The Dark Warrior Guide to Chinese Medicine

玄武中医指南

Volume II

Basic Concepts of Pathology

John E. Pirog

The Dark Warrior Guide to Chinese Medicine

Volume II Basic Concepts of Pathology

Preface to Volume II

This second volume of Dark Warrior continues where the first left off. Having learned how the body behaves when it functions normally, we will now explore what happens when it is ill. You will soon find that the arrangement of subject matter in this volume is quite different from that of standard Chinese medical texts. Decades of teaching experience has shown me that Chinese medicine is easier to learn if it is sequenced as it is here. You will get the most out of Dark Warrior, therefore, if you read it like a novel, from start to finish, without skipping chapters or jumping ahead. Each new idea is explained when it is first introduced, and later chapters build on ideas previously covered.

But while my pedagogy is designed for Western learning styles, I have taken pains to ensure that the ideas in Dark Warrior are representative of Chinese medicine as it is taught in China. I have used the vocabulary developed by Wiseman and his collaborators to establish a clear pedigree between translated technical terms and their Chinese- language originals. To make translatability even clearer, I have included the character whenever an important technical term is introduced. In a very few instances I have changed the Wiseman translation; these exceptions can be found in the appendix in the back of the book. If a deeper understanding of Chinese terminology is desired, I strongly urge the reader to obtain a copy of Wiseman’s Practical Dictionary of Chinese Medicine, 3rd edition (Paradigm 2010). The Practical Dictionary is also available as an iPhone or Android app from Pleco Software.

Table of Contents

14. Introduction to Chinese Medical Pathology …………………….…… 5 15. The Causes of Disease……………………………………..….………………. 9 16. The External Causes of Disease………………………….…..……………. 12 17. The Seven Affects….…………………………………………….……………… 20 18. The Neutral Causes of Disease ……………………………………………. 32 19. Introduction to the Eight Principles…………………….………..…….. 35 20. Introduction to Pulse Examination …………………………….……….. 43 21. Introduction to Tongue Examination …………………………….……. 53 22. Basic Deficiencies ………………………………………………….…….…….. 63 23. The Six Environmental Excesses in Detail……………………….…… 71 24. Bì Patterns ………………………………………………………………………... 96 25. Desertion Patterns ……………………………………………………………… 100 26. Qi Stagnation and Blood Stasis ………………………………………….. 103 27. Phlegm……………………………………………………………………………… 108 Appendix: List of Changed Translations of Wiseman Terms ……… 104

Chapter 14 Introduction to Chinese Medical Pathology

Disease vs. Pattern meaning within Chinese medical theory. Rather than being separate from the In modern Western medicine, the physician symptoms, the pattern is existentially examines his or her patient with the goal of dependent on them. Pattern “a” is the sum of establishing the presence of a specific symptoms “x” plus “y” plus “z.” In Chinese disease. Once recognized, this disease is the medicine, it is this disease pattern which acts key to finding a remedy, since it is the cause as the proper target of therapy. of—and yet separate from—the symptoms that have brought the patient to the clinic: Disease “a” causes symptoms “x,” “y” and “z.”

Let us take, for example, the disease known as streptococcal pharyngitis or “strep throat.” A patient presenting with sore throat, fever, headache, and malaise would likely have a throat culture taken and a positive presence of Streptococcus pyogenes would confirm strep throat. The important Figure 14.1 factor here is that the sore throat, fever and malaise do not constitute the disease but are The process known as pattern symptoms of the disease: The actual disease differentiation (辨证)—the Chinese medical entity is S. pyogenes infection and it is this infection that is the proper target of counterpart of Western diagnosis—is rather treatment (see Figure 14.1). like putting together a jigsaw puzzle or distinguishing a constellation in a starry sky. In Chinese medicine the physician It is a mental exercise that requires thorough examines his patient with the goal of memorization of the symptoms that form each pattern and the ability to perceive them discerning something called a “pattern” (症) in the data uncovered by traditional or “disease pattern;” (病证). Not quite the examination techniques. same as a disease, a pattern is a constellation of symptoms that come together to form a clinical picture that has

In modern Chinese clinical practice there by the demands of its own treatment model are about 100-200 commonly used patterns and each makes sense within that model. and each is connected with specific Identifying a causal microorganism is categories of herbs, herb formulas, and necessary if one were to treat with acupuncture points. Once the pattern is antibiotics; identifying a traditional Chinese known the treatment is expected to follow medical pattern is necessary if one were to naturally in a process known as “basing treat with herbs and acupuncture. treatment on patterns” (辨证论治). In modern China, Western and traditional Since it is the total symptom picture that Chinese diagnoses typically exist side by identifies the pattern, it is usually necessary side in the patient’s chart and the treatment to look for details that might not matter in a often involves both Western and traditional Western diagnosis. Let us take, for example, Chinese medicine. But if this integrative our strep throat patient exhibiting the usual approach is to do justice to the demands of signs of sore throat, headache, fever, and both systems, all practitioners must malaise. A Chinese medical practitioner understand that any one Western disease might note that the fever occurs together state could manifest as many different with a slight chilly sensation; that the patient patterns and any one pattern could be is sweating; that the tongue body is red with present in a host of different diseases. a yellow coat and that the pulse is floating (浮) and fast. All these signs point to a Let us again take streptococcal pharyngitis pattern referred to as “wind-heat” (风热) as an example. Depending on the total symptom picture, a number of different (see Figure 14.2) patterns could be present themselves. If a

patient has pus at the back of the throat, a pattern of “toxic heat” (热毒) is present; if scarlet fever develops, it indicates heat in the yíng aspect (营分热). If a patient presents with a sore throat and fever but no chilly sensations it suggests exuberant lung- stomach heat (肺胃热盛). If there is cough with thick yellow phlegm it indicates phlegm heat (痰热). If the sore throat is chronic and there is night sweat and recurring fever in the late afternoon it Figure 14.2 肺阴虚 indicates lung yin deficiency ( ) (see These two formal “diagnoses,” Figure 14.3). streptococcal pharyngitis and wind-heat, are not necessarily at odds with each other. Each Even if all patients with the above is a pathological statement made necessary presentations were to test positive for S. 6 pyogenes, the Chinese medical treatment (不孕) and nasal congestion (鼻塞). Any would be different for each one. Most one of these conditions could be caused by traditional practitioners would argue that a several distinct disease entities within the treatment that does not match the disease biomedical model. Likewise, each could be pattern is not likely to be effective and could associated with several different Chinese in fact cause harm. medical patterns. In either case, whether the disease state is defined traditionally or biomedically, treatment must always be based on the pattern.

Figure 14.3

But we can take this idea one step further: Any given pattern could be present in many Figure 14.4 different biomedically-defined diseases. In addition to streptococcal pharyngitis, the The Process of Examination symptoms that distinguish wind-heat could be present in a wide range of infectious One of the hallmarks of traditional Chinese illnesses such as cytomegalovirus, Epstein- medicine is its nearly exclusive reliance on Barr virus, rhinovirus and haemophilus diagnostic evidence that can be gleaned influenzae, to name a few (see Figure 14.4). from the physician’s five senses. There were This dissociation between disease and no thermometers, sphygmomanometers, pattern is summarized in the aphorism, “One weight scales, lab tests or x-ray images pattern, many diseases; one disease, many available to the pre-modern Chinese patterns.” physician. Disease-pattern differentiation depended entirely on the unaided It should be pointed out that the above examination of the patient in a process that principles apply even when the disease in came to be referred to as the four question is not a strictly defined biomedical examinations ( 四诊). These consisted of entity. In traditional contexts the word visual inspection (望诊), listening/smelling 病疾 “disease” ( or ) often refers to (闻诊), inquiry (问诊) and palpation (切诊). symptomatically-defined disorders such as The four examinations continue to be the dysentery (痢疾), jaundice (黄疸), infertility

7 primary basis for Chinese pattern symptomatic phenomena used to establish differentiation today. the pattern.

The four-examination process usually The examination ends with palpation, i.e., begins with visual inspection, where the the use of the hands or fingers to probe physician takes note of the patient’s overall specific diagnostic regions of the patient’s physical appearance, posture and movement; body. While palpatory signs can be found on as well as their “spirit” (神)—their speech, the chest, abdomen and extremities, in eye contact and overall self-expression. standard practice palpation is usually Visual inspection might include, where restricted to pulse examination. This final appropriate, an examination of the skin, hair, assessment is one of the skills for which eyes, mouth and throat. One of the most Chinese medicine has become famous. We important components of visual examination will study pulse and tongue examination is examination of the tongue (舌诊) which separately in Chapters 20 and 21. usually takes place toward the end of the examination.

While visually inspecting the patient, the physician is also performing the listening/smelling examination. The character 闻 wén can mean either “listening” or “smelling” depending on the context, and both are implied here. By listening the physician takes note of any abnormal respiratory sounds such as wheezing or shortness of breath, and any abnormality in the patient’s voice such as hoarseness. By “smelling” he or she takes note of any unusual odors. In former times, this examination included inspection of the stool and urine.

The physician then conducts the inquiry examination, a verbal interview that consists of questions taken from a formal list of symptomatic topics referred to as the “ten questions” ( 十问). In modern Chinese medical praxis, the verbal interview is often the longest part of the examination and typically uncovers the bulk of the

Chapter 15 The Causes of Disease

Righteousness and Robber Winds medical texts. And so we have one of the oldest and most frequently quoted aphorisms As we have just seen, Chinese medicine is in Chinese medicine: “Wind is the mother of based on clinical presentations; patterns a hundred diseases.” rather than diseases. Each medical pattern is defined by a standard constellation of But while the robber winds were seen as symptoms and all symptoms are the immediate cause of illness, the influence recognizable by unaided examination. of Confucianism was responsible for the belief that it was the patient’s lack of But while a pattern defines an illness righteousness that allowed the assailants to clinically and is the basis for prescribing gain entry. “Righteousness” ( 正 ) in this therapy, a pattern is not the cause of the context meant a peaceful and self- illness, only its manifestation. While pattern disciplined life. The human body could be identification alone might suffice if all one likened to a fortified city whose resistance to wants is treatment, a complete system of invasion was dependent upon the “right qi” medicine requires more than just treatment: (正气) of its inhabitants. It requires prevention. And if illness is to be prevented its cause must be understood. Chapter 1 of the Nei Jing Su Wen explains this concept as follows: In Chapter 2, we learned that Chinese medical pathology grew out of the ancient The people of high antiquity, those who knew shamanistic belief that disease was the result the Way, they modeled [their behavior] on yin of ghost-like entities (鬼邪) invading the and yang and they complied with the arts and body. By the time the Nei Jing was written, the calculations (術數). [Their] eating and the belief in such eldritch phenomena had drinking was moderate. [Their] rising and largely been set aside. resting had regularity. They did not tax [themselves] with meaningless work. Hence, they were able to keep physical appearance In the new understanding, it was the and spirit together and to exhaust the years tangible elements of nature that invaded the [allotted by] heaven. Their life span exceeded body to cause disease, not evil spirits. These one hundred years before they departed. disease-causing forces were generically The fact that people of today are different is referred to in the Nei Jing as “robber winds” because they take wine as an [ordinary] (贼风) 1. The term “robber” 贼 came to be beverage, and they adopt absurd [behavior] as replaced with “evil” 邪 in later Chinese regular [behavior]. They are drunk when they enter the [women’s] chambers. Through their

1 See, for example, Su Wen Chapter 13. 9

lust they exhaust their essence, through their ( 六淫): Wind, cold, damp, heat, 2 wastefulness they dissipate their true [qi]. summerheat, and dryness. A nearly identical list of environmental disease causes can be The above passage and others like it place found in Chapter 74 of the Su Wen, which the responsibility for wellness almost refers to them as the six qi (六气): entirely in the hands of the patient. Illness is caused by craving and discontentment that Now, as for the emergence of the one hundred gives rise to immoderate and dissolute illnesses, they all emerge from wind, cold, behavior. The sage who practices summerheat, dampness, dryness, and fire, because moderation and lives life according to the of the transformations and changes of these [six 3 “arts and calculations” (術數; i.e., astrology qi]. and other prognostic arts) has no need to Although the Su Wen was first to mention fear the robber winds. environmental evils as a cause of illness, it

was Chén Wú Zé and later authors who The Three Causes of Chén Wú Zé turned this idea into the comprehensive

system of pathology that is used in Chinese It was not until the Song Dynasty that a medicine today. more systematic—and less pedantic—theory of etiology appeared in the Chinese medical External Causes Internal Causes Neutral Causes literature. In 1174 Chén Wú Zé wrote A 外因内因不内外因 Unified Treatise on Diseases, Patterns, and Wind Anger Irregular Diet Remedies According to the Three Causes 风怒饮食失调 Cold Joy Sexual Intemperance ( 三因极一病症方论 ). Chén Wú Zé 寒喜房劳过渡 classified pathogenic phenomena into three Damp Preoccupation Taxation Fatigue sets of causes (三因): The external causes 湿思劳倦 Fire (Heat) Sorrow External Trauma (外因), the internal causes (内因) and the 火悲跌打 neutral causes (不内外因; literally, “neither Summerheat Fear Parasites internal nor external causes”) (see Table 署恐虫 15.1). This three-cause system continues to Dryness Fright Animal & Insect Bites 燥惊虫兽伤 be the basis for disease etiology in modern Anxiety

Chinese medical theory. 忧 Table 15.1 In Chén Wú Zé’s scheme the external The Three Causes causes are meteorological in nature and consist of the six environmental excesses The internal causes consist of the seven affects (七情): Anger, joy, preoccupation, 2 Nei Jing Su Wen Chapter 1, “Discourse on the True [Qi Endowed by] Heaven in High Antiquity.” Unschuld P, transl. Huang Di Nei Jing Su Wen: An 3 Note that the Su Wen uses the term “fire” instead of Annotated Translation of Huang Di’s Inner Classic – “heat,” as do most modern texts. As causes of Basic Questions. Berkley, Los Angeles, CA: disease, the two terms should be considered University of California Press; 2011, p. 30-2 synonymous. 10 sorrow, fear, fright, and anxiety. Note that this list includes the five emotions (五志; Modern Terminology Wiseman: “five minds”) associated with the five zàng-organs (see Chapter 4 Table 2), While not abandoning the traditional three- with the addition of fright and anxiety. cause system, modern Chinese medical texts will often abbreviate it by classifying The neutral causes include harmful disease into two broad categories: Externally personal behavior such as irregular diet, contracted disease ( 外感病 ) and internal sexual intemperance and taxation fatigue, as damage and miscellaneous disease (内伤杂 well as various vicissitudes of life such as 病). Externally contracted disease includes external trauma, parasites and animal bites. all disease caused by the six environmental excesses as well as “pestilential qi” (疠气), a Taken collectively, the three causes term roughly equivalent to epidemic illness. summarize both the natural and man-made Internal damage and miscellaneous disease sources of disease and provide a basis for includes all disease presumed to be caused both prevention and treatment. Thanks to the by the seven affects, diet and taxation three causes, the Nei Jing’s moralistic fatigue. It is externally contracted disease demands for abstemious behavior could be which occupies the bulk of Chinese medical supplemented with simple practical advice study. such as avoiding exposure to the elements and eating properly cooked foods. Perhaps more importantly, the three-cause system was the beginning of a more elaborate understanding of how disease develops as a response to external events.

Chapter 16 The External Causes of Disease:

Under the Weather point for a theory of pathogenesis. After all, did not certain diseases occur more In Volume One of this text we learned that frequently in certain types of weather? If hot many concepts in Chinese medicine cannot weather could make the body hot and cold be taken literally. We used metaphorical weather could make it cold, would not the reasoning when we compared the functions wind make it shiver and shake and humidity of the zàng-organs to their modern make it wet and heavy? biomedical counterparts. The Chinese medical “heart,” for example, was not really We learned in Chapter 1 that one of the the heart and the “liver” was not really the definitions of the word “qi” is weather. That liver. being the case, it is not much of a leap to equate evil qi (邪气) with evil weather, and So now we must ask the question: Can bad then to imagine each form of weather— weather literally cause illness? Certainly wind, cold, summerheat, dampness, extremes of heat and cold can injure the dryness—having its own distinct disease body, but when the Nei Jing makes character. If these various forms of statements such as “wind is the mother of a meteorological “qi” were to impose their hundred diseases” it is clearly intending will on a vulnerable host, they might force something far less prosaic. the individual to become in some way like themselves. Even in the modern world, we In modern biomedicine the external talk about “catching cold” or being “under environment induces disease mainly through the weather.” the transmission of pathogenic microorganisms. The streptococcus infection The six environmental excesses seemed to we discussed in Chapter 14 is an example of be a good compromise between folklore and just such a transmission. While one could formal professional medicine. They can be argue that inclement weather might make made to loosely correlate with the five the contagion more likely, the infection phases, thus fitting comfortably into the would not be possible without the presence standard associations of classical Chinese of S. pyogenes and this microbe comes from medical theory (see Table 16.1). people, not wind. Much later in the history of Chinese But in an earlier world that had no concept medicine—during the Ming Dynasty—it of cells and no understanding of microbes, became apparent that at least some illnesses the weather seemed to be a useful starting were in fact transmitted from person to

12 person. In his treatise On Epedimic Warmth, patterns, and when the pattern indicates Wú Yòu Kē posited that such illnesses were invasion of an external evil, the indicative caused by “a peculiar disease-causing symptoms are metaphors for the nature of substance of the natural world” called the evil. Wind, for example, produces pestilential qi ( 疠气). 4 This “substance” shaking and shivering, dampness produces a could come from “heaven”—i.e. from sensation of heaviness, dryness a dry cough nature—or from contact with sick people. and so on. As a new cause of disease, pestilential qi was a significant departure from the In other words, the six environmental traditional meteorological theories and excesses are eponymous with the pattern paved the way for Chinese acceptance of that they produce, and because of this they modern germ theory. are nearly indispensable in the pattern identification process. Identifying an illness Correlation Between the Five Phases and as being caused—all be it putatively—by the Six Environmental Excesses wind, damp or dryness evil is nearly Phase Environmental synonymous with saying that there is a Association Excess wind, damp or dryness pattern. Wood Wind Fire (Sovereign) Fire So while wind, dryness or dampness might not be the literal cause of an illness, they Fire (Minister) Summerheat nevertheless supply a tangible metaphor Earth Damp when identifying its symptoms. This metaphor is further extended to the selection Metal Dry of treatment. A pattern of external wind will Water Cold need to be treated with acrid herbs that have Table 16.1 wind-dispelling properties; dampness will be treated with bitter herbs that drain and dry The principles of biomedicine are now a and dryness will be treated with sweet herbs standard component of the modern Chinese that have a moistening effect. So while a medical curriculum and Western theories of strep throat patient may well have contracted infectious disease are accepted by virtually the infection from bacteria spread by all everyone. But even when an infectious aerosolized sputum, the herbs will have to agent is known to be the cause of an illness, be selected according to the implied a traditional practitioner will almost always presence of evil wind, heat, or dryness and revert to the six environmental excesses if the herbs prescribed accordingly. the selected treatment is in the form of Chinese medicine. Why? Because—as we We will have much more to say about the have learned—Chinese medicine is based on six environmental excess in future chapters. For now, let us confine ourselves to learning

4 Wen JM, Seifert G. Warm Disease Theory. about their personalities. Brookline, MA: Paradigm Publications; 2000, p. 12 13

hallmarks of wind invasion and coincide Wind with the early presentation in a broad range of acute infectious illnesses. Swift, sudden, and powerful, wind is the most invasive of the six environmental excesses. Like the vanguard of an attacking army, it easily penetrates the body’s surface, creating an opening for other evils and setting the stage for deeper and more threatening disease development. Since it frequently serves as the starting point for a new illness, wind is called “the mother of a hundred diseases.”

Illnesses caused by wind will develop as Figure 16.1 suddenly as an afternoon thunderstorm, Characteristics of Wind dragging a robust patient from health to sickbed in a matter of hours. And while Wind can sweep through the channels and anyone can be stricken by wind, those with cause pain that wanders from joint to joint or weakened defense qi are the most it can cause rashes that spread like a prairie vulnerable. fire across the surface of the body. And while wind develops rapidly, if it is resolved Just as storms wreak their worst havoc to while still on the surface, it might leave as the tiles of a roof, wind will focus its attack quickly as it came. And so the aphorism, on the upper and outer body, i.e., on the “Wind is adept at movement and many face, head, upper limbs and skin—as well as changes.” the lung, due to this organ’s superficial location and easy access through the nose Cold and throat (see Chapter 9). The body’s defense qi ( 卫气) will try to dispel the It is important to remember that in ancient invader by pushing aggressively toward the China there was no such thing as a surface and this will in turn cause the pulse thermometer. People understood cold by to “float” (浮脉)—one of the confirming direct perception and they measured its signs of external wind (see Figure 16.1). degree by the amount of cold they felt. So let us imagine for a moment what cold does Wind in nature causes the limbs of the to the body. trees to shake; in the body it causes trembling and chills, which, together with To start off, it makes one feel cold; and if fever—caused by the mobilization of the cold evil has invaded the body this sensation body’s defensive qi—constitute the is pronounced even in a warm environment.

Pathological cold can take the form of a water: The cold inhibits the body’s yang qi, chilly sensation (畏寒 Wiseman: “fear of which under normal circumstances would cold”) or cold limbs; there is a desire to “cook down” the fluids. As a result, the cover oneself and raise the room secretions and excretions increase in volume temperature. and become more watery. This pathological sign is summarized by the statement “All We know from experience that severe cold diseases with water humors that are clear, is downright painful; in analgesia pure, and cold are ascribed to cold.” experiments ice baths are often used to induce pain. This property of cold is Dampness recognized in the aphorism, “When cold prevails, there is pain.” This uncomfortable We are all familiar with that tired, muggy symptom of cold evil is due to its sensation that seems to accompany hot obstructive effects on the movement of qi humid weather, where the body feels like a and blood. Since cold causes syrup to wet rag. And if you are unfortunate enough thicken and rivers to freeze, it was imagined to suffer from weather-sensitive arthritis, to have a similar “congealing” (凝) effect on you know that you can predict rain by the qi and blood, both of which require fluidity pain in your joints. to circulate freely. The resulting qi stagnation and blood stasis will result in These perceptions, which appear in painful bodily sensations. medical folklore throughout the world, are built into the Chinese medical understanding The sensation of cold is often accompanied of dampness evil. It is taken as a given by by a feeling of contracture and tension (收 both the traditional Chinese physician and his patient that living near stagnant water, 引). The skin tightens, goosebumps form, sitting or lying in wet places or prolonged the pores close and the muscles stiffen. exposure to atmospheric humidity will Invasion of cold evil is therefore associated actually cause disease. We need not dwell with tight painful sinews; lack of sweat (due on the veracity of such beliefs; we have to the tightening of pores); a tight pulse (紧 already chosen to interpret the 脉) and a tendency to move the body slowly environmental excesses as metaphors rather and stiffly. than factual reality.

A final sign of cold evil is the production But it is through such metaphors that the of copious secretions and excretions that are symptoms of dampness make intuitive thin and clear. Symptoms such as runny sense. If a towel feels heavy when wet, then nose with clear mucus, coughing of clear a human body that feels subjectively heavy phlegm, evacuation of watery diarrhea or or “cumbersome” (困) must be somehow long voidings of clear urine point to the wet as well, even if this moisture can’t be presence of cold in the body. It is as if one seen or measured. And so we find that were trying to make soup or tea with cold

15 fatigued and cumbersome limbs are one of Fire the basic signs of dampness. We learned in our study of yin and yang And just as the wet towel takes forever to that the principle of fire is fundamental to air-dry—especially in humid weather—so the maintenance of life. That is particularly dampness in the body will “linger” (留恋) true for human life, since humans depend on and resist elimination. A good example of fire to cook food and remain warm in cold this lingering quality is a condition known environments. In our study of the kidney we as damp bì ( 湿痹), a type of chronic learned how the body’s inner fire is rheumatic condition that is characterized by responsible for its warmth, consciousness, stiff, heavy and painful joints and muscles and transformation of ingested fluids. that is worse in humid weather. Damp bì is often referred to as “fixed bì” ( 着痹) But fire is also one of the most destructive forces in the natural world. When we talk of because the heaviness and stiffness inhibits fire as one of the environmental excesses it movement. is this destructive capacity we are referring to: Fire as a pathogenic force capable of Dampness is associated with the earth devastating the body’s health. phase and can be likened to the qualities of muddy soil: Turbid, heavy and moist. We encountered dampness during our study of Our modern understanding of fire evil is the spleen in Chapter 10. Dampness can the result of a long evolutionary process that began in the Nei Jing and culminated in the invade the body and cause spleen 温病学 transformation failure (脾失化), leading to Warm Disease School ( ) that developed during the Qing dynasty. digestive symptoms such as loose stool, According to the earliest theories, fire is nausea, and loss of appetite. But dampness thought to form spontaneously from other can also originate in the spleen itself, in evils that have previously invaded the body which case a deficiency of spleen qi can and have lingered there for some period of cause the same failure to transform and the time. Chapter 3 of the Su Wen states “If one same symptoms. was harmed in winter by cold, in spring one

will develop a warm disease.” This concept, Finally, while the presence of dampness is 伏气 often metaphorical, there are some damp referred to as “latent qi” ( ), may have symptoms in which there is a physical come from the observation that organic presence of fluid, such as water swelling (水 matter tends to produce heat when left to ferment. Ancient farmers would have 肿 ; i.e., edema), vaginal discharge, and noticed the warmth that develops inside a exudating sores. compost pile even in cool conditions. Since

cold and dampness naturally tend to

stagnate, they are especially prone to the

development of fire in this fashion.

While cold slows things down, fire speeds But warm disease theory posits that it up, causing a rapid pulse and quick pathological fire is not always the result of restless movements. And anyone who has transformation from other excesses. And been in a hot room or suffered from a high while it recognized that hot weather can be a fever can relate to fire’s inflaming effect on source of fire pathology, illness contracted the spirit. The presence of fire evil is almost in this manner is relegated to the separate always marked by vexation (烦), agitation category of summerheat. Instead, warm (躁) and, in extreme cases, mania (狂). disease theory holds that fire can invade the body in the form of newly contracted warm Finally, fire can cause bleeding and red evil, an indefinite natural substance that skin eruptions through a process known as might not be physically hot but explodes “frenetic movement” ( 妄行). Like water into heat once it enters the body. splashing out of a rapidly boiling kettle, the

blood is imagined to spill out of its vessels Warm evils can thus be likened to when heated by fire. Examples of bleeding grenades that detonate only after reaching due to frenetic movement include nose their target. They are responsible, for bleed, vomit of blood, blood in the stool, example, for the wind-heat pattern we and expectoration of blood. Common skin discussed in our strep throat patient in eruptions caused by fire include measles, Chapter 14. The “heat” aspect of wind-heat shingles, carbuncles and hives. is the result of warm evils accompanying wind as it invades the body. It is important to distinguish bleeding due

to frenetic movement of blood from The symptoms of fire are the most bleeding causing by spleen failing to intuitive and easily recognized of all the six manage the blood (脾不统血), a condition environment excesses. Fire causes we encountered in Chapter 10. The former is generalized and/or localized increases in associated with distinct signs of heat while bodily temperature, reddening of tissues and the latter is associated with signs of spleen drying of bodily fluids. Fever, thirst, flushed qi deficiency. The differentiation of the two complexion and red tongue with a yellow patterns will become clearer in future coat are cardinal signs of the presence of fire chapters. evil. The effect of fire on bodily fluids is opposite that of cold: It over-cooks them, As a final word, it is important to point out boiling them down to become thicker, that fire is not exactly the same as darker, and more opaque. Urine that is dark inflammation. While the classical signs of and scanty and nasal mucus and phlegm that inflammation—redness, heat and pain— are thick and yellow are examples of this would seem to overlap with those of fire scorching effect of fire. evil, the two conditions are not always the

same. Inflammation is a Western medical concept, understandable through analysis of

17 cellular change. Fire, by contrast, is a dry cough with little phlegm together with historical Chinese concept that is recognized dry skin and dry nostrils is a common almost entirely by signs and symptoms that manifestation of external dryness attacking are noticeable by the unaided senses. If an the exterior of the body. inflammatory process is not causing redness, heat or other fire signs, it is not likely to be These acute exterior symptoms should not considered a fire disease in Chinese be confused with the chronic dry cough medicine. Some chronic inflammatory associated with lung yin deficiency. This diseases, like osteoarthritis, are more likely later pattern has its roots in kidney yin to manifest as damp or even cold when deficiency and includes deficiency heat analyzed according to traditional methods. signs such as vexing heat of the five hearts (五心烦热). We will return to these two Summerheat patterns in future chapters and add further clarity to their differentiation. Summerheat ( 署 ) is a type of fire that manifests only in the summertime. Pestilential Qi Summerheat is the only form of fire disease presumed to be caused by actual heat in the The concept of pestilential qi (疠气) is as atmosphere. Disease caused by summerheat old as Chinese medicine. It was always is thought to be particularly exhausting due recognized that there are some illnesses to the great sweating it induces and its which strike large populations and cause tendency to combine with dampness when massive casualties. Originally thought to be the weather is both hot and humid. Because caused by extreme weather such as droughts of these proclivities, summerheat often and prolonged heat, by the Ming Dynasty combines the symptoms of fire with those of pestilence was attributed to human-to- dampness and qi and yin deficiency. An human transmission. understanding of summerheat will require study of patterns that we have not yet Pestilential qi is nowadays counted as one encountered, so we will save that discussion of the external causes of illness. But unlike for Chapter 23. the six environmental excesses, it is not associated with a specific set of symptoms. Dryness It is distinguished from ordinary illness only by its virulence and its tendency to spread Dryness as an external cause of disease is quickly through a population. In modern associated in China with the fall season, Chinese medicine, diseases caused by although in colder dryer climates it may pestilential qi are usually regarded as a form extend through the winter. Dryness belongs to the metal phase and focuses its attack on the body parts ruled by that phase, mainly the lung and skin. The sudden occurrence of

18 of warm disease, and warm disease theory is used predict their development in the body.

We will learn about warm disease in more detail in future chapters.

Chapter 17 The Seven Affects

Internal Causes: The Seven Affects three-cause system of Chén Wú Zé. The seven affects include the above five The notion that emotions can be a direct or emotions with the addition of fright (惊) and contributing cause of illness is one of the anxiety (忧). most important and yet poorly understood features of Chinese medical theory. In spite The term emotion (zhì 志) appears to be of the interest this subject has raised among more directly associated with the five zàng- Western students, its understanding is often organs and would seem to connote a deeper compromised by cultural biases and failure and more constitutional emotional state, to take into account the ambiguities inherent something that is part of the individual’s in the ancient source materials. personality and not necessarily pathological.

By contrast, the term affect (qíng 情 ) is To begin with, there are two different more likely to be used when speaking of terms commonly translated as “emotion” in emotionality as a disease-causing force or as the English-language literature: Zhì 志 and a symptom of disease, and thus it implies a qíng 情. The first of these, zhì 志, can be more vigorous but relatively transient translated as “spirit,” “will,” “memory,” or mental state. “emotion,” depending on the context. The ambivalence of this term has led Wiseman Understood in this fashion, anger as an to translate all instances of 志 as “mind.” emotion (zhì 志) should refer to a generally irritable or quick-tempered personality trait, In this present discussion, we are interested while anger as an affect (qíng 情) should primarily in the meaning of 志 as emotion, refer to a burst of anger strong enough to not as mind or will, and will translate it as cause symptoms of mental and/or physical such. The five emotions belonging to the illness. Unfortunately, the two terms are five zàng-organs are listed in this present often used interchangeably in modern text as joy (喜), anger (怒), preoccupation literature and are even combined in the (思), sorrow (悲) and fear (恐). binomial qíng zhì 志情 (Wiseman: “affect- mind”), making it difficult to draw an The term qíng 情, translated by Wiseman empirical distinction between the two. and this present author as “affect,” is usually used when referring to the “seven affects” (七情). Taken together, the seven affects constitute the internal cause of disease in the

Organs and Presumed Emotional Term Being Translated Translating Liver Heart Spleen Lung Kidney Author and Date 怒喜思悲 or 忧* 恐 Beijing 1980a Anger Joy Meditation Grief & Melancholy** Fright & Fear Xinnong 1999b Anger Joy Worry Grief & Melancholy** Fright & Fear Kaptchuk 1983c Anger Joy Pensiveness Grief Fear Maciocia 1989d Anger Joy Pensiveness Sadness Fear Porkert 1974e Anger Pleasure Cogitation Sorrow Fear Wiseman 1994f Anger Joy Thought Sorrow Fear Wiseman 1998g Anger Joy Thought Anxiety Fear Pirog (present text) Anger Joy Preoccupation Sorrow Fear Table 17.1 Various translations of the five emotions belonging to the five organs. In the case of the lung, it is not always clear whether a text is using 悲 (“sorrow”) or 忧 (“anxiety”) as the assigned emotional term to be translated. Kaptchuk, Maciocia, Porkert and Wiseman 1995 appear to be translating 悲 while Wiseman 1990 and 2014 are translating 忧. In the case of Beijing 1980 and Xinnong 1999, it is unclear whether “grief and melancholy” are meant to be two different words for 悲 or whether one word is translating 悲 and the other 忧. a Beijing College of Traditional Chinese medicine. Essentials of Chinese Acupuncture. Beijing: Foreign Languages Press; 1980. b Xinnong C. Chinese Acupuncture and Moxibustion, revised edition. Beijing: Foreign Languages Press; 1999. c Kaptchuk TJ. The Web That Has No Weaver. New York: Congdon & Weed; 1983. d Maciocia G. The Foundations of Chinese Medicine. Edinburgh: Churchill Livingstone; 1989. e Porkert M. The Theoretical Foundations of Chinese Medicine: Systems of Correspondence. Cambridge, MA: MIT Press; 1974. f Wiseman N, Ellis A. Fundamentals of Chinese Medicine, revised edition. Brookline, MA: Paradigm Publications; 1994, p. 16. g Wiseman N, Ye F. A practical Dictionary of Chinese Medicine. Brookline, MA: Paradigm Publications; 1998.

But such terminological ambiguity is only the emotions assigned to the spleen and the the first of several sources of confusion lung by different authors. when the subject of emotions is addressed in Chinese medicine. Another problem stems In the case of the emotion of the spleen, 思 from inconsistent translations and, more sī, the inconsistencies appear to stem from seriously, different opinions on which different opinions on how to render the emotions actually belong in the basic group character 思, which means “to think,” “to of “five emotions” (五志). consider,” or “to contemplate.” Rendered as a noun, one could reasonably translate the Table 17.1 compiles the emotional terms term as “meditation,” “cogitation,” used in various English-language “pensiveness” or—in the negative sense, if publications over the last 40 years. There are one is describing the process of thinking too some confusing discrepancies with regard to much—as “worry” or “preoccupation” (the

21 latter being the choice of this present the text is corrupt and that the character 思 author). was mistakenly written as 悲 bēi, sorrow. If such is the case, then the remaining In the case of the discrepancies involving emotions would appear to leave anxiety, 忧 the lung the problem is more complex. On yōu, to be associated with the lung. the surface, there would appear to be a general consensus that the lung’s emotion is But it is also possible that the Su Wen was either sorrow or one of its English-language recording an alternative tradition regarding equivalents: Grief, melancholy, or sadness. the five emotions. This later interpretation is “Sorrow” is the term chosen by Wiseman in supported by the fact that the same list can his Fundamentals of Chinese Medicine,5 but be found in Su Wen Chapter 19, i.e., anxiety, in his dictionary he switched to “anxiety.”6 fear, sorrow, joy, and anger—with In this later iteration, Wiseman appears to preoccupation once again missing. While it have determined that the constitutional is possible that the same scribal error was emotion belonging to the lung is not 悲 bēi, made twice, we need to consider the a term which bears the unequivocal meaning possibility that anxiety was sometimes seen of sorrow, but 忧 yōu, a more ambiguous as the emotion belonging to the spleen, term which could mean worry, anxiety, rather than preoccupation. We will have concern or—serendipitously—sorrow. more to say about anxiety and the spleen later. One would hope that there exists some clear classical authority that would settle An even more confounding list can be such differences. But as it turns out, the Su found in Su Wen Chapter 23: Wen, from which all modern lists of the five emotions are derived, is itself an When essence qi collects in the heart, joy results. When it collects in the lung, sorrow results. When inconsistent source. Take, for example, the it collects in the liver, anxiety results. When it following statement from the Su Wen collects in the spleen, “fear” (畏) results. When it Chapter 5: collects in the kidneys, fear (恐) results.

Man has the five zàng-organs; they transform the In the above passage, preoccupation has 悲 five qi, thereby generating joy, anger, sorrow ( ), once again gone missing, being replaced in anxiety (忧), and fear. 畏 this case with a synonym for fear: wèi. The emotion of preoccupation, 思 sī, Even if we attribute this switch to another which one would expect to be assigned to example of scribal error (miswriting 思 as the spleen, is missing here. It is possible that 畏), we are left with an additional problem: Anger is absent as well, and this emotion 5 Wiseman N, Ellis A. Fundamentals of Chinese has been replaced by anxiety as the emotion Medicine, revised edition. Brookline, MA: Paradigm belonging to the liver. Publications; 1994, p. 16. 6 Wiseman N, Ye F. A practical Dictionary of Chinese Medicine. Brookline, MA: Paradigm Publications; 1998. 22

These various lists of “five emotions” Fear harms the kidneys; preoccupation dominates suggest a lack of consensus by ancient fear… authorities on which emotions form the basic psychic constitution of man. Is anxiety The idea here is that if an organ’s assigned (忧) the emotion of the lung, the spleen or emotion were to harm it, the damage could be reversed by generating the emotion the liver? Should preoccupation (思), which assigned to the organ which restrains (克) it could simply mean “thought,” belong on the list at all? Opinions seem to have varied. according to the laws of the five phases. So if we take the final example, “fear harms the Wiseman appears to have drawn his list of kidneys,” we can say that the kidneys and five constitutional emotions from Chapter fear belong to the water phase and water is 66 of the Su Wen: restrained by earth. Therefore by generating the emotion belonging to earth— Man has the zàng-organs; they transform the preoccupation—the fear is restrained and the five qi, thereby generating joy, anger, threat to the kidneys neutralized. preoccupation, anxiety, and fear. And so it is with the emotions of joy, This passage is nearly identical to the one preoccupation and anxiety; each is checked in Su Wen Chapter 5, but in this instance, by the emotion belonging to its restraining the missing emotion is sorrow, not phase. But when describing the emotion preoccupation. The above passage would belonging to the liver—anger—an exception leave anxiety as the emotion associated with seems to be made. If the overall symmetry the lung while avoiding any displacement of of the passage were followed, it should be the emotions assigned to the other organs. anxiety—the emotion of the lung—that Understandably, this passage might be dominates anger, since metal restrains wood. regarded as the cleanest and least confusing But instead, the text reads sorrow. The so far and the best choice for compiling an authors apparently made the same intuitive authoritative list of five emotions. judgement that we are likely to make: Sorrow checks anger much better than But the Su Wen is far too mercurial to anxiety. allow the matter to be settled so easily. In nearly identical passages interspersed in If we take this final group of passages as Chapters 5 and 67, the Su Wen makes the the definitive authority as to which emotions following statements. belong in the basic list of five, we can justify placing either anxiety (yōu 忧) or sorrow Anger harms the liver; sorrow ( 悲 ) dominates (bēi 悲) in the lung position. Given that the anger… bulk of translators (including Wiseman in Joy harms the heart; fear dominates joy… Preoccupation harms the spleen; anger dominates his earlier work) have chosen sorrow, and preoccupation… that the character for anxiety, 忧, could be Anxiety ( 忧 ) harms the lung; joy dominates rendered as sorrow anyway, this present anxiety… 23 author has chosen to place sorrow (悲) in the cultures. There is a common Western notion, lung position in the basic list of five for example, that emotions are harmful if emotions. While still recognizing the impact they are “bottled up” and that their of anxiety on the lung, we shall relegate expression can be cathartic, an idea that anxiety to the list of seven affects (See Table forms the basis of many forms of 17.2). psychotherapy. No such idea can be found in the Chinese medical literature. Also unique Five Emotions Seven Affects to the modern world is the use of fright as a 外因七情 form of entertainment, as in the case of Anger Anger horror films and thrill rides. 怒怒 Joy Joy 喜喜 Some emotions that Western culture Preoccupation Preoccupation regards as harmful, such as shame, lust, 思思 jealousy, apathy, compulsiveness, and Sorrow Sorrow 悲悲 feelings of inferiority are not on the Chinese Fear Fear lists. Should we ignore them as irrelevant, or 恐恐 should we try to expand the meaning of Fright some of the Chinese emotions to include 惊 them? There are some emotions that are Anxiety 忧 included on the Chinese lists that would not Table 17.2 be considered harmful in the Western imagination, even if they were intense. Joy, There is one final source of confusion that for example, is particularly problematic. It is must be confronted in any attempt to difficult to regard this emotion as harmful understand emotion, and that is the unless it is reinterpreted as over-excitement inescapably subjective nature of the or vexation. discussion. Our emotions are part of our inner experience and our principal No author can write on this subject and no understanding of them comes from self- student can study it without coloring it with awareness. Not surprisingly, everyone will his or her own viewpoints and that of his or bring to the table a pre-formed opinion on her culture. One should therefore take all the what is harmful or harmless. For example, teachings on the emotions and affects—both while all the modern Chinese books take ancient and modern—with a grain of salt. pains to point out that emotions cause disease only when carried to excess, who is Taking all these considerations as a caveat, to say at what point an emotion is “normal” let us examine what Chinese medicine has to and at what point it is “excess”? say about the seven affects (七情) and the impact they are supposed to have on the We also know that emotions are expressed health of the body. Recall that the seven and managed differently in different affects together form the internal cause of

24 disease in the three-cause system of Chén Symptoms caused by ascending liver yang Wú Zé. Just as the six excesses represented (肝阳上亢) include headaches, dizziness, harmful extremes in the external and red eyes. In extreme cases, liver yang environment, the seven affects represent could ascend so violently that it produces harmful extremes in the internal wind-stroke (中风), a pattern that loosely environment—a kind of stormy emotional corresponds to the “stroke” of modern weather that arises from within. medicine. Wind-stroke is associated with sudden loss of consciousness and Most of the Chinese literature on affect hemiplegia. damage is derived from Chapter 39 of the Su Wen, where the following statements can be While the qi that generates anger comes found: from the liver, we must not forget that all the affects are products of consciousness and in Anger causes the qi to ascend (上) some manner all must begin with the spirit 缓 Joy causes the qi to slacken ( ) light (神明) residing in the heart. Anger is Sorrow causes the qi to disperse (消) no exception. While anger’s power may Fear causes the qi to precipitate (下) Fright causes the qi to become deranged (乱) come from the liver, anger as an emotional Preoccupation causes the qi to bind (结) reaction comes only after the consciousness has interpreted an event as either a threat or Let us examine each of these statements in an insult. That interpretation comes from the detail. spirit. If, for example, a man were to notice two people laughing on the other side of “Anger Causes the Qi to Ascend” crowded room, it is his heart spirit that will decide whether he thinks they are just We learned in Chapter 11 that the liver has laughing or that they are laughing at him. If a natural tendency to ascend, and that this the later interpretation is made, the liver qi tendency was derived from its symbolic will likely kick in and anger will be the association with the wood phase and with result. the rising of the sun in the east. We also learned that it is far too easy for this “Joy Causes the Qi to Slacken” ascending energy to burst out of control. By saying that anger causes qi to ascend, the Su The term 缓 huǎn, translated here as Wen is warning us that this emotion serves “slacken,” means to relax or slow down. as a trigger for a group of liver patterns According to some interpretations of this characterized by violent upward motion. passage, the relaxing effect of joy is Modern expressions such as “flying into a beneficial, ensuring the smooth and rage” and “going ballistic” suggest that our uninterrupted flow of qi. Chapter 39 of the culture has an intuitive sense of the soaring Su Wen would seem to support this energy released by this emotion. viewpoint:

When one is joyous, the qi is in harmony and the It is interesting to note that the above mind is unimpeded. The construction (yíng 营) and passage counterposes sorrow with defense (wèi 卫 ) qi pass freely. Hence, the qi “excessive laughter,” thus suggesting that slackens. the former emotion is the result of an

insufficiency of joy and the later an excess. Chapter 8 of the Ling Shu, however, That would strengthen an argument that clearly states that joy is harmful: joy—at least in moderate amounts—could

be regarded as a functional necessity for In the case of happiness and joy (乐喜) the spirit health, and that a lack of joy might be just as shrinks and disperses (惮散) and cannot be stored. harmful as superabundance.

One can reconcile the two passages by suggesting that joy in moderation can “Sorrow Causes the Qi to Disperse” “loosen you up,” allowing the qi to circulate freely and harmoniously, while excessive In Chinese medicine, the term “disperse” joy will cause the qi to become loosened to ( 消 ) means to eliminate or cause to the point of weakness and the spirit to disappear. The term is most often used as a restlessly wander from its place of storage. principle of treatment, in which case it refers to the breaking up of hard masses or A later passage in Ling Shu Chapter 8 accumulations. As a descriptor of the effects provides a picture of what this “excess” joy of sorrow, it calls to mind the English might look like: expression “all broken up.” The meaning here is quite clear: Prolonged or severe When the heart qi is deficient, sorrow will occur; sorrow “breaks up” the qi, causing it to when excess, unceasing laughter will occur. disappear from the body. Everyone who has suffered a personal loss can testify to the “Unceasing laughter,” might be interpreted exhausting effects of sorrow. here as representing any state of uncontrollable excitement. The Ling Shu Since this affect targets the lung in appears to be saying that the heart is both particular, we might predict that lung the cause of this excitement and at the same deficiency symptoms will be prominent. time its principal victim. By generating Fatigue, shortness of breath and extreme excitement the heart loses its ability susceptibility to colds and flus could be the to store the spirit, thereby setting the stage logical result of severe or prolonged sorrow. for further excitability. The expected symptoms therefore, might include any of But let us recall once again that all seven the heart spirit disturbances, including affects originate in the heart, and the heart is palpitations, insomnia, vexation (烦) and in the first organ to be damaged by them. extreme cases, mania (狂). Elaborating on this, the Su Wen Chapter 39 states:

When one is sorrowful, the heart connection is But the liver is also implicated in the tense. The lobes of the lung spread open and rise production of fear, as the following passage and the upper burner is impassable. The from Ling Shu Chapter 8 makes clear: construction (yíng 营) and defense (wèi 卫) do not

dissipate (散). Heat qi is in the center. Hence the qi When the liver qi is deficient, fear results. When it disperses (消). is excess, anger results.

The above passage suggests that one of the The above statement counterposes fear and effects of sorrow is a kind of stagnation in anger, suggesting that the former emotion is the chest that disturbs both the heart and the the result of a lack of liver qi and the later of lung and gives rise to heat. Consequently, superabundance. If that is the case, one one possible effect of sorrow is the modern could argue that the “right” amount of liver pattern called hyperactive heart fire (心火亢 qi will produce constructive self-assertion. 盛 ), which produces symptoms such as Recall that the liver’s paired organ, the gall vexation, palpitations, and red eyes. We will bladder, is the seat of courage and explore this pattern in detail in future decisiveness. chapters. “Fright Causes the Qi to “Fear Causes the Qi to Precipitate” Become Deranged”

The character 下 xià, translated by The word “fright” (惊) implies a sudden Wiseman as “precipitate,” means to descend jolt of terror, as we might experience when or fall downward. The meaning of the something jumps up unexpectedly in a dark statement is thus intuitive: Sudden or severe room. It is distinguished from fear (恐) by fear can cause the qi to drop downward, as its intense, startling, shock-like effects, might be evident in the involuntary loss of which cause “derangement” (乱) or chaotic urine or stool. But 下 can also bear the movement of the qi. meaning of “depart” in which case the passage suggests that fear causes a loss of The Su Wen Chapter 39 has the following qi, particularly from the kidneys. to say:

Prolonged or severe fear will thus cause When one is frightened, the heart has nothing to deficiency of the kidneys which in turn will lean on, the spirit has nowhere to return, and one’s cause weak lower back and legs and various deliberations have nowhere to settle. Hence the qi urinary symptoms. Since fear originates in is deranged (乱). the heart spirit, it will likely damage the heart as well, causing such symptoms as Fright therefore mainly affects the heart palpitation, rapid heartbeat and a tendency spirit, resulting in disturbance so severe it to become ever more fearful, as is seen in may cause loss of rational thinking or even night terrors and phobias. permanent mental illness. The English expression “frightened out of one’s wits” is

27 brought to mind. The combat condition the connotation is closer to “obsession” or known as “shell shock” is a modern example “thinking too much.” One author translates of the effects of fright and the long-term 思 as “worry” 7. damage this affect can cause to the spirit is evident in post-traumatic stress disorders. In the statement “preoccupation causes the qi to bind,” the term “bind,” 消 jié, means to Seizure disorders in children are referred to tie as if in a knot. The sense is that as “fright-wind” (惊风); partly because the preoccupation or over-thinking causes one’s shaking of the limbs suggests intense fright ideation—and thus the body’s qi—to be and partly because the condition was “tied up in knots.” This is a sensation that traditionally thought to be caused by actual almost anyone can relate to. fright. But fright-wind is classified as a form of internal wind, and internal wind belongs Chapter 39 of the Su Wen describes this to the liver. As a result, a common aphorism binding process in detail: found in modern Chinese medical books states “the liver governs fright.” The When one is preoccupied, the right qi stays and symbolic imagery here suggests the shaking does not move. Hence, the qi binds. of the limbs in wind conditions and the shaking of the body in fright to be of a The term bind, however, as it is used in similar nature. Chinese medicine, is closely related to the terms “stagnate” (滞) and “depress” (郁), “Preoccupation Causes the Qi to Bind” and all three terms are used when describing obstruction of the free-coursing function of The process of thinking is one of the the liver. The pattern called “depression of functions of the spirit and therefore liver qi” ( 肝气郁 ) can also be called preoccupation is an emotion that ultimately “binding depression of liver qi” (肝气郁结). begins in the heart. But the association between the spleen and the thought process In order to fit the statement “preoccupation is so strong in Chinese medical philosophy causes the qi to bind” into modern Chinese that the spleen is sometimes imagined as a medical reasoning, we have to assume that kind of second heart. The spleen is said to the binding effect will damage the liver as store “ideation” (意 yì), which refers to the well as the spleen. The pattern called liver capacity to think. So while preoccupation invading the spleen ( 肝气犯脾) would begins in the heart, its primary impact will therefore seem to be the most likely be on the spleen. consequence of preoccupation. Symptoms of this pattern combine spleen qi deficiency The term being translated here as symptoms such as abdominal distention and “preoccupation,” 思 sī, in normal vernacular loose stool with liver qi stagnation simply means “thought” or “thinking.” But when used as a cause or symptom of disease 7 Xinnong C. Chinese Acupuncture and Moxibustion, revised edition. Beijing: Foreign Languages Press; 1999. 28 symptoms such as depression and ribside spleen as well. Chapter 8 of the Ling Shu pain. makes this connection more explicit:

Anxiety When worry and anxiety (愁憂) cannot be removed from the spleen, the ideation (意) will be injured. If The emotion of anxiety ( 忧 ) is not the ideation is injured, an “oppressive disorder” (悗 8 mentioned in the list of passages we have 乱) results and one will be unable to lift the four been quoting from Chapter 39 of the Su limbs…

Wen. But we have already learned that As for the impact of anxiety on the qi anxiety injures the lung and that its effect is itself, another passage in the same chapter likened to that of sorrow. But the damage has the following to say: caused by anxiety is not restricted to any one organ. As we are about to see, several other Worry and anxiety (愁忧) cause blocking (闭塞) organs are associated with anxiety in and non-movement (不行) of qi. different parts of the Nei Jing. “Blocking” and “non-movement” suggest In the Su Wen Chapter 5, anxiety is stagnation, and when stagnation is an issue mentioned in association with the fire phase the liver is almost always involved. and the heart, and the placement of anxiety Suddenly the perplexing statement we in the heart occurs in addition to the more earlier encountered in Chapter 23 of the Su typical emotion of joy: Wen, “When [essence qi] collects in the liver, anxiety results,” begins to make sense. Among the organs [the one representing fire] is the heart; among the colors it is red; among the tones it is zhǐ; among the voices it is laughing; among the The term anxiety is often paired with the movements [indicating] changes it is anxiety (忧), term 患 huàn, “suffering,” when describing among the orifices it is the tongue; among the a general state of distress, as can be seen in flavors it is bitter; among the emotions it is joy. the following excerpt from Chapter 14 of the Su Wen: Chapter 43 of the Su Wen confirms this association by indicating anxiety as one of If cravings and desires have no limits, if anxiety the emotions that occurs when excess qi and suffering (忧患) find no end, the essence qi will accumulates in the heart: be destroyed, the construction (yíng 营) is impeded, and the defense (wèi 卫) vanishes. Hence, the spirit leaves and the disease does not When excess qi [causes] anxiety ( 忧 ) and heal. preoccupation (思), a block has collected in the heart.

In the above passage anxiety is paired with preoccupation, the emotion belonging to the 8 In this passage, I have interpreted 悗 as an obsolete spleen. That would suggest that the damage version of 闷 . I have translated the term 乱 as “disorder” rather than “derangement,” in order to fit caused by anxiety could be extended to the the context of the passage. 29

Taken as a whole, we can say the depression as a condition of both body and following about anxiety: That it causes mind. stagnation of the qi; that it involves the lung, heart, spleen and liver; and that it causes Clinical depression is referred to in serious disturbance of both mind and body. Chinese medicine as “binding depression of As such, anxiety appears to have a more affects and emotions” (情志郁结). It is not generalized effect on the body than any one of the seven affects per se; it is a general other single affect, not easily captured in dampening of the mood that has an impact simple aphorisms. The closest Western on all seven affects, bringing out the more comparison is the concept of “stress.” negative and destructive side of each. Although depression is primarily the result Transformation into Fire of stagnant liver qi, by influencing the spirit it can have a negative impact on all the In addition to the damages listed above, all organs, particularly the heart. seven affects have a singular tendency to produce fire in the body. In the case of Depression of liver qi restrains the flow of anxiety and preoccupation, the fire forms as emotion as much as it suppresses the flow of a result of the stagnation that these emotions qi. In a normal individual there are many cause. But other emotions can cause fire by emotions that will pass through the mind their very nature. This fire is evident in the during the course of a given day. We might racing heartbeat that accompanies fear and be slightly disappointed at one moment and in the red face of a crying infant. Anger is then elated the next; angry then appeased; particularly prone to the generation of fire, a trepid then assertive. In a state of depression notion that is articulated in such English this smooth flow of emotions—governed by expressions “steamed up,” “flaring temper” the liver’s free-coursing—becomes sluggish and “seeing red.” and suppressed. Emotions that enter the mind become fixated within it and the spirit The heat thus generated can be in the form is unable to free itself of them. As the of deficiency or excess, and the two organs emotions linger they become more intense most likely to be impacted are the liver and and destructive. the heart. Affect disturbance plays a central role in heart and liver fire patterns, which The emotions most affected by depression we will explore in future chapters. are anger and anxiety—both associated with the liver. But with the likely exception of Depression and the Seven Affects joy, any emotion can rise to prominence in a depressed state, including sorrow, fear and In Chapter 11 we learned that a state of preoccupation. depression (郁) was the result of a failure of the liver’s free-coursing ( 疏泄) function, The Chinese medical treatment of and that Chinese medicine regarded depression requires the disinhibition (利) of

30 liver qi and in some cases the calming of the spirit. By encouraging the smooth flow of qi and blood, acupuncture and Chinese herbal medicine can starve exaggerated emotions of the stagnant energy that feeds their growth. It must be emphasized that herbs and needles are physical treatments; they are not forms of psychotherapy. But these remedies can definitely impact the mood and in so doing they can assist the psychotherapeutic process.

Chapter 18 The Neutral Causes of Disease

The neutral or “neither internal nor external” The flavor ( 味 ) of the food is also causes (不内外因) can be divided into two important, and is considered to impart broad categories. The first involves lifestyle specific medicinal properties. Sweet foods imbalances and covers behavior involving tend to nourish, for example, and bitter diet, sexual reproduction, and exercise. The foods tend to drain and dry. second involves miscellaneous hazards such as knocks and falls (跌打), worms, animal A healthy diet requires a balance of these bites, and anything else that is not under the various properties and this is accomplished direct control of the patient. by consuming the right foods prepared in the right way and in the right amounts. The Dietary Irregularity exact balance point will vary according to the constitution of the individual: Those of a The term “dietary irregularity” (饮食失调) hotter temperament, for example, will refers to overeating, undereating, eating at benefit from more cooling foods and those irregular intervals, or consumption of who tend to be cold should eat foods that are contaminated food. In Chinese medicine, warmer. diet therapy ( 饮食疗法) is an entire The specific medical harm induced by discipline in itself, and a thorough study of this subject is beyond the scope of the dietary excess will depend on which type of food is overconsumed. The following list is present book. by no means comprehensive and should be

considered only an introduction to the According to Chinese medical theory, all foods can be seen literally as medicines, and subject. the medicinal properties of each food item are catalogued in much the same way as  Too much sweet and/or greasy food Chinese herbs. Some foods, for example, are will cause dampness and phlegm. considered inherently “warming” such as  Too much hot spicy food will cause cinnamon, ginger, and most meats. Other heat. foods are considered “cooling,” such as  Most forms of alcohol are both sweet mints, leafy greens, and most fresh fruits. and warm and will cause heat, These inherent properties of foods can be dampness and phlegm. changed with cooking or preparation. For  Too much cold and/or raw food will example, well-cooked leafy greens are less damage the spleen yang and will cooling than raw. introduce cold and dampness into the body.

 Undereating will weaken the spleen and And on this later subject—sexually will cause deficiency of qi and blood. transmitted disease—Chinese medicine is tragically silent. The concept of “pestilential In modern clinical practice, dietary advice qi” does not appear to have been extended to should take into consideration the culture of sexual contact—or for that matter to blood- the patient and should include both borne transmission through surgical traditional and modern guidelines. While the instruments or acupuncture needles. Given broad features of Chinese diet therapy its centuries of obsession with the harmful appear sound, at times the specific loss of seminal essence, the failure to recommendations are at odds with modern consider sexual transmission as a cause of nutrition. For example, pregnant women are disease must be seen as a shortcoming of advised to avoid fruits and raw vegetables, traditional Chinese medicine. due to their cold nature. While this may have been prudent advice in a culture where Traditional Chinese concepts of raw food was often contaminated, it could pregnancy, however, are more compatible cause problems if it were applied in a with modern medicine.9 Pregnancy causes a modern Western country, where the main loss of essence and blood and stresses the sources of vitamin C are in just such foods. rèn ( 任 ) and chōng ( 冲 ) vessels, which Likewise, there is no concept of “food control the function of the uterus (see allergies” in traditional Chinese medicine, Chapter 13). Unless the woman’s and these play a crucial role in nutritional constitution is particularly strong, a great management with many Western patients. number of births is considered ill-advised and can cause weakening of the kidney Sexual Intemperance essence and dysfunction of the rèn and chōng vessels. This might produce such Throughout Chinese history, an opinion symptoms as low back and knee pain, held by both professional medical urinary dysfunctions, and menstrual practitioners and the public at large is that irregularities. excessive sexual activity (房劳过度) will lead to depletion of essence, and that this Taxation Fatigue will cause weakening of the body and even premature death. While this same notion can Historically, taxation fatigue ( 劳倦) be found in historical Western medical referred to excessive manual labor and literature, modern Western medicine has insufficient rest. This is said to cause injury largely abandoned it. With rare exceptions, to the spleen and affect the body’s ability to sexual activity is nowadays considered remain properly nourished. As a cause of physically and psychologically healthy— disease, debilitation from hard labor is unless, of course, it involves the risk of sexually transmitted disease. 9 Yves J, Katrien, V, Sanne V. A Systematic Review of Grand Multiparity. Curr Wom Health Rev. 2006; Volume 2, Number 1: 25-32(8). 33 uncommon in modern developed countries. Traumatic Injury In the modern world it is more common to see patients that are simultaneously Traumatology in Chinese medicine is overworked and under-exercised. This can referred to as “knocks and falls” (跌打), and happen to those who work in sedentary jobs, includes most forms of mechanical trauma, locked in a cubicle behind a computer including contusions, fractures, dislocations, monitor. Although lack of exercise is now sprains and muscle strains. All these accepted as a cause of disease in Chinese conditions involve blood stasis and qi medicine, there is no clear consensus on stagnation. Another form of traumatic injury exactly what organs are most likely to be involves burns and scalds, which damage injured. the skin and flesh and weaken the yin.

A potentially useful guideline can be found The above list is of course not exhaustive; in Chapter 23 of the Su Wen, which modern Chinese medicine recognizes injury enumerates the “five taxations” (五劳). from all sources such as bullets and shrapnel, animal and insect bites, drowning, To observe over a long time harms the blood. frostbite, poisoning, etc.. To lie down for a long time harms the qi. To sit for a long time harms the flesh. To stand for a long time harms the bones. Parasites To walk for a long time harms the sinews. Parasitic infections have been treated with Although the passage does not specifically Chinese herbal medicine throughout its long mention any organs, these can be easily history, helminthicides occupying a separate reckoned by matched each with the chapter in all Chinese material medicas. substance or tissue it controls: While each parasite causes its own unique symptoms and is killed by its own specific  Eye strain injures the heart and liver medicinals, most parasitic infections are  Lying for long periods injures the lung associated with signs of dampness and heat.  Sitting for long periods injures the spleen (although modern experience Phlegm and Blood Stasis would add the kidneys)  Standing for long periods injures the Phlegm (痰) and blood stasis (血瘀) are kidneys considered to be both a cause and result of  Walking for long periods injures the disease. They will be discussed in detail in liver Chapters 26 and 27.

Chapter 19 Introduction to the Eight Principles

Unifying Chinese Medicine this presentation that will allow the practitioner to identify an exact diagnostic Chinese medicine has a long and complex pattern and according to this pattern history, and this history has given birth to prescribe an effective treatment. numerous schools of thought. We have just seen in our study of emotions that even in By focusing on the eight principles the the Nei Jing, the founding text of Chinese physician can begin the diagnostic process medicine, it is common to find different by broadly characterizing a condition’s versions of the same conceptual model. That current status, setting the stage for the more conceptual diversity continued to expand as detailed and exacting diagnosis that will be Chinese medicine flourished over the last needed for the assignment of an herbal two millennia. formula or acupuncture treatment.

In the twentieth century, when traditional The Eight Principles medicine was incorporated into the health Yang 阳 Yin 阴 care system of post-revolutionary China, it became necessary to bring all this diversity Exterior 表 Interior 里 under a single roof. To do so, teachers and Hot 热 Cold 寒 practitioners of Chinese medicine came to rely heavily on a system of disease Excess 实 Deficiency 虚 identification called the eight principles (八 The Eight Principles 纲). This system is capable of incorporating Table 19.1 medical patterns that originated in very The eight principles are arranged in four different or even conflicting schools of pairs of counterposed opposites: Yang vs. historical Chinese medical thought. yin; exterior vs. interior; hot vs. cold and The eight principle system plays a critical excess vs. deficiency (see Table 19.1). They role in the organizational framework of are, in a sense, a further development of yin- Chinese pathology. In previous chapters we yang theory as it applies to pathology. The focused on the putative causes of disease, principles “exterior,” “excess,” and “heat” such as external evils; affect disturbances; are all expressions of the principle of yang, and irregular diet. But in clinical practice, and the principles “interior,” “deficient” and the causal history of a disease is only part of “cold” are all expressions of yin. the total picture; equally important is the Taken as a whole, the eight principles disease’s current clinical presentation. It is provide us with a series of yin-yang

35 differentiations that can be expressed as part of the fleshy exterior ( 肌表) of the challenge questions. Is the disease present body, most chronic skin symptoms occur as on the exterior or the interior? Is it an expression of interior patterns. manifesting as excess or deficient? Is it Consequently, we must think of the terms manifesting as heat or cold? Let us examine exterior and interior as metaphorical loci of each of these questions separately. disease activity, and not necessarily the physical whereabouts of the actual disease Exterior vs. Interior or even the symptoms. Let us see how this One should not confuse the terms concept works. “exterior/interior” (表 / 里 ) with the terms An exterior pattern is identified by the “external/internal” ( 外 / 内 ). Exterior and rapid development of the following interior are references to where the illness is constellation of symptoms: presently located, i.e., on the surface of the body or in its interior. External and internal  A sensation of chills (恶寒; Wiseman: are references to where the disease “aversion to cold”) combined with originated, i.e., from outside the body or fever (发热) from within it.  Headaches and body pain 浮脉 The first and arguably most important task  Floating pulse ( ) a physician faces when confronting a patient 恶寒发热 with a new illness is to determine whether “Chills and fever” ( ) refer to a the disease is located on the patient’s simultaneous experience of fever together with a chilly sensation. This combined exterior (表) or in his interior (里). In one sensation is present in the early stages of a sense, exterior and interior refer to physical broad range of infectious diseases and depth within the body, with the exterior everyone has experienced it as some point in encompassing the skin, body hair and their lives. According to modern superficial channels and the interior the bone biomedicine, the chilly sensation is the marrow and organs. result of the body’s attempt to generate the But this distinction is not as higher temperature demanded by the straightforward as one might think, since hypothalamus—the body’s thermostat—in “exterior” and “interior” are related to response to the presence of antigens. anatomical placement only in the most As explained by Chinese medicine, the oblique sense. Fever, for example, is a chilly sensation is caused by the surface of cardinal sign of exterior illness, but a the body being attacked by an external thermometer—something unavailable to the evil—usually wind—while the fever is the pre-modern physician—will show that the result of the fiery defense qi (卫气) which temperature increase is actually coming from inside the body. Another example can has been mobilized to fend off the invader. be found in skin diseases. While the skin is The headaches and body pains are a further indication that the exterior of the body is

36 being attacked; they are the result of acute, interior patterns can be either acute or external evils obstructing the flow of qi in chronic. Because of their enormous the channels and network vessels. The symptomatic variety, interior patterns are floating pulse is a tactile representation of typically identified by ruling out the the total disease process: The pulse floats up presence of an exterior pattern. This means toward the skin surface at the same time that that any clinical condition that does not the defense qi is being thrust outward to present with the combination of chills/fever, expel the invaders. headaches/body-pain, and floating pulse should be considered interior. Exterior patterns are virtually always the result of the external causes, i.e., the six While exterior patterns are caused by environmental excesses and/or pestilential invasion of the body by external evils, qi, with wind being the primary invading interior patterns can arise from either evil. Exterior patterns are almost always external invasion or internal and acute and of recent onset. Sometimes miscellaneous causes. In the former case, respiratory symptoms will accompany the external evils invading the body will usually pattern. This is due to the location of the pass first through the fleshy exterior, lung in the upper burner and its proximity to provoking the typical symptoms of the the body surface. If the lung is attacked exterior pattern (i.e, chills and fever, etc.). If during an external pattern, nasal congestion, the invasion is not halted at this stage, the sneezing or coughing may be added to the evils will likely interiorize, in which case clinical picture. The early stages of colds the most likely scenario is that the chills, and flus typically manifest as exterior headache and body pain will disappear while patterns. Aside from the lung, no other the fever intensifies; the pulse will no longer organ is affected by an exterior pattern. float but will become faster and forceful; the patient will overall become much sicker. We It is important to recognize that a fever will have more to say about the process of without chills—or chills in the absence of a interiorization in future chapters. fever—would not necessarily constitute an exterior pattern. Likewise, headaches, body If the interior pattern is caused by internal pain and floating pulse do not by themselves and miscellaneous causes, i.e., from indicate an exterior pattern, since all these emotions, diet or taxation fatigue, there will symptoms are capable of occurring in be no exterior symptoms at the onset, and different interior patterns. In order to the disease could have many possible positively confirm an exterior pattern, the presentations, depending on the organs three sets of symptoms listed above need to affected, the bodily substances involved, (i.e occur at the same time. qi, blood, fluids, etc.), and the presence and type of evils that may have taken up Compared to exterior patterns, interior residence in the body. The majority of patterns are much more complex, their patterns listed in this and other modern potential symptoms nearly endless. And Chinese medical texts interior. while exterior patterns are almost always 37

In general, exterior patterns are treated by  Acceleration of motion, such as fast inducing sweat, which will helps the defense pulse, rapid breathing or fast fidgety qi drive the evil from the body. In Chinese body movements herbal medicine, acrid, exterior-resolving  Vexation (烦) and other symptoms of medicinals will be used; examples familiar spirit disturbance to Westerners include fresh ginger (生姜),  Usually, increases in sweat scallion whites (葱白), and mulberry leaf ( 桑叶). In acupuncture, points will be The above list includes only those selected primarily on the yang channels and symptoms that can occur in any heat pattern, on the upper part of the body. Insertion will regardless of whether the heat is exterior or be shallow and accessory techniques such as interior, excess or deficiency (more on this plum blossom needle (梅花针), guā shā (刮 below). 痧 ), and cupping ( 拔罐法) might be Symptoms that are “cold” in nature employed. Since internal patterns include the following: encompass a vast variety of conditions, there is no way to generalize either herbal or  Cold body or cold limbs acupunctural treatment.  Clear, watery secretions or excretions and lack of thirst Heat vs. Cold  Pale bluish (苍白) complexion and pale Heat (热) and cold (寒) represent the literal or bluish (青) tongue body or—at times—metaphorical temperature at  Pain usually occurs somewhere in the which the disease is manifesting. When we body (due to the congealing effects of refer to heat and cold as contrasting pairs cold) within the eight principles, the context is  Possibly slow pulse; various other pulse much different from the fire and cold evils types depending on the type of cold which we encountered in our study of the causes of disease. Fire evil and cold evil are Here again the list is short since it includes forces of nature that induce illness. In the only those symptoms that can apply to any context of the eight principles, the terms cold pattern. In Chinese herbal medicine “heat” and “cold” are merely categories that cold patterns are treated with “warming” represent the manifestations of a disease that medicinals and heat patterns with “cooling” is already in progress. medicinals. Warming medicinals familiar to Westerners include dried ginger (干姜) and Symptoms that are “hot” in nature include cassia cinnamon twigs ( 桂枝), while an the following: example of a cooling medicinal is Chinese  Fever or local sensations of heat peppermint ( 薄荷). In acupuncture, heat  Redness of face, tongue, eyes, etc. patterns are treated with shorter needle retention, with extravasation using a three- edged needle or with cooling needle

38 manipulation techniques such as Heaven- in the broadest possible sense: On the one Penetrating Cooling Method (透天凉). Cold hand, it could refer to one or more of the six patterns are treated with longer needle environmental excesses together with retention, with the use of moxibustion or pestilential qi; on the other, it could refer to with warming needle manipulation pathological accumulations resulting from techniques such as Burn Mountain Fire (烧 the body mishandling its own substances. 山火). Examples of pathological accumulations include qi stagnation, blood stasis, and It is important to point out that, although phlegm. Even food can become a type of there is no such thing as a “neutral” pattern, evil if it is consumed in voracious quantities not all patterns can be characterized as hot or if it is not being transformed quickly or cold. Examples of patterns that are not enough. Such a condition is referred to as inherently hot or cold include qi deficiency, “food stagnation” (食滞). blood deficiency, qi stagnation, blood stasis, dampness, and phlegm. These conditions Each of these evil excesses will produce its contain no obvious hot or cold signs unless own unique symptoms, making it very they are combined with other hot or cold difficult to generalize. But there are a few patterns or if they have undergone some basic trends that can be seen in most excess form of pathological transformation. An patterns, regardless of the evil involved: example of pathological transformation is  Symptoms overall tend to be more the tendency for dampness to transform into severe and—especially if external damp-heat, due to the “compost pile” effect invasion is involved—more acute that was described in Chapter 16.  Pulses are more forceful Excess vs. Deficiency  Tongue coats are thicker  If there is pain, it is worsened by Excess and deficiency are two of the most pressure basic of the eight principles, so much so that they had to be introduced at the very In all cases of excess, the symptoms beginning of this book, in the discussion of convey the sense that the body is suffering right and evil in Chapter 2. The concepts of from the presence of something that does excess and deficiency are especially not belong. This explains the stronger than important for acupuncturists since these usual pulses and the excessive thickening of principles are recognized by virtually all the tongue coat. Pain is amplified by schools of acupunctural thought, even “five- pressure since it is occurring as a result of phase” schools which tend to ignore the some part of the body being overfilled. other six principles. In deficiency patterns, by contrast, the In the broadest sense, excess patterns are body is suffering from the absence of those that occur as a result of some form of something that should normally be present. evil having taken up residence in the body. In the broadest sense, the term “deficiency” In this context the term “evil” is being used 39 refers to a diminished quantum of the body’s right qi (正气). In more specific clinical All these signs point to the fact that some terms, deficiency patterns are usually essential ingredient of the body is missing: classified according to the bodily substance Since there is no evil present, the body is not most affected by the reduction, typically qi, engaged in an acute struggle for survival and blood, fluids, or essence. the symptoms are therefore weaker, less life- threatening, and can drag on for long periods A deficiency pattern can develop in one of of time, even years. The thin forceless two ways: It can occur as a result of damage pulses and diminished tongue coats caused by an invading evil, or it can occur as intuitively suggest deficiency. And the fact a result of internal and miscellaneous causes that pain, if present, is improved by pressure such as poor diet, taxation fatigue, sexual suggests that it is occurring as a result of intemperance, or a generally weak something missing in the body, with constitution. In the case of deficiency due to pressure serving as a momentary substitute damage, the deficiency symptoms will for the deficient substance. develop in the late stages of a disease that is first characterized by vigorous excess In clinical medicine, excess patterns are symptoms. A patient recovering from a high treated by a draining (泻) and deficiency by fever with copious sweating, for example, tonifying ( 补 ). Drainage refers to the will usually suffer from signs of damage to elimination of evils from the body or, in the yin (伤阴) such as fatigue and restlessness, case of pathological accumulation of the red tongue with no coat and a thin forceless body’s own substances, to movement and pulse. If the deficiency is caused by internal transformation of those substances. In most and miscellaneous causes, the symptoms cases this requires stronger and more will develop slowly and insidiously over pharmacologically active medicinals or in time. the case of acupuncture, stronger stimulus. Tonification, by contrast, is typically a Once again it is difficult to generalize; gentler and more long-term approach, using each substance will produce its own unique milder medicinals and softer acupuncture symptoms as it becomes deficient. A few stimulus to gradually build up the missing general trends are evident in most deficiency ingredients in the body’s right qi. patterns:

 Symptoms overall tend to be more mild and chronic  Pulses are forceless and often thinner  Tongue coats are thinner or in severe cases, missing altogether (i.e., mirror tongue, 镜面舌)  If there is pain, it is improved by pressure

Excess Heat, Deficiency Heat heat. An exterior cold pattern is an exterior Excess Cold, Deficiency Cold pattern caused by an invasion of wind-cold. We will differentiate wind-cold and wind- The principles of excess and deficiency, heat in detail in Chapter 23. hot and cold are often seen in combination Yin vs. Yang (相兼), producing four different combined patterns: Excess heat, deficiency heat, In modern practice, the principles of yin excess cold and deficiency cold (see Tables and yang act mainly as categorical titles for 19.2-3). the other six parameters: Patterns of external, heat and excess belong to yang The nomenclature here can be a little while internal, cold and deficiency belong to confusing. “Deficiency cold” means cold yin. The terms “yin” and “yang” are only occurring as a result of deficiency (typically, spoken of in the patterns of yin deficiency a deficiency of yang qi)—it does not mean and yang deficiency. Yin deficiency is that the body is somehow lacking cold. essentially the same as deficiency heat and Likewise “deficiency heat” means heat yang deficiency is deficiency cold. We will occurring as a result of deficiency (typically, cover yin and yang deficiencies in detail in a deficiency of yin humor). It does not mean Chapter 22. a lack of heat.

By looking at the symptoms of these combined patterns, we are able to get a more detailed picture of how the body can become sick and how the eight principles combine to help guide treatment. But it must be pointed out that even these combined patterns are quite broad and will manifest differently depending on which evils are involved in the case of the excesses and which substances are involved in the case of the deficiencies. Those details will become apparent in future chapters.

Exterior Heat and Exterior Cold

There are two more combinations of principles that commonly occur in practice: Exterior heat and exterior cold (Table 19.4). Since both of these patterns are manifestly excesses, the term “excess” is dropped from their names. An exterior heat pattern is an exterior pattern caused by invasion of wind-

Excess Heat Deficiency Heat Low chronic fever, usually occurring later in High fever the day More severe disturbances of spirit: Mania, Less severe disturbances of spirit: Insomnia, delirious speech vexation Red tongue, yellow coat Red tongue, thin white coat or no coat Rapid; more forceful pulse types (full, surging, Rapid and thin pulse etc.) Whole face red Pale or normal face with red cheeks Table 19.2

Excess Cold Deficiency Cold Cold body and possibly chills Cold limbs Pain improved by warmth but worse with Pain improved by warmth and better with pressure pressure Tight pulse Slow forceless pulses

Thick, moist white tongue fur Pale tongue with thin moist white fur Table 19.3

Exterior Heat Exterior Cold Chills and fever, fever more pronounced Chills and fever, chills more pronounced

Headaches and body pains less pronounced Headaches and body pains more pronounced

Sweat Little or no sweat

Floating rapid pulse Floating tight pulse Table 19.4

Chapter 20 Introduction to Pulse Examination

Pulse Examination in Context exposure to pulse examination that students receive in their internships is frequently The goal of this chapter is to teach you just wasted; Western students find it difficult to enough about pulse examination to learn by a process that essentially requires understand the patterns that you will that they copy the opinion of an elder and encounter in future chapters. A more have their wrong impressions corrected detailed and comprehensive coverage of this again and again. subject is reserved for a later chapter. Nevertheless, as long as you are learning the But pulse education has become pathologies that the different pulse types problematic even in modern China. The indicate, you might as well learn how to take traditional apprenticeship has been largely a pulse properly. replaced with internships in large hospitals where students must rotate through various You first need to be aware of the difficulty departments and where speed and efficiency of the task you are about to undertake. trump time-consuming traditional Learning pulses is in fact so difficult that educational methods. It is not surprising that you are unlikely to become proficient while modern research has found that the same you are still in school and you will pulse could be read differently—sometimes justifiably lack confidence for years after very differently—depending on who is your graduation. That is because the art of taking it.10 pulse taking was invented by and for a bygone age, a time when all learning took This is one of several reasons why modern place in one-on-one apprenticeships. A textbooks insist that pulse examination be disciple of medicine would spend years, carefully integrated into the rest of the four perhaps decades, working under the tutelage examinations and its readings weighed carefully against all other signs and of an accomplished teacher and during that 11 time he would take hundreds of pulses, symptoms . If pulse reading is part of a gradually learning to match his readings to comprehensive process, its inescapable his master’s. Every day would be a test of his skill and he would only be released into 10 Jiang L, Liu B, Xie Q, Yang S, He L, Zhang R, the professional world when his abilities met Yan S, Zhou X, Liu J. Investigation into the influence of physician for treatment based on syndrome his teacher’s satisfaction. differentiation. Evid Based Complement Alternat Med. 2013; 2013:587234. Traditional apprenticeships such as these 11 Wiseman N, Ellis A. Fundamentals of Chinese do not exist in the West. Even the brief Medicine, revised edition. Brookline, MA: Paradigm Publications; 1994, p. 121-2. 43 subjectivity can be checked against the other anyone attempting to learn the art of pulse signs and symptoms and a misreading will examination. hopefully be overpowered by the total clinical picture.  Take as many pulses as possible: Not just sick people, but everyone—friends, But even if one is to assume that a given family, and classmates. pulse reading is accurate, its interpretation will differ widely depending on the other  When you are first getting started, don’t signs and symptoms. A slippery pulse, for try to come up with a conclusive example, is quite normal in pregnant women reading; just feel each pulse and file its and robust athletes but in a sick person with sensation in your memory next to all other signs of damp-heat, it will confirm the the other pulses you have taken. Once presence of damp-heat. Likewise, a you have taken a wide range of pulses moderate pulse in an asymptomatic on different people, a mean normal individual is normal, but this same pulse will pulse will begin to emerge in your help confirm a diagnosis of qi deficiency if consciousness, and you will more easily there are additional signs of qi deficiency. discern any deviations from that norm. Often a pulse will contradict other signs and symptoms and the practitioner must  If you are working in a clinical determine which signs must take environment, try to have your pulse precedence. readings checked as often as possible by your supervisor. If your supervisor’s As you can see, we have scarcely begun readings differ from your own, don’t the subject and it has already become get discouraged and above all don’t complex and ambiguous. But the reader argue! Your supervisors are providing should not despair; many other students valuable feedback and you should try as have traveled the same pathway and while much as possible to adjust your true masters of pulse diagnosis may be rare impressions to theirs. in the modern world, it is possible through rigorous self-study to develop enough skill  Pay special attention to patients who to handle the majority of cases. Remember, are just coming down with exterior the first doctor had no one to teach him patterns or other acute conditions, pulse examination. Furthermore, the student especially if you are familiar with their should be reassured that simple and usual pulse from previous comparatively naïve pulse readings are more examinations. That will be your best useful and more likely to be accurate than opportunity to see the floating pulse the complex and detailed ones that some and other pulses that appear in acute Western teachers seem to encourage. illnesses. Given all these caveats, there are a few words of advice that can be offered to  Beware of spending too much time on your own pulse. Many students want to 44

learn by taking their own pulse and this the zàng-organs. The middle level reflects can lead to misreading other people’s the strength of the stomach qi. pulses. If you focus too much on your own pulse you run the risk of In theory, there are eighteen distinct pulse unconsciously seeing yourself as a kind positions (three pulse positions and three of norm against which other pulses are levels on each wrist). Although each of these measured. If your pulse is soggy, for position-levels provides information on example, everyone else’s will seem different elements of the patient’s condition, wiry and vice versa. in actual practice the practitioner will conflate this information into a single composite pulse reading such as “floating  When you’re first getting started, limit and moderate” or “slippery and fast.” the time you spend on any given pulse. If you obsess too long on a pulse you will begin to feel artifacts that are not there and the pulse will appear to be stronger than it really is. Remember, your task as a new student is simply to learn; you are not expected to get it right every time.

Pulse Positions

In modern Chinese medicine, pulse examination is performed at the wrist pulse (寸口). Anatomically, this is located on the radial artery at the region of the styloid process of the radius. The pulse is examined Figure 20.1 on both of the patient’s wrists, usually one The Three Positions wrist at a time.

The wrist pulse is divided into three distinct positions (see Figure 20.1). From distal to proximal, these three positions are referred to as the inch (cùn 寸), bar (guān 关) and cubit (chǐ 尺) pulses. In addition, the pulse is divided into three distinct levels: The superficial, middle, and deep levels (Figure 20.2). The superficial level relates to the surface of the body, the yang channels and the fǔ -bowels. The deep level relates to Figure 20.2 the interior of the body, the yin channels and The Three Levels

Pulse Examination Procedure It is customary to start the pulse reading with the patient’s left wrist. Using the The patient should be rested and relaxed middle finger of your right hand, find the during the pulse examination, and as the very tip of the styloid process of your practitioner, you should be calm, patient’s left hand. Once you can feel the tip comfortable, and breathing normally. The of the styloid process, move your finger room should be quiet with as few medially (i.e., toward the ulna) until it is distractions as possible. resting directly over the artery. This is the If you are examining the pulse while bar (关) position. You can then place your sitting at a desk, your patient should be index and ring fingers on the distal and seated on the other side facing you. Your proximal sides of your middle finger patient should rest their hands palms-up on respectively. Your index finger will be the desk top, as close to the level of their resting on the inch (寸) pulse and your ring heart as possible, legs uncrossed. If you are finger on the cubit (尺) pulse (see Figure not using a desk, your patient should sit with 20.3). On smaller patients you might need to their wrists resting on the arms of their squeeze your fingers more tightly together in chair, palms facing up, while you sit or stand order to fit them onto all three positions. On on either side of the chair as you examine taller patients with longer pulses, you might the pulse on each wrist. need to spread your fingers further apart. In hospital environments you might need to take the pulse while the patient is lying in a supine position. In any of these scenarios you should always endeavor to position yourself so that you can comfortably place your fingers at right angles to the patient’s forearms.

Your patient should rest the dorsum of their wrist on a very small pillow or folded towel which should be placed just Figure 20.3 underneath the TW 4 point (阳池). This will The Three Positions with Practitioner’s allow for a slight extension of the wrist, Left Fingers on Patient’s Right Wrist lengthening the pulse area and making it easier for you to fit your fingers over the On most patients the artery will have a three positions. If a pillow is not available, slight convex curve that peaks at the center you can cradle the patient’s wrist in your of the bar pulse (see Figure 20.3). You opposite hand. It is important that the patient should adjust your finger pressure to completely rest their hands and not try to accommodate this curvature, pressing a little hold them up during the reading. bit deeper in the inch and cubit pulses and more lightly at the bar pulse. 46

Once your three fingers are in position, A slippery fast pulse in a pregnant woman is press down very slightly until the pulse is normal, it does not represent damp-heat. A just perceptible by all three fingers. This is slow pulse in an athlete is normal, it does the superficial level. Now press your fingers not indicate yang deficiency. And although until you have almost (but not quite) obesity is not itself normal, a deep pulse on occluded the artery; this is the deep level. an obese person represents an expected The middle level is then found by bringing reading; in order to be judged as “deep” it your fingers to a level midway between the would have to be even deeper. superficial and deep levels. In some relatively rare cases there are Before we go over the different pulse anomalies that could confound the reading. types, it is important to list all the factors In some patients one or both arteries could that can confound a successful pulse be unusually thin, or there might be reading. You must be ready to make abnormalities based on surgery or previous adjustments to your reading based on size, injuries. In a small percentage of patients the age, gender, season, and recent activity of artery is found on the posterior side of the the patient radius, roughly along the large intestine channel. If the anomaly is serious, it might  Gender: A woman’s pulse is softer and be necessary to ignore the pulse on the slightly faster than a man’s. abnormal side.  Age: A child’s pulse is faster than an adult’s; in very old patients the pulse is Basic Pulse Types often tight.  Corpulence: Obese patients with a As explained earlier, this chapter is meant large girth to their wrists will tend to to be an introduction. We will only go over have deeper pulses. Thin patients will the pulses that frequently appear in the have pulses that are closer to the pattern descriptions that follow in future surface. chapters. We will explain the most straightforward and common indications for  Height: Short slight patients will have each pulse and avoid alternate thinner, shorter pulses while tall interpretations that sometimes crop up in patients will have longer and larger clinical practice. Such additional details will pulses. be saved for later in this text, where the  Athletic development: Athletes with pulses will be studied in greater depth. strong muscular development will often have slippery or even full pulses. Long For the time being, we are faced with the distance runners will have slow pulses. nearly impossible task of describing fine  Pregnancy: Pregnant women will have tactile sensations with visual and literary slippery and fast pulses. cues. It is important that you recognize that you will not learn pulses through a textbook All the above pulses represent different or in a classroom; such didactic teaching baselines for establishing a normal reading. methods are only designed to provide you

47 with the indications of the pulses that you pulse. It is felt only on firm pressure (Figure have learned to identify through rigorous 20.5). The deep pulse indicates interior clinical training. patterns.

But the didactic side of this subject is nevertheless important. And your learning will be immensely improved if you can make the indications for the different pulses intuitive. This should not be difficult, since the interpretations of the various pulses originate from metaphor, and grasping metaphor is intuitive. The ancient Chinese saw the pulse as a simulacrum of the body and its activity; a kind of tactile Figure 20.5 representation of bodily phenomena that The Deep Pulse (沉脉) could not otherwise be sensed.

Basic Pulse Types The significance of the deep pulse will depend on its forcefulness. If it is deep and The floating pulse is perceived mostly at also forceless it is called a weak pulse, in the superficial level (Figure 20.4). It feels as which case it indicates a deficiency of qi and if it is being thrust upward, like a cork in blood (Figure 20.6). water, leaving the deeper positions feeling somewhat empty. In the presence of exterior signs such as chills and fever, the floating pulse helps to confirm the exterior pattern.

Figure 20.6 The Weak Pulse (弱脉)

If it is deep but forceful it is called a deep Figure 20.4 wiry or deep full pulse depending on the The Floating Pulse (浮脉) texture (Figure 20.7). These last two pulses indicate stagnation deep in the body. The deep pulse (沉脉; Wiseman: “sinking pulse”), is the antithesis of the floating

Figure 20.8 The Rapid Pulse (数脉)

The slow pulse is the antithesis of the fast pulse. It is timed at three beats per breath of the practitioner or 40 to 60 beats per minute (Figure 20.9). In general a slow pulse indicates cold.

Figure 20.7 Deep Wiry (沉弦脉) or Deep Full Pulse (沉实脉)

Historically, the speed of the pulse was measured against the practitioner’s respiration. A normal pulse was four beats per breath, a rapid pulse six beats per breath, a slow pulse three beats per breath. This of course required carefully controlled Figure 20.9 breathing on the part of the practitioner. The Slow Pulse (迟脉)

Nowadays pulse speed is more reliably The moderate pulse (Figure 20.10) is measured with a stopwatch or smartphone, subtyped as a form of slow pulse. Its speed in which case a normal pulse is clocked at is slightly slower than normal, but not quite 60-72 beats per minute and a rapid pulse at as slow as the slow pulse. It is smooth and 90-139 beats per minute (Figure 20.8). In resilient and is neither forceful nor forceless. general, rapid pulses indicate heat patterns. In the absence of disease signs the moderate Rapid and forceful pulse types indicate pulse is considered normal. But this pulse excess heat while rapid and thin pulses signifies dampness or qi deficiency if indicate deficiency heat. symptoms of these patterns are present. The moderate pulse serves as a good example of how pulses need to be interpreted in the context of information gathered from the other four examinations.

Figure 20.10 Figure 20.11 The Moderate Pulse (缓脉) Slippery Pulse (滑脉)

A slippery pulse (Figure 20.11) is smooth, The rough pulse (Figure 20.12) is the resilient, and relatively forceful. It is said to antithesis of the slippery pulse; it is choppy feel like pearls rolling in a dish. In a and unsmooth, “like a knife scraping pregnant woman or a healthy athlete, the bamboo.” It is slightly thinner and slower slippery pulse is normal. But in the presence than normal. The rough pulse is relatively of disease, the slippery pulse can confirm a rare, but when it occurs it usually indicates wide range of patterns, depending on the blood stasis. additional signs and symptoms. These include the following:

 Dampness, especially damp-heat  Phlegm, especially phlegm-heat  Food stagnation  Interior excess heat

The fluidic quality of the slippery pulse signifies the turbid fluidity present in pathological accumulations such as phlegm, Figure 20.12 food stagnation, and damp-heat. But internal The Rough Pulse (涩脉) excess heat conditions—even in the absence of dampness or phlegm—can cause this The wiry pulse (弦脉; Wiseman: “string- same quality due to the tendency of heat to like”) feels like a guitar string—taught and cause more fluidity in the movement of the unyielding (Figure 20.13). The character qi and blood. xián 弦 literally means bow-string, as we

learned in Chapter 9. It represents the drawn-up, stagnant quality that easily develops in the liver. The wiry pulse can occur in any liver or gall bladder pattern, but

50 is most representative of binding depression also signify dampness. Like many other of liver qi (肝气郁结). It is clinically one of pulses, it must be interpreted in the context the most common pulse findings. of other signs and symptoms.

Figure 20.15 Figure 20.13 The Soggy Pulse (濡脉) The Wiry Pulse (弦脉) If the pulse is forceless and also large in diameter, it is called an empty pulse (虚脉; If a wiry pulse is particularly forceful it is Wiseman: “vacuous pulse”). Empty pulses termed a tight pulse (Figure 20.14). A tight indicate qi and blood deficiency (Figure pulse is common in conditions of excess 20.16). cold.

Figure 20.16 Figure 20.14 The Empty Pulse The Tight Pulse (紧脉) The surging pulse (Figure 20.17) has a The soggy pulse (Figure 20.15) is the wide diameter and is forceful at all three antithesis of the wiry pulse. It is soft and levels. It is said to be stronger coming than forceless, like a wet sponge. It is also going, like waves crashing against a shore. somewhat floating and thin, although it is The surging pulse indicates strong excess not as distinctly palpable as the thin pulse. heat, but the weaker receding phase of the Its lack of force signifies qi and blood beat suggests damage to right qi. It is deficiency but its soft, mushy quality can

51 common in conditions where exuberant heat (Figure 20.19). It should not be confused is damaging fluids. with the soggy pulse, which is also thin but less distinctly palpable. The thin pulse indicates qi and blood deficiency if it is of normal speed; if it is rapid it indicates yin deficiency.

Figure 20.17 The Surging Pulse (洪脉)

The full pulse (实脉; Wiseman: “replete pulse”) is similar to the surging pulse—large Figure 20.19 and forceful—but it is equally strong The Thin Pulse (细脉) coming and going (Figure 20.18). It also indicates excess heat but its strength at both The term “irregular” ( 结代; Wiseman: phases of the beat suggests that right qi “interrupted”) refers to several different remains undamaged. pulses, all of which appear to have skipped beats (Figure 20.20). Interrupted pulses occur in various heart patterns. We will distinguish the various subtypes when we return to this subject in later chapters.

Figure 20.18 Figure 20.20 The Full Pulse (实脉) Irregular Pulses (结代) The thin pulse (细脉; Wiseman: “fine”) is like a fine thread, very narrow in diameter but distinctly palpable under the fingers

Chapter 21 Introduction to Tongue Examination

The Role of Tongue Examination in appearance of the tongue is not subject to Chinese Medicine obfuscation by makeup or tanning. Furthermore, the coat of the tongue adds a second layer of diagnostic information that The examination of the tongue—its body, could never be matched by the complexion. coat and movements—is considered crucial to modern Chinese pattern differentiation. But while tongue examination may be an Together with the pulse, the tongue improvement over complexion examination, currently ranks as one of the “two pillars” of its reliability has been challenged in modern diagnosis. But unlike pulse examination, research literature 12 . Although a tongue tongue examination was developed much reading might seem more straight-forward later in Chinese history. For the authors of and objective than a pulse reading, there can the Nei Jing it was the complexion, not the still be disagreement between two experts tongue, which reigned together with the looking at the same tongue. How red does a pulse as the chief prognosticator of health. tongue have to be before it is considered Chapter 13 of the Su Wen likens the pathologically “red”? How thick the coat complexion and the pulse to the sun and the before it is called “thick”? In the absence of moon respectively: a system that quantifies such characteristics, the interpretation of tongue signs must depend to a large extent on the judgement The complexion is that by which [a physician and experience of the practitioner. establishes] correspondences to the sun. The [movement in the] vessels (i.e., the pulse) is that by which [a physician establishes] correspondences to In spite of these recent doubts, the signs the moon. appearing on the tongue continue to be counted among the most important of those While the first treatise of tongue diagnosis gathered in the four examinations. But appeared in the Yuan Dynasty, it was not Chinese medicine recognizes that no single until the Qing Dynasty that Tongue diagnostic technique is flawless. Even if the examination came to play a major role in reading of the tongue could somehow by Chinese medicine. Thanks largely to the verified as objectively accurate, it can efforts of the warm disease school, the rank 12 of this examination eventually rose above Kim M, Cobbin D, Zaslawski C. Traditional Chinese medicine tongue inspection: an examination that of complexion until the tongue is now of the inter- and intrapractitioner reliability for considered nearly indispensable as a specific tongue characteristics. J Altern Complement diagnostic tool. Unlike the complexion, the Med. 2008(5):527-36.

53 nevertheless provide misleading cues on Although every organ has some influence what is actually happening in the body. on the appearance of the tongue, it is the Serious illness, for example, does not always stomach which has the most direct impact, produce the expected changes in the tongue particularly on the tongue surface. The and sometimes pathological tongue signs tongue is part of the buccal cavity, the occur in healthy individuals.13 As in the case representative orifice of the earth phase (see of pulse readings, tongue readings must be Chapter 10). For this reason, pathological weighed against all other signs and changes in the stomach are easier to observe symptoms if mistakes are to be avoided and on the tongue than are those of other organs. the true disease pattern revealed. In order to Likewise, pathological products associated place the information gleaned from tongue with the stomach, such as phlegm, dampness examination in its proper context, therefore, and food stagnation ( 是滞) can strongly the tongue—together with the pulse—is influence the appearance of the tongue’s usually examined last. surface. This must be born in mind when using the tongue to diagnose complex Relationship of the Tongue to the Body conditions: It is possible for stomach conditions to obscure deeper pathologies, Thanks to the rich capillary network on the making it necessary to rely on other aspects tongue’s surface and the tongue’s nearly of the examination to get a more complete complete lack of surface pigmentation, it is picture of the patient’s condition. possible to see the blood almost transparently through this organ. The tongue As we learned in Chapter 8, the tongue body is therefore a more reliable tool for body is intimately tied to the function of the visualizing the status of the blood—and by heart. The motility of the tongue is essential extension the qi—than the facial to speech and is a direct expression of the complexion. The coat of the tongue is heart spirit. Abnormalities in tongue motility thought to be the result of the “steaming” can therefore indicate serious disorders of effect of stomach qi. Its thickness, density the heart, such as obstruction of the heart and moisture can therefore be used to orifices ( 心窍). In addition, heart fire determine the overall status of fluids in the patterns can cause reddening and erosion of body. Taken together, the tongue’s body and the body of the tongue, particularly at the coat provide important evidence for the tip. presence of pathological heat or cold, and this makes tongue examination critical to the Unlike pulse examination, which provides diagnosis of febrile disease. the practitioner with a minute-to-minute reading of events in the body, the tongue requires some time to develop observable changes. This can be a few hours or a few 13 Bin, ST. Atlas of the Tongue and Lingual Coatings in Chinese Medicine. Beijing, Strasbourg: People’s days, depending on the condition. The time- Medical Publishing House, Editions Sinomedic; lag between the development of pathology 1986, p. 7. 54 and its appearance on the tongue is both a the macroscopic appearance of these weakness and strength of tongue diagnosis. papillae account for many of the diagnostic It is a weakness in that illness that develops signs that can be visualized in the tongue suddenly will not be immediately evident on coat. the tongue. In the early stages of external wind invasion, for example, the tongue Most numerous are the filiform papillae, remains relatively unchanged in both body from the Latin filum meaning “thread.” and coat. But this slowness to change is an These typically appear as minute, brush-like advantage when analyzing diseases that projections covering the dorsal surface of develop over time, allowing the physician to the tongue, their normally whitish tint the determine if the illness is advancing or result of a thick, dense epithelium. It is the receding, and how deeply any invading evil filiform papillae that are the primary source has penetrated into the body. of the tongue “coat.” Changes in thickness, moisture, color and distribution of the All of these factors contributed to the filiform papillae are responsible for many of attraction tongue diagnosis held for the the pathological signs that we are about to warm disease theorists of the Qing Dynasty. study. This examination provides a clear and accurate indication of the severity and depth of febrile disease, so much so that the tongue is often the principal sign differentiating the later stages of warm disease. We will learn more about the role of the tongue in warm disease differentiation in future chapters. For now let us turn to a discussion of tongue anatomy.

Anatomy of the Tongue Figure 21.1

The tongue is a muscular body with a The fungiform papillae, after the Latin highly vascular mucous membrane surface. fungus, are mushroom-shaped projections in For purposes of Chinese medical diagnosis, the dorsum of the tongue that contain taste it is the anterior 2/3 of the tongue—the part buds. Far less numerous than the filiform that is most visible and most mobile—that is papillae, they are scattered throughout the the subject of examination (see Figure 21.1). dorsal surface but are more numerous on the The dorsum of this region is covered with tip and sides. In pathological states the different types of papillae or goblet-shaped papillae become distended with blood, in projections of the membrane surface; these which case they are referred to as “speckles papillae form the tongue’s coat. Changes in and prickles” (芒刺) in Chinese medicine.

In the posterior end of the visible portion The moisture on the dorsum of the tongue of the tongue surface, forming a kind of comes from scattered mucus and serous “horizon” at the back of the tongue, there glands under the tip and sides of the tongue, are a series of eight to twelve circumvallate as well as the parotid, submandibular, and papillae, from the Latin circum “around” sublingual glands. The appearance of and vallum, “rampart.” These papillae are excessive moisture or dryness of the tongue dome-shaped structures, one to two surface has diagnostic significance. millimeters in width, and are arranged in the form of a “V,” with the apex pointing The dorsum of the tongue is divided into posteriorly. Each is surrounded by a trench- two symmetrical halves by the median like depression, which is in turn surrounded sulcus, which ordinarily appears as a thin, by a ring of mucus membrane that is shallow fold extending from the back of the elevated to give the appearance of a wall tongue to the tip. This fold is normal and is (vallum) surrounding a circular fort (see only considered a “fissure” ( 裂 ) if it is Figure 21.1). The circumvallate papillae unusually deep, wide or irregularly shaped. contain taste buds and the surrounding depression emits serous secretions from A strip of tissue called the lingual lingual salivary glands called Von Ebner’s frenulum connects the underside of the glands. tongue to the floor of the mouth. On either side of the frenulum there are two visible The circumvallate papillae are not always veins called the deep lingual veins. Their visible, even when the tongue is fully thickness, color and shape are sometimes extended, and are not usually taken into factored into the tongue examination. account in the tongue examination. Since they are a normal part of the tongue’s Because the tongue possesses a rich anatomy, their seemingly swollen supply of blood vessels and lymphatics and appearance should not cause them to be its structure consists of loose areolar tissue, mistaken for speckles and prickles. it can easily become enlarged, and when this occurs it is interpreted as a diagnostic sign. The foliate papillae, from the Latin folium, When the mouth is closed the tongue “leaf,” are short vertical folds on the lateral completely fills the entire buccal cavity, edges of the tongue towards the back. They pressing its edges against the insides of the are not always visible when the tongue is teeth. This pressure can cause indentations extended. Their size is highly variable; when or “scallops” to appear in the lateral edges of they become visibly distended, they might the tongue, especially when the tongue has be interpreted in Chinese medicine as become enlarged. “scallops,” one of the signs indicating that the tongue body has become enlarged (舌胖 Most of the muscles of the tongue are 大). innervated by the hypoglossal nerve.

Because this nerve originates in the brain stem, paralysis, wryness or trembling of the It is important to be aware that the tongue tongue is an important sign of damage to the coat can be stained by various foods and this central nervous system. In Chinese can confound the examination. Candies and medicine, the functions of the central popsicles made with artificial colors will nervous system are largely relegated to the leave obvious stains that obscure the true heart and the liver, and so abnormalities in color of the coat. Recent consumption of tongue motility are likely to involve one or milk or milk substitutes can cause the both of these two organs. tongue coat to appear whiter than it really is. Foods or herbs high in carotenoids and other staining substances, including egg yolks, Proper Examination of the Tongue and oranges, Coptis (Huang Lian 黄连) and Ass Confounding Factors Hide Glue (E Jiao 阿胶) will all leave a yellowish stain on the tongue. Coffee, tea, In order to perceive the body and coat of and tobacco leave brown stains and recent the tongue accurately and to gauge their consumption of hot or spicy food will colors and moisture content correctly, it is redden the body of the tongue by causing the imperative that the tongue be properly surface capillaries to dilate. illuminated. This is best accomplished with a hand-held full-spectrum light such as an Consumption of hard or coarse foods such OttLite® or similar appliance. Normal as crunchy raw vegetables may remove or lamps will tend to distort the tongue’s color thin out the tongue fur and deepen the color. by adding tints of yellow or blue; this is also Chewing gum can have this same effect, as true of some LED lights. Background room can brushing the tongue, especially if these light, if it is not supplemented with a lamp are done just before the examination. held close to the mouth, will tend to reflect Tongues affected in this manner could be the hues present in the walls and ceiling. All misread. these factors can cause misreading of the colors of the tongue coat and body. If the practitioner suspects that the tongue appearance has been compromised, he may It is vital that the tongue be extended in a have to discount the aspects of the tongue flat, relaxed manner and the mouth opened that are affected and instruct the patient to wide enough to see the back of the tongue. avoid eating or drinking the offending The patient should be instructed not to curl substances before coming to the next visit. or tighten the tongue tip; doing so will cause the tip to redden. And if the tongue is Sometimes changes in the appearance of extended too far and for too long, the overall the tongue cannot be avoided. Missing or color will begin to darken and the moisture broken teeth can cause indentations in the on the coat will dry up, leading to a false body of the tongue, making the tongue reading. appear to be more swollen than it really is.

Patients who have been fasting or who have decreased tongue mobility due to wind strike  There should be an absence of speckles will have coats that are deceptively thick. and prickles (芒刺). Bear in mind that Patients who habitually breathe through the the fungiform papillae are a normal part mouth will dry out their tongue surfaces, and of the tongue surface, and it is only this could cause a misreading of the when these features become dilated and moisture content of the coat. reddened that they can be interpreted as speckles or prickles. The Normal Tongue The information below is meant to provide A “normal” tongue has the following the student with just enough information to attributes: begin reading the tongue on his or her own and to understand the tongue descriptions listed under the various patterns that we will  The body of the tongue should have a be studying. A more comprehensive bright, pale red ( 淡红) color. Most coverage of tongue examination will take English speakers would interpret the place in later chapters. term “pale red” (淡红) as “pink;” but to qualify as normal the color can be neither too pale nor too red. Abnormalities in the Tongue Coat

 The tongue body should have a soft, Changes in Moisture tender (嫩) appearance, like the flesh of a child. It should not be tough (老) or A moist coat (滑苔; Wiseman: glossy coat) lacking in resilience. indicates cold. A normal tongue should be somewhat moist, but the moisture is  The tongue body should be of the considered abnormal when saliva proper size, i.e., it should neither be completely covers the tongue, creating a swollen nor excessively thin. glossy sheen. In Chinese medical terms, a moist coat develops when yang qi is not  The tongue surface should be somewhat effectively transforming fluids. Because the moist (滑; Wiseman: glossy), but not so moisture is clear, the interpretation of this coat is consonant with the aphorism “All moist as to appear wet, and definitely diseases with water humors that are clear, not dry. pure, and cold are ascribed to cold.” The coldness thus indicated could be in the form  The coat should be clean and white and of excess or deficiency cold. just thick enough to hide the underlying

tongue body. The coat should have the 干苔 appearance of a lawn covered with a A dry coat ( ), by contrast, is the light coat of freshly fallen snow. antithesis of the moist coat. There is a lack

58 of saliva covering the tongue fur, making it coldness tends to predominate when it appear rough like a dry washrag. A dry coat combines with phlegm and dampness, and indicates heat damaging fluids. secretions associated with cold are clear.

Changes in Thickness Changes in Color

The thickness of the tongue coat is As explained earlier, the natural color of determined by the length and diameter of the the filiform papillae is white, and so a white filiform papillae. A thin coat (薄苔) is one coat by itself is normal. But a moist white in which the filiform papillae are shorter and coat ( 滑白苔 ) would have the same thinner, allowing the body of the tongue to indications as the moist coat, i.e., cold be visible between the papillae. A thin coat patterns. means that the condition is either one of deficiency or—if there is evil present—of A yellow coat (黄苔) indicates excess heat. weak evil. A thick coat (厚苔) occurs when The association between the color yellow the papillae have become long and thick, and heat seems intuitive in Chinese completely covering the tongue body like a medicine; yellow phlegm, yellow nasal shag carpet. It is a sign of excess and mucus, and bright yellow jaundice all are indicates stronger evil. diagnostic of heat. Microscopic examination of yellow tongue coats reveals increased length and number of filiform papillae.14 If Changes in Cleanness jaundice is present, the yellow color is due to the staining effect of bile pigments. Regardless of the color, the tongue coat should have a clean (净) appearance. In a A slimy yellow coat (腻黄苔) indicates clean coat the filiform papillae appear as damp-heat or phlegm heat. A brownish short fine threads, giving the surface of the yellow coat is called old yellow (老黄苔) tongue the appearance of a velvet cloth. and a blackish-yellow coat is called burnt yellow ( 苔焦黄). Both of these coats A slimy coat (腻苔) has a greasy, turbid indicate inner body heat bind (内热结), a appearance, like ice cream spilled on a severe form of excess internal heat which carpet. Sliminess indicates dampness, occurs when fire evil concentrates in the phlegm or food stagnation. Sliminess is a stomach and intestine. We will encounter visual representation of the buildup of turbid heat bind later in our study of febrile pathogens inside the body and a statement of disease. the spleen’s failure to transform. It is important to point out, however, that cold dampness and cold phlegm might not produce a slimy coat. These patterns often 14 Chen ZL. Chen MF. The Essence and Scientific manifest with a clear, moist coat, since Background of Tongue Diagnosis. Long Beach, CA: OHAI Press; 1989, p. 156-7. 59

Abnormalities in the Tongue Body tongue indicates yin or blood deficiency. It is the result of deterioration of the muscular Changes in Size structure of the tongue and is unlikely to occur except in severe illness or An enlarged tongue (舌胖大) with a moist malnutrition. white coat indicates qi deficiency or water- damp (水湿). The underlying presumption Changes in Tongue Body Color here is that the tongue has become enlarged 舌淡 because of a build-up of untransformed A pale tongue ( ) indicates deficiency water; in this sense the enlargement is a kind of qi and blood if its size is normal or thin. If of water swelling (水肿; i.e., edema). The the tongue is pale and also enlarged with a moist white coat, it indicates yang enlargement is the result of failure of yang deficiency. Note that pallor of the face has qi to transform bodily fluid. the same diagnostic interpretation.

An enlarged tongue with a slimy coat 舌红 indicates dampness. The enlargement in this A red tongue ( ) indicates heat; case has the same underlying whether it is excess or deficiency heat will pathomechanism as the slimy coat; i.e., the depend on the coat. A red tongue with a accumulation of untransformed fluid in the yellow coat indicates excess heat while a red body, and the two signs offer mutual support tongue with a very thin white coat, a peeling for the diagnosis of dampness. coat, or no coat at all (see mirror tongue below) indicates yin deficiency. A deep red It is not always easy to determine if the or crimson tongue (舌绛) indicates blood tongue is actually enlarged, since the tongue heat. This is a type of heat that is lodged body can vary in its natural anatomical size deep in the body and is associated with red from person to person. Many practitioners skin eruptions and bleeding due to frenetic look for scallops on the edges of the tongue movement. We will learn more about blood as signs of enlargement. But it is possible to heat in later chapters. have scallops without enlargement, as can happen in patients with crooked teeth or Red speckles and prickles (红芒刺) occur naturally prominent foliate papillae, and it is when the fungiform papillae have been also possible for the tongue to be enlarged injected with blood. When speckles and without any scalloping. The determination prickles spread across the surface of the of whether a tongue is enlarged usually falls tongue, they indicate a heat pattern that is to the judgement and experience of the particularly vigorous (壮热). Scarlet fever is examining practitioner. an example of a biomedical disease that produces this phenomenon. When numerous A shrunken or “thin” tongue body (舌瘦 red speckles and prickles occur on the tip of 瘪) is the opposite of the enlarged tongue; it the tongue it is an indication of heart fire. is a tongue whose size has dwindled. A thin

If a red or crimson tongue has fissures (舌 A bluish tongue (舌青; Wiseman: green- 裂) on its surface, it is a sign of vigorous blue tongue) indicates qi stagnation. Recall heat damaging fluids. Fissures are imagined that “bluish” ( 青 ) is the color associated to develop on the tongue like cracks in mud with the wood phase and the liver. The blue drying in the sun. The depth of the fissures color is seen as a nearly universal sign of and their number are indications of the stagnation in Chinese medicine, whether it severity of the illness. It is important to occurs on the tongue, the face, or the lips. If recall that the median sulcus—the line the tongue body is purple (舌紫) or bluish- running down the center of the tongue—is a purple ( 舌青紫) it indicates that qi normal part of the tongue’s anatomy and is stagnation has transfomed into blood stasis. not considered a fissure unless it becomes Blue or purple macules (舌紫斑) occurring wide, jagged or excessively deep. on the sides of the tongue are an indication of less severe, more localized accumulation A mirror red tongue ( 镜面红舌 ) is a of static blood. tongue that is red and devoid of filiform papillae. It is called “mirror” because the exposure of the underlying epithelial tissue gives the tongue a reflective appearance even when it is dry. A mirror red tongue indicates damage to yin (伤阴) humor by heat. In milder cases, the tongue coat will only peel off in patches, this is referred to as a peeling coat (剥苔).

Chapter 22 Basic Deficiencies

Missing Ingredients Qi Deficiency The term “deficiency” ( 虚 ; Wiseman: A deficiency of qi results in a reduction of “vacuity”) refers to a reduction in the one or more of the five functions of qi volume of some fundamental ingredient of covered in Chapter 5. Table 22.1 the body. Any of the basic substances of summarizes the signs that differentiate this Chinese medicine—qi, blood, fluids and pattern. essence—are capable of becoming deficient. In addition, modern Chinese medical literature recognizes deficiencies of yin and yang, these later two being spoken of almost as if they were substances in their own right.

Deficiency patterns are mostly characterized by relatively mild symptoms that tend to be chronic (desertion 脱 patterns are an exception to this rule; we will explore these in a future chapter). In this present discussion, we will focus on four Table 22.1 basic deficiencies that are most common in Patients with qi deficiency often have a clinical practice and which form the pale bright complexion (面色晄白), i.e., a backbone of many of the organ patterns that complexion that is pale but which maintains we will study later. These four patterns are a comparatively healthy luster. The pallor qi deficiency, blood deficiency, yang represents a lack of vitality but the deficiency and yin deficiency. brightness indicates that the skin is still Deficiencies are treated by various forms being nourished by blood. This complexion of tonification (补) and usually take some might not be observable in patients with time to resolve. Since most of the patients in darker skin or who have developed a dark Western acupuncture practices have tan. relatively chronic conditions, deficiency Perhaps the most significant signs of qi patterns are probably very common. An deficiency are lack of strength (乏力) and understanding of the differentiation and lassitude of spirit (神疲). “Weakness” refers treatment of the basic deficiencies is to physical exhaustion and “lassitude of therefore critical to clinical success. spirit” mental exhaustion. Mind-body

62 fatigue together with pale bright complexion case of qi deficiency, the stools are looser are the general confirming signs of qi but defecation may still be occurring at deficiency and can occur regardless of normal intervals. which organ is affected. Dribbling of urine after voiding (尿后余 The symptoms of shortness of breath (气沥) occurs if there is a weakening of the 短), faint voice (语声微) and laziness to bladder qi, which causes a lack of force in speak (懒言) all relate to the lung function. the evacuation of urine. Recall that one of the meanings of “qi” is Qi deficiency can be caused by overwork, breath, and that the voice receives its power stress or poor diet. It can also occur in the from the lung qi. In a state of qi deficiency aftermath of any serious illness that damages the lung is often first to be affected, the qi. Loss of blood can also lead to qi resulting in shortness of breath upon deficiency, since the blood nourishes organs relatively mild exertion such as climbing a that are responsible for creating the qi. flight of stairs. And since the lung will lack Finally, qi deficiency can be the result of a the qi necessary to give volume to the voice, generally weak constitution, in which case it the speech becomes faint and the patient is is part of a more general pattern of essence often to weary to converse. deficiency. Treatment of qi deficiency Spontaneous sweat (自汗) refers to sweat requires the use of herb formulas and that takes place during the day with little or acupuncture points that tonify original qi no exertion and with no increase in body and support the function of the lung and temperature. It is distinct from night sweat. spleen. It occurs in the absence of fever and is not Blood Deficiency caused by increased environmental Blood deficiency is characterized by a temperature or intense exercise. reduction in the nourishing activity of the Spontaneous sweat occurs because the blood (Table 22.2). It is important to defense qi (卫气) is too weak to close the remember here that the “blood” of Chinese sweat ducts. It is an example of failure of the medicine is a quasi-energetic phenomenon containment function of the qi (see Chapter with functions that do not correlate well 5). with what Western medicine terms “blood.” Loose stool ( 便溏; Wiseman: “sloppy A patient need not suffer from anemia to be stool”) refers to stool that is semisolid or diagnosed as “blood deficient;” many of the pasty, but not watery. It is a sign that the qi symptoms below could occur in patients deficiency has reduced the spleen’s ability to with normal blood counts. The pattern of transport and transform ingested foodstuff. blood deficiency needs to be understood Loose stool refers to the consistency of the strictly within the aegis of Chinese medical stool but not necessarily its frequency; it is theory. not the same as diarrhea ( 泄泻), which One of the most noticeable signs of blood implies both looseness and frequency. In the deficiency is the change it can produce in

63 the complexion. There are two possible faintness, or mild imbalance. Dizziness is complexions that can occur: Sallow (面色萎 caused by the liver, which stores blood, 黄; Wiseman: “withered yellow”) and pale being unable to properly anchor the qi, lusterless (面色白不华). causing it to spin out of control. The dizzy sensation is often accompanied by flowery A “sallow” complexion is waxy and dull vision (目花), a general term referring to and might possess a subtle yellowish tinge, floaters or loss of visual acuity. Flowery especially in patients of East Asian ancestry. vision is the result of the liver failing to This “withered yellow” skin color is not to nourish the eyes. Since the nails are be confused with jaundice, which has a nourished by the liver (see Chapter 11), they much more obvious yellow color and affects might become pale and brittle. both the skin and the whites of the eyes. The heart is particularly sensitive to any

reduction in the volume of blood in the body and consequently heart palpitations (心悸) and insomnia frequently accompany blood deficiency. The term “palpitations” refers to a rapid, throbbing or skipped-beat sensation in the chest. Sometimes referred to as “fearful throbbing” (怔忡), this sensation is described as unsettling to the patient but not in itself painful. Palpitations and insomnia are caused by a loss of the restraining effect of the blood, the absence of which allows the heartbeat to accelerate and which in turn prevents the spirit from settling comfortably into sleep.

Table 22.2 The symptom of numbness in the extremities, (肢体麻木) is attributable to the A pale lusterless complexion is a pale complexion that has a chalky, almost dry blood having insufficient volume to reach appearance that makes it distinct from the the extremities. The sensation of touch is not pale brightness that accompanies qi clearly explained in Chinese medical theory deficiency. In the pale lusterless complexion but presumably it is at least in part the the skin is not only pale but has begun to product of the nourishing action of blood. show signs of lack of moisture and Lack of nourishment can also cause dry skin nourishment from the blood. and hair and in severe cases, emaciation (形体瘦削; literally “shredding of flesh”). Dizziness ( 眩晕) is one of the key symptoms of blood deficiency. The dizzy Blood deficiency can develop as a result of sensation is usually one of light-headedness, a poor diet or from spleen qi deficiency, which leaves the body unable to form blood 64 out of the food that is ingested. It can be the of nourishment before normalcy is restored. result of blood loss from hemorrhage, The combined pattern of qi and blood trauma, or childbirth. Like qi deficiency, deficiency is treated by tonifying qi and blood can become deficient after long nourishing blood and supporting the debilitating illnesses and can accompany functions of the spleen and stomach. essence deficiency, particularly in the elderly. Yang Deficiency Treatment of blood deficiency requires the use of blood-nourishing medicinals, proper The pattern of yang deficiency contains all diet, and tonification of the spleen. the symptoms of qi deficiency but possesses Acupuncture and moxibustion can be used a colder and deeper quality (Table 22.3). to improve the function of the stomach and The underlying premise is that the term spleen. “yang” in this pattern refers to the fundamental fire of the body and includes all It should be pointed out that “blood five functions of qi but with a greater deficiency” is not mentioned nearly as often emphasis on those of warming and in the Chinese diagnostic literature as “qi transforming. While the symptoms of qi and blood deficiency.” This bears some deficiency focus mainly on the lung with explaining. Since blood is deeper than the some involvement of the spleen, the qi, it can be assumed that any condition symptoms of yang deficiency arise from involving deficiency of the blood will also greater depths, encompassing not only the involve deficiency of qi. This is borne out in spleen but the kidney as well. clinical practice: Symptoms such as palpitations and dizziness are usually accompanied by fatigue and shortness of breath. Since the blood nourishes the organs that are responsible for generating qi, a lack of blood will likely be accompanied by a lack of qi. But the opposite is not necessarily true. A deficiency of qi can and does happen by itself without any appreciable reduction in the amount of blood. That is because qi is a more superficial bodily substance that is constantly being expended and constantly regenerated. A vigorous bout of exercise or a skipped meal will produce a temporary state of qi deficiency, easily remedied by Table 22.3 rest and food. That is not the case for blood One of the most outward signs of yang deficiency, which can require some period deficiency is an inability of the body to

65 warm itself. The patient will likely yang is affected, there will be clear food experience fear of cold (怕冷), a term which diarrhea ( 下利清谷)—a kind of watery, here refers to a sensation of chilliness that is odorless stool that contains undigested food relieved by blankets or heavy clothing. This particles. If the kidney yang is affected there chilliness is different from the chilliness will be long voidings of clear urine (小便清 produced by invasion of wind-cold, the 长). latter being characterized by chills which are not relieved by blankets and which are The coldness and deficiency of this pattern accompanied by fever. In the case of yang makes the pulse slow and weak. The pale, deficiency there is no fever and in spite of moist, swollen tongue reflects the general the patient’s chilliness, there may also be state of deficiency cold as well as the non- spontaneous sweat. In severe cases the transformation of fluids. patient will experience reversal cold of the Like qi deficiency, yang deficiency can be limbs (四肢厥冷), a palpable frigidity that caused by chronic or unresolved illness and extends all the way to the elbows and knees. poor diet. Yang can become damaged by The odd use of the term “reversal” (厥) here exuberant yin evils due to external cold or is an attempt by ancient theorists to describe by consumption of cold or raw foods. This the underlying mechanism of this symptom. pattern can also be the result of yin or blood The cold limbs are caused by diminished deficiency failing to support the yang. And yang qi withdrawing its warmth into the because of its deeper source in the body, inner body, “reversing,” so to speak, its yang deficiency is more likely than qi normal outward radiation to the limbs. deficiency to be accompanied by a deficiency of essence. For this reason The complexion may be pale bright, as in traditional textbooks will often blame this the case of qi deficiency, or in some cases it condition on sexual intemperance. might develop a subtle bluish tinge, in which case it is called somber white (苍白). The Yang deficiency is treated by warming, blue tinge is caused by the congealing tonifying, and if necessary, transforming effects of cold inhibiting the normal flow of water. This is accomplished through the use qi and blood on the skin. of herbs that tonify yang and expel cold, and by the use of moxibustion. The treatment As in the case of qi deficiency, there will will typically target the spleen, the kidneys be a lack of strength and lassitude of spirit. or both. But the mind-body fatigue may be more severe in yang deficiency, resulting in Yin Deficiency hypersomnia (嗜睡)—a state in which the When speaking of bodily substance, the patient sleeps for abnormally long periods term “yin” refers to the principle of water yet remains drowsy during waking hours. and includes all the physical, fluidic components of the body. In this sense it In yang deficiency there is often a includes all the functions of blood and reduction of the ability of the spleen and shares most of the blood’s nourishing kidneys to transform water. If the spleen

66 properties. But “yin” also includes the “Vexing heat in the five hearts” is one of ability of water to act as a kind of radiator the most telling signs of this pathological fluid that keeps yang fire in check (see process. It refers to a feeling of vexation Chapter 3). A deficiency of yin, therefore, (烦) combined with palpable warmth in the will include most of the symptoms of blood palms and soles and a subjective sensation deficiency but with the added signs of of heat in the sternum. Note that this deficiency heat. Yin deficiency usually has symptom is the antithesis of the frigid limbs its roots in kidneys, but its symptomatic that occur in yang deficiency. In this case expression is often most evident in the heart there is not enough yin to hold the body’s or the liver. yang fire in its core, causing it to effuse abnormally outward toward the extremities. “Night sweat” refers to perspiration that occurs during the night, especially when sleeping, but that ceases by dawn. Yang qi normally withdraws more deeply into the body during sleep, in the anticipation that there will be a stockpile of yin humor to keep it in check. In states of yin deficiency this stockpile does not exist, resulting in the sleeping body’s unrestrained heat escaping toward the surface and causing the opening of the sweat ducts to release perspiration. “Upbearing fire flush” refers to a flushed

Table 22.4 red complexion due to heat rising upward from within the body. It typically develops The most distinctive signs of yin when there is pathological heat in the deficiency are those of deficiency heat, organs, and can occur in patterns of both including vexing heat of the five hearts (五 excess and deficiency heat. In this case the 心烦热), night sweat, and upbearing fire heat is due yin deficiency, and this will flush (面红升火). These all occur as a result cause the flush to be restricted to the of a deep imbalance between the forces of cheekbones with the rest of the face yin-water and yang-fire in the body. remaining normal or pale. This complexion In a state of yin deficiency the principle of is to be distinguished from the flushing that water diminishes while the body’s fire occurs in excess heat, which typically remains relatively strong. The result is involves the entire face. comparable to a car overheating due to loss Both yin and blood deficiencies can of radiator fluid. The overheating is the unsettle the heart, causing palpitations and result—not of increased fire—but of lack of insomnia. But the added element of the counterbalancing effect of water. deficiency heat causes the yin deficient

67 patient to suffer vexation (烦) during the almost always involves some deficiency of waking hours. essence. As in all conditions involving essence, traditional Chinese texts are quick The symptoms of dizziness and flowery to list sexual intemperance as a cause of the vision are the result of failure of yin to illness. nourish the liver and keep liver yang in check; this same symptom occurs in blood Yin deficiency is treated by nourishing yin deficiency. In severe cases emaciation and, if necessary, clearing deficiency heat. occurs because of a reduction of the The kidney is the organ most often targeted, nourishing and flesh-sustaining properties of together with the other organs being yin-blood. affected. Therapy involves the use of yin- nourishing medicinals together with Yin deficiency is the only pattern in this acupuncture. chapter to produce a red tongue body. It does so because of the enflaming presence Differentiating Basic Deficiencies of deficiency heat. Yin deficiency will also As we learned earlier, qi deficiency is produce a diminished tongue coat. The coat capable of occurring alone while blood of the tongue is the result of the body’s yin deficiency most often comes mixed with being “steamed” upward by stomach qi. A symptoms of qi deficiency. The practical lack of yin will cause the tongue fur to clinical distinction, therefore, is not so much become thinner or to shed in patches to between qi and blood deficiency but produce a peeling coat (剥苔). In more between qi deficiency as a solo pattern and. severe cases the tongue surface will qi and blood deficiency as a combined depapillate completely, resulting in a mirror pattern. red tongue. Qi deficiency occurring by itself is The body’s yin is imagined to fill the distinguished by a pale bright complexion. If arteries together with the blood. As in the it combines with blood deficiency the case of blood deficiency, therefore, a complexion will tend toward pale lusterless deficiency of yin will result in a thin pulse. or sallow. In qi deficiency there is fatigue But since yin deficiency is accompanied by and lassitude of spirit with the patient the presence of heat, the pulse will also be having no trouble falling asleep; with qi and rapid. blood deficiency there may be fatigue but Yin deficiency is often the result of there will likely also be insomnia. chronic disease, especially febrile disease, Furthermore, in a state of pure qi deficiency due to the tendency of heat evils to damage there should be no evidence of blood failing yin humor. Yin deficiency can also be the to nourish such as pale brittle nails, result of poor diet, blood loss, or yang emaciation, or dry skin and hair. The pulse deficiency causing a failure to generate yin. and tongue of the two patterns are similar Of the four patterns discussed in this and require some expertise to distinguish chapter, yin deficiency is the one most (see Table 22.5). closely associated with the kidneys and

Table 22.5 Table 22.6 When comparing qi vs. yang deficiencies Yang and yin deficiencies are easily and blood vs. yin deficiencies you should be distinguished by their respective able to recognize the signs that the patterns presentations as cold or heat patterns have in common as well as the signs that respectively. Table 22.6 highlights the make each unique. The Venn diagrams in contrast between the two. Figures 22.1 and 22.2 may prove helpful.

Qi vs. Yang Deficiency

Figure 22.1

Yin vs. Blood Deficiency

Figure 22.2

Chapter 23 The Six Environmental Excesses in Depth

The Internal and External Climate body as capable of independently causing excess, as if it were creating its own In Chapter 15 we explored the conceptual inclement weather from within. basis of disease causation in the Chinese medical model. We saw that the external In modern Chinese medical textbooks the forces of nature play a significant role in “environmental” excesses are sub-classified understanding that causation. We learned as “external” or “internal,” depending on whether they come from outside the body or that the six environmental excesses ( 六 from within it. Of the six environmental 淫 )—wind, cold, damp, fire, summerheat excesses, only summerheat retains its and dryness—produce symptoms that are original identity as a purely meteorological intuitively recognizable, each writing its cause of disease. own unique signature on the disease pattern it causes. We must now hammer down the Cold, for example, can invade the body specifics, listing signs and symptoms in all from the outside in the form of the detail needed for real-life application. environmental cold, or it can “arise from within” as a result of yang deficiency. And But before we get started, there is one so it is with wind, damp, fire, and dryness; more wrinkle we have to unfold. each is capable of developing entirely from Historically speaking, the six excesses began within the body, each through its own as strictly exogenous forces, i.e., evil unique pathomechanisms. weather that invaded the body to cause disease. Over time, however, the identity of In this chapter we will take pains to these evils became somewhat divorced from differentiate between the external and their role as meteorological agents. Instead, internal species of each environmental they came to be seen as patterns of disease excess being studied. But the reader must be in their own right—as disease processes reminded of the distinction between the rather than disease causes. terms external/internal ( 外 / 内 ) and exterior/interior ( 表 / 里 ). “External” and Because of this, Chinese medical theorists “internal” refer to where a disease comes were free to expand the pathways by which from, i.e., from the external environment or the six environmental excesses could cause the internal body. “Exterior” and “interior” disease, and the body itself came to be seen refer to where a disease is located, i.e., on as one of those pathways. Since these the surface of the body or in its interior. “external” causes had now come to be seen as at least partly metaphorical, it was not These two distinct forms of classification much of a stretch to imagine the internal are necessary because some external evils

71 are capable of producing interior patterns. If caused by the wind wafting over the surface external cold, for example, invades the of the body while the fever (发热) is the exterior of the body, the resulting disease result of the defense qi (卫气) being fired up pattern is referred to as “exterior cold” (外 to repel it. 寒), i.e., cold located on the surface of the body. But external cold can also invade the The blustery force of evil wind can interior of the body, in which case the term obstruct other types of movement in the body, much as a powerful headwind might “external cold” (外寒) refers only to the impede one’s ability to walk forward. This cause of the disease while the disease obstructive effect causes stagnation in the pattern itself is called “interior cold” (里寒). channels and this in turn results in Wind generalized pain (身痛). The pain is often worse in the upper body, particularly the External Wind head, nape and shoulders—areas with the greatest exposure to drafts. External wind is classified as a yang evil due to its violent and invasive nature, its Since the lung is the most superficial of all preference for targets on the upper and outer the organs, it is uniquely vulnerable to parts of the body, and its tendency to induce attacks by external wind, causing runny nose movement. External wind putatively owes or nasal obstruction (the nostrils being the its origin to drafts. When it attacks the body, portals of the lung) and possibly cough. it rarely penetrates farther than the surface, Most colds and flus manifest as external almost always manifesting as an exterior wind in their earlier stages. (外) pattern. A floating pulse (浮脉) is an important External wind is characterized by the indicator of external wind. The floating sudden onset of the following pattern of effect is the result of the body’s defense qi symptoms: being pushed to the surface to repel the invader. The effect of external wind on the  Chills and fever tongue will vary depending on the other  Headache and body pain, particularly in evils that accompany it (see below). the upper body  Respiratory symptoms such as cough, External wind usually attacks the body runny nose or blocked nasal passages together with additional evils such as cold,  Floating pulse heat, and dampness. We will leave the study of wind-dampness for a later chapter. For The simultaneous presence of chills and now, we will focus on the patterns of wind- fever (恶寒发热) is considered one of the cold and wind-heat. strongest indications of contraction of external wind. The chilly sensation, literally “aversion to wind” (恶寒), is thought to be

Wind-Cold and Wind-Heat as part of the Western triage process, the reading will not help to determine whether Wind-cold (风寒) and wind-heat (风热) the patient is suffering from wind-cold or present with the general signs of external wind-heat. Instead, the practitioner must rely wind but each with its own distinct bias on the patient’s report of their sensations, towards cold or heat. Wind-cold is a supplementing this with other signs gathered relatively straight-forward disease pattern; it from the four examinations. is caused by the invasion of the surface of the body by external wind combining with cold. Wind-heat, however, is more complex. It too is the result of invasion of external wind, but the presence of heat requires some explaining.

One theory posits that wind-heat begins as wind-cold but quickly transforms into wind- heat due to the obstructive effects of cold (more on stagnation transforming into heat later). Another theory posits that wind-heat is the result of “warm evils” ( 温邪) Table 23.1 attacking the surface of the body. These Since cold is particularly obstructive to the evils are not physically hot but transform movement of qi, wind-cold can be expected into heat once they have invaded the body. to create more severe body pain than wind- This later explanation is a more modern one, heat. This is consistent with the aphorism, originating in the warm disease school of the “Where cold prevails there is pain.” The late Qing Dynasty. We will examine the increased fever in wind-heat will cause historical roots of wind-heat in greater detail damage to liquids and therefore thirst; there when we study febrile disease in later is no thirst in wind-cold. chapters. For now, we need only differentiate its signs and symptoms from Not all external wind patterns involve those of wind-cold (see Table 23.1). respiratory signs, but if they should do so, one could expect clear and watery phlegm in Both wind-cold and wind-heat cause patterns of wind-cold. This is in keeping sensations of chills and fever, but in the case with the dictum, “All disease with water of wind-cold the sensation of chilliness will humors that are clear, pure and cold are be more pronounced while in wind-heat the ascribed to cold.” Wind-heat, by contrast, stronger sensation will be that of fever. It is will produce sticky yellow phlegm due to important to remember that in Chinese the thickening and darkening effects of heat pattern differentiation, the intensity of fever on body fluids. One of the most is not based on a thermometer reading. distinguishing signs of wind-heat is the While it makes sense to take the temperature pronounced presence of sore throat. Wind-

73 cold, by contrast, might produce an itchy acrid medicinals that disperse wind and by sensation in the throat but generally does not wind-dispersing acupuncture points. cause the throat to become sore. Internal Wind While all forms of external wind will produce a floating pulse, wind-cold is Internal wind ( 内风), also called “liver distinctive in that the pulse will also be tight. wind” (肝风), is a complex interior pattern This is due to the tightening effects of cold. that we first encountered in our study of the The pulse associated with wind-heat, by liver in Chapter 11. Unlike external wind, contrast, is not tight and is faster due to the which is the result of physical drafts accelerating effect of heat. It should be attacking the surface of the body, internal pointed out, however, that the pulse wind is entirely metaphorical, the result of occurring in wind-cold might also be faster wildly deranged movement of the body’s than normal since this pattern also exhibits own qi. fever, albeit a lower one. The principal This deranged movement produces three distinction between wind-cold and wind- distinct sets of symptoms that often overlap: heat pulses, therefore, should be the presence or absence of tightness and not the  Signs of yang qi ascending violently pulse’s speed. upward, including sudden severe headache or dizziness; There is little difference between the appearance of a normal tongue and that of a  Signs of “wind” inducing abnormal tongue presenting in wind-cold: The tongue movement of body parts, including body is unchanged and the coat is white and shaking, tremors or convulsions; moist—almost exactly what we would  Signs of “wind stroke” ( 中风), a expect in a normal tongue. As we learned in phenomenon characterized by sudden Chapter 21, however, warm febrile disease loss of consciousness and/or produces more noticeable changes in the paralysis—the “stroke” of biomedicine. tongue than other pathogens, and wind-heat is a pattern that evolved out of warm disease The development of internal wind usually theory. Since the heat present in wind-heat is represents a deep and serious threat to the just on the surface and is usually not very life and health of the patient. Internal wind intense, the tongue body will become red almost always involves the liver, turning the only on the tip and margins, and the coat normal free-coursing produced by this organ will be slightly yellow. into a destructive and destabilizing internal storm. In the words of the Su Wen, “All The differentiation between wind-cold and wind with shaking and dizziness is ascribed wind-heat is an important one in modern to the liver.” clinical practice since it is the first step in the diagnosis and treatment of most common There are three sometimes overlapping colds and flus. External wind is treated by causes of internal wind, and the exact signs

74 and symptoms will depend on which of severe and is accompanied by a pulling these are most prominent: sensation (头痛如掣) that is likened to an iron band squeezing the head. External wind  High fever can cause a kind of fire- is accompanied by exterior signs and storm effect on the body’s qi; this is symptoms such as chills and fever. While referred to as extreme heat stirring wind internal wind can occur as a complication of 热极生风 ( ) febrile disease, this usually occurs in the  Liver yang can become “hyperactive” later stages when the fever is much higher (亢) and ascend violently to the head. and the chills are gone. Likewise, tremors,  Yin-blood can become deficient, failing convulsions and dizziness are characteristic to provide the inertia needed to resist symptoms of internal wind that rarely occur the motion of qi; this causes the qi to in external wind. spin out of control. Internal wind is treated by wind- In addition to the above three mechanisms, extinguishing ( 熄风) medicinals and by phlegm is often a complicating factor. A lowering fever, anchoring yang, or tonifying detailed examination of internal wind is well yin-blood, depending on which of these is beyond the scope of this present chapter; we causing wind to stir. will return to this condition in much more detail when we study liver patterns later in Cold this text. For present purposes, we need only When speaking of cold as a cause of distinguish between internal and external disease, a distinction must be made between wind, and this task is fairly straightforward external (外) and internal (内) cold. External (see Table 23.2). cold refers to cold invading the body from the external environment; internal cold refers to cold originating from within the body as a result of debilitation (衰) of the body’s own yang qi.

To understand the relationship between external and internal cold, imagine the body as a warm cabin nestled in a snowy wilderness. The flame in the cabin’s fireplace is like the body’s yang qi; the cabin’s walls and windows are like the Table 23.2 body’s defensive exterior. So long as logs are crackling in the fireplace and the walls Both external and internal wind tend to and windows are tightly sealed, the cabin develop suddenly and both are typically will remain warm and comfortable—just as accompanied by headache. The headache the body remains warm so long as its yang caused by internal wind is particularly

75 qi is vigorous and its defensive exterior Cold causes chilliness (恶寒 literally, secure. “aversion to cold”), lack of warmth in the extremities (四肢欠温), a desire for But if a window were broken or a door left ajar, the cold outside air would fill the cabin, warmth, a subjective sensation of cold causing the temperature to drop even as the in the abdomen or coldness and pain in fireplace burns. This is what happens when the joints. external cold invades the inner body: It  A somber white facial complexion (面 pushes its way through the defensive qi and 色苍白), replaces the body’s internal warmth with its This complexion is described as a pale own frigid presence. with a tinge of blue. The pallor is due to a lack of the flushing effects of bodily But there is another way the cabin can get heat while the bluish tinge is a result of cold. If the fire is allowed to go out the the tightening effect of cold on the temperature will drop even if the doors and vessels at the body’s surface. windows are tightly closed. This is what  A slow and/or tight pulse. happens when internal cold arises from The congealing ( 凝 ) and stagnating within the body: Warmth recedes and cold effects of cold cause the qi and blood to accumulates due to a diminution of the slow down and the vessels to tighten. body’s own yang fire.  A pale and possibly swollen tongue External and internal cold are not mutually with a moist white coat. exclusive; one tends to give rise to the other. The pallor of the tongue body is due to Imagine a fireplace running out of fuel as it a lack of the flushing effects of bodily tries to warm a cabin with broken windows. heat while the moisture and swelling In like manner, external cold invading the represent the build-up of untransformed body can exhaust its yang qi. On the other fluids. hand, if the cabin’s fire were allowed to  Pain in the body regions most affected. burn out on its own, the slightest draft would This is due to the congealing and soon fill the cabin with cold air. In like stagnating effects of cold evil. Areas manner, a deficiency of the body’s yang qi most often affected are the abdomen, would make it exceptionally vulnerable to joints, and lower back. invasion of external cold evil.  An increase in thin clear secretions and excretions. Although external and internal cold are This is due to a waning of the body’s distinctive causes of disease, their similarity yang fire and a resultant increase in yin in nature, their mutual supportiveness and water. As the aphorism states, “watery their tendency to overlap pathologically humors that are thin clear and cold are cause them to share a number of symptoms. ascribed to cold.” Examples include These include the following: copious clear urine, clear-food diarrhea  Sensations of cold. and clear thin phlegm.

 A lack of thirst or a desire for warm to the inner body through two different fluids. pathways: It can penetrate directly from the The lack of thirst is due to the outside environment or it can enter through prevalence of yin water in the body; the the ingestion of cold food and drink. If the desire for warm fluids is driven not by cold is invading directly from the actual thirst but by a craving for environment, it is sometimes accompanied warmth. by dampness, in which case it is called cold- damp (see “dampness” later in this chapter).

External Cold Patterns Regardless of the path the cold takes, once it reaches the body’s interior it will manifest If external cold attacks only the surface of as one of two different patterns, depending the body—without penetrating to the on whether the dominant pathology is one of interior—it will typically manifest as a exuberant cold evil (盛寒邪) or deficiency of wind-cold pattern. We have already studied yang qi. wind-cold; it is distinguished from other types of cold in that the chilly sensation is If exuberant cold evil dominates the accompanied by a sensation of fever (i.e., clinical picture, the pattern will have a more “chills and fever”) and the pulse is not only excess presentation. In our wilderness cabin tight but also floating. These two paired metaphor, this would be like cold air filling symptoms—chills combined with fever and the cabin through a broken window in spite pulse that is both tight and floating—are of an ongoing fire in the fireplace. The cardinal signs of wind-cold. symptoms of such a condition will typically be more acute; the coldness and pain more The terms “wind-cold” ( 风寒) and severe. There could be acute cold abdominal “exterior cold” ( 表寒) are virtually pain or sudden and violent (暴) vomit or synonymous in modern Chinese medical diarrhea. The complexion will be bluish (青) texts. To avoid confusion, however, the and the pulse tight. reader should remember that the term “exterior” ( 表 ) does not have the same If insufficiency of yang dominates the meaning as “external” (外). Exterior cold clinical picture, the pattern will have a more (表寒) refers only to the fact that the cold deficient presentation. In this case, the body’s yang qi is damaged by the invading evil is located on the exterior surface of the cold. Using our wilderness cabin metaphor, body. External cold (外寒) refers to the cold this would be like a fireplace that runs out of evil itself as a disease-causing force wood trying to keep up with the cold air originating in the external environment. rushing in. The symptoms will typically be External cold is not only capable of milder and more chronic. In addition to the attacking the exterior of the body: It can also general cold signs listed earlier, the patient plough its way into the interior. In practical will have a liking for quiet, a curled up lying clinical terms, external cold can gain access posture, long voidings of clear urine, clear-

77 food diarrhea, and a pulse that is slow and defines the pattern of cold shàn (see Table possibly weak. 23.3).

Since cold evil can damage yang and yang deficiency can engender cold, the distinction between these two presentations is not hard and fast. And just as many of the symptoms overlap, so do many of the medicinals and acupuncture points. In general, patterns dominated by the invading cold evil will be treated by warming and dispersing while patterns dominated by yang deficiency will be treated by warming and tonifying. Moxa, for example is a warming remedy that can Table 23.3 be applied with a tonifying or reducing technique depending on the demands of the Cold Pain pattern. Another pattern caused by external cold 16 Cold Shàn invading the interior is cold pain (寒痛) (Table 23.4). This pattern is characterized by A good “textbook” example of external abrupt-onset severe abdominal pain that is cold invading the body is a disease entity the result of a direct strike ( 直中) of 15 referred to as cold shàn (寒疝; Wiseman: environmental cold on the spleen and “cold mounting”). In modern usage, the term stomach or from the ingestion of cold food “shàn” almost always refers to inguinal and drink. The principal pathomechanism hernia or epididymitis. One potential cause here is acute, inner-body stagnation caused of shàn disease is external cold invading the by the congealing effects of rapidly invading liver channel. The cold evil will obstruct the cold evil. flow of qi along the pathway of this channel, particularly in the section that curves Since cold pain is an excess cold pattern, through the inguinal region and genitals. the pain is exacerbated by pressure as well This causes the coldness, swelling, and pain in the genitals and inguinal region that 16 In the present context the term “cold pain” refers to a specific pattern of exuberant cold evil in the abdomen. In other contexts “cold pain” is a general term referring to any pain exacerbated by cold and 15 The term “shàn” (疝) is translated by Wiseman as relieved by warmth. Chinese texts will sometimes “mounting.” He explains this choice by the presence make the distinction by using the classical word for of the mountain radical (山) and the fact that shàn is cold, 寒 hán, when referring to cold pain as an acute a historical name for various conditions characterized abdominal pattern and the more modern Chinese 冷 by masses that protrude through the lower abdomen lěng when referring to cold types of pain in general. or genitals, giving the appearance of a mountain Unfortunately, it is difficult to convey this distinction being pushed up. See Wiseman N, Ellis A. in English translation. See Wiseman N, Ellis A. Fundamentals of Chinese Medicine, revised edition. Fundamentals of Chinese Medicine, revised edition. Brookline, MA: Paradigm Publications; 1994, p. 196. Brookline, MA: Paradigm Publications; 1994, p. 195. 78 as exposure to cold (see Chapter 19). If the because cold air is leaking in—but because cold interferes with splenic transformation the flame in the fireplace is simply not and the downbearing of stomach qi, there strong enough. could be clear diarrhea or clear vomit. In some cases the cold will “freeze up” the In theory, internal cold is a pattern of pure intestine and cause constipation. deficiency. In actual practice, however, the condition could be complicated by the presence of small amounts of external cold or damp. It is possible, for example, that the yang was damaged at some time in the past by a cold or cold-damp invasion, in which case a small amount of excess cold or dampness might still persist side-by-side with the yang deficiency. It is also possible that the body’s weakened yang is allowing small amounts of external cold or dampness to seep in from the environment. Both of Table 23.4 these scenarios exemplify the fact that external and internal cold are not mutually Like other cold patterns, the tongue in cold exclusive. pain will have a moist white coat and a pale body. But the severe stagnation may cause Cold Diarrhea the tongue body to turn a bluish color (青). An example of a disease pattern attributed The fact that the stagnation is occurring primarily—but not exclusively—to internal deep in the body is reflected by a pulse that cold is cold diarrhea (寒泄) (Table 23.5). is not only wiry and tight but also deep. In severe cases, the pulse could be “hidden” The primary symptom of this condition is clear, thin, watery diarrhea that may contain (伏脉); i.e., so deep that substantial pressure undigested food particles, together with is needed to find it. general signs of cold such as lack of warmth Internal Cold in the extremities and a drop in body temperature. The presence of abdominal Internal cold (内寒) is sometimes referred pain relieved by warmth and pressure is a to as “cold arising from within.” It is cold sure sign of deficiency cold, as is the deep that develops entirely as a result of and slow pulse. But the pulse might deficiency of the body’s yang fire, without alternatively be tight and wiry, a sign of cold any invasion of external cold. In this sense, excess. In addition, this pattern is often internal cold is nearly synonymous with complicated by signs of dampness. yang deficiency, a pattern that we covered in detail in Chapter 22. If internal cold were The treatment of cold diarrhea involves the likened to a wilderness cabin, the inside use of warm medicinals that not only warm temperature would be dropping—not 79 the yang qi but also drive out any cold evil numerous pathological changes in the body, that might be present. the stage where disease often reaches its climax. And while wind is swiftest in its descent on the body, once fire develops it is often the most ferocious. Its destructive force is evident in the colorful terms that Chinese medicine uses to describe its action, terms such as “blazing” ( 燔), “steaming” (蒸) and “scorching” (灼), to name a few.

Symptoms of fire can include the following:

 Increases in bodily temperature. The most obvious effect of fire is an Table 23.5 increase in temperature. This can take We must conclude our study of cold with the form of generalized fever (身热) or one final note. Since it is the nature of cold it can occur as localized temperature to stagnate and congeal ( 凝 ); and since increases, often combined with redness stagnation fosters the creation of heat, it is and swelling. Sometimes fire produces common for cold patterns to transform into subjective burning sensations in the heat patterns, as we are about to learn. abdomen and ribsides.

Fire  Reddening of bodily tissue. The color red is the universal emblem We must begin our study of fire by of fire, a color that fire disease will clarifying its nature and source. Unlike the paint across the face, lips, eyes, tongue other five environmental excesses, fire does body, throat or on the skin surface in not come from the weather, at least not the form of rashes. directly. Instead, fire is usually the result of transformation of other evils. To be sure,  Damage to fluids (津液损伤). fire can invade the body from the outside world, but it does so in the form of “warm” One of the most destructive effects of evils—theoretical substances that are not fire is the parching of bodily fluids. physically hot. It does not come from hot Warning signs that heat is damaging weather per se. If the cause of a disease is fluids include dry mouth, thirst, short actual environmental heat, it is classified as voidings of dark urine and constipation. summerheat, a separate environmental Damage to deeper levels of bodily fluid excess which we will cover below. is referred to as “damage to yin” (伤阴 ), and symptoms produced by this We have learned that wind is the “mother” more serious form of dryness will be of a hundred diseases, but it is fire that is described below. often her child. Fire is the end product of 80

or surging (洪). Deficiency heat will  Thickening and opacification of cause the pulse to become thin (细). secretions and excretions. Whereas cold causes watery and clear  Red tongue body; coat varies. secretions, fire does the opposite: It Fire will make the tongue body red, but thickens and opacifies like the cooking the color and quality of the coat will of gravy. Nasal mucus ( 涕 ) and vary according to the type of heat and phlegm, for example, become thick and the presence of other evils. Excess heat sticky, with color ranging from opaque causes the tongue coat to become white to dark yellow. If fire takes the yellow; in patterns of phlegm-heat and form of damp-heat, it can produce damp-heat the coat will be yellow and cloudy urine, sour vomit and thick, slimy. Deficiency heat will cause a thin foul-smelling diarrhea (see damp-heat white coat and in severe cases a mirror below). tongue ( 镜面舌)—i.e., complete disappearance of the tongue coat (see  Bleeding and red skin eruptions (斑疹). Chapter 21). Fire causes “frenetic movement of blood heat” (血热妄行), a process that is likened to hot liquid splashing out of Causes of Fire a rapidly boiling pot. Frenetic In the narrow sense, “fire” ( 火 ) refers movement causes hemorrhage as well specifically to one of the six environmental as red maculopapular skin eruptions (斑 excesses and therefore tends to be reserved 疹). for excess heat patterns, especially those in which the heat is severe or where it rises  Disturbances of spirit. upward from internal organs. In the broader Fire produces many forms of spirit sense that we are using here, “fire” refers to unrest, ranging from vexation (烦) and pathological heat in general, both excess and insomnia in mild cases to manic deficiency types, and as such it has many agitation (狂躁) and delirious speech possible causes. (谵语) in the more extreme.  Fire can be the result of invasion of

pestilential qi (疠气) or warm evils (温  Rapid pulse; other qualities vary. 邪). Although fire causes the pulse to Pestilential qi and warm evils are accelerate, that is not the only change it disease-causing forces that originate in induces. A rapid pulse (数脉) will be nature but—unlike summerheat—are compounded by additional qualities not physically hot. They transform into depending on the type of heat involved. fire only after they are released in the Excess heat will manifest in forceful body—like a hand grenade that 有力滑 ( ) pulse types such as slippery ( ) explodes after being thrown in a room.

Wind-heat is an example of warm the staged progression of externally- disease attacking the surface of the contracted febrile disease (外感热病). body. We will have much more to say We will have more to say about the about warm disease in later chapters. various transformations of fire occurring in febrile disease in later chapters.  Fire can form spontaneously from

stagnation. As we learned in Chapter 16, this  Fire can develop from hyperactivity of process is based on the observation that yang. organic matter left to decompose “Hyperactivity” (亢) here refers to a becomes warmer. We will refer to this process whereby the body’s own yang transformative mechanism in the future fire becomes overly powerful, as the “compost pile” effect: Any dangerously tipping the scales of the substance left to stagnate in the body body’s yin-yang balance. Although will eventually become “hot.” This is hyperactivity of yang can be the result true of qi, blood, bodily fluids and of yin deficiency or emotional ingested food: All are capable of a kind disturbance (see below), it often of spontaneous combustion if they are develops without a clear instigating allowed to remain motionless. External cause. Hyperactive yang should not be evils that invade the body are capable confused with fire forming from of this same fire-forming process; this stagnant substances or from invasion of is particularly true of dampness and— external evils. The organs most likely ironically—cold, since both of these to develop hyperactivity of yang are the evils tend to depress motion. liver and heart.

 Fire develops when external evils move  Emotional disturbance can transform from the surface of the body to the into fire. interior. We learned in Chapter 17 that any of In this process, exterior patterns the seven affects could transform into characterized by chills and fever and a fire if carried to an extreme. The organs floating pulse will transform into most vulnerable to this disease interior excess heat patterns when evils mechanism are the heart and liver. push past the surface and invade the interior of the body. This interiorization  Depletion of yin can cause deficiency heat. ( 入里) of the disease is marked by Yin deficiency can lead to the disappearance of chills, an increase in development of deficiency heat as a fever and a pulse that changes from result of a reduction of the ability of yin floating (浮脉) to surging (洪脉). The to check yang fire in the body. When formation of fire plays a critical role in

82 we encountered this phenomenon in damaged by excess types of fire, Chapter 3, we likened it to the deficiency heat often occurs in the later overheating of a car due to a lack of and more chronic stages of febrile radiator fluid. Since yin is easily disease, after the fire has scorched the body’s yin humor.

Table 23.6

Exterior Heat vs. Interior Heat; as “aversion to heat” ( 恶热). The patient may experience a scorching (灼) sensation Fire disease should first be classified in the chest and abdomen. The whole face according to whether it is located on the tends to flush red. Disturbances of the spirit exterior (表) or interior (里) of the body. In are severe, including agitation, delirium and this context exterior heat is synonymous in extreme cases, mania (see Table 23.6). with wind-heat, which we have already described above. Wind-heat is always a By contrast, deficiency heat will present pattern of excess heat. Interior heat (里热) with subtler but deeper and more persistent refers to all other forms of heat besides heat signs. Rather than a generalized fever, wind-heat, and is sub-classified into excess for example, the sensation of heat may be and deficiency types. present only in the palms and soles—the so- called “vexing heat of the five hearts” (五心 Excess Heat vs. Deficiency Heat 烦热) described in Chapter 12. If a Interior heat patterns must always be generalized fever occurs, it is more likely to differentiated into excess heat ( 实热) or come later in the day and will feel as if it is deficiency heat (虚热). We first encountered radiating from deep within the body, a the patterns of excess heat and deficiency phenomenon known as “steaming bone tidal heat in Chapter 19; it remains now to fever” ( 骨蒸潮热 ). The change in delineate them in more detail (see Table complexion will also be subtler, with only 23.6). the cheeks turning red. The spirit disturbances will be milder but more Excess heat develops from invasion of persistent, manifesting as chronic vexation evils from the external environment; from or insomnia. transformation of stagnant bodily substances; from hyperactivity of yang or Excess heat will cause the tongue body to from affect damage transforming into heat. turn red and the coat to turn yellow. Deficiency heat is a by-product of yin Deficiency heat will also redden the tongue, deficiency, which is itself the result of old but its more enduring nature can cause the age, poor nutrition, or intemperate habits. surface to fissure—a deeper tissue change Deficiency heat can also develop from that requires a more prolonged disease excess heat damaging yin (see Chapter 22). course. Deficiency heat does not change the color of the tongue coat. Instead, the coat As a general rule, excess heat tends to be will remain white but will thin out or peel more ferocious and acute while deficiency away in patches. In severe cases the coat heat tends to be milder and more chronic. will disappear altogether leaving the tongue Excess heat will usually distinguish itself mirror red (镜面红) (see Chapter 21). with hotter, more fulsome symptoms. There may be vigorous fever (壮火) accompanied Both excess heat and deficiency heat will by intense discomfort in the presence of cause rapid pulses, but in the case of excess warm environments, a symptom referred to heat the pulse will be wider in diameter and

84 more forceful. In deficiency heat the pulse yin-blood. Since emaciation is the result of will be rapid and thin. deep and prolonged changes in the body it is not likely to occur in uncomplicated cases of Excess heat causes more direct and excess heat. Finally, both excess and immediate signs of damage to fluids, deficiency heat can cause bleeding and red including thirst with desire for cold drinks, maculopapular eruptions (斑疹; a general dark urine and constipation. These term for skin rashes) due to frenetic symptoms are caused by damage to liquids movement of blood. The overall (津), i.e., the more superficial and visible presentation of the patient will determine species of bodily fluids that includes sweat which of the two patterns is responsible. and saliva. Damp-heat is an exception: It causes thirst with no desire to drink and From the above descriptions it is clear that sometimes causes foul-smelling diarrhea excess heat conditions tend to be of more instead of constipation. These symptoms are recent origin and are more violent and due to the contradictory natures of dampness blistering in their effect on the body, while and heat and will be explained under conditions of deficiency heat tend to have a dampness below. longer history and are weaker and more tepid. There are some exceptions to this In the case of deficiency heat it is the general rule, however. Damp-heat, for deeper form of bodily fluid—humor (液)— example, can last a long time with relatively which has been damaged (refer back to mild symptoms due to the lingering and fire- Chapter 5). Injury to humor is usually suppressing effects of dampness, as we will referred to as “damage to yin” (伤阴) or in see below. And if the cause of deficiency severe cases, “humor desertion” ( 脱液). heat is damage to yin by externally Since yin-humor is harder to actually see, contracted febrile disease, some sparks of any dry signs it produces are less obvious. In the original fire evil may still be present in a state of deficiency heat, therefore, there is the body, resulting in more severe and acute usually no thirst but the mouth or throat symptoms than one would expect if the might still feel dry. Stools and urine are disease were solely the result of yin usually unaffected, so long as the condition deficiency. We will have more to say about is not complicated by the additional this process when we study febrile disease presence of excess heat. later in this text.

If excess heat affects the lung, there will be There are two special fire patterns that we cough with thick yellow phlegm due to the will encounter in future discussions and it “boiling down” effects of heat described behooves us to examine them now. These earlier. If cough occurs in deficiency heat it are the patterns known as blood heat (血热) will be chronic and dry. In prolonged cases and fire toxin (火毒). of deficiency heat the damage to yin can result in emaciation due to a reduction in the nourishing and flesh-sustaining functions of

Blood Heat (血分) of the body. As a febrile disease pattern blood heat can be life-threatening Blood heat is the result of fire delving into and would nowadays correspond with the deepest regions of the body, where it has serious infectious disease states such as entered into and is traveling with the hemorrhagic infections, scarlet fever and circulating blood. It is recognized by the measles. presence of one or more of the following signs: In contemporary Chinese medical theory, however, the concept of blood heat has been  Bleeding extended to include a wide range of chronic  Red maculopapular eruptions skin diseases and gynecological conditions  Crimson tongue which are not febrile and are presumed to be the result of internal and miscellaneous The bleeding and red skin eruptions are causes rather than invading warm disease caused by frenetic movement ( 妄行) of evils. In these more chronic and internally- blood. Bleeding is often profuse and the generated forms of blood heat, the blood is bright red or purple-black, as if symptoms are milder and the source of the sautéed in a pan. Blood can be present in heat is often yin deficiency. vomit, in expectorated phlegm, in the stools or in urine; it can seep from the nose or Fire Toxin eyes. Blood heat might also occur as a 火毒 gynecological disease, in which case it will Fire toxin ( ), sometimes called “heat manifest as excessive bleeding during or toxin” ( 热毒 ), refers to fire diseases between menstrual periods or as periods that characterized by pus or pustules with return before they are due. localized redness and swelling. The word “toxin” ( 毒 ) here is to be taken The maculopapular eruptions caused by metaphorically rather than literally; it blood heat are distinguishable by their describes the appearance of the lesions, intense red color and by the presence of which look as if they had been caused by the other heat signs such as vexation and rapid bite of a venomous insect or snake. pulse. Finally, blood heat is characterized by a tongue that is deep red or “crimson” (舌 Fire toxin virtually always manifests as an 绛), a dramatic color change that strikingly excess heat pattern and is typically a depicts the depth of the heat afflicting the complication of depressed fire or of body. externally-contracted febrile disease. Examples of fire toxin include carbuncles, The pattern of blood heat was originally furuncles, abscesses, tonsillitis, local conceived as a way of understanding late- infections, and lymphangitis. Dysentery (痢 stage febrile disease. Blood heat was 疾 ) is classified as a fire toxin disease imagined to develop after warm disease because it is characterized by pus and blood evils had penetrated into the “blood aspect” in the stool. In modern China, the concept of

86 fire toxin has been extended to include  Dampness is a yin evil. internal abscesses in the lung and appendix and some forms of cancer. Unlike the other five environmental excesses, dampness is conceptualized Dampness as a kind of physical substance—even Chinese medical theory begins with the in the cases where this “substance” is more metaphorical than literal. It is said study of metaphor, and metaphors must be 17 understood in the context of the society to be “clammy and viscous” in nature, which produced them. The population of its putative physical presence making it China has long inhabited a land that is mired more difficult to expel than other evils. in dampness and prone to floods; where Dampness therefore has a stagnant human survival depends on management of quality—rather like standing water— waterways and drainage of marshes. It is and produces disease states that endure only natural that the Chinese saw dampness for long periods of time. It also has a as a major source of disease in the body. predilection for the lower parts of the body. It is in many ways the antithesis And yet damp disease is not a vestige of of evil wind, which is yang in character, rural life and is not restricted to China. Any prone to movement and change and Western acupuncturist can testify to the tends to strike the upper body. prevalence of dampness in his or her practice, for this pattern is responsible for a  Dampness causes a sensation of broad range of chronic symptoms common heaviness. in the modern world. Since dampness is closely associated with weight gain, the When dampness invades the body, it obesity epidemic in the West has magnified feels as if the tissues of the body have the interest in damp evil and in the herbal become saturated, like a wet towel medicines and acupuncture treatments that drawn from a washing machine. This are used to treat it. “heavy” ( 重 ) sensation may be generalized throughout the body or Dampness by itself is neither hot nor cold restricted to the affected part. Damp bì, (there is no term for “neutral” in Chinese for example, will cause pain with a pathology), but dampness often combines sensation of heaviness and stiffness in with heat or cold when it sickens the body. the affected joints or muscles (see Dampness can also invade the body together Chapter 24). Sometimes the sensation with wind, but this pattern is mainly of heaviness is accompanied by fatigue restricted to bì patterns, which we will cover or by a “bag-over-the-head” sensation in Chapter 24. Regardless of the evils with 头重如裹 which dampness combines, it exhibits ( ). certain inherent characteristics and these underlie any pattern in which it is present. 17 Wiseman N, Ellis A. Fundamentals of Chinese Medicine, revised edition. Brookline, MA: Paradigm Publications; 1994, page 202 87

muddy, murky presence lurking in the  Dampness easily invades the spleen body, impeding digestion and and stomach. preventing the normal movement of clear fluids. Dampness tends to weaken spleen qi, preventing it from transforming and  Dampness may be characterized by the transporting ingested fluids; this in turn accumulation of water. leads to further accumulation of damp and further weakening of the spleen. While symptoms such as heaviness and For this reason, although dampness is oppression are purely subjective, technically an excess it is almost dampness is sometimes associated with always accompanied by some degree of the objective accumulation of fluid spleen qi deficiency. In treating damp substances in the body. Manifestations patterns, therefore, the practitioner must of such “literal” forms of dampness decide how much focus should be include water swelling ( 水肿; i.e., placed on removing dampness and how edema), vaginal discharge, weeping much on tonifying the spleen. eczema and sores with copious, sticky discharge. The edema that accompanies Because spleen qi deficiency and beriberi, referred to as “leg qi” (脚气) dampness typically overlap, the in traditional Chinese literature, is symptoms of the two patterns can be regarded as a form of dampness. difficult to tell apart. For example, both dampness and spleen qi deficiency External Damp vs. Internal Damp cause reduction of appetite, indigestion and loose stool and both can cause a External damp ( 外湿) refers to soggy or moderate pulse. Dampness environmental humidity that seeps into the differs, however, by the additional body to cause damp diseases. Internal damp presence of several key symptoms. (内湿) refers to dampness generated from within the body by failure of the spleen to Dampness often causes oppression of transform ingested fluids. The distinction is the chest (胸闷)—a tight sensation that blurred, however, by the fact that these two feels as if something is being pushed up pathologies tend to spawn each other. from below the diaphragm—as well as The invasion of external dampness easily abdominal distention (腹胀). And since overwhelms the spleen qi and stifles its the presence of dampness implies ability to transform, like rain smothering a retention of fluids in the body, short small camp fire. This weakening of spleen voidings of scant urine (小便短少) are transformation will lead to the accretion of to be expected. Finally, the tongue fur internal damp due to non-transformation of is usually thick and slimy. These signs the body’s own ingested fluids. To further all convey the impression of a kind of complicate the matter, the accumulation of

88 dampness combined with spleen qi Below is a list of the general signs of damp- deficiency will now leave the body heat. vulnerable to further invasion of environmental damp. As a result, the final  Fever that may be low and chronic. presentation will often be a combination of external and internal dampness together with As a yin evil, dampness tends to stifle spleen qi deficiency. fire, keeping any fever it produces relatively low. But at the same time the The question of whether a given damp stagnant, viscous nature of dampness pattern is caused by external or internal tends to bury evil heat deeper in the forces is therefore not as important as it is body, preventing it from venting for the other five environmental excesses. outward. This effect can be likened to a More important is the question of how much large kettle of freshly cooked beans that emphasis should be placed on the removal remains hot in the core even after the of dampness and how much on the surface cools. The fever produced by tonification of spleen qi. damp heat is therefore low, chronic, and presumed to lie deep within the Damp-Heat body. Sometimes the skin needs to be The pattern of damp-heat can develop from palpated at length before any warmth either of two distinct pathways. Damp-heat can be felt, a sign referred to as can invade the body directly from the “generalized fever failing to surface” external environment or it can develop from (身热不扬). internal and miscellaneous causes. Dampness can develop internally, for  Fullness and pain in the stomach duct example, from the ingestion of sweet and and abdomen. fatty foods, and once formed can transform into damp-heat. This process is referred to as While dampness alone can cause a “dampness forming with heat” (湿从热化). sensation of fullness, the additional presence of heat causes an expanding Damp-heat is responsible for a broad range effect, making the discomfort more of disease states. It can accumulate in any of pronounced. This is in keeping with the the three burners and it can localize in aphorism, “All great abdominal specific organs such as the spleen, stomach, distention is ascribed to heat.” The term liver, gall bladder, urinary bladder, or large “stomach duct” ( 脘 ) bears some intestine. Although symptoms will depend explaining. It refers to the stomach as on the organ or burner afflicted, there are an anatomical entity and is used when some general symptoms of damp-heat that describing uncomfortable sensations can be expected in most conditions. These occurring in the vicinity of the point symptoms often possess a compound nature Ren 12 ( 中脘; “Center Stomach that is the result of the contradictory forces Duct”). It should not be confused with of yin-dampness contending with yang-heat.

the stomach defined as a fǔ-bowel (胃), The combination of heat and dampness which is a largely functional entity leaves the patient with dry sensation in responsible for the rotting, ripening, the mouth with a desire only to sip at and downbearing of ingested food. small amounts of fluid.

 Nausea, vomiting, lack of appetite.  Short voidings of scant, dark urine.

Dampness accumulating in the middle Dampness reduces urine by retaining burner will tend to inhibit the functions fluid within the body; heat reduces and of the spleen and stomach, leading to concentrates the urine by damaging loss of appetite and nausea due to liquids. The combined effect of the two counterflow stomach qi. The additional evils makes the urination infrequent, presence of heat serves to amplify these dark, and scanty. If damp-heat pours symptoms by adding greater force to down into the urinary bladder, however, the counterflow upbearing, leading the effect is almost the opposite: The vomiting. urine becomes frequent and urgent and is accompanied by a burning sensation  Constipation or diarrhea. when evacuating.

Heat by itself causes constipation while  Fast slippery or fast soggy pulse. dampness by itself causes diarrhea. When dampness and heat combine, the Damp-heat is usually characterized by a patient will suffer from one symptom or rapid and slippery pulse (数滑脉), in the other depending on which of the which case heat is responsible for the two evils dominates. There is one speed and dampness for the exception to this rule, however: Damp- slipperiness. If dampness has damaged heat pouring down into the large spleen qi, however, the pulse might be intestine ( 湿热下注大肠 ) manifests rapid and soggy (数濡脉). Recall that a exclusively as diarrhea, never soggy pulse, like a slippery pulse, has a constipation. In any case, damp heat fluidic texture but differs in that it is will tend to cause all stools—hard or relatively forceless. The fluidic quality loose—to be malodorous. of a soggy pulse reflects the retention of dampness; the lack of force reflects the  Thirst without desire to drink. absence of spleen qi; the rapidity signifies the presence of heat. This sign exemplifies the contradictory forces of dampness and heat. While  Thick, slimy yellow tongue coat. heat causes thirst by damaging liquids, dampness leaves the body feeling as if Dampness makes the tongue coat thick it already contains too much moisture. and slimy while heat makes it yellow.

The more likely scenario, however, is that the cold and dampness will accumulate internally due to spleen yang becoming devitalized ( 不振). This latter process is known as “dampness forming with cold” (湿从寒化) and can be likened to cooking soup without fire.

In either case, when cold and dampness combine, cold is usually the predominant evil. The symptoms of cold-damp are Table 23.7 similar to those of spleen yang deficiency Damp-heat is treated by transforming but with additional signs indicating the dampness while simultaneously clearing presence of untransformed water-damp. heat. Based on the variable signs described These include water-swelling ( 水肿), above, the practitioner determines which of reduced urination, abdominal fullness, and a the two methods is emphasized in treatment. heavy sensation in the body (see Table A patient with high fever, constipation, 23.8). abdominal distention and a slippery rapid pulse is likely suffering from a greater presence of heat than dampness and so heat clearing herbs will play a more prominent role in the treatment. A patient with low chronic fever, poor appetite and a soggy pulse is likely suffering from a greater presence of dampness and so more emphasis will be placed on the transformation of damp.

Cold-Damp Table 23.8 Cold-damp can invade the body directly from the external environment or it can Summerheat accumulate internally due to spleen yang “Summerheat” (暑) refers to a series of deficiency. Environmental cold and damp disease states caused by exposure to hot can invade the body through exposure to weather and usually occurring during the rain or the wearing of wet clothing; cold- hottest and most humid summer months. damp can also enter the body through over- Unlike the other five environmental consumption of cold drinks and raw foods. excesses, summerheat does not have an Disease caused by this type external “internal” form; it is caused exclusively by invasion tends to develop quickly. invasion of external heat. Although there are 91 many different patterns of summerheat category of symptoms that include described in the modern Chinese medical convulsions, rigidity of the nape of the neck, literature, for simplicity’s sake we will focus clenched jaw ( 口噤; i.e., trismus) and on just two: Summerheat-heat (暑热) and arched-back rigidity ( 角弓反张 i.e., summerheat-damp (暑湿). opisthotonus). The term “reversal” (厥) here refers to sudden loss of consciousness. The Summerheat-Heat combined term “tetanic reversal” means loss Summerheat-heat is a severe form of of consciousness combined with symptoms excess heat that is caused by exposure to of tetany (see Table 23.9). high temperatures. It presents with high fever, thirst, scant urine and vexation. There are several additional features of summerheat-heat that make this pattern particularly dangerous.

One of these is its tendency to damage both qi and yin. In a desperate attempt to rid itself of the excess heat, the body releases copious amounts of sweat. This causes not only a loss of yin but also of qi, since energy

消 is needed to “disperse” ( ) sweat to the Table 23.9 surface of the body. The additional presence of qi and yin deficiency complicates the The above clinical picture suggests such clinical picture, producing such symptoms biomedically defined conditions as heat as fatigue, lack of strength, and dry tongue exhaustion, heat stroke, tetanus, fur. Depending on the severity of the heat encephalitis, and meningitis. and the degree of damage to qi and yin, the pulse could be rapid and surging, rapid and Summerheat-Damp fine, or large and empty. Finally, if the body Summerheat-damp is a pattern that continues to sweat it will lead to exhaustion combines summerheat evil with dampness. of fluids, after which there will be complete Although it shares many of the features of absence of sweat (i.e., clinical dehydration). damp-heat, its onset is restricted to the Another dangerous feature of summerheat- summer months when the weather is both heat is the threat it poses to the heart spirit. hot and humid. Table 23.10 provides a list of Its blistering intensity can lead to clouding the more general signs of summerheat- of the spirit (神昏) i.e., stupor. In its most damp. severe form, summerheat-heat can lead to a type of internal wind referred to as “tetanic reversal” (痉厥). “Tetany” (痉) is a general

Dryness the metal phase; recall that the lung is “a dry organ that needs dampness” (see Chapter 9). In order to understand dryness ( 燥 ), a Contraction of dryness evil is indicated by distinction has to be made between external the abrupt appearance of a dry cough, with and internal forms of dryness disease. phlegm that is scant or sticky and difficult to External dryness (外燥) is caused by the expectorate. There is also dryness of the direct contraction of dryness evil from the throat, lips, tongue and nostrils. The lack of outside atmosphere. Internal dryness (内燥), moisture of the nasal passages could lead to by contrast, is usually a complication of nosebleed. Since the lung is contiguous with other disease processes. the skin, the skin can become dry and cracked. And because the large intestine is the paired organ of the lung, dryness sometimes affects this organ as well, causing constipation.

The cough caused by dryness evil needs to be distinguished from the dry cough that occurs in lung yin deficiency. The latter pattern produces a dry cough that is chronic, appears later in the disease, and is accompanied by yin deficiency signs such as tidal fever, night sweat and vexing heat of the five hearts. The cough caused by dryness

Table 23.10 evil is acute and abrupt and occurs together with the exterior signs described below. External Dryness External dryness usually accompanies the External dryness is attributed to exposure invasion of wind-cold or wind-heat. In the to dry air and in China this is usually presence of wind cold it is known as “cool restricted to the autumn months. Since dryness” (凉燥) and in the presence of wind droughts are less common in China than heat “warm dryness” (温燥). In addition to floods, there has been far less attention the general signs of external dryness, cool given to dryness than to dampness in the dryness presents with chills and mild fever historical Chinese medical literature. The together with headache. The tongue body phenomenon of dryness evil may be more remains unchanged while the coat is thin, relevant in Western countries that are cooler dry and white. Warm dryness also presents and drier, such as northern Europe and parts with headache but the overall symptoms are of North America. hotter and drier. This pattern produces External dryness evil focuses its attack on higher fever with milder chills as well as the lung and upper respiratory tract. This is sore throat. The cough is sometimes so because dryness is the evil associated with severe it causes chest pain (see Table 23.11). 93

Damage to Liquid

Liquid (津) is the most superficial of the bodily fluids and is first to be affected by internal dryness. Recall that liquid includes both sweat and saliva. Damage to liquid is usually the result of high fever and sweating, although it can also be caused by loss of fluid from vomiting or diarrhea. The principal symptoms are thirst with desire to drink and a red tongue with a dry coat. The appearance of these two signs in any disease state is an indication that in addition to treating the underlying cause, attention must be placed on nourishing liquids.

Damage to Yin

Damage to yin (伤阴) is also referred to as “humor desertion” ( 脱液) because it involves depletion of the inner, unseen Table 23.11 aspects of bodily fluid (see Chapter 5 for the differences between liquid and humor). It Internal Dryness typically occurs in the later stages of febrile Internal dryness is not caused by dry air or disease, where warm evils have plundered seasonal climatic factors. Instead, it is an the deeper levels of body substance. internal complication that develops in the Damage to yin produces dryness in the course of other disease states. It arises most throat and mouth, but unlike damage to typically when externally-contracted febrile liquids, thirst is not pronounced. The tongue disease ( 外感热病) causes fever, sweat, is smooth and uncoated and the color is vomiting or diarrhea. It can also develop in crimson. The tongue may have a desiccated internal and miscellaneous diseases, where (枯) appearance—dry and withered like beef blood loss, chronic disease or overuse of jerky. In severe cases, there may be clouding diuretic medicinals can have the same effect. of the spirit and tetanic reversal (see Table Internal dryness patterns are sub-classified 23.12). as damage to liquid (伤津) or damage to yin (伤阴), depending on the level of bodily fluid affected.

Table 23.12

Chapter 24 Bì Patterns

Aches and Pains 痹 “throat bì ”). It can be used in a broad sense to mean all rheumatic complaints or it This chapter deals with one of the most can be used more narrowly to refer only to common and enduring afflictions of those caused by invasion of wind, cold and mankind: Musculoskeletal pain. Our subject damp. matter includes such biomedically-defined conditions as osteoarthritis, rheumatoid The ambivalence surrounding the term bì arthritis, bursitis, tendonitis and back and has confounded attempts to find an English- neck pain of virtually all causes. In the language equivalent. The character 痹 bì is United States, one in five adults report composed of the disease radical 疒 nè and having physician-diagnosed arthritis 18 and the phonetic 畀 bì. It is possible to interpret nearly half of all adults are expected to have 畀 bì as a pictogram illustrating lameness or knee osteoarthritis by age 85 19 . We are addressing these conditions at the present impaired walking. By extension, therefore, point in your study because they represent the composite character 痹 bì could be every-day examples of disease caused by interpreted as a general term for various invasion of external evils. forms of obstructed bodily movement.

A common rendering of 痹 bì in the In many modern Chinese medical texts, the English literature is “painful obstruction”20, various forms of musculoskeletal pain are although Wiseman prefers “impediment”21. lumped together under a common category The various editions of Chinese called “bì zhèng” (痹症) or “bì patterns.” Acupuncture and Moxibustion render bì The term bì 痹, however, is ambivalent in 22 zhèng (痹症) as “bi syndrome.” In this meaning, difficult to translate, and is used present book, we will use the term bì in its inconsistently by clinicians. It is sometimes untranslated Pinyin form wherever it occurs. used to indicate pain that is not musculoskeletal, such as non-arthritic chest 20 Maciocia, G. The Foundations of Chinese pain (胸痹 “chest bì”) and sore throat (喉 Medicine, 2nd edition. Elsevier: 2005. See also Bensky D, Gamble A. Chinese Herbal Medicine 18 Barbour KE, Helmick CG, Theis KA, et al. Materia Medica revised edition. Seattle, WA: Prevalence of Doctor-Diagnosed Arthritis and Eastland Press; 1993. Arthritis-Attributable Activity Limitation — United 21 Wiseman N, Ye F. A practical Dictionary of States, 2010–2012. Morb Mortal Wkly Rep. Chinese Medicine. Brookline, MA: Paradigm 2013;62(44):869-873. Publications; 1998. 19 Murphy L, Schwartz TA, Helmick CG, et al. 22 Xinnong C. Chinese Acupuncture and Lifetime risk of symptomatic knee osteoarthritis. Moxibustion, revised edition. Beijing: Foreign Arthritis Rheum 2008;59(9):1207–1213. Languages Press; 1999. 96

For the time being, let us focus on bì in its Cold Bì narrowest meaning, i.e., as a term for pain and stiffness in the joints and sinews caused Cold bì (寒痹) is sometimes referred to as by invasion of the channels by external “painful bì ” (痛痹). Recall the aphorism: wind, cold and damp. In any given case of “Where cold predominates there is pain” bì, we can expect that all three of these evils (Chapter 16). Cold bì is characterized by will be present. There is a tendency, relatively severe pain together with general however, for either wind, cold or damp to bodily cold as well as sensitivity to dominate the overall presentation in any environmental cold. The affected part is given clinical case. Textbooks therefore often cold to the touch and the patient will distinguish between three different sub-types instinctively apply heat to relieve of bì, depending on which of the three evils discomfort. The pulse will be tight and the plays the dominant role. tongue will have a moist white coat. See Table 24.2. Wind Bì

Wind bì (风痹) is also called “moving bì ” (行痹) because of its tendency to migrate from one joint or region of the body to another. This motility of symptoms is in keeping with the aphorism, “wind is adept at movement and many changes.” The onset of illness often occurs after exposure to drafts. In the early stages there might be chills and fever and a floating pulse. In wind-dominant bì patterns, it is the upper body that is most likely to be affected, including the head, Table 24.2 neck, shoulders and arms (see Table 24.1). Damp Bì

Dampness is the most prevalent of all the bì-producing evils and the most likely to dominate the clinical picture in any given case. Damp bì (湿痹) is sometimes called “fixed bì ” (着痹) due to its chronic and intractable nature. It is distinguished by a sensation of heaviness in the body and the tendency for symptoms to become worse during humid weather. The pulse tends to be slippery and the tongue coat slimy. There Table 24.1 may be signs of internal dampness as well, such as loose stools, poor appetite and water

97 swelling ( 水肿; i.e., edema) (see Table 24.3).

Table 24.4

Other Causes of Musculoskeletal Pain

Even if we assume that external wind, cold Table 24.3 and damp are the immediate causes of bì Heat Bì patterns, it is through qi stagnation and blood stasis that these evils give rise to the Heat bì (热痹) is caused by wind, cold and characteristic pain and stiffness. Dispelling damp that have stagnated in the channels wind, cold, or dampness is therefore not and transformed into fire. This sufficient; treatment must emphasize transformation process is often encouraged opening through the channels ( 通经络), by the prior existence dampness and heat coursing qi (疏气) and quickening blood (活 “brewing” (蕴) deep in the body. Although 血). In the case of chronic knee or low back heat bì is less common than wind-cold-damp pain the underlying cause is often kidney bì, its symptoms are more acute and deficiency, since the kidneys control these disabling. Heat bì is characterized by joints areas of the body (see Chapter 12). that are hot, red, painful and swollen. There Tonification of kidney yin or kidney yang may be thirst, dark urine and dry stool; in must therefore be added to the treatment. severe cases there may be fever. The pulse is slippery and fast and the tongue is red with a It is not unusual to see clinical cases of yellow coat. Rheumatoid arthritis and gout musculoskeletal pain with no obvious signs typically present as heat bì (see Table 24.4). of wind, cold or damp. When faced with this reality, many modern acupuncturists prefer to supplement traditional theories with ideas born of modern orthopedics, seing pain as the result of structural defects and mechanical stress. The term “channel obstruction” ( 经络阻 ) can be used as a generic replacement for the traditional term bì, since it could refer to musculoskeletal

98 pain in either the modern or traditional paradigm.

Other Uses of the Term “Bì”

The term bì is sometimes used to imply obstruction and is often reserved for severe conditions. The terms heart bì (心痹) or chest bì ( 胸痹) roughly correspond to “angina” and refer to the chest pain associated with biomedical heart disease. The term throat bì (喉痹) refers to a sore throat with severe swelling and possibly occlusion.

Chapter 25 Desertion Patterns

Extreme Deficiency to as “yang collapse” (亡阳), “yin collapse” (亡阴) and “qi deserting with blood” (气随 Up until now we have regarded deficiency 血脱 patterns ( 虚症) as mild to moderate ). conditions that typically occur in chronic, Yang Collapse self-limiting disease states. This chapter examines a type of deficiency that is an Yang is said to “collapse” (亡) when there exception to this general rule: Desertion (脱 is an extreme and abrupt loss of its power. 症). This triggers a process referred to as “separation of yin and yang,” in which “Desertion” refers to deficiency that is expiring yang energy drifts upward and extreme and potentially life-threatening. outward, leaving a cold, unconscious and Arising in acute illness or after severe injury possibly lifeless body behind. The process it is referred to as “fulminant desertion” (暴 can be likened to smoke rising from an 脱) or “collapse” (亡). Fulminant desertion expired candle or to poles of an occurs in the later stages of febrile disease, electromagnet coming apart when the as a consequence of severe injury, or in current is switched off. conditions of wind-stroke or heart bì. It is Yang collapse is characterized by a rapid often caused by critical loss of bodily drop in temperature accompanied by the substance due to vomit, diarrhea, sweat, or sudden appearance of cold sweat. The loss of blood. A state of hypovolemic shock sweat—sometimes referred to as “expiration following acute blood loss, for example, sweat” ( 绝汗)—possesses an oily would be considered fulminant desertion. consistency and tends to stick to the skin in Desertion arising gradually in the course big droplets. In the most severe cases, of enduring illness is referred to as however, the sweat can be cold and watery, “deficiency desertion” ( 虚脱; Wiseman: streaming relentlessly down the patient’s “vacuity desertion”). The gradual reduction skin. The patient’s skin is palpably cold and of consciousness that occurs in end-stage there is reversal cold of the limbs. The drop renal failure is an example of deficiency in bodily temperature is a result of desertion. disappearance of the warming function of yang qi and the sweating is the result of In this chapter we are concerned mainly critical failure of yang qi to contain bodily with fulminant desertion. The three patterns fluids. described in this chapter are usually referred

100

The patient’s spirit is described as midst of febrile disease, where high fever “apathetic” ( 暮气, literally “sunset qi”), and severe sweat have caused critical meaning that he or she is conscious but too damage to yin (伤阴). exhausted to interact meaningfully with caregivers. In severe cases there is clouding of the spirit (神昏), i.e., stupor. Apathy and clouding are the result of failure of yang qi to support the spirit-affect (神情), which dwindles like a flashlight with a spent battery. In some cases, yang collapse can produce the opposite effect, making the patient uncannily alert and agitated ( 躁 ). This paradoxical presentation is the result of the body’s last remaining yang fire momentarily activating the spirit as it soars Figure 25.1 up and out of the body, as if it were the last Yin collapse is characterized by copious flicker of a dying candle. sweat combined with increased bodily The patient either has no thirst at all or is temperature due to deficiency heat. The thirsty with desire only for hot liquids. The sweat differs from that of yang collapse in tongue is pale. The pulse is described as that it has a watery consistency, and the skin “hidden and faint” (伏微脉), i.e., so deep is palpably hot instead of cold. Likewise, the and forceless as to be almost imperceptible. limbs are hot, not cold. It might also be “agitated and racing” (躁疾 The presence of intense deficiency heat 脉 ), which refers to a pulse that has will usually cause vexation and agitation, surpassed seven beats per breath of the but in critical cases the loss of yin-blood can practitioner (nowadays interpreted as greater have the opposite effect, clouding the spirit. that 140 beats per minute). This combination The patient is thirsty but, unlike someone of extreme speed and extreme weakness is suffering yang collapse, wishes to drink only the result of critical exhaustion of heart cold liquids. The loss of yin is felt most yang. We can explain these pulse types by acutely by the lung, resulting in rapid imagining that heartbeats that are weak and breathing and severe shortness of breath. rapid require less energy to produce than The tongue is dry and red and the pulse is those that are slow and strong. In biomedical forceless and rapid (see Table 25.2). terms, yang collapse corresponds with shock (see Table 25.1). In the absence of treatment, collapse of yin will eventually lead to collapse of yang. This Yin Collapse is in keeping with the principle “yin and yang are rooted in each other.” One way to Yin collapse is a severe and acute form of understand this progression is to imagine yin deficiency that typically occurs in the

101 yin-blood serving as a kind fuel for yang qi, (苍白) complexion. The pulse is rapid and like oil feeding the flame in a lamp. If the oil forceless at the deep level—a type often is exhausted, the flame will expire. referred to as a “scallion stalk” pulse (芤脉). Likewise, a patient who survives yang There is profuse cold sweat, a drop in blood collapse is likely to remain in a state of yin pressure and a rapid deterioration of collapse due to the loss of yin from the consciousness referred to as “clouding expiration sweat described above. reversal” (昏厥).

Since plasma transfusions were not available in pre-modern times, patients suffering from acute blood loss were rescued by stopping the hemorrhage and strongly boosting ( 益 ) original qi. Tonification of blood would not be attempted until after the bleeding had stopped and the qi deficiency was no longer life-threatening.

Table 25.2

Qi Deserting with Blood

Qi deserting with blood (气随血脱) is a pattern that describes the collapse of original qi (元气) that occurs in acute blood loss. It is the qi that is responsible for propelling the constant motion of the blood; this is evident Table 25.3 in the spurting that occurs when an artery is slashed—an injury the ancients would have had plenty of opportunities to observe. As the blood deserts the body, therefore, qi by necessity leaves with it. This means that the immediate signs of acute blood loss belong to qi deficiency, not blood deficiency, the latter pattern becoming noticeable only after the bleeding has stopped and the immediate crisis has passed.

The signs of qi deserting with blood closely approximate modern descriptions of hemorrhagic shock (Table 25.3). There is a bright white (面色晄白) or somber white

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Chapter 26 Qi Stagnation and Blood Stasis

In Chapter 5 we learned that Chinese caused by affect damage is referred to medical theory imagines the body to be as “qi depression” (气郁). The word filled with fluidic substances that sustain life “depression” (郁) in Chinese medicine through constant motion. Obstruction of this is a mind-body term; it refers both to motion plays a crucial role in many disease depression of the mood and depression processes, sometimes as a cause and of bodily energy. As we learned in sometimes as an effect. And of all the Chapter 11, the liver is particularly substances in the body, it is the free motion sensitive to affect damage and qi of qi and blood that is most vital to the stagnation developing in this organ is overall health. An understanding of qi called depression of liver qi (肝气郁). stagnation (气滞) and blood stasis (血瘀) is therefore indispensable to understanding  Evil qi. Chinese medical pathology as a whole. Qi stagnation can be caused by almost An important aphorism we have previously any form of evil qi, be it externally or encountered states “Where there is stoppage internally generated. Dampness and cold are the most obstructive; dampness ( 不通) there is pain.” As the most because of its substantial and persistent fundamental manifestations of stoppage, qi nature and cold because of its stagnation and blood stasis exhibit pain as 凝 their principal symptom. It is through the congealing ( ) properties. quality of this pain and the symptoms that attend it that qi stagnation and blood stasis  Physical trauma are clinically differentiated. All forms of physical trauma will cause qi stagnation and—if there is damage to Qi Stagnation tissue—blood stasis as well. Cutting, compressing or burning of tissue will Qi stagnation refers to stoppage in the interfere with the flow of channel qi normal flow of qi which causes pain and and the resulting pain is a form of qi other discomfort in the patient. Qi stagnation stagnation. It is worth pointing out that can be caused by several different factors. biomedicine seems to be saying just the  Affect damage (内伤七情). opposite: Pain is the result of an Qi stagnation can be the consequence increase in motion—in this case of of extremes in any of the seven affects, nerve signals through an afferent particularly preoccupation, sorrow and pathway—and is inhibited by blocking anxiety (see Chapter 17). Qi stagnation that very motion.

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Qi stagnation is common in dysentery (痢  Qi or yang deficiency. 疾) and manifests as a cramping sensation in While qi stagnation is in itself an the rectum referred to as “tenesmus” (里急 excess, it can be caused by and coexist 后重; literally, “abdominal urgency and with deficiencies, particularly qi and heaviness in the rectum”). yang deficiencies. In a state of qi deficiency there is not enough force to Qi stagnation will sometimes cause create the necessary flow, causing the palpable masses in the abdomen, but these qi to stagnate like sandbanks are soft to the touch and appear and accumulating in a slowly moving river. disappear periodically. Such palpatory In yang deficiency the presence of findings can be seen in hernia or lymphoma, deficiency cold will congeal the qi and or they might simply be the result of food or retard its movement. gas moving through the intestines. In any case, their soft texture and transient nature The principal symptoms of qi stagnation suggest once again that it is the body’s qi are pain (痛), distention (胀) and oppression that is the site of obstruction. ( 闷 ). “Distention” refers to a swollen or Qi stagnation causes the pulse to become bloated sensation; “oppression” refers to a wiry or tight, both types representing the feeling of tightness or pressure. Although qi constriction taking place in the channels and stagnation can cause these sensations vessels. Uncomplicated cases of qi anywhere in the body, it is the chest, stagnation do not necessarily cause abdomen, ribsides and breasts—areas pathological changes in the tongue. The traversed by branches of the liver channel— tongue coat remains unaffected while the that are the most frequently affected. body of the tongue, if it is affected at all, The pain varies in intensity and might will become bluish. come and go in waves or “attacks” (攻). The There is a kind of motile, energetic quality pain is often brought on by emotions and to the above symptoms that is a result of the tends to accompany depressed moods. The obstruction taking place in the qi dynamic pain can migrate from one site to another or (气机)—the purely functional aspect of the it can “scurry” ( 窜 ) from a single focal body—rather than in the body’s physical point—what Western patients typically refer tissues. That is quite the opposite of the to as “shooting pain.” obstruction caused by blood stasis, as we are Sometimes the distention in the chest and about to see. abdomen is relieved by belching or flatus. Blood Stasis This suggests that pain and bloating caused by gas in the gastrointestinal tract is a form Blood stasis differs from qi stagnation in of qi stagnation. Recall that one of the that the character of the symptoms suggests meanings of the word qi is “gas.” that there is some physical change in the underlying tissues and not just impediment

104 of the body’s energy. Blood, as we have learned, is deeper and more substantial than  Qi deficiency. qi and stoppage of its flow will affect As we learned above, the most structure as well as function. immediate effect of qi deficiency is qi stagnation. But if qi deficiency and the Blood stasis can occur as a primary disease qi stagnation it causes remains over a state or as a complication of other illnesses. long period of time, it will lead to the It can arise spontaneously in any long- development of blood stasis. standing condition and is particularly common in the elderly. The appearance of  Cold. blood stasis usually suggests that the Cold can stop the flow of blood through condition is deeply rooted and will be more the same congealing process that causes difficult to treat. Blood stasis is responsible, qi stagnation. When blood stasis for example, for many of the symptoms of develops out of cold evil it is called biomedically-defined diseases of the heart, “blood cold” (血寒). liver, and kidneys as well as most forms of cancer.  Hemorrhage. There are several different causes of blood Hemorrhage can paradoxically lead to stasis: blood stasis through the formation of clots.  Physical trauma. Damage to bodily tissues from  Blood heat. traumatic injury is one of the most Blood heat can cause blood stasis due common forms of blood stasis. The to the scorching action of fire, which pain, swelling and discoloration of a solidifies the blood as if it were being bruise, for example is a manifestation sautéed in a pan. of blood stasis.

As in the case of qi stagnation, the single  Qi stagnation. most important sign of blood stasis is pain. It is the activating function of qi that is This pain, however, differs significantly responsible for the motility of the from that of qi stagnation. It is stabbing blood. Long-standing stagnation of qi rather than distending, fixed rather than will naturally transform over time into moving, and is more easily pinpointed by blood stasis. Typically, qi stagnation the patient. The pain is also more persistent occurs in the earlier stages of an illness and unremittent than that of qi stagnation and blood stasis develops as the and is less likely to be brought about by stagnation becomes deeper, more emotional states. tangible and more solid. Blood stasis can cause masses and swellings but—unlike qi stagnation—these

105 are hard to the touch and unmoving. Bruises, radiate out from the umbilicus. This sign is venous clots and solid tumors are all referred to as “caput medusae” in examples of masses associated with blood biomedicine and is seen in advanced liver stasis. disease.

In yet another paradoxical sign, blood The pulse indicating blood stasis is rough stasis can cause bleeding (as well as being (涩脉). Although blood stasis is a form of caused by it). The bleeding is explained by excess, it can also cause a thin pulse (细脉) the obstruction of movement that static due to the inhibited flow of blood in the blood is imagined to have on the vessels, vessels. This can be likened to the which causes the blood to spill out like a downstream narrowing of a dammed river. dammed river overflowing its banks. The body of the tongue is dark and purple Bleeding associated with blood stasis tends with “stasis speckles” (瘀点)—blue spots— to be dark purple and clotted and is on the sides. commonly seen in menstrual and post- partum conditions. Table 26.1 provides a side-by-side comparison of qi stagnation and blood In severe cases, blood stasis can cause stasis. dramatic changes on the surface of the body due to inhibition of flow in the capillaries under the skin. The complexion can become soot-black (黧黑) and the skin so dry and rough as to look like snake scales. Red or purple petechiae can form if there is subcutaneous bleeding. The veins can become darkened, tortuous and varicose, and thin spider veins may appear on the surface.

In serious illness blood stasis can acutely unsettle the spirit, causing delirious speech and mania. It can block the flow of water in the body, causing an accumulation of fluid in the abdomen referred to as “drum distention” ( 鼓胀; i.e., ascites). Drum- distention derives its name from the drum- like tightness that develops in the abdominal skin as it stretches from the swelling. Drum distention caused by blood stasis is referred to as “blood drum” and is characterized by the appearance of engorged veins that

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QI STAGNATION BLOOD STASIS

Pain and distention with sensations of oppression in general area, e.g., chest, abdomen, breasts Stabbing pain in local site

 Pain varies in intensity  Pain constant  Often triggered by emotions  Pain fixed in location  Pain comes in attacks  Pain confined to site of obstruction  Location unfixed  “Scurrying pain”

Abdominal and chest discomfort may be temporarily relieved by belching or flatus

Tenesmus

Abdominal masses that are soft to the touch Fixed, hard, masses and swellings; bruises and disperse and reform periodically

Hemorrhage with dark purple clotted blood, especially in menstrual and post-partum conditions

Changes on the surface of the body:  Soot-black complexion  Skin may be dry, rough, lusterless  Possible petechia  Darkening or thickening of surface veins  Development of spider veins

Severe cases:  Delirium, mania  Blood drum (ascites with caput medusae)

Pulse: Wiry or tight Pulse: Rough, possibly thin

Tongue: Dark and purple with blue spots on Tongue: Normal or slightly bluish body the sides Table 26.1

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Chapter 27 Phlegm

Phlegm (痰) is a pathological substance that Causes of Phlegm plays a significant role in Chinese There are four main pathological processes pathology. Similar to dampness, phlegm is that can give rise to phlegm formation. formed from the body’s own untrasformed fluids. It differs from dampness, however, in  External evils invading the lung. that it is sticky in texture, more localized Contraction of any evil by the lung can and more obstructive. Although phlegm impair its diffusion and downbearing often develops together with dampness (宣降) functions and lead to phlegm when the spleen fails to transform, it can formation. also be produced independently by the lung or kidneys as a result of impairment in the  Dietary irregularities. fluid transformation and distribution The excessive consumption of alcohol functions of these two organs. and sweet, fatty food can impair spleen Phlegm is said to be of two types: transformation, leading to the “Visible” and “invisible.” The visible form accumulation of dampness and the of phlegm is the same as expectorated formation of phlegm. People who are mucus and occurs only in the lung. The obese are particularly prone to phlegm invisible form is a bit more difficult to formation. describe. This type of “phlegm” is best understood as a largely theoretical  Kidney yang deficiency. conceptualization, meant to provide the Severe deficiency of kidney yang can diagnostician with an imaginable cause untransformed water to “flood” “substance” that can explain a particular ( 泛 ) upward into the lung, where it class of symptoms and serve as a target for severely impedes respiration. This medicinal treatment. Phlegm, in short, is not process is descriptive of the condition always a “real” substance in Chinese biomedicine refers to as pulmonary medicine. We encountered this invisible, edema; we will study it in greater detail “imaginary” form of phlegm during our in future chapters. study of the (equally imaginary) heart orifices in Chapter 8.  Fire. Fire can overheat body fluids, causing them to gelatinize like overcooked gravy. This route of phlegm formation

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can occur in both excess and deficiency  Upper body. forms of heat. Turbid phlegm can harass the upper body (痰盂浊上扰), causing dizziness Like blood stasis, phlegm is both a cause (眩晕) together with distention of the of disease and its effect. Impaired spleen head and heavy-headedness. Dizziness transformation, for example, can give rise to caused by phlegm is characterized by a phlegm, but once formed the phlegm can room-spinning sensation that might further impair the function of the spleen. force the patient to recumbency. This Likewise, phlegm can be both the cause and type of dizziness is referred to as the result of disrupted diffusion and objective vertigo in Western literature downbearing of the lung. Phlegm that and is distinct from the dizziness lingers in an organ or body part for any caused by yin and blood deficiencies, length of time is said to be “lodging” (留). the latter producing only mild Deeply lodged phlegm can obstruct the flow imbalance or light-headedness. of qi and blood and easily transform into fire due to the “compost pile” effect.  Chest and ribside. Phlegm lodged in the chest and ribside Overview of Phlegm Patterns ( 痰留胸胁 ) causes coughing and Below is a list of phlegm patterns arranged wheezing with pain in one side of the according to the organ or region affected. chest that is amplified when turning on the affect side. This presentation is  Lung. commonly seen in pleural effusion. Phlegm accumulating in the lung

causes coughing and wheezing with  Channels. expectoration of copious amounts of Phlegm lodged in the channels (痰留经 mucus. In phlegm-cold patterns the 络 phlegm is thin and clear, the pulse is ) can cause soft palpable swellings. wiry and the tongue coat is moist and Examples include goiter, white. In phlegm-heat patterns the lymphadenopathy ( 瘰疠; Wiseman: phlegm is thick and yellow or sticky “scrofula”) and “phlegm nodes” ( 痰 and white; the pulse is slippery and the 核 )—a general term for small soft tongue is red with a slimy yellow coat. masses such as ganglion cysts and fatty tumors.  Heart. Phlegm lodged in the heart can cause  Limbs. palpitations, clouded spirit or—if it If phlegm lodges in the limbs (痰留肢 transforms into phlegm-heat—mania. 体) it can give rise to numbness and This is an archtypical example of pain in the affected extremities. This imaginary or “invisible” phlegm. pattern must be carefully differentiated

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from more common causes of limb pain more so in patterns when the phlegm is of such as wind-cold-damp. the “invisible” variety. The pulse associated with phlegm is either slippery or slippery  Throat. and wiry. Phlegm on its own is associated Phlegm binding with stagnant qi in the with a slimy tongue coat; in the case of throat can cause a subjective sensation phlegm-heat the coat will also be yellow. In of a lump in the throat called plum- case of phlegm-cold, however, the coat stone glomus (梅核痞). This symptom might be clean, white and moist—similar to is referred to as “globus hystericus” in the tongue coat encountered in cold-damp Western literature. (see Chapter 23). This is because of the thinning and clarifying effect that cold has Pulse and Tongue on secretions.

Many of the above presentations overlap with the signs of other disease patterns. The pulse and tongue are therefore critical when confirming the presence of phlegm, even

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Appendix List of Changed Translations of Wiseman Terms Other Wiseman Dark Warrior Pin Yin Character Translations repletion excess shí 实 full vacuity; vacuous deficiency; deficient xū 虚 empty replete pulse full pulse shí mài 实脉 vacuous pulse empty pulse xū mài 虚脉 externally contracted external pathogenic febrile disease wài găn rè bìng 外感热病 (heat) disease influence chills, in some cases fear of cold Wiseman's "fear of cold" is wèi hán 畏寒

retained chills, in some cases fear of wind Wiseman's "fear of wind" is wèi fēng 畏风 retained green-blue or blue bluish or blue qīng 青 cyan heat effusion fever rè 热 painful obstruction; bi impediment bi bì 痹 syndrome wheezing (if the chuān is excess type) --or panting chuān 喘 dyspnea shortness of breath (if the chuān is deficiency type) sloppy stool loose stool biàn táng 便溏 strangury lin lín 淋 string-like pulse wiry pulse xián mài 弦脉 supplement tonify bŭ 补 wilting wei wĕi 痿 paralysis mounting shan shàn 疝 hernial disorder glossy coat (referring moist coat huá tāi 滑苔 wet coat to tongue coat) fine pulse thin pulse xì mài 细脉 post-meridian tidal afternoon tidal fever wŭ hòu cháo rè 午后潮热 heat [effusion] withered yellow miàn sè wĕi sallow complexion 面色萎黄 complexion huáng six environmental excesses environmental extreme; (I have added the qualifying term 六淫 six excesses “environmental” to distinguish liù yín external pathogenic influence between 淫 yín and 实 shí) five minds five emotions wǔ zhì 五志 snivel nasal mucus tì 涕 scrofula lymphadenopathy luǒ lì 瘰疠

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END OF VOLUME 2

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