms, and an intense epidemic infection. Pestilent evils may be transmitted by air or contact and often invade the body through the mouth and nose. Diseases caused by pestilent factors may occur sporadically or pandemically and examples include erysipelas of the face, mumps, fulminate dysentery, diphtheria, scarlatina, smallpox, cholera and plague. In fact, these all include many epidemic and intense epidemic diseases. The occurrence and epidemic of pestilential diseases usually involve the following factors: (1) Natural Climatic Factors Abnormal changes in the climate including prolonged drought, flooding, burning heat, bad fog, and natural disasters such as earthquakes. (2) Environment and Diet These include air, water and food pollution. (3) Social Factors Warfare or germ warfare, conditions of poverty, and, social turbulence may all lead to epidemics of pestilential diseases. (4) Prevention of Disease and Immunity The body may acquire immunity (even life long immunity) after an invasion by pestilent factors. TCM practitioners as early as the tenth century have realized how to strengthen the immune system, the forerunner of world artificial immunity The Seven Emotions The seven emotions include joy, anger, melancholy, thinking, sorrow, fear and fright. All psychological states of the body and seven emotions are different reflections of the body to objective things, and under normal conditions generally do not cause diseases. Sudden, intense or prolonged emotional stimulation beyond the regulatory range of physiological activities of the body can cause disturbances of qi movement, disorders of yin yang and the qi-blood of viscera thus giving rise to the onset of disease. As they are 39

40 major pathogenic factors in causing endogenous diseases, they are also known as the "endogenous even emotions." Relations of the Seven Emotions to Qi-Blood and Viscera TCM theory holds that emotional activity is closely related to the viscera, and function al activities of the viscera depend on the driving and warming actions of qi, and the nourishment of blood. A viscus is generally related with an emotion, i. e., the heart is associated with joy, the liver anger, the spleen thought, the lungs melancholy, and the kidneys fear. Joy, anger, thought, melancholy and fear are collectively known as the "five emotions." Different emotional changes have different impacts on the viscera, and changes in qi-blood and the viscera also influence emotional changes Pathogenic Character of the Seven Emotions There are differences between the seven emotions and six exopathic factors in their pathogenicity. Six exopathic factors invade the body through the skin or mouth and nose. At the early stage, the disease is an exterior syndrome. An endogenous injury by the seven emotions however, directly affects the relative viscus, causing a disorder of qi movement in the viscus, a disturbance of qi-blood, and thus resulting in a variety of diseases. (1) Direct Injury of the Viscus In the Su Wen (Plain Questions) it is stated that "rage hurts the liver," "overjoy hurts the heart," "overthinking hurts the spleen," "grief hurts the lungs" and "great fear hurts the kidneys." Since the heart governs the spirit, it is the master of five zang and six fu viscera. If the heart-spirit is damaged, it will involve other viscera. The heart governs blood and houses the spirit. The liver is in charge of the smooth of qi, and stores blood. The spleen governs transformation and transportation, is located in the middle jiao, is the hub of qi movement in ascending and descending, and is the source for generation of qi and blood. The diseases and syndromes caused by emotional factors, therefore, are often seen in the heart, liver and spleen, and in disturbances of qi-blood. For example, overthinking and overstrain of mind often harm the heart and spleen, leading to a deficiency of both qi and blood in the heart and spleen. This condition is seen as a disorder of the heart spirit and failure of the spleen in transformation and transportation. Emotional depression and rage harm the liver, rage causes qi to rebel upward, and blood follows adverse qi, and thus hypochondriac distension or sighing are seen in liver qi stagnation in the liver meridian. Hypochondriac pain, menorrhagia, amenorrhea, and abdominal masses are seen in qi stagnation with blood stagnation. In addition, endogenous injury by emotional factors may also cause formation of fire, or what is known as the "five emotions turning into fire." This may lead to flaming up of fire with yin deficiency, or stagnation of damp, food and phlegm. (2) Influence on Qi Movement of the Viscera To quote from the Su Wen (Plain 40

41 Questions) "Rage causes qi to go upward, overjoy causes qi to relax, grief causes qi to be consumed, great fear causes qi to sink, great fright causes qi to become disordered, over thinking causes qi to be depressed." Rage causes qi to go upward and as an example overanger may cause liver qi to go adversely upward, blood following with it. Clinical manifestations of this condition are a flushed face with congested eyes, hematemesis, and even syncope. Overjoy causes qi to relax, and might relax mental tension or make the heart qi sluggish. Under normal conditions, joy can relax mental tension, making the circulation of qi and blood smooth and putting the mind at ease. However, too much joy will make heart qi sluggish, and the spirit will be unable to rest, manifesting with absent mindedness, and mental confusion. Grief causes qi to be consumed. Great sorrow will result in depression and consumption of lung qi, marked by despondency, listlessness shortness of breath, and lassitude. Great fear causes qi to sink. Great fear will make the kidney qi unconsolidated and sink downward. Clinically there might be incontinence of both urine and feces, soreness and weakness of the bone, and spermatorrhea due to damage of the essence by prolonged fear. Great fright causes qi to become disordered. Sudden fright makes the heart lose its base, and the spirit lose its house. As a result the individual will hesitate and be panic stricken. Overthinking depresses qi. Overthinking and anxiety can harm both the spleen qi and the heart spirit. Overthinking may also cause the consumption of the heart-blood and result in a loss of nourishment for the heart spirit, manifesting with palpitation, amnesia, insomnia, and dreaminess. Overthinking may also lead to qi stagnation, causing the spleen to fail in transformation and transportation, and the stomach to fail in receiving and digestion. Thus loss of appetite, abdominal distention, and loose stool may occur. (3) Emotional upset may aggravate the patient's condition or rapidly exacerbate it. For example, if a patient with a history of hypertension becomes enraged, liver yang will suddenly rise, and blood pressure will rapidly increase. This can result in dizziness, sudden coma, hemiplegia, and deviation of the eye and mouth. A patient with heart disease may be aggravated by emotional upset Dietary Factors, Overstrain and Overease Proper diet, work and rest are indispensable to human life. However, diet should be moderate, with reasonable amounts of work and rest. Otherwise, they will negatively influence the physiological functions of the body, disordering qi movement, damaging antipathogenic qi, and hence disease will ensue Dietary Ignorance Food and drink are essential materials for the body to get nourishment and maintain 41

42 its vital activities. However, an immoderate, unsanitary or imbalanced diet may be important factors leading to disease. Food and drink mainly depend on the digestion of the spleen and stomach. So, dietary ignorance mainly damages the spleen and stomach, disorders the ascending and descending of qi, can lead to accumulation of dampness, production of phlegm, generation of heat, or other disorders. (1) Immoderate Diet It is good to be moderate in eating and drinking. Starvation or overeating may result in disease. Starvation may lead to a reduction of the source of production of qi and blood due to shortage of food. After a period of time, it will result in deficiency of qi and blood and cause disease. Meanwhile, because of deficient qi and blood, the antipathogenic qi becomes weak, and the strength of resistance decreases. The body will then be subject to invasion by exopathic factors and other diseases. Overeating and fullness may cause stagnation of food and drink and harm the spleen and stomach due to intake beyond their capacities of digestion and absorption. As a result, epigastric or abdominal distention with pain, foul belching and acid regurgitation, anorexia, vomiting, and diarrhea with foul and stinking stools will become evident. (2) Unsanitary Diet Intake of dirty food may cause a variety of gastrointestinal diseases, marked by abdominal pain, vomiting, diarrhea, and dysentery. Some parasitic diseases caused by roundworm, hookworm, and tapeworm will be marked by a sallow complexion with emaciation, paroxia, and abdominal pain. If the roundworm enters the biliary tract, it will result in "hui jue" (colic syndrome caused by roundworm) with symptoms of acute paroxysmal epigastric pain, cold limbs, and even vomit of roundworm. If poisonous or stale food is ingested, it will often lead to acute abdominal pain, vomit, diarrhea, or in severe cases even coma and death. (3) Particular Diet Diet should be reasonably regulated and only in this manner can it supply the nutrition demanded by the body. An improper diet easily results in a deficiency of nutrients, or an excess of a food group can both lead to a decline of either yin or yang, and hence disease. For example, rickets and night blindness are the outcome of malnutrition. Excessive intake of raw or cold foods may easily damage spleen yang, leading to a formation of internal cold damp resulting in abdominal pain, and diarrhea. Over consumption of greasy or spicy foods or indulgence in alcohol may lead to the formation of damp heat, phlegm, stagnation of qi and blood, and thus, bleeding hemorrhoids, carbuncles and sores Improper Work and Leisure Improper work and leisure include over strain and over-ease. Appropriate work and physical exercise are helpful in maintaining the proper circulation of qi and blood, and at the same time build-up the physique. Suitable rest can dispel tiredness and restore the energy of both body and mind. Prolonged over-work, or over-ease may cause disease. (1) Over-work includes three aspects: physical over strain, mental over-strain and sexual over-strain. 42

43 Physical overstrain is a long period of physical over-work leading to disease. Over straining the body consumes qi, leading to a deficiency of qi over a period of time. Manifestations including feebleness, lassitude, reluctance to talk, listlessness, shortness of breath on exertion, and sweating can be indicative of qi deficiency. Mental overstrain relates to over thinking and harms the spleen and heart. Mental over-strain consumes heart blood and harms spleen qi, and leads to the heart spirit losing its nourishment. This condition can manifest with palpitation, amnesia, insomnia and dream disturbed sleep, in addition to a failure in transport and transformation, poor appetite, abdominal distention, and loose stools. Sexual over strain implies intemperance in sexual activities or excess sexual intercourse. It consumes kidney-essence, resulting in aching and weakness of the lower back and knee joints, dizziness, tinnitus, lassitude and listlessness, spermatorrhea, premature ejaculation, impotence, menstrual disorders and leukorrhea. (2) Over-ease Over-ease includes lack of work and exercise. The human body needs suitable physical exercise everyday for good circulation of qi and blood. Over-ease may cause stagnation of qi and blood, flaccid tendons, weak bones, and hypofunction of the spleen and stomach manifesting with listlessness, general weakness, poor appetite, palpitation, dyspnea and sweating on just a little exertion, obesity, weak resistance against disease, and being subject to invasion of exopathic factors Traumatic Injuries These include gunshot wounds, incised wounds, bruises, sprains, scalds, burns, frostbite, and insect or animal bites. Gunshots, incisions, bruises, sprains, etc. may cause skin and muscle blood stagnation with swelling and pain, bleeding, injury of the tendons, fracture of the bones, and dislocation. In severe cases they can damage the internal organs, and with heavy bleeding coma, convulsion, depletion of yang, and collapse may result. Scalds and burns are usually caused with high temperatures, boiling water, hot oil, or fire. In mild eases, there is only injury to the skin, and the area may be red, swollen, hot, painful, or blistered. In severe cases, the muscles, tendons, and bones may be damaged, with analgesia, leathery, waxy, or brown, wounds. In more serious eases with the extensive wounds, there are, in addition to local symptoms, acute pain, exudate, fidgets, fever, thirst, oliguria, or even death. Frostbite is a general or local injury caused by an invasion of the body by s low temperature. The lower the temperature, and the longer the time of exposure to cold, the more severe the frostbite. The manifestations of general frostbite are chill, lower body temperature, listlessness, coma, feeble respiration, and a slow and thready pulse. If not treated immediately, the patient can die. Local frostbite often occurs in the hands, feet, and tips of the ears, nose, and cheeks. In the beginning frostbitten skin is pale, cold and numb, gradually becoming swollen and purplish, with an itching, painful, burning 43

44 feeling, or with small or large blisters that often cause infection after ulceration. Insect or animal bites include bites of poisonous snakes, dogs, or stings of scorpions and wasps. In mild cases there might be a local injury, manifesting with swelling and pain, or bleeding. In severe cases, internal organs may be damaged, or heavy bleeding can ensue leading to death. In the case of poisonous snakebite symptoms of general intoxication might appear. If not promptly treated the patient may die. In the case of a mad dog bite, at the beginning there might be local pain and bleeding. After the wound heals and a period of incubation, fidgets, panic, lockjaw, convulsion, hydrophobia, and amenophobia might appear Phlegm, Stagnant Fluids, and Stagnant Blood Phlegm, stagnant fluids, and stagnant blood are the pathological outcome of the course of disease due to pathogenic factors. Once formed, they may directly or indirectly disturb viscera and tissues, resulting in new disorders. Hence they are also pathogenic factors Phlegm and Stagnant Fluids (1) Phlegm and Stagnant Fluids Phlegm and stagnant fluids are the pathological result of a water metabolism disorder. Generally, phlegm is thick and turbid, and stagnant fluid is thin and clear. Phlegm not only implies sputum that is coughed up and visible, but also includes phlegm that is seen such conditions as scrofula, subcutaneous nodules, or stagnate in the viscera and tissues. The latter can be determined by the syndrome caused by it, and is known as "invisible phlegm." Stagnant fluid implies body fluid accumulation in a certain area of the body. According to the place where it accumulates and the symptoms it causes, it is known by different names. (2) Formation of Phlegm and Stagnant Fluids Phlegm and stagnant fluids farm as body fluid stagnates in water metabolism disturbances due to dysfunctions of the lungs, spleen, kidneys and san-jiao in qi transformation. This condition is usually caused by an exogenous invasion of the body by one of the six-exopathic factors, by endogenous injury of the body by dietary ignorance or the seven emotions. The retained water may become phlegm when it is simmered by yang-qi, and condense to stagnant fluids when it meets yin qi. After formation, stagnant fluids usually stay in the stomach, intestines, hypochondrium, chest, and subcutaneous areas. Phlegm follows the ascending and descending of qi into the viscera internally, and tendons, bones, skin and muscles externally, leading to a variety of disorders. Therefore, there is a saying in TCM that "hundreds of diseases are caused by phlegm." (3) Character of Disorders Caused by Phlegm and Stagnant Fluids The disorders have different manifestations clinically according to the location of the phlegm and stagnant fluids. When they block meridians, they may adversely influence the circulation of qi, 44

45 blood and physiological functions of the meridians. When stagnating in the viscera, they may influence the functions of the viscera and the ascending-descending movement of qi. A. The character of disorders caused by phlegm includes visible phlegm such as sputum that is coughed out. Invisible phlegm may cause different symptoms based on the different places it settles. For example, phlegm staying in the lung may cause cough, asthma and expectoration; phlegm in the heart may cause chest distress and palpitation due to an unsmooth flow of heart blood; phlegm confusing the heart orifice may cause coma and dementia; phlegm-fire disturbing the heart may cause depression and mania: phlegm in the stomach may lead to a failure in the descending of stomach qi, marked by nausea, vomiting, epigastric distress and fullness; phlegm in the meridians, tendons and bones may cause scrofula, phlegm nodules, numbness of the limbs, hemiplegia, yin carbuncles and multiple abbesses. Turbid phlegm rising upward to the head may cause dizziness and vertigo, and phlegm and qi gathering at the throat may result in the symptom of feeling a foreign body blocking the throat, something that can neither be swallowed down nor brought up. B. The character of disorders caused by stagnant fluids includes it settling in the intestines, called "gastrointestinal fluid retention." This condition may cause a gurgling sound of the intestines. Stagnant fluid retention in the chest and hypochondrium are known as" suspended fluid retention" and may cause distention in the chest and hypochondrium, and induce pain upon coughing and spitting. Stagnant fluid retention in the chest and lungs is known as "propping fluid retention," and leads to chest distress, cough, asthma, failure to lay down flat, and puffiness. Stagnant fluids overflowing into the subcutaneous areas is known as "spilling fluid retention," and may cause general edema, anhidrosis, along with pain and heaviness of the limbs. In addition, TCM practitioners often comprehensively analyze and determine disorders caused by phlegm and stagnant fluids according to the tongue coating (glassy or sticky) and pulse (smooth or wiry) Stagnant Blood (1) Stagnant Blood Extravasated blood that is held within the body, flows sluggishly and stagnates is one example of blood stagnation. Stagnant blood is the pathological outcome of the progression of a disease. It is also a pathogenic factor for some diseases. (2) Formation of Stagnant Blood There are two main aspects involved in the formation of blood stagnation. One type of blood stagnation is due to circulatory retardation caused by various factors including qi deficiency, qi stagnation, blood-cold and blood-heat. Qi is the commander of blood, and deficient or stagnate qi cannot properly circulate blood. Other possible causes of blood stagnation include a cold evil invading the blood vessels, making the vessels contract and spasm or a heat evil 45

46 invading the blood vessels and mingling with blood. Secondly, extravasated blood held by the body caused by various traumas, a deficiency of qi and thus lack of controlling blood, or an abnormal increase in blood circulation are also factors in blood stagnation. (3) Character of Blood Stagnation Disorders Disorders caused by blood stagnation is differentiated by their location and cause and clinically manifest differently. For example, stagnant blood in the heart may cause palpitation, chest distress and cardiodynia; stagnant blood in the lungs may cause chest pain and hemoptysis; stagnant blood in the stomach and intestines lead to hematemesis and melena; stagnant blood in the liver may cause hypochondriac pain and abdominal masses; stagnant blood invading the heart may cause mania; stagnant blood in the uterus may cause pain in both sides of the lower abdomen, menstrual disorders, dysmenorrhea, amenorrhea, deep colored menstrual flow with clots, metrorrhagia and metrostaxis. Stagnant blood in the ends of limbs may cause gangrene of the fingers or toes and stagnation of blood blocking a local region of the body surface may cause local swelling, pain and purplishness. The disorders caused by stagnant blood are complicated, but their clinical manifestations can be summarized by the following common aspects such as a generally stabbing, fixed pain which is aggravated by pressure and is worse at night. In the case of trauma there may appear purplish swelling at the traumatized surface area and when blood stagnates in the interior of the body in a protracted course, immobile abnormal masses may occur. In menstrual bleeding, the blood is often purplish with clots. Upon inspection, a patient with a long history of blood stagnation may appear with a deep colored complexion, squamous and dry skin, purplish lips and nails, a dark purplish tongue with echymoses and petechiae, and sublingual varices. The pulse will be thready, unsmooth, deep and wiry, or knotted and intermittent. 5.2 Pathogenesis Pathogenesis is the mechanism of onset, development and change of a disease. The onset, development and change of disease are related to the strength and physique of the patient and the nature of the pathogenic factors. Pathogenesis includes two aspects, the attack mechanism and basic pathogenesis Attack of Disease Under normal conditions, the viscera and meridians of the body function well physiologically and qi blood and yin-yang are in a harmonious balance. This state is known as "yin calms and yang steadies. When the body is invaded by pathological factors, the physiological functions of the viscera and the meridians become disordered, and the harmonious balance of qi blood and yin yang break down, leading to an "imbalance of yin and yang" manifested by various clinical symptoms as well as the onset of a disease The Onset of Disease, Anti-pathogenic-qi and Pathogenic Factors 46

47 Anti-pathogenic qi, also known as "the vital," includes functional activities (including the functions of the viscera, meridians, qi and blood) and the resistance and recovery capacity of the body. Pathogenic factors generally include various factors causing disease and are known as "the evils. " The onset and change is a reflection of the struggle between the vital and evils in a certain condition. (1) A deficiency of anti pathogenic-qi is the first step in the onset of a disease. The pathogenesis of disease in TCM attaches a great importance to anti pathogenic qi. It is believed that when anti pathogenic qi is vigorous, qi and blood are abundant, external defensive power is strong pathogenic factors cannot invade the body, and disease will not occur. When anti-pathogenic-qi becomes relatively weak, the defensive power externally unconsolidated, resistance is not sound, and pathogenic factors invade the body, leading to disease. (2) The invasion of pathogenic factors play a significant role in the onset of a disease In TCM weak anti pathogenic-qi is emphasized in leading to the onset of disease. However, TCM does not rule out pathogenic factors, which are a requirement for the onset of disease, and at times even play dominant roles in disease onset. Two examples might be diseases caused by pestilent factors or traumatic injury. Therefore, when talking about prevention of various infectious diseases, the Su Wen put forth that in addition to the importance of maintaining vigorous anti pathogenic qi, one must also strive to "keep away from the toxic." The Vital and the Evil The struggle between anti-pathogenic-qi and pathogenic factors not only involves the onset of a disease, but also governs the development and prognosis of the disease. (1) When the vital defeats the evil, no disease occurs in the process of the struggle between the vital and the evil, if the anti pathogenic-qi is vigorous and strongly fights against the pathogenic factors, the latters will fail in invading the body, or will be promptly eliminated by the anti pathogenic qi. Thus, no pathologic change occurs and no disease appears. As an example, in nature various pathogenic factors exist, but not everyone exposed to them becomes ill. This is an example of the vital defeating the evil. (2) When the evil defeats the vital, disease occurs In the process of the struggle between the vital and the evil, if the pathogenic factor is superior in strength to the anti-pathogenic-qi, the evil will defeat the vital, leading to an imbalance of the yin-yang and qi-blood of the viscera, disorders of qi movement, and hence disease. After the onset of a disease, different syndromes may appear because of differences in the strength between anti-pathogenic-qi and pathogenic factors, the quantity of the invading evil, and the depth or location of the pathogens. The relation of disease to the strength of anti-pathogenic-qi plays an important role in one' s health. Vigorous anti-pathogenic-qi fights strenuously against pathogenic factors and is usually marked as an excessive syndrome. While weak anti-pathogenic-qi fights 47

48 weakly against pathogenic factors, it often manifests as a deficient syndrome or s mixed syndrome of deficiency and excess. The relation of disease to the nature of the invading evil is often seen in terms of yin-yang. Generally, a yang-evil invasion is apt to lead to an exuberance of yang and consume yin, resulting in an excess-heat syndrome; a yin-evil is likely to cause an exuberance of yin and damage yang, and would be a cold excess or cold damp syndrome. The relation of disease to the quality of the invading evil is generally, the less the evil, the milder the disease and the more of an evil, the more severe the disease. The relation of disease to a given location represents different syndromes as the pathogenic factors may invade tendons, bones, meridians, and or viscera Various Factors Influencing Anti-pathogenic-qi TCM theory holds that pathogenic factors (evils) are the significant condition in the onset of a disease, and deficiency or relative deficiency of anti-pathogenic-qi is the internal ground in onset of disease. The major factors that influence anti-pathogenic qi are the constitution and psychological state of a patient. (1) The Relation of the Constitution to Anti-pathogenic-qi A person with a strong constitution, fully functioning viscera, abundant essence, qi, blood, body fluids, is seen as having strong anti-pathogenic-qi. A person with a weak constitution has weakly functioning viscera, deficient essence, qi, blood, body fluids, is looked upon as having weak anti-pathogenic-qi. The constitution of an individual is related to heredity, nutrition, and physical training. Generally, one with an ample endowment from her or his parents enjoys a strong physique while one with a deficient endowment has s weak physique. A reasonable diet and proper nutrition are essential for a person to grow and develop. Lack of food and or malnutrition will decrease the formation of qi and blood and in turn lead to a weak physique. Eating and drinking too much at one meal will damage the spleen and stomach. An improper diet will cause an imbalance in nutrition and also adversely influence the physique. Physical training and work may maintain the smooth circulation of qi and blood and at the same time keep one fit. Over-ease and a lack of exercise will harm (decrease) the circulation of qi and blood, define the functions of the spleen and stomach and ultimately result in a weak physique. (2) The Relation of the Psychological State to Anti pathogenic-qi The psychological state of an individual is directly influenced by emotional factors. A relaxed mind and happy feeling contribute to s smooth movement of qi, harmony of qi and blood, and cooperative functions of the viscera, thus, the anti-pathogenic qi will be vigorous. Conversely, an uneasy mind and depressed feeling may cause disturbances of qi movement, imbalances of yin yang and qi blood, and dysfunctions of the viscera, hence, weak anti-pathogenic-qi. Therefore, when one pays attention to mental hygiene, keeps an easy mind, and is absent of strong desires the genuine qi will be harmonious 48

49 and the individual will be full of go. Briefly, deficiency of anti-pathogenic-qi is the internal mechanism of the onset of a disease. The constitution and psychological state concern the strength of the anti pathogenic qi. A strong constitution and happy mood contribute to sound anti-pathogenic-qi with strong resistance, in which case pathogenic factors won't be able to invade the body. Or if they are able to invade the body, they are easily driven out and disease would not develop. If the constitution is weak and the mood is unhappy, the anti pathogenic-qi will be deficient, resistance weak, and thus the body will be easily invaded by the pathogenic factors to cause disease Basic Pathogenesis Pathology means the mechanism of onset, development and change of disease. The on set, development and change of disease are related to the strength of constitution of the patient and the nature of pathogenic factors. When a pathogenic factor invades the body, anti-pathogenic-qi fights against the evil and leads to a struggle between the vital and the evil. This in turn leads to break down of the relative balance of yin and yang in the body, disorders the ascending and descending qi movements in the viscera, and disturbs the functions of qi and blood. As a result, a series of pathological changes occur. Diseases are complex and changeable, but their pathological processes generally fall under the struggle between the vital and the evil, imbalances of yin and yang, or disorders in the ascending and descending of qi The Struggle Between the Vital and the Evil The struggle between the vital and the evil means the struggle between the anti -pathogenic-qi and pathogenic factors. This kind of struggle not only concerns the onset of disease, but also governs the development and conversion of disease. Meanwhile, it also directly influences the deficient and excessive changes of a syndrome. Thus in one sense, the course of many diseases is the outcome of the struggle between the vital and the evil. (1) The struggle between the vital and the evil, and the deficient and the excessive is in a constant state of change. In their struggle, both the vital and the evil display signs of growth and decline. In general, as the vital grows the evil declines, and as the evil grows the vital declines. Following the outcome of the growth and decline of the vital and the evil, the patient will present with pathologies and syndromes of deficiency and excess. Excessive in this case means that the pathogenic factors are excessive. It is a pathological reflection indicating that excessive pathogenic factors are the principal aspect in the struggle of health and disease. When pathogenic factors are excessive, the anti-pathogenic-qi is in a state of decline but yet strong enough to fight against the pathogenic factors, thus the struggle between the vital and the evil is acute. Clinically 49

50 this condition is looked upon as an excess syndrome. It is often seen in the early or middle stages of exogenous diseases, and in disorders caused by stagnation of phlegm, food, blood or water. For example, such clinical symptoms as high fever, mania, speaking lustily, coarse breathing, abdominal pain aggravated by pressure, retention of urine and stool, and a forceful pulse all come under the category of excess syndromes. A deficiency implies that the anti-pathogenic-qi is deficient. This condition is a pathological reflection of deficient anti-pathogenic qi and is the principal aspect in such a syndrome. When pathogenic-qi is deficient and fails to fight against pathogenic factors, the pathological reaction lacks intensity, and clinically one might see a series of hypoactive and weak syndromes. Deficient syndromes usually occur in patients with a weak physique, in the late stage of a disease, or in chronic disease. Consumption of essential qi due to a serious or protracted disease, consumption of qi, blood, body fluids, or the yin-yang of the body due to hyper-hidrosis, profuse vomiting or diarrhea, may cause a deficiency of anti-pathogenic-qi with hypofunction, manifesting as listlessness, lassitute, a wan and thin appearance, palpitation, shortness of breath, spontaneous or night sweating, dysphoria with a feverish sensation in the palms and soles, an aversion to cold with cold limbs, and a feeble pulse. The struggle between the vital and the evil can not only give rise to deficient or excessive pathological changes, but also often lead to mixed deficiency and excess disorders caused by stagnation and blockage of phlegm, food, blood and water due to either damage of anti pathogenic-qi by a long term illness pathogenic factors or an original deficiency of anti pathogenic qi due to chronic, prolonged or complicated disease. In the clinic there are also cases of "excess syndromes with pseudo deficient symptoms" and "deficient syndromes with Pseudo-excessive symptoms" caused by either a failure of the circulation of qi and blood resulting from a blockage of a meridian by retention of substantial evils, or a hypo function of a viscera due to a deficiency of qi and blood. (2) The Struggle Between the Vital and the Evil and Conversion of Disease In the course of a disease the outcome of the struggle between the vital and the evil results in either a superiority of the vital with a decline of the evil (recovery) or a superiority of the evil with a deficiency of the vital (deterioration or death). If the vital and the evil are evenly matched in strength then it will result in a situation known as "the vital and the evil in a stalemate. Superiority of the Vital with a Decline of the Evil. In the struggle between the vital and the evil should anti pathogenic-qi be sufficient and resistance strong, pathogenic factors will have difficulty growing and the effects of such evils on the body will disappear or stop, the viscera and the meridians with 50

51 pathological injury will gradually recuperate, the essence, qi, blood and body fluids consumed will gradually be replenished, the dynamic balance between yin and yang will be restored, and the disease cured. For example, in exogenous diseases caused by one of the six exopathic factors, the pathogenic factors invading the body via the skin, hair, mouth and nose, when anti pathogenic qi is sufficient enough to fight against the evil, the disorder will not only be confined to the body surface or meridians, but the evil will later be driven out by anti pathogenic qi. Through diaphoresis, which can relieve the exterior and eliminate evils, the defensive and the nutritive qi will become harmonized, and hence the disease will be cured. Superiority of an Evil with a Deficiency of the Vital In a struggle between the vital and the evil should the pathogenic factors be excessive and anti-pathogenic-qi deficient, the resistance will become more and more insufficient and might not check the growth of pathogenic factors. This condition will result in the injury of the body pathologically and will become more and more serious. Hence, the condition of the patient will tend to deteriorate. If anti-pathogenic-qi collapses and pathogenic factors are rampant, the physiological functions of qi blood, viscera and meridians will become insufficient, and yin and yang will separate. Thus, the vital activities of the body will stop and the patient will die. Examples of this are the "depletion of yin" and "depletion of yang" in the progress of exogenous febrile diseases. In addition, in the struggle between the vital and the evil, if the two sides are evenly matched in strength the vital and the evil will be at a stalemate, the vital is deficient while the evil lingers, or the evil is will be eliminated while the vital is not yet restored. This is often seen in cases where diseases proceed from acute to chronic, the sequelae of disease and protracted diseases Imbalance of Yin-yang The imbalance of yin and yang is a pathological state in which either yin fails to check yang or yang fails to check yin, or when a superiority or inferiority of either yin or yang results from a loss of the relative balance between yin and yang due to pathogenic factors on the body. An imbalance of yin and yang is also a generalization of the disharmonious interrelations in viscera, meridians, qi blood, nutritive, and defensive qi, and a disorder of qi in ascending and descending. Since various pathogenic factors acting on the body such as the six exopathic factors, seven emotions, improper diet, and overstrain must lead to an imbalance of yin and yang in the body causing disease, the imbalance of yin and yang is again the foundation in the onset and development of disease. Though the pathological changes caused in an imbalance of yin and yang are very complicated, their manifestations, however, all come under the aspects of superiority of yin or yang, inferiority of yin or yang, mutual affecting of yin and yang, blockage of yin 51

52 or yang, and depletion of yin or yang. (1) The Superiority of Yin or Yang This condition which is an excess syndrome is summed in the following quote: "Exuberance of evil-qi leads to excess syndromes." An invading pathogenic factor is bound to associate itself with yin or yang. In other words, a yang-evil invading the body may cause a superiority of yang and a yin evil invading the body may cause a superiority of yin. Yin and yang have an inter-restrictive relationship. Yang is bound to wane as yin is waxing, and yin is bound to wane as yang is waxing. A superiority of yang will certainly check yin and cause a yin deficiency. A superiority of yin will also check yang and cause a yang deficiency. A superiority of yang is a pathological state that results in a course of a disease with hyperactive functions and surplus heat. The pathological feature is an excess heat syndrome resulting from exuberant yang without fin deficiency. The causative factors for a superiority of yang are mostly invasions by warm-heat evils of a yang nature, invasion by yin evils that turn into heat by later joining yang, fire transforming from extreme emotions, and or heat from qi stagnation, blood stasis, or food retention. Yang is characterized by heat, and is dynamic and dry. Thus a superiority of yang will cause an excess-heat syndrome manifesting with a high fever, flushed face, red eyes, restlessness, a red tongue with a yellow and dry coating, an abdominal distending pain which is aggravated by pressure, tidal fever, and delirium. Predominating yang makes yin suffer and in a syndrome of yang superiority yin deficient symptoms of thirst with a desire for cold drink, constipation, and scanty urine might also appear. The superiority of yin is a pathological state occurring in the course of a disease in which yin qi is prevailing with hypoactive functions, a decrease in thermo genesis, and an accumulation of pathological products metabolized. The main pathological feature is an excess-cold syndrome resulting from exuberant yin without yang deficiency. The causative factors for a superiority of yin mostly include an invasion by a cold-damp evil of a yin nature, or an excess intake of raw and cold food resulting in retention of cold damp in the middle-jiao This in turn leads to a failure of yang in checking yin and yin then becomes excessive. Yin is characterized by cold and stillness. A superiority of yin is often manifested with a cold body and limbs, a pale tongue, abdominal pain with a cold feeling aggravated by pressure, and loose stools. The previous are examples of a cold-excessive syndrome. Since predominating yin makes yang suffer, in a case of yin superiority, yang deficiency symptoms of aversion to cold, listlessness, and lying curled up might also appear. (2) The Inferiority of Yin or Yang This is a deficient syndrome known as an "inferiority of vital qi leading to a deficient syndrome." When there is loss of substance or a decrease in the function of yin or yang, it is bound to lead to a relative exuberance of the counterpart, developing respectively into pathological changes of a "superiority 52

53 of yin with yang deficiency," "inferior yang leading to a cold syndrome" (deficient cold); "hyperactivity of yang with yin deficiency," or "inferior yin leading to a heat syndrome" (deficient-heat). An inferiority of yang is a pathological state developed in the course of a disease manifesting with yang deficiency, and a hypofunction and shortage of quantity of thermogenesis. The main pathological feature is of a deficient-cold syndrome resulting from a relative exuberance of yin due to a failure of yang in checking yin. This is caused by yang deficiency. The causative factors are congenital defects, dietary ignorance, overstrain, or damage of yang-qi due to a protracted disease. An inferiority of yang leads to cold. Clinically this condition is often a deficient-cold syndrome manifesting with an aversion to cold, cold limbs, restlessness, lying curled up, abdominal pain responsive to warmth and pressure, loose stools, clear and profuse urine, and a slow and forceless pulse. An inferiority of yin is a pathological state that results in the course of a disease with consumption of essence, blood and body fluids, and hyperfunction of a deficient nature due to relative hyperactivity of yang because failure of yin to check yang. The pathological feature is a deficient heat syndrome resulting from relative exuberance of yang due to decreased action of yin in nourishing, calming and restricting yang-heat which is caused by deficiency of yin-fluids. Inferiority of yin is mostly caused by damage of yin by yang evils, consumption of yin by fire resulting from extreme emotional changes, or injury of yin due to protracted disease. An inferiority of yin leads to a heat syndrome. Clinical manifestations of a deficient beat syndrome are dysphoria with a feverish feeling in the five centers, tidal fever as if spreading out from steaming bones, a flushed face, emaciation, night sweating, a dry throat and mouth, a red tongue with little coating, and a thready, rapid forceless pulse. (3) The Mutual Affecting of Yin and Yang The mutual affecting of yin and yang, mean that in a deficiency of yin and yang, illness progresses and involves either yin or yang, resulting in a pathological state of deficiency of both yin and yang. The theory of yin affecting yang implies that because of a shortage of yin fluids, the illness involves yang-qi, leading to dyspoiesis or escape due to losing what it depends on; hence, on the basis of yin deficiency, there appears yang deficiency, forming a pathological state of deficiency of both yin and yang, but with more yin deficiency. For instance, in deficiency of kidney-yin, there is dizziness and vertigo, and soreness and weakness in the lower back and knees. Once the production of kidney yang is affected, it may lead to kidney-yang deficient symptoms such as impotence or cold limbs. The illness might then turn into a deficiency of both yin and yang due to yin affecting yang. Yang affecting yin originates from a deficiency of yang qi, and involves yin fluids, leading to dyspoiesis. 53

54 As a result due to yang deficiency, yin deficiency appears and develops into a pathological state of deficiency of both yin and yang, with a prevalence of yang deficiency standing out. For instance, edema due to yang deficiency with blood deficiency will affect production of yin-essence, and may be complicated by such fin deficiency symptoms as emaciation, dysphoria, or chronic convulsion. Then, the illness transforms into a deficiency of both fin and yang due to yang affecting yin. (4) Blockage of Yin or Yang Pathological changes in the imbalance of yin and yang include exuberant yin blocking yang and exuberant yang blocking fin. The mechanism of a blockage of yin or yang relates to yin or yang becoming so extreme that it condenses internally and holds its counterpart external, rendering yin and yang unable to hold together. This manifests as a cold syndrome with pseudo-heat symptoms or a heat syndrome with pseudo cold symptoms. Exuberant yin blocking yang is a pathological state of blocked yang due to a yin-cold evil which is excessive internally and forces yang-qi to go to the exterior. This leads to a lack of communication between yin and yang. The essence of yin-cold internal disease is exuberant. However, because yang is blocked externally, clinically thirst, and a large pulse appear. Thus it is called a cold syndrome with pseudo-heat symptoms. Exuberant yang blocking yin is a pathological state of yang-qi failing to move out and a blockage of yin externally because of condensed yang-qi causing extreme yang-heat located deep inside the body. The essence of the disease is exuberance of yang inside. However, because yin is blocked externally clinically the signs will manifest as pseudo-cold such as cold limbs, and a deep and hidden pulse. Therefore, it is called a heat syndrome with pseudo-cold symptoms. (5) Depletion of Yin or Yang Depletion of yin or yang is a pathological state of critical illness caused by a sudden massive loss of yin-fluids or yang-qi of the body. Depletion of yang is a pathological state of the sudden collapse of bodily functions caused by a sudden exhaustion of yang-qi. Depletion of yang is often caused by excessive evils that defeat the vital and lead to a sudden exhaustion of yang-qi, by a deficiency of yang with a weak anti-pathogenic qi and over consumption of qi due to overstrain, excess diaphoresis, emesis, and purgation which lead to a massive loss of body fluids with consequent exhaustion of yang-qi, or outside escape of deficient yang in a chronic consumptive disease. The manifestations of profuse sweating, cold skin and limbs, listlessness, and a faint pulse that is hard to feel are signs of a critical syndrome. Depletion of yin is a pathological state of collapse of the functions of the entire body caused by a sudden and massive loss or consumption of yin-fluids. The causative factors are too much heat evil, protracted detention of heat evil, factors that greatly consume away yin fluids, or a massive consumption of yin-fluids. The clinical manifestations of 54

55 this critical syndrome are short and rapid breathing, thirst, warm limbs, and hyper-hydrosis with a tendency to collapse. Depletion of yin and depletion of yang are different in both pathology and manifestations. However because of the interdependence of yin and yang, yin depletion will make yang lose a base and thereby yang dies out; and yang depletion will lead to a yin loss of production. Yin will then become exhausted. Therefore, a depletion of yin and depletion of yang usually occur in succession, and finally lead to a separation of yin and yang, or the end of life Disorders of Ascending and Descending Qi Ascent, descent, exit and entrance are the four essential forms of qi movements and are the basic processes of motion for viscera, meridians, yin-yang and qi-blood. Disorder in the ascending and descending of qi is generally a pathological state reflecting a disturbance of visceral qi in ascent, descent, exit and entrance, along with disorders of yin-yang and qi-blood. Since qi movements in ascent, descent, exit and entrance concerns various aspects of the viscera, meridians, qi-blood and yin yang, disorders in ascending, descending, exiting and entering may lead to dysfunctions of various tissues and organs such as the viscera, limbs, sense organs, and orifices. For example, chest distress, cough and asthma are due to a failure of the lung in dispersion and descending; belching, nausea, vomiting and hiccup are signs of rebellious stomach-qi; loose stools or diarrhea can indicate a failure in the spleen in sending up essence and transformation and transportations falling down and coma are signs of disorders of yin yang and qi blood. TCM holds that both exogenous diseases and endogenous diseases have their own unique disorders of ascending, descending, exiting and entering. An exogenous disease is from the outside, and mainly takes the form of a disorder that exits and enters. An endogenous disease is from inside, and mainly disorders ascending and descending qi. Ascent-descent and exit-entrance are closely related physiologically and influence each other path-logically. For example, in cough and asthma caused by exogenous wind-cold invading the body surface, the striae of the muscle and skin are obstructed, the defensive-qi cannot disperse, and disorders of exiting and entering will manifest chill, fever, and no sweating. The lungs correlate with the skin and hair and if an evil in the exterior is not driven out, it can invade the lungs internally, leading to a loss in the lungs dispersing and descending functions. This disharmony will manifest cough, asthma and dyspnea. This shows that a disorder of exiting and entering and disorder of ascending and descending influence each other. Qi movement in ascending, descending, exiting and entering is a synthesis of various viscera and tissues. However, the ascending and descending of spleen and stomach qi are the most important factors. This is because the spleen and stomach are the origin of acquired constitution, are located in the middle jiao, 55

56 communicate with the upper and the lower and are the center of the ascending and descending qi movements. Normal ascending and descending of spleen qi and stomach qi can maintain the functions of sending up essence and sending down the turbid, nourishing the whole body and discharging waste, and maintain the normal physiological functions of the viscera.if the ascending and desending of the spleen qi and stomach qi become disordered, the clear yang-qi will not distribute, the acquired essence can not be stored, the clear qi of food can not be absorbed, and waste from metabolism can not be properly discharged. It may also influence other viscera, thus leading to various diseases. Therefore, a disorder in the ascending and descending of spleen qi and stomach qi influences the functional activities of the entire body, and regulating the ascending and descending of qi should be paid attention to treating diseases of the spleen and stomach. ( 邓红 ) 56 Chapter Six Diagnostic Methods Traditional Chinese diagnostic is an important component of the theoretical system of traditional Chinese medicine. It includes two parts: diagnosis and differentiation of syndromes. Diagnosis is a way to identify the manifestations and nature of a disease by the unique diagnostic methods adopted in traditional Chinese medicine; while differentiation of syndromes is process in which the characteristics of a disease and syndrome are decided through interpretation and summing up of the phenomena collected from the four basic methods of diagnosis. Traditional Chinese diagnostics diagnostics is an important branch of traditional Chinese medicine, which makes a study of cases, determines syndromes under the guidance of the theory of traditional Chinese medicine, and provides a basis for prevention and treatment of diseases. It is a bridge linking the basic theory and clinical branches of traditional Chinese medicine, and a necessary fundamental subject in study of traditional Chinese medicine. The four diagnostic methods: Inspection, auscultation and olfaction, inquiry and pulse-feeling and palpation. Inspection: It refers to examining the general condition of the body, the mental faculty, signs, secretions and excretions of the patients. In a word, it includes inspection of the physique, facial expression, color of the complexion and physical condition and behavior. Auscultation and olfaction: It is a method to gather information about the body from the sounds of the voice and breathing, and smelling of the odor of the body. Inquire: It is a way to interview the patient, his or her family to determine the patient s health state, major complaints, progress and duration of an illness. Pulse-feeling and palpation: Pulse-feeling is an approach by which a physician understands the condition of a disease, meridians and collaterals, qi and blood and the

57 relative strength of pathogenic qi. Palpation means to examine various parts of the body touching to find out abnormal conditions. The four diagnostic methods are the important part of the Chinese medical system in differentiation of syndromes and treatment, and the basis for diagnosis and treatment. 6.1 Inspection Inspection is a diagnostic method, by which a physician visually inspects a patient's abnormal changes of his expression, color of complexion, physique, behavior and excretions to collect information related to the disease and infer the pathological changes of the internal organs. In Ling Shu Ben Zang (Treatise on the Original Organs, in Miraculous Pivot) it says: "We may know the condition of someone's internal organs and the place in which the disease occurs by observing the external manifestations". It indicates the exterior of the body is closely related to the internal organs, and disturbance in yin yang, qi and blood of the zang-fu organs must reflect on the exterior of the body. That is why observation of the abnormal manifestations helps diagnosis Observation of the Mental Faculty Conception of the Mental Faculty According to traditional Chinese medicine, the mental faculty of a person reveals his or her vitality as well as mental and spiritual state. In a broad sense, it refers to life, but in a narrow sense, it refers to mental activity or spirit. The two must be included in observation of the mental faculty. Significance of Observation of the Mental Activity Vitality and spirit come from the congenital essence and nourished by the acquired essence. It is the outward sign of a preponderance or discomfiture of qi and blood. Generally, sound health and vigorous spirit indicate abundance of qi. In such a condition, even if one falls ill it is a mild case. On the contrary, weak body build and lack of vitality suggest one suffering from declining of qi. In such a condition, if he falls ill, it is a severe case. Thus, observation of the mental faculty helps to identify the condition of qi, the case and its prognosis. Focal Points in Observation of the Mental Faculty Mental faculty is reflected in spirit, consciousness, language, breathing, patterns of movement and reaction, but most important in observing a person's mental faculty are the eyes, for eyes are dominated by mentality and their function is closely related to abundance or discomfiture of qi and essence of the five zang and six fu organs. Content of Observation of the Mental Faculty It includes the following five aspects: vigorous spirit, lack of vitality, loss of vitality, pseudo vitality and mental disturbance. Vigorous spirit: Signs of vigorous spirit are attentiveness, a sparkling in the eyes, lustrous face, full consciousness, natural expression and posture, clear utterance, easy 57

58 breath, fine-looking flesh and sharp response, known as" possession of vitality", implying a mild case without serious damage of qi and injury to functions of the zang fu organs. If it is a serious case, favorable prognosis is expected. Lack of vitality: Lack of vitality may be inferred when a patient appears spiritless with dull eyes, slow movements, shortness of breath and feeble voice, weariness and sleepiness, implying deficiency in the heart and spleen, or insufficient kidney yang, attributed to a deficiency syndrome. Loss of vitality: In the course of a disease a patient shows a dull look in the eyes, luster less complexion, apathetic expression, lassitude, sluggish response, coma, delirium, sudden loss of consciousness, and urinary and fecal incontinence, implying exhaustion of essence and qi. It indicates a serious case with poor prognosis. Pseudo-vitality: It refers to a false appearance of vitality that occurs in a protracted, serious disease when a patient's qi is severely depleted. The physician may suspect pseudo vitality when the patient switches from very low spirits to very high spirits; or the patient's face has been pale and lusterless, but suddenly becomes flushed; or the patient has had poor appetite but suddenly has a good appetite and raises food intake; or the patient has been apathetic and breathing feebly, but suddenly becomes talkative. Such a temporal improvement is not in accordance with the synchronous alleviation of the pathological conditions. They are critical signs of the imminent divorce of yin from yang due to excessive yang hindering yin or the failure of yin to hold yang, and exhaustion of the zang-fu organs essence and qi. They are thus usually known as "the last radiance of the setting sun" or the "reglowing of a candle that is about to burn out". This is critically ill at one's last gasp. Mental disturbance: Symptoms include irritability, delirium, depressive psychosis, mania and epilepsy. Irritability and delirium are frequently seen in patients with hyperactivity of pathogenic heat, which disturbs the mentality. Depressive psychosis manifests itself as an apathetic expression, dementia, abnormal be havior, uncommunication, muttering to oneself which stops on encountering people, unreasonable crying and laughing caused by mental confusion due to phlegm in the heart or by deficiency in the heart and spleen and poor mentality. Mania is often marked by restlessness, shouting, excessive motor activity and violent be havior, usually caused by phlegm invading the heart and pathogenic fire disturbing the mind, or due to the mind confused by stagnated blood. Epilepsy is often marked by falling down in a fit, loss of consciousness, foam on the lips, convulsion, caused by upward perversion of wind phlegm that disturbs the mind. After the seizure, the patient behaves as normal Tongue Inspection Tongue inspection is also known as tongue diagnosis, an important component part of 58

59 observation. Traditional Chinese medicine places much emphasis on the inspection of the tongue as a method of diagnosis The Tongue and Zang-fu Organs Tongue is a mirror of the heart and the outward or external reflection of the spleen condition. It is connected both directly or indirectly with several zang-fu organs, e.g. a collateral of the Heart Meridian of Hand-Shaoyin links the root of the tongue and the Spleen Meridian of Foot-Taiyin reaches the root of the tongue and spreads over its lower surface. The Kidney Meridian of Foot-Shaoyin and the Liver Meridian of Foot-jueyin terminate at the root of the tongue. Qi of the zang-fu organs may go up and nourish the tongue and a morbid state is often reflected by the tongue condition, which is the diagnostic basis for detecting the pathological changes in the internal organs. In the long medical practice, physicians throughout ages have found a definite part of the tongue is related to a certain organ, and reflects its pathological changes. Then the tongue is divided into four portions, which correspond to the organs as follows. The tip corresponds to the heart; the middle corresponds to the spleen and stomach; the root corresponds to the kidney; the edges correspond to the liver and gallbladder. These relationships have been proved useful in diagnosis How to Inspect the Tongue Inspection usually focuses on the change of the tongue proper, including its muscles and vessels, and the tongue coating, a layer of fur-like substance covering the surface of the tongue formed by stomach-qi. A soft nimble tongue body with lightly red color and a thin white cornfield layer, neither dry nor moist, is considered as a normal healthy tongue. In brief, it is a "lightly" red tongue with thin white coating". Abnormal tongue body and coating is discussed as follows. Observation of the Tongue Proper Inspection of the tongue proper or the tongue body is of great importance in determination of prosperity and decline of the essence and qi of the zang-fu organs, and prediction of a disease and its prognosis. The tongue proper may have a change in its surface condition, color, shape and pattern. Surface condition: It is manifested as luster and lusterlessness of the tongue. Luster: It means the tongue is moist, red and lustrous, suggesting injury to the body resistance and a mild condition. Lusterlessness: It means the tongue is wizened, suggesting injury to the body resistance and a severe condition. Color: Pale, reddened, crimson red and purple. Pale tongue: A pale tongue indicates syndromes of deficiency and cold caused by insufficient yang-qi and blood, usually seen in diseases due to deficiency of yang and blood. 59

60 Reddened tongue: A reddened tongue indicates a heat syndrome caused by an excess of qi and blood, usually seen in the syndrome of interior heat, or endogenous heat due to yin deficiency. Crimson: A deep red tongue is a sign of severe endogenous heat. It is also a sign of exogenous heat invading the ying and xue systems, usually found at the advanced stage of febrile diseases, or in protracted and critical cases, suggesting hyperactivity of fire due to deficiency of yin. Purple: A purple tongue is seen in either cold or heat syndromes. A purple tongue with deep red coloration indicates inadequate fluid; it suggests that exuberant heat has led to consumption of yin and fluid, and stagnation of qi and blood. A pale purple or moist blue-purple tongue indicates a blockage of vessels due to preponderant endogenous cold. Purple spots on the tongue also suggest stagnation of blood. The following is a table describing the color of the tongue. Shape: Enlarged tongue, thin tongue, cracked tongue, tongue with teeth imprints and thorn tongue. An enlarged tongue: It is larger than the normal, divided into two kinds. The first is the flabby tongue pale in color, indicating insufficiency of spleen-yang and failure in the transformation of body fluids and retention of phlegm anti-dampness due to excessive heat in the heart and spleen. A swollen, crimson tongue indicates exuberant heat in the heart and spleen. A swollen, dark blue purple tongue usually indicates poisoning. A thin tongue: It is small and shrunken, indicating consumption of yin and blood. A thin and pale tongue is attributable to deficiency of qi and blood. A thin, deep red and dry tongue indicates hyperactivity of fire due to deficiency of yin and consumption of fluid. A cracked tongue: It has fissures of different depth on its surface, indicating consumption of yin and fluid. A cracked, deep red tongue indicates injury to body fluids due to exuberance of heat. A pale cracked tongue found in a healthy person does not have any clinical significance. A tongue with teeth imprints: It is a tongue with teeth imprints along its outer edge as a result of the pressure of dental coronae on the puffy tongue. This is why teeth imprints are seen in flabby tongues, indicating deficiency of spleen-qi. A pale, moist tongue with teeth imprints is due to hypofunction of the spleen and exuberance of cold-dampness. A thorny tongue: It is shaped by the hyperplastic lingual papillae, causing a prickly feeling when they are touched. A dry thorny tongue indicates exuberance of heat and the more exuberant the heat is the more "thorns" may appear on the tongue. According to the occurring parts of the thorns, location of heat in individual zang-fu organs can be known. For example, thorns only on the tip of a tongue indicate hyperactivity of heart-fire, whereas thorns on the edge of a tongue suggest exuberance of liver and gallbladder fire. Thorns in the middle of the tongue mean exuberance of heat in the stomach and 60

61 intestines. Observation of the Tongue pattern: Rigid, flaccid, trembling, wagging, deviated and shortened. A rigid tongue: It is a stiff tongue body, unable to move freely, impeding speech caused by invasion of the pericardium by heat, accumulation of phlegm or disorder of body fluids in cases of high fever and excess of heat, usually found in exogenous affection of heat. It is also a sign of impending apoplexy found in miscellaneous diseases. A flaccid tongue: It is a weak tongue, unable to protrude and curl or move freely, often attributable to severe consumption of qi and blood and yin fluid, resulting in failure of the tongue muscles and vessels to be nourished. A pale and flaccid tongue in protracted diseases is a sign of deficiency of qi and blood. A crimson, flaccid tongue suggests extreme depletion of yin. In a recent illness, a dry, red and flaccid tongue is due to impairment of yin by heat. A trembling tongue: It is a tongue trembling continuously and involuntarily. In a protracted illness, a trembling tongue indicates deficiency of qi and blood or hypofunction of yang-qi. But in exogenous affection of heat, it is attributable to production of wind caused by exuberance of heat, or stirring-up of endogenous wind due to deficiency. A wagging tongue: It is a tendency to stick out the tongue or to play with it, suggesting heat in the heart and spleen. Protrusion of the tongue is seen in cases of the heart attacked by pestilential heat or depletion of qi. Playing with the tongue is a sign of the wind syndrome or poor mental development in children. A deviated tongue: It is a tongue turning to one side, a sign of apoplexy or a precursor of apoplexy. A shortened tongue: It is a shortened, contracted tongue, indicating a critical disease. A pale, blue, moist and shortened tongue is due to excessive cold; a puffy and shortened tongue is due to accumulation of phlegm-dampness; a crimson dry and shortened tongue is due to impairment of fluid. The changes of the patterns of the tongue are listed in the following table. Observation of the Tongue Coating Tongue coating is produced by the upward steaming of stomach-qi. The tongue coating of a healthy person is thin and whitish, moderately moist and neither smooth nor dry, indicating normal stomach-qi. On the other hand, a morbid tongue coating is created by upward steaming of stomach-qi together with evil qi. The condition of the tongue coating tells us the condition of the zang-fu organs In this way, observation of the tongue coating assists diagnosis.. Inspection of the tongue coating consists of observing its color and texture. Observation of the color of the tongue coating. 61

62 There are four colors: white, yellow, grey and black. A white tongue coating: It is usually seen in an exogenous syndrome and a cold syndrome. A thin white coating: It is a normal condition. But it is also seen at the onset of an exogenous disease that hasn't invaded the interior of the body. This is why the thin white coating can be regarded as a proof of an exogenous syndrome. A pale tongue with white coating is a sign of a cold syndrome. A tongue covered totally with white coating, looking like heaped powder but not being dry is called the powder like coating. It is caused by affection of exogenous filthy turbid pathogens or excessive interior heat, often seen in pestilence or abscess in internal organs. A yellow tongue coating: It indicates heat and interior syndromes. Created by excessive heat, it indicates a heat syndrome. In general, the deeper yellow the coating, the more severe the interior heat is. A light yellow coating indicates a mild heat while a deep yellow coating suggest accumulation of heat. As a yellow coating indicates an interior syndrome, white coating turning to yellow is a sign of heat transformed from the exogenous pathogenic factors after they have invaded interiorly. Since the yellow coating indicates an interior heat syndrome, a yellow coating and crimson on the tongue exist at the same time. If there is a pale, flabby and lustrous tongue with yellow, smooth and moist coating, it indicates disturbance in water-metabolism due to yang deficiency. A grey tongue coating: It indicates an interior syndrome, either of interior heat or cold-dampness. Grey is light black and a grey coating may turn to a black one, so a greyish-black coating is often found at the same time. A grey coating may be transformed from a white one, and it appears together with a yellow coating. A smooth, grey coating indicates accumulation of cold-dampness or retention of phlegm and fluid while a dry grey coating indicates impairment of body fluids due to abundant heat, or exuberance of fire due to deficiency of yin. A black tongue coating: It indicates an interior syndrome either of extreme heat or abundant cold. A black coating usually develops out of a grey or brown coating, often seen in critical cases. A black, dry, cracked or thorny coating is a sign of extreme beat and exhaustion of body fluids. A black moist coating indicates deficiency of yang and exuberance of cold. The above suggests that a black coating tells a cold syndrome or a heat syndrome. Dryness and moisture of a tongue coating is of great clinical significance. Observation of the quality of the tongue coating: The quality of the tongue coating includes the following conditions. A thin or thick coating: A thin coating refers to a thin layer of fur through which the tongue proper is faintly visible. A thick coating, however, refers to a thick layer of fur through which the tongue proper is invisible. 62

63 Observation of the thickness of a coating is conducive to finding out the condition of a disease, its alleviation or deterioration. In general speaking, at the initial stage of a disease it is often a mild case and a thin tongue is seen. After the invasion of the interior by pathogenic factors or in the case of retention of phlegm and dampness or foot, a thick coating is usually seen. A thickening coating indicates the invasion of the interior by exogenous pathogenic factors, a sign of deterioration; when the coating comes thinner, it indicates pathogenic factors have been driven out and the disease is alleviated. A moist or dry coating: A moist coating is a normal one, indicating plenty of body fluids which is evenly distributed. Stress is laid on the change of body fluids when the coating is observed. A dry coating has no moisture on its surface and a rough coating is manifested as rough grains covering the tongue and offensive while touched, caused by failure of body flu ids to reach the tongue surface, usually found in injury to body fluids due to an excess of heat or consumption of yin fluid. A dry coating may also be attributable to failure of body fluids to reach the tongue surface due to deficiency of yang-qi. A glossy coating, feeling wet, is created by excessive dampness, indicating retention of fluids. If a dry coating turns moist, pathogenic heat has subsided and the fluid has been replenished. If a moist coating turns dry, body fluids have been impaired usually by exuberant beat. A sticky and curd like coating: A sticky coating is a layer of turbid, slimy, compact and little grain like fur on the tongue, difficult to be scraped off. It is a result of inhibition of yang-qi by pathogenic factors of yin nature, such as phlegm-dampness, pathogenic dampness and warmth. A curd-like coating is a thick, soft, flabby coating with large granules that resemble the crushed bean curd. It is easy to be scraped off, usually formed by upward steaming of turbid, stale qi from the stomach due to exuberant heat. It is common in cases of dyspepsia or retention of phlegm. A peeled coating: Presence and absence of a tongue coating indicates a confrontation between the antipathogenic qi and pathogenic factors. When the coating of a tongue is suddenly peeled, and no longer comes back, leaving behind a permanently bare, glossy surface, known as the "mirror like tongue", it indicates depletion of stomach-yin and complete exhaustion of stomach-qi. If the coating is partially peeled, and the peeled parts look bare and smooth, it is called "lingua geographical", indicating impairment of stomach qi and yin. A peeled coating associated with sticky coating indicates unsolved phlegm and damage of the antipathogenic-qi. It is a complicated case. A firm or loose coating: If a coating closely adheres to the tongue surface, difficult to be scraped off and it seems a part of the tongue proper and the coating appears to grow out of the tongue, it is a firm coating or real coating. If a coating does not closely adhere to the tongue surface, and looks like a paint on the tongue, easy to be scraped off and appears not to grow out of the tongue, it is a loose coating or a false coating. A firm and loose coating is of great clinical significance in understanding the state of pathogenic 63

64 factors and antipathogenic qi, the condition of stomach-qi and in differentiation of syndromes of excess and deficiency. In general, a firm coating indicates an excess syndrome, a heat syndrome and strong stomach-qi, whereas a loose coating indicates a deficiency syndrome, cold syndrome and weakened stomach-qi The Tongue Proper and Tongue Coating Diseases may go through complicated processes. The change of the tongue proper and coating reflects sophisticatedly pathological changes. That is why it is essential to notice the relation between the tongue proper and tongue coating in addition to recognition of the basic changes of them and their suggestion about the problems, and their change must be analyzed together. In general, there is a unified change of the tongue proper and tongue coating and the problems they indicate tend to be an integrated conclusion. For example, interior heat in an excess condition is manifested as a dry reddened tongue with yellow coating and a cold and deficiency syndrome is marked by a pale and white coating. In the course of disease, however, the change of the tongue proper is not in keeping with the shift of the tongue coating. For instance, a crimson tongue usually indicates a heat syndrome, while a white coating is seen in a cold syndrome. But sometimes, crimson tongue and white coating are found simultaneously. In an epidemic febrile disease, a crimson tongue with a white, glossy and sticky coating indicates heat and dampness invading the yin system and qi system respectively, but in miscellaneous diseases it indicates exuberance of fire due to deficiency of yin, together with retention of phlegm and food. A crimson tongue with a white dry coating refers to impairment of body fluids caused by dry heat. The former is owing to accumulation of damp heat and the latter is owing to dryness quickly turning to fire, a sign of deterioration. Before the coating changes to yellow, dry-heat has already invaded the yin system, which severely damages body fluids. Therefore, they are different from the rule in which a yellow coating is seen in a heat syndrome. Since the tongue proper and tongue coating reflect the condition of a disease from various angles, situation of both should be taken into consideration in differentiation of syndromes, and be analyzed synthetically to get a reliable basis for differentiation of syndromes Clinical Significance of Tongue Inspection It has been proved by clinical practice that the change of the tongue condition may relatively and objectively reflect the prosperity and decline of qi and blood, the nature of pathogenic factors, location of a disease, its alleviation or deterioration and prognosis. Under certain conditions, it serves as the chief basis in differentiation of syndromes. The abnormalities of a tongue proper and tongue coating reveal the condition of a disease in different aspects, so observation of them is of differed significance in diagnosis. In general, inspection of the tongue centers on telling the deficiency or excess syndrome, and inspection of the tongue coating on the location of pathogenic factors and 64

65 the existence of stomach qi. The clinical significance of the inspection of the tongue is as follows. To Judge the Abundance and Decline of the Antipathogenic Qi: Wax and wane of qi and blood of the zang-fu organs is reflected on the tongue proper and tongue coating. To Tell the Site of a Disease: In terms of the exogenous affection of pathogenic factors, the thickness of the tongue coating often reflects the location of a disease. To Differentiate the Category of Pathogenic Factors: Different pathogenic factors are marked by changes of the tongue condition. To Judge the Alleviation or Deterioration of a Disease: Since the change of the tongue coating reflects the wane and wax of the antipathogenic qi and pathogenic factors, and the location of a disease, inspection of the coating may reveal the alleviation or deterioration of a disease, which is considered more important in acute febrile diseases. But it should be pointed out that little change of the tongue condition is clinically found when the disease is deteriorated, or abnormal tongue condition appears in healthy persons. Thus, alongside the inspection of the tongue, the case history, symptoms and signs must be taken into consideration. Only by a comprehensive analysis can an accurate diagnosis be worked out Methods of Tongue Diagnosis and Precautions On inspection of the tongue stress is laid on light, the posture to protrude the tongue and the stained tongue coating. Light: On inspection of the tongue, sufficient natural light is needed, and it is better to have the light directly shining the mouth. At night it is not easy to make an accurate diagnosis by inspection of the tongue and a recheck seems necessary in daytime. The Posture to Protrude the Tongue: It is requested that the tongue should stick out naturally to expose the tongue body sufficiently, the tip of the tongue slightly goes down ward and its surface keeps flat. It should not be rolled up or struck out too much to affect its color. Stained tongue coating: The tongue coating may be discolored by food or drugs taken, e. g. black plum or olive may turn the coating into black; coptis or ovoflavin may turn the coating into yellow; cigarette smoking may turn the coating into grey. Clinically if you find the patient's coating suddenly has a change or the coating is inconsistent with the disease condition, diet and drugs taken should be inquired to rule out the pseudo coating. Moreover, the rub of food and tongue scraping may reduce a thick coating to a thin one; intake of hot or irritating food may turn the tongue red; dry tongue is often seen in patients with a stuffy nose or those who breathe with the mouth open Observation of Excretions of the Body Excretions of the human body include sputum, vomitus, feces and urine Sputum and Morbid Fluid 65

66 Thick and turbid stuff expectorated is called phlegm, whereas thin and clear stuff expectorated is known as morbid fluid. In diseases caused by exogenous pathogenic factors clear and foamy sputum and white, dilute sputum are called sputum due to wind and sputum due to cold respectively. Profuse white sputum easy to expectorate is named sputum due to dampness, while thick, sticky and yellow sputum is known as sputum due to heat. Scanty yellow sputum difficult to expectorate or bloody sputum refers to dryness fire. Expectoration of stinking and purulent sputum or purulentbloody sputum is found in pulmonary abscess. Profuse saliva preferred to spit indicates cold in the stomach Vomitus The color, amount and shape of vomitus coming from the stomach must be noticed, e.g. hematemesis is marked by vomiting dark red or brown or brightly red mass with no definite amount, but mixed with food residues. It indicates injury to vessels of the stomach. Thick, foul vomitus suggests heat in the stomach or indigestion, while dilate vomitus implies cold in the stomach Feces Normal stools are yellow and thread like, neither too dry nor too damp. Abnormal stools reveal various syndromes-cold, heat, excess and deficiency. Information about feces is obrained from asking. For details see "Inquiry" Urine Clear profuse urine suggests a cold syndrome but scanty dark brown urine a heat syndrome. Deep yellow urine points to a damp heat syndrome. Hematuria is a result of heat in the lower-jiao. 6.2 Ausculation and Olfaction Ausculation includes giving attention in hearing of a patient's voice, speaking, respiration, coughing, vomiting, hiccup, belching, sighing, sneezing and borborygmus. Olfaction means to us the nose to tell various odors of the body, secretions, excretions and wards Listening to the Sound of Voice The sound of voice is produced by a coordinative working of the lungs, larynx, epiglottis, tongue, teeth, lips and nose. The lung controls qi of the body and it is viewed the motive power of voice. Voice is created by vibration of air. The larynx is the organ to produce the sound of voice, and others play a regulatory role in voice production. Abnormal changes of sound of voice are related to the condition of lung qi. Since the kidney aids the lung in inhaling, qi produced in the kidney goes upward to the tongue surface; the sound of voice is created. Pathological changes of other zang-fu organs affect the lung and kidney via meridians and collaterals. Thus, listening to the sound of voice not only knows the morbid state of the vocal organs, but also the internal organs according to sound change. 66

67 Normal Sounds of Voice The sound of voice of healthy people, though varied individually, is sent out naturally with harmonious and appropriate tone, viewed as the common features of normal voice Diseased Sounds of Voice Speech: Speech of a patient, vigorous or weak, reflects, on one hand, abundance or deficiency of qi of the body, or body resistance, and on the other it is related to the condition of pathogenic factors. In general, a loud and sonorous speech sound together with talkativeness and irritability often implies an excess syndrome and a heat syndrome; a low feeble speech voice together with peaceful behavior is attributable to a deficiency syndrome and a cold syndrome. A recent onset hoarseness or aphonia due to exogenous affection of wind cold or wind heat, or associated with irregular diet indicates an excess syndrome; chronic hoarseness or repeated aphonia due to internal injury denotes yin deficiency of the lung and kidney, leading to failure of body fluids to go upward. It is a deficiency syndrome. In a protracted or critical case if hoarseness suddenly appears, it is a manifestation of complete exhaustion of qi of the zang organs. Aphonia during pregnancy occurring in the ninth month is caused by the growing fetus constricting the collaterals of the kidney, resulting in failure of kidney essence to nourish the throat and tongue proper. It is considered normal and will have spontaneous cure after childbirth. A low muffled voice suggests obstruction of lung qi, usually found in exogenous affection of wind-cold or interior dampness. Groan or a cry in alarm is often related to a case of pain or distension. Speaking Mode: Abnormal speaking mode tells a syndrome deficiency from excess. Delirium: It happens in a dreamy state in a serious illness. A patient speaks sonorously, attributable to an excess syndrome due to the mind disturbed by heat. Fading murmuring: It happens in a dreamy state in a critical condition. A patient speaks repeatedly and intermittently in a feeble voice. It is due to severe injury to heart qi and a disturbed mind. Soliloquy: It is an act of talking to oneself alone without coherence. When he sees some one he stops. It is attributable to insufficient heart-qi and a disturbed mind. Paraphasia: A patient employs wrong words in speech or talks nonsense. But after speaking he awares of his own problem. It is caused by insufficient heart qi and a disturbed mind. Raving: It happens in a mad man or woman, talking widely and nonsense caused by mental disturbance due to phlegm-fire, or to blood retention attributable to injury by cold. Dysphasia: It is a morbid state characterized by impairment of speech, consisting of lack of coordination and failure to arrange words in their proper order, due to a stiff tongue and blockage of meridians by wind-phlegm. 67

68 Sound of Breathing: A patient having normal, sound of breathing implies qi is not yet afflicted. Abnormal sound of breathing refers to impairment of both qi and physique. Loud, coarse breathing indicates an excess syndrome due to exogenous pathogenic factors, while faint breathing indicates a deficiency syndrome due to impairment of qi. However, intermit tent, harsh breathing is also seen in patients with complete exhaustion of qi of the lung and kidney, but it is not an excess syndromes faint breathing is found in patients with heat in the pericardium, and it is not a deficiency syndrome. In short, differentiation of syndromes needs help from other diagnostic methods. Abnormal sounds of breathing are as follows: Asthma It is marked by difficulty of respiration and lying flat even with the mouth opened and shoulders raised. Asthma is classified into two types-deficiency and excess. Asthma of the excess type is characterized by a sudden onset, replete pulse, loud and harsh breathing, feeling easy on exhalation. It is due to abundant heat in the lung or retention of phlegm and fluid. Asthma of the deficiency type is marked by a slow onset, fatigue, and feeble pulse, gasping, low and short breathing, feeling easy at a longer interval. Bronchial wheezing It is marked by intermittent, sonorous wheezing due to retention of phlegm and fluid, associated with affliction of exogenous cold which resides at the superficial portion of the body. Wheezing occurs when they work together. Sometimes, it is caused by exogenous pathogenic factors, which invade the lung, or by long residence at a cold-damp place, or over intake of sour or cold, raw stuffs. It is a protracted illness, difficult to cure. Coughing with dyspnea It refers to blockage of the air passage by reversed flow of qi and short breath. Coughing and reversed flow of qi are attributable to retention of phlegm and fluid marked by difficulty of lying flat and spitting frequently. Reversed flow of qi due to upward flaring of fire is caused by deficiency of yin and exuberance of fire, resulting in a throat problem. Reversed flow of qi may be triggered by unsmooth dispersion of lung-qi, retention of body fluids when pathogenic factors reside at the superficial portion of the body (usually with general edema). Shortness of breath It refers to a rapid and interrupted breathing, similar to asthma but without shoulder raising and rale. The sound of breathing likes a groan but there is no suffering. Retention of fluid in the chest is characterized by short breath, thirst, joint pain of the limbs and a deep pulse. Weak physique, short breathe and smooth urination imply deficiency of lung-qi, where as a stuffy sensation in the chest and abdominal region induced by cold indicates an excess syndrome with interior invasion by pathogenic factors. Abdominal distension and short breath is a deficiency syndrome, suggesting 68

69 invasion of the interior by pathogenic factors. Insufficient qi It is a condition marked by feeble breathing with rapid and low sound. By comparison, it is thought more natural, indicating a deficiency syndrome and weak physique. Coughing It is the result of an adverse flow of qi due to failure in the dispersing and descending function of the lung. Coughing is caused by exogenous affection of pathogenic factors and internal injury. According to the sound of coughing and presence or absence of sputum and other symptoms, the nature of it is known. In general, coughing with a coarse voice indicates an excess syndrome; coughing with a low, weak and rapid voice indicates a deficiency syndrome. Damp sputum means coughing with profuse sputum easily expectorated. A dry rapid coughing with scanty sputum is also named dry cough, caused by insufficient lung-yin or invasion of the lung by dryness and failure in the dispersing and descending function of the lung. Coughing characterized by spasmodic paroxysm with an inspiratory wheezing sound like a bird's voice at its end is referred to as whooping cough. It is a result of exogenous affection of epidemic pathogenic factors, blockage of the air passage by sputum and failure in the dispersing and descending function of the lung. A hoarse-voiced coughing with difficult respiration implies an acute throat trouble. A severe case may lead to suffocation, so it should be especially concerned. Vomiting The ancient Chinese classified vomiting into three heads throwing out with vomiting sound and stuff; throwing out with stuff and without vomiting sound; and dry vomiting (nausea with attempts at vomiting, but with the ejection of nothing but gas). There are many causes of vomiting, but adverse flow of stomach-qi is the main reason. By the sound of vomiting one can tell the nature of syndromes. For instance, vomiting due to deficiency and cold is manifested as slow throwing out with a weak, low vomiting sound, while violent throwing out with a strong vomiting sound indicates an excess and heat syndrome. But the true cause of vomiting should be determined by a combination of the four diagnostic methods. Sometimes, food intake should be inquired to rule out poisoning Smelling the Odor Here odor includes two: the odor of a patient and in a ward, both related to diseases. The odor in a ward comes from patients or their excreta. The odor of a patient fills the air of the ward indicated his critical condition The Odor of Patients The Odor from the Mouth: A foul breath does not come from healthy people and it is a sign of indigestion or decayed teeth or a filthy mouth. An acid foul breath indicates 69

70 indigestion; a foul breath indicates heat in the stomach. A fetid breath indicates the internal ulcer or abscess. The Smell of Sweat: The smell of sweat given off from a patient implies that he has had perspiration. Sweating with a smell of fish and mutton suggests accumulation of damp-heat in the skin and steaming of body fluids. The Odor from the Nose: A foul odor from the nose associated with a continual running nose and pus like discharge is usually indicative of sinusitis. The Foul Odor from the Body: When it occurs, ulcer or abscess should be found. Patients themselves may sense the abnormal odor, then the abnormal odor coming from such excreta as sputum, stools and urine, menses and leukorrhea can be known from asking patients or their family members. For instance, expectoration of purulent and bloody sputum with a fishy foul smell is a sign of pulmonary abscess. Fetid stools pertain to heat; fishy-smelled stools indicate cold. Foul and dark yellow urine implies damp heat. Acid and foul fart suggests retention of food. Foul menses and leukorrhea indicate heat, whereas a fishy smell of menses and leukorrhea, cold The Ward Odor At the initial stage of pestilence, a fetid odor can be smelled. In a mild ease, it fills the bed and the mosquito net, but in a severe case, it fills the room. When a fetid smell or odor of putrefaction fills in a ward, it is a sign of decayed zang-fu organs and a critical condition. Hemorrhagic patients may fill the ward with a bloody smell. Other offensive smells such as ammonia in a ward is often found in edematous patients at the advanced stage. A smell of rotten apples (ketone bodies) is attributable to diabetes at the late stage. 6.3 Inquiry This is a diagnostic method of interviewing a patient and his or her family to determine the patient's chief complaints. It is an important approach in understanding a patient's condition and it plays a significant role in the four diagnostic methods. Only by inquiry can a physician know the symptoms, onset, progress and duration of an illness and the past history. Information gathered from inquiry may serve as clues to make an accurate diagnosis. It is more essential to get in formation from patients for some diseases or at the early stage of a disease because they only have complaints but no signs. In addition, by asking, the physician may know what the patient is thinking about and give advice in time. Thus, asking is an important procedure for a physician to recognize the disease, so it is wrong to overlook and do it perfunctorily. For an emergency case, questions brief and to the point are asked together with a key examination. After rescue more questions are asked. On inquiry, stress is laid on focal points. If the answers are not clear, some related questions are asked to remind the 70

71 patient. But the physician must be amiable without dropping any hint to avoid lopsided and false information. Do not use medical terms so often. The language should be easy to understand to allow the patient to express his ideas clearly. Never try to show any astonishment or impatience to avoid negative influence on the patient. If a patient is in low spirits and feels disheartened towards his illness, persuasion and advice should be given. Asking includes making inquiries of a patient about his entire condition, main complaints, case history and the present problem Asking about the General Condition The general condition refers to a patient's name, age, sex, marital status, nationality, occupation, native place, employed institution and address. These are the reference information for diagnosis. Concerning the age, a physician may have some idea about a patient's physique condition and easily occurring illnesses at the age. Different diseases also occur in man and woman, e.g. man may suffer from seminal emission, spermatorrhea and impotence, and woman may suffer from problems in pregnancy, childbirth and disorders of menstruation and leukorrhea. Moreover, any disease is related to age and sex too. Occupation and native place can be used as some references in diagnosis, especially for occupational and endemic diseases Asking about the Chief Complaints The chief complaints refer to a patient's statement of his subjective discomfort and the reason to see a physician. In general, the chief complaints produce the chief syndrome, by an analysis of which, the physician may know what problem it is and then an accurate diagnosis is made. If a patient complains about coughing, shortness of breath and chest pain, it should be considered that the lung is involved. Then after further inquiry about other symptoms connected with the chief complaints, analysis, judgment can be made. The record of the chief complaints should include one or several most-suffered symptoms and marked signs, their nature and duration. A brief description is made. When there are several chief symptoms, they are recorded one by one in the order of their attack. Thus, the physician may preliminarily decide the site and nature of the disease Asking about the History of Present Illness The history of present illness refers to the onset, progress and transmission of a disease and treatment adopted. On asking about it, the following should be emphasized. Onset: It includes the date of the onset, a sudden or slow attack, the cause or predisposing cause, initial symptoms, nature and site, and treatment adopted. Asking about the onset of a disease may greatly help know its cause and nature. Progress: In the order of time, ask a patient about the progress of a disease from the date of appearance to the present visit, e.g. chief symptoms in a period, severeness, alleviation or deterioration, any new problems, any rules of development, etc. It is much 71

72 important to know the progress of a disease, through which the confrontation between the body resistance and pathogenic factors is comprehended. Treatment adopted: It includes examinations, laboratory tests and result, conclusion of diagnosis and its reasons, treatment, treating methods, medications, dose, course of treatment and result, the previous diagnosis and treatment. Present symptoms: These are included in the chief questions and will be discussed in the Asking about the Present Symptoms Chinese medicine places particular emphasis on understanding a patient's chief symptoms in the context of more general information. This general information is gathered according to the formula developed by Zhang Jingyue, a physician of the Ming dynasty based on over centuries of practice, known today as "The Ten Questions". The topics of "The Ten Questions" are as follows: "1. Chill, fever and a feverish sensation; 2. perspiration; 3. pain; 4. defecation and urination; 5. state of diet and sense of taste; 6. chest; 7. hearing; 8. thirsty; 9. previous illnesses; 10. disease cause and herbal medicines taken; menstruation, menstrual cycle, amenorrhea and uterine, bleeding in women patients and small pox and measles in children" Asking about Chills and a Feverish Sensation A patient is firstly asked whether he has chills, fever or a feverish sensation. If so, ask him whether they appear simultaneously or alone, the severity, appearing time, their features and associated symptoms. Here is a detailed discussion. Chills and Fever If chills and fever are found at the initial stage of a disease, it is an affliction with exogenous pathogenic factors, indicating they reside in the superficial portion of the body, and a confrontation between the defensive qi and pathogenic factors is going on. Because of the difference between wind cold and wind-heat, there may appear extreme chills and mild fever, or slight chills and high fever. Extreme chills and mild fever are caused by affliction with exogenous wind-cold, which resides in the superficial portion of the body and impairs yang, marked by serious aversion to cold. When cold confines the defensive qi to dissipate, fever occurs associated with a headache, general pain, absence of perspiration and a floating and tense pulse. An illness caused by exogenous wind heat is characterized by a high fever and slight chills because wind heat attributes to yang pathogens, which lead to exuberance of yang and a high fever. Slight aversion to wind and cold is a result of superficial attack by wind heat, leading to open of the texture and interstitial spaces of the muscles owing to the weakened defensive qi. Symptoms seen are thirst, perspiration and a floating and rapid pulse. 72

73 The severity of chills and fever in an exterior syndrome is not only related to the nature of pathogenic factors, but to preponderance or discomfiture of the antipathogenic-qi. Affliction with weaker pathogenic factors and lowered body resistance result in slight chills and fever, while abundant pathogenic factors and strong body resistance produce severe chills and a high fever. But in a case of abundant pathogenic factors and lowered body resistance, there may appear severe chills and a mild fever. Chills without Fever or a Heat Sensation It implies that a patient only has an aversion to cold but no heat sensation or fever, a sign of the deficiency and cold syndrome. It is because of insufficient yang and failure of it to warm the skin, marked by pallor, cold limbs and preference for more clothes. When the zang fu organs are directly attacked by cold and yang-qi is impaired, there may appear chills or cold and pain in the affected area. It is known as "an excess of yin leading to a cold syndrome." Fever without Chills It refers to fever without chills or aversion to heat. The following is frequently seen. High fever: It means that a patient with a persistent high fever has no chills but aversion to heat, usually found in an interior heat and excess syndrome due to wind cold which invades the interior and turns to heat. A high fever caused by exuberance of interior heat, which reflects outwardly, a struggle between the strong antipathogenic qi and excessive pathogenic factors, is known as" an excess of yang leading to a heat syndrome, "often associated with profuse sweating and thirst. Tidal fever: It is seen in a fixed time, usually in the afternoon. There are three conditions found clinically. Tidal fever due to deficiency of yin: It appears in the afternoon or at night owing to production of interior heat due to deficiency of yin, marked by a feverish sensation in palms, soles and the heart region, or heat penetrating from inside to outside, termed "bone steaming and tidal fever", associated with night sweats, flushed cheeks, dryness of the mouth and throat, and a reddened tongue and less saliva. Tidal fever due to damp-heat: It is characterized by an afternoon fever and a heat sensation more severe in the interior as there are disorders of the spleen and stomach, leading to accumulation of damp heat, which fails to penetrate quickly. The skin is not felt hot at a stroke, but if you keep your hand on the skin, a burning sensation is felt. It is often accompanied by stuffiness in the chest, nausea, sluggishness of the head and body, loose stools and a sticky tongue coating. Tidal fever due to stomach problems: It is caused by accumulation of dryness-heat in the stomach and intestines. The accompanied symptoms are abdominal distension, aggravated by pressure, dry stools, palm and sole sweating, a yellow and dry tongue coating or even a thorny tongue. Prolonged low fever: It refers to a long-term low fever (in general not over 38C) or a subjective feverish sensation without presence of a higher 73

74 body temperature. The pathogenesis of the condition is quite complicated. For instance, a tidal fever due to deficiency of yin or a fever in summer may be marked by a prolonged low fever. Here a prolonged low fever due to deficiency of qi is discussed. A prolonged low fever is often associated with poor appetite, fatigue, shortness of breath and dislike to speak, a pale tongue and a weak pulse. It is caused by deficiency of spleen-qi, sinking of qi in the middle-jiao and lung yang failing to rise. Medicinal herbs warm in property and sweet in taste are administered to activate the spleen and to promote its smooth functioning in transport. When lucid yang rises normally, fever is gone. Alternate spells of chills and fever: Alternate spells of chills and fever suggest a syndrome due to attack of the site between the superficies and interior by pathogenic factors, seen in the Shaoyang disease and malaria. Alternate spells of chills and fever at irregular intervals are often accompanied by a bitter taste in the month, a dry throat, dizziness, stuffiness in the chest and hypochondriac region, loss of appetite and a wiry pulse, manifestations of the Shaoyang disease. It is due to a lingering of exogenous pathogenic factors between the exterior and interior with a confrontation between the antipathogenic qi and pathogenic factors. When the latter prevails over the former, chills appear, and when the former prevails over the latter, fever presents, so there are alternate spells of chills and fever. Malaria is marked by an alternate attack of chills and fevers once a day or every two or three days, accompanied by a sharp headache, thirst and profuse sweating. It is a result of the pathogens of malaria lingering between the exterior and interior. When it enters the interior to combat yin, abundant yin checks yang, leading to chills. But when it goes out to combat yang, abundant yang checks yin, resulting in fever. Then an alternate spells of chills and fever occur Asking about Perspiration Sweat, originating from body fluids, comes out of pores while being evaporated by yang-qi. Abnormal sweating is often seen in both exterior or interior syndromes. The purpose of asking about perspiration is to determine whether sweating is occurring, when and where it is occurring, how much it is occurring and its accompanied symptoms. A detailed description is as follows: Perspiration in an Exterior Syndrome: By questioning about sweating or absence of sweating a physician may know the category of pathogenic factors and the disturbance in the ying and wei systems. In an exterior syndrome, absence of sweating associated with severe aversion to cold, a mild fever, stiff neck, headache, a floating and tense pulse, indicates an excess condition caused by exogenous cold. Cold is a yin pathogenic factor, characterized by astringency, leading to density of the textual and interstitial spaces of the muscles, functional disturbance in the ying and wei systems and blockage of pores. Finally, 74

75 absence of sweating appears. Sweating in an exterior syndrome accompanied by a fever, aversion to wind, a floating and relaxed pulse, is an attack of the Taiyang Meridian by wind or it is named the exterior deficiency syndrome. Wind is a yang pathogenic factor, changeable and pervasive. It tends to cause the textual and interstitial spaces of muscles to loose and pores to open, and make body fluids release. As a result, sweating appears. In an exterior syndrome, presence of sweating associated with a high fever; slight aversion to cold, a headache, a sore throat and a floating and rapid pulse indicates an exterior heat syndrome. Heat is a yang pathogen, having a dissipating action. When pathogenic heat attacks the superficial portion of the body, the textual and interstitial spaces of muscles open and body fluids release. As a result, sweating appears. Perspiration in an Interior Syndrome: Asking about perspiration in an interior syndrome helps tell the cause of a disease, cold or heat, and preponderance or discomfiture of yin and yang of the body. The following four conditions will be discussed Spontaneous sweating: It refers to breaking out in a sweat during the day, intensified when active. It is a syndrome of yang deficiency due to hypofunctioning of the wei system, usually accompanied by lassitude, fatigue, shortness of breath, aversion to cold-manifestations of yang deficiency. Yang deficiency leads to hypofunctioning of the defensive qi, letting out of body fluids and spontaneous sweating due to more opening and less closing of pores. When active yang-qi must be consumed and body fluids are letting out more, much spontaneous sweating appears. Night sweats: It refers to sweating during sleep and ceasing of sweating while one awakes. It is often accompanied by a feverish sensation in palms, soles and the heart region, insomnia, flushed cheeks, dryness in the mouth and throat, usually due to production of internal heat caused by yin deficiency. During sleep yang-qi enters the interior and the superficial portion of the body lacks of defense. Heat in a deficiency condition steams body fluids and drives it out, finally sweating appears. But when one awakes, yang-qi goes out again and guards the exterior. Then sweating stops. Profuse sweating: It refers to massive release of body fluids in various conditions. An excess heat syndrome: It is marked by profuse sweating and a high fever, thirst, preference for cold beverages and a full pulse. It is due to overabundant internal heat compelling sweat to release. Sweating of the dying: When a patient has profuse perspiration, accompanied by shortness of breath, lassitude, feeble breathing, cold limbs and a faint pulse, it is a condition of collapse of yang-qi, leading to uncontrolled discharge of body fluids. Perspiration after shivering: It refers to a condition in which a patient is first attacked by severe chills, and then perspiration follows. It indicates a confrontation between 75

76 pathogenic cold and body resistance, regarded as the turning point of an illness. Abundant pathogenic factors and declined body resistance are the cause of the condition. When the body resistance is strengthened, a struggle between the pathogenic factors and body resistance is going on, leading to perspiration after shivering. After sweating, if fever subsides and the pulse calms down and the patient no longer has a heat sensation, it is a sign of recovery. If a high fever persists after sweating, accompanied by a swift pulse and irritability, it is a sign of deterioration, suggesting abundant pathogenic factors and further declined body resistance. Thus, perspiration after shivering is the turning point for better or worse of a disease. Local Perspiration: Asking about local abnormal sweating helps diagnosis too. It can be classified into the following conditions. Sweating on the head: It implies that much sweating over the head is usually caused by pathogenic heat in the upper-jiao or by steaming of accumulated damp-heat in the middle-jiao, or by upward floating of yang in a deficiency condition. Much sweating over the head and face, associated with vexation, thirst, a red tongue tip with yellow, thin coating and a rapid pulse indicates collected damp heat in the middle-jiao, which goes up to the head via the yang meridians after evaporation, often seen in diseases caused by damp warm pathogenic factors. Perspiration on the forehead after a severe disease seen in aged patients with weak constitution and shortness of breath indicates a deficiency syndrome. At the late stage of a severe illness, sudden profuse sweating on the forehead, accompanied by cold limbs, shortness of breath and a faint pulse suggests a critical condition, in which yin fluid discharges following collapse of yang-qi due to exhaustion of essence and qi in a protracted disease and upward floating of yang in a deficiency condition and separation of yin and yang. Perspiration on one side of the body: It may occur on either side or on either the upper or lower of the body due to blockage of meridians or obstruction of the ying and wei systems by wind phlegm or wind dampness, or disturbance in qi and blood. Sweating in the palms and soles: A little sweating in palms and soles is a normal state, whereas excessive sweating, associated with dryness in the mouth and throat, constipation, dark yellow urine and a fine pulse is an abnormal state due to steaming of stagnated heat in the yin meridians, because the Pericardium Meridian of Hand-Jueyin and the Kidney Meridian of Foot-Shaoyin pass through the palms and soles respectively. Profuse sweating is especially found in the chest, attributable to impairment of the spleen due to over-anxiety. In addition, cold sweating and heat sweating should be known. The former is often caused by deficiency of yang, insufficient defensive qi that fails to guard the superficial portion of the body, while the latter by affliction with exogenous pathogenic wind heat or by steaming of internal heat Asking about Pain 76

77 Questions about pain focus on its onset, quality and duration. Painful Site: Since a part of the body is connected with a definite zang-fu organ or meridian, location of a painful site helps know pathological changes of the zang-fu organs and meridians. Headache: The head is the confluence of all the yang meridians and the brain is known as the reservoir of marrows. Most of the twelve regular meridians and eight extraordinary meridians are connected with the head. Especially, the three yang meridians run to the head. Headache due to exposure to wind, cold, summer heat, dampness; fire or to phlegm, blood stasis, or disturbance in lucid yang is an excess syndrome, whereas that due to consumption of qi, blood, essence and body fluids, which fails to nourish the head is a deficiency syndrome. If a sudden onset of continuous headache involving the neck, it is an exogenous syndrome. Long- term intermittent headache accompanied by dizziness but without chills and fever, is an interior syndrome. In general, a sharp headache suggests an excess syndrome and a dull pain in the head often points to a deficiency syndrome. Headaches aggravated by exposure to wind cold are caused by wind-cold. Headaches aggravated by exposure to warmth and heat, associated with dizziness suggest hyperfunction of liver yang, or upward flaming of phlegm-fire. Headaches with a heaviness sensation in the head like being tightly bandaged is due to upward going of phlegm-dampness. A pain occurring the forehead is a headache due to problems of the Yangming meridians. A pain occurring in the temples is a headache due to problems of the Shaoyang meridians. A pain occurring in the nape is a headache due to problems of the Taiyang meridians. A pain occurring in the top of the head is a headache due to problems of the jueyin meridians. Chest pain: Since the chest is the place where the heart and lung are located, a chest pain may result form impeded qi flow in this area due to insufficient yang-qi, cold, blood stasis, phlegm obstruction or injury to vessels due to fire heat. Hypochondriac pain: Since the Liver and Gallbladder Meridians run past the hypochondriac region, a hypochondriac pain indicates impeded flow of liver qi, damp heat in the liver and gallbladder or stagnation of qi and blood, and retention of fluid in the hypochondriac region. A hypochondriac distending pain with a suffocating feeling or tenderness at the right hypochondriac area indicates problems of the liver and gallbladder, or stagnation of liver qi, damp-heat in the liver and gallbladder. A hypochondriac pain accompanied by shortness of breathe, difficulty of lying flat points to retention of fluid in the chest and hypochondrium. Epigastric pain: A pain in the stomach is often due to invasion of it by pathogenic cold, retention of undigested food in the stomach or a disturbance in the stomach caused 77

78 by perverted flow of liver qi. Abdominal pain: The abdominal cavity includes three parts: the upper abdomen, lower abdomen and the sides of the lower abdomen. The first one houses the spleen and stomach, the second one houses the kidneys, urinary bladder, large and small intestines and uterus, and the third one is the Elace where the Liver Meridian runs through. According to the painful site, one may tell the organs involved. A dull abdominal pain, alleviated by warmth and pressure, associated with loose stools indicates deficiency of spleen qi and cold. A sharp abdominal pain, alleviated by warmth and aggravated by pressure is an excess syndrome. An abdominal pain relieved by cold and aggravated by pressure with constipation is caused by heat in a deficiency condition. A fixed abdominal pain, aggravated by pressure associated with hard masses, indicates lumps in the abdomen. An intermittent pain around the umbilicus indicates parasites. A lower abdominal pain, involving testes suggests hernia or cold in the Liver Meridian. A sharp lower abdominal pain and constipation suggest blockage of intestines. Low back pain: The kidney is housed in the low back and a low back pain often indicates pathological changes of the kidney. When it is caused by obstruction of meridians and collaterals by wind, cold and dampness or blood stasis, it is an excess syndrome, whereas when it is produced by insufficient kidney essence or deficiency of kidney-yin and kidney-yang and failure of the kidney to be warmed and nourished by them, it is a deficiency syndrome. Pain of limbs: A pain of limbs, joints, muscles or meridians is usually caused by an attack by wind, cold and dampness, impeding smooth flow of qi and blood, or by hypofunction of the spleen and stomach and failure of the limbs to be nourished by food essence. A heel pain, involving the low back in severe cases, indicates deficiency in the kidney. Quality of Pain As there are different causes of pain, the quality of pain varies too. Questioning about the quality of pain helps tell the cause and pathogenesis. Distending pain: It may be found in various parts of the body, especially in the chest and abdomen. A distending pain is caused by stagnation of qi, and a distending pain in the head, however, tends to be seen in hyperfunction of liver-yang or upward flaming of liver-fire. Pain with a heavy sensation: It is often found in the head, limbs and low back caused by stagnation of qi and blood due to dampness. Dampness in nature is weighty, turbid and sticky. In the body, when dampness dwells in meridians, a feeling of heaviness appears. Pricking pain: It is a sign of blood stasis, frequently seen on both sides of the abdomen, in the lower abdomen and chest. 78

79 Colicky pain: It is usually caused by obstruction of qi flow due to pathogenic factors. A real cardial pain is produced by stagnation of heart-blood. It is also seen in the chest and abdominal pain due to an upward attack by roundworms, in the lower abdominal pain due to stranguria caused by the passage of urinary stone. Burning pain: A burning pain is relieved by exposure to cold and often found in the hypochondriac region and stomach due to pathogenic fire, deficiency of yin and exuberance of yang. Pain with a cold sensation: A pain with a cold sensation, alleviated by warmth is usually seen in the head, low back, chest and abdomen caused by an attack of meridians by cold or insufficient yang, which fails to warm up the zang-fu organs and meridians. Dull pain: It is a pain, tolerable and lingering, usually caused by insufficient qi and blood, leading to inner production of yin-cold and impeded flow of qi and blood. It often occurs its the head, chest, abdomen and low back, characterized by deficiency. Radiating pain: It is usually caused by undernourishment or blockage of tendons and muscles. Problems of the liver often produce a radiating pain as the liver dominates tendons. Questioning about pain includes the site, quality and duration. You may ask whether it is relieved or aggravated by pressure. In general, any present continuous pain, aggravated by pressure indicates an excess syndrome, while a protracted intermittent pain, relieved by pressure indicates a deficiency syndrome. 6.5 Pulse-Taking and Palpation In this chapter we are going to deal with pulse taking and palpation of the body to collect the necessary information for diagnosis and differentiation of syndromes. In this part, we will introduce the pulse-taking in brief The Principle of the Formation of Pulse Conditions and the Clinical Significance of Pulse-Taking The Principle of the Formation of Pulse Conditions: As we know in traditional Chinese medicine, qi and blood are circulating in meridians and vessels under the power of heart qi, the process of which is called pulsation. The circulation of qi and blood without an end depends on two elements. Firstly, in structure blood vessels are connected to the heart and are the house of blood. Blood and vessels form a functional integrity, in which the heart governs blood and vessels. Secondly, heart-qi is the power of blood circulation and blood flow is con fined in vessels. The volume and quality of blood play an important role in the whole process. Functionally, they influence each other. In view of their structure and function they are interacted. It is mid that "pulse is produced by heart beating" and "pulse can be taken because of pulsation". Based on this concept the pulse condition is shaped. The pulse condition is not only related to the heart, blood and vessels, but to an 79

80 overall functional activities of the zang-fu organs. The origin of qi is concerned with the lung, and the source of blood is the essential substances from food blood circulation is dominated by the heart, and blood is governed by the spleen, stored in the liver and distributed by lung-qi. By the above process, it flows all over the body through meridians and vessels. Blood is the essence of yin and it is stored in the kidney. Qi of the middle-jiao is transformed into blood with the help of the function of the vital gate. In this way, blood flows in meridians and vessels, and the pulse condition is closely linked to the functional activities of the zang-fu organs. The Clinical Significance of Pulse Taking: Since the formation of the pulse condition is closely bound up with the condition of qi and blood of the zang-fu organs, pathological changes of qi and blood may impede smooth flow of them, resulting in a change of the pulse condition. Then, through pulse taking we may predict the location of a disease and its prognosis. To determine the location of an illness, its nature and the condition of the body resistance and pathogenic factors: Although the manifestations of diseases are quite complicated, the location of a disease is either in the exterior or interior of the body, and the characteristics of the floating and deep pulse concern the depth of location. A floating pulse often indicates the disease is in the exterior, while a deep pulse in the interior. The nature of any disease can be divided into the cold and heat syndromes and the characteristics of the slow and rapid pulse reflect the nature of diseases. For instance, a slow pulse points to a cold syndrome, whereas a rapid pulse a heat syndrome. In the course of the pathological changes, along with the confrontation between the pathogenic factors and body resistance, deficiency and excess conditions appear. As a result, there present forceless and forceful pulses. The former indicates a sign of inadequate body resistance, and the latter, an excess syndrome, a sign of abundant pathogenic factors. To determine the development and prognosis of an illness: In a chronic case, if the pulse condition turns to better, it is a sign of recovery, because stomach-qi is going to restore. A full pulse is seen in a protracted illness or consumptive disease leading to deficiency of qi, or in loss of blood. It indicates a critical condition due to exuberance of pathogenic factors and declined body resistance. When the pulse condition turns to better in a febrile disease caused by exogenous pathogenic factors and fever is subsiding, it suggests recovery; deterioration of a disease is marked by a rapid pulse and irritability. If in an exogenous febrile disease, fever subsides and a smooth pulse appears after sweating, it is a sign of recovery; a rapid pulse accompanied by irritability points to a critical stage of an illness Portions for Pulse-Taking Portions for pulse-taking varies in different stages of development of traditional Chinese medicine. In general, there are three ways of pulse taking: general pulse taking, pulse taking in 80

81 three parts and pulse-taking at cunkou. As it has been wildly used, the last one is applied now. General pulse taking: It was described firstly in Plain Question. The three portions or arteries of the body to be palpated are on the head (upper), hand (middle) and foot (lower) and each is further subdivided into three portions, namely, heaven (upper), man (middle) and earth (lower). Pulse-Taking at Cunkou: As it is easy to take pulse in this area, it is commonly accepted by practitioners throughout ages and widely used today. Cunkou is also named qikou and maikou, located at the area next to the crease in the wrist where the radial artery throbs. The theoretical background of the pulse- taking at cunkou: Pulse at cunkou may reveal the pathological changes of the zang-fu organs. Firstly, cunkou is the confluent place of the arteries of the Lung Meridian as vessels converge in the lung. In other words, cunkou is an artery of the Lung Meridian of Hand Taiyin; and the meeting place of qi and blood of the Lung Meridian, known as "a point where vessels assemble. The circulation of qi and blood of the zang-fu organs and the twelve meridians starts form the lung and ends at the lung, so pathological changes often zang-fu organs can be seen from the condition of cunkou pulse. Secondly, the Lung meridian of Hand-Taiyin originates in the middle jiao and the Spleen Meridian pertains to Taiyin too. Spleen-qi and stomach qi are interconnected. The spleen and stomach are the origin of the acquired constitution and the source of qi and blood. That is why the cunkou pulse reflects the condition of qi and blood of the zang-fu organs.on the left hand, the cun, guan and chi correspond to the heart, liver, gallbladder and kidney respectively. On the right hand, the cun, guan and chi correspond to the lung, spleenistomach and kidney respectively The Normal Pulse Normal pulse refers to the pulse condition of healthy persons. Pulse can be felt at the cun, guan and chi regions. A normal pulse has a frequency of about four to five beats per breath (or beatsiper minutes). It is even, stable, harmonious and forceful with regular rhythms. When a heavy pressure is applied to the chi pulse, one may feel a forceful beating. It varies with physiological and climatic conditions, however. In summary, the normal pulse has the following three features. Adequacy of stomach-qi: The stomach is the reservoir of foodstuffs, the acquired constitution of the body and the source of the nutrient qi and defensive qi. Life and death depend presence and absence of stomach-qi. It was said that "life depends on existence of stomach-qi and death occurs in absence of stomach-qi" indicating the importance of it, Therefore, stomach-qi is the basis of pulse. Pulse condition showing adequate stomach-qi was described differently by the ancient Chinese, but in general, the pulse, neither floating and rapid nor deep and slow with regular rhythms, reflects 81

82 existence of stomach qi. Even if it is an abnormal pulse, regardless of its floating, deep, slow or rapid but harmonious, it indicates the existence of stomach-qi The condition of stomach-qi reveals alleviation or deterioration of a disease. Existence of Vitality: It can be seen in a normal pulse. The heart dominates blood and stores spirit, and vessels are the house of blood. Abundant qi and blood bring about vitality and the pulse certainly reflects the existence of vitality. A soft and forceful pulse suggests the existence of vitality. Even if it is a faint pulse beating with some force, it still means the existence of vitality. A wiry and replete pulse beating harmoniously points to vitality too. Existence of Kidney-Qi: Vital essence is stored in the kidney, which is the congenital constitution of the body and the motive power of the functional activities of the zang-fu organs and tissues. A heavy pressure applied to the chi region, if the pulse is forceful, means existence of kidney qi. In a disease, when the chi pulse is found on heavy pressure, it indicates existence of kidney qi and the congenital constitution still exists, and there is a chance of survival Abnormal Pulses and Their Suggestion of Problems The pulse condition reflecting various pathological changes of a disease is known as the abnormal pulse. In general, besides pulses due to normal physiological changes and individual physiological specificity, all is included in the abnormal pulses. The pulse condition is known by its location, beating, quality, shape and force. For instance, a floating pulse and deep pulse indicate the depth of location of the pulse, and a slow pulse and rapid pulse indicate the coming speed of the pulse, a feeble pulse and excessive pulse indicate the force of beating. Some pulse conditions, such as the full pulse and thready pulse concern about the shape and force. Types of the Poise Condition and Their Suggestion of Problems (1) The floating pulse Pulse condition: It responds to the finger when pressed lightly but feels weak when a heavy pressure is applied. Suggestion of problems: It indicates the exterior syndrome and deficiency syndrome. Explanation: The floating pulse indicates the exterior syndrome, and the attack of the superficial portion of the body by exogenous pathogenic factors. It occurs when the meridian qi rises to the surface as the defensive qi emerges to combat the attack by pathogenic factors. As a result, a floating pulse appears. Clinically it is often seen at the initial stage of diseases caused by the six external etiological factors, such as common cold and influenza. The pulse is floating and forceful. The floating pulse, however, may be found in protracted and consumptive diseases, loss of blood and outward going of yang qi. But they are marked by a floating and forceless pulse, suggesting a deficiency syndrome. (2) The deep pulse 82

83 Pulse condition: It only responds to the finger when pressed heavily. Suggestion of problems: It indicates the interior syndrome. A deep forceful pulse indicates an interior syndrome of excess; a weak deep pulse indicates an interior syndrome of deficiency. Explanation: The former is caused by accumulation of pathogenic factors in the interior and a combat between the antipathogenic qi and pathogenic factors, whereas the latter is produced by insufficient qi and blood, declined function of the zang-fu organs and weak flow of meridian qi. (3) The slow pulse Pulse condition: A slow pulse is one with three or fewer beats per breath. Suggestion of problems: It indicates the cold syndrome, or accumulation of cold when it is forceful, or cold and deficiency when it is forceless. Explanation: A slow pulse is usually caused by impeded circulation of qi and blood due to accumulation of cold. In general, a slow and forceful pulse indicates an excess cold syndrome while a slow and forceless pulse indicates deficiency of yang qi. But it should be pointed out that a slow and forceful pulse may aim be the result of a disruption of qi and blood circulation by pathogenic heat. For instance, it may be seen in an excessive heat syndrome caused by accumulation of heat in the stomach and intestines, so a slow pulse does not always point to the cold syndrome. The only way to distinguish the cause heat or cold is to refer to other signs and symptoms. Athletes and manual workers often have a slow and forceful pulse. This is their normal physiological condition. (4) The rapid pulse Pulse condition: A rapid pulse is one with more than five beats per breath. Suggestion of problems: It indicates the heat syndrome, or presence of excessive heat when it is forceful. If it beats without force, the condition is usually one of heat in a deficiency condition. Explanation: In the former case, the confrontation between exuberant pathogenic heat in the interior and abundant yang qi of the body accelerates blood flow, while in the latter case, when body fluids and blood have been consumed by a prolonged illness, and there is internal production of beat, a rapid pulse beating without force appears. A rapid pulse also indicates the deficiency syndrome, but it is a rapid and large pulse without force. Accurate identification of the three conditions depends on an overall analysis of the pulse and symptoms. (5) The deficient pulse Pulse condition: A feeble pulse can be felt with a light, moderate and heavy pressure but feels forceless and void to the fingers. Suggestion of problems: It indicates deficiency of qi. Explanation: It is forceless because qi is insufficient to impel blood flow, and it feels 83

84 void because blood is inadequate to fill the vessels. (6) The excessive pulse Pulse condition: An excessive pulse is palpable under light moderate and heavy pressures. Suggestion of problems: It indicates the excess syndrome. Explanation: It means that the body is functioning well and will respond with strength to any disease. The struggle between abundant pathogenic factors and sufficient qi produces an abundance of qi and blood, which in turn, produces an excessive pulse. (7) The surging pulse Pulse Condition: A surging pulse feels large and its beat is likened to dashing waves that rise forcefully and then decline suddenly. Suggestion of problems: It indicates excessive heat in the qi system. Explanation: Excessive internal heat produces dilation of the blood vessels, an abundance of qi and surge of blood, all of which produces a sensation that the pulse is full. It is also seen in such conditions as deficiency of qi due to a prolonged illness, consumptive diseases, loss of blood and persisted diarrhea, suggesting a critical case due to abundance of pathogenic factors and declined body resistance. (8) The faint pulse Pulse condition: It is an extremely thready and soft pulse, palpable faintly. Suggestion of problems: It indicates deficiency of yang-qi and deficiency of yin, yang, qi and blood. Explanation: A faint pulse occurs when yang qi is exhausted. When it seems unpalpable under a light pressure, it is a sign of yang exhaustion; when it seems unperceptible under a heavy pressure, it is a sign of yang exhaustion. When it occurs in a prolonged disease, it is indicative of exhaustion of vital qi; when it occurs in a recent attack of disease, it indicates abrupt collapse of yang-qi. But the pathogenic factors are not too strong, and it is a hopefulcase. (9) The thready pulse Pulse condition: A thready pulse is fine, however, it is clearly perceptible under a pressure. Suggestion of problems: A thready pulse is a sign of the deficiency syndrome. Sometimes, it points to pathogenic dampness. Explanation: It is caused by deficiency of qi and blood, and failure of the vessels to be replenished by blood and impeded blood circulation due to inadequate qi. A thready pulse is also seen in consumption of qi and blood due to a prolonged illness and senility, intake of less food due to hypofunction of the stomach, excitation of the seven emotions, internal injury to qi and blood, consumptive diseases and overstrain. Sometimes, a thready pulse may occur when pathogenic dampness has produced a prolonged injury to the vessels. When a thready and forceful pulse appears in an acute febrile disease with 84

85 coma and delirium, it is a sign of invasion of blood and the pericardium by pathogenic heat, indicating a blood heat excess syndrome. (10) The scattered pulse Pulse condition: A scattered pulse is one that feels diffusing with irregular beats. Suggestion of problems: It indicates exhaustion of qi. Explanation: It occurs when the qi of the zang-fu organs is exhausted due to heart failure and scattering of yang qi or depletion of yin and yang, or failure of blood circulation. It is usually seen in critical cases. (11) The smooth pulse Pulse condition: A smooth pulse feels slippery and flowing, like beads rolling on a plate. Suggestion of problems: It indicates retention of phlegm, fluid and undigested food and excessive heat. Explanation: A smooth pulse appears in patients with undigested food, retention of phlegm and fluid and sufficient antipathogenic qi. It may appear in healthy people with very strong constitution or during pregnancy in women with ample qi and blood. (12) The unsmooth pulse Pulse condition: An unsmooth pulse is fine, short and slow, coming and going unsmoothly, opposite the smooth pulse. Suggestion of problems: It indicates injury to vital essence, insufficiency of blood, stagnation of qi and blood, retention of phlegm or undigested food. Explanation: A pulse, unsmooth and forceless, is produced by deficiency of essence and blood, which leads to malnutrition of vessels and impeded flow of blood. A pulse, unsmooth and forceful, is caused by stagnation of qi and blood, retention of phlegm or undigested food and impeded flow of qi and blood. (13) The long pulse Pulse condition: The pulse stretches to a longer length, beyond its original region. Suggestion of problems: It indicates abundant liver-yang, abundance of yang and internal heat. Explanation: A long and gentle pulse suggests sufficiency of qi of the middle jiao and free circulation of qi and blood. It is considered normal, while a long and wiry pulse or accompanied by other coexisting pulse conditions indicates hyperactivity of liver-yang, accumulation of heat in vessels and a combat between pathogenic factors and antipathogenic qi. (14) The short pulse Pulse condition: It is a pulse with short extent, only palpable at the guan region but distinct at the cun and chi regions. Suggestion of problems: A short pulse throbbing with force indicates stagnation of qi and slow circulation of blood; while a short pulse throbbing without force suggests 85

86 deficiency of qi and blood, retention of phlegm or undigested food. (15) The wiry pulse Pulse condition: To the fingers the wiry pulse gives the sensation of pressing on a violin string. Suggestion of problems: It indicates disorders of the liver or gallbladder, pains, retention of phlegm and fluid and malaria. Explanation: The liver keeps smooth flow of qi and this function must be moderate under normal conditions. But as dysfunction of the liver takes place because of an attack of the liver by pathogenic factors, smooth qi flow is impeded. As a result, a wiry pulse appears. Sometimes it occurs owing to various pains, retention of phlegm or fluid, leading to obstruction of qi. It is also seen in malaria when the pathogens are between the superficies and interior, causing impairment of qi flow, so malaria is characterized by a wiry pulse. In addition, it is often found in consumptive diseases, insufficiency of qi of the middle jiao and in liver problem involving the spleen. If a pulse feels wiry, thready and rapid like the edge of a knife, it indicates a difficult case because of complete loss of stomach-qi. (16) The hollow pulse Pulse condition: It is a pulse that feels floating, large and hollow like a scallion stalk. Suggestion of problems: It indicates severe loss of blood and injury to yin. Explanation: A hollow pulse is usually seen in severe loss of blood and injury to yin, e.g. hematemesis, hemafecia, uterine bleeding or profuse sweating. It is often the result of hemorrhage, unruliness of blood in vessels or exhaustion of body fluids. (17) The tense pulse Pulse condition: A tense pulse is one that feels tense and forceful, like a stretched, twisted cord. Suggestion of problems: It indicates syndromes of cold, pains and retention of undigested food. Explanation: When pathogenic cold attacks the body, yang-qi is obstructed and there is a combat between pathogenic cold and body resistance, leading to contracted vessels and a tense pulse. Pathogenic cold in the exterior often manifests itself as a floating and tense pulse, whereas pathogenic cold in the interior, as a deep and tense pulse. A tense pulse due to a sharp pain, retention of undigested food is also characteristic of a confrontation between pathogenic factors and body resistance. (18) The moderate pulse Pulse condition: A moderate pulse is one with four beats per breath. Suggestion of problems: It indicates a dampness syndrome and hypofunction of the spleen and stomach Explanation: A moderate pulse appears when dampness attacks because dampness is 86

87 viscosity, weighty and turbid, and it impedes qi flow. It is also seen in hypofunction of the spleen and stomach, leading to less production of qi and blood and unsmooth flow of blood. (19) The tympanic pulse Pulse condition: It is an extremely wiry and hollow pulse, giving the feeling like touching the surface of a drum. Suggestion of problems: It indicates depletion of blood or essence, miscarriage and uttering bleeding. Explanation: It is usually caused by exhaustion of blood and essence, leading to outward floating of qi. (20) The firm pulse Pulse condition: It is a pulse forceful, large, wiry and long on a heavy pressure. Suggestion of problems: It indicates abundance of internal cold, hernia and lumps in the abdomen. Explanation: It is usually seen in accumulation of yin-cold, such as abdominal mass, hernia, qi stagnation, pain in the chest and abdomen due to cold, produced by abundant pathogenic factors and downward going of yang-qi. (21) The weak pulse Pulse condition: It is a pulse that feels extremely soft, deep and thready. Suggestion of problems: Deficiency of qi and blood Explanation: It appears when there is insufficient blood, failure of the vessels to be replenished by blood, insufficient yang-qi and impeded flow of blood. A weak pulse appearing in a protracted illness with lowered body resistance indicates a favorable prognosis. When it appears in a recent disease with abundant pathogenic factors, it may have an unfavorable prognosis. (22) The soft pulse Pulse condition: It is a pulse that feels floating, thready and forceless. Suggestion of problems: It indicates the deficiency syndrome and dampness syndrome. Explanation: Injury to essence and blood leads to a thready pulse and deficiency of qi, and declined and diffusing yang produces a forceless and floating pulse. A floating, thready and forceless pulse is called the soft pulse. It is also seen when vessels are obstructed by dampness. (23) The hidden pulse Pulse condition: A hidden pulse is felt on pressing hard to the bone or it is difficult to feel. Suggestion of problems: It indicates a deep invasion of the body by pathogenic factors, syncope, a severe pain and declined yang. Explanation: It occurs when pathogenic factors have invaded the interior of the body 87

88 and obstructed the meridian qi, usually found in a sudden severe disease due to abundance of pathogenic factors. It is also seen when yang-qi is exhausted. (24) The tremulous pulse Pulse condition: It is a pulse that feels smooth, quick and forceful, like a bouncing pea. Suggestion of problems: It is seen in cases of terror and pain. Explanation: Terror and pain are due to imbalance of yin and yang, disorder of qi and blood, leading to a tremulous pulse. (25) The running pulse Pulse condition: It is a pulse that feels hasty and rapid with irregular intermittence. Suggestion of problems: It indicates exuberance of yang and heat, stagnation of qi and blood and retention of phlegm and undigested food. Explanation: A running forceful pulse is due to exuberance of yang and heat, disharmony between yin and yang, seen in disorders of qi and blood, retention of phlegm and undigested food and carbuncles, indicating a heat excess syndrome, whereas a running, thready and forceless pulse suggests a deficiency syndrome. (26) The knotted pulse Pulse condition: It is a pulse that feels slow with irregular intervals. Suggestion of problems: It indicates stagnation of qi due to abundant yin and accumulation of phlegm due to cold and blood stasis. Explanation: The pulse appears when there is stagnation of qi due to accumulation of cold and impeded flow of qi and blood, leading to obstruction of the meridian qi. (27) The intermittent pulse Pulse condition: It is a pulse that feels slow and weak, pausing at regular long intervals. Suggestion of problems: It indicates hypofunction of the zang organs, wind and pain syndromes, terror and traumatic injury. Explanation: The intermittent pulse is usually seen in cases of hypofunction of the tang organs, consumption of qi and blood, insufficient primordial qi, leading to disconnection of the meridian qi. As to the wind and pain syndromes, terror and traumatic injury, disconnecting of the meridian qi result in the intermittent pulse. The pulse is also seen in pregnant women, but it is different from the morbid intermittent pulse. (28) The swift pulse Pulse condition: A swift pulse is one with seven to eight beats per breath. Indication: It indicates exhaustion of yin due to over exuberance of yang or prostration of the primordial qi. Explanation: In overexuberance of yang and exhaustion of yin the pulse feels swift. A swift, forceless pulse suggests diminished yang. Tuberculosis is marked by a swift pulse, 88

89 and it is a critical condition When the Pulse Contradicts the Symptoms, What to Do? Generally, a pulse condition agrees with the symptoms of a patient. Sometimes, however, a pulse may contradict the observed symptoms. For example, symptoms occurring in an excess syndrome usually coincide with the presence of a pulse showing excess, such as a surging, rapid, smooth and excessive pulse. In these cases, the qi is vigorous enough to resist abundant pathogenic factors, and a favorable prognosis is expected. On the contrary, when a thready, faint, weak and unsmooth pulse appears in an excess syndrome, it means the pathogenic factors are rampant and about to prevail over the antipathogenic qi. The prognosis is prognosis. In a recently developed acute disease a floating, surging, rapid and excessive pulse points to strong antipathogenic qi over pathogenic factors and a favorable prognosis. A deep deficient, weak and thready pulse seen in a chronic disease shows the antipathogenic qi has declined; a floating, surging, excessive and rapid pulse found in a protracted illness indicates the antipathogenic qi has declined, while the pathogenic factors remain undiminished. A poor prognosis is expected for both of them. Since a pulse may contradict symptoms, true symptoms and false pulses or vice versa may occur. So it is imperative to tell the true from the false and decide what measures to be taken. Making a diagnosis on the basis of the pulse condition rather than on symptoms and signs: h should be followed when the symptoms are false but the pulse condition is true. Take the febrile disease induced by cold as an example, in which cold limbs, a smooth and rapid pulse is found; it indicates existence of interior heat. In this case, cold limbs are false symptoms. Thus, the diagnosis is made on the basis of the pulse condition rather than on the symptoms. Making a diagnosis on the basis of symptoms and signs rather than on the basis of the pulse condition: It should be followed when a pulse contradicts symptoms and signs. For example, an abdominal distension and pain, aggravated by pressure, constipation, a red tongue with thick deep yellow coating and a slow and thready pulse indicate accumulation of heat in the stomach and intestines. The symptoms are true, but the pulse gives a false phenomenon. A slow and deep pulse is produced by interior heat which impedes smooth flow of qi and blood. In this case, diagnosis should be made based on symptoms observed rather than the pulse condition. From above, we know that the pulse condition is only one of the clinical manifestations, and it cannot be considered as the exclusive diagnostic evidence. Only by analyzing the data gathered from all the diagnostic methods can a comprehensive and correct diagnosis be made. ( 邓红 ) 89

90 90 Chapter Seven Differentiations of Syndrome 7.1 Differentiations of Pathological Changes in Accordance with the Eight Principal Syndromes The eight principal syndromes serving as guide lines in diagnosis are yin, yang, exterior, interior, cold, heat, deficiency and excess. It is a method of differential diagnosis used to determine the nature-heat or cold, and the location-deep or superficial, the confrontation between the ant pathogenic qi and pathogenic factors and the category of diseases-yin or yang, based on a comprehensive analysis of all the data obtained by means of inspection, auscultation and olfaction, inquiry, pulse-taking and palpation Differentiation of the Exterior and Interior Syndromes Exterior and interior are the principles that describe the location and tendency of a disease. In general, an exterior syndrome refers to an attack of the superficies-skin and hair, texture and interstitial spaces by pathogenic factors; an interior syndrome indicates disorders in the internal organs, blood and vessels and bone marrows. The exterior syndrome or interior syndrome may be found at the moment of the onset of a disease. But in some cases, an interior syndrome may result from a transmission of exogenous pathogenic factors to the interior with or without manifestations of an exterior syndrome. In some cases, an interior syndrome may involve the exterior with manifestations of both interior and exterior syndromes Exterior Syndromes They refer to an attack of the superficies by the six exogenous pathogenic factors through the skin, hair, mouth and nose. It is usually seen at the early stage of illness due to exogenous pathogenic factors marked by a sudden onset and it is short-lived. Clinical Manifestations ; Fever, aversion to cold (or wind), headache and general aching, a stuffy and running nose, an itchy throat and coughing, a sore throat and a thin, white yellow coating on the tongue. Treatment: Relieving the exterior syndrome with herbs pungent in flavor and cool in property Interior Syndromes They are contrary to the exterior ones, and are characterized by pathological changes in the zang-fu organs, qi and blood systems, and bone marrows. To sum up, except the exterior ones all syndromes are under the head of the interior syndromes. Clinical Manifestations: An interior syndrome due to transmission of exogenous pathogenic factors to the interior is marked by a high fever or tidal fever, absence of chills,aversion to heat, thirst, abdominal distension or pain, nausea or vomiting, dry stools or hot offensive stools, scanty deep yellow urine, coma, irritability or delirium, a red tongue with thick, yellow coating and a surging pulse or deep, rapid and forceful pulse.

91 Treatment: In the interior syndrome of excessive heat, internal heat must be eliminated. But the interior syndrome covers a wide range and there are varieties of treatment, including reinforcing the body resistance, eliminating pathogenic factors or "regulating the functional relation among the internal organs", employed in light of particular conditions Differentiating the Exterior and Interior Syndromes On telling an exterior syndrome from an interior syndrome, it is essential to observe manifestations of cold and heat, changes of the tongue coating and pulse condition. In general, a present disease with a short course usually belongs to an exterior syndrome, while a persisted illness with a long course often belongs to an interior syndrome. Coexistence of fever and chills points to an exterior syndrome, whereas fever, absence of chills or chills without fever is an interior syndrome. Little change of the tongue coating is seen in an exterior syndrome, but much change of the tongue coating is seen in an interior syndrome. A floating pulse indicates an exterior syndrome while a deep pulse refers to an interior syndrome Differentiating the Cold, Heat, Deficiency and Excess Conditions in the Exterior and Interior Syndromes The exterior and interior syndromes do not exist separately; rather, they are connected with the cold, heat, deficiency and excess conditions. Differentiating the exterior and interior syndromes only answers the site of the disease-superficial or deep. It does not answer the nature of pathological changes-cold or heat, and the strength of body resistance. To know the nature of the exterior and interior syndromes it is necessary to differentiate their attribute-cold, heat, deficiency and excess. See tables below. In addition to a simple cold or heat syndrome, there may appear syndromes of coexisting and interlocking cold and heat, heat turning to cold, cold turning to heat, and true cold with pseudo-heat, and true heat with pseudo-cold. Syndromes of cold and heat are usually linked to the exterior, interior, deficiency and excess conditions. Thus, complicated clinical manifestations appear Differentiation of the Cold and Heat Syndromes Cold and heat are the principles that identify the specific nature of a disease. Since cold and heat reflect exuberance and discomfiture of yin and yang, differentiating syndromes of cold and heat, in fact, is telling the condition of yin and yang. In general, cold syndromes are provoked by insufficient yang-qi or exposure to pathogenic cold. Heat syndromes result from hyper functioning and preponderance of yang or exposure to pathogenic heat Cold Syndrome They are caused by exposure to exogenous pathogenic cold or insufficient yang of the body due to a protracted illness, consumed yang-qi or by intake of cold foodstuffs, giving 91

92 Differentiation of Cold, Heat, Deficiency and Excess Exterior Syndromes Syndrome Common Symptoms Chief Symptoms for Differentiation Cold in the exterior Heat in the exterior Exterior deficiency Exterior excess Aversion to cold, fever Headache,aching pain of the limbs, thin, white tongue coating, floating pulse Severe aversion to cold and a low fever, general aching, thin, white, moist tongue coating, floating and tense pulse Slight aversion to cold, higher fever, slight thirst, thin, white, dry tongue coating, reddened tongue tip, floating and rapid pulse Sweating or sweating and aversion to wind, floating, slow and forceless pulse Absence of sweating, floating and forceful pulse rise to internal cold. The cold syndromes include cold in the exterior, cold in the interior, cold in a deficiency condition and cold in an excess condition. Clinical Manifestations ; The commonly-seen ones are intolerance to cold, preference for heat, pallor, cold limbs, huddling up with cold, a diminished sense of taste in the mouth, absence of thirst, clear and thin sputum, saliva and nasal discharge, clear profuse urine, loose stools, a pale tongue with white, glossy coating and a slow or tense pulse. Treatment: Expelling cold by medicinal herbs warm in property Heat Syndromes They are caused by contracting of exogenous fire, internal of heat turned from cold, heat due to excitation of the seven emotions and irregular diet, or by hyper function of yang due to yin deficiency owing to excessive sexual activity that consumes essence. The heat syndromes include heat in the exterior, heat in a deficiency condition and heat in an excess condition. Clinical Manifestations : Manifestations vary in different heat syndromes, but the commonly-seen ones are intolerance to heat and preference for cold and cold beverages, thirst, flushed complexion and reddened eyes, irritability, thick, yellow sputum and nasal discharge, hematemesis, nose bleeding, concentrated urine, constipation, a reddened tongue with dry, yellow coating and a rapid pulse. Treatment: Clearing up heat and purging fire Differentiating Syndromes of Cold and Heat Differentiating syndromes of cold and heat cannot solely depend on a symptom. The total clinical manifestations should be collected and analyzed. Among them, it is most imperative to analyze the condition of preference for cold or heat, thirst or absence of 92

93 thirst, pale or flushed complexion, cold or warm limbs, stools and urine, and conditions of the tongue and pulse. Their main difference is as follows: Differentiating Items in Cold and Heat Syndromes Symptoms and signs Cold and Heat Thirst Complexion Four Limbs Stools and Urine Tongue Condition Pulse Condiction Cold syndrome Intolerance to cold, preference for heat Absence of thirst Pale Cold Loose stools, clear profuse urine Pale tongue with white sticky coating Slow or tense Heat syndrome Intolerance to heat, preference for cold Thirst preference, for Cold beaverages Flushed Hot Constipation, concentrated urine Red tongue with dry yellow coating Rapid Differentiations of Deficiency and Excess in Cold and Heat Syndromes Syndromes of cold and heat must be further differentiated according to deficiency and excess. Their main difference is as follows, See tables below Differentiation of the Deficiency and Excess Syndromes Deficiency and excess conditions describe the struggle between the antipathogenic qi and pathogenic factors. Deficiency denotes a condition in which the body resistance is lowered and its function is weak. Excess denotes a condition in which the pathogenic factors are hyperactive. Since any disease can be classified into the condition of deficiency or excess, which are related to cold or heat in the exterior or interior, these two syndromes are quite complicated when they occur. An excess syndrome may transform into a deficiency one and vice versa. Also, conditions of false deficiency and false excess can appear, and the two occur simultaneously Deficiency Syndromes Deficiency syndromes are conditions in which the body resistance is lowered, its physiological functions are weak or declined. In general, there is a mutual connection among the antipathogenic qi, pathogenic factors, deficiency and excess conditions, and they are mutually affected. Clinically, however, many conditions attribute to sole deficiency of qi or blood, yin or yang. As to the condition of pathogenic factors-presence or absence, preponderance or discomfiture, a concrete analysis is made clinically. Clinical Manifestations: The deficiency syndromes vary greatly; however, they may be grouped under the following four heads: deficiency of yin, deficiency of yang, deficiency of qi and deficiency of blood with various clinical manifestations. The commonly-seen 93

94 Differentiating Deficiency and Excess in Cold and Heat Syndromes Syndrome Pathogenesis Chief Symptoms Cold Excess cold Abundant pathogenic cold and yang being checked Aversion to cold, cold limbs, pain and coldness in the abdomen, constipation sometimes, pale tongue with white coating, deep, wiry or deep, slow and forceful pulse Cold Deficiency cold Declined yang-qi, overabundance of internal cold Intolerance to cold, cold limbs, pallor, lassitude, diarrhea with undigested food, clear and profuse urine, pale, flabby tongue with thin, glossy coating, slow, thread or fine, thread pulse Heat Excess heat Overabundance of pathogenic heat High fever, thirst, coma, delirium, distending pain of the abdomen, aggravated by pressure, constipation, red tongue with thick, yellow and dry coating, rapid or surging, rapid pulse Deficiency heat Insufficiency of yin and hyper functioning of fire Tidal fever, night sweats, emaciation, lassitude, feverish sensation in palms, soles and the heart region, dry throat and mouth, no desire to drink water, red tongue with a little coating, thread, rapid pulse symptoms are pallor or a sallow complexion, general lassitude, listlessness, palpitation, shortness of breath, chills and cold limbs, a feverish sensation in palms, soles and the heart region, spontaneous sweating or night sweats, incontinence of feces and urine, a pale tongue with thin coating or no coating and a fine and weak pulse. Treatment: Restoring qi and blood to strengthen the body resistance (including therapies of warming yang, reinforcing qi, nourishing blood and replenishing yin) Excess Syndromes The excess syndromes are provoked by either overabundance of exogenous pathogenic factors and functional hyperactivity of the body, or functional disorders of the organs or metabolic system that result in accumulation and stagnation of pathological products. In general, although the excess syndromes are characterized by hyperactivity of pathogenic factors, the body resistance is still strong enough to combat them, indicating an intense struggle between the body resistance and pathogenic factors. Clinical Manifestations; Because of the variety of possible pathogenic factors and of possible location of the disease, clinical manifestations vary greatly. However, the chief indicators of an excess syndrome are: fever, pain and distension in the abdomen, aggravated by pressure, a suffocating feeling in the chest and irritability. In severe cases 94

95 the symptoms may also include coma, delirium, harsh breathing, excessive phlegm and saliva, constipation, difficulty of urination, an excessive, forceful pulse and a thick, sticky coating on the tongue. Treatment: Eliminating pathogenic factors Differentiating Syndromes of Deficiency and Excess Differentiating Syndromes of Deficiency and Excess Syndrome Item for Differenttiation Excess Syndrome Deficiency Syndrome Course of disease Short(currently occurred ) Long (chronic ) Physique Stronger Weaker Spirit Exited Listless Voice and breathing Sonorous sound, harsh breathing Low voice, feeble breathing Pain Aggravated by pressure Alleviated by pressure Chest, abdomen Painful on pressure Painless on pressure Fullness Not relieved Relieved occasionally Fever Aversion to cold High fever Not alleviated with warm clothing and heavy bedding Feverish sensation in palms, soles and the heart region, slight fever in the afternoon Alleviated with warm clothing(chills) Tongue Old-looking tongue with thick coating A little coating or no coating on the tongue Pulse Forceful Forceless The key factors in differentiating deficiency and excess syndromes are thus: the strength of the physical appearance, signs of vitality, presence or absence of sweating and distension, the effect of pressure on areas that are painful and the condition of the tongue and pulse Differentiation of Syndromes of Yin and Yang As already mentioned, yin and yang are two guidelines in differentiation of syndromes. Clinically, syndromes vary and are changeable, but they are always under two classes-either yin or yang. Thus on diagnosis, yin and yang must be differentiated first. Thus, syndromes of the exterior, heat, and excess conditions are classified as the yang syndromes, while those of the interior, cold and deficiency conditions are the yin syndromes Yin and Yang Syndromes The yin syndromes are characterized by weakening of yang and overabundance of yin 95

96 in the body. They also belong to the cold and deficiency syndromes and the disease is interiorly located with deteriorative symptoms, such as lassitude, pallor, dull eyes, shortness of breath, feeble voice, slow movements, cold limbs, chills, need of warm clothing, absence of thirst, preference for hot beverages, clear profuse urine, loose stools, a pale tongue with white coating and a deep, slow, forceless pulse. Yang syndromes are characterized by a preponderance of internal heat and yang-qi due to hyper functioning of the body. The disease often pertains to an excess heat syndrome with hyperactive manifestations, such as excitement, mania, a flushed face, harsh breathing and sonorous voice, brightly piercing eyes, forceful movements, a high fever and intolerance to heat, thirst, preference for cold beverages, deep yellow urine, a dark red tongue with thick, yellow coating and a surging, rapid or smooth, rapid and forceful. Differentiating Syndromes of Yin and Yang Syndr ome Spiritual Condition Conplex -ion Cold and Heat Respiration and Voice Symptoms Feces and Urine Thirst and Drinking Tongue Coating Pulse Condition yang Excitem -ent, mania Red High fever, intolerance to heat Harsh breathing Sonorous voice Constipa -tion, deep yellow urine Thirst, preference for cold beverages Dark red Surging, tongue, rapid, yellow coating Smooth and forceful yin Lassitude Pallor Cold limbs, chills Shortness of breath, low voice Loose Sto -ols,clear urine Absence of thirst,pre- Pale tongference for ue, white hot bevera- coating ges Deep, slow, thready and forceless The Syndrome of Yin Deficiency or Yang Deficiency,The Syndrome of Perishing Yin or Yang Differentiation of the condition of yin-fluid and yang-qi must be conducted too. Deficiency of yin is characterized by insufficient vital essence and deficiency of yang by insufficient yang-qi. Collapse of vital essence (yin) is called perishing of yin while collapse of yang-qi, perishing of yang. Vital essence and yang-qi of the kidney, also known as genuine yin and genuine yang, are the material basis of life. Thus, perishing of yin and perishing of yang are closely related to impairment and collapse of the vital essence and yang-qi of the kidney, resulting from chronic or acute diseases. For example, a high fever, profuse sweating or over sweating induced by medicinal herbs, or drastic vomiting, massive loss of blood may all lead to perishing of yin and perishing of yang. The above four syndromes are attributive to the deficiency syndromes but they are different in cold and heat conditions. Deficiency of yin and perishing of yin have heat 96

97 manifestations, while deficiency of yang and perishing of yang have cold manifestations. See the following symptoms. Yin Deficiency : Emaciation, a gaunt appearance, a tidal fever in the afternoon, a feverish sensation in palms, soles and the heart region, night sweats, flushed cheeks, fidgets, insomnia, dizziness, blurred vision, ringing in the ear, nocturnal emission, a dry throat and mouth, a red tongue with scanty coating or no coating and a thread, rapid pulse. Yang Deficiency : Pallor, cold limbs, chills, listlessness, feeble voice, shortness of breath, spontaneous sweating, a cold feeling below the low back, weak and aching legs, impotence, seminal emission, a diminished sense of taste, poor appetite, clear, profuse urine, loose stools, a thin, white coating and a deep, slow or large and forceless pulse. Perishing Yin: Sticky sweating, hot skin and warm hands and feet, irritability, coma and harsh breathing in severe cases, thirst, and preference for cold beverages, a red and dry tongue and a thread, rapid and forceless pulse. Perishing Yang: Profuse sweating, cold limbs, chills, listlessness, (or irritability, coma), feeble breathing, absence of thirst, preference for hot beverages, a diminished sense of taste and a fading and thread pulse. Since the body s yin and yang are mutually supporting, perishing of yin thus results in a dispersion of yang as yang-qi has nothing to support it; perishing of yin leads to an exhaustion of vital essence due to failure of transport and transformation. Perishing of yin may quickly transform into perishing of yang, and after the occurrence of perishing of yang, perishing of yin follows. It should be pointed out that when perishing of yin is present, yang-qi is not unfailing, and when perishing of yang appears, it does not mean uninjured to the vital essence. These two conditions cannot be isolated and they only appear one after another. 7.2 Differentiation of Syndromes in Accordance with the State of Qi, Blood and Body Fluids Differentiation of syndromes in accordance with the state of qi, blood and body fluids deals with pathological changes of qi,blood and body fluids to recognize the exact syndrome. Physiologically,qi, blood and body fluids are the material basis of the functional progress of the zang-fu organs, and the product of the functional activity of them as well. Thus, pathologically, any disorder of the zang-fu organs must affect qi, blood, and body fluids and any disturbance in qi, blood and body fiuids inevitably affects some zang-fu organs. In this sense, pathological changes of qi, blood and body fluids are related to the zang-fu organs. When the general laws about the pathological changes of qi, blood and body fluids are known, the basis for differentiation of syndromes according to the 97

98 theory of the zang-fu organs can be laid. Similar to differentiation of syndromes based on the eight principal syndromes, differentiation of syndromes in accordance with the state of qi, blood and body fluids is a1so viewed as the foundation for syndrome differentiation. No matter what etiology it is, whether it is caused by exogenous pathogenic heat or internal injury, any disorder can be classified into two kinds-disorder either of the qi system or of the blood system. In general,disorder of the qi system is often found in a recent disease, and disorder of qi and blood systems is usually seen in a chronic disease. But it does not mean the qi system must be attacked first and the blood system second. In some chronic diseases, only the former is attacked and the latter is not, and in some recent diseases, the blood system is involved at the very beginning. From above we know that the qi system and blood system are closely related,mutually affected and transformed Differentiation of Syndromes According to the State of Qi Disorders of qi cover a wide range and among various diseases of the zang-fu organs,many are related to qi disturbance. Thus, the state of qi plays an important role in syndrome differentiation. Differentiation of syndromes according to the state of qi includes differentiation of the syndromes of qi deficiency, sinking of qi, stagnation of qi and adverse flow of qi The Syndrome of Deficiency of Qi It indicates functional recession of the zang-fu organs. Clinical Manifestations : Dizziness, lack of strength to breathe and speak, general lassitude, spontaneous sweating that is worse when active, a pale tongue and a deficient and forceless pulse Treatment : Strengthening qi 7.2.l.2 The Syndrome of Sinking of Qi Sinking of qi is a kind of deficiency of qi, characterized by failure of qi to rise. Clinical Manifestations: Dizziness, blurred vision, lassitude, a bearing-down sensation in the abdomen, prolapse of rectum or uterus, a pale tongue with white coating and a weak pulse Treatment : Strengthening and lifting qi 7.2.l.3 The Syndrome of Stagnation of Qi It refers to impeded flow of qi in a certain part of the body or in an individual organ. Qi circulates over the body. When any part of the body, any organ or meridian is diseased, disturbance in qi flow appears. It is named stagnation of qi. Disturbance in qi usually occurs earlier in the course of a disease. That "qi is diseased" often implies "stagnation of qi". Clinical Manifestations : A suffocating feeling marked by pain, e. g. a distending pain at the hypochondriac region or chest and abdomen. Treatment : Promoting qi flow 98

99 The Syndrome of Adverse Flow of Qi It refer to a disturbance in the downward function of the qi of the body, due usually to upward attack of lung-qi and stomach-qi or liver-qi. Clinical Manifestations : Ascending of lung-qi : Coughing and shortness of breath Ascending of stomach-qi, Hiccup, belching, nausea and vomiting Excessive ascending of liver-qi: Headache, dizziness, coma and hematemesis Treatment ; Bringing the adverse flow of qi down Differentiation of Syndromes According to the State of Blood While there are many syndromes that involve disorders of the blood, they may be grouped into four classes : deficiency of blood, stagnancy of blood or stasis of blood, heat in blood and cold in blood The Syndrome of Deficiency of Blood The syndrome of deficiency of blood is thus named when there is a failure of the zangfu organs and vessels to be nourished owing to the decreased quantity of blood. Clinical Manifestations : Pallor or sallow complexion, pale lips, dizziness, palpitation, insomnia, numbness of the hands and feet, scanty menstruation, delayed menstrual cycle or amenorrhea, a pale tongue and a thready, forceless pulse Treatment : Tonifying blood The Syndrome of Stagnancy of Blood and Stasis of Blood It covers a wide range of blood disorders, e. B. escaped blood from vessels, blocked blood in meridians, zang-fu organs and tissues. Stagnancy and stasis of blood have several reasons : trauma, escaped blood from vessels staying in tissues, impeded blood flow due to stagnancy of qi, retarded blood circulation due to qi deficiency and coagulation of blood due to cold and heat. Clinical Manifestations ; Pain, blood clots, hemorrhage, ecchymosis, dark red lips and nails, a dark red tongue with purplish spots or patches and an unsmooth pulse Treatment : Invigorating blood flow to remove stagnancy and stasis of blood The Syndrome of Noxious Heat in Blood It refers to heat in blood or invasion of the blood system by pathogenic heat. The condition is caused by a constant hyperactivity of yang-qi in the body,or production of internal fire turned from excessive emotional excitation, or by over-intake of food pungent and dry in property, leading to heat in blood owing to consumption of body fluids; or by exogenous pathogenic heat invading the blood system. Clinical Manifestations : Irritability or mania,coma in severe cases, thirst without a desire for drinks, a feverish sensation in the body, that is worse at night, a deep red tongue and a rapid pulse seen in hemorrhage. Treatment : Clearing up heat and cooling blood The Syndrome of Cold in Blood 99

100 It is also known as the syndrome of cold in blood vessels characterized by impeded flow of blood due to cold that makes qi stagnate. Clinical Manifestations : Pain of hands, feet and lower abdomen, relieved by warmth, accompanied by aversion to cold, cold limbs, delayed menstrual cycle, dark red menses with clots, a pale tongue with white coating and a deep, slow and smooth pulse Treatment ; Warming meridians to activate blood circulation Differentiation of Syndromes in Accordance with Disorders of Qi and Blood Qi pertains to yang and blood to yin. Because they are interpromoting and interdependent, they affect each other when a disease occurs, i. e. disorders of both qi and blood appear. The frequently seen syndromes are ; deficiency of qi and blood, deficiency of qi and loss of blood, prostration of qi after massive loss of blood, deficiency of qi and stasis of blood and stagnancy of qi and blood The Syndrome of Stagnancy of Qi and Blood It refers to impeded blood flow due to stagnation of qi and eventually stasis of blood. Clinical Manifestations : Fullness and a distending pain in the chest and hypochondriac region, irritability, presence of a painful mass, aggravated by pressure, a dark red tongue or with ecchymosis on it, amenorrhea, dysmenorrhea with discharge of dark red blood and blood clots and a distending pain in the breast. Treatment :Reinforcing qi to promote blood circulation Deficiency of Both Qi and Blood It refers to simultaneous existence of deficiency of qi and blood. Clinical Manifestations : Lack of strength to breathe and speak, lassitude, spontaneous sweating, pallor, sallow complexion, palpitation, insomnia, a pale, moist tongue and a thready, weak pulse. Treatment : Reinforcing qi and blood Deficiency of Qi and Loss of Blood It refers to loss of blood due to insufficient qi, which fails to control blood. Hemorrhage due to deficiency and sinking of qi is known as "bleeding resulting from exhaustion of qi" Clinical Manifestations : Hemorrhage, shortness of breath, lassitude, pallor, a faint and weak pulse and a pale tongue Treatment ; Reinforcing qi to keep blood flowing in vessels Prostration of Qi after Massive Loss of Blood Clinical Manifestations : Massive hemorrhaging associated with pallor, cold limbs, profuse sweating, fainting, and a feeble, thready or hollow pulse. Treatment : Invigorating qi to prevent collapse Deficiency of Qi and Stagnancy of Blood It refers to impeded blood flow or stasis of blood due to deficiency of qi. Clinical Manifestations : Lassitude, lack of strength, spontaneous sweating, pain aggravated by pressure, a dark red tongue with ecchymosis 100

101 Treatment : Invigorating qi to promote smooth flow of blood Differentiation of Syndromes in Accordance with the State of Body Fluids Disorders of body fluids can be classified into two categories : insufficiency of body fluids and retention of water Insufficiency of Body Fluids Insufficiency of body fluids is also known as injury to body fluids. It refers to dryness in some zang-fu organs and tissues owing to lack of body fluids caused by inadequate production and over-consumption of it. Inadequate production of body fluids is due to two factors : declined functioning of the spleen and stomach in transport and transformation and on diet for a long time or long-term intake of less food because of some diseases(dysphagia and regurgitation) Over-consumption of body fluids may be caused by abundant heat, profuse sweating, severe vomiting and diarrhea. Clinical Manifestations : Dryness in the mouth, lips and tongue, dry skin, scanty urine, constipation, a red tongue with scanty saliva and a thready, rapid pulse Treatment : Promoting production of body fluids Retention of Water It refers to general or local retention of fluid, usually seen in edema, tympanites and retention of phlegm and morbid fluid. The chief cause is functional disturbance in the lung, spleen and kidney, which brings about problems of fluid distribution and excretion. Here is a description about how to differentiate edema and retention of phlegm and morbid fluid. Edema, It can be found in any part of the body, such as the head, face, eyelid, chest, back and the whole body. Clinically it is divided into two types-yang edema and yin edema. Yang edema : It is an excess condition caused by exposure to cold, obstruction of lung-qi, or invasion by dampness and failure of the spleen in transport. Clinical Manifestations: Puffy lids and face, edema of limbs and the whole body by a quick attack, sluggishness of limbs, difficulty of urination, aversion to wind-cold, fever, a thin, white coating on the tongue and a floating, tense pulse; or a sore throat, a red tongue and a floating, rapid pulse ; or general edema developing slowly, sluggishness of limbs, scanty urine, fullness in the chest, loss of appetite, nausea, a white, sticky coating on the tongue and a deep, slow pulse. Treatment : Dispelling wind and promoting the dispersing function of the lung,strengthening the spleen to remove dampness, activating yang and promoting diuresis. Yin edema : It is a deficient condition usually caused by weakened antipathogenic qi due to protracted diseases, lassitude, internal injury and excessive sexual activities. Clinical Manifestations : Edema, severe below the low back, difficulty of urination, fullness in the chest, abdominal distension, lack of appetite, loose stools, pallor or sallow complexion or an aching pain and a cold sensation in the low back and knees, cold limbs, aversion to cold, listlessness, a pale, puffy tongue with white, smooth coating and a deep, 101

102 slow, forceless pulse Treatment : Invigorating yang to promote fluid flow Retention of phlegm and morbid fluid : Phlegm and morbid fluid are pathological products due to functional disturbance in the zang-fu organs and disorders of water metabolism. The syndrome of phlegm ; Phlegm is the retained fluid of thick quality. The syndrome of phlegm means local obstruction by phlegm or phlegm flows over the body. It is produced by contracting exogenous pathogenic factors or excessive emotional excitation, leading to functional disturbance of the zang-fu organs. Clinical Manifestations: Coughing, shortness of breath, a suffocating feeling in the chest, fullness in the gastric region, nausea, loss of appetite, dizziness, delirium, mania, raling, numbness of limbs, hemiplegia, scrofula, goiter, nodules of the breast, a foreign body in the throat,a white, sticky or yellow, sticky coating on the tongue and a smooth pulse Treatment : Eliminating phlegm Retention of morbid fluid ; It is a syndrome due to retention of thin, clear morbid fluid in the zang-fu organs and tissues, usually caused by constant deficiency of yang and contracting cold and dampness, or by irregular diet or overwork, resulting in disturbance of water distribution and excretion. Clinical Manifestations : Distention of the stomach and abdomen,retention of morbid fluid in the stomach and intestines, vomiting of clear fluid, dizziness, palpitation, fullness in the chest and hypochondriac region, productive coughing, pain on breathing, dyspnea with chest distention, difficulty to lie flat, edema and an aching pain of limbs, difficulty of urination, a white, smooth coating and a wiry pulse Treatment : Expelling phlegm and retained morbid fluid 7.3 Differentiation of Syndromes in Accordance with the Theory of Zang-fu Organs Differentiation of syndromes in accordance with the theory of zang-fu organs is the diagnostic basis of any branch of clinical medicine, and an important component part of the study of differentiation of syndromes adopted in traditional Chinese medicine. Based on the physiologlcal function of the zang-fu organs and their pathological manifestations, symptoms and signs are analysed to detect pathogenesis, the location and nature of diseases and preponderance and discomfiture of the antipathogenic qi and pathogenic factors Differentiation of Syndromes of the Heart and Small Intestine The heart is in the chest and it is covered by the pericardium. The Heart Meridian of Hand-Shaoyin connects the Small Intestine Meridian of Hand-Taiyang, forming a zang-fu pair. The heart governs blood and vessels, controls mental activities and is linked to the 102

103 tongue. The small intestine differentiates the rarefied substances from the nonusable and converts food into useful substances Syndromes of Deficiency of Heart-Qi, Heart-Yang and Depleted Heart-Yang The above syndromes are usually caused by prolonged diseases in patients with a weak physique, a sudden attack of a severe illness injuring the antipathogenic qi, or by insufficient congenital essence or over-consumption of qi of the zang organs in the aged. Clinical Manifestations : Deficiency of heart-qi : Palpitation, shortness of breath, worse when active, a thready, weak or knotted and intermittent pulse, associated with pallor, lassitude, spontaneous sweating, lack of strength and a pale tongue with white coating. Deficiency of heart-yang : Palpitation, shortness of breath worse when active, a thready weak or knotted or intermittent pulse, associated with aversion to cold, cold limbs, sallow complexion, a distending pain in the chest, and a dark red and puffy tongue Depleted heart-yang : Profuse sweating, cold limbs, purplish lips, feeble breathing, a faint pulse, delirium or loss of consciousness Treatment : Deficiency of heart-qi : Reinforcing heart-qi Deficiency of heart-yang ; Replenishing heart-yang Depleted heart-yang ; Recuperating depleted yang and rescuing a patient from collapse Syndromes of Deficiency of Heart-Blood and Heart-Yin Deficiency of heart-blood and heart-yin refers to lack of heart-blood and heart-yin, which fails to nourish the heart. The two conditions are usually due to consumption of yin-blood in protracted illnesses, or to massive loss of blood, inadequate production of yin-blood or to depression, inner accumulation of fire that consumes yin-blood. Clinical Manifestations : Deficiency of heart-blood : Palpitation, amnesia, insomnia, dream-disturbed sleep, accompanied by dizziness, pallor, a pale tongue and lips and a thready, weak pulse Deficiency of Heart-Yin ; Palpitation, amnesia, insomnia, dream-disturbed sleep, accompanied by a feverish sensation in palms, soles and the heart region, night sweats, dryness of the mouth, a red tongue with a little saliva and a thready, rapid pulse. Treatment ; Deficiency of heart-blood ; Enriching blood to tranquilize the mind Deficiency of heart-yin : Replenishing yin to tranquilize the mind 7.3.I.3 The Syndrome of Hyperactivity of Heart-Fire It refers to a morbid state due to hyperactivity of heart-fire, usually resulting from production of fire due to depression, invasion of the interior by fire or excessive intake of fat, heavy food, or from alcohol drinking and smoking of cigarettes. Clinical Manifestations : Irritability, insomnia, flushed complexion, thirst, an ulcerous mouth and tongue, a red tongue and rapid pulse,or mania,delirium in severe 103

104 cases,associated with concentrated urine, a pain on urination and hematuria Treatment ; C:learing up heart-fire The Syndrome of Obstruction of the Heart Collaterals and Vessels It refers to a morbid state under the influence of pathogenic factors found in the aged and patients of a weak physique, or in protracted illnesses and lowered body resistance cases, resulting in stagnation of heart-blood, coagulation of phlegm and cold and qi stagnancy. Clinical Manifestations : Palpitation and frequent violent palpitation, an intermittently suffocating pain in the chest, a pain involving the shoulder, back and arm ; a stabbing pain, a dark red tongue with purplish spots or patches on its surface, a thready, unsmooth pulse or knotted, intermittent pulse found in stagnation of heart-blood in the heart collaterals and vessels ; obesity with profuse expectoration of phlegm, sluggishness of the body, a severe suffocating pain in the chest, a white sticky coating on the tongue and a deep, smooth pulse found in obstruction of the heart collaterals by phlegm ; a sharp pain alleviated by warmth, intolerance to cold, cold limbs, a pale tongue with white coating and a deep, slow or deep, tense pulse found in the condition of coagulation of cold ; a distending pain due to emotional factors, a light red or deep red tongue with thin, white coating and a wiry pulse found in stagnation of heart-qi Treatment : Activating yang and removing stagnation of qi and blood The Syndrome of Mental Confusion due to Phlegm It refers to problems of consciousness due to invasion of the heart by phlegm. It is also caused by excessive phlegm turned from dampness, or production of phlegm due to emotional upsets and stagnation of qi. Clinical Manifestations : Apathy, dementia depression, improper behavior or sudden loss of consciousness, laryngeal raling, delirium, associated with sallow complexion, a suffocating sensation in the chest, profuse phlegm, a sticky tongue and a smooth pulse. Treatment : Eliminating phlegm to resuscitate The Syndrome of Phlegm-Fire Attacking the Heart It is a morbid mental condition due to pathogenic fire and phlegm attacking the heart. Emotional upsets, anger and stagnated qi may produce fire, which scorches body fluid and turns it into phlegm. The invaded pathogenic heat scorches body fluid and turns it into phlegm too. Then phlegm is the chief cause of the condition. Clinical Manifestations : Irritability, thirst, insomnia, dream-disturbed sleep. profuse phlegm, a suffocating feeling in the chest, a flushed face, harsh breathing, constipation, concentrated urine, various mental disorders in severe cases, a red tongue with thick, yellow and sticky coating and a wiry, smooth and forceful pulse. Treatment : Clearing up fire and phlegm The Syndrome of Excessive Heat in the Small Intestine The syndrome of excessive heat in the small intestine is caused by heart-fire which moves to the small intestine. 104

105 Clinical Manifestations : Irritability,thirst,ulcer in the mouth and on the tongue,concentrated urine, a pain on urination, hematuria, a red tongue with yellow coating and a rapid pulse. Treatment: Eliminating heart-fire and dark urine Differentiation of Syndromes of the Lung and Large Intestine The lung is situated in the chest, and the Lung Meridian connects the Large Intestine Meridian, forming a zang-fu pair interiorly and exteriorly. The lung controls qi, respiration, skin and hair, regulates the dispersion of qi to keep the passageway of water open and It is linked to the nose. The function of the large intestine is to "convey" and "transform, and expel the solid wastes from the body The Syndrome of Deficiency of Lung-Qi It refers to hypofunction of the lung due usually to chronic coughing, shortness of breath or to inadequate production of qi. Clinical Manifestations : Coughing, shortness of breath, lack of strength to breathe worse when active, lassitude, a feeble voice, spontaneous sweating, aversion to cold, pallor, a pale tongue and a feeble pulse. Treatment : Activating lung-qi The Syndrome of Deficiency of Lung-Yin It refers to inadequate lung-yin and production of inner heat in a deficiency condition,usually caused by chronic coughing, which impairs yin, and by tuberculomyces, or injury to yin-fluid after a febrile disease. Clinical Manifestations; Coughing without expectoration of phlegm or with sticky phlegm scanty in amount, dryness in the mouth and throat, emaciation, afternoon fever, a feverish sensation in palms, soles and the heart region, night sweats, flushed cheeks, expectoration of bloody phlegm, a hoarse voice, a red tongue with scanty saliva and a thready, rapid pulse Treatment : Replenishing yin to moisten the lung The Syndrome of Invasion of the Lung by Wind-Cold It refers to the lung attacked by exogenous wind and cold, and impeded movement of lung-qi. Clinical Manifestations : Coughing with expectoration of thin white phlegm, nasal obstruction and watery nasal discharge, slight aversion to cold, a low fever, absence of sweating, a white coating on the tongue and a floating, tense pulse Treatment : Relieving the exterior syndrome with medicinal herbs pungent in property The Syndrome of Invasion of the Lung by Wind-Heat It refers to invasion of the lung by wind-heat and injury to the defensive qi. Clinical Manifestations : Coughing with expectoration of thick, yellow phlegm, nasal obstruction and thick, yellow nasal discharge, fever, slight aversion to wind and cold, dryness of the mouth and a sore throat, a reddened tongue tip with yellow coating and a 105

106 floating and rapid pulse Treatment : Clearing up heat from the lung The Syndrome of Accumulation of Heat in the Lung It refers to invasion of the mouth and nose by pathogenic heat or invasion of the interior by wind-cold or wind-heat, which accumulate in the lung. Clinical Manifestations : Coughing with expectoration of thick, yellow phlegm, shortness of breath, harsh breathing, high fever, thirst or flaring of nares, a chest pain, expectoration of foul purulent phlegm, constipation, deep yellow urine, a reddened tongue with yellow coating and a smooth, rapid pulse Treatment : Clearing up heat, dissolving phlegm and easing shortness of breath The Syndrome of Invasion of the Lung by Dryness It refers to pathogenic dryness attacking the lung. Clinical Manifestations : Dry cough with no or scanty phlegm, difficulty of expectoration due to thick phlegm, dry lips, tongue, throat, nose and skin, $ever, aversion to cold, a chest pain, hemotypsis, a thin coating, scanty saliva on the tongue and a thready, rapid pulse Treatment ; Eliminating dryness and moistening the lung The Syndrome of Blockage of the Lang by Phlegm-Dampness It refers to phlegm-heat accumulating in the lung, usually caused by contracting cold and dampness, or by chronic coughing, which disturbs the distribution of body fluids and leads to production of phlegm-dampness, or by insufficient spleen-qi and accumulated dampness, which turns to phlegm in the lung. Clinical Manifestations ; Coughing with expectoration of profuse copious phlegm, or thin, white, frothy phlegm, a suffocating feeling in the chest, or rasping in the throat, a pale tongue with white, sticky coating and a wiry, smooth or soft, slow pulse Treatment : Eliminating dryness, dissolving phlegm and regulating the flow of lung-qi The Syndrome of Accumulation of Damp-Heat in the Large Intestine It refers to damp-heat invading the large intestine, usually caused by contracting exogenous damp-heat or irregular diet. Clinical Manifestations ; Abdominal pain, discharge of bloody and mucous stools, tenesmus or foul diarrhea, accompanied by a burning sensation in the anus, concentrated urine, thirst, or aversion to cold, fever, or fever with aversion to cold, a reddened tongue with yellow, sticky coating and a soft, rapid or smooth, rapid pulse. Treatment ; Clearing up heat and dampness The Syndrome of Insufficient Fluid in the Large Intestine It refers to failure of the large intestine to be moistened owing to insufficient body fluids, usually caused by a weak physique, impairment of yin due to chronic diseases, or unrecovery of body fluids after a febrile disease ; or massive loss of blood during childbirth. 106

107 Clinical Manifestations ; Habitual constipation, a reddened tongue with yellow, dry coating, a thready and unsmooth pulse associated with vertigo and foul breath. Treatment : Moistening the large intestine to activate bowels movement The Syndrome of Incontinence of Feces due to Deficiency of Qi in the Large Intestine It refers to declined yang-qi of the large intestine, which fails to lift, usually caused by persisted diarrhea and dysentery. Clinical Manifestations ; Chronic diarrhea or dysentery, incontinence of feces, prolapse of rectum, a dull pain in the abdomen, alleviated by heat and pressure; a pale tongue with white, smooth coating and a deep, weak pulse Treatment : Strengthening yang to check incontinence of feces Differentiation of Syndromes of the Spleen and Stomach The spleen and stomach are situated in the middle-jiao and connected by meridians, forming a zang-fu pair. The spleen transports nutrients and the stomach is to take in and digest food. Spleen-qi is always ascending while stomach-qi descending, and they are responsible for digestion and assimilation and distribution of nutrients. The spleen and stomach are regarded as the source of qi and blood,or the foundation of the acquired constitution. In addition, the spleen keeps blood in vessels arid controls limbs and muscles The Syndrome of Deficiency of Spleen-Qi It refers to impeded transport and transformation of nutrients, usually caused by irregular diet, overwork and other chronic diseases, which impair the spleen. Clinical Manifestations : Loss of appetite, gastric distension after meals, loose stools, lack of strength to speak, lassitude, emaciation, sallow complexion, a pale tongue with white coating and a slow, weak pulse. Treatment ; Invigorating qi and activating the spleen The Syndrome of Deficiency of Spleen-Yang It refers to declined spleen-yang and inner production of cold, usually developed from deficiency of spleen-qi, or caused by excessive intake of cold and raw foodstuffs, or insufficient kidney-yang. Clinical Manifestations : Lack of appetite, abdominal distension, gastric and abdominal pain, alleviated by warmth and pressure, a diminished sense of taste and absence of thirst, cold limbs, loose stools, or edema of limbs, difficulty of urination or excessive thin vaginal discharge, a pale and moist tongue with white, smooth coating and a deep, thready or slow, weak pulse. Treatment : Regulating the function of the middle-jiao and removing cold The Syndrome of Sinking of Spleen-Qi It refers to insufficient spleen-qi, which goes downward rather than upward, usually caused by further deficiency of spleen-qi or by protracted diarrhea or dysentery or 107

108 overstrain. Clinical Manifestations : Dizziness, a feeble voice, lassitude, spontaneous sweating, lack of appetite, gastric distension after meals, a bearing-down sensation in the stomach and abdomen, tenesmus, prolonged diarrhea or prolapse of rectum or uterus and a pale tongue with white coating and a weak pulse Treatment : Invigorating the spleen to restore its normal function The Syndrome of Failure of the Spleen to Keep Blood in Vessels It refers to failure of the spleen to keep blood in vessels due to deficiency of spleen-qi, usually caused by prolonged diseases and insufficient spleen-qi, or by overwork and impairment of the spleen. Clinical Manifestations : Hemafecia, hematohidrosis, menorrhagia, uterine bleeding and hemorrhage of other parts of the body sometimes accompanied by deficiency of spleen-qi. Treatment : Invigorating qi to control blood The Syndrome of Invasion of the Spleen by Cold-Dampness It refers to yang of the middle-jiao besieged by excessive cold-dampness, usually caused by irregular diet, over-intake of raw and cold foodstuffs, exposure to rain, cold water, residence in a damp place or by constant abundance of inner dampness. Clinical Manifestations : Fullness in the gastric and abdominal regions, lack of appetite,nausea, vomiting, a diminished sense of taste and absence of thirst, abdominal pain and loose stools, the head being tightly bandaged, sluggishness of the body, edema, sallow complexion, yellow tinges of the skin and face, a flabby tongue with white, sticky coating and a soft and slow pulse. Treatment : Eliminating dampness and activating the spleen The Syndrome of Accumulation of Damp-Heat in the Spleen It refers to excessive damp-heat in the middle-jiao, usuauy caused by contracting exogenous damp-heat or excessive intake of heavy, sweet food and alcohol, which turn to heat. Clinical Manifestations : A suffocating sensation in the gastric and abdominal regions, nausea, poor appetite, sluggishness of the limbs and body, loose stools, difficulty of urination, concentrated urine, a yellow tinge of the complexion and sclera, itching skin, fever sometimes, and no alleviation after perspiration, a yellow, sticky coating on the tongue and a soft, rapid pulse. Treatment : Clearing up heat and dampness The Syndrome of Deficiency of Stomach-Yin It is usually caused by prolonged gastric disorders or unrecovery of yin-fluid after a febrile disease or by preference for food pungent and hot in property, or emotional disturbance, or fire turned from stagnated qi, which injures stomach-yin. Clinical Manifestations: A dull pain in the gastric region, no desire for food when 108

109 hungry, dryness in the mouth and throat, dry stools, fullness in the stomach or retching and hiccuping, reddened tongue with a little saliva, thready and rapid pulse. Treatment : Replenishing stomach-yin The Syndrome of Retention of Food in the Stomach It refers to retention of food in the stomach declined function of the stomach, usually caused. by irregular diet, eating too much food at one time, or weakened stomach-qi, resulting in retention of food due to improper diet. Clinical Manifestations : A gastric distending pain, poor appetite, eructation with fetid odor, or vomiting of undigested food, alleviation of pain after vomiting accompanied by borborygmus, flatus, foul diarrhea, a thick, sticky coating on the tongue and a smooth or deep, replete pulse Treatment : Eliminating undigested food The Syndrome of Cold in the Stomach It refers to excessive yin-cold in the stomach, usually caused by exposure of the abdomen to cold,excessive intake of raw and cold foodstuffs or overstrain and contracting cold. Clinical Manifestations : A gastric pain, mild or severe, aggravated by cold and alleviated by warmth, a diminished sense of taste and absence of thirst associated with lassitude, cold limbs and pain relieved after meals ; or associated with a sound of water in the stomach, vomiting of watery fluid; a pale tongue with white coating and a slow or wiry pulse Treatment : Expelling cold by warming the stomach The Syndrome of Heat in the Stomach It refers to overabundance of heat in the stomach due usually to constant intake of pungent and greasy food, or to emotional upsets, which generates inner heat, or to invasion of the stomach by heat. Clinical Manifestations : A burning pain in the stomach, gastric discomfort, acidic regurgitation, vomiting immediately after taking food, thirst and preference for cold beverages, halitosis, gingival ulcer or bleeding, foul breath, constipation, concentrated urine, a reddened tongue with yellow coating and a smooth, rapid pulse Treatment : Clearing up stomach-fire Differentiation of Syndromes of the Liver and Gallbladder The liver is situated in the right hypochondrium and the gallbladder is attached to the liver. The Liver Meridian communicates with the Gallbladder Meridian, forming a zang-fu pair exteriorly and interiorly. The liver controls the condition of tendons and the condition of the liver can be seen in the condition of nails. The liver is linked to the eyes. It favors a smooth flow of qi and has an aversion to stagnancy. It stores blood, regulates the volume of blood and the secretion of bile. Smooth flow of qi serves two purposes. First, it regulates emotional activities and second, it ensures the normal operation of the 109

110 digestion The Syndrome of Stagnation of Liver-Qi It refers to unsmooth flow and stagnation of liver-qi, usually due to depression, sudden mental excitation and invasion of the body by other pathogenic factors. Clinical Manifestations : Fullness and a distending and wandering pain in the gastric, hypochondriac regions and lower abdomen, preference for deep sighing, emotional depression, irritability, a sensation of foreign body in the throat or goiter, masses in the abdomen, a distending pain in the breast in women, dysmenorrhea, menstrual irregularity or amenorrhea Treatment : Removing stagnation of liver-qi The Syndrome of Flare-up of Liver-Fire It refers to hyperactivity and flare-up of liver-fire, usually caused by emotional upsets, fire transformed from stagnated qi, or invasion of the liver by exogenous pathogenic fire, or fire produced by excessive intake of alcohol. Clinical Manifestations: Dizziness, ringing in the ear, a flushed face, a bitter taste in the mouth and a dry throat, a burning pain in the hypochondriac region, irritability, insomnia, nightmare or hematemesis, epistaxis, constipation, urination with a reddish tinge, a reddened tongue with yellow coating and a wiry, rapid pulse Treatment : Clearing up liver-fire The Syndrome of Deficiency of Liver-Blood It refers to insufficient liver-blood, usually caused by poor generation of blood, massive loss of blood, or impaired liver-blood in chronic diseases. Clinical Manifestations : Sallow complexion, dizziness, ringing in the ear, dream-disturbed sleep, blurred vision, night blindness, numbness of limbs, spasm of tendons, pale nails, scanty menstrual flow or amenorrhea in women, and a pale tongue and thready pulse Treatment : Replenishing liver-blood The Syndrome of Deficiency of Liver-Yin It refers to deficiency of liver-yin and internal disturbance by heat, usually caused by constant hyperactivity of yang, or consumption of yin after febrile diseases, or by deficiency of kidney-yin. Clinical Manifestations : Dizziness, dry eyes, blurred vision, a feverish sensation in the face, a burning pain in the hypochondriac region, a feverish sensation in palms, soles and the heart region, a tidal fever, night sweats, a dry mouth and throat, tremor of hands and feet, a reddened tongue with scanty saliva and a wiry, thready pulse Treatment : Replenishing liver-yin The Syndrome of Exuberance of Liver-Yang It refers to hyperactivity of liver-yang and hypoactivity of liver-yin, usually caused by yin deficiency of the liver and kidney, which fails to check excessive liver-yang. As a 110

111 result, there appears hyperactivity of liver-yang in the upper portion of the body. Or it is caused by fire due to anger, worry or stagnation of qi, consumption of blood and failure of yin to check yang. Clinical Manifestations : Dizziness, ringing in the ear, a distending pain in the head and eyes, a flushed face, reddened eyes, irritability, palpitation, amnesia, insomnia, dreamdisturbed sleep, weakness of the low back and knees, top-heavy, a reddened tongue and a wiry, forceful or wiry, thready pulse Treatment : Calming the liver and suppressing yang hyperactivity Syndromes of Endogenous Wind Stirring in the Liver It is triggered by many factors manifested chiefly as dizziness, numbness, spasm and trembling. Under this head, there are four sub-categories : liver-yang turning to wind, stirring-up of wind in the liver by extreme heat, endogenous growth of wind in the liver due to blood deficiency and wind stirring due to yin deficiency. The Syndrome of I.iver-Yang Turning to Wind : It is manifested as dizziness, tremor or stroke caused by over-consumption of liver-yin and kidney-yin, failure of yang to be checked. Clinical Manifestations : Dizziness, headache, a stiff neck, numbness and trembling of limbs, tremor of hands and feet, tongue rigidity that impairs speaking, walking haltingly, a reddened tongue, a wiry and thready pulse or sudden loss of consciousness, deviation of the eye and mouth, hemiplegia, speaking problem and rasping in the throat in wind-stroke. Treatment ; Subduing hyperactivity of the liver and endogenous wind The Syndrome of Stirring-up of Wind in the Liver by Extreme Heat : It is manifested as convulsions due to extreme heat, usually caused by overpreponderance of heat, which scorches the Liver Meridian, or by invasion of the pericardium by heat. Clinical Manifestations : High fever, thirst, convulsions, rigidity of the neck, upward staring of eyes, opisthotonos, coma, a reddened tongue with yellow coating and a wiry, rapid pulse. Treatment : Clearing up pathogenic heat, cooling the liver and subduing the endogenous wind The Syndrome of Endogenous Growth of Wind in the Liver due to Blood Deficiency : It is marked by symptoms indicating deficiency of liver-blood characterized chiefly by dizziness and numb limbs. For particular symptoms, please see the section of deficiency of liver-blood. The Syndrome of Endogenous Growth of Wind in the Liver due to Deficiency of Liver-yin : It is marked by symptoms indicating deficiency of liver-yin and interior heat characterized chiefly by tremor of hands and feet, dizziness, ringing in the ear. For details see the syndrome of deficiency of liver-yin. 111

112 The Syndrome of Accumulation of Cold in the Liver Meridian The condition is usually caused by contracting exogenous cold, such as exposure to rain and cold water, or cold in sexual life, leading to accumulation of cold in the Liver Meridian. Sometimes, it is caused by constant insufficiency of yang-qi and getting exogenous cold. Clinical Manifestations : A lower abdominal distending pain, a dragging sensation and pain in testes or contracture of scrota, aggravated by cold and aileviated by warmth, associated with aversion to cold, cold limbs, a white, smooth coating on the tongue and a deep, wiry or slow pulse. Treatment : Warming the liver to expel cold The Syndrome of Damp-Heat in the Liver and Gallbladder It is usually caused by contracting damp-heat, excessive intake of alcohol, heavy and sweet food, producing damp-heat ; or by dysfunction of the spleen and stomach, leading to growth of damp-heat. Clinical Manifestations : A distending burning pain in the hypochondriac region or masses in the region, poor appetite, abdominal distension, a bitter taste in the mouth, nausea, irregular bowels movement, scanty urine with reddish tinges, a reddened tongue with yellow, sticky coating and a wiry, rapid pulse; or alternate attack of fever and chills, yellow tinges of the body and sclera, eczema of scrota, or swollen testes, or foul, yellow vaginal discharge and itching of vulva Treatment : Clearing up damp-heat from the liver and gallbladder The Syndrome of Dysfunction of the Gallbladder and Attack of It by Phlegm It refers to dysfunction of the gallbladder and inner attack of it by phlegm-heat, usually caused by emotional upsets and stagnation of qi, which turns to fire and phlegm. Clinical Manifestations : Palpitation, insomnia, irritability, a bitter taste in the mouth, fullness in the chest, distending hypochondrium, dizziness, ringing in the ear, a yellow, sticky coating on the tongue and a wiry, smooth pulse Treatment, Clearing up heat and phlegm, removing liver and stomach heat Differentiation of Syndromes of the Kidney and Urinary Bladder The kidney stores vital essence and kidney-yang-source of energy of the vital gate. Kidney-yin or vital essence is the material basis of life, which controls reproduction, growth and development, and kidney-yang-the vital energy, is the dynamic force of the life process The Syndrome of Deficiency of Kidney-Yang It refers to declining of kidney-yang, usually caused by inadequate yang of the body or declined fire of the vital gate in the aged, or deficiency of yang in other organs affecting the kidney, or injury to the kidney due to chronic diseases and intemperate sexuality. Clinical Manifestations : Pallor or sallow complexion, aversion to cold, cold limbs, worse below the low back and knees, weakness of the low back and knees, lassitude, impotence, cold sperms, infertility in women due to coldness in the uterus, sexual 112

113 hypoesthesia, frequent and profuse urine, frequent urination at night, or scanty urine and edema, worse below the low back, abdominal distension, or accompanied by palpitation, shortness of breath, coughing, rasping in the throat, a pale, flabby tongue or a teeth imprinted tongue with white, smooth coating and a weak pulse, worse on both chi portions. Treatment : Warming kidney-yang to invigorate the vital function The Syndrome of Deficiency of Kidney-Yin It refers to insufficient kidney-yin usually caused by consumption of kidney-yin due to protracted illnesses that impair the kidney, intemperance in sexual life, loss of blood, or to excessive intake of foodstuffs dry in property that impair yin, or to emotional disturbance. Clinical Manifestations : Dizziness, ringing in the ear, declined vision, amnesia, insomnia, weakness of the low back and knees, a gaunt form, a dry mouth worse at night, a feverish sensation in palms, soles and the heart region, tidal fever, night sweats, flushed cheeks, seminal emission, scanty menstrual flow, amenorrhea, uterine bleeding, a reddened tongue with thin, dry coating and a thready, rapid pulse. Treatment : Replenishing kidney-yin The Syndrome of Insufficiency of Kidney-Essence It refers to consumption of kidney-essence usually caused by congenital weakness, lack of proper care after birth, or by overstrain and chronic diseases that impair the kidney. Clinical Manifestations : Infertility in men due to low sperm count, infertility in women due to amenorrhea, sexual disorders, retarded development in infants, short and small in figure, mental retardation, sluggishness, delayed close of the fontanel, weakness of bones, premature senility, loss of hair, loosened teeth, ringing in the ear, hypoacusis, amnesia and weakness of feet Treatment : Reinforcing kidney-essence The Syndrome of Unconsolidated Kidney-Qi It refers to consumption of kidney-qi, usually caused by deficiency of kidney-qi in the aged, or by inadequate supply of kidney-qi in children, or by intemperance of sexual life injuring the kidney. Clinical Manifestations : Lassitude,ringing in the ear, aching pain of the low back, weakness of the knees, frequent and profuse urine, dribbling after urination, enuresis or incontinence of urine, spermatorrhea, premature ejaculation, uterine bleeding, watery vaginal discharge, habitual miscarriage, fecal incontinence, diarrhea, a pale tongue with white coating and a deep, weak pulse. Treatment : Consolidating kidney-qi, arresting polyuria and preventing miscarriage The Syndrome of Failure of the Kidney in Promoting Inspiration It refers to diminished kidney-qi, usually caused by impairment of kidney-qi due to persisted coughing and disorders of the lung involving the kidney. 113

114 Clinical Manifestations : Coughing, asthmatic breathing more pronounced when active ; qi exhaled more than that inhaled, spontaneous sweating, lassitude, a feeble voice, weakness of the low back and knees, a pale tongue with white coating and a deep, weak pulse; or aggravated asthmatic breathing, profuse cold sweating, cold limbs, greyish green complexion and a floating pulse ; or shortness of breath, a flushed face, irritability, a dry mouth, a reddened tongue and a thready, rapid pulse. Treatment : Strengthening the kidney to invigorate inspiration The Syndrome of Damp-Heat in the Urinary Bladder It refers to a morbid condition due to damp-heat in the urinary bladder, usually caused by affection of damp-heat or irregular diet, leading to inner growth of damp-heat which pours downward into the urinary bladder. Clinical Manifestations: Frequent urination and an urgent need to urinate, a burning pain in the urethra, scanty urine with deep yellow tinges, lower abdominal distension, or associated with fever, pain in the low back, hematuria, urine stones, a reddened tongue with yellow sticky coating and a rapid pulse Treatment t Eliminating heat and dampness Syndromes of More Than One Organ The zang-fu organs interact with each other in pairs physiologically. The activities of each zang organ depend on those of the corresponding fu organ and vice versa. Similarly, if one member of a zang-fu pair fails to function properly, the other will also become diseased,i. e. disorders involving two of the zang-fu organs simultaneously The Syndrome of Discord between the Heart and Kidney It refers to breakdown of the normal physiological coordination between the heart and kidney, usually caused by over-anxiety or emotional disturbance, leading' to production of fire, hyperactivity of heart-yang and consumption of kidney-yin, or by intemperance in sexual life and chronic diseases resulting in insufficiency of kidney-yin and exuberance of kidney-yang. Clinical Manifestations : Fidgets, insomnia, palpitation, dizziness, ringing in the ear, amnesia, soreness and a weak sensation in the low back, a feverish sensation in palms, soles and the heart region, a dry throat and mouth, a reddened tongue and a thready, rapid pulse, or associated with soreness and a cold sensation in the low back and limbs. Treatment : Replenishing yin and eliminating fire to restore the coordination between the heart and kidney The Syndrome of Deficiency of Heart-Yang and Kidney-Yang It refers to insufficiency of yang of the heart and kidney and inner exuberance of yin-cold, usually caused by persisted deficiency of heart-yang with the kidney involved ; kidney-yang becomes deficient too, leading to dysfunction of water metabolism and upward going of water to affect heart-yang. Clinical Manifestations : Chills and cold limbs, palpitation, especially continuous 114

115 violent palpitation, dozing off, difficulty of urination, edema, cyanosis of lips and nails, a dark purplish tongue with white, smooth coating and a deep and feeble pulse. Treatment : Tonifying the heart and kidney with medicinal herbs hot in property The Syndrome of Qi Deficiency in the Heart and Lung It refers to insufficiency of heart-qi and lung-qi usually caused by a weak physique due to chronic diseases, persisted coughing injuring the lung, overstrain and deficiency of spleen-qi. Clinical Manifestations : Palpitation, coughing, shortness of breath, worse when active, a suffocating feeling in the chest, thin phlegm, pallor, dizziness, spontaneous sweating, a feeble voice, a pale tongue with white coating and a deep, weak or knotted, intermittent pulse Treatment ; Tonifying the heart and lung The Syndrome of Deficiency in the Heart and Spleen It refers to insufficiency of heart-blood and spleen-qi usually caused by improper care after diseases, chronic hemorrhage, over-anxiety, overstrain or irregular diet injuring spleen-qi. Clinical Manifestations : Palpitation, especially contiouous violent palpitation, insomnia,dream-disturbed sleep, dizziness, amnesia, sallow complexion, poor appetite, abdominal distension, loose stools, lassitude, subcutaneous hemorrhage, scanty menstrual flow or uterine bleeding, a pale tongue and a thready, weak pulse Treatment : Tonifying the heart and spleen The Syndrome of Deficiency of Blond in the Heart and Liver It refers to insufficiency of heart-blood and liver-blood, usually caused by over-anxiety, overstrain, or by massive hemorrhage and chronic diseases. Clinical Manifestations: Palpitation, amnesia, insomnia, dream-disturbed sleep, dizziness, ringing in the ear, pallor, dry and blurred eyes, pale nails, numbness of limbs, tremor, contracture of tendons, scanty menstrual flow, amenorrhea, a pale tongue with white coating and a thready, weak pulse Treatment : Strengthening qi and blood and tonifying the heart and liver The Syndrome of Invasion of the Lung by Liver-Fire It refers to upward attack of the lung by liver-qi or liver-heat and failure of lung-qi to descend, usually caused by rage. Clinical Manifestations : A burning pain in the chest and hypochondriac region, irritability with a smothery sensation, dizziness, reddened eyes, a bitter taste in the mouth, coughing, scanty sticky yellow phlegm, hemoptysis, a reddened tongue with thin, yellow coating and a wiry, rapid pulse Treatment : Clearing up liver-fire to restore the lung function The Syndrome of Disharmony between the Liver and Spleen It refers to stagnation of liver-qi and unsmooth transport and transformation of the 115

116 spleen, usually caused by emotional disturbance, or rage that impairs the liver or by irregular diet and overstrain that injures the spleen. Clinical Manifestations : A distending and wandering pain in the hypochondriac region,preference for deep sighing, emotional depression, irritability, poor appetite, abdominal distension, loose stools, borborygmus and flatus, or abdominal pain and diarrhea, pain alleviated after diarrhea, a white. sticky coating on the tongue and a wiry pulse Treatment : Restoring the normal function of the liver and tonifying the spleen The Syndrome of Disharmony between the Liver and Stomach It refers to unsmooth flow of liver-qi and failure of stomach-qi to descend, usually caused by emotional depression, or fire turned from stagnated qi or by invasion of the liver and stomach by cold. Clinical Manifestations : A distending pain and fullness in the chest and hypochondriac region, hiccup and belching, discomfort in the stomach, acidic regurgitation, irritability, a reddened tongue with thin yellow coating and a wiry or wiry, rapid pulse; or a pain in the top of the head, aggravated by cold and alleviated by heat, salivation, chills and cold limbs, a pale tongue with white, smooth coating and a deep wiry pulse Treatment : Restoring the normal function of the liver and regulating the stomach function The Syndrome of Yin Deficiency of the Liver and Kidney It refers to insufficiency of yin-fluid of the liver and kidney usually caused by improper care in chronic diseases, excessive sexual activity and emotional disturbance. Clinical Manifestations: Dizziness, ringing in the ear,amnesia, insomnia, dreamdisturbed sleep, a dry throat and mouth, soreness and weakness in the low back and knees, a hypochondriac pain, a feverish sensation in palms, soles and the heart region, flushed cheeks, night sweats, seminal emission,scanty menstrual flow,a reddened tongue with scanty coating and a thready, rapid pulse. Treatment : Tonifying the liver and kidney The Syndrome of Yang Deficiency of the Spleen and Kidney It refers to deficiency of yang-qi of the spleen and kidney, usually caused by protracted illnesses injuring yang-qi, or by insufficiency of kidney-yang due to retention of dampness, which fails to nourish the spleen ;or by chronic diarrhea and dysentery and declined spleen-yang involving the kidney. Clinical Manifestations: Aversion to cold, cold limbs, pallor, cold and pain in the low back, knees and lower abdomen, chronic diarrhea, dysentery or diarrhea before dawn, diarrhea with undigested food in the stools, difficulty of urination, edema, tympanites, a pale flabby tongue with white, smooth coating and a deep, thready pulse Treatment : Strengthening the spleen and kidney The Syndrome of Qi Deficiency of the Spleen and Lang 116

117 It refers to insufficiency of qi of the spleen and lung, usually caused by persisted coughing that impairs the lung, with the spleen involved, or by irregular diet that injures spleen-qi and produces damp-heat and fails to supply the lung with essence. Clinical Manifestations : Persisted coughing, shortness of breath, profuse thin, white phlegm, poor appetite, abdominal distension and loose stools, a feeble voice, lassitude, pallor,edema, a pale tongue with white coating and a thready, weak pulse. Treatment : Strengthening the spleen and kidney The Syndrome of Yin Deficiency of the Lung and Kidney It refers to deficiency of yin-fluid of the lung and kidney, usually caused by dryness, heat, tubercular agents or persisted coughing, injuring lung-yin and kidney ; or by excessive sexual activity and consumption of yin-essence, which fails to flow upward ; or by impairment of lung-yin due to fire in a deficiency condition. Clinical Manifestations, Coughing with expectoration of scanty phlegm, bloody phlegm,a dry mouth and throat, a hoarse voice, a gaunt form, soreness and weakness of the low back, afternoon fever, flushed cheeks, night sweats, seminal emission, irregular menstruation, a reddened tongue with scanty coating and a thready and rapid pulse Treatment : Strengthening the lung and kidney ( 王峥 ) Chapter Eight Treatment And Therapeutic Methods 8.1 Principles for Disease Prevention and Treatment Prevention Prevention includes taking certain steps in advance to stop the occurrence and development of diseases Prevention Before Disease Occurs This implies that before a disease occurs, various measures should be taken to prevent its occurrence. The onset of a disease involves two aspects: first, a deficiency or functional disturbance of anti-pathogenic-qi; second, an invasion of body by pathogenic factors. The pathogenic factor is an important condition while the anti-pathogenic-qi is seen as the internal cause, with the former becoming operative through the latter. Therefore, for prevention of occurrence of a disease both aspects should be taken into consideration Increasing Resistance Against Disease The strength of one s anti-pathogenic-qi depends upon the physique. Generally, one who has a strong physique enjoys vigorous anti-pathogenic-qi. Thus building a good physique is the key to enhance the power of anti-pathogenic-qi to protect against pathogenic factors. In order to build up one s health, he or she should pay attention to spiritual health, physical training, regular living style and avoiding drugs. 117

118 (1)Spiritual Health TCM theory holds that spiritual activities are closely related to physiological and pathological changes. Having a tranquil mind and being in a good mood will lead to the free movements of qi, harmony between qi and blood, and vigorous anti-pathogenic-qi-all significant in preventing the onset and development of disease. Sudden, intense, or repeated persistent emotional stimulation may lead to disorders in qi movement and disturb both qi blood and yin-yang. This can in turn lead to weak anti-pathogenic-qi and thus the body will be subject to invasions by exopathic factors. (2) Physical Training Participating in regular physical exercise can build up one s health and increase resistance against disease, thus reducing or preventing the occurrence of disease. (3) Regular Living Style People live in nature and need to understand the laws of nature, adapt to environmental changes, arrange and regulate a healthy diet, lead a proper life style, and balance work and rest. (4) Herbs and the Prevention of Disease There is a record in the Su Wen (Plain Questions) of taking Xiaojin Pellets ten pellets can keep pestilence away. which proved that long ago in China herbs were used to prevent disease Avoiding Invasion By Exopathic Factors Pathogenic factors are an important consideration in the disease process. To prevent disease before it occurs, in addition to building up a good physique and increasing the power of anti-pathogenic-qi against the evil, one should pay attention in preventing the invasion of pathogenic factors Treatment Before Disease Develops Prevention before a disease occurs is the ideal preventative measure. However, once a disease already occurs, one should strive for an early diagnosis and treatment so to stop the disease from further the development and progress Early Diagnosis If the internal organs are invaded and the disease condition becomes serious, it is difficult to be cured. Therefore, practitioners should, according to the developing law and transmission of disease, strive for an early diagnosis and an effective treatment to stop the progress of the disease Treating the Undiseased First and the Progress Law The liver is wood and the spleen is earth in five elements. The liver wood can subjugate spleen earth. In clinical treatment of a liver disease, the method of strengthening the spleen and normalizing the stomach is often taken as an auxiliary method Treatment Principles The treatment principle is the general method in treating disease. It is formulated under the guidance of the concept of wholism and treatment determination based on syndrome differentiation. It is a universal guiding principle for the determination of methods, 118

119 formula and dosage. Disease syndromes are varied with complicated pathological changes. The state of disease may be mild or severe, chronic or acute. Furthermore, the time, place and individual may all exert different influences on disease. Practitioners must be adept at understanding the essential aspects of a disease in with the complicated and changeable manifestations and give treatment aimed at its root aspect; strengthen the vital and dispel the evil based on changes of deficiency or excess; regulate yin and yang according to changes of imbalance of yin and yang; and prescribe the treatment to varied according to different season, locality and individual. In paying attention to such factors a satisfactory effect will be achieved Treatment Aimed at the Root Disease Treatment aimed at the root aspect of a disease means a cardinal principle of treatment based on syndrome differentiation. The root is judged by comparing it with the branch. The root and branch are relative concepts with multiple meanings. They may be used to explain the primary and the secondary in relation to various contradictions in the course of a disease. Clinically when using the principle of treatment aimed at the root of disease, one must understand routine treatment and contrary treatment, and treating the branch and treating the root Routine Treatment and Contrary Treatment (1) Routine Treatment This is a commonly used therapeutic method which goes against the nature of a syndrome. It is used to treat a disease with herbs and formulas whose natures are opposite to the nature of the disease. This method is used for a case whose signs are consistent with its essence, i.e. a cold disease is marked by cold manifestation, a heat disease with heat manifestation, a deficient disease with deficient manifestation, and an excess disease with deficient signs. In treatment, one must apply the principle of heating what is cold, cooling what is hot, tonifying what is deficient, and reducing what is excessive.the routine treatment is the most commonly used method clinically. (2) Contrary Treatment This is a therapeutic method for the false signs of a disease. It is a way of treating disease with herbs and formulas whose natures are consistent with the false manifestations of the disease.it is suitable for cases whose manifestations are opposite of the natures of diseases, for cold syndromes with pseudo-heat symptoms, for heat syndromes with pseudo-heat symptoms, excess syndromes with pseudo-deficient symptoms, and deficient syndromes with pseudo-excess symptoms. For treatment, treat heat with heat, treat cold with cold, treat obstruction with tonics, and treat openness with purgatives. Treating heat with heat uses hot natured herbs to treat a case with pseudo-heat 119

120 symptoms. It is used for a cold syndrome with pseudo-heat symptoms due to the blockage of yang externally by exuberant internal yin. Treating coldness with cold uses cold natured herbs to treat a case with pseudo-cold symptoms. It is used for a heat syndrome with pseudo-cold symptoms due to the block of yin externally by exuberant yang resulting from extreme internal heat. Treating obstruction with tonics uses tonics to treat a case with obstructive symptoms. It is used for deficient syndromes with pseudo-excess symptoms due to deficiency with obstruction. Treating openness with purgatives uses purgatives to treat cases with opening symptoms.it is used for a excess syndromes with pseudo-deficient symptoms. Cases of diarrhea and abdominal pain due to blood stasis. In addition, there is another method which was classified by ancient Chinese practitioners and deals with contrary treatment Treating the Branch and the Root In the course of a complex and changeable disease, different conditions often exist in terms of the branch and root (of secondary and primary). Thus in treatment there must be differences between the first and following treatments, or in emergency or chronic cases. In general, clinical treatment principles should include a treatment aimed at the root of disease. Under some special circumstances however, the branch condition is very urgent and if not treated it will endanger the life of the patient and influence treatment of the root condition. Therefore, one should follow treatment of the branch for emergency, treating the root for chronic conditions as the principles in treating the branch and root conditions. If the branch and the root are equal in seriousness, one should treat both the branch and the root simultaneously. (1) Treating the Branch in Emergencies When the branch aspect of the condition is very serious and becomes the principal aspect of a disease,the emergency measures should then treat first its branch condition. (2) Treatment of the Root in Chronic Condition When the state of disease is mild, the root cause of the disease should be understood and treated. It is important in guiding treatment for a chronic disease or in the convalescent stage of an acute disease. (3) Treating the Branch and Root Simultaneously When both the branch and root are acute of chronic, the branch and the root should be treated at the same time. As one can see there is a sense of principle and adaptability in treating the branch and root. Practitioners should grasp the main contradictions in the disease, determine treatment based on syndrome differentiation according to the state of the patient s 120

121 condition, and achieve the goal of treatment aimed at the root Strengthening the Vital and Dispelling the Evil The course of a disease, in a certain sense, is the process of the struggle between the vital and the evil decides the progress of a disease. When the evil gains the upper hand, the disease will progress; when the vital gains the upper hand, the disease will weaken. Thus in treatment strengthening the vital and dispelling the evil should be carried out to change the ratio in strength of the two sides of the vital and evil in order to gain recovery. Therefore, strengthening the vital and dispelling the evil are important principles in clinical treatment Concepts (1) Strengthening the Vital, Assisting the Anti-pathogenic-qi, Building up a Good Physique, All Increase the Power of the Body in Defending Against Evils.It is a suitable treatment method when there is deficiency of the vital and evil is not excessive. (2) Dispelling the Evil, Eliminating Pathogenic Factors to Support the Vital. These method are mostly used to reduce an excess.the methods differ according to different pathogenic factors and their location. (3) Relationship Between Strengthening the Vital and Dispelling the Evil Strengthening the vital and dispelling the evil are different, yet inter-dependent and supplementary. Strengthening the vital is important for the body to resist and eliminate pathogenic factors; whereas dispelling evil relates to anti-pathogenic-qi for it eliminates the injuries and its vicious influence produced by pathogenic factors Application (1) Attack, Dispelling the Evil, and Strengthening the Vital Dispelling an evil and or strengthening the vital are important principles in cases where the evil is prevailing and the vital is deficient yet able to stand the attack, or if when strengthening the vital has the effect of strengthening the evil. (2) Reinforcement Before Attack, Strengthening the Vital, Dispelling of Evil. If a patient with deficiency of the vital has an excess of an evil, the vital is too weak, and simply dispelling the evil will conversely damage the vital further. (3) Attack, Reinforcement, Strengthening the vital and Dispelling the Evil These methods are considered for cases of deficiency of the vital with excess evil.the two measures are used at the same time to support the vital while not strengthening the evil, and to eliminate the evil but not harm the vital Regulating yin and yang The occurrence of a disease is essentially the outcome of the superiority or inferiority of yin or yang and destruction of the relative balance they share. Therefore regulating yin and yang to remedy and restore their relative balance is a cardinal principle in treatment Eliminating the Surplus Eliminating the surplus includes treating a case with an excess of yin or yang, yin or 121

122 yang with reducing measures, or reducing what is excessive. Clearing away yang heat in an excess heat syndrome due to exuberance of yang heat or dispelling yin cold in a case of excess cold syndrome due to exuberance of internal yin cold are but a few examples Supplementing the Deficient Supplementing the deficient is used in cases of an inferiority of yin or yang, deficiency of either yin or yang with tonifying measures, or tonifying what is deficient. For example, nourishing yin to check yang in a deficient heat syndrome due to yin deficiency; supplementing yang to check yin in a deficient cold syndrome due to yang deficiency; or supplementing both yin and yang in a deficient syndrome of both yin and yang Treatment and the Season, Locality and Individual These concepts involve determining a suitable treatment for disease according to differences in season, local and the patient` s constitution, sex, and age Suiting Treatment to the season Climatic changes of the four seasons may exert a certain impact on physiological and pathological functions. A clinical principle based on the characteristics of different seasons is suiting treatment to the season. Generally, in spring and summer, the temperature gradually changes from warm to hot, with yang-qi rising and the striae of skin and muscles loose and open. At this time, even in a case of wind-cold attack, pungent and warm herbs with dispersing actions should not be heavily used in over dosage so as not to injure the qi and yin to prevent too much dispersion Suiting Treatment to Locale A principle in deciding treatment based on geographic characteristics is known as suiting treatment to locality. In different regions and geographic environments climatic conditions, people customs, physiological activities and pathological features differ. Thus treatment methods and principles should differ as well Suiting Treatment to the Individual A principle determining treatment based on the characteristics of the patient` s age, sex, constitution, and customs is known as suiting treatment to the individual. (1) Age. In people of different ages the physiological states and abundance of qi and blood differ as do pathological features. As a result practitioners should differ the treatment according to the relevant differences involved in the case. (2) Sex. A female differs from males both physiologically and pathologically. Women have special considerations such as menstruation, pregnancy and delivery which all need to be addressed when prescribing herbs. (3) Constitution.Individuals have different types of physiques such as cold or heat, and are strong or weak.as a result even when treating the same disease the prescription should be tailored to the specific conditions and cases. 122

123 The principle of suiting treatment to the season, locale and individual fully embodies the essential character of TCM-wholism and treatment determination based on syndrome differentiation. 8.2 Therapeutic Methods Therapeutic methods of TCM are treatments of great specificity based on the ascertained differentiation of the syndrome and the ascertained diagnosis of pathogenic factors and pathogenesis. The traditional treatments fall into eight categories which are referred to as eight therapeutic methods: diaphoresis, emesis, purgation, mediation, warming, heat-reducing, elimination and tonification Diaphoresis Outline Diaphoresis is a therapeutic method that treats diseases with proper diaphoretics to disperse and relieve the exterior pathogens, mainly for the exterior syndromes and also for the early stage of wind edema, skin and external diseases such as sores, carbuncle and ulcers, and measles without adequate eruption Classification Diaphoresis is subdivided into two kinds as follows. (1) Pungent-warm relief of exterior syndrome: relieving the exterior syndrome with drugs pungent in flavor and warm in property. This treatment is applicable to exterior wind-cold syndrome (such as heavy chills, slight fever and non-thirst). The usual recipe contains mainly drugs pungent in flavor and warm in property that relieve the exterior syndrome, mostly having the antiseptic, antiviral and diaphoretic functions. (2) Pungent-cool relief of exterior syndrome: relieving the exterior syndrome with drugs pungent in flavor and cool in property. This treatment is applicable to exterior wind-heat syndrome (such as fever, slight chills, thirst and sore throat). The usual recipe contains mainly drugs pungent in flavor and cool in property that relieve the exterior syndrome, mostly having the functions of antisepsis and abatement of fever Point for attention in using diaphoresis: (1) Sweat is a part of body fluid. Too much sweating would cause the exhaustion of body fluid. Therefore, an efficient cure for many diseases as it is, diaphoresis should never be abused. Special care must be given to the application of diaphoresis to patients who lack the yin fluid. These patients include: 1 those who suffer from severe vomiting or diarrhea; 2 those who suffer from open sores and deficiency of qi and blood; 3 those who are deficient of yang by nature and suffer from frequent spontaneous perspiration; 4 those who suffer from hemorrhage or tend to hemorrhage; and 5 cases of measles in full eruption. (2) Diaphoresis is not applicable when the pathogenic factors have invaded the inner body and the exterior syndromes have disappeared while the interior syndromes have 123

124 emerged. It is contraindicated to patients suffering from heart failure or extreme debility Emesis Outline Emesis is a therapeutic method to expel phlegm, saliva, undigested food or toxic substances that retain in the throat, thoracic cavity or stomach, mainly for the removal of the phlegm and saliva clogging in the throat, or the stubborn phlegm retaining in the thoracic cavity, or the undigested food and toxic substances accidentally taken that still stay in the stomach Point for attention in using emesis: (1) Emesis is an emergency treatment and should be avoided except in a few very urgent cases that call for immediate vomiting. (2) As vomiting may impair the body fluid and vital-qi, emesis is seldom advised. It is advised to try as much as possible the various other usual therapeutic methods to remove phlegm and undigested food. (3) Vomiting brings about drastic changes of the pressure inside the chest and abdomen. Therefore, emesis is contraindicated to patients with hypertension, arteriosclerosis, aneurysm, peptic ulcer, hemorrhagic tendency of pulmonary tuberculosis and to pregnant women. For those who are too weak or suffer from heart diseases, emesis should be performed with great care Purgation Outline Purgation is a therapeutic method that discharges through the lower orifice (anus) the undigested food, dry stool, cold accumulation, stagnant blood, phlegm and water retaining in the stomach and the intestines by clearing up the stomach and intestines and excreting the stercoroma, hydrops and coagulated blood there. It is applicable to constipation due to enterogastric pathogenic factors, or to syndromes caused by the domination of pathogen and vital-qi, such as fecal impaction due to heat with both watery discharge, stagnant phlegm and fluid retention, blood stasis and retention of water Classification (1) Purgation with drugs of cold nature: This is a method to attain purgation with purgative drugs bitter cold or salty cold in nature as the major drugs supported by drugs promoting the circulation of qi, mainly for interior heat syndromes of excess type, namely, qi-fen syndrome in the middle or later stage of a febrile disease. It is also applicable to the following indications: 1 early stage of dysentery due to damp-heat pathogen, accumulation of heat in the stomach and intestine marked by diarrhea accompanied with stasis of excrement; 2 fire of excess type such as conjunctivitis, encephalemia, pneumorrhagia and nose bleed; 3 for food or drug poisoning, this method can help clean up the poisonous substances in the stomach and intestines. 124

125 (2) Purgation with drugs of warm nature: This is a method to achieve purgation with drugs pungent in flavor and warm in nature as the major drugs supported by proper purgative drugs. It has the effects of augmenting blood circulation, promoting enterogastric peristalsis and digestion. It is applicable to syndromes such as yang deficiency of the spleen and stomach, cold accumulation in the stomach and intestines, hypofuncion of the digestive system, slowing down of the enterogastric peristalsis, abdominal distention, abdominal cold pain, constipation or even cold limbs. (3) Laxation with emollient cathartics: This is a method to realize purgation with emollient cathartics as the major drugs supported by drugs promoting the circulation of qi. It has the effects of lubricating the intestinal walls and feces, resulting in promotion of purgation. It is applicable to deuteropathic and postpartum constipation, constipation due to old age and weakness, habitual constipation, and constipation of hemorrhoid sufferers. (4) Purgation with hydrogogue: This is a method to treat hydrops by cleaning up through the bowels the large quantity of water retaining within the human body with drastic hudrogogues that lead to relatively violent purgation. It is advisable for physically strong patients who suffer from hydrothorax and ascites Point for attention in using purgation: (1) Purgation is mainly used to treat interior diseases or gastrointestinal disorders and constipation. If it is syndrome still with pathogens in exterior or half-exterior and half-interior, both the exterior and interior syndromes should be dealt with at the same time. (2) Purgation is a comparatively drastic method to eliminate pathogenic factors. It can impair the body fluid. Therefore, drugs should be stopped immediately once the therapeutic effect is achieved and never be overdosed. Purgation should be handled with great care when applied to patients with deficiency of vital-qi, those deficiency of yin fluid in particular, and women in pregnancy or during menstrual period Mediation Mediation is a therapeutic method that eliminates pathogenic factors by way of mediation or regulation, and is mostly used to treat half-exterior and half-interior syndrome. It regulates the prosperity and decline of yin and yang and thus further regulates the somatic functions under new conditions, consequently building up the patient s resistance to diseases, eliminating the pathogens and helping recover the patient s health. It is applicable to the derangement of visceral qi and blood, or to the simultaneous occurrence of cold, heat-dampness pathogens, or to intermingled asthenic and sthenic syndrome Warming Outline Warming is a therapeutic method that warms the middle-jiao, dispel pathogenic cold and helps recover yang, removes obstruction in the channels and collaterals, and 125

126 regulates the blood vessels by getting rid of the cold, recuperating the depleted yang and activating the channels and collaterals. It is applicable to diseases in the viscera and in the channels and collaterals due to pathogenic cold Classification (1) Warming the middle-jiao to dispel cold: Also referred to as warming the interior to dispel cold, this is mainly for interior cold syndromes due to the insufficiency of the spleen-yang and stomach-yang. The cold syndrome results from the hypofunction of the human body, especially the hypofunction of the alimentary system, which weakens the normal digestion and absorption, lowers energy metabolism and causes insufficient heat production and gives rise to cold syndrome. Warming the middle-jiao to dispel cold aims at warming the spleen and stomach, replenishing heat indirectly by promoting and strengthening the digestive function of the gastrointestinal tract so as to make up for the deficiency of energy. (2) Warming yang to treat collapse (depletion of yang): This is an emergency treatment used when the disease reaches the stage of circulatory failure. (3) Warming the channels to expel pathogenic cold: This is mainly applied to arthralgia-syndromes such as blockage in the channels and collaterals due to pathogenic cold, stagnation of qi and blood, arthralgia and difficulty in getting about. It has the functions of relieving pain and improving blood circulation Point for attention in using warming (1) Warming is inadvisable for heat syndromes, interior heat syndrome due to deficiency of yin, heat syndrome with pseudo-cold symptoms as well as hemorrhagic symptoms such as hematemesis and hematochezia due to heat syndromes. (2) Certain drastic hot-natured drugs should be used with great caution on pregnant women Heat-reducing Outline Heat-reducing is a therapeutic method that removes pathogenic heat and fire by clearing away heat and purging fire. It is applicable to interior heat syndromes. It has the functions of antisepsis, relieving inflammation and reducing fever. It is applicable to interior heat syndromes, chiefly heat syndromes of excess type, and also to certain heat syndromes of deficiency type Classification (1) Clearing pathogenic heat from the qi system: This is the usual heat-clearing method. It is applicable to indications of febrile diseases in the metaphase with heat in the qi system. (2) Clearing pathogenic heat from the ying system and from the blood: This is mainly applicable to febrile diseases in the later stage when the pathogenic heat has entered the ying system and the blood. 126

127 (3) Clearing away heat and removing toxic substances: This is a method to clear away pathogenic fire and toxin in the viscera by using heat-clearing and fire-purging drugs or heat-clearing and detoxifying drugs. In clinical practice it is usually applied to treat bacterial infections, especially purulent inflammation due to gram-positive bacteria. It has the functions of antisepsis and reducing fever. (4) Clearing away heat of deficiency type: This is applicable to fever due to deficiency of yin or persistent low fever Point for attention in using heat-clearing: (1) Heat-clearing is mainly used to treat interior heat syndromes. It should be contraindicated to cold syndromes and cold syndromes of deficiency type. It can never be used to treat cold syndromes with pseudo-heat symptoms. (2) Most of the heat-clearing drugs are of cold or cool nature. An overdose may impair the function of the spleen and stomach and give rise to symptoms like anorexia. Therefore, administration of such drugs should not last long unless necessary indeed Elimination Outline Elimination is a therapeutic method that gradually eliminates the tangible lumps formed by the accumulation and stagnation of qi, blood, phlegm, retained food, water, worm and the like by promoting digestion and removing stagnancy as well as resolving masses and dissolving lumps Classification (1) Regulating the flow of qi: This is a therapy that normalizes the flow of qi by regulating the functional activities of qi in the body, mainly for syndromes due to the stagnation of qi in the spleen, stomach, lung and liver. The therapy includes promoting the circulation of qi, elevating the collapsed yang and lowering the adverse flow of qi. Its clinical application can be classified as follows: promoting the circulation of qi, sending down abnormally ascending qi, elevating the collapsed yang. (2) Promoting blood circulation: This is also referred to as promoting blood circulation to remove blood stasis. It has the function of activating blood circulation and removing obstruction in the channels and vessels, removing blood stasis, promoting blood flow, regulating the smooth muscles of the various system and organs of the human body, and relieving the spasm of the smooth muscle, thus promoting the circulation of blood and the function of the viscera. In clinical practice it is mostly applied to treat emmeniopathy, chronic inflammation, angiocardiopath, fractures, soft tissue injuries and hepatosplenomegaly. (3) Removing dampness by diuresis: This is a therapy by using diuretics to remove pathogenic dampness. Its main function is diuresis. It should be applied with caution to those who are insufficient of yin-fluid. Its clinical application can be classified as follows: 1 Inducing diuresis to treat stranguria: Mostly applicable to inflammation or calculus of 127

128 urinary tract manifested as lower abdominal distension and fullness, frequent micturition, urgency of urination, urodynia and dark urine. 2 Inducing diuresis to alleviate edema: This is applied to treat hydrops. It eliminates the retained water within the body by diuresis. 3 Clearing away heat and promoting diuresis: This is applicable to diseases or syndromes with damp-heat symptoms. 4 Warming and resolving dampness: This is applicable to the cold-dampness syndromes due to the stagnation of water as a result of asthenia of the spleen-yang or the kidney-yang. (4) Removing phlegm: This is a therapy that removes the phlegm stagnating in various parts of the body. It is mainly applied to treat diseases in the respiratory system. It is also applicable to certain diseases or syndromes in the alimentary, circulatory and nervous systems. (5) Promoting digestion and removing stagnated food: This is a therapy to remove the stagnated food by using stomachics that can promote the digestive function of the stomach and intestines. It is mainly applicable to dyspepsia syndromes. (6) Resolving sores and carbuncles: The sores and carbuncles include skin and external diseases as well as abscess of internal organs. They are removed and cured by the diagnosis and treatment based on their characteristics and their individual reactions and in accordance with the differentiation of syndromes, namely exterior and interior, yin and yang, qi and blood Tonification Outline Tonification is a therapeutic method that nourishes and invigorates the qi, blood, yin and yang of the human body. It is applicable to one or several of zang and fu-organs, or one of the qi, blood, yin and yang, or the weakness of all of them as a whole Classification (1) Invigorating qi: This generally refers to nourishing and replenishing qi of the spleen and lung. In clinical practice it is often applied to treat deficiency of qi. Sometimes it is also applicable to deficiency of blood (as only when qi is sufficient in the spleen and heart can blood be generated there). (2) Enriching the blood: This is a therapy to treat deficiency of blood (pale lips, dim complexion, scanty and light coloured mensis.) (3) Invigorating yang: This has the effects of regulating the function of the human body and promoting metabolism. In clinical practice it is mainly used to treat deficiency of yang, endogenous cold syndromes due to deficiency of the kidney-yang as well as cold syndromes due to deficiency of the spleen-yang. (4) Nourishing yin: This has the effects of regulating the function of the human body and promoting metabolism. The term yin actually includes essence of life, blood and body fluid Point for attention in using tonification: 128

129 (1) Attention should be paid to the function of the spleen and stomach (or the digestive system). Patients suffering from weakened digestive function should first be given treatment to regulate the spleen and stomach. Sometimes digestants and drugs strengthening the spleen and stomach can be added to the tonics. (2) Tonification can be used only when obvious syndromes of weakened body resistance are manifested. If the weakened body resistance is not serious while the domination of pathogen is obvious, major efforts should be made to eliminate pathogenic factors, or add tonics to drugs eliminating pathogenic factors to assist the vital-qi and strengthen the body s resistance to pathogenic factors. (3) As for complicated cases, one single therapeutic method can seldom satisfy the requirements of the treatment. In such cases, two or more therapeutic methods should be used in coordination to keep all the aspects in view. ( 吕妍, 胡瑞 ) 129

130 130 Section Two Acupuncture And Tuina Chapter One The Meridian-Collaterals and Acupoints A General Introduction to Meridians and Collaterals Jing-luo, is a general term for the jing mai (meridians) and luo mai (collaterals), which are the pathways through which the qi and blood of human body circulates. Jing means go through or a path. They are the main trunks, thick and large. They run longitudinally and interiorly within the body. They include the twelve regular meridians, the eight extra meridians and the twelve divergent meridians. Luo means something that connects or a net. They are the branches of the meridians, thin and small. They run transversely and superficially, and crisscross and net the whole body. They include the fifteen collaterals, the minute collaterals, and the superficial collaterals. Many ancient medical books recorded that the meridians-collaterals are the pathways in which the qi and blood of human body are circulated. In chapter 23 of Classic on Medical Problems, it says, The meridians and collaterals transport qi and blood and adjust yin and yang, in order to nourish the body. In volume 4 of Compendium of Acupuncture and Moxibustion, it says, The twelve meridians and the fifteen collaterals, which distribute exteriorly on the whole body are the pathways in which the blood and qi circulate. They originate from, and are rooted in the kidney and are the source of life. So we can see that the meridians-collaterals have a close relationship with the activities of human life. In summary, the meridian-collaterals pertain to the zang-fu organs interiorly and link the extremities and joints exteriorly. They run and connect the upper and lower aspects of the body, unifying all parts of the body into an organic whole. They transport the qi and blood, nourish the whole body, and maintain the harmonious balance of all the functions and activities of the many parts of the body. The theory of meridians-collaterals is a theoretical doctrine that analyses the course and distribution, physiological function and pathological changes of the meridian-collaterals of the human body and their relationship with the zang-fu organs. It is a fundamental concept in the basic theory of traditional Chinese medicine, and the cornerstone theory underlying acupuncture-moxibustion. It integrates physiology, diagnostic theories and treatment principles in Chinese medicine, with the theory of yin-yang, the five elements and the theory of zang-fu, thus forming the theoretical basis of Chinese medicine. For a long time, it has been of great significance in guiding Chinese medical clinical practice in many areas. This is especially so in the practice of

131 acupuncture whereby syndrome differentiation, point selection, the needling techniques of reinforcing and reducing, and acupuncture anesthesia is seen as arising from the theory of the meridians and collaterals. 1.1 Classification of the Meridian-Collateral System The meridian-collateral system is composed of the twelve regular meridians, the eight extra meridians, the twelve divergent meridians, the twelve muscles regions and the twelve cutaneous regions, the fifteen collaterals, and the minute and superficial collaterals. Amongst these, the twelve regular meridians can be seen as the primary system. Running transversely and longitudinally, they intersect with each other, both in the interior and exterior of the body, forming a complete system. See Tab The Twelve Regular Meridians The Composition of the Twelve Meridians The twelve regular meridians are a general term for the three yin meridians of hand, the three meridians yang of hand, the three yin meridians of foot, and the three yang meridians of foot The Nomenclature of the Twelve Meridians As the major trunks in the system of the meridians-collaterals, the twelve meridians pertain also to the twelve zang-fu organs, and are also known as the zheng jing (the regular meridians). They are also classified into hand, foot, or yin and yang meridians. The nomenclature of the twelve regular meridians is based on yin and yang, the associated zang and fu organ, and their pathway on either the hand or foot. The Yang meridians are classified as Shaoyang, Yangming and Taiyang; whilst the yin meridians are classified as Shaoyin, Jueyin and Taiyin. In accordance with the fact that the zang organs pertain to yin, the fu organs to yang, and the medial aspect is attributed to yin, and the lateral aspect to yang, each of the meridians is given a name according to the zang-fu organ it pertains to and its distribution on the human body, for examples, the Lung Meridian of Hand-Taiyin, the Large Intestine Meridian of Hand-Yangming, etc The Characteristics of the Distribution of the Twelve Meridians The meridians pertaining to the six zang organs (the five zang organs plus the pericardium) are yin meridians. They are mainly distributed on the medial aspect of the four Limbs and chest and abdomen after originating internally from the six zang organs. Those traveling along on the medial aspect of the upper limbs are the three yin meridians of hand, while those traveling along the medial aspect of the lower limbs are the three yin meridians of foot. (see Fig.1). The meridians pertaining to the six fu organs are yang meridians. They are mainly distributed on the lateral and posterior aspects of the four limbs, head, face and trunk after originating internally from the six fu organs. Those traveling along on the lateral aspect of the lower limbs are the three yang meridians of foot. 131

132 The twelve meridians are arranged in a sequence on the medial and lateral aspects of the body. The Taiyin meridians are on the anterior border, Jueyin meridians on the middle and Shaoyin meridians on the posterior border; Yangming meridians on the anterior border, Shaoyang meridians on the middle and Taiyang meridians on the posterior border. This sequence is the same for the upper lower limbs. This is not the case, however, on the lower shank where the Liver Meridian of Foot-Jueyin is on the anterior and the Spleen Meridian of Foot-Taiyin is in the middle. Table 1-1 The Classification of Meridians and Collaterals Three Yin of Hand Lung Meridian of Hand-Taiyin Pericardium of Meridian of Hand-Jueyin Heart Meridian of Hand-Shaoyin Three Yang of Hand Large Intestine Meridian of Hand-Yangming Sanjiao Meridian of Hand-Shaoyang Small Intestine Meridian of Hand-Taiyang Twelve Regular Meridians Three Yang of Foot Stomach Meridian of Foot-Yangming Gallbladder Meridian of Foot-Shaoyang Bladder Meridian of Foot-Taiyang Three Yin of Foot Spleen Meridian of Foot-Taiyin Liver Meridian of Foot-Jueyin Kidney Meridian of Foot-Shaoyin Meridians Twelve Divergent Meridians Twelve Muscle Regions Twelve Cutaneous Regions Meridians and Collaterals Eight Extra Meridians Du Meridian Ren Meridian Chong Meridian Dai Meridian Yinwei Meridian Yangwei Meridian Yinqiao Meridian Yangqiao Meridian Collaterals Fifteen Collaterals Minute Collaterals Superficial Collaterals 132

133 The Characteristics of the Distribution of the Twelve Meridians The meridians pertaining to the six zang organs (the five zang organs plus the pericardium) are yin meridians. They are mainly distributed on the medial aspect of the four Limbs and chest and abdomen after originating internally from the six zang organs. Those traveling along on the medial aspect of the upper limbs are the three yin meridians of hand, while those traveling along the medial aspect of the lower limbs are the three yin meridians of foot. (see Fig.1). 图 1. 十四经循行分布示意图 Fig.1 Distribution of the fourteen Meridians The meridians pertaining to the six fu organs are yang meridians. They are mainly distributed on the lateral and posterior aspects of the four limbs, head, face and trunk after originating internally from the six fu organs. Those traveling along on the lateral aspect of the lower limbs are the three yang meridians of foot. The twelve meridians are arranged in a sequence on the medial and lateral aspects of the body. The Taiyin meridians are on the anterior border, Jueyin meridians on the middle and Shaoyin meridians on the posterior border; Yangming meridians on the anterior border, Shaoyang meridians on the middle and Taiyang meridians on the posterior border. This sequence is the same for the upper lower limbs. This is not the case, however, on the lower shank where the Liver Meridian of Foot-Jueyin is on the anterior and the Spleen Meridian of Foot-Taiyin is in the middle The Direction of Flow and the Connecting Places of the Twelve Meridians The three yin meridians of hand run from the chest to the hand (connect with the three yang meridians of hand); the three yang meridians of the hand run the hand to the head 133

134 (and there connect with the three yang meridians of foot); the three yang meridians of foot run from the head to the foot (and there connect with the three yin meridians of foot); and the three yin meridians of foot run from the foot to the abdomen and chest (and there connect with three yin meridians of hand). The connecting places of the twelve meridians are as follows: (1) The yin meridians connect with yang meridians in the four limbs. For example, the three yin meridians of hand meet the three yang meridians of hand at the tips of the fingers; the three meridians of foot meet the three meridians of foot at the tips of the toes. (2) The yang meridians connect with the yang meridians bearing the same name on the head and face. The Large Intestine Meridians of Hand-Yangming meets the Stomach Meridian of Foot-Yangming beside the nose; the Small Intestine Meridian of Hand-Taiyang meets the Bladder Meridian of Foot-Taiyang beside the inner canthus; the Sanjiao Meridian of Hand-Shaoyang meets the Gallbladder Meridian of Foot-Shaoyang beside the outer canthus. (3) The yin meridians of hand connect with the yin meridians of foot in the chest The Spleen Meridian of Foot-Taiyin and the Heart Meridian of Hand-Shaoyin meets together in the heart region; the Kidney Meridian of Foot-Shaoyin and the Pericardium Meridian of Hand-Jueyin in the chest region; the Liver Meridian of Foot-Jueyin and the Lung Meridian of Hand-Taiyin meet together in the lung region. Since the twelve meridians link to one another due to the connection of the meridians of the hand and foot, yin and yang, and interior and exterior meridian, forming a cyclical system without end. It originates from the middle jiao, starts from the lung and ends in the liver after completing a cycle through the body, finally returning to the lung. The cyclical flow of qi in the twelve regular meridians is as following (Tab.1-2). Table 1-2 The Cyclical Flow of Qi in the Twelve Regular Meridians Liver meridian Tip of the great toe Gallbladder meridian External canthus Sanjiao meridian Tip of the ring finger Pericardium meridian In the chest Kidney meridian Tip of the small toe Bladder meridian Middle Jiao In the lung inner canthus Lung meridian Tip of the index finger Large Intestine meridian Beside the nose Stomach meridian Tip of the great toe Spleen meridian In the heart Heart meridian Tip of the small finger Small Intestine meridian 134

135 The Exterior-Interior Relationship of the Twelve Meridians The twelve meridians have an internal-external relationship with the twelve zang-fu organs (including the pericardium). The exterior and interior relationships are determined on the relationship to zang and fu, and the yin and yang aspect. The zang organs pertain to yin and interior, so the six zang organs correspond to the six yin meridians. The fu pertain to yang and the exterior, thus the six fu organs correspond to the six yang meridians. Thus the twelve meridians form six pairs of internally-externally related meridians. The lung meridian and the large intestine meridian, the pericardium meridian and the Sanjiao meridian, the heart meridian and the small intestine meridian, the spleen meridian and the stomach meridian, the liver meridian and the gall bladder meridian, the kidney meridian and the urinary bladder meridian. The exteriorly-interiorly related meridians promote and control each other in physiological situation, and transform and affect each other in pathological situation The Function of the Twelve Meridians The twelve meridians functions are to connect the zang-fu organs interiorly, to link to the limbs exteriorly, and to transport the qi and blood and nourish the whole body The Eight Extra Meridians The eight extra meridians refer to the eight meridians that have specific functions, and include the Du, Ren, Chong, Dai, Yangqiao, Yinqiao, Yangwei and Yinwei meridians. The characteristics: Compared to the twelve regular meridians, the extra meridians have the following characteristics: (1) None of them pertain to or connect with a zang or fu organ; (2) They are not exteriorly-interiorly related; (3) They don t have related hand or foot meridians, some of them don t have a yin or yang aspect; (4) They don t have a cyclical flow of qi as in the regular meridians; (5) Apart from the Du and Ren meridians which have their own points, the other meridians share their points with the twelve regular meridians. Their functions: Because they connect the twelve regular meridians, they store, drain and adjust the qi and blood of the regular meridians. When there is a surfeit of qi and blood in the twelve meridians, qi and blood are absorbed by the eight extra meridians to be stored for future use. When there is an insufficiency of qi and blood, they release qi and blood to the twelve regular meridians. The Du Meridian: The Du Meridian runs along the midline of the back and ascends to the head and face and meets all the yang meridians. It is therefore described as the sea of the yang 135

136 meridians. Its function is to regulate the qi of all yang meridians. 136 The Ren Meridian: The Ren Meridian runs along the midline of the abdomen and the chest, and proceeds upward to the chin. It meets all the yin meridians. Thus it is called the sea of the yin meridians. Its function is to regulate the qi of all the yin meridians The Fifteen Collaterals The fifteen collaterals include the twelve collaterals separating from the twelve regular meridians, two collaterals of the Ren and Du meridians and the major collateral of the spleen. Their functions are to connect the externally-internally related meridians and to strengthen the circulation of qi and blood of the twelve meridians. Characteristics of distribution of the fifteen collaterals: All the collaterals of the twelve meridians originate from the luo-(connecting) points and run to their externally-internally related meridians (the collaterals of yin meridians separate from the yang meridians, while the collaterals of yang meridians separate from the yin meridians). The collateral of the Du meridian disperses in the head and joins with the Bladder Meridian of Taiyang, to connect the meridian-qi on the back. The collateral of the Ren meridian disperses in the chest and abdominal region, to spread the meridian-qi in chest and abdomen. The major collateral of the spleen disperses in the chest and hypochondrium. Of all the meridians, the fifteen collaterals are the largest. The visible branches, which are distributed on the superficial parts of the body, are called superficial collaterals. The finest and invisible branches that distribute all over the body are called the minute collaterals. They function to transport qi and blood to the Muscle and Cutaneous Region. 1.2 The Physiological Functions and Pathogenic Changes of the Meridians and Collaterals The ancestors recognized that the function of the meridians and collaterals arose from long term clinical practice and observation. It reflects the regularity of some of the physiological and pathological phenomena that occur within the human body. It also has implications for guiding treatment in clinic The Physiological Functions (1) Connecting the interior and exterior, and linking the thorax and the limbs In Chapter 33 of Miraculous Pivot, it says: The twelve meridians pertain to the organs internally and connect to the limbs externally. It points out that the meridian-collaterals are a network that runs transversely and longitudinally inside the body, connecting the interior and exterior and linking the upper and lower portions of the body. This network connects the organs and tissues of the body, the four extremities, the head and face, the

137 skin and hair, thus signifying a dynamic and integrated organism. (2) Transporting qi and blood and nourishing the whole body Chapter 47 of Miraculous Pivot says: The meridians and collaterals transporting blood and qi to adjust yin and yang, nourish tendons and bones and improve joint function. It points out that the meridians and collaterals have the function of transporting qi and blood, regulating yin and yang, and nourishing the whole body. (3) Resisting pathogens and protecting the body The meridians and collaterals have the role of resisting pathogens and protecting the body. Since the meridians and collaterals can transport blood and qi to adjust yin and yang, and since the nutrient qi flows inside the meridians and defensive qi runs outside the meridians. The defensive qi is dispersed to the skin thereby strengthening the function of defending the surface the body. (4) Regulating the function of the zang-fu organs and keeping the equilibrium The meridian and collateral system is a dynamic system that flows continuously. The course of qi and blood circulating in the meridians facilitates a dynamic equilibrium within the body. A functional disorder of a zang-fu organ, meridian and collateral will be adjusted through the functions of the meridians and collaterals, thus restoring the equilibrium of the body and preventing the onset of diseases The Pathological Reactions Under pathological conditions, the meridians and collaterals reflect the disease process. (1) The relationship between the meridian-collaterals and the pathology of the zang-fu When there is an attack by an external pathogen on the body surface, with failure of the body in resisting the pathogens due to a disorder of the meridians and collaterals, the pathogen may invade the skin and hair, and transmit from the exterior to the interior, from the superficial to part of the body by way of the meridians and collaterals. There is first, an attack on the collaterals, then the meridians, and later internally the zang-fu organs, giving rise to disorders of the zang-fu organs. Invasion of evils directly in the internal organs will also involve the meridians and collaterals. A disorder of an internal organ due to invasion of evils may transfer outward to the surface of the body by way of the meridians and collaterals, reflecting various pathological changes. For instance, acute pneumonia may give rise to spindle-shape nodes on Feishu (BL 13) on the upper back. (2) The relationship between the meridians and collaterals and the pathology of the five sense organs The five sense organs and the zang-fu organs are linked through the meridians and collaterals. A disorder of a meridian may give rise to the disease of the organs the meridian passes or pertains to. (3) The relationship between the meridians and collaterals and the pathology of the 137

138 superficial area of the body A disorder of a meridian on the superficial area of the body may give rise to a pathological change on the head, face, trunk and the four extremities, where even the meridian traverses or dominates. From the above we can see that the pathological changes of the meridians and collaterals reflect the association between the exterior and interior aspects of the body. 1.3 Clinical Application The theory of the meridian-collaterals is of great importance in guiding clinical practice, especially in acupuncture practice and acupuncture anesthesia Guidance of Diagnosis (1) Distinguishing the disordered meridian from location Each of the twelve meridians has its specific pathway. A disorder of a meridian may indicate a specific syndrome. The symptoms on a different part of the body may be identified by the specific meridian through which the pathway of the meridian passes. For instance, a headache can be identified by identifying the courses of the meridians on the head. (2) Distinguishing the disorders of meridians according to the specific symptoms Chinese medicine believes that invasion of evils in the meridian and collateral may transmit to zang-fu organs interiorly. Conversely, a disorder of zang-fu the organs may reflect on the meridians and collaterals. If the patient manifests a bitter sensation in the mouth, dry throat, blurred vision, deafness and hypochondriac pain, it could be considered to be a disorder of the Gallbladder Meridian of Foot-Shaoyang. (3) Distinguishing the disorders of the zang-fu organs according to the meridian and collateral Each of the twelve meridians has its own pathways and link with its corresponding zang-fu organ. A disorder of a zang-fu organ may reflect on the meridian and collateral on the superficial area of the body by way of transmission. Pathological reactions, such as tender spots, sensitive point, or nodes may occur along the course of the pertaining meridian or on the back shu points, front mu points, xi-(cleft) points, yuan(primary) points where the meridian-qi gathers. These phenomena may provide clues for the diagnosis of diseases of the internal organs. For example, tender sport may be found on Zhongfu (LU 1) in lung diseases Guidance of Acupuncture and Moxibustion Treatment The doctrine of meridian-collateral can be used as guide for the theoretical basis for treatment based on differentiation, selection of points and the reinforcing and reducing method in acupuncture and moxibustion therapy. For acupuncture treatment, the disease of the zang-fu organ and the meridian is first identified. Then the joint selection of distal, local and adjacent points is adopted according to the interrelationship of the zang-fu 138

139 organs, the meridians and points. The prescription is then determined. In the manipulation of the reinforcing and reducing technique, the direction of the meridian course should be considered. In clinic, the practitioner should apply the meridian-collateral theory to facilitate the analysis of the physiology and pathology of different organs according to the concept of wholism, in order to identify the illness and increase the therapeutic effect. The meridians and collaterals link with the zang-fu organs internally, connect the limbs exteriorly, and transport qi and blood. Each of these meridians has attributed acupoints. Acupoints are the sites where the meridian qi is transmitted to the superficial aspect of the body, and is closely related with the function of the zang-fu organs. At the same time, the acupoints are the reacting points which permit external stimulation on the surface of the body. If there is a stagnation of a meridian-collateral and/or disorder of qi and blood, the acupoints on the related meridian are selected, to dredge the meridians and collaterals, regulate the function of the zang-fu organs and to treat the disease. This is the principle of selecting points on the meridian which takes the points are indicated where the relevant meridian flows as the basis for application. For instance, Zusanli (ST 36) is used for stomachache, Waiguan (SJ 5) and Fengchi (GB 20) for migraine. There is a poem which says disorders of the stomach and abdomen, retain the needles in Zusanli (ST 36); disorders of the back, seek Weizhong (BL 40); disorders of the head and the neck, use Lieque (LU 7); diseases of the face and mouth apply Hegu (LI 4). This is a generalization by the ancient doctors from theory of selecting a point on the meridian. The ancestors emphasized this experience, believing that rather miss a point but not the meridian. This statement indicates that the application of acupoints is closely related to the distribution of the meridians in acupuncture treatment Application in Acupuncture Anesthesia Developed sine 1958, acupuncture anesthesia is a productive achievement based on the theory of meridian-collaterals. Like acupuncture-moxibustion treatment, acupuncture anesthesia needs to determine the meridian traversing the operating area, then select the points along the meridian to obtain the purpose of anesthesia. So the doctrine of meridian-collateral is emphasized in acupuncture anesthesia during an operation. 139

140 140 General Introduction To Acupoints Acupoints are the specific sites through which the qi of the zang-fu organs and meridians is transported to the body surface, and through which acupuncture and moxibustion and other therapies are applied by external stimulation. Shuxue (acupoints) are also termed xue, or xuewei. Shu means transportation and transmission, while xue means hole or gathering. In the medical literature of the past dynasties, acupoints have had other names such as qi point and aperture. Distributed on their related meridian pathways, acupoints are closely linked with the meridians and collaterals. So the acupoints should not be regarded as superficial points alone, but as special sites which connect with each other, and through which the internal tissues and organs are related. The meridians-collaterals connect the whole body, both interiorly and exteriorly, and diseases of the body can by treated by puncturing the points on the body surface to regulate the related meridians, zang-fu organs and the circulation of qi and blood. The Development and Classification of Acupoints The Development of Acupoints The formation and development of acupoints has a long history. They were gradually discovered by the Chinese people during the course of struggling against diseases over a long period. Their development may be classified into three stages. (1) Unfixed location Initially, people only knew that when pain or discomfort happened on the body, then massage, beat, or acupuncture and moxibustion could be applied to local area. This selection of local points is called using tender sports as acupoints. There is no fixed location or name for the point when utilizing this method of point selection. (2) Fixed location and name Through a long period of medical practice, people got to know that puncturing some points could treat some diseases. Further, people knew that some points may not only treat one disease, but other diseases as well; and that they may not only treat local disorders but diseases at a distance as well. At this time, people accumulated rich experiences and knew some knowledge of the features of the location of the points and their therapeutic effects. Through agreeance and classification by the medical doctors, the points were given a definite location and name. (3) Systematic classification Through accumulating medical experiences over a long period of medical practice, the ancient doctors began to identify more features regarding the location of points, and gradually grasped the regularity of the therapeutic effects of the points. They not only determined definite locations and indications of the points, but also gave them specific

141 names. Later on, the points were systematically classified, and respectively attributed the related meridians Classification of Acupoints After the systematic classification, acupoints are classified into three categories acupoints of the fourteen meridians, extraordinary points and Ashi points. (1) Acupoints of the fourteen meridians The acupoints distributed along the twelve regular meridians and the Du and Ren meridians are called acupoints of the fourteen meridians, or meridian points. Through the ensuing medical practice of people after the discovery of acupoints, the points were localized and named, becoming increasingly more in number, and further systematized. Since the points are distributed on the course of the fourteen meridians, the points are very closely to the meridians. They can not only treat the diseases of meridians themselves, but also reflect disorders of the fourteen meridians and the related zang-fu organs. The twelve regular meridians are distributed symmetrically in pairs on the left and right sides of the body (309 pairs of points), while the Du and the Ren meridians are single, aligning on the posterior and anterior midlines respectively (24+28=52 points). The acupoints of the 14 meridians total 361. (2) Extraordinary points Extraordinary points, also called exra points, are points with a definite location and a specific name, but are not related to the fourteen meridians. These points are especially effective in the treatment of certain diseases. For instance, Taiyang located on the head, is used to treat headache. While Yaoyan on the waist, is used to treat low back pain. Although scattered over the body, they are still related to the meridian system. For examples, Yintang is related to the Du Meridian, and Taiyang is related to the Sanjiao Meridian. From the acupuncture literature of the past dynasties, it can be seen that some of extraordinary points were gradually absorbed into points of the fourteen regular meridians. (3) Ashi points Ashi points are also called tender spots, sensitive points, or reflex points. These points have neither specific names nor definite location. They are neither points of the fourteen meridians nor the extra points. They are the tender spots and other reflexive spots that are used as sites for needing and moxibustion. Ashi points are usually near the affected areas, but not necessarily The Therapeutic Properties of Acupoints Points have the following three properties The Local and Adjacent Therapeutic Property of the Points All the acupoints (including the points of the fourteen meridians, the extraordinary points and the Ashi points) share a common feature in terms of their therapeutic 141

142 properties. Acupoints can treat disorders of nearby tissues and organs. For examples, points around the eyes such as Jingming (BL 1), Chengqi (ST 1), Sibai (ST 2) and Qiuhou(EX-HN 7) can be used to treat eye disorders; points around the ears such as Tinggong (SI 19), Tinghui (SJ 21) and Ermen (GB 2) can treat disorders of the ears; Zhongwan(RN 12), Liangmen (ST 21) are used for gastric disorders The Remote Therapeutic Property of the Points The remote therapeutic property of the points is a fundamental therapeutic property of the points of the fourteen meridians. The points of the fourteen meridians, especially those of the twelve regular meridians located below the elbow and knee joints, are effective not only for local disorders but also for disorders of the tissues and zang-fu organs so far as the course of their pertaining meridians can effect. Some acupoints also have systemic therapeutic property. This property is obviously related to the meridians and collaterals. For example, Hegu (LI 4) not only treats diseases of the upper limbs; but also diseases of the neck, head and face, as well as fever in febrile diseases. Zusanli (ST 36) not only treats disorders of the lower limbs, but also regulates the whole digestive system, and has a defensive effect with regard to an immune reaction within the body The Special Therapeutic Property of the Points Clinical practice has demonstrated that puncturing certain points may bring forth homeostatic beneficial regulation on a variety of functional abnormalities of the body. Puncturing the same acupoint may have two opposite reactions when the body is in different functional states. When the body is in a hyperfunctional state, acupuncture may decrease the function. On the Contrary, when body is in a hypofunctional state, acupuncture may increase the function. For instance, puncturing Neiguan (PC 6) corrects both tachycardia and bradycardia. Puncturing Hegu (LI 4) can stop sweating when there is fever and profuse sweating, but also make the body sweat when there is absence sweating. Needling Tianshu (ST 25) relieves both diarrhea and constipation. The indications of the fourteen meridians can be summarized as such: the points of a meridian are indicated in the disorders of the particular meridian; points of the exteriorly-interiorly related meridians can be used to treat disorders of these two meridians; neighboring points can be combined to treat local diseases. Each point has its own specific reaction but also shares common properties Specific Points Specific points refer to those of the fourteen meridians that have special properties. Since they have different therapeutic effects, the ancient doctors gave them different names. Knowing the meaning, indications and clinical applications of these points is of importance clinically for point selection. The commonly used specific points are introduced as follows The Five Shu Points 142

143 Each of the twelve regular meridians has five specific points below the elbows or knees, namely, the jing- (well), ying- (spring), shu- (stream), jing- (river) and he- (sea), which are termed five shu points. It was first stated in Chapter 1 of Miraculous Pivot "The points which qi springs up are called jing- (well) points; the points where qi flows copiously are called ying- (spring) points; the points where qi flows like a stream are called shu- (stream) points; the points where qi flows through are called jing- (river) points; and the points where qi gathers are called he-(sea) points. " The five shu points were perceived by the doctors of the past as flowing water, representing the volume of qi and blood in the meridians. They were respectively given the names of jing- (well), ying- (spring), shu- (stream), jing- (river) and he- (sea), to demonstrate that the qi of meridians flow from the distal extremities to the elbows or knees. The jing- (well) points are situated on the tips of the fingers and toes where the meridian qi starts to bubble, just like the origin of water, hence the name jing- (well) points. The ying- (spring) points are situated distal to the metacarpal-phalangeal joints and the metatarsophalangeal joints where the meridian qi starts to gush, just like a spring, hence the name ying- (spring) points. The shu- (stream) points are situated proximal to the metacarpal-phalangeal joints and the metatarsophalangeal joints where the meridian qi flourishes, just like a stream, hence the name shu- (stream) points. The jing- (river) points are situated above the wrists and ankles where the meridian qi is pouring abundantly q just like a river, hence the name jing- (river) points. Finally, the he- (sea) points are situated near the elbows and knees, where the qi goes into the body q and gathers in the tang-fu organs, just like the confluence of rivers in the sea, and hence the name the he- (sea) points Methods of Locating Acupoints There are hundreds of points on the human body, each of them having its own location. In order to select the points correctly, we need to locate them. In the clinic, correct location of acupoints is closely related to the therapeutic result. So the ancient doctors emphasized the location of points. In order to locate acupoints accurately, the practitioner must understand the methods of locating acupoints. In modern clinic, the commonly used methods of point location include proportional measurements, finger measurement and simple measurement Proportional Measurement This method utilizes the bones and joints as landmarks to measure various portions of the human body. It locates acupoints by means of respectively dividing the width or length of various portions of the human body into definite numbers of equal units, as the 143

144 standard for measurement. This measurement is applicable on patients of different sexes, ages and body sizes. This method was supplemented and revised by generations of past dynasties, became a basic standard for point location. The proportional measurements of the commonly used portions of the body are introduced as follows. (Fig. 2, Tab. 1-3) 图 2 骨度分寸示意图 Fig.2 Proportional Measurement Finger Measurement The length and width of the patient's finger (s) are taken as a standard for point location. There are many kinds of finger measurements. The commonly used methods are as follows.( Table 1-3) Middle finger measurement When the patient's middle finger tip and the thumb tip touch together, the distance between the two medial ends of the creases of the interphalangeal joints is taken as one cun. This method is employed for measuring the points on the four limbs, or for measuring the horizontal distance to locate the points on the back (Fig. 3). 144

145 Table 1-3 Standards for Proportional Measurement Body Distance Proportional Measurement Explanation Head From the anterior hairline to the posterior hairline 12 cun If the anterior and posterior hairlines are indistinguishable, the distance from the glabella to Dazhui (DU 14) then is taken as 18 cun. The distance from the glabella to the anterior hairline is taken as 3 cun. The distance from Dazhui (DU 14) to the posterior hairline is taken as 3 cun. Chest and abdomen From the sternocostal angle to the center of the umbilicus Between the center of the umbilicus and the upper border of symphysis pubis 8 cun 5 cun The distance between the bilateral Quepen (ST 12) can be used as the substitute of the transverse measure -ement of the two nipples Between the two nipples 8 cun Upper limbs Between the end of the axillary fold and the transverse cubital crease 9 cun Used for the three yin and the three yang meridians of the hand Between the transverse cubital crease and the transverse wrist crease 12 cun Lower limbs From the prominence of the great trochanter to the middle of patella 19 cun Between the center of patella and the tip of lateral malleolus 16 cun Used for the three yin meridians of the foot. From the tip of the lateral malleolus to the heel 3 cun Thumb measurement The width of the interphalangeal joint of the patient's thumb is taken as one cun. This method is employed for measuring the vertical distance to locate the points on the four limbs (Fig. 4) Four-finger measurement The width of the four fingers (index, middle, ring and little) close together at the level of the dorsal skin crease of the proximal interphalangeal joint of the middle finger is taken as three can (Fig. 5). It is used to locate points on the limbs and in the abdominal region. 145

146 图 3 中指同身寸法 Fig.3 Middle fnger mcasurcmcnt Simple Measurement 图 4 拇指同身寸法 Fig.4 Thumb mcasurcmcnt 图 5 横指同身寸法 Fig.4Four-fingcrs mcasurcmcnt Simple measurement is a simple method in which various anatomical landmarks on the surface of the body are used as the basis for the location of points. Some of the locations of points are simple. For instance, Baihui (DU 20) is located directly above the two ear apexes. Yintang (EX-HN 3) is located at midway between the two eyebrows. Zanzhu (BL 2) is located on the medial extremity of the eyebrow. Suliao (DU 25) is located on the tip of the nose. Tanzhong (RN 17) is located midway between the two nipples. When the index fingers and thumbs of both hands are crossed with the index finger of one hand stretched, Lieque (LU 7) is in the place directly under the tip of the index finger. Fengshi (GB 31) is located at the tip of the middle finger when standing at attention. Zhangmen (LR 13) is located at the end of the eleventh rib. Jingmen (GB 25) is located at the end of the twelfth rib. Shenque (RN 8) is in the center of the umbilicus. Locate Mingmen (DU 4) is located at the level of the umbilicus. Dazhui (DU 14) is below the spinous process of the 7th cervical vertebra. And the points on the back are located according to the number of the vertebra. Meridians And Points 3.1 The Twelve Regular Meridians The Lung Meridian of Hand-Taiyin The course of the meridian a. Originating from middle jiao, running downward and connecting with the large intestine (1)... winding back, going along the upper orifice of the stomach (2)... passing through the diaphragm (3)... entering the lung, its pertaining organ (4). b. From the portion of the lung communicating with the throat, coming out transversely (Zhongfu, LU 1) (5) descending along the medial aspect of the upper arm, passing in front of the Heart Meridian of Hand-Shaoyin and the Pericardium Meridian of 图 6 手太阴肺经循行示意图 Fig.6 The lung Mcridian of Hand-Taiyin 146

147 Hand-Jueyin (6) reaching the cubital fossa (7) going downward along the medial aspect of the forearm (8) arriving at radius Cunkou (9) passing the thenar eminence (10) going along radial border of the thenar eminence (11) ending at the medial side of the tip of the thumb (12). c. Emerging from Lieque (LU 7) and running directly to the radial side of the tip of the index finger (Shangyang, LI 1) to link with the Large Intestine Meridian of Hand Yangming (Fig. 6) Main disorders of the meridian Cough, asthma, pain in chest, hemoptysis, sore throat, aphasia, fever, pain along the meridian Indications a. Disorders of the throat, chest and the lung; b. Other disorders along the course of the meridian. 1) Zhongfu (LU 1) Location: Below the acromial extremity of the clavicle, six cun lateral to the mid line of the body, level to the first rib (Fig. 7). Indications: ⑴ Respiratory system disorders: cough, asthma, and fullness in chest; ⑵ Pain syndromes: pain of shoulder and back, chest pain. Method: Puncture obliquely or horizontally cun with the tip directed laterally. Deep puncture is not advisable, as it may puncture the lung. 2) Chize (LU 5) Location: At the transverse crease of the elbow, on the radial side of tendon of biceps brachii. (Fig. 8). Indications: ⑴ Respiratory system disorders: cough, asthma, hemoptysis, and fullness in chest; ⑵ Febrile diseases: tidal fever, swollen and sore throat, infantile convulsion ; ⑶ Digestive system disorders: vomiting, diarrhea; ⑷ Pain syndrome: pain and spasm of the wrist and arm. Method: Puncture perpendicularly cun, or prick to cause bleeding. 3) Kongzui (LU 6) Location: 7 cun above the transverse crease of the wrist, on the line joining Chize (LU 5) and Taiyuan (LU 9) (Fig. 9). 图 7 Fig.7 图 8 Fig.8 Indications: ⑴ Respiratory system disorders: cough, asthma, and hemoptysis; ⑵ Pain syndromes: swelling and pain of the throat, pain and spasm of the elbow and arm. 147

148 Method: Puncture perpendicularly cun. 4) Lieque (LU 7) Location: Superior to the styloid process of the radius, 1.5 cun above the transverse crease of the wrist (Fig. 9). Simple method: When the index fingers and thumbs of both hands are crossed with the index finger of one hand placed on the styloid process of the radius of the other, the point is in the depression directly under the tip of the index finger (Fig. 10). Indications: ⑴ Head and facial diseases: headache, stiff neck, swollen and sore throat, deviation of mouth and eye, toothache; ⑵ Respiratory diseases: wind-cold, cough, asthma. Method: Puncture obliquely cun. 图 9 Fig.9 图 10 Fig.10 5) Taiyuan (LU 9) Location: At the transverse crease of the wrist, in the depression on the radial side of the radial artery (Fig. 9). Indications: ⑴ Respiratory system diseases: cough, asthma, and hemoptysis; ⑵ Pain syndromes: pain in the chest, swollen and sore throat, pain of the wrist and arms; ⑶ Acrotism. Method: Puncture perpendicularly cun. 6) Yuji (LU 10) Location: On the radial aspect of the midpoint of the 1st metacarpal bone, on the junction of the red and white skin. (Fig. 9). Indications: ⑴ Respiratory diseases : cough, hemoptysis ; ⑵ Swollen and sore throat, aphasia, fever. Method: Puncture perpendicularly cun. 7) Shaoshang (LU 11) Location: On the radial side of the thumb, about 0.1 cun posterior to the corner of the nail. (Fig. 9). Indications: ⑴ Disorders of the lung: cough, epistaxis; ⑵ Febrile disease: sore throat, fever; ⑶ Mental disorder, loss of consciousness. 148

149 Method: Puncture perpendicularly 0.1 cun, or prick to cause bleeding The Large Intestine Meridian of Hand-Yangming The course of the meridian a. Starting from the tip of the index finger (Shangyang, LI 1) (1)... Running upward along the radial side of the index finger and passing through the interspace of the 1st and 2nd metacarpal bones dipping into the depression between the tendons of m. extensor pollicis longus and brevis (2) lateral anterior of the forearm (3) reaching the lateral side of the elbow (4) lateral anterior aspect of the upper arm (5) to the highest point of the shoulder (6) along the anterior border of the acromion (7) -going up to the 7th cervical vertebra (Dazhui, DU 14) (8) descending to the supraclavicular fossa (Quepen).- b. Descending from supraclavicular fossa and connecting with the lung (9) passing through the diaphragm (10) entering the large intestine, its pertaining organ (11). c. Running upward from supraclavicular fossa (Quepen) to the neck (12) passing through the cheek (13) entering the gum of the lower teeth (14) curving around the upper lip and crossing the opposite meridian at the philtrum, ending at the opposite Yingxiang (LI 20) to link with the Stomach Meridian of Foot-Yangming (15) (Fig. 11) Main disorders of the meridian Abdominal pain, diarrhea, dysentery, constipation; swollen and sore throat, toothache, watery nasal discharge or epistaxis; redness, swelling and pain Indications a. Facial and head diseases; b. Fever; c. Other diseases along the course of the meridian. 1) Shangyang (LI 1) Location: On the radial side of the index finger, about 0.1 cun posterior to the corner of the nail (Fig. 12). Indications: ⑴ Head and facial disorder: deafness, toothache, sore throat, swelling of the submandibular region; ⑵ Febrile disease, loss of consciousness; ⑶ Numbness of fingers. Method: Puncture perpendicularly 0.1 cun, or prick to cause bleeding. 2) Erjian (LI 2) 图 11 手阳明大肠经循行示意图 Fig.6 The Large lntestine Mcridian of Hand-Yangming Location: On the radial side of the index finger, in the depression distal to the 149

150 metacarpophalangeal joint, at the junction of the white and red skin. The point is located with the finger slightly flexed (Fig. 12). 150 Indications: ⑴ Blurring of vision, epistaxis, toothache, sore throat, facial paralysis; ⑵ Febrile diseases. Method: Puncture perpendicularly cun. 3) Sanjian (LI 3) Location: When a loose fist is made, the point is on the radial side of the index finger, in the depression proximal to the head of the 2nd metacarpal bone (Fig. 12). Indications: ⑴ Head and facial disorders: ophthalmalgia, toothache, sore throat; ⑵ Fever; ⑶ Disorders of the digestive system: abdominal fullness, borborygmus. Method: Puncture perpendicularly cun. 4) Hegu (LI 4) Location: Between the 1st and 2nd metacarpal bones, approximately in the middle of the 2nd metacarpal bone on the radial side (Fig. 12). Simple method: Place the transverse crease of the interphalangeal joint of the thumb at the margin of the web between the thumb and the index finger of the other hand. The point is at the tip of the thumb (Fig. 13). Indications: ⑴ Head and facial diseases: headache, redness, swelling and pain of the eye, epistaxis, toothache, deviation of the eye and mouth, deafness, mumps, sore throat; ⑵ Febrile disease with anhidrosis or profuse sweating; ⑶ Digestive disorders: abdominal pain, constipation; ⑷ Gynecological diseases: amenorrhea, delayed labor. Method: Puncture perpendicularly cun. Puncture is forbidden for pregnant women. 5) Yangxi (LI 5) Location: On the radial side of the wrist, when the thumb is tilted upward, it is in the depression between the tendons of m. extensor pollicis longus and brevis (Fig. 12). Indications: ⑴ Head and facial diseases: headache, redness, swelling and pain of the eye, deafness, tinnitus, toothache, sore throat; ⑵ Wrist pain. Method: Puncture perpendicularly cun. 6) Shousanli (LI 10) 图 13 Fig.13 图 12 Fig.12

151 Location: 2 cun below Quchi (LI 11), on the line joining Yangxi (LI 5) and Quchi (LI 11) (Fig. 14). Indications: ⑴ Toothache and cheek pain; ⑵ Numbness of hand and arm; ⑶ Digestive system disease: abdominal pain, diarrhea. Method: Puncture perpendicularly cun. 7) Quchi (LI 11) Location: When the elbow is flexed, the point is in the depression at the lateral end of the transverse cubital crease, midway between Chize (LU 5) and the lateral epicondyle of the humerus (Fig. 14, Fig.15). 图 14 Fig.14 图 15 Fig.15 Indications: ⑴ Head and facial disorders: swollen and pain of the throat, toothache, redness and pain of eye; ⑵ Disorders along the course of the meridian: numbness, pain or motor impairment of the arm and hand; ⑶ Febrile disease, urticaria, scrofula; ⑷ Digestive system diseases: abdominal pain, vomiting, and diarrhea; ⑸ Hypertension, manic-depressive psychosis. Method: Puncture perpendicularly cun. 8) Yingxiang (LI 20) Location: In the nasolabial groove at the level of midpoint of the lateral border of ala nasi (Fig. 16). Indications: ⑴ Head and facial diseases: nasal obstruction, epistaxis, deviation of mouth and eye, itching of face; ⑵ Biliary ascariasis. Method: Puncture perpendicularly cun or obliquely cun, moxibustion is not applicable The Stomach Meridian of Foot-Yangming The course of the meridian a. Starting from the lateral side of ala nasi 图 16 Fig

152 (Yingxiang, LI 20) (1) ascending to the bridge of the nose (2) turning downward along the lateral side of the nose (3) entering the upper gums (4) reemerging, curving around the lips (5) descending to meet the Ren meridian at the mentolabial groove (6) running posterolaterally across the lower portion of the cheek at Daying (ST 7) (7) winding along the angle of the mandible (Jiache, ST 6) (8) ascending in front of the ear and traverse Shangguan (GB 3) (9) following the anterior hairline (10) reaching the forehead (Shenting, DU 24) (11). 152 b. Facial branch meridian: Running downward Renying (ST 9), then going along the throat (12) entering the supraclavicular fossa (13) descending and passing through the diaphragm (14) entering the stomach, its pertaining organ, and connecting with the spleen (15). c. The straight portion of the meridian arising from the supraclavicular fossa, running downward (16)... passing through the nipple, descending by the umbilicus and entering Qichong (ST 30) on the lateral side of the lower abdomen (17). d. The branch from the lower orifice of the stomach (18) descending inside the abdomen and joining the previous portion of the meridian at Qichong (ST 30). Running downward, traversing Biguan (ST 31) (19) further through Futu (ST 32) (20) reaching the knee (21) continuing downward along the anterior border of the lateral aspect of the tibia (22) passing through the dorsum of the foot (23) reaching the lateral side of the tip of the 2nd toe (24). e. The tibial branch emerging from 3 cun below the knee (Zusanli, ST 36) (25) entering the lateral side of the middle toe (26). f. The branch from the dorsum of foot arising from Chongyang (ST 42), terminating at the medial side of the tip of the great toe (Yinbai, SP 1), where linking with the spleen meridian of foot-taiyin (Fig. 17) Main disorders of the meridian Borborygmus, abdominal distention, edema, stomachache, vomiting or polyorexia; mania, swollen and sore throat, epistaxis Indications 图 17 Fig.17 足阳明胃经循行示意图 The Stomach Meridian of Foot-Yangming

153 a. Digestive system diseases; b. Diseases in head, nose, eye or mouth; c. Other diseases along the course of the meridian. 1) Chengqi (ST 1) Location: Between the eyeball and midpoint of the infraorbital ridge (Fig. 18). Indications: Redness, swelling and pain of the eye, lacrimation when attacked by wind, night blindness, twitching of eyelids, facial paralysis. Method: Push eyeball upward with left hand, puncture cun slowly along the infraorbital ride. 18). 2) Sibai (ST 2) Location: Below Chengqi (ST 1), in the depression at the infraorbital foramen (Fig. Indications: Redness and pain of the eye, blurred vision, facial paralysis and pain, twitching of eyelids, headache, dizziness. Method: Puncture perpendicularly or obliquely cun. 3) Dicang (ST 4 ) Location: 0.4 cun lateral to the corner of the mouth (Fig. 19). Indications: Deviation of the mouth., salivation,, twitching of eyelids. Method: Puncture horizontally or obliquely cun. 4) Jiache (ST 6) Location: One fingerbreadth anterior to the lower angle of the mandible where m, masseter attaches at the prominence of the muscle when teeth are clenched. (Fig. 19). Indications: Facial paralysis, toothache, swelling of cheek, mumps, and trismus. Method: Puncture perpendicularly cun or obliquely cun toward Dicang (ST 4). 5) Xiaguan (ST 7 ) Location: In the depression at the lower border of the zygomatic arch, anterior to the condyloid process of the mandible, this point is located with the mouth closed (Fig. 19). Indications: Deafness, tinnitus, otorrhea, facial paralysis, toothache, motor impairment of the jaw. Method: Puncture perpendicularly cun. 6) Touwei (ST 8 ) Location: 0.5 cun above the anterior hairline g at the corner of the forehead (Fig. 19). Indications: Headache, blurring of vision, lacrimation. Method: Puncture horizontally cun. 图 19. Fig. 19 图 18 Fig

154 7) Liangmen (ST 21) Location: 4 can above the umbilicus, 2 can lateral to front-midline (Fig. 20). Indications: Digestive system diseases: gastric pain, vomiting, anorexia, abdominal distention, diarrhea. cun. Method: Puncture perpendicularly ) Tianshu (ST 25) Location: 2 cun lateral to the umbilicus (Fig. 20). Indications: ⑴ Digestive system diseases: abdominal distention, borborygmus, constipa- tion, diarrhea, and -dysentery; ⑵ Gynecolo- gical diseases: irregular menstruation, abdomi- nal mass. Method: Puncture perpendicularly cun. 9) Liangqiu (ST 34) Location: 2 can above the laterosuperior border of the patella, on the line joining the anterior superior iliac spine and lateral border of the patella (Fig. 21). Indications: ⑴ Pain and swelling of the knee, motor impairment of the lower extremities; ⑵ Gastric pain; ⑶ Pain of the breast; ⑷ Hemuresis. Method: Puncture perpendicularly cun. 图 20 Fig 图 21 Fig ) Dubi (ST 35) Location: When the knee is flexed, the point is in the depression below the patella and lateral to the patellar ligament (Fig. 22). Indications: ⑴ Pain of the knee, numbness and motor impairment of the lower extremity ⑵ Beriberi. 图 22 Fig. 22

155 Method: Puncture obliquely can with the needle directed slightly towards the medial side. 11) Zusanli (ST 36) Location: 3 cun below Dubi (ST 35), one fingerbreadth lateral to the anterior border of tibia (Fig. 22). Indications: ⑴ Digestive system diseases: gastric pain, vomiting, belching, abdominal distention, diarrhea, dysentery, constipation, and borborygmus ; ⑵ Motor impairment of the lower extremities; ⑶ Other diseases: edema, mental disorders, beriberi, consumptive diseases. Method: Puncture perpendicularly 1-2 cun. 12) Shangjuxu (ST 37) Location: 3 cun below Zusanli (ST 36) (Fig. 22). Indications: ⑴ Digestive system diseases: borborygmus, abdominal pain, diarrhea, constipation, and appendicitis; ⑵ Motor impairment of the lower extremities; ⑶ Beriberi. Method: Puncture perpendicularly 1-2 cun. 13) Tiaokou (ST 38) Location: 8 cun below Dubi (ST 35), one fingerbreadth from the anterior border of tibia (Fig. 22). Indications: ⑴ Muscular atrophy, motor impairment, pain and paralysis of the leg, shoulder pain; ⑵ Abdominal pain. Method: Puncture perpendicularly cun. 14) Xiajuxu (ST 39) Location: 3 can below Shangjuxu (ST 37) (Fig. 22). Indications: ⑴ Digestive system diseases: lower abdominal pain, diarrhea, and dysentery; ⑵ Paralysis of the lower extremities; ⑶ Mastitis, low back pain referring to testis. Method: Puncture perpendicularly cun. 15) Fenglong (ST 40) Location: 8 can above the external malleolus, 1 cun lateral Tiaokou (ST 38) (Fig. 22). Indications: ⑴ Digestive system diseases: vomiting, constipation; ⑵ Paralysis of lower extremities; ⑶ Headache, dizziness ; ⑷ Cough with prof use sputum, edema, mental disorders, and epilepsy. Method: Puncture perpendicularly cun. 16) Jiexi (ST 41) Location: On the dorsum of foot, at the midpoint the transverse crease of the ankle joint, between the tendons of m. extensor digitorum longus and hallucis (Fig. 23). Indications: ⑴ Digestive system diseases: abdominal distention, constipation; ⑵ Headache; dizziness; ⑶ Pain and paralysis of the lower extremities; ⑷ Mental 155

156 disorders. 156 Method: Puncture perpendicularly cun. 17) Neiting (ST 44) Location: Proximal to the web margin between the 2nd and 3rd toes (Fig. 23). Indications: ⑴ Digestive system disease: gastric pain, regurgitation, abdominal distention, diarrhea, dysentery, constipation; ⑵ Head and facial disorders: toothache, pain and swollen throat, deviation of mouth and eye, epistaxis; ⑶ Febrile disease; ⑷ Pain of the dorsum of foot. Method: Puncture perpendicularly or oblique- ly cun. 18) Lidui (ST 45) Location: On the lateral side of the 2nd toe, about 0.1 cun proximal to the corner of the nail. (Fig. 23). Indications: ⑴ Abdominal distention; ⑵ Head and facial disorders: epistaxis, toothache, pain and swelling of the throat; ⑶ Febrile disease, profuse dreaming, mental disorders. Method: Puncture shallowly. 0.1 cun The Spleen Meridian of Foot-Taiyin The course of the meridian a. Starting from the tip of the great toe (1) running along the medial aspect of the foot at the junction of the red and white skin (2) ascending in front of the medial malleolus (3) up to the leg (4) following the posterior aspect of the tibia (5) crossing and going in front of the liver meridian of Foot-Jueyin (6) passing through the anterior medial aspect of the knee and thigh (7) entering the abdomen (8) relating to the spleen, its pertaining organ, and connecting with the stomach (9) ascending and traversing the diaphragm (10) running along the esophagus (11) reaching the root of the tongue and spreading over its lower surface (12). b. The branch from the stomach goes upward through the diaphragm (13), and flows into the heart to link with the Heart Meridian of Hand-Shaoyin (14) (Fig. 24). 图 23 Fig. 23 图 24 足太阴脾经循行示意图 Fig.24 The Spleen Meridian of Foot-Taiyin

157 Main disorders of the meridian Stomachache, vomit after eating food, abdominal distention, loose stool, jaundice; heavy sensation of the body, stiff tongue, swelling, cold of the medial aspect of the lower extremities Indications a. Digestive system diseases; b. Gynecological diseases and reproductive diseases; c. Other diseases along the course of the meridian. 1) Yinbai (SP 1) Location: On the medial side of the great toe, about 0.1 can posterior to the corner of the nail (Fig. 25). Indications: ⑴ Abdominal distention; ⑵ Bloody stool, hematuria, profuse menstruation, uterine bleeding; ⑶ Mental disorders, dream disturbed sleep, convulsion. Method: Puncture shallowly. 0.1 cun. 2) Sanyinjiao (SP 6 ) Location: 3 cun directly above the tip of the medial malleolus, on the posterior border of the tibia (Fig. 26). Indications: ⑴ Borborygmus, abdominal distention, diarrhea; ⑵ Gynecological diseases: irregular menstruation, leukorrhagia, prolapse of the uterus, sterility, difficult labor. ⑶ Andropathy: seminal emission, impotence, enuresis, hernia; ⑷ Muscular atrophy of lower extremities, beriberi. Method: Puncture perpendicularly cun. 3) Yinlingquan (SP 9 ) Location: On the lower border of the medial condyle of the tibia (Fig. 26). Indications: ⑴ Abdominal distention, diarrhea, jaundice; ⑵ Edema, incontinence of urine or dysuria, knee pain. Method: Puncture perpendicularly cun. 4) Xuehai (SP 10) Location: 2 cun above of mediosuperior border of patella (Fig. 27). Simple method: when the patient's knee is flexed, the practitioner places the right palm to the upper border of the left patella of the patient, the thumb forming an angle of 45 with the other four fingers pointing upward. 图 27 Fig. 27 图 25 Fig. 25 图 26 Fig

158 158 The point is where the tip of the thumb rests. Indications: ⑴ Irregular menstruation, uterine bleeding, amenorrhea ; ⑵ Urticaria, eczema, pain in the medial aspect of the legs. Method: Puncture perpendicularly cun The Heart Meridian of Hand-Shaoyin The course of the meridian a. Originating from the heart, emerging, spreading over the "heart system" (i. e., the vessels connecting the heart with the other zang-fu organs) (1) passing through the diaphragm, and connecting with the small intestine (2). b. The ascending portion of the meridian from the "heart system" (3) running alongside the esophagus (4) connecting with the "eye system" (i. e., the tissues connecting the eyeball) (5). c. The straight portion of the meridian from the "heart system" going upward to the lung (6). Then turning downward and emerging from the axilla (Jiquan, HT 1). From there it proceeds along the posterior border of the medial aspect of the upper arm behind the Lung Meridian of Hand-Taiyin and the Pericardium Meridian of Hand-Jueyin (7) down to the cubital fossa (8) descending along the posteriorborder of the medial aspect of the forearm to the pisiform region proximal to the palm (9) and entering the palm (10). Then following the medial aspect of the little finger to its tip (Shaochong, HT 9) (11) and linking with the Small Intestine Meridian of Hand-Taiyang (Fig. 28). d. Other diseases along the course of this meridian. 1) Jiquan (HT 1) 29). Location: In the center of the axilla, on the medial side of the axillary artery (Fig. Indications: ⑴Pain in the costal and cardiac regions, pain in the shoulder and arms; ⑵ Thirst, dry throat, scrofula. Method: Puncture perpendicularly or obliquely cun, avoid puncture of the artery. 2) Shaohai (HT 3) Location: When the elbow is flexed, the point is at the medial end of the transverse cubital crease, in the depression anterior to the medial epicondyle of the humerus (Fig. 30). Indications: ⑴Cardiac pain, pain and contracture of the arm and elbow, pain in the axilla and hypochondriac region, pain of the head and neck; ⑵ Scrofula. Method: Puncture perpendicularly cun. 3) Tongli (HT 5) Location: 1 can above the transverse crease of the wrist, on the radial side of the tendon of m. flexor carpi ulnaris (Fig. 31).

159 图 28. 手少阴心经循行示意图 Fig.29 The Heart Meridian of Hand-Shaoyin 图 30 Fig.31 图 29 Fig.30 Indications: ⑴Cardiac pain, irritability, palpitation; ⑵ Poor memory, insomnia, mental disorders; ⑶ Cardiac and costal pain. Method: Puncture perpendicularly cun. 4) Shenmen (HT 7 ) Location: On the transverse crease of the wrist, in the articular region between the pisiform bone and the ulna in the depression on the radial side of the tendon of m. flexor carpi ulnaris (Fig. 31). Indications: ⑴Cardiac pain, irritability, palpitation; ⑵ Poor memory, insomnia, mental disorders; ⑶ Cardiac and costal pain. Method: Puncture perpendicularly cun. 5) Shaochong (HT 9) Location: On the radial side of the little finger., about 0. 1 can posterior to the corner of the nail (Fig. 31). 图 31 Fig.31 Indications: ⑴Palpitation, cardiac pain, pain the chest and hypochondrium ; ⑵ Mental disorders, febrile diseases, loss of consciousness; 159

160 Mental disorders, febrile diseases, loss of consciousness; 160 Method: Puncture obliquely 0.1 cun or prick to cause bleeding Main disorders of the meridian Pain in cardiac, costal regions, and the medial aspect of the upper arm; thirst, dry throat, yellow sclera, feverish in palms Indications a. Disease of heart and chest, mental disorders; Indications: ⑴Palpitation, sudden hoarseness of vice, aphasia with stiffness of the tongue; ⑵ Pain in the wrist and arm. Method: Puncture perpendicularly cun The Small Intestine Meridian of Hand-Taiyang The course of The meridian a. The meridian starting from the ulnar side of the tip of the little finger (Shaoze, S1 1) (1) following the ulnar side of the dorsum of hand and reaching the wrist, emerging from the styloid process of the ulna (2) ascending along the posterior of aspect of the forearm, passing between the olecranon of the ulna and the medial epicondyle of the humerus (3) running along the posterior border of the lateral aspect of the upper arm (4) to the shoulder joint (5) circling around the scapular region (6) meeting the Du Meridian on the superior aspect of the shoulder at Dazhui (DU 14) (7) turning downward to the supraclavicular fossa (8) connecting with the heart (9) descending along the esophagus (10) passing through the diaphragm (11) reaching the stomach (12) entering the small Intestine, its pertaining organ (13). b. The branch meridian ascending from supraclavicular fossa (14) going along the neck (15) to the check (16) entering the ear (Tinggong, SI 19) (18). c. The second branch meridian running upward from the check to the infraorbital region and further to the lateral side of the nose (19) reaching the inner canthus (Jingming, BL 1), linking with the urinary Bladder meridian of Foot-Taiyang (20) (Fig. 32) Main disorders of the meridian a. Deafness, yellow sclera, swelling of the cheek, sore throat; b. Lower abdominal pain, low back pain spreading to the testis, pain on posterior line of the lateral aspect of the shoulder and arm. 图 32. 手太阳小肠经循经示意图 Fig.32 The Small Intestine Meridian of Hand-Taiyang

161 Essentials of indication a. Head and facial diseases; b. Febrile diseases, mental disorders; c. Pain along the course of the meridian. 1) Shaoze (SI 1) Location: On the ulnar side of the little finger, 0.1 cun posterior to the corner of the nail (Fig. 33). Indications: ⑴ Head and facial diseases: headache, cloudiness of the cornea, swelling and pain of the throat; ⑵ Insufficiency of lactation, breast pain; ⑶ Febrile diseases, loss of consciousness. Method: Puncture 0.1 can or prick to cause bleeding. 2) Houxi (SI 3) Location: When loose fist is made, the point is proximal to the head of the 5 th metacarpal bone on the ulnar side, at the junction of the red and white skin (Fig. 33). 图 33 Fig. 33 Indications: ⑴Headache, stiff neck, redness of the eyes, swelling and pain of the throat; ⑵ Pain in back and lumbar region, contracture and pain in the elbow and arm; ⑶ Mental diseases, malaria. Method: Puncture perpendicularly cun. 3) Yanglao (SI 6) Location: When the palm faces the chest, the point is in the bony cleft on the radial side of the styloid process of the ulna (Fig. 34). Indications: ⑴Blurred vision; ⑵ Pain in the shoulder, back, elbow and arm. Method: Puncture perpendicularly cun. 4) Xiaohai (SI 8 ) Yanglao (SI 6) 小肠 6 养老 图 34 Fig. 34 Location: In the depression between the olecranon of the ulna and the medial epicondyle of the hurnerus. The point is located with the elbow flexed (Fig. 35). Indications: Elbow and arm pain, epilepsy Method: Puncture perpendicularly cun. 5) Jianzhen (SI 9 ) Location: Posterior and inferior to the shoulder joint. When the arm is adducted, the point is 1 cun above the posterior end of the axillary fold (Fig. 36). Indications: Pain of the shoulder and arm, scrofula, tinnitus. Method: Puncture perpendicularly cun. 161

162 图 35 Fig. 35 图 36 Fig. 36 6) Tianzong (SI 11) Location: In the infrascapular fossa at the junction of the upper and middle third of the distance between the lower border of the scapular spine and the inferior angle of the scapula (Fig. 36). Indications: Pain in the scapular region, asthma mastitis. Method: Puncture perpendicularly or obliquely cun. 7) Quanliao (SI 18) Location: Directly below the outer canthus, in the depression on the lower border of zygoma (Fig. 37). Indications: Facial paralysis, twitching of the eyelids, toothache, yellowish sclera. Method: Puncture perpendicularly cun. 8) Tinggong (SI 19) Location: Between the tragus and the mandibular joint, in a depression that is formed when the mouth is slightly open (Fig. 37). 图 37 Fig. 37 Indications: ⑴Tinnitus, deafness, otorrhea, toothache; ⑵ Mental disorders, epilepsy. Method: Puncture perpendicularly can when the mouth is open The Bladder Meridian of Foot-Taiyang The course of the meridian a. Starting from the inner canthus (Jingming, BL 1) (1) ascending to the forehead (2) joining the Du Meridian at the vertex (Baihui, DU 20) (3). b. A branch meridian arising from the vertex: running to the temple (4). 162

163 c. The straight portion of the meridian: entering and communicating with the brain from the vertex (5) emerging and bifurcating into two lines, descending along the medial aspect of the neck (6) running downward alongside scapula and parallel to the vertebral column (7) reaching the lumbar region (8) entering the body cavity via the paravertebral muscle (9)... connecting with the kidney (10) and joining its pertaining organ g the bladder (11). d. The branch of the lumbar region: descending through the gluteal region (12) and ending in the popliteal fossa (13). e. The branch from the posterior aspect of the neck: running straight downward along the media border of the scapula (14) passing through the gluteal region (Huantiao, GB 30) (15) downward along the posterior aspect of the thigh on the lateral side(16) meeting the preceding branch descending from the lumbar region in the popliteal fossa (17) from there descending to the leg (18) and further to the posterior aspect of the external malleolus (19) running along the tuberosity of the 5th metatarsal bone (20) reaching the lateral side of the tip of the little toe (Zhiyin, BL 67), where it links with the Kidney Meridian of Foot-Shaoyin (Fig. 38) Main disorders of the meridian Dysuria, enuresis, pain of eyes, lacrimation when attacked by wind., nasal obstruction, rhinorrhea, epistaxis, pain along the course of the meridian, manic, depressive psychosis, malaria Indications a. Disorders of this meridian occurring on the head, neck, eyes, back, loin and lower limbs; b. Mental disorders; c. Diseases of relative zang-fu organs. 1) Jingming (BL 1) Location: 0.1 cun superior to the inner canthus (Fig. 39). Indications: Redness, swelling and pain of the eyes, lacrimation when attacked by wind, 图 38 足太阳膀胱经循行示意图 Fig.38 The Bladder Meridian of Foot-Taiyang 图 39 Fig

164 blurring of vision, night blindness, colour blindness. 164 Method: Ask the patient to close the eyes when locating the point. Puncture perpendicularly can along the orbital wall. Don't twist or lift and thrust the needle vigorously. Press the point for a while after withdrawal of the needle. Moxibustion is not applicable. 2) Zanzhu (BL 2) Location: In the depression on the medial end of the eyebrow (Fig. 39). Indications: ⑴ Headache, redness, swelling and pain of the eyes, pain in the supraorbital region; ⑵ Blurring of vision, lacrimation, twitching of eyelids, deviation of the eye and mouth, drooping of the eyelids. Method: Puncture horizontally cun. 3) Tianzhu (BL 10) Location: 0. 5 cun above the posterior hairline, 1.3 can lateral to Yamen (DU 15), in the depression on the lateral side of m. trapezius (Fig. 40). Indications: ⑴Headache, neck rigidity, pain in the shoulder and back; ⑵ Febrile diseases, manic, depressive psychosis and epilepsy. Method: Puncture obliquely or perpendicularly cun. Deep puncture with the needle tip toward the superomedial border is prohibited to prevent from the injury of medulla. 4) Fengmen (BL 12) Location: 1.5 cun lateral to the lower border of the spinous process of the 2nd thoracic vertebra (Fig. 41). Indications: Common cold, cough, fever and headache, neck rigidity g pain in the chest and back. Method: Puncture obliquely cun. 5) Feishu (BL 13) Location: 1.5 cun lateral to the lower border of the spinous process of the 3rd thoracic vertebra (Fig. 41). Indications: ⑴Cough, asthma, nasal obstruction; ⑵ Tidal fever, night sweating, hematemesis ; Method: Puncture obliquely cun. 6) Xinshu (BL 15) Location: 1.5 cun lateral to the lower border of the spinous process of the 5th thoracic vertebra (Fig. 41). Indications: ⑴Heart and chest disorders: cardiac pain, panic, cough, hematemesis; ⑵ Insomnia, forgetfulness, epilepsy; ⑶ Night sweating, seminal emission. 图 40 Fig. 40

165 Method: Puncture obliquely cun. 7) Ganshu (BL 18) Location: 1.5 cun lateral to the lower border of the spinous process of the 9th thoracic vertebra (Fig. 41). Indications: ⑴Diseases of the liver: jaundice, pain in the hypochondriac region; ⑵ Disorders of the eyes: redness of the eyes, blurred vision, night blindness; ⑶ Bleeding syndrome: hematemesis, epistaxis ; ⑷ Mental disorders: manic-depressive psychosis. epilepsy; ⑸ Pain in the back. Method: Puncture obliquely cun. 8) Danshu (BL 19) 图 41 Fig. 41 Location: 1.5 cun lateral to the lower border of the spinous process of the loth thoracic vertebra (Fig. 41). Indications: ⑴Jaundice, bitter taste in the mouth, pain in the chest and hypochondriac region; ⑵ Pulmonary tuberculosis, tidal fever. Method: Puncture obliquely cun. 9) Pishu (BL 20) Location: 1. 5 cun lateral to the lower border of the spinous process of the 1 ith thoracic vertebra. (Fig. 41) Indications: ⑴Abdominal distention, jaundice, vomiting, diarrhea and dysentery; ⑵ Bloody stool, edema; ⑶ Pain in the back. 165

166 166 Method: Puncture obliquely cun. 10) Weishu (BL 21) Location: 1.5 cun lateral to the spinous process of the 12th thoracic vertebra (Fig. 41). Indications: Pain in the chest, hypochondriac and epigastric region, vomiting, abdominal distention, borborygmus. Method: Puncture obliquely cun. 11) Shenshu (BL 23) Location: 1.5 cun lateral to the lower border of the spinous process of the 1st lumbar vertebra (Fig. 41). Indications: ⑴ Disorders of the urinary system: enuresis, edema ; ⑵ Disorders of the reproductive system: irregular menstruation, leukorrhagia, seminal emission, impotence; ⑶ Deafness, tinnitus; ⑷ Lumbago. Method: Puncture perpendicularly cun. 12) Dachangshu (BL 25) Location: 1.5 cun lateral to the lower border of the spinous process of the 4th lumbar vertebra (Fig. 41). Indications: ⑴ Abdominal distention, borborygmus, diarrhea, constipation; ⑵ Lumbago. Method: Puncture perpendicularly cun. 13) Pangguangshu (BL 28) Location: At the level of the 2nd posterior sacral foramen, 1.5 cun lateral to the posterior midline (Fig. 41). Indications: ⑴Dysuria, enuresis; ⑵ Diarrhea, constipation; ⑶ Stiffness and pain of the lower back. Method: Puncture perpendicularly cun. 14) Chengfu (BL 36) Location: In the middle of the transverse gluteal fold (Fig. 42). Indications: ⑴Pain in the lumbar, sacral, gluteal and femoral region; ⑵ Hemorrhoids. Method: Puncture perpendicularly 1-2 cun. 15) Weizhong (BL 40) Location: Midpoint of the transverse crease of the popliteal fossa midway between the tendons of m. biceps femoris and m. semitendinosus (Fig. 42). Indications: ⑴Low back pain, muscular atrophy, motor impairment and pain of the lower limbs; ⑵ Dysuria enuresis; ⑶ Abdominal pain, vomiting and diarrhea. 图 42 Fig. 42 Method: Puncture perpendicularly cun, or prick to cause bleeding.

167 43). 16) Kunlun (BL 60) Location: In the depression between the external malleolus and tendo calcaneus (Fig. Indications: ⑴ Head and facial diseases: headache, neck rigidity, blurring of vision, epistaxis; ⑵ Pain in the lumbosacral region, swelling and pain in the heel; ⑶ Infantile convulsion, epilepsy; d. Difficult labor. Method: Puncture perpendicularly cun. Puncture is contraindicated for pregnant women. 17) Zhiyin (BL 67) Location: On the lateral side of the small toe, about 0.1 cun posterior to the corner of the nail (Fig. 43). Indications: ⑴ Headache, pain of the eyes, nasal obstruction, epistaxis; ⑵ Malposition of fetus, difficult labor. Method: Puncture 0.1 cun The Kidney Meridian of Foot-Shaoyin The course of the meridian a. Starting from the inferior aspect of the small toe and running obliquely towards the sole (Yongquan, KI 1) (1) emerging from the lower aspect of the tuberosity of the navicular bone (2) and running behind the medial malleolus (3) entering the heel (4) then ascending along the medial side of the leg (5) to the medial side of the popliteal fossa (6) and going further upward along the postero-medial aspect of the thigh (7) towards the vertebral column (Changqiang, DU 1), where it enters the kidney, its pertaining organ (8) and connects with the bladder (9). b. The straight portion of the meridian re-emerges from the kidney (10) ascending and passing through the liver and diaphragm (11) wentering the lung (12) running along the throat (13) and terminating at the root of the tongue (14). 图 43 Fig. 43 图 44. 足少阴肾经循行示意图 Fig.44 The Kidney Meridian of Foot-Shaoyin 167

168 c. A branch exits from the lungs, joining the heart, flowing into the chest and linking with the Pericardium meridian of Hand-Jueyin (15) (Fig. 44). and loss of consciousness, insomnia; ⑶ Dysuria and constipation. Method: Puncture perpendicularly cun Main disorders of the meridian Dysuria, enuresis, edema, diarrhea, constipation, irregular, menstruation, seminal emission, impotence, cough, hemoptysis, asthma, sore throat, dry tongue, lumbago, pain in the medial posterior aspect of the legs, weakness and paralysis of foot, feverish sensation in the sole of the foot Indications a. Diseases of the urinary system; b. Diseases of the reproductive system; c. Disorders occurring in the lung and the throat; d. Other diseases of this meridian. 1) Yongquan (KI 1) Location: In the depression appearing on the sole when the foot is in plantar flexion, approximately at the junction of the anterior and middle third of the sole (Fig. 45). Indications: ⑴Head and facial diseases: headache, dizziness, blurring of vision, sore throat and lose of voice; ⑵ Mental disorders: infantile convulsion, manic-depressive psychosis, 2) Taixi (KI 3) Location: In the depression between tip of the medial malleolus and tendo calcaneus (Fig. 46). Indications: ⑴Diseases of the urinary system: frequency of urination; ⑵ Diseases of reproductive system: irregular menstruation; seminal emission, impotence; ⑶ Tinnitus and deafness; ⑷ Pain in the lower back; ⑸ Disorders of the lung and throat hemoptysis, asthma, sore throat; ⑹ Constipation, diabetes, insomnia. Method: Puncture perpendicularly cun. 图 45 Fig. 45 图 46 Fig. 46 3) Zhaohai (KI 6 ) Location: In the depression below the medial malleolus (Fig. 46). Property: One of the eight confluent points, communicating with the Yinqiao Meridian. Indications: ⑴ Irregular menstruation. leukorrhea, prolapse of uterus; ⑵ 168

169 Frequency of urination, retention of urine, constipation; ⑶ Dryness and pain of the throat; ⑷ Insomnia, epilepsy. Method: Puncture perpendicularly cun The Pericardium Meridian of Hand-Jueyin The course of the Meridian a. Originating from the chest, emerging and entering its pertaining organ, the pericardium (1) then, descending through the diaphragm (2) to the abdomen, connecting successively with the upper, middle and lower jiao (i. e., san jiao) (3). b. A branch arising from the chest running inside the chest (4) emerging from the costal region at a point 3 cun below the anterior axillary fold (Tianchi, PC 1) (5) and ascending to the axilla (6) following the medial aspect of the upper arm, running downward between the Lung Meridian of Hand-Taiyin and the Heart Meridian of Hand-Shaoyin (7) to the cubital fossa (8) proceeding downward to the forearm between the tendons of m. palmaris longus and m. flexor carpi radialis (9) ending in the palm(10) from there passing along the middle finger right down to its tip (Zhongchong, PC 9) (11). c. Another branch arising from the palm at Laogong (PC 8) running along the ring finger to its tip (Guanchong, SJ 1) and linking with the Sanjiao Meridian of Hand-Shaoyang (12) (Fig. 47) Main disorders of the meridian Palpitation, cardiac pain g cough, fullness q sensation illness or pain in the chest, gastric pain vomiting, hiccup, manic-depressive psychosis, epilepsy, spasm of the elbow and arm feverish sensation in the palm Indications a. Disorders of the heart, chest, stomach and mental activities; b. Other disorders along this meridian. 1) Tianchi (PC 1) Location: 1 cun lateral to the nipple, in the 4th intercostal space (Fig. 48). Indications: ⑴ Disorders of the heart and chest: cough, asthma, suffocating sensation in the chest, 图 47. 手厥阴心包经循行示意图 Fig.47 The Pericardium Meridian of Hand-Jueyin 图 48 Fig

170 pain in the hypochondriac region, acute mastitis; ⑵ Disorders along the course of this meridian: scrofula, swelling and pain of the axillary region. Method: Puncture obliquely cun, deep puncture is prohibited to avoid injuring of the lung. 2) Jianshi (PC 5) Location: 3 cun above the transverse crease of the wrist, between the tendons of m. palmaris longus and m. flexor carpi radialis (Fig. 49). Indications: ⑴Disorders of the heart : cardiac pain, palpitation; ⑵ Digestive system disorders: gastric pain, vomiting; ⑶Mental disorders: manic depressive psychosis, epilepsy; ⑷ Febrile diseases, malaria. Method: Puncture perpendicularly cun. 3) Neiguan (PC 6) Location: 2 cun above the transverse crease of the wrist, between the tendons of m. palmaris longus and m. flexor carpi radialis (Fig. 49). Indications: ⑴Disorders of the heart and chest: cardiac pain, palpitation, fullness sensation in the chest; ⑵ Digestive system diseases : gastric pain, vomiting; ⑶ Mental disorder: insomnia, dizziness, epilepsy; ⑷ Diseases along the course of this meridian pain of the upper extremities, hemiplegia. Method: Puncture perpendicularly cun. 4) Laogong (PC 8) Location: Between the 2nd and 3rd etacarpal bones. When the fist is made, the point is under the tip of the-middle finer (Fig. 50). Indications: ⑴ Disorder the heart s cardiac pain; ⑵ Digestive system diseases: vomiting; ⑶Mental disorders: manic-depressive psychosis, epilepsy; ⑷ Stomatitis, foul breath. Method: Puncture perpendictlarly cun. 5) Zhongchong (PC 9) Location: In the center of the tip of the middle finger (Fig. 50). Indications: ⑴ Cardiac pain; irritability; ⑵ Heat stroke, loss of consciousness, febrile diseases, infantile convulsion; ⑶ Aphasia with stiffness of the tongue. Method: Puncture obliquely 0.1 cun or prick to cause bleeding The San jiao Meridian of Hand-Shaoyang The course of the meridian 170 图 50 Fig.51 图 49 Fig.49

171 a. It originates from the tip of the ring finger (Guanchong, SJ 1), (1) running upward between the 4th and 5th metacarpal bones (2) along the dorsal aspect of the wrist (3) to the lateral aspect of the forearm between radius and ulna (4) passing upward through the olecranon (5) along the lateral aspect of the upper arm (6) reaches the shoulder region (7) where it goes across and passes behind the Gallbladder Meridian of Foot-Shaoyang (8) reaching forward the supraclavicular fossa (9) spreads in the chest to connect with the pericardium (10) it descends through the diaphragm down to the abdomen, and links with its pertaining organ, the sanjiao (11).b. The branch of the chest originates from, the chest (12) emerges from the supraclavicular fossa (13) it ascends along the neck up (14) to the retrosuricular region, running along the posterior border of the ear. (15) further to the angle of the forehead (16) it turns down ward to the cheek and terminates in the infraorbital region (17).c. The auricular branch arises from the retroauricular region and enters the ear. Then it emerges in front of the ear, crosses the previous branch at the cheek (18) reaches the outer canthus (Sizhukong, SJ 23) to connect with the Gallbladder Meridian of Foot-Shaoyang (19) (Fig. 51) Main disorders of the meridian Tinnitus, deafness, swelling and pain in the throat, swelling and pain in the eyes, swelling of the cheek, pain in the retroauricular region, abdominal distention, ed,erna, enuresis, difficult urination, pain occurring in the region along the course of the meridian Indications a. Diseases of the- head, face and five organs; b. Febrile diseases; c. Other diseases along the course of the meridian. 1) Guanchong (SJ 1) Location: On the ulnar side of the ring finger, 0.1 cun lateral to the corner of the nail (Fig. 52). Indications: ⑴ Disorders of the head and five sense organs: headache, redness of the eyes, deafness, swelling and pain in the throat; ⑵ Febrile diseases and loss of consciousness. Method: Puncture 0.1 cun perpendicularly, or prick to cause bleeding. 图 51. 手少阳三焦经循行示意图 Fig.51 The San jiao Meridian of Hand-Shaoyang 图 52 Fig

172 2) Yangchi (SJ 4) Location: At the transverse crease of the dorsum of the wrist, in he depression on the ulnar side of the tendon of m. extensor digitorum (Fig. 52). Indications: ⑴ Disorders of the head and five sense organs: swelling and pain in the eye, deafness, swelling and pain in the throat; ⑵ Wrist pain; ⑶ Malaria and diabetes. Method: Puncture perpendicularly cun. 3) Waiguan (SJ 5) Location: On the lateral side of the forearm, at the line joining Yangchi (SJ 4) and the tip of the elbow, 2 cun above the transverse crease of the dorsum of the wrist, between the ulna and radius (Fig. 53) Indications: ⑴ Fever, headache, body pain, pain in the upper limbs and hypochondrium; ⑵ Swelling and pain in the eyes, tinnitus, deafness, scrofula. Method: Puncture perpendicularly cun. 4) Zhigou (SJ 6) Location: On the lateral side of the forearm, at the line joining Yangchi (SJ 4) and the tip of the elbow, 3 cun above the transverse crease of the dorsum of the wrist, between the ulna and the radius (Fig. 53) Indications: ⑴ Pain in the hypochondriwm constipation; ⑵ Tinnitus, deafness, sudden aphasia, scrofula, and febrile diseases. 172 Method: Puncture perpendicularly cun 5) Yifeng (SJ 17) Location: Posterior to the ear lobe, in the depression between the mastoid process and the angle of the mandible (Fig. 54). Indications: Tinnitus, deafness:, facial paralysis, trismus, toothache, swelling of the cheek and scrofula. Method: Puncture perpendicularly cun. 6) Ermen (SJ 21) Location: In the depression anterior to the supratragic notch and behind the posterior border of the condyloid process of the maxible, the point is located with the mouth open (Fig. 54). Indications: Deafness, tinnitus, otorrhea, toothache. 图 54 Fig. 54 图 53 Fig. 53 Method: Puncture perpendicularly cun with the mouth the open. 7) Sizhukong (SJ 23) Location :In the depression at the lateral end of the eye brow (Fig. 54). Indications. Headache, swelling and pain in the eye, twitching of the eyelids, toothache, epilepsy and mania. Method: Puncture subcutaneously cun.

173 The Gallbladder Meridian of Foot-Shaoyang The course of the meridian a. Starting from the outer canthus (1) ascending to the corner of forehead (2) curving downward to the retroauricular region (3) running along the side of the neck in front of the Sanjiao Meridian of Hand-Shaoyang to the shoulder (4) turning back, traversing and passing behind the Sanjiao Meridian of Hand-Shaoyang down to the supraclavicular fossa (5). b. The retroauriular branch arising from the retroauricular region (6) entering the ear, then exiting out and passing the preauricular region (7) reaching the posterior aspect of the outer canthus (8). c. The branch arising from the outer csnthus (9) running downward to Daying (ST 5) (10) meeting the Sanjiao Meridian of Hand-Shaoyang in the infraorbital region (11) passing through Jiache (ST 6) (12) descending to the neck and entering the supraclavicular fossa where it meets the main meridian (13) further descending into the chest (14) passing through the diaphragm and connecting with the liver (15) entering its pertaining organ, the gallbladder (16) going along ribs (17) running inside the lower abdomen near the femoral artery at the inguinal region (18) running superficially along the margin of pubic hair (19) going transversely into the hip region (Huantiao, GB 30) (20). d. The straight portion of the meridian running downward from the supraclaular fossa (21) passing in front of the axilla (22) along the lateral aspect of chest (23) passing through the free end of the floating ribs (24) reaching the hip region where it meets the previous branch (25) descending along the lateral aspect of the thigh (26) to the lateral side of the knee (27) proceeding downward along the anterior aspect of the fibula (28) reaching the anterior aspect of the external malleolus (29) following the dorsum of the foot to the lateral side to the tip of the 4th toe (Zuqiaoyin, GB 44) (30). 图 55. 足少阳胆经循行示意图 Fig.55 The Gallbladder Meridian of Foot-Shaoyang e. The branch of the dorsum of the foot diverges from Zulinqi (GB 41) running 173

174 between the 1st and 2nd metatarsal bones to the distal portion of the great toe and terminating at the extremity, where it link with the liver Meridian of Foot-Jueyin (31)(Fig. 55) Main disorders of the meridian Headache, dizziness, bitter taste in the mouth, pain of the outer canthus, swelling and pain of the supraclavicular fossa, and axilla pain in the chest, hypochondrium and lateral side low extremities, burning sensation in the feet, malaria, febrile diseases, mental diseases Indications a. Head and facial diseases; b. Disorders along the course of the meridian; c. Other disorders: malaria, febrile diseases, mental disorders. 1) Tongziliao (GB 1) Location: Lateral to the outer canthus in the depression on the lateral side of the orbit (Fig. 57). Indications: Headache, redness, swelling and pain of the eyes, cloudiness of the cornea, blindness. Method: Puncture cun horizontally. 2) Tinghui (GB 2) Location: Anterior to the intertragic notch at the posterior border of the condyloid process of the mandible, the point is located with the mouth open (Fig. 56). Indications: Tinnitus, deafness, toothache, deviation of the mouth. 图 56 Fig. 56 Method: Open mouth, puncture cun. 3) Wangu (GB 12) Location: In the depression posterior and inferior to the mastoid process (Fig. 57). Indications: ⑴ Headache, pain and stiffness of the neck, swelling of the cheek, toothache, facial paralysis; ⑵ Epilepsy, malaria. Method: Puncture obliquely cun. 4) Yangbai (GB 14) Location: On the forehead, directly above the pupil and 1 cun above the midpoint of he eyebrow (Fig. 57). Indications: Headache, blurring of vision, twitching of the eyelids. 174

175 Method: Puncture horizontally cun. 图 57. Fig. 57 5)Fengchi (GB 20) Location: In the depression between the upper portion of m. sternocleido-mastoideus and m. trapezius (Fig. 58). Indications: ⑴Headache, blurring of vision, red and painful eyes, rhinorrhea, tinnitus, pain and stiffness of the neck. ⑵ Common cold, fever, malaria; ⑶ Wind-stroke, epilepsy, febrile diseases, goiter. Method: Puncture cun obliquely towards the tip of the nose or Fengfu (DU 16) horizontally. 图 58. Fig. 58 图 59. Fig. 59 6) Huantiao (GB 30) Location: At the junction of the middle third and lateral third of distance between the 175

176 great trochanter and the hiatus of the sacrum (Fig. 59) 176 Indications: Muscular atrophy of the lower extremities, low back pain. Method: Puncture perpendicularly 2-3 cun. 7) Yanglingquan (GB 34) Location: In the depression anterior and inferior to the head of the fibula (Fig. 60). Indications: ⑴Hypochondriac pain, bitter taste in the mouth, jaundice, vomiting; ⑵Muscular atrophy of the lower extremities, beriberi; ⑶ Infantile convulsion. Method: Puncture perpendicularly cun. 8) Guangming (GB 37) Location: 5 cun directly above the tip of the external malleolus, on the anterior border of the fibula (Fig. 60). Indications: ⑴ Pain in the eyes, night blindness; ⑵ Muscular atrophy of the lower extremities, breast distention. Method: Puncture perpendicularly cun. 9) Qiuxu (GB 40) Location: Anterior and inferior to the external malleolus, in the depression lateral to the tendon m. peronaeus longus (Fig. 61). Indications: Hypochondriac pain, muscular atrophy of the lower extremities,malaria. Method: Puncture perpendicularly cun. 10) Zulinqi (GB 41) Location: In the depression distal to the junction of the 4th and 5th metatarsal bones, on the lateral side of the tendon of m, extensor digit minimi of foot (Fig. 61). Indications: ⑴Swelling and pain of the eyes, pain of the hypochondriac region, pain and swelling of the dorsum of foot; ⑵ Irregular menstruation, mastitis; ⑶ Incontinence of urine, scrofula, malaria. Method: Puncture perpendicularly cun. 11) Zuqiaoyin (GB 44) Location: On the lateral side of the 4th toe, about 0.1 cun posterior to the corner of the nail (Fig. 61). Indications: ⑴ Headache, swelling and pain of the eyes, deafness; ⑵. Febrile diseases, insomnia, hiccup, irregular menstruation, hypochondriac pain. Method: Puncture shallowly 0.1 cun, or prick to cause bleeding. 图 60 Fig. 60 图 61 Fig. 61

177 The Liver Meridian of Foot-Jueyin The course of the meridian a. The meridian starts from the dorsal hairy region of the great toe (Dadun, LR 1) (1) runs upward along the dorsum of the foot (2) passes through Zhongfeng (LR 4), 1 cun in front of the medial malleolus (3) ascends to an area 8 cun above the medial malleolus, where it runs across and behind the Spleen Meridian of Foot-Taiyin (4) -runs further upward to the medial side of the knee (5) along the medial aspect of the thigh (6) the pubic hairy region (7) curves around the external genitalia (8) goes up to the lower abdomen (9) curves round the stomach enter the liver, its pertaining organ, and connect with the gallbladder (10) passes through the diaphragm (11) branches out in the costal and hypochondriac region (12) ascends along the posterior aspect of the throat (13) the nasopharynx (14) connects with the "eye system" (15) emerges from the forehead (16) meets the Du Meridian at the vertex (17). b. A branch arises from the "eye system" runs downward into the cheek (18) curves around the inner surface of the lips (19). c. Another branch arises from the Liver (20) passes through the diaphragm (21) flows into the lung and links with the Lung Meridian of Hand-Taiyin (22)(Fig. 62) Main disorders of the meridian Lower back pain, fullness of the chest, hiccup, enuresis, dysuria, hernia, swelling of the lower abdomen Indications (1) Disorders of the reproductive and urinary system: irregular menstruation, amenorrhea, dysmenorrhea, uterine bleeding, seminal emission, impotence, enuresis, retention of urine, hernia, etc. (2) Disorders of the digestive system: vomiting, hiccup, diarrhea, etc. (3)Disorders along the regions along the course of this meridian: pain,numbness and motor impairment along the course of the meridian at the lower extremities. etc. 图 62. 足厥阴肝经循行示意图 Fig.62 The Liver Meridian of Foot-Jueyin (4) Hypertension, stroke, infantile convulsion, epilepsy, swelling and pain of the eye, 177

178 1) Taichong (LR 3) Location: On the dorsum of the foot, in the depression distal to the junction of the 1st and 2nd metatarsal bones (Fig. 63). Indications: ⑴ Headache, dizziness, redness, swelling and pain of the eye, sore throat; ⑵ Irregular menstruation, retention of urine, enuresis, hernia; ⑶ Epilepsy, infantile convulsion, insomnia, mental disorders; ⑷ Fullness in the hypochondriac region, pain in the dorsum of foot, muscular atrophy, numbness, pain and flaccidity of the lower extremities. Method: Puncture perpendicularly cun. 2) Ququan (LR 8) Location: When the knee is flexed, the point is above the medial end of the transverse popliteal crease (Fig. 64). Indications: ⑴ Irregular menstruation, dysmenorrhea, prolapse of uterus, dysuria, seminal emission, pruritus vulvae; ⑵ Pain in the knee. Method: Puncture perpendicularly cun. 图 63. Fig The Extraordinary Meridian 图 64. Fig The Ren Meridian The course of the meridian It originates in the lower abdomen, and emerges downward from the perineum (1) runs upward to the pubic region (2) and ascends along the anterior midline (3) to the throat (4) then circulates upward around the lips (5) passes through the face (6) and enters infraorbital region (Chengqi, ST 1) (7) (Fig. 65) Main disorders of the meridian Leukorrhea, hernia, mass in the abdomen Indications a. Local diseases of the abdomen, chest, neck, head and face; b. The diseases of the corresponding internal organs; c. Mental illness; d. A number of acupoints on the meridian have a tonification effect. 178

179 图 65. 任脉循行示意图 Fig.66 The Ren Meridian 图 66. Fig. 66 1) Guanyuan (RN 4) Location: On the midline of the abdomen, 3 can directly below the umbilicus (Fig. 66). Indications: ⑴Disorders of the reproductive system: emission, impotence, irregular menstruation, leukorrhagia, sterility; ⑵ Disorders of the urinary system: nocturnal enuresis, dysuria; ⑶Disorders of the digestive system and local: diarrhea, abdominal pain; ⑷ Tonification effect. Method: Puncture perpendicularly 1-2 cun. 2) Qihai (RN 6) Location: On the midline of the abdomen, 1.5 can directly below the umbilicus (Fig. 66). Indications: ⑴ Disorders of the digestive system: abdominal pain, diarrhea, constipation, hernia, prolapse of rectum; ⑵ Disorders of the reproductive system: prolapse of uterus, irregular menstruation, amenorrhea and seminal emission: ⑶ Disorders of the urinary system: enuresis; ⑷ Collapse; ⑸ Tonif ication effect. Method: Puncture perpendicularly 1-2 cun. 3) Shenque (RN 8) Location: In the centre of the umbilicus (Fig. 66). Indications: Abdominal pain, diarrhea, prolapse of uterus, edema and collapse. Method: Puncture is usually not used. Moxibustion is suitable. 4) Zhongwan (RN 12) Location: On the epigastrium, at the anterior midline, 4 cun directly above the center of the umbilicus (Fig. 66). Indications: Stomachache, vomiting, abdominal distention, diarrhea, jaundice. 179

180 180 Method: Puncture perpendicularly cun. 5) Tanzhong (RN 17) Location: On the anterior midline of the chest, at midpoint of the line joining two nipples, level with the 4th intercostal space (Fig. 66). Indications: Cough, asthma, chest pain, palpitation, lactation insufficiency. Method: Puncture subcutaneously cun. 6) Tiantu (RN 22) Location: At the base of the neck, on the anterior midline, at the centre of the suprasternal fossa (Fig.67). Indications: Cough, asthma, chest pain, swelling and pain of the throat, goiter, globus hystericus. Method: Firstly puncture 0.2 cun perpendicularly, then puncture downward cun close to the posterior aspect of the sternum. 7) Chengjiang (RN 24) Location: In the depression of the middle of the mentolabial groove (Fig. 67). Indications: Deviation of the mouth, gingivitis, salivation, mental disorders. Method: Puncture obliquely cun The Du Meridian The course of the meridian It originates in the interior of the lower abdomen. Descending, it emerges at the perineum (1) it ascends posteriorly along the interior of the spinal column (2) and runs upward to Fengfu (DU 16) at the nape, where it enters the brain (3) it further runs upward to the vertex (4) and proceeds along the forehead to the bridge of the nose (5) (Fig. 68) Main disorders of the meridian Stiffness and pain in the spinal column, opisthotonos, etc Indications a. Mental diseases; b. Febrile diseases; c. Local diseases in the lumbosacral region, back, head and nape; d. Diseases of the corresponding internal organs. 图 67. Fig.67 图 68. 督脉循行示意图 Fig.68 The Du Meridian

181 1) Mingmen (DU 4) Location: On the lumbar region, at the posterior midline, in the depression below the spinous process of the 2nd lumbar vertebra (Fig.69). Indications: ⑴ Reproductive system disorders: Impotence, emission, leukorrhea, irregular menstruation; ⑵ Stiffness and pain along the spinal column. Method: Puncture perpendicularly cun. 2) Dazhui (DU 14) Location: At the posterior midline, in the depression below the spinous process of the 7th cervical vertebra (Fig.69). Indications: Febrile diseases, headache, stiffness of the neck, cough, asthma, tidal fever, night sweat, epilepsy, malaria. Method: Puncture obliquely cun. 3) Baihui (DU 20) Location: At the vertex, 5 cun directly above the median of the anterior hairline, or the midpoint of the line joining two auricular apexes (Fig. 70). Simple location: Crossing point of the anterior midline meridians and the line connecting two ear apex. Indications: Headache, vertigo, aphasia from apoplexy, epilepsy and mania, prolapse of the uterus and insomnia. Method: Puncture subcutaneously cun. 4) Shangxing (DU 23) Location: At the head, 1 can directly above the midpoint of the anterior hairline (Fig. 70). 图 69 Fig.69 图 70. Fig.70 Indications: Headache, pain in the eye, rhinorrhea with turbid discharge, epistaxis, epilepsy and mania, febrile diseases. Method: Puncture subcutaneously cun. 5) Suliao (DU 25) Location: On the tip of the nose (Fig. 70). Indications: Rhinorrhea with turbid discharge, coma, convulsion, asthma. 181