Download Chinese - Zhong Yi Zhen Duan Xue - Diagnostics of TCM...
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1998- 1
English-Chinese Collegiate Textbooks in Traditional Chinese Medicine 1Fsr Institutions of TraditionaII Chinese Medicine of Higher Learning Edited by Beijing University of Traditional Chinese Medicine
General Chief Editor : Long Zhixian Associate Chief Editors : Zheng Shouzeng He Min He Xingdong Liu jinsheng Gao Baozhong Chen Jing Chief Reviewers of Chinese : Wang Yuchuan Yan Zhenghua
Diagnostics of Traditional Chinese Medicine
Chief Editor of Chinese: Yang Weiyi Chief Editor of English : Meng Fanyi Associate Editor of English : JiangYuanan Translators: (in the order of the name of Chinese strokes in the surname) Meng Fanyi Hu Hui
Jiang Yuanan
Guo Jian
Fu Yanling
Special Invited International Editors Chief Reviewer : Nengyu Fang Associate Reviewer : Concetta Maria Pirrone Advisor : George Francis Mclean
Preface Beijing University of Chinese Medicine and Pharmacology under the auspices of the Department of Science and Education for the State Administration of Traditional Chinese Medicine has compiled the English-Chinese textbook series in traditional Chinese medicine (TCM) for undergraduate of college. These textbooks include Basic Theories of Traditional Chinese Medicine, Diagnostics of Traditional ~ h i n e s eMedicine, Chinese Materia Medica , Formulas of Traditional Chi nese Medicine, Traditional Chinese Internal Medicine, Acupuncture & Moxibustion and an English-Chinese Dictionary of Traditional Chinese Medicine. This project is very scholastic and now is coming into publication for the first time domestically and abroad. Traditional Chinese medicine possesses a unique theoretical system, rich clinical experience and excellent clinical effects. It has made great contributions to the health of mankind. Either now or future, based on its own potential, TCM will play an increasingly important role in promoting the development of a world medicine, and more attention of people in the world. More and more international friends are interested in TCM and they are studying and practicing TCM throughout the world. In order to overcome the language barrier and to understand TCM correctly they are eager for a set of TCM textbooks. They want these textbooks to be suitable for use in colleges of higher learning and with accurate in English translation. Beijing University of Chinese Medicine and Pharmacology is a key university among the TCM teaching institutions of higher learning in China. The university began to enroll foreign students in 1957. Since then about one thousand foreign students coming form more than 70 countries and regions in the world graduated form it. At present, there are nearly 300 foreign students form 41 countries and regions studying at the university. Our university has accumulated rich experience in teaching foreign students and understands their special needs in the study of TCM. These years of practice in teaching has greatly helped the compila-tion of the TCM textbooks. The authorities at our university highly evaluate the task of compiling and 1
translating the TCM textbook series and organized a special working group of experienced professors and other professionals to compile the series. Based on the fi4th edition of relevant all-China TCM textbooks of higher learning, the TCM textbooks absorb the latest achievements of scientific research in TCM lay more stress on logicality, scientificality and praciicality, make every effort to contain more
information and to build a rational framework of the content in an
understandable and ereadable manner. This TCM texkbook series is suitable for both foreign and Chinese students and all those who are interested in T C M , both at home and abroad: In order to ensure academic standards and an accurate English translation of this textbook series, we invited well-known TCM experts Prof. Wang Yuchuan and Prof. Yan Zhenghua to examine and review the Chinese language part of the series, and invited American medical and English language experts Fang Nengyu, Concetta Maria Pirrone and George Francis Mclean to review the
F:nglish transla-
tion. The diagnostics of TCM is an important subject connecting to different clinical departments of Chinese medicine. Including diagnostic methods and syndrome differentiation, its contents are the knowledge that must be grasped by everyone who wants to do clinical job with Chinese medicine. In the part of diagnostic methodi9 various skills required by the four diagnostic methods, i. e. observation, auscultation and olfaction, interrogation, palpation, are introduced in detail. In the part of syndrome differentiation, various methods for syndrome differentiation such as eight principle syndrome differentiation, visceral syndrome differentiation, meridian syndrome differentiation, etc. and their clinical application are introduced systematically. Finally, any correction to errors and suggestions concerning its contents and format will be appreciated. We will take them into careful consideration in the next edition and we believe that with such help, these TCM textbooks will be much improved in the next edition. During the compilation of the TCM textbook
series, we have been greatly
helped by the relevant official departments and experts and we would like to express our profound thanks to them. The compiler and translator February, 1995
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Francis Mclean
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CONTENTS
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II Applying Four Diagnostic Methods in Combination
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Chapter 1
Introduction
Diagnostics of TCM is a study concerning the examination of body, diagnosis of diseases and differentiation of syndromes under the guidance of the basic theories of TCM, The contents of diagnostics of TCM include examining patient, collecting data relating to health, sorting out, analyzing, synthesizing and reasoning the data on basis of basic theories of TCM, finally, determining the characteristics of clinical manifestations and the change laws of illness condition after disease occurring. By doing so, we can know and identify the diseases and syndromes and provide basis for the treatment and prevention of diseases. The main task of clinical medicine is to make a diagnosis of a disease and then to carry out treatment on basis of diagnosis. So, correct diagnosis is the prerequisite for effective treatment. The diagnostics.of TCM is a bridge which links up the fundamental courses of TCM with all branches of clinical medicine. It is such a subject that is based on the basic theories of TCM to study especially on how to inspect the manifestations, to analyze the changes, to understand the pathologic laws, and to predict the transformation of diseases. After having studied diagnostics, it is possible to differentiate syndromes, to seek for the causes of diseases, to judge patients9 conditions on basis of clinical manifestations of patient. Then, it can establish a good basis for studying the clinical courses further. During the long period of medical practice, doctors of past ages accumulated rich experience of diagnosis which formed the comprehensive diagnostic system special for TCM, i. e . , four diagnostic methods (observation, auscultation and olfaction, interrogation and palpation) and syndrome differentiation. And based on those, they established diagnostics of TCM. From ancient time to now, the diagnostics of TCM has been playing its constant role in clinical practice. Recently, modern scientific methods have been applied to conducting the four diagnostic methods and syndrome differentiation in combination with traditional methods. It is developing in the way of keeping the distinctive features and combining with modern sciences.
Section 1 The Main Contents of Diagnostics of TCM Diagnosing a disease includes two aspects. One is to observe, to inspect and to investigate. The other is to analyze, to reason and to judge. So the diagnostics of TCM can be divided into two main parts, namely, diagnostic methods and syndrome differentiation*
EL. Diagnostic Methods The methods which are applied to observing, inspecting and investigating on patient, and to collecting the data relating to the health changes of a patient are called diagnostic methods. According to the theories of TCM, the human body is an organic whole. The local disorder of the outside of body can influence the inside, and .the inside disease can also show on body surface. This means that the external manifestations can show the nature of internal disease. Therefore, when making a diagnosis by TCM, it is to reason the internal pathological changes of a patient mainly by means of the patient's self-sensation and external manifestations which are known by physicians through their sensory organs. Grand Discussion on the Correspondence of Y i n and
Yang, one chapter of Plain Questions, said: "To know the interior according to the exterior would ensure the correct diagnosis. That means the external changes can "
reflect the internal disease. It is pointed out more clearly in Speculation from Exte-
rior (one chapter of Spirit Pivot) : "The obvious manifestation cannot be hidden because it dose not leave yin and yang. The correct diagnosis can be made by means of observing and pulse feeling comprehensively. If one could not distinguish the different five sounds and five colors, it would not be possible to cognize the disorder of the five zang-viscera. So the interior corresponding to the exterior is just like the shade always accompanying the figure. Physician can speculate the interior according to the external changes, but also can speculate the exterior according to the internal changes. "Such theory of diagnostic method about "knowing the interior by the exterior" still plays its role in clinical practice nowadays. The diagnostic method of "knowing the interior by the exterior'' includes four diagnostic methods. They are observation, auscultation and olfaction, interrogation and palpation. All these methods were recorded in Internal Classic. For instance,
Grand Discussion on the Correspondence of Y i n and Yang said: "A good diagnostician distinguishes the yin and yang first by observing the complexion and feeling O
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the pulse. In order t o make proper treatment and correct diagnosis, one should distinguish the clear or turbid of color to know the pathological parts; should observe the breath and listen to the sound to judge what is suffered by patient; should analyze the seasonal pulse changes to recognize which is responsible of the disease; should analyze the floating, deep, slippery or sluggish pulse in chi and cun pulse-portion to understand where is the pathologic position". T h e above points out three kinds of diagnostic methods, i. e. , observation, auscultation and olfaction, pulse reading. T h e importance of interrogation was emphasized in Discussion o f
Four Faults (one chapter of P l a i n Question) . It said : "In diagnosis, if one does not ask the starting time of onset, the patient's worries, the improper diet, the indulgence in living fashion, or injury due to poison, but takes just pulse, how could one make a correct diagnosis?" . Observation means to look over the patient's mental activity, complexion, appearance, movement, body shape and secretion, discharge, e t c . , by means of doctor's visual sense. Because of that "if there are internal changes, they would definitely be displayed externally", thus, by observing the patient's
abnormal
outside changes we can know the pathological changes of the viscera and blood and qi. Among observations, the facial complexion and tongue are the most important parts since they correspond with the viscera, blood and qi closely. Auscultation and olfaction, by means of doctor's auditognosis and osphresis, are used to distinguish whether there is something abnormal in patient's speaking, breath, cough, voice and odor of secretion and discharge in order to judge the condition of patient's disease. Interrogation means that a doctor questions a patient and his/her surrounding people purposefully to find out the patient's symptoms, the cause or predisposing factors of disease, the process of clinical development and treatment, and the patient's living habit, environment, personal relationship, and so on, in order to collect useful data for diagnosing disease or syndrome. Palpation means to feel certain parts of pulse beating on the body surface or to press-touch some parts of the body (e. g . , chest, abdomen, limbs, acupoints, etc.
)
.
Doctor can understand the condition of illness based on the pulse change and the local abnormal reaction felt by tactile sensation. T h e four diagnostic methods of observation, auscultation and olfaction, interrogation and palpation have their unique clinical functions and can not be replaced by one another. They must be applied simultaneously t o diagnosis to ensure correct * 3 0
diagnosis. The dependence only on one method may lead to deviation, so as to misdiagnosis.
11.Syndrome Differentiation T h e judgment on pathological conditions made by TCM can be divided into
.
two aspects, the "disease differentiation" and "syndrome differentiation" Since the syndrome differentiation is the unique feature and quintessence of TCM, which is the common method applied to diagnosis in every branch of clinical medicine, the focal point of this textbook is paid to elaborate the syndrome differentiation. The content of disease differentiation will be seen in clinical medicines.
Symptom (including sign) is the abnormal phenomenon which deviates from the normal physiological range after disorder occurs, such as fever, aversion to cold, and so on. It is the reflection of human body's disease. It includes the patient's self-feeling of discomfort and the data obtained by doctor through examination. By symptoms, the pathologic position and changes can be sought out. So symptoms are the important bases for the disease differentiation and syndrome differentiation.
Disease is the generalization of the distinct features of a disorder in the whole process and the specific law of pathologic development. The process of making analysis and judgment. then identifying the disease, on basis of the patient's symptoms, is called disease differentiation.
Syndrome is neither the symptom which simply reflects a certain disorder nor completely determined by special pathologic factor which causes a certain disorder. Syndrome is the summarization of environment, causes (e. g . , internal or external, etc.
) , pathological
location (e. g. , exterior and interior, rostra1 and caudal, zang-
viscera and fu-viscera, etc.
) , pathogenesis,
the condition of vital-qi, pathogenic fac-
tors and constitution of patient, and so on, based on the data obtained by means of the four diagnostic methods. It reflects comprehensively and concretely the feature, nature and key crux of disease during a given stage. So, it reflects the nature of a disease in certain degree.
Syndrome differentiation, which is made under the guidance of TCM theories and on basis of the clinical data obtained by the four diagnostic methods, is a process of analyzing and synthesizing the different symptoms which relate to each other intrinsically, then determining which syndrome the patient i s suffering from. It is such a diagnostic method which considers the environment, nature of pathologic factors, strong or weak of the vital-qi and character of disease holistically. With the change of time, the syndrome may change. The change of syndrome .4.
concretely reflects the development and process of a disease. The changes include:
(1) Natural change: Change occurs naturally after a certain time but not artificially. This kind of change often follows certain laws, such as the transformation law of exopathic disease. However, the change of syndrome is always different in accordance with seasonal conditions, local conditions and the physique of an individual.
(2) Change after treatment or nursing: Correct treatment or nursing can promote disease changing to good direction; otherwise, disease changes to worse direction. In the long process of medical practice, ancient doctors created many methods of syndrome differentiation, such as eight principle syndrome differentiation, etioI
logical syndrome differentiation, qi-blood-body-fluid syndrdme differentiation, visceral syndrome differentiation, meridian syndrome differentiation, six meridian syndrome differentiation, defensive-qi-nutrient-blood syndrome differentiation, triplejiao syndrome differentiation, etc. These methods sum up the laws and the understanding of syndromes from different aspects. Each one has its own features respectively. During diagnosis, each method has its special emphasis, however, they are related to and supplemented by each other. Among them, eight principle syndrome differentiation is applied to determining the nature of disease; etiological syndrome differentiation to finding pathogenic factors; visceral syndrome differentiation and meridian syndrome differentiation to identifying the disease location; qiblood-body-fluid syndrome differentiation to analyzing the abnormal changes of qi, blood, water and nutrient, etc. ; six meridians, defensive-qi-nutrient-blood and triple-jiao syndrome differentiation to diagnosing the exopathic febrile diseases.
Section 2
The Principles of Diagnosis in TCM
In the long process of medical practice, the unique TCM diagnostic system is formed gradually. There are some main principles in diagnosing as the following.
I. The Holism The holism is a basic concept of TCM. The holism in diagnosing refers to the comprehensive consideration of human body (the inner) and the natural surrounding (the outer). It is also called "inspecting of both the inner and outer". It includes two aspects as follows.
I. The Human Body as a Whole The upper and lower parts, the inner and outer parts, zang-viscera and fu-vis*
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cera, the meridians of the body are linked as an inseparable whole. The inner viscera are the center of the body. All the limbs, five sensory organs, nine orifices, the skin, muscles, vessels, tendons and bones are linked to viscera through meridians. So the local disorder can affect the whole body through meridians. The diseases of viscera or qi, blood can also be shown in local parts,five organs or orifices through meridians. The inner abnormality can present on outer parts, while the outer disease can turn into the inner parts. For example, the sore on body surface can result from spleen dampness or heart fire; the liver fire can manifest as the red eyes and hypochondriac pain, and so on.
2. The Unification of Human Body and the Surroumdbng During the long time evaluation, the physiologic function of human body has adapted itself to the general changes of surrounding and nature. If the inner disorder occurs and leads to the body inadaptable to the changes of surrounding or nature, or the changes of surrounding is too furious and over the acceptable range of human body, it will lead to uncontrolled actions of viscera, qi and blood, thus, the disease occurs. The Plain Questions said: "In eastern area, most of the diseases are carbuncle and ulceration. In western area, the disease occurs internally. In northern area, the fullness due to cold viscera is often seen. In southern area, the diseases of withering, reversion, chill and fever are more often seen. The Plain Question also "
said: "In spring, there is nose bleeding. In middle summer, there is more hypochondriac pain. In late summer, there is diarrhea. " They demonstrated that due to the geographic and climatic differences, the diseases are also different. On diagnosis, we must consider disease with the surrounding. Besides, the tiredness, mental stress and improper diet can all affect the visceral functions and cause diseases. And the diseases of viscera will result in a lower endurance to tiredness, mental changes and poor appetite, etc.
geographical conditions, seasons and living conditions mental surroundings
skin, muscles, vessels, tendons and bones
T o sum up, the importance of holism (inspecting both the inner and outer) lies not only on the relation between local disorders and whole body, but also on the ef-
fect on human body from the surrounding. All the theories, such as correspondence relation between heaven and human, the unity of opposites of yin and yang, the inter generation and restrain1 of five elements, the interior-exterior relation of viscera and meridians, demonstrate the unity and whole of the body and unity of the body and the surroundings. The theories can be applied to guiding diagnosis.
411.Applying Four Diagnostic Methods in Combination It mainly relies on the doctor's sensory organs to diagnose a disease in TCM. The nature of disease is judged from the external abnormal signs which demonstrate the internal pathological changes and the patl"eRt9sself-feeling of discomfort. That means the accuracy of diagnosis is determined by doctor's subjective feeling and patient's subjective feeling and description. Symptoms are the bases of syndrome differentiation. If the doctor's and patient's subjective feeling and description are not correspond with the actual condition, or lack of symptoms, then problems and difficulties will arise in process of syndrome differentiation, they may even lead to misdiagnosis. In order to make a correct diagnosis, especially for the difficult, complicated and critical cases which have more and complex syndromes, it is essential to collect comprehensive and detailed data as far as possible. Then it is possible to reduce deviation. The fundamental way of collecting all the available clinical data is to combine the four diagnostic methods together. The different sensory organs have their unique own sensory functions. Observation, auscultation and olfaction, and palpation are applied to examining patient by means of doctor's visual sense, auditognosis, osphresis and tactile sensation, while interrogation summarizes the patient's feeling and description on the questions about the onset, development of disease. They can only be supplemented to but not be replaced by each other. Therefore, only to collect the data from the four diagnostic methods completely, it is possible not to miss the data needed for syndrome differentiation, thereby to create a good condition for making correct diagnosis. Li Yanxia, a doctor in Ming Dynasty, made a very imagery metaphor to the four diagnostic methods. He said: "The four diagnostic methods are just like the four limbs of the body. That a good physician cannot neglect any one of the four diagnostic methods is just like that a human body cannot lose any one of the four limbs. " T h a t showed that applying four diagnostic methods in combination was highly evaluated by ancient doctors.
111.Differentiating the Syndrome of a Disease T o differentiate syndrome on the basis of disease differentiation is the intrinsic and specific content in TCM. For instance, Treatise on Febrile Disease (one chapter of Plain Questions) said: "Generally speaking, all the febrile diseases are caused by cold. " It determines the condition is a febrile disease caused by cold attack first, then differentiates which meridian is affected in three yin or three yang. All methods of syndrome differentiation adhere to this principle. For example, six meridian syndrome differentiation, defensive-qi-nutrient-blood syndrome differentiation, and so on. This principle was also emphasized in other chapters of Internal Classic such as Discussion on Malaria, Discussion on Wind Disease, Discussion on Blockage Disease, Discussion on Withering, Discussion on Rebellion, Discussion of Strange Disease, etc. In order to get the accurate diagnosis, one should judge a disease first and then differentiate syndrome on basis of patient's symptoms. T o seek for the cause of a disease is one of the main contents of disease differentiation and syndrome differentiation. The "cause" in TCM has two meanings of narrow sense and broad sense. Cause in narrow sense refers to the pathogenic factors, such as six climatic factors, seven emotional factors, diet, fatigue, injury due'to animals or weapons, etc. In addition to the above mentioned meaning of cause in narrow sense, the cause in broad sense includes some pathological productions, such as stagnated qi, blood stasis, undigested food, retained phlegm and fluid, etc., which are produced during the process of a disease. In this time, the original pathological factors may still exist, or may have disappeared, but the pathological productions have become the main crux or the essence of the disease, which becomes the chief object of syndrome differentiation and treatment. The central task of differentiating syndrome of a disease is not to seek for the causative agent or some organic pathologic change directly, but to grasp the essence of the disease on basis of various abnormal changes appearing in the disease. This essence of disease includes causes, location and nature of disease, pathogenesis, patient's constitution and environment, etc. In brief, to differentiate syndrome of a disease is, under the guidance of the concept of holism, by means of the four diagnostic methods and the theories of syndrome differentiation, to carefully observe and analyze the symptoms which appear when the human body is influenced by pathogenesis factors, and to find out the main crux from the complex phenomena, and finally to make a diagnosis of the disease and syndrome. T o differentiate syndrome of a disease is neither like the differentiation of only .8*
the disease which dose not consider the patient's concrete conditions, nor like the symptom-relieving treatment such as treating fever by cooling method and treating sputum by improving expectoration. It can be used to make a diagnosis on the name of disease and syndrome, so as to set basis for applying correct treatment principle and selecting effective formula and herbs. For instance, a patient goes to hospital with fever for two days. Fever is one of the most common symptoms in clinic. It can be caused by many diseases. So it has to determine to which disease the fever pertains. If the fever is accompanied by aversion to cold, headache, cough, it can be diagnosed as exopathic disease. If it is characterized by a light fever with a heavy aversion to cold, it can be diagnosed as cold-attack disease further. As soon as the name'of disease has been determined, it needs to make further syndrome differentiation. Because the fever coexisting with the aversion to cold, and without thirst, the location of disease is the exterior. If there are floating and tight pulse, neither red tongue, nor sweating, it is clear that the nature of disease pertains to cold; the cause of disease is the exogenous cold; the pathological mechanism is wind-cold attacking the exterior, thus leading to failure of lung-qi in dispersion. So, it is differentiated as exterior syndrome of cold-attack, namely the cold-attack syndrome of Taiyang. For another example, arthralgia belongs to "blockage" (disease). But we have to make further syndrome differentiation. If there is a migratory pain, it is called wandering-blockage which is caused mainly by wind evil. If the pain is severe, it is called pain-blockage which is caused mainly by cold evil. If the pain is lingering with heavy limbs, it is called fixed-blockage which is caused mainly by dampness evil. Therefore, the correspondent prescription and herbs should be selected according to the different conditions of the patient for the treatment. T o sum up, to differentiate the syndrome of disease enables us to grasp the disease essentials more comprehensively and to make an accurate diagnosis of disease, so as to meet the requirement of "treating disease from the rootJ).
Section 3 The Brief History of TCM Diagnostics During the process of daily life, the mankind are struggling against diseases constantly. They gradually accumulated abundant medical knowledge and summed up the methods of examining diseases. The TCM diagnostics has been developed in the process and become a subject with the characteristics of the Chinese culture. In Chinese character inscription in bones or tortoise shells unearthed from Yin Dynasty ruins, there are many oracle inscriptions recording many diseases knowl-
edge including sixteen kinds of diseases involving head, eye, ear, mouth, tongue, throat, nose, abdomen, foot, toe, urine, delivery, etc. They belong to diseases of internal medicine, surgery, gynecology, obstetrics, pediatrics, infectious diseases of modern medicine. It had unexquisite classification of diseases and could name diseases according to the different parts where diseases occur. The records of disease preserved in bones or tortoise shells unearthed from Yin Dynasty ruins can be regarded as the 'most primordial medical records in China. For example, among which there is a record about dental caries in oracle inscriptions of the thirteenth century B. C . , (Wuding period). This record is 1, 000 years earlier than that recorded in Record of History, and 700 years earlier than that of abroad record. It is the earliest record in the world about the same content. Zhou Rituals is an ancient book recording the social conditions in Zhou Dynasty. In this book, doctors were classified into physician, surgeon, dietitian and veterinarian. It is clear that at that time there were internal department, surgery department and nutrition department, etc. Diagnostic methods such as observation, listening and smelling had been applied to diagnosing some diseases. The report on cause of death should be written by doctors and be preserved. In fact, this was also a kind of medical case record in early stage. According to Record of History, Chun Yuyi, a famous doctor in Western Han Dynasty (200 B. C. ) , kept all case records of his patients and verified the effect of treatment by means of case notes, thereby to improve his medical level in practice. This showed the ancient doctors had a rigorous scientific approach and a good way I
of medical practice in the aspect of diagnosis. Internal Classic is a classic book in TCM. It summarized the medical theories and medical experiences of Chinese people from the Spring and Autumn Period, the Warring States Period to Qin and Han Dynasties. In the aspect of diagnostic method, there are a lot of records about the four diagnostic methods of observation, listening and smelling, questioning and palpation in the book. It paid especial attention to questioning among diagnostic methods. It mentioned that in diagnosing a disease, if the doctor did not ask the cause of disease, the diet abnormality, the disorder of emotions, the difference of living conditions, the disposition and constitution of patient, it was the default of doctor. In the Discussion of Five Defaults (one chapter of Plain Questions), it said: "When wise man deals with disease, he knows the heaven and earth, the yin and yang, the law of four seasons, the eight rights and nine phenomena first, and then the diagnosis can be made right. " I t was lo
pointed out in the Internal Classic that when making a diagnosis, one should combine the climatic conditions, geographic conditions, living environment and individual constitution with the application of the four diagnostic methods, to understand the conditions of disease comprehensively, and to collect all the data relating to syndrome differentiation and treatment. It is then possible to make the correct diagnosis. The "nineteen items of pathological mechanism", the theories of viscera, yinyang and five elements in Internal Classic are guiding principles for the syndrome differentiation methods, which were created by the later generations, for instance, eight principle syndrome differentiation, etiological syndrome differentiation, qiblood-body-fluid
syndrome differentiation, visceral
syndrome differentiation,
meridian syndrome differentiation, six meridian syndrome differentiation, defensive-qi-nutrient-blood syndrome differentiation, triple-jiao syndrome differentiation. They are all originated from the Internal Classic. As for some diseases, such as, malaria, blockage syndrome and some common symptoms in clinic such as cough, pain, etc., they are analyzed and differentiated in the Internal Classic from the aspects of nature of pathologic factor, deficiency or excess of viscera, predominance or weakness of yin and yang, and so on. It is clear that at that time the syndrome differentiation had already reached the stage of comparatively exquisite.
Treatise on Cold Attack and Miscellaneous Disease, written by Zhang Zhongjing in the later years of Eastern Han Dynasty, is a classic book on syndrome differentiation and treatment in TCM. The four diagnostic methods and syndrome differentiation are described detailedly in this book. About the four diagnostic methods, Zhang paid special attention to the pulse reading. When describing a disease, he usually discussed pulse condition and symptoms simultaneously. As for syndrome differentiation, there is the complete content of six meridian syndrome differentiation. Except for defensive-qi-nutrient-blood syndrome differentiation, this book also records all other methods of syndrome differentiation, From it we can know that the syndrome differentiation of TCM had reached a very high level in the late years of the Eastern Han Dynasty.
Classic on Medical Problems, written in Three States Period, specially stressed the pulse-reading in the diagnostic methods, and changed the three part method of pulse taking, i. e. , renying pulse, cunkou pulse and fuyang pulse, into three portion method of pulse taking, i. e.. cun pulse, guan pulse and chi pulse. It exerts a great influence on the later generations. It marked that in the late Han Dynasty and 11
Three States Period, both the practice and theory of pulse-reading had been going to mature. Though there were a lot of books on pulse study in ancient time, most of them had been lost. Wang Shuhe, a doctor in the Western Jing Dynasty, synthesized the various discussions on the pulse study and wrote the Pulse Classic. This book is the earliest monograph on pulse-reading which summarized the ancient pulse studies. In this book he discussed the visceral parts corresponding with the pulse of cun, guan and chi as well as the twenty-four types of pulse conditions and their significances as the indicators of disease. In Song Dynasty, Cui Jiayan wrote the book Verse of Pulse, which took the floating, deep, slow and rapid pulse as the principles. T h e written language of this book is popular, so it is easy to be understood for the new hand. Based on New Book of Pediatrics (written in Song Dynasty), which discussed the method of observing superficial venules of finger in children, Hua Shou (in Yuan Dynasty) clearly pointed out that the superficial venules should be observed in children under three years old. And only when the child is three years old, it is then possible to make diagnosis from pulse-reading. Wei Yiling, in his book Effective Prescriptions Handed Down for Generations, discussed the ten paradoxical pulses such as bubble-rising pulse, sparrow-packing pulse etc. , which provided the comparatively imaginary explanation for the "genuine visceral pulses" in critical cases discussed in Internal Classic. In Jin Dynasty, physicians had made a more and more deep understanding on infectious diseases because of their continuous prevalence. For instance, smallpox, leprosy and other infectious diseases were recorded in Handbook of Prescription for Emergencies, written by Ge Hong. Besides, there are a lot of discussion on emergencies in this book, which shoinrs that at that time physicians had already obtained certain knowledge of clinical manifestations and prognosis for some emergencies. With the intensifying of knowledge on diseases, people had a more and more urgent requirement for the differential diagnosis on disease. Treatise on the Causes and Symptoms of All Diseases, written by Chao Yuanfang in Sui Dynasty, is a monograph discussing the causes and symptoms of diseases. In this book, there are detailed explanation on the causes, pathological mechanisms and symptoms of diseases covering all medical fields. In the aspect of differential diagnosis on symptoms, the descriptions were especially exquisite. For instance, cough was divided into fifteen types. Such exquisite classification was seldom seen in medical books of *
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later generations. So this book can be regarded as a monumental work on differential diagnosis in ancient time. From Tang Dynasty to Jing and Yuan Dynasty, syndrome differentiation had been developed further. Chen Yan proposed the etiological syndrome differentiation which thought there were three types of pathological causes. Liu Wansu conducted the syndrome differentiation based on the viewpoint of fire-heat in the treatment of exopathic diseases. Besides, some doctors emphasized specifically on the visceral syndrome differentiation. For example, Sun Simiao, a physician in Tang Dynasty, wrote the book named as Essential Presc?-iptions Worth a Thousand Gold. There are ten volumes discussing diseases from the viewpoint of zang-fu-viscera. Qian Yi, in his work Key to Therapeutics of Children's Diseases, carried out the syndrome differentiation on children diseases especially from the viewpoint of five zang-viscera. Zhang Yuansu, the author of T h e Evolution of Medicine, took the viscera as the center in differentiating syndromes, working out treatment methods, prescribing formulae and applying herbs. Because the development made by Zhang Yuansu was far more elaborate than his predecessors, then the dominant position of the visceral syndrome differentiation was established among the various methods of syndrome differentiation. In addition, there were syndrome differentiation on the spleen and stomach, the internal injuries and exopathic diseases proposed by Li Dongyuan, syndrome differentiation on yin and yang proposed by Wang Haogu and Zhu Danxi, etc. They all made their contributions in different aspects of visceral syndrome differentiation. The method is specially worth to be mentioned that was applied to examining the urine of patients suffering from jaundice, which is recorded in the fourth volume of The Medical Secrets of an Official (written in 7 5 2 A. D.
)
. It said: "Drench-
ing a little strip of silk in urine every night, and recording its change every day. If the yellow color gradually becomes white, it means the disease is cured. " It is the earliest recorded diagnostic method of clinical experiment in the Chinese history, even in the world medical history. The development of diagnostics in the Ming and Qing Dynasties (including the periods before the founding of the People's Republic of China) is mainly in the four aspects, i. e. , tongue inspection, questioning, palpation and the syndrome differentiation.
I.Tongue Inspectia~n Following the book AO'SGolden Mirror of Cold-Attack Disease compiled by Du 13
Qingbi in Yuan Dynasty, which is the earliest existing monograph on tongue inspection in China, many books were published one after another. These are T h e Ex-
periences of Tongue Observation on the Cold-Attack Disease written by Shen Douyuan, Differentiation of the Tongue Pictures in the Cold-Attack Disease by Zhang Deng, T h e General Records of the Tongue and Coating by Fu Songyuang, and A Guide to Differentiate the Tongue Pictures by Cao Bingnan. Cao Bingnan combined the discussion on tongue inspection in different dynasties with the research and viewpoint on tongue diagnosis made by the traditional Chinese and western medicine in recent centuries into his book A Guide to Distinguish Tongue
Pictures. In the book, more than 100 colored pictures were displayed. It was the best book on tongueainspection before the founding of P. R. China.
2.Questioning The patterns of questioning and case note were basically formed in the Ming Dynasty. Zhang Jingyue summarized the experience of process and proposed ten basic contents for questioning, namely The Song of Ten Questioning. Han Mao pointed out the six aspects of case-record in his books Plan9 Book on Medicine. The six aspects are observing configuration and complexion, listening of the sound, questioning conditions of disease, pulse condition, discussion on the disease cause and therapeutic methods and prescription. Yu Chang and his disciples drew out the format for recording case record, the so called medical history at presents. Its contents were comprehensive and detailed including the disease condition, result of syndrome differentiation, prescription and herbs, and the process of treatment.
3. Palpation
1) Pulse-Reading: In Ming Dynasty, Li Shizhen summed up the essence of various pulse studies and wrote the book Binhu Studies of Pulse. He listed out twenty-seven kinds of pulses and discussed the various different pulse conditions, their meanings as the indicators of disease and the distinction from analogous pulses. 1t gave rise to a great influence on the later generations. In the Chapter on Pulse
Vitality (one chapter of Jingyue9s Complete W o r k s ) ,there are incisive analyses on the various pulses as the indicators of disease and which pulse or symptoms are reliable. Li Yanxia, in his book The Collection of Pulse Verse for Differentiation, put forward that the key point of pulse-reading was to differentiate
the analogous
pulses, to choose the opposite pulses, to know the accompanying pulse, to be familiar to the normal pulses, to understand the pulse changes in the four seasons, and
14
a
to identify the genuine visceral pulses. Zhou Xuehai summarized the various works on pulse study ever since Internal Classic and wrote four kinds of monographs on pulse study, such as ?'he Revised Key for Diagnosticians. In this book, he elaborated very detailedly about the methods of pulse-reading. pulse conditions and their meanings as indicators of disease. He also proposed that the eight items, i. e . , the location, pace, figure and power of pulse, and the weak or forceful, complex or single pulse, should be taken as the principles for pulse distinguishing. The discussion is the most detailed one in ancient works on pulse study.
2) Press-Touching Examination The press-touching examination was initiated from Internal Classic and developed by Zhang Zhongjing. Physicians in the Qing Dynasty such as Cheng Zhongling, Wang Mengying, Zhang Lu, etc., paid more attention to it. For instance, in The Popular Treatise on Cold-Attack Disease written by Yu Genchu, there is a chapter of Press-Touching the Chest and Abdomen. The content of this chapter includes press-touching the chest, diaphragm and hypochondrium, presstouching Xuli-region, press-touching abdomen, press-touching the palpitant-qi around umbilicus, and so on. It was more clearly pointed out by He Lianchen that the method mentioned above was even more reliable than that of taking fuyang pulse and taixi pulse.
In the Ming and Qing Dynasty, physicians made great progress on syndrome differentiation. Zhang Jingyue took yin and yang as the principle, and the exterior, interior, deficiency, excess, cold and heat as the six-changes. He pointed out clear)
ly: "If the six-changes and yin-yang could be understood, then all the diseases could not be beyond them. " H e advocated the value of the eight principle syndrome differentiation in diagnosis. In the aspect of the syndrome differentiation on miscellaneous diseases, there were certain developments in the books such as A Guide of the Origin and Development of Miscellaneous Diseases written by §hen Jinao, Records of Syndrome Differentiation written by Chen Shiduo, A Guide to Clinical Practice with Medical Records written by Ye Tianshi. T h e study of visceral syndrome differentiation and etiological syndrome differentiation were further intensified during this period, such as the discussion on liver diseases made by Lin Peiqin and Wang Xugao, the discussion on blood syndrome differentiation made by Tang Rongchuan, the discussion on spleen and stomach syndrome differentiation made by Ye Tianshi and the syndrome differentiation on dryness and dampness made by *
15
§hi Shoutang, and so on.
A lot of developments were made in the understanding of infectious diseases and the distinction between cold-attack disease and warm diseases during the period of Ming and Qing Dynastys. In the book A Collection on Tracing Back to Medical Classic, Wang Lu made out a distinction between cold-attack disease and warm disease. In the book Differentiating
the Cold-Attack Disease and Warm Disease,
Yang Lishan put forward a comparative detailed elaboration in the different aspects of disease causes, symptomp and treatment between cold-attack diseases and warm diseases. There were also some development in these books such as Treatise on Pestilence written by Wu Youke, Developed Treatise on Pestilence written by Dai Tianzhang and A View of Pestilence with Rashes written by Yu Lin. T h e most great achievement got by physicians in the Qing Dynasty on syndrome differentiation is the foundation of the defensive-qi-nutrient-blood syndrome differentiation and triple-jiao syndrome differentiation, which are used to diagnose the warm diseases. Because of the prevalence of warm disease in the Southern of China, Ye Tianshi, Xue Shengbai and Wu Tang, etc., based on their clinical experience, proposed the syndrome differentiation methods, which is completely different from that for differentiating cold-attack diseases. From then on, a new situation was formed that the syndrome differentiation and treatment on cold-attack disease and warm diseases went on along different ways. Since the foundation of the P. R. China, the TCM diagnostics has been getting further development. In the researches on modernization of the four examining methods and principles of syndrome differentiation, studies have been conducted comprehensively by means of acoustics, optics, magnetics, electricity, chemistry, physics and biomedical engineering. Certain achievement have been gotten. From now on, under the guidance of basic theories of TCM, absorbing the latest achievements in modern science, in combination with the clinical and experimental research, the TCM dialgnostics will develope continuously and make its new contribution to the health service of mankind.
Chapter 2
Observation
Observation is one kind of examining method which is applied to knowing the condition of disease by means of doctor's visual sense to look over the vitality, color, figure, posture of patient's whole or partial body and the changes of the figuration, color, texture and quality of the patient's discharges. Observation is an important diagnostic method in TCM and is -taken seriously by doctors in successive dynasties. Just as it is said in T h e golden Mirror of Medicine that "There is no exception for all the excellent physicians to look over first. " It means the observation method is regarded as the first one among all diagnostic methods. It is realized through the long-term process of medical practice that the path01 logical changes of internal organs can be understood by means of inspecting the outside of the human body. It is said in the 47th chapter of the Spirit Pivot: "Observing the outside manifestations in order to understand the inside organs, so as to identify the diseases. " I t is also said in the Experience of Danxi: "In order to know the inside, the outside should be observed. Only observing the outside, it is then possible to understand the inside. Generally speaking, if there are changes internally, they are inevitably manifested externally. " Among the various contents of observation method, the face and tongue have a closer relationship with viscera and meridians. Because they are more sensitive and accurate to reflect the pathological changes of internal organs by means of facial complexion, tongue texture and tongue coating, which have high practical values. It is then formed the two specific observing methods in TCM, namely, complexion inspection and tongue inspection. Now, the contentsof observation are listed respectively as follows.
Section 1 Observing Vitality, Color, Figure and Posture All
h e vitaiity.
color. figure and posture in health\; human body have their nor-
mal manifestations. Any change different from the normal manifestations means pathosis. It is possible to understand the disease condition by means of looking over the whole body of patient, i. e . , to observe the abnormal changes of the vitality, color, figure and posture of whole body.
I. Vitality It is said in the 26th chapter of Plain Questions: "The blood and qi are the vitality of human body. So vitality is the generalization of all the physiological activ"
ities of human body. It can reflect the normal or abnormal life activities. But vitality cannot be severed from the physique. Only the physique exists, there is the vitality. Sound vitality comes from strong physique and weak physique results in declined vitality. Vitality can be distinguished in broad sense and narrow sense. Vitality in broad sense rneans the total external manifestations of the life activities of human body which are the reflection of visceral functions. Vitality in narrow sense means the mental activities including consciousness and thinking of human being. Vitality observation includes to observe the vitality state in the two senses. About the origin of vitality, it is said in the 8th chapter of the Spirit Pivot: "The combination of two kinds of essences is called vitality. " That shows the vitality comes from the congenital essences. I t is also said in the 32nd chapter of the
Spirit Pivot: "The vitality is the essence and qi of foodstuff. That demonstrates "
the vitality takes the essence and qi of the acquired foodstuff as its supporter. Therefore, only the essence and qi are sufficient, the vitality will be exuberant and the body be healthy. Even if suffering from some diseases, it will not be serious. Otherwise, the insufficiency of essence and qi will result in weak body and declined vitality. The disease will be serious too. By means of vitality observation, we can know the patient's conditions such as the state of essence and qi, the state of viscera and the seriousness of disease. It plays an important role in diagnosis. T o observe vitality, one should put attention to the patient's facial expression, mental state, physical activity and reactivity. Special emphasis should be put on eye movement. The eye is regarded as the window of the liver and the messenger of the heart. All the essence and qi of the five zang-viscera and six fu-viscera flow up to the eyes. It was thought by the ancients that: "The vitality is stored in the heart and manifested in the eyes. " T h u s the key of vitality observation should be the observation of eyes. Four conditions should be distinguished in the vitality observation. They are full vitality, lack of vitality, loss of vitality and false vitality.
I.Full Vitality Full vitality is also called "having vitalityJ'. It is the normal manifestation of sufficient essence and qi and exuberant vitality. Even if suffering from certain ill18. \<
ness, it means the genuine-qi has not been injured and the vitality has not been weakened, so the illness is not serious. Full vitality is manifested by the lustrous complexion, alert and lustrous eyes, natural expression, clear speech, normal mentality, well rhythmic breath, plump muscles, free movement of limbs and agile reaction. Among them, those reflecting the sufficiency of heart qi are the lustrous complexion, natural expression, clear speech, normal mentality and agile reaction. That reflecting the sufficiency of lung qi is the well rhythmic breath. Those reflecting the sufficiency of spleen qi are the plump muscles and free movement of limbs. Those reflecting the sufficiency of liver and kidney qi are the alert and lustrous eyes. The sufficiency of the five zang-visceral essence and qi means health or the favorable prognosis, though suffering from illness.
2.Lack of Vitality It is a condition of no enough vitality. This condition is the most common one in clinic cases. It is manifested by less lustrous complexion, less lustrous eyes, listlessness, shortness of breath, indolence of speaking, retarded reaction, fatigue and sleepiness. Lack of vitality is due to the insufficiency of essence and qi of the five zang-viscera and is commonly seen in deficient syndromes.
3. Loss of Vitality Loss of vitality is the reflection of essence insufficiency, declined vitality and serious damage of the genuine-qi. It marks the failure of visceral functions and means critical condition and unfavorable prognosis. Loss of vitality is manifested by the dim complexion, dull and gloomy eyes, indifferent expression, sag mentality, sluggish reaction, feeble or intermittent breath, lean muscles, difficulty in acting, even coma with murmuring, floccilation, or sudden fall with unconsciousness, close eyes with opened mouth, paralyzed hands, urinary and fecal incontinence. Among them, that reflecting the failure of heart essence and qi is the dim complexion, indifferent expression, sag mentality and sluggish reactions. That reflecting the failure of lung essence and qi is the feeble or intermittent breath. Those reflecting the failure of spleen and stomach essence and qi are lean muscles and difficulty in acting. Those reflecting the failure of liver and kidney essences and qi are the dull and gloomy eyes. As for the coma with murmuring, floccilation, opened mouth with paralyzed hands, urinary and fecal incontinence, they reflect the crisis due to the evil sinking into the pericardium or prostra19
tion of the essence and qi.
4. False Vitality False vitality means a kind of pseudo-phenomenon of temporary improvement which appears suddenly at the crisis stage when the patient's essence and qi are extremely declined because of chronic disease or serious disease. For instance, the former indolence of speaking, weak and intermittent voice suddenly turn into polylogia (liking to speak) and clear voice; the former listlessness and unconsciousness suddenly turn into consciousness and spiritedness; the former dim complexion suddenly turns into flush zygomatic region like being made-up; the former poor appetite or anorexia suddenly turns into excessive appetite; and so on. The false vitality marks the essence and qi will be exhausted and the yin and yang will be divorced because of the failure of yin in astringing yang which results in the outward escape of deficient yang. This means the exacerbation of disease condition which is dangerous critically. It was called by the ancients as "the last radiance of the setting sun" or "the last light of a dying-out candle" to analogize the pseudo-phenomenon of temporary "improvement" appeared during critical stage. False vitality is the state just before the death. The differences between full vitality and the false vitality are:
1) False vitality usually appears after loss of vitality in fatal cases and is obviously not in accordance with the whole development process of disease condition;
2) False vitality is only a temporary phenomenon which will become worse promptly in short time. During the process of disease, that the condition changes from full vitality to lack of vitality, or from lack of vitality to loss of vitality, even to false vitality is the mark that the visceral essence and qi become gradually deficient and the disease condition becomes serious from mild. In the contrary, that if it is from the loss of vitality to lack of vitality, even to full vitality marks the visceral essence and qi is restored gradually and the disease state is lessened. So observing the changes of vitality in the clinic has an important significance for understanding the transformation of disease.
5. Mental Abnormality Mental abnormality includes fidget, coma, delirium, and the mental disorders such as depressive psychosis, manic psychosis, epilepsy and so on.
Table 31
Table for Differentiating Full Vitality, Loss of Vitality and False Vitality
Manifestation
Full Vitality
Loss of Vitality
False Vitality
Complexion
lustrous
dim
flush zygomatic region like makeup suddenly
Eyes
alert & lustrous
dull & groomy
Breath
well-rhythmic
feeble or
sudden lustrous
intermittent Figure
plump muscles
lean muscles
lean muscles
Senses
consciousness and
sag mentality, dull
sudden improvement
agile reaction
reaction, even
clear voice
coma with murmuring, sudden fall, closed eyes with opened mouth Diet Urine and Feces
normal normal
poor appetite
sudden excessive
or anorexia
appetite
incontinence
Fidget Fidget is generally due tp heart fire. After suffering from cold-attack disease. there will be deficiency-vexation accompanying with slight fever, insomnia with restlessness, which is caused by the remained heat and insufficient yin-fluid. The severe one of deficiency-vexation is called indescribable vexation, i. e. , the smothering feeling in chest with n o w a y out. The severest one of deficiency-vexation is smothering fainting, i. e. , fainting all day with restlessness, even to coma with delirium, which is often due to the heat evil attacking on the heart and kidney.
Depressive Psychosis The manifestations of depressive psychosis are apathy with hopologia, murmuring soliloque, laughing or crying irregularly, and in low spirit of common condition. It is often due to the stagnated phlegm and qi covering the mind.
Mania: Psychosis The manifestations of manic psychosis are raving with swearword, madness and restlessness, singing at high place, wandering nakedly, hitting people or destroying things regardless of relatives or strangers. The common cause is the stage
21 ,
nation of liver qi transforming into fire and phlegm, and the phlegm-fire disturbs the mind. Sometimes it may be caused by the exorbitant heat or accumulated blood in Yangming Meridian.
Epilepsy The manifestations of epilepsy are sudden syncope with saliva dropping and tic of limbs. After onset the patient looks like no abnormality. It is often caused by the liver-wind with phlegm and the phlegm-fire disturbing the heart.
PI.Color Color observation mainly refers to looking over the color and luster of the facial skin. Since all the qi and blood in the twelve regular meridians go upward to face, the color and luster of face can reflect the exuberance or declination of qi and blood of the internal organs. The exuberance qi and blood result in lustrous complexion, while the declination of qi and blood in withered complexion. By observing the complexion, the ancients usually mentioned the qi color or the vitality color in the same breath. For the qi color, it is the outside manifestation of the five zang-visceral qi. It was said in Compilation About the Four Diagnostic
Methods: "Qi is radiated from the zang-viscera and the color is manifested following the qi. " T h e qi is manifested by luster. It represents the exuberance or declination of the essential qi. The color is in accordance with the five zang-viscera. According to the theories of TCM, the five colors correspond to the five zang-viscera. The correspondences of them are: blue to the liver, red to the heart, yellow to the spleen, white to the lung and black to the kidney. It was said in Observation Diagnosis by
Adhering to Classics: "The brightness and luster are the reflection of qi. T h e green, red, yellow, white and black are the reflection of colors. It dose not need to be worried about the color change if there is the reflection of qi, but it should be worried if there are only colors without the reflection of qi. So, no matter what the color it "
is, if only there is the brightness and luster, which is manifested in the skin implicitly, it means the color being with qi and is called benign color. On the contrary, if there is the dim color without luster, or the brightness exposes outside the skin obviously, it means the color being without qi and is called malignant color*T h e benign color marks the essence and qi are not exhausted, and the disease is mild and is possible to be cured. So the prognosis is f a v o r a l ~ l e 1. ' 1 1 ~ malignant color means the exhaustion of essence and qi, and the disease is serious and difficult to be cured. So the prognosis is unfavorable. As for the vitality-color, it was said in Principle and
Prohibition for Medical Profession: "The color is the flag of vitality. The exorbitant 22
vitality results in good color and the declined vitality bad color. So the implicit color means the stored vitality and the obvious color the exposed vitality.
"
This
demonstrates that the vitality observation should must be taken simultaneously with color observation. The vitality is expressed by brightness, too. The color with brightness means the color with vitality. If not so, it means the color without vitality* When observing the facial complexion, the first thing should be to distinguish the normal complexion and disease complexion.
8. The Normal Complexion The normal complexion refers to the facial color and brightness in a healthy state. It reflects the fullness of qi and blood and the normal visceral functions. So it should be shown as brightness and luster. Observation Diagnosis by Adhering to
Classics said: "The brightness is the reflection of vitality, and the luster is the reflection of full essence and blood. " Chinese belongs to yellow race. So the normal complexion is implicit reddish yellow with brightness. It is the outside manifestation of the full essence and blood and the visceral harmony. Among the normal complexion, there are divisions of host complexion and guest complexion.
1) Host Complexion. The host complexion refers to the basic complexion or skin color which does not change in one's whole life. But it is different in accordance with the races and constitutions. For instance, the Chinese belongs to yellow race, generally the skin color presents a slight yellow. So the slight yellow is taken as the host complexion. Because of the different natural endowment, there are somewhat differences such as a little white, a little black or a little red, etc., on the basis of slight yellow.
2) Guest Complexion. The guest complexion refers to the slight change of complexion which follows the seasonal changes. The Golden Mi'irror of Medicine said: "The seasonal complexion follows the four seasons. Owing to their changability, they are called the guest complexion. "Therefore, in the four seasons, the complexion in spring presents a slight blue, in summer a slight red, in autumn a slight white, in winter a slight black. All these are the results of seasonal changes and should be known as the normal.
3) Changed Normal Complexion: The complexion can change due to the different working condition, climates, areas and living environments, diet, sexual activity and emotional changes. For example, the complexion presents a slight white for those who stay in room for a long time, the complexion presents a slight black for a
23
those who work outside under the sunlight for a long time, the complexion presents a slight red after the emotional excitement or alcoholic drinking. T h e Plain Ques-
tions said: "In the Eastern ....the people like eating fish and salty food ....so the facial color is blackish.
"
In a word, the normal complexion is divided into the host complexion, guest complexion and changed normal complexion. Their common feature is the brightness and luster presented implicitly. Observation Diagnosis by Adhering to Classic pointed out: "To know the disease complexion, it is necessary to know the normal complexion. T o know the normal complexion, it is necessary to know the changes of normal complexion first. T o know the changes of normal complexion, it is necessary to know the changes within the changed normal complexion. " So long as to understand the normal complexion correctly, it is then possible to recognize the disease complexion and to diagnose disease correctly based on the abnormal complexion.
2. The Abn~rrnalComplexion The abnormal complexion refers to the changes of skin color and brightness because of disease. There are five kinds of abnormal complexions, i. e . , blue, red, yellow, white and black.
1) The Bemdgn or Malignant of the Five Colors The abnormal complexion has the divisions of being benign and malignant. The benign complexion refers to the presence of both qi and color with implicit luster. Though the body suffers from disease, the visceral essence and qi are not exhausted and the stomach qi can still gloss the face in this condition. So it is also called "the arrival of qi" . While the malignant complexion refers to the withered and dim complexion , or the obvious exposure of color. It shows the exhaustion of visceral essence and qi, and the failing of stomach qi to gloss the face, or the deficiency yang floating upward due to yin failing to astringe it. This is called "the non-arrival of qi" or "dying colorJ'. The changing from benign complexion to malignant complexion marks the condition aggravated to critical, while the changing from malignant to benign complexion is a presage of improvement. The 10th and 17th chapters of Plain Questions had listed the distinguishing points of benign and malignant complexion in five colors as table 2.
2) The Five Colors and Their Indicated Diseases It was pointed out in the 49th chapter of Spirit Pivot: "To name zang-viscera with five colors. It showed the five colors are in correspondence with five zang"
24
viscera. Now the indicated diseases of the five colors are discussed respectively as follows. Table! 2 Benign and Malignant Complexion i n Five Colors iia Plain Question Benign or
Benign Complexion
Malignant Complexion
Malignant
brightness & luster implicitly
lusterless or obvious exposure
Chapters
tenth
seventeenth
tenth
seventeenth
(the color looks like)
Five Colors Blue
kingfisher feather green rock
Red
cockscomb
cinnabar wrapped
withered grass
blue dye
coagulated blood
red ochre
unripe orange
loess
by calice Yellow
crab belly
realgar wrapped by silk
White
pig fat
goose feather
dried bone
salt
Black
crow feather
dark pitch
soot
dried black grass
Pathologic
non-exhaustion of the qi and
loss of stomach qi or
Mechanism
essence of stomach and viscera
exhaustion of a viscus
good
bad
Prognosis
A. Blue: It suggests cold syndrome, pain syndrome, blood stasis syndrome, infantile convulsion and liver disease. Blue is a sign of obstructed meridians and stagnation of qi and blood. The cold has a character of contraction. If the exorbitant cold stays in vessels, it will impede the flow of blood and qi and lead to a pale complexion with bluish or dark blue color. Pain is often the result of blockage and obstruction of meridians, so there is blue color. The stagnated blood in vessels is often shown by blue color. If there is grayish blue complexion with cyanotic lips, it usually pertains to the insufficiency of heart yang and stasis of heart blood. In cases of liver disease, since the functional activity of qi fails to disperse, which leads to stagnation, there will also be blue color. The liver-fire is shown by blue complexion with conjunctival congestion, hypochondriac pain and lusterless nails. If blue complexion seen in female, it usually due to the exorbitant liver qi with insdfficient spleen qi, which is often accompanied with irritability, poor appetite and irregular menstruation. Infantile high fever with blue or cyanotic complexion which is especially noticeable between eyebrows or on nose and around mouth, it usually means the omen of convulsion. 25
B.Red: It
is a reflection of heat syndrome. Red is the color of blood. Heat ac-
celerates blood flow and makes the vessels filled up, so the skin presents red color. The heat syndrome can be divided into excess and deficiency. The excessive heat syndrome is shown by full flushed face. It generally represents the yang-qi being stagnated in the exterior. If the red complexion with tidal fever and delirium, it represents the excessive heat accumulating in the interior. The deficient heat syndrome is reflected by hectic cheek. It pertains to the deficient fire flaming-up due to yin deficiency in the chronic disease. If the chronic disease or serious disease results in exhaustion of essence and qi, so that yin fails to astringe yang and the deficient yang floats upwards, there will be reddish complexion like being made-up, or wandering reddish color on the zygomatic region. This is called the floating yang syndrome. C. Yellow: It suggests spleen deficiency and dampness syndrome. Yellow is the
sign of spleen deficiency and dampness retention. The spleen dominates transportation and transformation. It is the source of the regeneration of qi and blood. If the spleen fails in transporting, the food essence cannot be transformed into qi and blood, the skin is then not nourished well, there will be yellow complexion. If the water and dampness accumulate inside because the deficient spleen fails to transport them, there will be yellow complexion, too. The yellowish and lusterless complexion is called sallow yellowness, which is usually due to qi deficiency of the spleen and stomach. In this condition, the nutrient qi and blood fail to gloss the face. The yellow complexion with puffiness is usually the results of spleen qi deficiency and interior retention of water and dampness. The yellow complexion with yellow stained skin of whole body and eye sclera is called jaundice. The dim yellow like smokiness is named yin-jaundice, while the bright yellow like orange peel is named yang-jaundice. The yin-jaundice is usually due to the interior retention of cold-dampness which encumbers spleen yang and blocks bile discharge, and then leads the bile spilling over to the skin. While yangjaundice results from interior accumulation of damp-heat which steam the gallbladder, so that the bile spills over to the skin. if the yellow complexion with petechial hemorrhage accompanied with subcutaneous varicose vessel on abdominal wall, it is the tympanites. T h e infantile malnutrition is manifested by yellow complexion with fringy hair, emaciation, large abdomen with mass and engorged vessels. Bluish yellow complexion with malnutrition is the manifestation of parasitosis. The luster yellowness on glabella and nose tip predicts the decline of disease, while the luster-
. 26 .
less marks the disease is difficult to be cured,
D. White: It suggests cold syndrome and deficiency syndrome (loss of blood or q i ) . White is the manifestation of insufficient qi and blood failing to nourish the body. The declined yang-qi fails to promote the flow of qi and blood, so that qi and blood cannot nourish the face and skin. It can also be the result of loss of qi and biood which could not fill up vessels. The pale complexion with puffiness is usually due to deficiency of yang and qi which could not enable qi and blood to go up to face. Pate eomplexian with ernaeia-
tion is usually due to insufficiency of blood. The bluish white complexion is usually due to yang deficiency with exorbitant cold, or massive bleeding. Parasite infection is manifested by white macule or spot on face. The sudden appearance of pale complexion with profuse cold sweating is usually due to yang-qi collapse. Table 3 Diseases Suggested by Five Co%ors Five Colors
Five Zang-Viscera
Diseases Suggested
blue
liver
wind syndrome, liver disease pain syndrome, cold syndrome blood stasis
red
heart
heat syndrome
<
excessive heat deficient heat
floating yang syndrome yellow
spleen
spleen deficiency dampness syndrome jaundice
white
lung
kidney
yin-jaundice
cold syndrome deficiency
black
<
yang-jaundice
<
loss of blood loss of qi
kidney deficiency
<
kidney yang deficiency kidney yin deficiency
water or fluid-retention leukorrhea disease blood stasis, cold syndrome
E.Black: It
suggests kidney deficiency, water or fluid retention, blood stasis,
pain syndrome and cold syndrome. Black is the color of yin-cold and water. Black
can be seen in conditions of deficiency of kidney yang, non-evaporation of water, interior exuberance of cold evil and blood stasis. The dim bluish black complexion is due to insufficiency of kidney yang regardless whether it is a new affection or protracted disease. Black complexion with dried face is usually due to the chronic consumption of kidney essence and the essence failing to nourish the face. Blackness surrounding the orbits is usually see'n in leukorrhea disease which is due to the insufficiency of kidney yang that leads to interior retention of water-dampness or pour down of cold-dampness. The blood stasis is manifested by the black complexion with squamous and dry skin. The butterfly-like black spots on female's face are due to kidney deficiency and blood stasis.
3. The Facial Portions Corresponding to the Viscera The viscera have their certain correspondent portions on the face. Combining it with the color observation will be contributory to making better diagnosis. There are two methods to divide the facial portions proposed in Internal Classic as follows.
A. It is recorded in the 49th chapter of Spirit Pivot as :.* ......99The throat portion is above the glabella. The lung portion is between the glabella. Below the glabella is heart portion and below the heart portion is liver portion. Lateral to liver portion is gallbladder portion and below liver portion is the portion of spleen. The stomach portion is on the wing of nose. The large intestine portion is on the cheek. On lateral side of large intestine portion is the portion of kidney. Below kidney portion is the portion of umbilicus. Above cheek is the portion of small intestine. The portion of urinary bladder and uterine is between the nose and lip. " According to the foregoing recording, the following picture is drawn.
B. In the 32nd chapter of Plain Question, the facial portions corresponding to the five zang-viscera are distinguished as follows: The left cheek corresponds to the liver, the right cheek to the lung, the forehead center to heart, the lower cheek to the kidney and the nose to the spleen. The Internal Classic proposed a method of matching the five sense organs with the five zang-viscera to diagnose disease based on the color changes of the five sense organs. For instance, it is said in the 37th chapter of Spirit Pivot: "The nose is the organ of lung, the eyes are of liver, the lips of spleen, the tongue is of heart, and the ears are of kidney.
o n a e O e
So lung disease presents dyspnea and nares flaring,
liver disease blue canthi, spleen disease yellow lips, heart disease curled-up and 28
a
shortened tongue and red cheek, and kidney black cheek and face.
"
Based on abnormal color changes on the different facial portion, in combination with the benign or malignant changes and the suggested disease of five colors, we can identify the affected viscus, the nature and the prognosis of disease.
Picture 2
Picture 1 @forehead @nose
Qbefween the eyebrows
@cheeks
@front of ears
@throat
@lung
@small intestine
@heart Qstomach
@large intestine @urinary bladder
@gallbladder @spleen
@liver @kidney
@umbilicus @uterus
111.Figure The figure observation is to observe the robustness or weakness and corpulence or emaciation of the patient's body, and the condition of different parts of the body and the constitution, etc.,, so as to understand the internal changes of disease. Of the human body, the five zang-viscera pair with the five elements respectively in the interior, while the figure pair with the five zang-viscera in the exterior. The robustness or weakness of the body's outer figure is corresponding to the exuberance or declination of the functions of five zang-viscera. The inner exuberance results in outer robustness, while the inner declination results in outer weakness. So, by means of observing thepatient's figure, it is possible to speculate the solidness or fragileness of viscera, the exuberance or declination of qi and blood, the wax or wane of the genuine-qi and the e ~ i l - ~The i . five body constituents, namely skin. muscle, tendon, bone and vessel, match with the five zang-viscera. The five zangvisceral functions are the roots of the five body constituents which can reflect the 29 *
exuberance or declination of the five zang-viscera. The so-called five houses refer to the head, back, lumbus, knee and bone. By observing the five houses, it is possible to speculate the disease location of viscera and the severity of the disease.
1. Raabustness, Weakness, Corpulence and Emaeiaaiasn Robustness refers to a strong physique. It is shown by bulky skeleton, wide and thick chest, plump muscle and luster skin. The robust figure means the solid viscera and exuberant qi and blood. The prognosis is favorable even though suffering from disease. Weakness refers to a feeble physique. It is reflected by the thin skeleton, narrow chest, lean muscle and lusterless skin. The weak figure means the fragile viscera and insufficient qi and blood. The prognosis is unfavorable if suffering from ' d isease.
Corpu~ence.Corpulence with a good appetite is thought as exuberant figure, while corpulence with poor appetite as exuberant figure with qi deficiency. The former means sturdiness and latter means insufficiency of yang-qi and infirmity. The corpulent body is susceptible to suffer from damp and phlegm accumulation. The accumulated phlegm and obstructed qi are likely to be transformed into fire, which is apt to lead to apoplexy or sudden syncope. Emaciation. Emaciation with polydipsia (too much food intake) pertains to the fire-flaming in the middle-jiao, while emaciation with small food intake pertains to the deficiency of spleen and stomach. Lean muscle suggests the exhaustion of qi, body fluid and visceral essence. Emaciation with feverish sensation in the five
ten-
ters and night sweating implies yin and blood deficiency with hyperactivity of ministerial fire.
2 e Five Body Constituents and Five Houses
(1) Five Houses. Head is the house in which the essence assembles. Drooped head with lusterless sunken eyes often reflects the vitality exhaustion. Back is the dwelling place of organs in chest. Curved back with drooped shoulders reflects exhaustion of viscera in chest. For examples, the pigeon chest or tortoise back is due to improper care after birth, mainly the deficiency of the spleen and stomach, or the congenital insufficiency, namely the deficiency of kidney essence. Flat chest mostly attributes to deficiency syndrome, while barrel chest is usually due to latent fluid and phlegm retention. Eumbus is the house of kidneys. The kidney deficiency is usually characterized by lumbago with difficulty in turning round. Knee is the as30
*
sembling place of tendons. The tendon exhaustion is often characterized by difficulty in crooking and stretching of the knees. Bone is place where the marrow is stored. If the patient cannot stand for enough long time, or shows unstable walk, it is the manifestation of bone exhaustion because of the marrow failing to nourish bone.
(2) Five Body Constituents. The skin can be thick, thin, lustrous or lusterless. Muscles can be plump or lean, lessening or enlarging. Vessels have changes of large, small, slow or rapid pulses. Tendon can be thick, thin, loose or tight. Bones can be the large, small, solid and fragile. So the strong or weak of the defensive qi can be speculated from the loose or tight of the skin. The quantity of body fluid can be speculated from the moisture or dryness of skin. The exuberance or declination of the spleen and stomach can be speculated from the plump or lean of muscles. T h e sufficiency or insufficiency of liver blood can be detected from the bending and stretching of tendons. The deficiency or excess of the kidney qi can be probed from the large or small bone. The exuberance or exhaustion of qi and blood can be speculated from the large or small of pulse.
3. Constitution There are certain relations between the body type and constitution. The relationship between body type, constitution and disease is always emphasized in TCM. For exarriple, the relationship between constitution and disease was discussed in the 13th chapter of Plain Questions and the 6th, 64th, 72nd chapters of Spirit Pivot. There were some studies made by the later doctors on that issues, such as "what kind of disease is susceptible to for a certain constitution? And what kind of different symptoms will take place if the same disease is suffered by patients in different constitutions?" Wu Dehan, in his Collection for Important Medical Principles, said: "The one of native deficiency of the exterior-qi is susceptible to wind; the one of native insufficiency of yang-qi is susceptible to cold; t h e one of native declination of yin-qi is susceptible to heat; the one of native insufficiency of the spleen and stomach is susceptible to food-injury; the one of native consumption of the middle-qi is susceptible to overstrain injury. "So the different constitutions are susceptible to different diseases. For t h e future, it will be contributory to the development of TCM diagnostics to further explore the relationships between different constitutions and diseases. 31
IVePosture The kinetic and static postures of patients are closely related to disease. Different diseases show different mobile postures, such as hemiplegia and wry face in wind-stroke ; spasm and opisthotonus in convulsive diseases ; slim legs with difficulty in walk in atrophy syndrome; corpse-like figure with intermittent breath in syncope; bulged abdomen with lean limbs in tympanites; swelling joints with difficulty in movement in syndrome of wind-pain; hand keeping on abdomen with bending forward posture in abdominal pain; knitted brows with droopy head in headache; 'bend back in lumbago; orthopnea and unable to lie flat in asthma, and so on. So by observing the different posture of patients, it is possible to speculate the nature of disease and its prognosis. Observing patient's sitting and lying position and activity is contributory to diagnosis of disease in following points.
I. Lying Position. Supine position pertains to yang while prone position to yin. When lying, if the patient can turn over easily and likes supine position with stretched legs, or wishes to remove clothing, it pertains to yang syndrome, heat syndrome or excessive syn~ i strong genuine-qi. If the drome, which is usually due to the exorbitant e ~ i l - with patient can not turn over easily and wishes to have more clothing on with crooked limbs and body, it pertains to yin syndrome, cold syndrome or deficiency syndrome, which is usually caused by the insufficiency of genuine-qi.
2.Sit$ing Positions. Sitting with raised head and asthma with plenty of expectoration pertain to the lung excess. The condition of sitting with droopy head and shortness of breath with less talk pertains to the lung deficiency. When patient can only sit, but not lie, if on lying there is cough, it is a condition of lung-distention or fluid-retention in chest or abdomen. The sudden faint on sitting up from lying is due to loss of blood and qi deficiency. The restless changing of posture or moving around pertains to fidget or abdominal distention.
3. Abnormality in Activity. Stiffness of neck and back is due to the evil in Taiyang Meridian. The symptom of twitching in eyelid, face, lip or limbs in acute febrile disease is the presymp32
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tom of wind-stroke; while in chronic consumption disease it is due to wood failing to nourish tendons because of insufficiency of the liver blood. Shiver is the phenomenon of struggling between genuine-qi and the evils, which can be seen in exopathic disease, or in tetanus, or in the condition of inward sinking of purulent poison in surgical case. Carphology and groping the air are the risky symptoms of the mind failing to guard inwardly, which might be due to the extreme excess (namely, over exorbitance of the heat evil impairing the heart yin), or due to extreme deficiency (e. g. chronic consumption of qi and blood failing to nourish the heart) .
Section 2
Local Observation
Local observation is to observe patient's local parts on the basis of whole observation and the chief complaints by patient. So it is also called observation of divisions. T h e content includes observing the abnormal changes of shape and posture, color and luster of head, hair, face, eyes, nose, ears, lips, teeth and gum, throat, neck, chest and abdomen, limbs, skin, muscle, external genitals, anus, etc.
I.Head Observation The head is the confluence of all yang meridians. Three yang meridians of hand and foot, Ren Meridian and Du Meridian all travel upwards to the head. For example, Yangming Meridian travels in the front; Taiyang Meridian travels in the behind; Shaoyang Meridian in the lateral side; Jueyin Meridian assembles on the vertex; Du Meridian travels through head to nose along back; Ren Meridian starts from the inside of the lower abdomen and ascends to head and passes through the cheek; Chong Meridian curves around the lips and Qiao Meridians reaches the inner
.
canthus (Jingming, UB) The brain is the house of the primordial mind and the sea of marrow. Since the kidney stores essences and dominates the production of marrow, and is in charge of bones, the state of head is related to the disorders of brain and kidney and to the exuberance or declination of qi and blood. The raised head means the disease pertains to yang and the droopy Read to yin. Stiffness of neck shows excess of evil while the insuspended head leaning on something shows deficiency of the genuine qi. Soft neck reflects the insufficiency of kidney qi, while the uncontrollable shaking head is usually the presymptom of the liver wind stirring or the insufficiency of qi and blood in senile patient. In infant, the larger or smaller head with dementia is usually caused by congenital insufficiency, insufficiency of kidney essence or the water retention in 33
a
brain. The sudden bulging of fontanel is due to the upward attack of warm, heat or fire evils, which pertains to the excess-heat syndrome. The sunken fontanel usually pertains to the deficient cold of spleen and stomach, which is due to the depletion of body fluid caused by vomiting and/or diarrhea, or to the insufficiency of qi and blood or the maldevelopment. Infantile metlopism indicates the insufficiency of kidney qi or maldevelopment. At any time, when diagnosing for baby, the fontanel should be observed. If the sunken fontanel like a plate, the condition is critical.
II.Face Observatfom Face observation includes to observe the complexion and facial figure. In the aspect of complexion, liver disease shows blue complexion, heart disease red complexion, spleen disease yellow complexion, lung disease pale complexion and kidney disease black complexion. In the aspect of figure, swelling feverish Face with red complexion and tenderness is due to the upward attack of wind-heat, such as erysipelas. Sudden facial edema appearing preceding the edema of abdomen and lower limbs pertains to yang-edema, while the abdominal edema and leg edema appearing slowly preceding the facial edema pertains to yin-edema. Sudden swelling in unilateral or bilateral parotid with red complexion and swelling sore throat is usually mumps. Wry mouth and eyes pertains to wind-stroke. If there is only wry mouth and eyes or facial numbness, it means the wind attacks the collateral, while accompanied by hemiplegia or coma, it is the critical syndrome of wind-stroke, which means the wind attacks the zang-viscera. The terrific facial expression is usually seen in infantile convulsion. The tetanus is usually demonstrated by lockjaw. It was called "closed mouth windJ'in ancient time. Leprosy is characterized by lumps on forehead or around eyes, loss of brows and hair and loentiasis (the face looks like a lion9s face).
IHI. Hair Observation Hair observation mainly refers to observation of the abnormal changes of hair color and texture and the loss of hair. Since the spleen is the producting and transformating source of qi and blood, and hair is the surplus of blood and the outside manifestation o'f the kidney qi, the abnormal changes of hair are closely related to spleen and kidney. The black lustrous and exuberant hair is the phenomenon of sufficient essence and blood, which reflects the spleen and kidney are in good conditions. On the contrary, if the hair is withered and lusterless, and likely to be loosen, it is the manifestation of insufficient essence and blood of the spleen and @
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kidney, which is usually seen in chronic or critical disease. Insufficiency of both qi and blood leads to scarce hair. Blood-heat brings about yellowish and scarce hair. Exhaustion of both qi and blood results in gray hair and loss of hair. Alopecia area-
ta is usually due to wind attacking on the deficient blood. Infantile malnutrition is reflected by curved hair like spike.
HV.Eye Observation Eye is the window of the liver and has a close relationship to viscera. It is pointed out in chapter 80 of the Spirit Pivot: "All the essential qi of the five zangviscera and six fu-viscera pours upward into the eyes". T h e different parts of eye are attributed to the five zang-viscera respectively. T h e theory of five rings is developed on the foregoing basis by doctors of the latter generations, i. e . , the collateral in inner canthus and paropia pertain to the heart (blood ring) ; the white of eye pertains to the lung (qi ring) ; the black of eye pertains to the liver (wind ring) ; the pupil pertains to the kidney (water ring) and the eyelids pertain to the spleen
(muscle r i n g ) . Besides, the Meridian of Hand Shaoyin, Hand Taiyang, Foot Taiyang, Hand Shaoyang, Foot Jueyin, and Ren Meridian are all related to the eyes. So it is said in chapter 10 of the Plain Questions: "All the meridians are related to the eyes". This means that all essential qi of the twelve regular meridians pours upwards into the eyes. Observing the eyes is contributory to differentiation of the disorders of the twelve regular meridians. The contents of eye observation include:
1. Observing the Vitality of Eye The manifestations of eye-vitalit y are : good vision. obvious distinguishable
Picture 3 Q o u t e r conthus
Corresponding Parts of Five Zang-Viscera in the Eye
@inner canthus
@spleen
@heart
@lung
@Liver
OKidney
black and white of the eyeball, lustrous eye-light, with little tears and eye secretion, which means the disease pertains to yang syndrome and is easily curable, The manifestations of no eye-vitality are: poor vision, turbidity in the white of eye, blurred color in the black of eye, gloomy eye-light, without tears and eye secretion, which means the disease pertains to yin syndrome and is difficult to be cured.
2. Observing the Color of Eye Red eye usually reflects the excess-heat. The red color in the white of eye shows lung fire, which usually is due to epidemic hemorrhagic conjunctivitis; the reddish color in canthus represents the heart fire, which is usually due to flamingup of the heart fire; a whole congested eye with swelling pain is usually due to the wind-heat of liver meridian; the reddish and blear eyelid is due to the spleen-fire. Pale canthus pertains to blood deficiency syndrome, which is due to the insufficient blood failing to nourish the eye. Yellowish color seen in the white of eye means jaundice, which is caused by the overflowing bile due to the steaming damp-heat. Being above and (or) below the eyelids, the bright black color usually means fluidretention; the bluish color means the depressed anger; the greenish black color without luster is usually due to the kidney deficiency.
3. Observing the Shape of Eye Swelling pain of eyelids means the excess of evil qi; simple puffiness without pain usually pertains to edema; slow swelling of eyelids with flabbiness is usually due to the spleen deficiency failing to transport water-dampness; slight swelling of the lower eyelid with flaccidity is usually due to deficiency of both spleen and kidney in the senile. Sunken eyes are due to the insufficient body fluid and blood failing to nourish the eyes, which are seen in the patient after vomiting, diarrhea or loss of blood; if seen in the chronic or critical disease with deep sunken eye socket, they mean the exhaustion of visceral essential qi, and are difficult to be cured or haveanunfavorable prognosis; if they are accompanied by unconsciousness and genuine visceral pulse, they mean the collapse of essential qi and divorce of yin and yang. Protrusive eyeballs with swelling neck, palpitation, polyphagia and emaciation indicate the cervical tumor. Protruding eyeballs with dyspnea, even asthma with inability to lie flat, palpitation, purplish complexion and lips, usually pertain to lungdistention. The single protruding eyeball usually suggests the intracranial tumor. Nebula on the white or black of eye pertains to external oculopathy. T h e
,/
changed color or changed shape of pupil without external abnormality but with visual disturbance pertains to internal oculopathy. The former usually pertains to excess and is caused by the six climatic evils and phlegm dampness; the latter usually pertains to deficiency and is caused by insufficiency of the liver and kidney or deficiency of both qi and blood. The canthus hyperemia and protruding granulation transversely spreading over the white of eye, even invading the black of eye, are called pterygiam, which can be caused by exorbitant wind-heat, or damp-heat in the spleen and stomach, or insufficiency of kidney yin, or the flaming-up of heart fire. Malt-like nucleus on the margin of eyelid with light swelling pain is called stye; diffusible swelling on the margin of eyelid with severe pain is called suppurative blepharitis; both of them are caused by the wind-heat settling on the eyelids or the heat-poison of spleen and stomach attacking t h e eyes.
4. Observing the State of Eye Keeping eyes opened and liking light pertains to yang syndrome while keeping eyes closed and disliking light pertains to yin syndrome. Photophobia with tears is due to the acute contagious conjunctivitis, which is caused by fulminant exogenous wind-heat. Slightly fixed eyes are due to internal closure of phlegm-heat. Hyperexophoria, dully staring, or strabismus (with the exception of congenital strabismus) are the phenomena of the internal stirring of the liver-wind, or of dangerous conditions. Half-closed eyes in sleeping are due to the spleen deficiency which lead to the lucid yang failing to rise, so that the eyelids lose the nourishment and fail to dominate the opening and closing. Such symptom can be seen in infantile deficiency of spleen and stomach or chronic infantile spleen-wind. Platycoria is usually due to the exhaustion of kidney essence which fails to pour upward into the eyes to\ bind the pupils, so as resulting in dilatation. It is usually the sign of terminal stage of ill, but sometimes it can also be seen in glaucoma caused by the ascendant disturbance of wind-fire of the liver and gallbladder or in some toxonosis. The contracted pupil is usually due to flaming-up of liver and gall'
bladder fire, or intoxication of Sichuan aconite root, or poisonous mushroom.
Eyelid twitching is usually due to attack of wind-heat or deficiency of qi and blood failing to nourish meridians. Blepharoptosis is divided into the congenital and acquired. The congenital one usually shows biblepharoptosis while the acquired one may be unilateral blepharoptosis or bilateral blepharoptosis but with different degrees. The eyelids are dominated by the spleen. The acquired blepharoptosis is usu37
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ally due to the deficiency of spleen qi or disharmory of qi and blood which causes the collateral obstructed. The congenital blepharoptosis is usually due to insufficiency of both spleen and kidney.
V.Ear Observation Ear is the window of kidney. All the three yang meridians of hand and foot travel into (around) the ears. So ears are the confluence organs of various meridians and have certain relation to viscera. Thick and large ear means the exuberant figure while thin and small ear means the deficient figure and insufficiency of kidney qi. Swelling ear means the excess of the evil, which is usually due to flaming-up of ministerial fire of Shaoyang; while the emaciated ear means the deficiency of genuine qi, which is usually due to the insufficiency of kidney essence and kidney yin. Withered and parched helix is due to exhaustion of kidney qi. Squamous and dry helix is due to blood stasis or chest carbuncle. Red streaks seen on the back of ears of infant accompanying with cool ear lobes, aversion t o cold, fever, cough and running nose, are the predromal symptoms of measles. Intra-aural running sore is called impacted cerumen, which is caused by ascendance of exorbitant wind-heat or damp-heat of liver and gallbladder.
VH.Nose Observation Bright and lustrous nose means stomach qi or the recovery of stomach qi after disease, while withering of nose means the exhaustion of spleen and stomach qi and reflects severe disease. Nostril dryness with black color shows the exorbitant heat injuring yin, and the black nostril with cool and slippery feeling indicates the extremity of yin-poison. Nares flaring, while seen at the beginning of disease, means the wind-fire and excessive heat accumulating in the lung; if seen in chronic disease with asthma and cold sweating, indicates the exhaustion of lung and kidney essence. Swelling nose is due to the exorbitance of the evil while the sunken nose to the deficiency of genuine qi. Nasal polyp is caused by stagnated heat in the Yangming Meridian. Reddish nose with acne is called rosacea, which is caused by blood-heat entering the lung. Ulcerous and sunken nasal septum is usually seen in syphilis. Sunken nasal septum with loss of brows is seen in leprosy. Clear nasal discharge means the external attack of wind-cold; while turbid nasal discharge indicates the external attack of wind-heat. Chronic turbid nasal discharge with headache is called rhinorrhea. Epistaxis is usually due to heat injuring 38
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the lung and stomach.
VIP. Lip Observation The spleen opens into the mouth and has its outside manifestation on the lips. Both the Hand and Foot Yangming Meridians travel around lips. So the disorders of spleen and stomach can be reflected on the lips. I. Observing the C o b r of' Lips Reddish and lustrous lips are the normal condition. Pale lips mean deficiency of both qi and blood. Dark red and dry lips are due to heat exorbitance. Carmine lips indicate the flaring of fire due to yin deficiency. Cherry lips are usually seen in gas poisoning. Cyanotic lips are usually due to blood stasis because of cold congealment. Blue and dark purple lips indicate the internal stagnated heat. Blackish color around the mouth mean the tendency of kidney qi exhaustion. Circular pale around the mouth can be seen in scarlet fever.
2. Observing the State of Lips Dry and chopped lips means the dryness-heat impairing body fluid. Lockjaw usually belongs to excessive syndrome while opened mouth to collapse syndrome. Involuntary drooling is usually due to spleen deficiency with exorbitance of dampness, or accumulated heat in the spleen and stomach. Tight mouth and purplish lips in neonate with spasm of limbs and opisthotonus are seen in the umbilicus-wind. Aphthous stomatitis is marked by white erosion in mouth but showing reddish color with stabbing pain if erasing out the debris on the erosion, which is usually caused by the steaming of damp-heat of spleen and stomach. Canker sore is characterized by folliculi on internal lips and reddish swelling pain after broken, which is due to the heat in heart and spleen. Infantile mycotic stomatitis is marked by white patches over the full mouth, which is due to the fetal heat accumulation in the heart and spleen. Lip-wind is characterized by itching and swelling lips, with running water and burning pain after broken, which is caused by flaming-up of stomach-fire of Yangming. Carcinoma of lip is marked by bean-like knot in lip at beginning, growing gradually to be as large as silkworm cocoon, solid and painful, which is due to phlegm-heat coagulated in lips and belongs to malignant syndrome.
VPIH. Teeth amall. Gum Observation Teeth are the surplus of bone and bone is dominated by the kidney. Gum is the site where the Yangming Meridians of Hand and Foot travel. So observing teeth and gum is contributory to inspection of the disorders of kidney, stomach and in, 39 ,
testines. It is specially important to observe the changes of teeth and gum in the conditions of heat injuring the stomach fluid or heat scorching the kidney yin in warm-disease.
1.Observing
the Teeth Yellowish and dry teeth indicate the exorbitant heat injuring body fluid. Dry in sleep is teeth like dead-bone mean the exhaustion of kidney yin, Odo~~toprisis usually due to interior heat or food retention. Loss of teeth with exposed root of teeth is usually due to flaming-up of deficient fire because of insufficiency of kidney yin. Pyogenic gingivitis is marked by decayed teeth and loss of teeth.
2.Observing the Gum Pale gum means blood deficiency. Atrophic and pale gum indicates the insufficiency of stomach yin or deficiency of kidney qi. Reddish swelling gum is usually due to the flaming-up of stomach fire; if accompanying with bleeding, it reflects the stomach-fire impairing collateral.
IX, Throat Observation
,
Throat is the gate of lung and stomach and the passage of breath and food-intake. All the meridians of heart, kidney, liver, stomach and spleen connect with the throat. So the changes of throat can reflect the visceral disorders. The normal throat is characterized by pink color and moistness with normal breath sound and smooth swallowing. The reddish swelling pain of throat means heat in the lung'.and stomach. Severe swelling pain with yellowish white purulent spots is called tonsillitis, which is caused by scorching heat leading to flesh decay because of exorbitant heat-poison in lung and stomach. Scarlet and tender throat with sharp pain is usually due to flaring of fire because of yin deficiency. Chronic sore throat with pink color but no swelling is due to flaming-up of deficiency fire. Grayish white pseudo-membrane in throat, which cannot be erased, if erasing it forcefully, then bleeding would follow and the pseudo-membrane will reoccur quickly, is the diphtheria, which is usually caused by lung heat with yin deficiency. If the severe local swelling of throat brings about obstruction of throat, even dyspnea, it is called throat-blockage, which is caused by the joint attack of windphlegm, stagnated fire and heat-poison.
X.Neck Observation Tumor on laryngeal protuberance, being movable with swallowing, is called the cervical tumor, which is caused by stagnation of liver qi with phlegm accumula40
1
tion, or is related to the local geographic factors. Bead-roll-like lumps on the lateral neck are called scrofula, which are usually due to yin deficiency of the lung and kidney, and deficient fire concentrating the liquid into phlegm, then into lump, or caused by wind-fire and seasonal poison which coagulates in the neck. Stony and unmovable tumor on neck, becoming larger and larger gadually, is called cachexia, which is due to coagulation of phlegm-fire, and belongs to malignancy, so it is hard to be cured. Stiff neck with coma is usually seen in interior wind or due to ascendant attack of fire evil in warm-disease. Soft neck with droopy head usually pertains to deficient syndrome, which is due to insufficiency of kidney qi. Obvious pulsation of the cervical vessels is usually seen in edema. Obvious exposure of the cervical vessels when lying flat is due to the pathogenic water insulting the heart because of insufficiency of heart yang.
XI. Chest and Abdomen Observation 1.Observing the Chest The chicken-breast-like chest in child is named chicken breast, which is usually due to lack of proper care after birth or the wind-phlegm accumulating in the lung. Distending hypochondrium with dragging pain on coughing is the suspended fluid retention. Blacking areola with mammary swelling and mammalgia in pregnant female is named breast carbuncle. Stony mass of breast without red skin and pain, but becoming cauliflower-like after erosion, is breast cancer.
2. Observing the Albdasmen The unmovable abdominal lump is called abdominal mass while the movable one is called abdominal gathering. The upper and down movement of lump is due to parasitic infestation. Abdominal swelling with obviously engorged vessels is difficult to be cured, but the one without the vessel exposure is curable. Severe sunken abdomen is due to extreme insufficiency of spleen and stomach qi in chronic disease, or exhaustion of both qi and yin because of over use of emetic or purgative in newly occurred disease. Protruding umbilicus can be seen in crying baby, if complicated with reddish swelling and exudation, it is the umbilical ulceration, which is caused by accumulation of damp-heat due to internal attack of water-dampness. The protruding umbilicus seen in edema is due to exhaustion of spleen and kidney and is difficult to be cured. 41
XII. Lumbus and Back Observation
1.Observing the Lumblas Lumbus is the house of kidney, and related to Foot Meridian of Taiyang and Dai Meridian. Its disorder is due to kidney deficiency, cold-dampness or blood stasis. Lumbago with sensation of contraction and difficulty in action is due to colddampness attacking the collateral or sprain. Herpes zostor on the lumbar region is characterized by string-bead-like vesiculae with reddish surroundings and severe pain, if broken, having running fluid, which is due to infiltration of damp-heat.
2. Observing the Back Du Meridian and Foot Meridian of Taiyang travel along the back, so the back disorder is concerning with these two meridians. The feature of kyphosis is backward protuberance of vertebrae, which is due to congenital insufficiency, or improper care after birth, or deficiency of Du Meridian, or insufficiency of the kidney qi. Opisthotonus is marked by backward bend of the inflexible back, which is seen in convulsive disease or tetanus. Back sores with reddish swelling and burning pain is named lumbodorsal ju,which is caused by internal coagulation of fire-poison.
XIII. Limbs Observation
1.Observing Wand and Foot Fatty hands and feet indicate excess syndrome while thin hands and feet indicate deficiency syndrome. Tic of limbs with opisthotonus is convulsive disease, which is usually caused by wind from extreme heat. Twitch of limbs is usually due to deficiency of both qi and blood. Flaccid limbs suggest withering syndrome. Painful joints with difficulty in action pertain to arthralgia syndrome. Paralyzed hands mean external collapse of yang qi while grasped hands indicate internal closure of the evil qi. Crooked limbs without stretch suggest tendon disease and stretched limbs. without crook suggest bone disease. Simple swelling pain on the knees is named arthroncus of knee.
2.Observing Wrist and Palm Lustrous skin of wrist and palm means plenty of body-fluid while dry skin means insufficiency of body-fluid. Thick palm indicates the plenty of visceral qi Q
42
Q
while the thin palm indicates the insufficiency of visceral qi. Solid muscle reflects sufficiency of stomach qi while soft muscle reflects insufficiency of stomach qi. Tinea anguium is marked by dry and cracked skin of palm, which is due to blood dryness producing endogeneous wind. Observing the thenar eminence is contributory to understanding the stomach qi. If the collateral on the thenar eminence shows blue color, it indicates cold in the stomach. The red collateral reflects heat in the stomach. Emaciation of the thenar eminence is the sign of extreme deficiency.
3. Observing Fingers, Toes and Nails Clasping fingers are named chicken-claw-wind, which is due to failure of blood to nourish tendons accompanied with wind-cold attack. The wrinkled finger tip is called spiral-shrinkage, which reflects the damage of body-fluid due to severe vomiting or diarrhea. Dark purple toes with severe pain, if broken, having exudation, are called toe ju, which is caused by internal accumulated cold-dampness transforming into fire. Swelling and deformed joints of fingers and toes are due to internal accumulated wind-dampness with yin insufficiency of the liver and kidney. Nail is the outside manifestation of the liver. The normal reddish luster means the plenty of qi and blood. Dark red nail indicates the exorbitance of heat. Carmine nail means yin deficiency. Pale nail indicates cold syndrome. Yellowish nail means blood deficiency. If nail color turns into white when pressed, and the color recovers normally at once on removing the pressure, it means the plenty of qi and blood. In this condition, even suffering from serious disease, the patient can be cured. If the recovery is slow, or very uneasy, it reflects the exhaustion of qi and blood. If it is seen in khronic disease or fulminant disease, the prognosis is very unfavorable.
4. Observing Infantile Index Finger Colillaterafl (Finger-Vein Observation) The infantile finger-vein refers to the exposed collateral on the palmar of index finger, which is a branch of Lung Meridian of Hand Taiyin. It belongs to the same meridian of cunkou pulse. Observing the finger vein plays the same role of taking cunkou pulse in diagnosis. Because the infantile pulse is shorter and infant is usually in crying or restlessness when diagnosing, which make it difficult to take pulse, and the infantile skin is thin and tender and the collateral is obvious to see. The finger-vein observation is used to diagnose disease for infants below three years old instead of pulse-taking.
A. Locations of the three passes: The collateral of the index finger can be die
43
e
vided into wind-pass, qi-pass and life-pass. The position of the first phalanx of index finger, namely, from the cross striation of metacarpophalangeal to that of the second phalanx, is the wind-pass. The position of the second phalanx, namely, from the cross striation of the second phalanx to that of the third phalanx, is the qipass. The position of the third phalanx, namely, from the cross striation of the third phalanx to the tip of index finger, is the life-pass.
Picture 4
Three Passes of InfaratiBe Index Finger cCol8atesall (ijwind-pass
Qqi-p'ass
@life-pass
B. Method of observing the finger vein: Having the infant face to the light, holding infantile index finger with doctor's left hand, the doctor puts his right thumb on infant index finger and pushes forwards from the life-pass to the qi-pass and to the wind-pass for several times successively. Then the collateral will become more obvious and easy to be observed. C. Normal figuration and color: The normal collateral color of the index finger
is light red which is indistinct within the wind-pass. Usually the finger vein is invisible but not obvious, and has a monobranched oblique figuration with a medial diameter.
D. Figuration, color and position as indicators of disease: The obvious collateral within the wind-pass means the evil qi entering collateral and is characterized by shallow evil qi and light illness. The obvious collateral reached the qi-pass with a comparative dark color indicates the evil qi entering meridians and is characterized by deep evil qi and serious illness. The obvious collateral reached the life-pass reflects the evil qi entering viscera. If the obvious collateral through the three passes reached the end of finger, it is called "going through the passes to nail", which 44
means the disease condition is serious and the prognosis is very unfavorable. There are some morbid figurations and colors as following:
a. Floating and deep: The floating exposed collateral indicates that the disease is in the exterior and is commonly seen in the exterior syndrome of external evil attack. The deep obscure collateral indicates that the disease is in the interior and is commonly seen in the interior syndrome of external evil attack or internal injury.
b. Dark and light: The dark color means disease is serious while the light color means the disease is light. In addition, the clear color is of deficient syndrome while the obscure color is of excessive syndrome. c. Type of color: Scarlet indicates the exterior syndrome of external heat; blue reflects the wind syndrome and pain syndrome; pale indicates the deficient syndrome; and purplish black means the obstruction of blood vessels and is seen in critical cases.
d. Figuration: The growing thick collateral is usually of heat syndrome and excessive syndrome while the decreased thin collateral is usually of cold syndrome and deficient syndrome. Monobranched oblique figuration is usually of light illness. Curved, circular, and multi-branched figuration is of serious disease which usually pertains to excessive syndrome.
XIV.Genital and
Anus Observation
31. Observing the Genital The external genital is the confluence of tendons in which the meridians of Yangming and Taiyin assemble. The orifice concerning reproduction connects with the kidney and the orifice concerning urination connects with the urinary bladder. The external genital is connected with Liver Meridian and Du Meridian. It is bound by Dai Meridian and nourished by Chong and Ren Meridians, and is moistened by Yangming Meridian. As a result, the external genital has a close relationship with some of the regular and extra meridians. The tight scrota1 skin with purple color in infants reflects the fullness of qi and blood; relaxed skin with pale color means the insufficiency of qi and blood; the water-hernia is demonstrated by swollen and transparent scrotum; the fox-hernia is characterized by swollen and opaque scrotum, which is caused by the fall of small intestine into scrotum. The swelling pain of testes is also the reflection of hernia. Retraction of penis, scrotum or/and vulva into the abdomen is caused by cold cone
45
e
gealment in meridians or heat-evil entering Liver Meridian and is called genital contraction. Sores of external genital with bleeding or papula is usually due to venereal disease or unsanitary sexual activity. There are two conditions of the swelling vulva, the one with pain is usually due to excess of sexual intercourse which impairs the blood; the other one without pain is usually due to edema. The prolapse of uterus is characterized by pear-shaped protuberance from vagina, which is commonly caused by sinking of the middle qi or overuse of strength after delivery.
2. Anus Observation Anus connects with the large intestine which has the exterior-interior relationship with the lung, so the anus disease is related to the lung, spleen, stomach and large intestine. Proctoptosis is the dropping out of the large intestine from the anus. In mild condition, it may spontaneously retract backwards into anus after defecation. In heavy condition, it keeps dropping out even after being pushed into anus. It pertains to sunken-qi syndrome resulting from qi deficiency. It occurs mainly in old people, children, women after delivery and those who suffer from chronic diarrhea. The hemorrhoid in or out of the anus is usually caused by stasis of qi and blood due to internal accumulation of heat. Th'e chronic ulcerated hemorrhoid leads to the formation of fistula, which is termed anal fistula and is caused by the combination of the four kinds intestinal evils of dampness, heat, wind and dryness. Anal fissure is characterized by painful anal crack and bleeding when defecation, which is caused by heat accumulation in the large intestine. The anus-lock hemorrhoid pertains to cancer, which is demonstrated by indurations on the anal skin cauliflower-like ulceration, and difficult defecation.
XV.Skin Observation Skin covers the body surface. It is irrigated by the whole body's blood vessels and correlates with the lung internally. Skin is the outside manifestation of qi and blood, and acts as the protective shield of human body. Generally, the attack of exogenous evils or disorders of qi, blood and body fluid can all cause changes of skin.
I. coaos : Red skin indicates internal heat. Yellow skin means jaundice. Black skin implies black-jaundice, which is a variation of jaundice and is also called "jaundice due *
46
to sexual intemperance".
2. Moistness and dryness : The moist skin reflects the exuberance of lung qi, while the dry skin indicates the decline of lung qi. Dry and scaling skin is due to blood stasis or internal carbuncle. Shedding of skin like snake, or like tinea on the whole body, or ulceration without pus, usually concerns with leprosy.
3. Swelling and distention : Dropsy head, face, chest, abdomen and limbs is named "edema". The abdominal expansion and bulge is named "distention". Edema with flat supraclavicular fossa, or flat sole, or flat back, or protrusive umbilicus, or black lips, is difficult to be cured.
4. Pox, Rash, MacuPla and Miliiarpia A. Chickenpox: It concerns with Spleen and Lung Meridians and is caused by the invasion of exogenous seasonal evils. The exogenous evil enters the lung through mouth and nose. I t has symptoms of exterior syndrome, such as fever, aversion to cold, running nose, cough, etc. , in its initial stage. Afterward, the dampheat stagnates in the lung and spleen. Then, poxes appear on the skin with the characteristics of oval-shape, susceptible to be broken, without umbilicus in the top, different sizes and appearances, and occurring in succession. Within pox, there is crystal watery liquid. After being cured, there no pox-scar left.
IB. Bash: It has millet-like shape, red color, and is high above the skin. It can be felt by touching. Its red color will disappear by pressing. There are different kinds of rash with different general symptoms because of the different natures of invading evils.
a. Measles: It is due to invasion of exogenous seasonal evil which is stagnated in the lung and enters inward to blood phase, then erupts on skin through the collateral. It is a common infectious disease in children. At the beginning of onset, there are symptoms of fever, aversion to cold, cough, nasal discharge, conjunctival congestion with tears and swollen eyelids. Three or four days later, there appears reddish collateral behind the ear. Then the eruption appears on the hairline and face in succession, gradually spreading to trunk and limbs. The rash has a pink color, and is high above the skin with distinct demarcation. It is sparse at first, and denser and denser gradually. 47
About measles, if there is slight sweating, thorough eruption on whole body with reddish color, and not high fever, and after that, rashes gradually disappear in the order of its appearance, accompanying with the gradual coming down of fever, it shows favorable prognosis. If there are symptoms of sthenic fever with no sweating, incomplete eruption or sudden concealment of rashes accompanying with coma, dyspnea, persistent fever, it is the manifestation of sinking of measles poison.
b. Wind-Rash: When wind-heat evil stays in the lung, defensive-phase and interspace of muscles, because the qi and blood combat evil, the evil is pushed outwards to skin and muscles, then the wind-rash occurs. It is characterized by small rnaculo-papular eruption appearing on face and head firstly and then on the whole body. Its clinical manifestations are slight fever first, and one or two days later, the appearance of eruption which is marked by tiny and sparse rash-shape, light protuberance with reddish color and severe itching. The eruption order is from face to neck, to trunk and to limbs. It erupts completely within a day. After three days , it will disappear. So it is termed sometimes as "three-day eruption".
c . Obscure-rash: It is usually caused by wind-evil attack on meridians due to deficiency of nutrient qi and blood. It is clinically characterized by severe itching. On scraping, the skin swells at once in white red color and cloudy shape. The rashes appear intermittently, so it is called "obscure-rash" . C. Macula: It is a kind of skin rash appearing during disease process (common-
ly seen in warm-disease) . It is characterized by red patches without swelling on the skin. There are yang-macula and yin-macula according to the different pathological mechanism*
a. Yarag-macula: It is characterized by large brocade patches with red or purple color without touchable skin change by palm. It is commonly seen when heat invades ying-phase and blood-phase in warm-diseases. Heat compels blood to overflow into muscles and then causes macula. The case of favorable prognosis is marked by sparse rnacula with lustrous red color which appear on chest and abdomen first, and then on limbs, accompanying with abating fever and clear consciousness. It reflects the evil is dispelled. The case of unfavorable prognosis is characterized by dense macula with dark red or purplish black color which appear on limbs first, and then on chest and abdomen, accompanying with sthenic fever and coma. It means the failure of genuine qi in defeating evils and the interior sinking of evil-poison.
b. Yin-macula: It is characterized by scarse irregular macula in different sizes a
48
with reddish or blackish purple color, no fixed location. Besides, it usually accompanies clear consciousness, cold limbs, shortness of breath, no thirst, and thready and weak pulse. It is usually due to deficiency of qi and blood in internal injury.
D. Milliaria: Namely miliaria alba. It refers millet-sized crystalline vesicles on skin. It usually appears in neck and chest, sometimes in limbs, rarely in face. It is commonly seen in damp-warm disease. Milliaria alba may appear repeatedly because the damp-heat is difficult to be eliminated. However, the appearance of miliaria alba indicates the exit of retained dampness. There are different cases of favorable and unfavorable prognosis. T h e "crystal miliaria" is characterized by millet-sized and bright crystal vesicles. After its appearance, the fever and other symptoms will disappear. It is the case of favorable prognosis and indicates t h e plenty of body-fluid and qi. I n this condition, the genuine qi defeats evils and the damp-heat evil escapes by way of miliaria. T h e "dry miliaria" is characterized by pale without lustrous, dry and withering vesicles. I t is of unfavorable prognosis which means the insufficiency of qi and body-fluid.
5. Casbuncfle, Ju, Ding and Furuncle All these are sores of surgical diseases and commonly seen in clinic.
A. Carbuncle: It is characterized by red swelling and pain on local skin with scorching sensation and distinct demarcation. It is usually accompanied by aversion to cold, fever. headache, red tongue with yellow coating, and large rapid pulse. It is caused.by internal accumulation of fire-poison which leads to necrosis of fleshes.
B. J u : I t is characterized by boundless swelling without change of skin color, thin pus, no fever and seldom pain. I t may be accompanied by pale complexion, lassitude, pale tongue with white coating, deep and weak pulse. It is usually due to insufficiency of qi andblood and internal stagnancy of yin-cold. C. Ding: It is characterized by millet-sized boil with white top and hard root.
Numbness, itch and pain are felt in local position at first. Then, it may accompany fever, aversion to cold, headache, nausea, vomiting, poor appetite, etc. If a red line appears from the lesion and extends to the heart direction from distal part, it is called "red-streak d i n g " , or "deteriorated d i n g " , which means internal sinking of heat-poison, and is usually caused by congealment of qi and blood due to the skin evil-poison entering meridians.
D. Furuncle: It is on the superficial skin and characterized by tiny round boil with slight reddish swelling and pain. In addition, it will be soft if it is suppurative,
and the rupture of pus-pocket will lead to healing. Its accompanying symptoms are light, but it is easy to relapse. Usually, it is caused by stagnation of qi and blood due to damp-heat retaining in skin.
Section 3
Observation of Excreta
The excreta includes wastes and some organs9 secretions that are discharged out the body. Observing excreta is to diagnose disease by means of watching the color, quality, quantity and other abnormal changes of patient's excreta.
1.Observing Sputum, Saliva, Nasal Discharge and Spittle The sputum refers to the expectorated mucus. The saliva is the mucus in mouth. Nasal discharge is mucus excreted by nose. The spittle is the foam mucus spitted from mouth.
Heat Sputum: The sputum is yellow and stick. It is accompanied by dry mouth and nose, red tongue with yellow coating, etc.
Cold Sputum: The sputum is white or clear and thin, with some black particles in it. It is accompanied by cough, aversion to cold, etc.
Wind Sputum: The sputum is watery and full of foam. It is accompanied by cynostic facial complexion, dizziness and chest choke, and so on, which are symptoms of the upwards disturbing of liver wind carrying the phlegm.
Damp Sputum: The sputum is white and profuse, and easily to be expectorated out. It is accompanied by cough and asthma, chest distress, fatty tongue and soggy pulse, etc.
Dry Sputum: The sputum is scanty and thick, and difficult to be expectorated out. It is accompanied by dry mouth and nose, thirst, etc.
Bloody sputum is due to lung collateral damaged by heat. Pus and bloodysputurn or pus sputum means lung carbuncle. T h e foam sputum with shortness of breath and mouth breathing indicates lung-withering. The watery saIiva is often due to deficiency and cold of spleen and stomach. If saliva flows out unconsciously and aggravates at night, it is a condition of spleen qi deficiency, or heat in stomach with parasitic infestation in children. Watery nasal discharge means the invading of wind and cold evils, while turbid nasal discharge of wind-heat evils. The prolonged condition of turbid nasal discharge, even bloody nasal discharge is due to chronic rhinorrhea. Profuse spittle can be a sign of stomach cold, dampness retention, food retena
50
tion, kidney cold, or kidney deficiency.
11. Observing V~miflills Vomiting is due to the disharmony and reverse flowing of stomach qi.
Cold Vomit: The vomitus is watery with special odor. It is usually because
of-
yang deficiency of the spleen or kidney, or cold evil attacking the stomach.
Heat Vomiting: The vomitus is turbid with acid and foul odor. It is often due to heat evil invading stomach. It can also result from stagnated liver fire which makes stomach qi flowing reversely.
Vomiting due 'to Food-Retention: The smell of vomitus is putrid and sour. There is undigested food in it. The cause is usually the over-intake-of food or drinking, which injures the spleen and stomach and leads to food-retention. The retained food makes stomach qi flowing upwards reversely.
Vomiting due to Fluid-Retention: Vomitus is water-like mucus. It is accompanied by thirst but dislike to drink, chest choke and greasy tongue coating, etc. It is due to the fluid or phlegm-retention resulting from spleen dysfunction.
Vomit due to Damp-Heat inLiver and Gallbladder: The vomitus is yellowish green mucus with bitter taste. Because damp-heat invades the liver and gallbladder and the heat evil compels bile over flowing, the heat evil and bile make stomach qi flowing upwards.
Bloody Vomiting: There is blood and undigested food in it. It is caused by the accumulation of heat in the stomach, or liver fire invading stomach, or blood stasis.
Section 4 Tongue Observation Tongue observation is also named tongue inspection. It is a method of observing the changes of tongue body and tongue coating to analyze disease. It is a main component of observation. There are many records of tongue observation and its theories in Internal Classic. After that, many medical works like Treatise on C o l d - ~ t i a c kClassic , of Viscera, A Thousand Gold Worthy Prescriptions, An Official's
Secret Prescriptions,
recorded this method. After the Records of Golden Mirror, the monograph of tongue examination appeared in Yuan Dynasty, many monographs of tongue examination were published one by one. Based on many doctors experiences accumulated in the long time medical practice, the unique examining method forms the system. *
51
o
1. The Relatiag~raBetween Tongue and Viscera Tongue
p
the sprout of the heart and the heart is the supreme monarch of all
1
organs. So disease of viscera can influence not only the the heart, but also the tongue. Tongue is called the out-show of the spleen. The spleen dominates transportation and transformation. So, the tongue is closely related to splenic function. Tongue coating has special relation with stomach qi. Zhang Xugu said : "In healthy body, there is a little thin coating like grass roots. It is the embodiment of stomach qi activity. " Meridians, for example, three yang meridians of foot, three yin meridians of foot, Taiyang Meridians of Hand, Shaoyang Meridians of Hand, have connection to the tongue. Shen Douyuan said: "All qi of meridians flow up to tongue. So we can know the deficiency or excess, cold or heat of viscera and meridians by observing tongue. " Because tongue is closely related to viscera and meridians, viscera have their representative areas on tongue surface. The ancient statements on this were different. The most popular one was from the Bihua9s Medical Mirror: "The tip of tongue belongs to the heart, the middle to the spleen and stomach, the bilateral margins to the liver and gallbladder, the root to the kidney. " I t can also be explained as the tip portion to upper-jiao, the middle to the middle-jiao and the root to the lower-jiao. The correspondence is the same one of that of cunkou pulse, namely "the upper shows upper body, the middle shows middle body and the lower shows lower body.
"
Besides the above mentioned portion division, one proposal suggests that when tongue inspection is applied to diagnosing spleen and stomach diseases, the top of tongue shows the upper part of the stomach, the middle portion shows the middle part of the stomach and the root portion the lower part of the stomach. But this method is not popular in clinic.
11. Signif icalrace of Tongue Inspection The changes of tongue reflect inner visceral changes. The tongue is the orifice of heart. The stretching and retracting are the action of tendons which reflects the function of liver. The red small particle on tongue tip are projections made up of heart qi and genuine-fire of life-gate. The white soft prickle like hairs on tongue a
52
Picture 5
Division of Tongue Surface
@root of the tongue (lower-jiao) @tip of the tongue (upper-jiao) @spleen and stomach
@middle of the tongue (middle-jiao) @margins of the tongue
Oliver and gallbladder
@kidney
@heart (lung)
surface is produced by lung qi with genuine-fire. The toiigue fur (coating) are made up of steaming stomach qi. So by observing tongue, we can know the visceral conditions. The tongue body and coating have their unique significance in diagnosis. Tongue body exhibits conditions of five zang-viscera, while tongue coating shows that of six fu-viscera. By observing tongue body, we can ascertain the deficiency or excess of genuine-qi and the severity of disease. By inspecting tongue coating, we can judge the cold or heat of evils and the location of disease. Tongue body and coating can reflect disease in different aspects. Among the four examination methods, tongue observation is thought to be more reliable than others by some doctors. There are three reasons. The first, the pulse is covered by skin but tongue is not covered. Tongue is watched by eyes directly. So it is clear. Pulse is felt by fingers. It is difficult to understand. The second, tongue connects viscera internally and meridians externally. Both normal and morbid condition can be shown on tongue. The last, when evil enters the inner body, every changes of it will embody in tongue. The tongue is not like the pulse being obscure. The inner conditions will be exhibited clearly by the change of dry or moister and the thick or thin of coating. So the changes of tongue can reflect the conditions of genuine qi and evils, and the tendency of disease. T o sum up, the significances are as follows:
(1)T o judge the exuberance or decline of the genuine qi: The exuberance or decline of visceral qi and blood can be shown in tongue. For example, the red and 53
moist tongue means the exuberance of qi and blood; while the pale tongue is a sign of deficiency of both qi and blood. The white, thin and moist coating indicates a exuberant stomach qi; while no coating is due to the decline of stomach qi, or impairment of stomach $in.
( 2 ) T o distinguish the nature of disease: Evils of different natures will make different changes in tongue. For example, if there is no prickle on tongue surface and the coating is white and moist, or the tongue is bluish black without prickle, it is due to cold evil. If there is a red and dry tongue with yellow coating, or red prickle tongue with yellow, thick and greasy coating, it is due to warm or heat evil. The greasy or putrid coating indicates the food-retention. The blue macule or spot on tongue suggests blood stasis.
( 3 )T o detect the location of disease: In exogenous diseases, the thick or thin of the coating can reflect the deep or shallow of disease location. For example, the thin coating suggests that the disease is in its initial stage, the disease is located in shallow part and it is an exterior syndrome; while the thick coating suggests that the evils enter into the inner part of the body, the disease is located in deep part and it is an interior syndrome. The crimson tongue means heat evil is in nutrient or blood-phase, disease is very deep, it is a critical condition.
(4)T o infer the tendency of disease: The changes of tongue usually follow the changes of genuine qi and evils, and disease location. We can infer the tendency of disease by observing tongue, especially in exogenous febrile diseases. For example, the turning of coating from white to yellow, and from yellow to black, is usually due to the transferring of evils from exterior to interior, or from cold to heat. It shows the deterioration of disease. If a moist coating turns into dry, it is usually due to loss of body-fluid resulting from heat. The change from dry to moister implies the recover of body-fluid. The change of coating from thick to thin is a sign of improving or curing. However, it should be pointed out that sometimes the tongue is only slightly changed in some severe cases, and the abnormal changes of tongue are seen in normal people. So, the tongue observation should be used in combination with other examinations. Only by comprehensive analysis on whole clinical data, can we make a correct diagnosis.
111.Special Attentions on Observing Tongue In order to avoid mistake when observing tongue, special attention should be paid to some points which can make false changes in tongue picture. 54
a
1.The Light It is best to observe tongue in day time under the full natural light. The lamp lights often make difficult to get the true colors. For example, in lamp light, the yellow coating can be seen as a white coating, the pale tongue is seen as dark purple tongue, etc. When observing tongue at night, the fluorescent lamp can be chosen because it is similar to nature light.
2.The Posturt.e of Patient There is no limitation of the body posture. The patient should stretch out the tongue in a natural way to expose tongue thoroughly. The muscles of tongue should be relaxed. The tongue tip droops slightly. The upper surface of tongue should be expanded to two sides without curve. The over extension of tongue with too much strength should be avoided, so as not to make effect on blood circulation of tongue, which will change the tongue color.
3. Diet T h e patient had better to avoid taking food before seeing a doctor. The tongue keeps its true state before food intake. After meal, the moist or dry of coating is difficult to be distinguished. If patient has taken food or drugs, the doctor should pay attention on dyed coating. Some food or drugs can make the color of tongue coating changed. For example, smoked plum and chinese olive can change coating color into black; loquat and gold-thread root can dye coating in yellow; heavy smoking can turn coating color into black. If tongue conditi0n.i~not corresponding to the whole symptoms, one should ask the patient about the food and drugs to prevent from being confused by the false tongue conditions. In addition, chewing food and scraping on coating will thin the coating; peppery and pungent food will redden the tongue body; mouth breath due to stuffy nose will dry the tongue upper surface. If chewing food in one side of mouth, the coating will be thinner than that of another side. If there is hypoactivity of mouth or tongue, the coating is often thick. Attention should be given to these points.
IV. Contents of Tongue Diagnosis Tongue diagnosis includes observing tongue body (texture) and observing tongue coating. Tongue texture is the main body of tongue made up of muscles and vessels. Tongue coating is the fur-like material on tongue upper surface. The nor-
ma1 tongue is characterized by a middle size, soft, neither tough nor tender, free ,
movement, pink color, covered by thin and even white coating with moderate moist, which could not be scraped away and has its root in tongue. It is usually called "pink tongue with white and thin coating. " In tongue observation, tongue coating and tongue texture have their own applying field respectively. The observation of tongue texture is more important. Generally speaking, observation of tongue texture mainly probes the visceral conditions; while observation of tongue coating inspects the nature and location of disease and the clear or turbid of stomach qi. If changes are only in tongue coating, the illness is mild. When changes develop from tongue coating to tongue texture, it indicates the disease developed. If tongue texture is no vitality, it is a critical condition. Now the abnormal changes of tongue coating and texture are introduced as follows :
1. Tongue Texture
,
Observing tongue texture is to observe the abnormal changes of the vitality, color, shape and movement of tongue body.
1) Tongue Vitality The tongue vitality is shown in the flourish or withering of tongue texture. The flourish means full of vitality. The flourish of tongue refers to light red tongue body with energetic movement and enough fluid of it. It suggests the normal stomach qi. If the condition is red, moist and vigorous, no matter the color of tongue coating is yellow, white or black, the prognosis is good. T h e withering is out of vitality. The withering of tongue refers to dark and dry tongue body with sluggish movement. No matter there is coating or not, the prognosis is bad in this condition.
2) Tongue Color
'
Red is the normal color of tongue body. T h e normal condition is neither too light nor too deep pink color of whole tongue body. If the color change is out of this range, it is abnormal. The color changes in disease condition are as follows.
A. Pale Tongue: The color of tongue is lighter than that of normal people. The severe case shows no red at all. It is due to decline of yang and qi, or blood deficiency. The deficient yang fails to send qi and blood up to the tongue, and the deficient blood fails to nourish the tongue, so the color becomes pale. The decline of yang will lead to inner deficient cold. The dysfunction of spleen yang leads to water-dampness retained inside, so the color of tongue is pale and tongue body is corpulent with surplus fluid on it. I t is accompanied by aversion to .
56
a
cold, cold limbs, listlessness, poor appetite, loose stool, deep arid slow pulse or deep and weak pulse. T h e blood deficiency is often due to qi deficiency, which is not strong enough to generate blood, and acute or chronic bleeding. In this condition the color is pale and the tongue body is small and thin with little fluid on it. Usually there is no coating. It is accompanied by sallow complexion, pale lips, palpitation, lusterless nails, and thready pulse.
B. Red Tongue: When the red color of tongue is heavier than that of normal condition, it is called a red tongue. It suggests internal heat. Heat in body makes qi and blood boiling. Then the vessels of tongue are filled up. So the tongue shows red. Heat can be divided into deficient and excessive types. Excessive heat is a condition of too much yang. The exogenous evil enters the interior of body and then changes into fire. Improper emotions can transform into fire. T h e phlegm and food retention in long time will become fire. All those lead to qi and blood boiling, and make tongue red. In these cases, the tongue is red and dry, and there are prickles or cracks on tongue upper surface. It is often accompanied by sthenic fever, extreme thirst and profuse drinking, surging pulse, etc. If the red color is only at the tongue tip, it is due to heart fire flaming up. The red tongue in bilateral margins is due to liver and gallbladder fire. If it is accompanied by zigzag shaped cracks in the middle tongue, it is due to the extreme exorbitant heart fire. Red small points on tongue is due to heat-toxin. Heavy red small points over all the tongue surface are called "red star tongue". It is due to damp-heat which attacks the heart and spleen and leads to heat in both zang-viscera and fu-viscera. '
Small black points in a deep red tongue are due to extreme heat in viscera.
If it is due to deficient heat, the tongue is bright red without coating or with little coating, or a dry tongue with red in middle. It is often accompanied by tidal fever, hectic cheek, fidget, hot sensation in "five centers", night sweating, thready and rapid pulse, etc.
C. Crimson Tongue: Crimson tongue comes from red tongue. The color is more heavier and darker than red. It is often seen in the stage of extreme fever in exogenous febrile diseases. It can also be seen in internal injury diseases. T h e crimson tongue is usually seen in the extreme stage of febrile disease. Ye Tianshi said that when warm-heat evils entered nutrient-phase, the tongue color must be crimson; and if the crimson was bright, it was due to disease in pericardium. It is clearly pointed out that when warm evil enters nutrient-phase or peri57
cardium, the tongue color will change into crimson. From that we know the degree of heat in crimson tongue overpasses that of red tongue, which is in qi-phase. If the tongue surface is greasy or dry by observation but moist by touching, it is complicated by turbid evil in middle-jiao. The crimson and dry tongue with prickles or cracks is often due to heat in nutrient-phase and insufficient body-fluid. If the crimson tongue can only reach teeth but fails to stretch out, it is due to phlegm obstructed in tongue root. Crimson tongue -with large red spots is due to toxin-heat invading the heart. The crimson tongue tip is due to heart fire. If only the middle is crimson and dry, it is due to fire in heart and stomach consuming body-fluid. In internal injury disease, when there is yin deficiency, crimson tongue can also be seen. Crimson and dry tongue with little coating or without coating, and thin tongue body, or cracks, is the sign of yin deficiency. Crimson and moist tongue with little coating is due to blood stasis. If the tongue is crimson and withering without coating, and the tongue surface is mirror-like, it is called "mirror-tongueJ' and belongs to the critical condition of stomach and kidney yin exhaustion.
D. Purple Tongue: When tongue body is purple, it is called a purple tongue. There is difference in cold or heat of the diseases indicated by purple tongue. If it is due to extreme heat, it is dark purple. The bluish purple is often due to extreme cold. Dark Purple Tongue: The color of tongue is purple or dark. It is caused by: 1) Heat evil entering interior. The purple and dry tongue with cracks is seen in severe case of yin exhaustion caused by heat. If purple is seen in whole tongue, it is due to extreme heat in viscera. If purple is seen only at one part, it is due to stagnated heat in the viscus corresponding to the part. The purple and swelling tongue with large red spots is due to heat invading the heart. 2) Blood stasis. The tongue is dark purple and moist. If the whole tongue is dark purple, it is due to qi and blood stagnation of whole body. T h e purple macule in some parts of tongue indicates the blood stasis in some viscera relating to the part. 3) Phlegm-dampness. Phlegm and dampness accumulate in the interior and produce heat, then the tongue shows purple color and the coating is slippery and greasy. 4) Injury by alcoholic toxin. The purple and swelling tongue is due to alcoholic toxin invading the heart. T h e deep purple and dry tongue is due to alcoholic toxin accumulated internally. 5) Yin exhausiion. Tongue body is dark purple and dry just like a pig liver or pig kidney with capsule pealed. It is due to kidney and stomach yin exhaustion. Bluish Purple: When the tongue body is light blue and purple, it is called 58
bluish purple tongue. It is due to yin deficiency of liver and kidney, blood stasis or phlegm stagnation caused by yang deficiency which fails to warm and push them in movement. If tongue body is bluish purple, moist and small in size, and no coating, it is because cold evil attacks liver and kidney directly, and belongs to extreme cold. If the tongue body is bluish purple with spasm and tenderness in epigastrium or around navel, it is due to the combination of phlegm and blood.
E. Blue Tongue: When the tongue is blue without any red color, it is called a blue tongue. In ancient time, it was called a "buffalo tongue". It is seldom seen in clinic. T h e blue tongue often indicates yin-cold and blood stasis. Because yin-cold evil prevails, the yang is stagnated and hard to move, then blood stasis occurs, thus the blue color is seen in tongue. Blue tongue with slippery coating is due to direct cold attack on the liver and kidney. Blue in tongue margins is due to internal blood stasis. Blue tongue with dry mouth, dislikeness of swallowing water but gargling, is a sign of blood stasis. Blue tongue with slippery and greasy coating is due to internal accumulation of damp-phlegm. Blue tongue without coating is due to extreme deficiency of qi and blood.
3) Tongue Shape Cao Bingzhang said: "If one wants to know visceral diseases, one should observe tongue shape first. "Tongue shape is the out figure of tongue body. Its abnormal changes include eight main categories as follows:
A. Tenderness: The striae of tongue are delicate, fine and smooth. It indicates deficient syndrome. For example, the red, moist and tender tongue is due to deficient heat in the Heart Meridian.
B.Toughness: The
striae of tongue are rough and sturdy. It indicates excess
syndrome. It is mainly seen in excessive heat or blood stasis. C. Corpulence: If the tongue is larger than that of normal size, it is called a corpulent tongue. It is mainly due to stagnation of phlegm, dampness, and water or fluid-retention. T h e pale, tender and corpulent tongue is due to yang and qi deficiency of the spleen and kidney. If in combination with watery coating, it is due to fluid-retention resulting from non-transformed body-fluid. The red and corpulent tongue with yellow greasy coating is due to damp-heat in spleen and stomach, or internal phlegm and fluid-retention. Most of the corpulent tongue is accompanied by teeth-prints on the margins.
D. Swelling. The enlarged and swollen tongue body, even filling up mouth, is ,a
59
,a
called a swollen tongue. If tongue body is swelling to fill up mouth and the color is red, it is usually due to excessive heat and blood in the heart and spleen. The swollen tongue in dark purple is often seen in alcohol poisoning or drug intoxication. The purple swollen tongue is also seen in congenital deform of vessels in tongue, such as angioma in tongue.
E.Thinness: T h e small and emaciated tongue
body is called a thin tongue. The
pale thin tongue is usually due to qi and blood deficiency, or deficiency of both heart and spleen. The dry thin tongue in red or crimson is often due to fire flaring in yin deficiency. T h e withering thin tongue in dark color is due to exhaustion of both qi and yin.
F.Crack
(fissute) : If there are cracks on tongue surface, it is called a crack
tongue. The size, depth and shape of cracks are different. There are two causes. The one is deficiency. Guides for Tongue Diagnosis had said: "Cracks are due to blood deficiency. T h e shallow cracks in little amount show the slight decline. The deep cracks in large amount show the severe decline. Transverse crack is seen in yin deficiency constitution. Borneolvein like cracks are often seen in the aged or deficiency condition. The short crossed cracks in red or crimson tongue are due to "
yin and body-fluid deficiency. Cracks in pale tongue is often due to blood deficiency. Cracks in pale and tender tongue is due to spleen deficiency and dampness overflow. Cracks are also seen in excess syndrome. For example, Cracks in red or crimson tongue is often due to heart fire flaring. If the bean-like projections in tongue root make a deep and long crack, it is due to evil accumulation in stomach. Crack with bleeding is because fire evil compels blood to overflow. Cracks can also be seen in normal people. They are formed inborn. It can be known by asking patients.
I
6. Prickle: T h e soft prickles in tongue surface is made up of lung qi and genuine fire in life-gate. So they are seen in normal conditions. T h e enlarged and increased prickles are due to excessive evils, while thinned and lessened prickles result from deficiency of genuine-qi. Awn-prickle belongs to the iarge one. Ail awnprickles are due to internal accumulation of heat evils. The more exorbitant the heat evils is, the Aore and larger the awn-prickles are. In clinic, we can ascertain the location of disease according to the position of awn-prickles. For example, awnprickles on tongue tip are due to heat evil in the heart; awn-prickles on the sides of tongue are due to heat in the liver and gallbladder; awn-prickles on middle tongue
are due to heat in the spleen and stomach. Awn-prickles with yellow thick coating are due to Yangming excess. Awn-prickles with black dry coating are due to heat in yin meridians.
H . Smoothness: T h e smooth tongue surface without coating is called a smooth tongue. Because stomach yin is exhausted and stomach qi fails to produce tongue coating, there is no coating on tongue surface. It is a critical condition due to stomach exhaustion. If tongue is pale, it is due to the extreme deficiency of both qi and blood. While it is red or crimson. it is because fire drying up the water, the stomach fluid and kidney yin are both exhausted.
I. Teeth-Print (teeth-dent) : The pressing marks of teeth on lateral sides of tongue are called teeth-print. It is usually due to enlarged tongue body pressing on teeth. So it is often seen with swollen tongue. If it is seen in pale and moist tongue, it belongs to internal cold-dampness. While in pink tongue. it is due to spleen deficiency or qi deficiency. Appendix : Double Tongue: T h e vessels under tongue are swollen and like a small tongue. It is called a double tongue. It is due to fire flaming up from heart and spleen. The condition is often seen in children. Tongue Carbuncle: Carbuncle in tongue is red and swelling with pain. T h e pain radiates to cheek. It is due to heart fire and spleen heat. Tongue Ding: T h e bean-like purple nodule in tongue with severe pain and hard root is called tongue ding. It is due to heat-toxin in heart and spleen. Tongue Mushroom: It is hard nodule in tongue. At beginning, it is small. And it becomes larger and larger. Then, ulceration and severe pain happen. I t can affect food intake. It is due to stagnated fire in heart and spleen which leads to heat-toxin coagulating. It is also called tongue cancer and belongs to malignant condition. Tongue Bleeding: It is due to heat in the heart compelling blood overflowing. It can also be due to liver fire, heat in lung or stomach, or spleen deficiency failing to control blood. Hypoglossal Vessels
( vessels
below tongue ) : Excellent Prescriptions for
Women recorded how to observe vessels below tongue. In normal condition, beside the frenulum of tongue, two thick bluish purple vessels can be seen. Their diameter is no more than 2.7mm. Their length is no more than the 3/5 of the length from tongue tip to sublingual caruncle. There is no branch or spot. If their color becomes darker, or they are thickened, or there are bluish or purple black vesicles on them. 61
it is due to liver qi stagnation, which leads to phlegm and heat accumulated inside, and then blood stasis. Its meaning is similar to bluish purple tongue. When patient suffering from blood stasis, it occurs earlier than bluish purple tongue and stasis spot on tongue. A score method is applied to diagnose blood stasis as follows. The content of observing vessels below tongue (six large items and sixteen small items)
1. The shape of main part 1) No varicosity (crooked and dilatation), maybe many branches O point 2) Varicosity in some parts
2 points
3) Diffuse varicosity
4 points
2. The length of main part
1) No overreaching the middle point of tongue tip and sublingual carbuncle 0 point 2) Overreaching the middle point
2 points
3. The filling degree of main part
1) Filling up only in lower part
0 point
2) filling up all parts with little crooked
2 points
3) Dilation with crooked
4 points
4. T h e color
1) Light red, light blue, purple, dark purple
0 point
2) Bluish purple
2 points
3) Purple black
4 points
5. The peripheral parts 1) Reticular small vessels in dense form
0 point
2) Cystic, thick processes just like grape-string
2 points
6. The diameter
1) < 2 m m
0 point
2) 2--2. 7 mm 3)>2.7mm
2 points -
4 points
If the total points is over 10, it is abnormal. T h e greater the points is, the more valuable it is to make a diagnosis of blood stasis. 4) The Moving State of Tongue Observing the moving state of tongue is to watch the abnormal changes in tongue movement. The common clinical changes of moving state are as follows:
A. Stiffness : It is an inflexible tongue with difficulty in moving or inability of *
62 *
turning. It causes slurred speech and difficulty in food intake. It is caused by heatfire, phlegm and wind. When exogenous evils invade the body and enter the interior, they will transform into heat. The heat evil enters pericardium and disturbs the mind in heart. That makes the tongue loss its dominator. And the high fever exhausts the bodyfluid. So the tendons in tongue lose their nutrients, the blood and qi are stagnated. In this condition, the tongue moves difficultly. It is not soft and flexible and becomes stiff. It is also called a "dull tongue". If the fire is cleared up, the tongue will turn to soft spontaneously. In miscellaneous diseases, if turbid phlegm obstructs the meridians in tongue, or liver wind stirring internally makes the tendons malnourished, the stiff tongue can be caused. If stiff tongue is accompanied by inability of speech, vague mind, wry mouth and eyes, hemiplegia, it is the critical condition of wind stroke of zang-viscera. All conditions of stiff tongue, no matter what disease it is and what color the tongue is, belong to critical cases.
HI. Atrophy: The tongue is flaccid and weak, and inability to move. The sudden onset of tongue atrophy is usually due to heat scorching the body-fluid, the tongue is often red and dry. The tongue atrophy in chronic diseases usually belongs to deficiency syndrome. T h e atrophied tongue in pale color is due to deficiency of both qi and blood, because of the malnutrition of muscles, tendons and vessels. The dry and atrophied tongue in crimson is due to extreme deficiency of liver and kidney yin.
C.Tremor: It refers to shivering and swaying which are not controlled by the patient oneself. It is also called a "trembling tongue.
"
After a chronic disease,
tremor in a pale tongue with slow wriggling is due to deficiency of both qi and blood, or yang' and body-fluid deficiency which lead to malnourished muscles and tendons. Tremor in red or crimson tongue is often due to extreme heat which damages the body-fluid and leads to internal wind stirring. It is seen in exbgenous diseases or alcohol intoxication.
D. Protruding and Licking: The tongue stretching out of mouth is called a protruding tongue. And that tongue stretches out and immediately retracts into mouth is called licking. Protruding tongue: Because of excess heat in heart and spleen and kidney yin failing to reach upper part, the tongue extends out of mouth. Among them, the sharp shaped tongue means heat is not severe; the dull and flat one indicates a see
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a
vere heat a n d belongs to pestilential toxin invading the heart. If the protruded tongue can not retract in mouth and the patient can not speech, it is the impasse of heart qi. Playing tongue: Heat in the heart and spleen leads to fire and wind. They disturb the tongue. Tongue can not keep quiet. Then it sways left and right, up and down. It is usually a omen of wind-stroke. It can also be seen in child dementia (mental retardation)
.
E.Wryness: When tongue protruding out of mouth, it is inclined to one side. I t is mainly due to wind entering collateral or wind-phlegm obstructing in collateral. It is often seen in wind-stroke, hemiplegia or convulsive diseases. If it occurs suddenly and the tongue is red or purple, it is a condition of convulsion due to liverwind. While it occurs gradually and the tongue is pale, it is a condition of hemiplegia or wind-stroke. When disease is in left, the tongue wrys to right, and vice versa.
F. Shortness: The tongue contracts and shortens, and is inability to stretch, even can not reach teeth. It is called a shortened tongue. If it is inborn, it is harmless. If it occurs in diseases, no matter what condition it is, it is a critical case. It can be caused by heat, cold, phlegm, or deficiency, etc. 1
The shortness due to cold: Evil sinks into three yin and forms a cold syndrome. In this condition, the shortened tongue is moist in pale or bluish purple. It is due to cold coagulated in meridians. When the evil in Shaoyin, there is a shortened tongue.While in Jueyin, there are shortened and curved tongue, blue lips and contracture of scrotum. T h e shortness due to heat: When heat damages the body-fluid, the tendons and collateral are not nourished. The shortened tongue is red or crimson and dry. The shortness due to phlegm: If accompanied with corpulent tongue and greasy coating, it is due to damp-phlegm retention. If yellow coating is in tongue root and tongue is numbness, it is due to phlegm carried by liver-wind.
2. Tongue Coating Tongue coating is made up of stomach qi. There is thin coating on tongue in normal people. It means the stomach qi is vigorous. It is just like that grass grows in fertile soil. If there is no coating, it means stomach is short of vitality. It is just like that grass could not grow in barren earth. Because of the normal function of spleen and stomach, the tongue coating is thin in white, and properly moist, neither slippery nor dry. The coating in diseases is made up of stomach qi and steaming up a
64
evil in combination. So observing tongue coating can help to diagnose diseases. Observing tongue coating includes observing the color and the texture of coating. There are white, yellow, gray and black colors of coating. The texture can be classified into thick or thin, slippery or dry, greasy or putrid, even or not, exfoliation, true or false.
1) Colors of Tongue Coating A. White Coating: White coating usually indicates exterior syndrome and cold syndrome. In exogenous disease, the white coating means the disease is in the exterior. If the whole coating is white, the disease is completely an exterior syndrome. The yellowish white coating means the disease is partially in both interior and exterior. White coating indicates also the cold syndrome due to cold-dampness. White coating is often related to lung diseases. White coating with a tough tongue means excess syndrome of the lung. While white coating with corpulent and tender tongue body indicates lung deficiency. White coating can also be seen in heat condition. Because the evils transform into heat too fast for the coating to change its color into yellow to keep up with the process of disease. The common white coating is: White and thin coating: The slippery, thin and white coating is often seen in exterior cold syndrome. It shows the cold has not been transformed into heat. The dry, thin and white coating is due to warm evil in the lung at the initial stage, or dry evil invading. White, slippery and greasy coating: It is seen in condition of spleen encumbered by cold-dampness. The accompanying symptoms are chest congestion, vomiting after drinking, sweet taste in mouth, and tiredness. White and thick coating: White, thick and dry coating is due to body-fluid damaged by damp-heat, or loss of stomach qi and body-fluid. White, thick and slippery coating is because the exogenous evil draws forth the internal dampness. It is accompanied by chilling and fever, stuffy chest, cough and expectoration, etc. If cold-dampness or cold-phlegm accumulates above diaphragm, this kind of coating can be seen, although without exogenous evil. White, thick and putrid coating is a coating like bean dregs on tongue. It is because food retention in stomach produces heat, and the turbid qi then steams up to tongue. White coating like piled flour is a white, greasy coating like wheat flour over all the tongue body. It is seen in warm diseases, pestilence and seasonal diseases. It is because the exogenous turbid qi and heat evil spread over all triple-jiao. White and rough coating is often seen in warm diseases. The coating is dry and white, like sands on red tongue body. It is due to a
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the rapid entering interior of warm-heat evil. In this condition, the coating can not be transformed in time. The purgation method should be used promptly. white coating like snow flakes on tongue is called a "snow-flake coating". It is the emblem of cold in spleen. Besides,
B. Yellow Coating: The tongue coating is yellow. Three kinds of conditions are commonly seen in clinic. The first one is due to spleen disease. The yellow and tough coating indicates evil in spleen and stomach. The second one indicates the interior syndrome. The color changing from white to yellow means the evil from the exterior into the interior. If the coating is purely yellow without any white, it is the emblem of all evils in the interior. The third one indicates heat syndrome. All heat syndrome, no matter where it is, can show the yellow coating. The light yellow coating means the heat is not severe, while the deep one means a severe heat. T h e brown coating showes the bound heat. But the yellow moist coating in a pale, corpulent and tender tongue is due to water-dampness retention and yang deficiency, instead of the heat syndrome, Yellow and thin coating: The moist one is because the evil has just entered the interior from the exterior, the heat is not severe and the body-fluid is not impaired. The dry one is because the exogenous evil has just entered the Yangming or the. initial stage of warm-heat evil enters the qi-phase. In the time, the heat is not exorbitant and damages the body-fluid. It can also be seen in the condition that evil is expelled and the body-fluid is already consumed. Yellow and thick coating : Yellow, thick and greasy coating: In exogenous diseases, it belongs to interior heat without coagulated excess evil. If it is rooted, it is due to evil entering the interior. The darker the yellow is, the deeper the evils enter the interior. The coating must be yellow, thick and greasy when damp-heat in the interior. Yellow, thick and dry coating: It is due to excessive interior heat which damages the body-fluid. The heat fumigates the tongue and makes the coating yellow. T h e insufficiency of body-fluid leads to dry coating. If accompanied by cracked tongue, it is due to the severe bound heat which consumes the body-fluid and aiso leads to dry stool in intestines. It is usually accompanied by distending pain in abdomen. Yellow coating can also be classified as toughness and tenderness. In the beginning of diseases, the interior heat is not severe and the body-fluid is not exhausted, the coating is tender yellow. When heat is exorbitant internally, the yang *
66
prevails the yin, stomach fluid is used up, the yellow coating is dry but not moist, it is called tough yellow coating. The black yellow coating is call.ed brown coating. There is another kind of yellow coating. It is a light yellow coating accompanied by corpulent, tender and moist tongue. It is an emblem of yang deficiency and failure of the earth. C. Gray Coating: The gray is the light black color. It is the mild case of black coating. So it indicates the similar diseases to that of black coating. All conditions of gray coating mean the severe cases and belong to interior syndromes. None of them is exterior syndrome. Gray coating may indicate heat or cold syndrome. If the heat e n t e r s t h e interior, the coating will turn from white to yellow, and to gray, the tongue is dry and deep red. It belongs to interior heat syndrome and should be treated by purgative to discharge the heat. If cold evils attack the three yin directly, the coating will be gray and moist, with cold limbs and no thirst. It should be treated by warming meridians and expelling cold. Gray coating in edema, with abdominal pain, vomiting, diarrhea, cold limbs and skin, severe edema in lower limbs, deep and thready pulse, is due to cold-dampness retained internally and the coldwater reversely restraining the earth.
D. Black Coating: Black coating is deeper in color than gray coating. It usually comes from gray or brown coating. It indicates interior syndrome and can be seen in either cold or heat, deficiency or excess syndrome. Generally speaking, black coating belongs to the critical condition due to extreme heat or cold. If black coating is moist, it is mainly due to yang deficiency leading to cold, or spleen disorder due to dampness. If black coating in middle tongue at the beginning of disease, the tongue is corpulent and pale, it is because cold-water insults the heart. Black and dry coating with red tongue, even prickled tongue, is an extreme fire like water condition, the heat consumes the water and the genuine-water of Shaoyin will be exhausted. T h e red in middle and black in sides of tongue and coating is due to the flaming of monarch and minister fire. In heatstroke, the coating is often black. It is due to damp-phlegm and stagnated heat. Black dry coating in middletongue, if being with black lips and gum, suggests stomach failure; while without black lips and gum, is due to dry stool in the bowel. Black coating at tip of tongue is due to heart fire burning. Black coating in root of tongue suggests the heat in lower-jiao. It should be pointed out that black coating can be caused by damp-phlegm, blood stasis and smoking. So it does not absolutely suggest the critical case. For example, Wu Youke mentioned a whole black coating in pregnant women, or in yin 67
o
.
syndrome with good prognosis. So there is black coating but no other s,v e r e symptoms, and tongue is pink with free movement, it is due to turbid qi in stomach, but not the critical condition.
E.Combined Colors of Coating: The combined colors of tongue coating are commonly seen in clinical practice. They reflect the dynamic state and the complexity of disease. Zhang Lu said: "The half yellow and half black, or half yellow and half white, and so on, are due to changing evils or coexisting of cold and heat. The "
common combined colors are : a. Combined white and yellow coating: The changing of coating color from white to combined white and yellow is because the evils enter the interior from the exterior. In the time, because evils do not enter the interior completely and some of them still in the exterior, there are chilling and fever; because some evils transform into heat, there is dry throat; because evils block in the interior, there are chest choke and stuffy epigastrium. The changing from yellow to combined yellow and white is a good omen for recovery. If it is seen in internal miscellaneous diseases, it usually suggests the internal retention of phlegm-fluid, or heat in stomach. b. Combined white and gray-black coating: If the coating is moist and easy to be scraped off, and there is no thirst, or thirst but dislikeness to drinking, it is dampness in Taiyin Meridian and should be treated by reliving muscles and seeping out the dampness. If it is dry and thick, and is hard to be scraped off, it is due to interior heat or damp-heat retained internally.
\
c. Combined white and yellow-black coating: If the coating on middle and rear tongue is white and grayish yellow, and the other part is white, it is because the damp-heat in Taiyang Meridian enters Yangming Meridian. If the mixed color is seen in all coating, it is due to cold evil transmitting into the interior and transforming into fire. doCombined yellow and gray-black coating: The slippery and greasy coating in black and yellow is due to damp-heat accumulated in Taiyin. The yellow coating with black in middle is due to interior excessive heat syndrome of Yangming. The black coating in the tip and middle tongue is an emblem of extreme heat-toxin in the deep part of viscera.
2) The Texture of Tongue Coating The texture of coating includes the thick or thin, maist or dry, putrid or greasy, even or uneven, exfoliative, wax and wane, and true or false.
A, Thickness and Thinness 68
The "bottom can be seen" or "bottom can not be seenJ'is taken as the standard of judging thickness and thinness. The thin coating refers to that we can see the I
tongue body (bottom) indistinctly through the coating. The thick coating is a coating through which we can not see the tongue body. Observing the thickness and thinness of coating is helpful to know the deep and shallow, the wax and wane of disease. Generally speaking, when disease is in the exterior, or symptoms are mild, the coating is often thin. Namely, thin coating suggests the exogenous exterior syndrome and mild syndrome of internal diseases. When evils enter the interior, or disease is more severe, or there are retentions of food, fluid, phlegm and/or dampness, the coating is usually thick. Namely, thick coating indicates interior syndrome.
If thin coating becomes thick, it indicates that evil enters the interior from the exterior and the disease changes from mild to severe, the disease is deteriorating. While thick coating turns into thin, i t is a mark of evils being cleared up or expelled, the disease is improving.
B. Msiskness and Dryness The moistness and dryness reflect the wax and wane and the distribution of body-fluid. The well moisterized coating is taken as the normal condition. It reflects the normal state of body-fluid.
If there is much fluid on coating, even to drop when stretching out tongue, it shows the enough body-fluid or water-dampness retention. It is often seen in cold syndrome or damp syndrome. If it is a condition that evil has just entered the interior, and the coating is white, slippery and greasy, it is due to cold in stomach. The spleen deficiency with exorbitant dampness is shown by pale tongue with slippery and greasy coating, chest choke, poor appetite, etc. The deficiency of the middle yang and overflowing of water are shown in white and slippery coating, aversion to cold, cold limbs, etc. The dry coating without fluid on it, even rough like sands on it, is called rough coating. It is due to insufficient body-fluid resulting from heat, or depletion of yin. Dry coating in yellow is usually due to extreme heat in stomach. If in black, it is usually due to yin exhaustion and extreme heat, or phlegm-heat in chest. Dry and black coating with prickled tongue is often due to body-fluid exhaustion resulting from heat. However, some of the dry coating are not due to heat. When the deficient yang fails to transform water into body-fluid to moisterize the upper, or dampness enters 69
\
the qi-phase and makes failure of the qi in producing body-fluid, dry coating may be seen. In this condition, it is often accompanied by dry mouth without thirst, or thirst but dislikeness of drinking. Some of the moist coating are yet not due to cold. For example, when warm-heat evils enter nutrient-phase, it is a condition of the yang-evils entering yin and making the yin streaming up, the coating becomes moist contrarily.
C. Putrid and Greasiness Putrid coating: If the coating looks like coarse mulch granules as putrid bean dregs piling on tongue, and is easy to be scraped off, it is called putrid coating. It is formed by the excessive yang-heat steaming the turbid and putrid qi up. So, there is theory of "no putrid coating belongs to cold syndrome. " There are three common conditions with putrid coating: The first is food-retention. The second is "pus-putrid coating" from internal abscess. The coating looks like pus, white with little red color, thick and sticky. The white one is seen in lung carbuncle and toxin-accumulating chancre. The
ell ow
one is seen in stomach carbuncle. The third one is
"mouldy-putrid coating. " The coating is white and all over tongue, or like mouldy rice. Because the rotten stomach makes the fluid in it transformed into turbid qi, and the turbid qi steams up through esophagus and throat to tongue and even to lips and gum. i t is a tough situation.
Greasy coating: The greasy means sticky. The greasy coating is made of fine particles. It is thicker in middle and thinner in margin and difficult to be scraped off. It looks like being covered by greasy mucus. It is because the yang is encumbered by accumulated turbid-dampness inside. The greasy coating suggests phlegm, dampness and food retention. If it is white, it is due to turbid-dampness or cold-dampness. If it is accompanied by sweet taste in mouth, it is due to damp-heat in the spleen and stomach. If it is yellow, it is due to phlegm-heat, food-retention, damp-warm, etc.
If the putrid coating is easy to be scraped off, it means the genuine-qi is tend to transform into evils. It is due to excess of yang-qi. The greasy coating is hard to be scraped off, it is due to turbid evils in the middle and stagnated yang.
D. Evenness and Unevenness T h e coating evenly spreading all over tongue surface is even coating. It is due to the over spreading evil, or dampness in the middle. If the coating is only on some parts of tongue surface, it is called uneven coating. The uneven coating may be on the left, right, inner, outer part. It was thought by ancients that the uneven coating
on outer part (near tip part) was due to evil in the interior but not deep, and the stomach qi deficiency; that on inner part (near root part) was due to the little exterior evil but heavy food retention in stomach and intestines, and it could also be seen in phlegm or fluid-retention. The uneven coating on one side, left or right, is due to evils in half-exterior and half-interior, or teeth loss in one side in which condition the patient could only use teeth of one side to chew food. If there is no coating in the middle or the coating is thick at margin but thin in the middle, it is due to insufficient stomach qi, or kidney yin deficiency failing to moisten the upper, or deficiency of all yin, essence, qi and blood.
E. ExPo%iatlion If there is coating on tongue but now coating of some parts or all coating disappears, it is called exfoliation of coating. If before breakfast there is coating, after meal the coating decreases, it is a normal phenomenon. The exfoliation suggests the insufficiency of stomach qi or body-fluid. The partial exfoliation of coating, and there is no coating at the exfoliated part, is called versicolor exfoliative tongue (coating). That looks like map is called geographic tongue. If the exfoliated part is somewhat rough and covered with new produced particles, it is called "exfoliativelike tongue. "All of them show stomach qi exhaustion. If all the coating disappears suddenly, the tongue is smooth and dry, it is called bare tongue. It is due to sinking of evil and failure of genuine-qi to conquer evil, or exhaustion of stomach qi.
IF. Wax and Wane The wane of tongue coating refers to thinning and decreasing of the tongue coating. The wax of tongue coating refers to thickening, or the reappearing of coating. They reflect the state of the genuine qi and evil and the prognosis. The former shows gradually recovering of genuine-qi and improving of disease condition; while the latter indicates growing of evil and developing of disease.
If the changing of wax and wane is gradual, it is good. If the coating thickens suddenly, it is due to the suddenly declining of genuine-qi and suddenly increasing of evil. If the thick coating disappears suddenly, it means dying of stomach qi. So, it is important to distinguish the true and false of wax and wane. T h e true wane is preceded by quality change. For example, the aperture appearing on coating and the softening of coating is often followed by the gradually thinning and disappearing of coating. And the change is from the root part to the tip part. It shows the gradual decrease of internal retentions. Sudden disappearance is false wane. If disappearance is not followed by regeneration of coating, it means exhaustion of stomach qi 71
and yin. Versicolor exfoliative coating shows the damage of stomach qi.
G. The True and False The "rooted" or "non-rooted" is taken as the criterion to distinguish the true from the false. The rooted coating refers to the even coating which is closely adhered to the tongue body and is difficult to be scraped off. It looks like growing out from the tongue body. The non-rooted coating is a thick coating with clear boundary and is easy to be scraped off. It looks like being put on tongue body. The nonrooted coating in chronic disease is because at first there is stomach qi to produce coating, then due to the disease developing or mistreating, the stomach qi becomes too deficient to produce coating, and the old coating is still on tongue. If it has just developed after the yang injury due to taking cold herbs erroneously or yin injury due to taking hot herbs erroneously, it is possible to cure; while the prolonged one is hard to be cured. The rooted coating is called "true coating" and the non-rooted coating "false coating.
"
T o inspect whether the coating is rooted is important for judging the state of evils, genuine-qi and stomach qi. The thin, even and rooted coating is seen in normal person or in condition of mild illness in which the genuine-qi is not hurted. The thick rooted coating is due to excessive evils and enough genuine-qi. In the nonrooted coating, whatever it is thin or thick, if only it is smooth without reappearing or easy to be scraped off, it belongs to the exhaustion of genuine-qi and failure of stomach and kidney qi to tide up. Because coating is made up of turbid evils, the rooted coating means the severe disease in the initial or middle stage; the non-rooted coating means the slight turbid evils and the mild disease. In addition, in normal body, the coating is thick over tongue in morning, and becomes thin after breakfast. It is false coating, but not due to disease. In the late stage of disease, the nonrooted coating is a sign of severe condition because of depletion of stomach qi. Another condition of thick coating on the surface and thin new-produced coating below it is a good omen of the recover.
3. Combining Consideration of Tongue Texture and Coating The abnormal changes of tongue picture include both tongue texture and tongue coating. Because the diseases are different, some diseases have more effect on tongue texture; while others are mainly shown by changes of coating. In order to make correct diagnosis, both tongue texture and coating should be observed in combination and respectively. In common conditions, the changes of tongue texture and coating are consis72
tent and they suggest the diseases in combination. For example, the crimson tongue with yellow dry coating belongs to excess heat syndrome; the pale tongue with white slippery coating belongs to deficient cold syndrome. But diseases are complicate, tongue body and coating may suggest different diseases. The diseases suggested by tongue picture is not the simple sum of the suggested diseases of tongue body and those of coating. For example, the crimson tongue indicates heat syndrome and white coating is often seen in cold syndrome, but they can be seen at same time. T h e crimson tongue with white, slippery and greasy coating in warm diseases is due to heat in nutrient-phase and the heat wrapped in dampness. When it is seen in internal miscellaneous diseases, it is often due to yin deficiency with phlegm or turbid retention. The crimson tongue with white dry coating is because the turbid phlegm transforms into heat rapidly and enters into nutrient-phase, and consumes up bodyfluid, it is too rapid that the change of coating could not keep up with the change of disease synchronously. So the disease is in the interior but there is no yellow coating. Therefore, the tongue observation should be done in combination with the other disease conditions, so as to make correct diagnosis. The common tongue pictures are as follows :
11) Pale Tongue with Different Kinds of Coating
A. Pale tongue with transparent coating: The tongue body is pale and there is a thin white and transparent coating on it. It indicates the deficient cold of the spleen and stomach. In aged people or people with weak spleen and stomach, the invading wind-cold evil could not transform into heat, so it is seen. It can also resulte from taking of herbs erroneously which hurt the stomach qi.
B. Pale tongue with white dry coating: The tongue is pale and the coating is white and dry. It indicates accumulation of heat and depletion of body-fluid. If the coating is dry, thick and smooth, it is due to yang deficiency and evil obstructing in middle-jiao, where they transforme into heat and consume the body-fluid. If the coating is dry and hard as sand, it is due to heat evil accumulation inside and the depletion of body-fluid.
C. Pale tongue with white slippery coating: The coating is white, thin and slippery in middle and root parts in a pale tongue body. It is an emblem of the initial stage of cold attack on weak people. If the coating is thick, it is due to cold-dampness in the spleen and stomach. It is found in both exogenous diseases and endogeneous diseases,
D. Pale tongue with yellow cracked coating: The tongue body is pale and the O
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@
coating is yellow and dry with some cracks. It is due to weakness of qi and bodyfluid in ordinary time, and then attacked by fire evil which damages bodv-fluid. The deficient qi could not produce body-fluid and lead to body-fluid deficiency. T h e deficient body-fluid could not moisten the tongue, that makes fissures.
E. Pale tongue with yellow slippery coating: There are light and bright yellow, watery and slippery coating in the pale tongue body. It is due to inactivity of spleen yang which leads to water-dampness retention in the interior.
F. Pale tongue with black slippery coating: The tongue body is pale and corpulent and there is gray or black slippery coating on it. It belongs to the extremely deficient cold resulting from yang deficiency. The deficiency of yang implicates the qi and blood, so the tongue is pale, tender and corpulence. The deficiency produces cold which makes the coating black.
yang
G. Pale tongue with black dry coating: There is black, dry and rough coating in pale tongue body. The coating is easy to be scraped off. It belongs to the
in-cold
syndrome of yang deficiency and body-fluid retention. It is different from the black dry coating of extreme heat damaging body fluid.
2) The Pink Tongue with Different Kinds ~pfCoating A. Pink tongue without coating: The tongue is pink and tender without coating. It is due to deficiency of stomach qi and yin.
B. Pink tongue with white coating on root part and yellow coating on tip part: The tongue body is pink and the coating is white and thin. But the coating on tip part is slight yellow. It is due to heat in upper-jiao, or wind-heat in the exterior, or the wind-cold transforming into heat and tending to enter the interior.
C. Pink tongue with yellow-black coating: The tongue body is pink. T h e coating on the margins is yellow and in middle is black, thick and greasy. It is because the damp-phlegm transformes into heat which damages the yin , or because dampheat accumulates insid
3) Wed sr Crimson Toague with Different Kinds of Coating
A. Red or crimson tongue with white thin coating: The tongue body is bright red or crimson and the coating is white, thin, and even. It is usually seen in the condition that the patient is of yin insufficiency in ordinary time and is attacked by wind-cold evil; or that the wind-cold evil in the exterior implicates the qi and nutrient-phase. The difference between the two conditions is: in the former, the crimson tongue appears before the exterior syndrome; in the latter, because the evil implicates the qi and nutrient-phase from the interior, the color of tongue body changes a,
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a,
from pink to red and deep red gradually.
B. Red or crimson tongue with white greasy coating: The tongue body is bright red or deep red. The coating is white and thick and greasy, neither dry nor slippery. It is often seen in warm diseases of dampness in qi-phase and heat in nutrientphase. It is also seen in the conditions of yin deficiency in ordinary time complicated with dampness in stomach and intestines, or of food-retention. C. Red or crimson with white flour-like coating: T h e tongue body is bright red or deep red. There is white, thick coating on it, just like flour piles on tongue. It is due to the accumulation of warm pestilential toxin.
D. Crimson tongue with yellow-white coating: The tongue is crimson at the beginning and there is yellow-white coating on it. It is due to evil in the qi-phase and nutrient-phase. It is the condition of fire flaming in both qi and nutrient-phase.
E. Red or crimson tongue with yellow moist coating: The tongue body is bright red or deep red and the coating is bright yellow and moist. I t is seen in the following conditions : The first, yin deficiency with damp-heat in stomach and intestines. The second, alcohol addiction which produces dampness and the dampness transforms into heat, the heat accumulates in blood and the dampness in the middle-jiao. The third, the exogenous evils enter nutrient-phase from qi-phase. All of them are due to heat with dampness.
F. Crimson tongue with yellow greasy coating: The tongue body is dark red and there is yellow greasy coating with yellow mucus like yolk on it. It suggests the deficient heat in nutrient-phase with phlegm or fluid-retention inside.
G. Red or crimson tongue with yellow, dry and cracked coating: The tongue body is red or crimson. The coating is yellow and cracked. It is called "yellow petal coatingJ'. It is because exogenous evils transform into heat and enter the interior, and the body-fluid is consumed, then the heat evil accumulates in intestines with waste.
H. Red or crimson tongue with gray or black coating: The red tongue with black slippery coating is due to pestilence in Taiyang Meridian. If it is accompanied by aversion to cold, it is an exterior syndrome and can be treated by slight di-, aphoresis. If the middle of tongue is red and gray or black coating is on the out part, it is because the heat evil enters the Jueyin from Yangming. It is often with coma and should be treated by purgation immediately. The red tongue never suggests the cold syndrome, so it should be considered as heat syndrome.
I. Red tongue with little black coating in tip part: The black coating is only in 75
the tip part and no coating in other part. It suggests internal heat in the heart.
J. Red or crimson tongue with gray or black dry coating: It is the sign of excess heat and exhausted body-fluid. It can be seen in condition of heat evil in the interior with exhausted body-fluid or blood, or in condition of heat in miscellaneous diseases.
4) Bluish Purple Tongue with Different Kinds of' Coatings
A. Purple tongue with white coating: If the coating is white and slippery, it is due to yin-cold. If the coating is white, thick and greasy, it is seen in condition of alcohol-toxin transforming into damp-heat, or that damp-heat accumulating inside. B. Bluish purple tongue with yellow slippery coating: It is due to food retention in middle-stomach, and the cold in Taiyin. The cold coagulates the blood, and makes the tongue bluish purple. Food-retention in stomach with phlegm stasis, makes the coating slippery.
C. Dark purple tongue with yellow dry coating: The purple tongue with yellow dry coating in the middle is due to damp-heat exorbitance inside. For example, the latent heat in viscera, the heat from alcoholic indulgence, the dryness or fire evil entering inside, or over-taking of herbs in warm or heat nature can all lead to the condition.
D. Light purple tongue with gray coating: If the tongue is moist, it is usually due to cold. The cold coagulates the blood and the blood is stagnated, then the tongue is blue. The extreme cold makes coating black and moist. If it is dry, it is because the heat enters the blood-phase in warm diseases or pestilential diseases.
E. Blue tongue with black coating: The tongue is bluish pale with gray or black coating on it. It is due to extreme cold. The cold mak,es blood stasis, so the tongue is bluish. The deep invading of cold makes coating black.
4. Tongue Pictures in Critical Conditions In critical conditions, the visceral functions are declined, the yang, qi, yin and essence are exhausted, so there are some special changes on tongue pictures. For example : The tongue is smooth like a mirror or uncapsuled pig kidney which is due to exhaustion of liver and/or kidney yin, or dying stomach qi. T h e shortened tongue with contracture of scrotum is due to exhaustion of liver qi. T h e white coating like snow flakes is a sign of expiring spleen yang. The tough tongue with prickles and dry cracks is due to exhaustion of body*
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*
fluid. Withering tongue like a dry litchi is due to extreme heat and depletion of body-fluid.
Section 5
Modern Research on Observation
Observation is an important component of inspecting methods in TCM. The facial observation and the five sensory organ observation recorded in Internal Classic and Treatise on Cold-Attack have been studied extensively at home and abroad. From the 1980s, the field of observation has been expanded. The new observing methods such as observing the mucous membrane of palate, observing of rugosity of ear lobe, come forth. Some scholars have been studying on modernization of observation such as the clinical verification and normalization. At the same time they also make the content of observation richer. The results of modern research can be briefly introduced as follows:
I. Facial Color Observation T h e facial color and luster can reflect the visceral functions and the state of qi and blood. After Japanese scholars put forward the objectified method for testing skin color and luster and applied the infrared photograph to examining the facial color, many scholars have applied many kinds of instruments to detecting the facial color. Now, they are mainly focused on the infrared picture and chromatograph. Some achievements on quantitative and qualitative research have been obtained. Some investigators had made the researches on the facial brightness and color measurement on the normal people who have shown the color deviation in white, yellow, blue and black. They found out that there were deviation tendencies of five colors in normal facial complexion. The researches proved that the instruments and technology of color analysis could provide an objective and quantative basis for diagnosis. Some scholars compared the infrared photographs of normal people and heart disease sufferer. They found out differences between these two groups in the homogeneity and symmetry, thereby they proved some objective reactions on face in coronary heart disease. By comparing the infrared photographs before and after treatment, they found the treatment effective to disease could also turn the facial reactions to normal. Chromatograph was applied to measuring the color changes of 131 patients suffering from pulmonary tuberculosis. The differences between different groups on syndrome differentiation were found. Among them, the chromatic 77
aberration in yang deficiency was the most prominent; that of yin deficiency and blood deficiency was inferior to that of yang deficiency, and that of qi deficiency and normal condition was small. Some doctors proposed that the observation of crablike stripe on face was one method to check up the meridian in TCM. By analyzing data of 105 patients, they found out that in heart disease the stripes were mainly in temporal region, in liver and kidney diseases they were mainly in nose and cheek regions, in lung disease they were mainly in zygomatic region, in kidney disease they were mainly in cheek region. The distribution of crab-like stripes was related to the diseases. Investigators did observe the vessels (subcutaneous capillary) in root region of nose of 1000 children. They found that the vessels in normal children were obscurely bluish, and that in diseases were obviously dark blue. When the vessels were in the shape of "-", it was due to diseases of digestive system; while they were in
"
I " shape, it was mainly due to diseases of
respiratory system. The blue
color of the vessels indicated the wind, cold, painful syndrome and liver diseases. The yellow indicated the dampness, heat, deficiency, spleen and stomach diseases. The bright color suggested the recently occurred diseases which were mild and easy to cure, while the dark color was due to old diseases which were severe and difficult to cure. The shape and color of the vessels were related to the cause, location and other conditions of diseases. Some foreign doctors proposed a concept of facial examination based on the theory that all the parts of the body had their projection on face. They thought the meridian and point system on face was different to the traditional theories of TCM, and it was a projective system of meridians. The facial examination was to observe the abnormal spot on face to diagnose diseases. T h e visceral representation on face they gave was different to that recorded in Internal Classic.
II.Eye Observakiom Eye observation can help to diagnose many diseases. In recent years, its applying range was expanded to diagnose parasitosis, tumor, trauma and hemorrhoid, etc. For example, it was reported that the stasis spots in the upper half of bulbar conjunctiva indicated the trauma of chest and arm, those in the lower half refleced the trauma of back and leg, that in the left eye suggested the trauma in the right of body and vice versa. The accuracy rate of all diagnosis was 91. 2%. It was suggested that the dilated, curing, congested vessels in the region of 5-6 09clock of bulbar conjunctiva were the sign of hemorrhoid. T h e 85% of diagnosis in 1270 cases were correct. Some doctors applied ophthalmoscope to inspected the vessel changes of 78
\ \
fundus. The vessels being bright red, even in width, regular in distribution were the embodiment of regular liver qi. Those in dark red, uneven in width, or congestive were due to liver qi stagnation. Those being thickened, dilated, curing, or with bleeding were due to stagnated heat in liver. Atrophy of the vessels even hard to recognize with pale-yellow dry fundus was due to liver blood deficiency.
111. Ear Observatiasm Scholars at home and abroad all thought that the shape, color and luster of ear were related to the visceral functions. Some foreign scholars thought the ear was the mirror of spirit. The ear shape in some psychosomatic diseases was different from the normal, thus we could diagnose psychosomatic diseases by observing ears. Scholars at home have made a lot of researches in the field. They observed the size, thickness, shape, color and vessels of ears, or pressed the points on ears to find tender points. Some diseases could be recognized by these examinations, such as cholecystisis, cholelithiasis, silicosis, coronary heart diseases, myocardic infarction. stomach diseases, hyperosteogeny, cancer and tumors. For cancers, it was suggested that on the corresponding points of ears there were pain, hot, protruberance, color change and changes of electric conductivity. In northern Jiangsu, more than 50, 000 people were examined in mass survey of cancer, the detective rate in upper digestive tract cancer was l o % , it was higher than the average rate of 2 4 % at home and abroad. The ear examination is used popularly in China.. By using WR-F ear-point comprehensive detector, it was found that the potential voltage in disease group was higher and the resistance was lower than those of control group. Some doctors applied XZ-20 information detector to examining ears of people aged more than 60 years. The changes of electric. current in ear-point were related to the endocrine function. Some people took the average energy consumption as the index instead of the resistance, thus the sensitivity was improved. They did manage to minimize the disturbing signals and the resistance between the electrode and the skin. Therefore, the accuracy of diagnosis was improved. The oblique rugosity on earlobe was related to the coronary heart diseases. That was reported in 1973. But the research is still in progress. According to the statistics, the form of the rugosity was related to the arteriosclerosis b u t not to the fat metabolism.
IV.Nose Examination The theory that the nose column corresponds to the liver, the two sides of nose to the gallbladder, and the apex of nose to the spleen, the two sides of the apex to the stomach was proved by clinical verification. Some body thought that nose observation could diagnose diseases of the liver, gallbladder, spleen and stomach. The crab-like stripe on nose suggested liver diseases. T h e spot on the middle point below apex suggested the diseases of reproductive system. The philtrum was observed in addition to the nose. T h e obscurely blue in philtrum suggested the cold dysmenorrhea. T h e obscurely purple indicated the dysmenorrhea due to stagnated heat. T h e pale and dry philtrum suggested the amenorrhea due to blood exhaustion. T h e red in philtrum near lip indicated the metrorrhagia or metrostaxis due to heat in blood. T h e bright white in philtrum near nose suggested the metrorrhagia and metrostaxis due to qi deficiency. If the pale philtrum or shortened philtrum shorter than one third czm was seen in male, it suggested impotence, lack of sperm or no sperm.
V. Mouth and Lip Observation Observing lips can help to diagnose parasitosis or tumors. Research have been made by many doctors. In recent years, some white, sand-like hard newplasms in upper labial frenum was found in the patients of lumbosacral joint injury. It was also reported that the nodes in upper labial frenum suggested the hemorrhoid, and the number and size of the nodes were in direct proportion with the number and size of hemorrhoid. T h e red and soft nodes suggested the beginning of hemorrhoid, while the white and hard nodes the old hemorrhoid. In 1981, a Japanese scholar pointed out the soft and hard palate mucous membrane would have changes corresponding to diseases. These changes were termed sign of palate mucous membrane. It was applied to diagnosing blood stasis syndrome. Hereafter, Chinese scholars had also made researches in this field. T h e smaii varicose vein, dilatation of smaii artery, bleeding and color change have been studied. T h e blood stasis in liver cancer, hepatocirrhosis, coronary heart diseases, diabetes mellitus and irregular menstruation was more obviously shown in the sign of palate mucous membrane. Its value was equal to that of bluish purple tongue and vessels below tongue. Experimental studies showed that the sign of palate mucous membrane was related to micro-circulatory disturbance. 80
VI. Tongue Examination Since the foundation of P. R. China, all medical works of modern medicine and T C M have made many researches on tongue examination in not only clinical observations, but also experimental studies, such as studies of cytology, pathology, hemodynamics, blood
rheology, biochemistry, immunology, analysis of
trace
elements and chromatograph. T h e progresses have been achieved in normalizing and objectifying tongue examination. By the investigation on tongue pictures of normal people, it was found that 81*82% of them were pink tongue, 75. 88% of them were white thin coating, 68. 2 % of them were normal tongue body shape, and 93. 65% of them were normal vessels below tongue. By analyzing the pictures of different ages groups, it was found that the ratio of normal tongue picture decreased with the age increasing and the sexual difference existing. These data were helpful for correct diagnosis. T h e researches on the abnormal tongue picture: T h e pale tongue was often seen in deficiency syndrome. It is related to anemia, hypoviscosity of whole blood and plasma, decrease of plasma colloid osmotic pressure, lower plasma albumin, disturbance of albumin synthesis and edema, dysfunction of digestive system which leads to malnutrition and hypometabolism, and endocrine dysfunction. Pathological examination found atrophy and decrease of lingual fungiform papillae, thickened membrane of tongue, hyperplasia of prickle cells and the parakeratosis of the epithelial cell of tongue. T h e red and crimson tongue were often seen in fever, infection, dehydration,
B,
surgical operation, disturbance in the absorbing and metabolism of vitamin
hypermetabolism, sympathetic hyperfunction, inflammation of digestive system, hyperazotemia, hypoxia, acidosis, disorders of consciousness, etc. Pathological examination showed obvious atrophy of filiform papillae, decrease or atrophy of fungiform papillae, parakeratosis of the epithelial cell, increase or dilatation of capillary in the proper mucous membrane, bleeding, and lymphocyte infiltration. T h e purple tongue was usually seen in heart diseases, liver and gallbladder diseases, respiratory system diseases and tumors. It was related to decreased blood oxygen saturation, vein stasis, slow blood circulation, increase of blood viscosity, increase of platelet aggregation, deformity and increased fragility of capillary, etc. T h e incidence rate of purple tongue rised with aging. T h e white coating was seen in not only exterior syndrome and cold syndrome, but also deficiency syndrome. It could be seen in the restoration stage of all
81
o
diseases, non-organic diseases like neurosis, diseases without symptoms like early breast cancer. chronic infections, etc. There were changes of filiform papillae, such as increased and thickened cutin of filiform papillae. T h e notable difference was found between the normal white coating and pathological white coating in rate of red and white fluorescence when examined by fluoroscope. It provided an objective basis for judging pathological white coating from the normal. T h e yellow coating was often seen in inflammatory infections and fever. When
W. B. C. was over 15,000/mm3, the incidence rate of yellow coating reached 7 2 9%. It was also seen when there were congestion, edema, ulcer or bleeding of gastric mucous membrane which were due to active gastric ulcer, superficial gastritis, carcinoma of stomach. In yellow coating condition, there were bacteria gathering and inflammatory exudate on tongue surface, hyperplasia of filiform palillae and hyperkeratosis*T h e yellow color was produced by the bacteria. The gray and black coating were usually seen in critical conditions in which the heat was the main cause. They were related to the high fever, dehydration, toxin, disorders of central nerve system and digestive system, fungi and other color-producing
bacteria, chronic
inflammation
and
kidney
deficiency, etc.
Pathological examination showed the thickened mucous membrane, enlarged palillae, and hyperplasia of basal cells. In prickle cell layer, the interspace of upper cells disappeared, and vascuoles and hyperkeratosis appeared. There were mixture of cutin, piled bacteria, fungi, etc. The greasy coating was related to metakeratosis of cells and large amount of bacteria on tongue surface. T h e smear examination of thick coating showed the hyperkeratosis, large a
white blood cells.
Many researches have been done on the tongue pictures in some common diseases. They include :
Hypertension: T h e micro-circulation examination showed abnormal microcirculation in patients of hypertension was higher than that of normal people. T h e coincidence rate of purple tongue was also higher than that of the normal. T h e incidence rate o i abnormai micro-circulation was in directly proportion to that of the purple tongue and to the degree of hypertension. It was suggested that the vessels in the tongue sides could reflect the degree of arteriosclerosis in the same way as in observing arteries of eye fundus. Experimental research showed that the cAMP/cGMP ratio of hypertension patients with pale and corpulent tongue was lower than that of the patients with red tongue.
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Acute myocardiae infarction: The tongue body was mainly purple with stasis spot and the main coating was white. According to tongue picture and other symptoms, the syndromes were mainly the qi deficiency and blood stasis, accompanied by phlegm and dampness. The curative effect was much improved when treated by the combination therapy of strengthening the qi and activating blood and modern medicines.
Pulmonary heart disease: In the early stage, red tongue was often seen; while in the late stage, bluish purple tongue, red'and crimson tongue, mirror tongue or smooth tongue were the main. The coating was mainly yellow and greasy, thick and greasy, or no coating. The changes of tongue picture were related to the changes of blood gas and pH. While the increase of blood oxygen, the tongue turned from dark purple to crimson, red, and bright red: while the increase of carbon dioxide, the color of tongue changed from red to bluish purple.
I
Cerebrovascular diseases: The tongue picture of the patients of ischemic cerebrovascular disease was mainly purple tongue with greasy coating. If it was thin coating and non purple tongue, the curative rate was high. If it was yellow and greasy coating, the curative rate was lower. That in patient with purple tongue was the lowest. The changing into white of coating meant the improvement of diseases, while the changing into yellow meant deterioration of diseases.
Stomach diseases: In stomach disease, the coating was mainly yellow and thick. The tongue in superficial gastritis. was often bright red and the coating was yellow, thin and greasy. In gastric ulcer, the tongue was red or crimson with yellow, thick and greasy coating in most conditions. In duodenal ulcer, the coating was often clear. In atrophic gastritis, the tongue was often dark with yellow thin coating, or yellow thick coating. In some cases, the tongue was smooth with cracks. In stomach cancer, the tongue was often dark purple with stasis spot. The coincidences rate of smooth tongue and cracked tongue were 49. 3% and 62. 6% respectively. They were obviously higher than that of other diseases.
Hepatitis: In acute icteric hepatitis, the tongue picture was often corpulent tongue with white gre,asy coating. If the coating was white, thick and greasy, the SGPT was certainly high. The immune depression was showed in corpulent tongue with teeth print. T h e yellow, thick and greasy coating showed the developing tendency of the disease. In chronic hepatitis and cirrhosis, the change of tongue picture was mainly on tongue body. It was often dark purple with stasis spot. The vessels below tongue was thickened. 83
*
Tumors: T h e tongue picture changed along with different locations and conditions. The purple tongue was the most common one. The dilatation of vessels below tongue was valuable for distinguishing whether the disease was tumor or not. Generally speaking, the sign of blood stasis such as purple tongue and dilatation of hypoglossal vessels was the main character of tongue picture in tumors.
To sum up, the researches on tongue examination verified and enriched the theory, and clarified the formative factors of tongue picture, by the clinical verification and modern scientific methods. The laws of tongue pictures change in common diseases has been recovered. In some diseases, such as hepatitis, cardiac vascular disease and tumor, tongue picture was taken as animportant index for diagnosis. Because the tongue examination is important for diagnosis, non-invasive and acceptable for patients, its application in diagnosis was very promising.
VII. Hand Examination The striae of skin was an important inherited property of mankind. It was controlled by the gene. The TCM attached great importance to the constitution when differentiating syndrome. The striae of skin could be used judge to constitution and heritage person. For example, in spleen deficiency, the coincidence rate of whorl and double loops was lower than that in normal condition, the general number of crest was high, most of the whorl and loop are big, flower-like wrinkle between index finger and middle finger and in the thenar and hypothenar was more often seen. These abnormal changes could be taken as index for diagnosing spleen deficiency constitution.
Some investigators used the infrared photograph to observe the heat emission form the back. They found the abnormal changes at the points which were closely related to or corresponding to the viscera. For example, in 24 cases of urinary bladder cancer, 22 cases showed the abnormal change at Pangguanshu (BL28, the corresponding point of urinary bladder) : in 9 cases of lung cancer, 8 cases showed the abnormal change in Feishu (BL13, the corresponding point of lung). These findings suggested that the viscera might connect to body surface by ways of meridians. So, acupoint examination was useful for diagnosis in some degree. Some investigators applied acupoint thermometer to detect the temperature changes at the Xindaxi (used to ascertain if the disease is cancer) and Feishu (used to determine if the disease is in lung) of 113 cases of lung cancer and the same cases of normal people as a
84
control group. They found the difference between two groups was obvious. The method could be used to detect cancer in mass screening. Another report said the acupoint examination could be used to diagnose cholecystitis, ~ h o l a n ~ i e c t a s i s , cholecystolithiasis and liver diseases. Some Japanese scholars proposed that acupoint examination could judge the yin-yang, deficiency or excess of viscera and meridians, so as to guide the treatment.
Chapter 3
Auscultation and Olfaction
Auscultation is to find the abnormal sound of speech, respiration and cough etc. by means of auditognosis (hearing). Olfaction is to know the smell of the patient's body, the secretion and excreta by means of osphresis (smelling). It is a method that doctors use their auditory and olfactory organs to diagnose diseases. In ancient time, it followed mainly the laws of "five voices and five scales" to distinguish the five zang-visceral diseases. In Han Dynasty, Zhang Zhongjing took the speech, respiration, asthma, cough, vomiting, hiccup and moan as the main content of the auscultation and olfaction. The doctors of later generations added the odor of mouth, nose, secretion and excreta to the contents.
Section 1 Auscultation The production of sound is related to the lung, throat, epiglottis, tongue, teeth and nose. The lung plays a main role. The lung dominates the qi of whole body. The movement of qi leads to sound production. The abnormal change of qi results in changes of sound. T h e auscultation is to inspect not only the above mentioned organs, but also other viscera. According to some theories from Internal CLassic, the abnormal change of sound can reflect conditions of five zang-viscera. Doctors of later generation did not want restrict themselves on the theory of "five voices and five scales. " T h e y put all the things that can be heard or smelled into the contents of auscultation and olfaction. That made the method more important in diagnosis.
I. Voices The voice of normal people is produced naturally and fluently in a harmony way. Though the structures of the body are the same, the individual difference exists. So there are differences of voice in the aspects of volume, tone, clear or vague. The voice changes in accordance with the differences of constitution, age, sex and emotion. In condition of disease, if the voice is loud and successive, it belongs to heat or excess syndrome. The voice is often lower and vague in condition of wind, cold and 86
dampness invasion. If the voice is low, weak and non-successive, it belongs to deficiency or cold syndrome, or condition of evil being eliminated and genuine qi being injured.
1. Hoarseness: It is also called "huskiness". The voice of speech and cough looses the clear and smooth characters. It is usually due to invasion of wind-cold, or the combined invasion of wind-heat and wind-cold. The heat transformed from cold or wind-heat evil fumigates the lung, the lung looses its purity, so the voice looses its clear character. The hoarseness can be classified into two types as follows: The first one, cold evil attacks body firstly, and when the cough is not cured, the heat evil invades the body. T h e cold closes the qi in the interior and heat fumigates qi in the exterior. Thus hoarseness of voice is resulted. It has a popular name of "heat wrapping cold". T h e second one, heat hides in body in ordinary time, and cold evil invades the body. The heat is stagnating in the interior and the cold stays in the exterior. Popularly, it is called "heat wrapped by cold. " In addition, the shouting in fury can also leads to hoarseness.
2.Aphonia: It is also called "loss of voice" . It is a condition of inability to make voice. One of them is the aphonia of tongue disorder. It is due to the inability of tongue to move. The throat is in normal condition and can make voice. It is not true aphonia. It can be seen in wind-stroke. The other is the aphonia due to throat disorder. In this condition, the tongue movement is normal but the throat is unable to produce voice. The condition is different in disease course. The sudden onset of aphonia is usually due to wind-cold invading the epiglottis, or damp-phlegm stagnating in lung collateral, which leads to dysfunction of lung qi to disperse and descend. The lung could not keep the state of purified. The evil fills up the hollow organ, so it is said "a solid bell does not sound. " The condition could also be caused by the violent cough and shout in fury. The chronic aphonia is often due to prolonged diseases of lung in which condition lung yin is insufficient and the deficient fire scorches the metal (lung) and injures the lung, the lung could not produce sound. It is said "broken bell does not sound. " T h e sudden one is often due to attack of exogenous evils, while the chronic one is often due to endogenous disorders. The former can be cured and the latter belongs to incurable case. In addition, the aphonia in pregnancy is due to fetus which obstructs the kidney essence and qi to nourish the upper part of body.
3. Snore: It is the noise of breath when sleeping, and is due to hindrance of air flow in respiratory tract. The snore is often heard in fat or old people. If the snore a
87
is gruff with fever, aversion to wind and sweating, the condition is wind-attack at defensive phase. If the snore is heard in apoplexy with coma, paralyzed arm and urinary incontinence, it is a critical condition of wind-stroke in zang-viscera.
4. Moan and Groan: They are due to pain or distention. If the voice is loud and gruff, the condition belongs to heat or excess. While low and vague voice is heard in deficiency or cold syndrome. The vague and intermittent moan is due to disease between the heart and diaphragm. The groan or cry of child with frightened expression is due to fright-convulsion.
11. Speech The state of diseases can be known by listening to the speech. The cold leads to taciturn a'nd the heat to chatter. The deficiency makes speech voice low and inconsistent, and the excess makes the voice loud. 1
The indistinct speech is due to wind-phlegm which covers the clear orifice or obstructs meridians. The incoherent speech results from failure of heart to store the mind. There are differences between the deficiency and the excess. That of excess syndrome includes the following :
1. Raving: It is the incoherent speech which is characterized by laughing, cursing, crying or shouting, and is accompanied by irregular running, singing in high place, exposing the naked body. It is seen in mania, phlegm-fire disturbing the heart, blood accumulation in cold-attack diseases, and so on.
2. Delirium: The condition occurs in unconscious patients who could not be wakened by calling. The speech is incoherent, forceful and loud, and could not be understood. It is due to heat disturbing the mind in heart. It is often seen in syndromes of warm evil in pericardium or Yangming fu-visceral excess in warm diseases. T h e "repeated murmuring" is the main condition of incoherent speech of deficiency. The speech is in broken sentences, repeated words, vague and feeble voice. It belongs to deficient syndrome of heart qi. In addition, the "soliloquy" is the speech to oneself in a murmuring way. It stops when meeting people. The content is incoherent. The "wrong speaking" is the speech in words or sentences which express the wrong meaning that one do not want to speaking out. The patient can find the mistake by himself/herself at once. Both of the two speech conditions are due to insufficiency of heart qi which could not support the mind. The "depleted speech" is characterized by faint sound and in-
.88 .
constant sentences. In this condition, the patient could not express himself/herself clearly. It is a sign of damage of the middle qi.
111. Respiration T h e normal respiration in disease means the disease in physique but not in qi; while the abnormal respiration means the disease in both physique and qi. T h e deep breath means excessive qi in the heart and lung. T h e weak breath is due t o qi deficiency of both the liver and kidney. T h e main purpose of listening to respiration is to distinguish the deficiency from excess. T h e rough respiration in a rapid exhaling and slow inhaling belongs to heat and excess. It is often seen in exogenous diseases due t o excessive evil. T h e faint respiration in slow exhaling and inhaling indicates the deficiency. It is usually seen in chronic endogenous diseases. But in chronic disease of expiring lung and kidney, the breath can also be rough and intermittent. It belongs to pseudo-excess. In syndrome of heat in pericardium, the breath can be faint with stupor. It belongs to pseudo-deficiency. If the breath is faint, shallow and rapid with dyspnea, it belongs t o extreme deficiency and the primordial qi damage. T h e often encountered abnormal respirations can be classified as follows:
1. Dyspnea: T h e respiration is difficult, short and rapid. In severe case, there is open mouth breath with lifting shoulders and nares flaring, and the patient could not lie flat. T h e dyspnea can be classified into deficiency type and excess type. T h e excess type is often due to exogenous evils invasion, excessive heat or phlegm-fluid retention in the lung. T h e deficiency type is caused by kidney yang deficiency or lung qi deficiency. T h e excess dyspnea is characterized by sudden onset, rough and loud voice of breath. T h e chest is distended. T h e patient feels a little better when exhaled out. There are supine position headrest, protruding of eyes, strong body movement and breath with forceful pulse. T h e deficiency asthma is characterized by gradual onset, low breathing sound, weak and dimming breath. T h e patient feels hardly to inhale and exhale. So, a deep breath gives great comfort. T h e body is weak and the pulse is feeble. It is due to deficiency of the lung and kidney which leads t o failure of kidney qi to receive the air.
2. Wheezing: T h e breath is rapid like asthma with loud sound as if phlegm in throat. It is seen in early stage of exogenous evil invasion. T h e evil retains in the interior of the lung in addition of the hiding fluid-retention. When wind-cold attacks the body, the evil makes the qi obstructed, so there is rapid breath. T h e wheezing attacks repeatedly and may prolong for years. It can also be caused by liv*
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ing in cold-damp area for long time or over intake of salty, sour, uncooked and cool food.
3. Upper stuffing breath: When evil is fighting with genuine qi, the genuine qi can not flow normally, then the qi rises upwards to throat and obstructs the air tract. The condition is called "upper stuffing qi" . If exogenous evils invade skin, the lung qi is stuffed, the body fluid is not dispersed to body surface, then the upper stuffing qi is complicated by edema. If phlegm and fluid retained in chest, the upper stuffing qi is accompanied by cough, expectoration of turbid sputum, orthopnea. If the upper stuffy breath is due to yin deficiency with fire blazing, it is accompanied by sore throat due to fire.
4.Shortness of breath: The shortness of breath is an inconstant shallow and rapid respiration without sounds. It likes asthma but no lifting shoulders, and likes moan but no pain. It is usually resulted from lung qi deficiency. The accompanied symptoms are physical weakness and dysuria. If there is fluid-retention in chest, there are shortness of breath, thirst and deep pulse. It belongs to excess syndrome. The key point of judging excess or deficiency in this condition lies in examining the chest and abdomen. The distending and hard ones are due to excess, while the soft to deficiency.
5. Shortage of qi: The qi is too less to make speech. The shortage means the qi is in a little amount. The breath is weak but near the natural state. The breath and speech sound is low and short. It is not like shortness of breath. It is an emblem of all kind deficiency and declination. The above mentioned symptoms usually are not be separated distinctly. For example, the asthma can occur with upper stuffing qi. This should be keep in mind.
PV*Cough Cough is closely related to the lung. But in Internal Classic, it is said: "The five zang-viscera and six fu-viscera can all make cough, not only the lung. " From that we know not only lung disorder, but also other visceral diseases can cause cough. Listening to the sound of cough can help to judge the cause and nature of diseases. The muffled sound of cough reflects cold and dampness. If the cough is accompanied by white clear sputum, stuffy nose, chill and fever, it is due to invasion of exogenous wind-cold. If the sound is low with profuse sputum, which is easy to be expectorated, it is due to cold or dampness, or phlegm in lung. The unclear sound of cough with yellow sticky sputum which is difficult to be expectorated, sore throat, hot air out from nose, is due to heat in lung. T h e parox90
ysmal cough is often due to wind. The clear sound of cough belongs to dry-heat. It is a condition of no sputum or little sticky sputum. The paroxysmal cough characterized by uninterrupted cough, even leading to vomiting, and making sound like the shout of heron when ending, and reoccurring after moment, is called whooping cough or "hundred-day cough". It is often seen in children. The cause is the wind evil in combination with the hiding phlegm obstructing the air tract. In diphtheria of children, the cough sounds like bark of dog. It is due to yin deficiency of both the lung and kidney and fire-toxin attacking throat. The low and feeble sound of cough with rapid breath belongs to lung qi deficiency. T h e nocturnal cough belongs to kidney yin deficiency. The dawn cough is caused by spleen deficiency or cold-dampness in large intestine. '"6. Vomiting
The stomach is in good condition when its qi descends. The vomiting is due to stomach qi rebellion. The seriousness of diseases can be know by inspecting the sound and other aspects of vomiting.
If vomit is clear mucus, the action of vomiting is slow, the sound is low, the tongue coating is white slippery and the pulse is small and weak, it belongs to deficient cold. While the vomit is yellow sticky sputum-like with sour or bitter taste. the action is violent, the sound is loud, the coating is yellow and pulse is large and forceful, it is due to excessive heat. When heat disturbs the mind, the vomiting is projectile, it is a serious condition. Evening vomiting of undigested morning meal is due to stomach yang deficiency or deficiency of both spleen and kidney which leads to inability for digesting food. It is called iirebellious stomach". The vomiting with distending chest and abdomen and constipation is caused by the dry stool in intestines which makes the foul qi flowing upwards. In cold-attack diseases, the evil remaining in the exterior makes the dysfunction of interior qi, then there are chill and fever; general aching and vomiting. The vomiting due to liver stagnation and ,
wood attacking earth is accompanied by chest choke and hypochondriac pain. In cholera, the vomiting and diarrhea occur simultaneously. If patient is thirst and likes to drink, and when drinking, there is vomiting, it is caused by fluid retention. Vomiting of pus is due to stomach abscess.
VI. Hiccup
It is the rebellious stomach qi which rushes out through throat. T h e rushing makes short sound frequently. According to the characters of the sound, we can know the nature of disease. If the sound is loud and clear without mental change and other discomfort, it is due to a hasty meal, or wind-cold attack, or temporary qi rebellion. It will recover spontaneously. The new occurred hiccup is due to cold or heat evils in stomach. The hiccup occurred in prolonged disease means critical condition. T h e constant loud sound of hiccup, even though there is cold limbs, is due to fire-heat because of dry stool. It is often seen in mistreated cold-attack diseases by purgation which makes the stomach qi flows upwards instead of downwards. T h e low sound is usually due to prolonged diarrhea which leads to spleen yang deficiency and stomach qi rebellion. It belongs to deficient cold. If the hiccup is weak interrupted and reoccurred after a longer break, it is often seen in terminal stage of chronic disease or febrile disease and is due to defeated stomach qi.
VIH. Belching Belching is also called eructation. It is the up flowing of stomach qi from stomach which makes sound when flowing through throat. It belongs to stomach qi rebellion, too. The belching due to excess is long and the one of deficiency is short. The mechanism of belching can be divided into two types. The first one is cold evil attacking stomach which leads to food retention and qi rebellion. There are distention in chest and abdomen, fetid odor of the eructed air, acid regurgitation which are due to undigested food in stomach. The second one is deficiency. It is caused by oversweating, vomiting or purgation which damages the stomach qi. There is chest and epigastric stuffiness which is relieved by belching. The air of belching is no special odor. It is also seen in chronic disease or aged patients in which the spleen and stomach qi is weak. The belching sound is low. There is not odor of the air. The appetite is poor. If the belching is due to rebellious liver qi which attacks the stomach, the belching is frequent with loud and clear sound. It is accompanied by fart and abdominal distention which is relieved by fart or belching. The patient sighs frequently in ordinary time and the condition changes according to the emotional changes. "'
VIII. Sigh The sigh is the sound of emotion. When in a bad mood or in adverse circum*
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stance, the liver qi will be stagnated. Then there is chest distress and the patient makes a deep expiration with short sound. It is sigh'.
IX. Sneeze T h e sneeze is caused by lung qi flowing up to nose. It is often seen in syndrome of wind-cold invasion. If it occurs in a prolonged disease, it is an omen of recovery of yang and qi.
X. Bowl Rcamblilrag It is necessary to distinguish the location and character of the sound. If the sound is in the upper abdomen, the disease is in stomach; while in lower part of abdomen, the disease is in intestines. The thunder-like bowel rumbling is caused by wind, cold and dampness. The low sound is due to fluid-retention or deficiency. The bowel rumbling in epigastrium just like the sound made by water waving in bottle, if stand up or pressed, the sound changes its place to lower part, is due to phlegm and fluid retention accumulating in stomach. It is often accompanied by dizziness, palpitation, chest distress and poor appetite, etc. The restless sound as if due to hunger, relieved by warming and aggravated by cooling, relieved by food and aggravated by hunger, belongs to deficiency of stomach and intestine. The bowel rumbling due to wind is accompanied by diarrhea; that due to dampness is by stuffiness in epigastrium and abdomen and loose stool; that due to cold is by abdominal spasm and pain, even cold limbs, vomiting or syncope, because the cold can make qi and blood coagulated. Hearing is specially useful when dealing with children. Zhou Xuehai said: "When inspecting child, the listening is the first and the observation of color is the second. " T h e clear sound means survival while the vague and faint voice means dying. Crying with bending body is due to abdominal pain; crying aggravated by pressing is due to pain in the pressed part; crying but keeping in low voice is due to sore throat; suddenly crying after awakened from sleep with crying is due to abdominal pain or general pain; crying followed by diarrhea is seen in abdominal pain due to stagnation; crying in constant thready voice with knitted browns and bowed head is due to headache. In condition of sudden crying in loud sound without other disorders, the child's clothes and whole body should be examined, because it may be caused by foreign body or sores in skin. @
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Section 2
Olfaction
When something is stale, there a r e changes of odor. In healthy body, the qi and blood circulate smoothly, the viscera and meridians function well, so there is no abnormal odor. When diseases occur, the qi and blood movement is abnormal, the foul and turbid waste could not be cleared away, then there are abnormal odors. Olfaction is to smell the odors related to diseases, such as odors from excreta and secretion including sputum, nasal discharge, sweat, stool, urine, menstrual blood, and vaginal discharge, etc. The foul odor is usually due to excessive heat; while the little fishy odor is often due to deficient cold.
I.Sputum and Nasal Discharge The foul odor of turbid pus and bloody sputum is due to exorbitant heat-toxin. It belongs to lung abscess. The thin sputum with salt but not fishy odor belongs to cold phlegm. The turbid nasal discharge with foul odor belongs to rhinorrhea due to heat in brain. That without odor is due to wind-cold attack.
HI. Odor of Mouth T h e foul odor of mouth is related to mouth and stomach disorders, and is often due to indigestion. In dental caries, the odor is sour and fetid, because there is cavity in tooth and the food remains in the cavity which rots and produces the fetid odor. The odor will disappear when keeping the mouth clean. In pyogenic gingivitis, the fetid odor is stinking and foul which comes from the rotten gum. In stomach heat syndron~e,the heat makes stool dry and filthy qi steaming up, so the odor of mouth is foul. In condition of food retention in stomach, the movement of qi is abnormal in descending and ascending, the food qi flows up, so there is an odor like that of rotten egg. The putrid odor in mouth usually indicates the inner abscess or ulcer.
IHI.Sweat The smell of sweat in patients of cold-attack or warm diseases indicates the perspiration. If the sweat is sticky with fishy odor, or in yellow color, it is due to the wind and dampness which accumulate in skin and pollute the body-fluid. T h e foul odor of sweat is smelled in patient of pestilence. In terminal stage of edema, there is an odor of urine in sweat. 94
PV;Odor of Body If there is ulcer or broken sore on patient's body, the odor of the body will be abnormal. For example, odor of the body of the gangrene is described as the odor of "rotten field snail" in Golden Mirror of Medicine.
V.Menstrual Blood and Vaginal Discharge The foul odor of menstrual blood is due to heat while the fishy odor to cold. When vaginal discharge is due to damp-heat, the odor is fetid; while due to deficient cold, the odor is fishy stench.
VI*Stool and Urine The turbid yellow urine with foul is of damp-heat. The heavy smell of urea is due to exorbitant heat in heart and urinary bladder. The incontinent urine without odor means the fire is defeated. T h e fetid stool is resulted from heat and the fishy stench of stool is due to cold. The stool without bad odor indicates the expiring large intestine and stomach. The sour stool of children is of food retention. The fetid {art is caused by food retained in stomach and stool stagnated in intestines.
VII, Vomit T h e odorless vomit, with preference to hot drinking, belongs to stomach cold. The sour and foul vomit, with thirst liking cold drinking, is due to stomach heat. If the vomit is undigested food with putrid odor, it is of food retention. The pus and bloody vomit with fishy and foul odor is caused by internal abscess.
VIHI. Odor of Ward The offensive odor in ward indicates a serious condition. That is shown the most obviously in pestilence. The pestilent qi steams from the middle to the exterior and gives off the offensive odor. In mild case, the smell is just surrounding the bed. In severe case, the fetid odor fills up the ward. Other diseases can make abnormal odor in ward too. For example, in the ward of patients suffering from massive bleeding, there is blood odor. In condition of decayed visceral, internal abscess or leukorrhea diseases, the foul odor is often smelled. The urea odor is smelled in the ward of late edema patients. The smell of rotten apple is found in severe case of consumptive thirst disease ( diabetes mellitus) .
Chapter 4 Interrogation
Interrogation is to know the onset, development, treatment, present symptoms and other information of disease by questioning patient or the accompanying people for diagnosis. Interrogation is very important in diagnosis, because the self feeling and the disease history can only be known from the description given by patient. Qoctors in all dynasties attached great importance to it. It is said in Internal Classic: "You must ask the beginning of disease and the present condition. " T h a t tells us the interrogation is the indispensable method for diagnosis. The main points of diagnosis of three yang and three yin in Treatise on Cold-Attack can be gained only by questioning. In the Thousand Worthy Prescriptions for Emergence, Sun Simiao put forward the principle of "questioning first. " In Qing Dynasty, some doctors attached even more importance to it and listed it at the first place of all the four diagnosis methods. Li Rong pointed out that every symptom such as cough, fever, pain and so on had its distinctive character. .When treating cough, if the fire character is known by asking, the cough should be treated according to fire; and if there is phlegm known by questioning, the cough should be treated from phlegm. By questioning we can know the disease and its cause. So the disease can be treated from the "root" .
Section 1 T h e Purpose and Method of Interrogation
41. The Purpose of Interrogation Shi Peinan gave a brief explanation to the purpose. He said: "The disease is in the inner, the symptoms are shown in the exterior. The doctor good at interrogation is to find the disease cause through symptoms by questioning. " The purpose of interrogation is to collect the data for diagnosis which could not be obtained by other methods. T h e hobby, custom of the patient, as well as the onset and development of diseases should be grasped, so as to judge the cause and nature of disease, to make diagnosis and to treat the disease. It should be pointed out that the subjective symptoms and self feeling of pa@
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tient are not the only basis for diagnosing. In certain condition, they are not reliable. So data from all diagnostic methods should be taken into comprehensive consideration in order to avoid mistake in diagnosis.
PI. The Method of Intwrogatiorra
1. Selecting a suitable environment before questioning: When questioning, the environment should be quiet, so as to avoid the disturbance and make the doctor and patient in a calm mood. The doctor can focus on questioning and the patient can describe the disease in detail.
2. The doctor should ask the patient directly. If the patient is in severe case or unconscious, or is a baby who could not describe the disease, the doctor can question the accompanying people. But, in order to collect the reliable and accurate data, the doctor should question the patient oneself after the disease improved or patient awakened, to confirm and supplement the data obtained before.
3. The questioning method determines the accuracy of data. At the beginning, the doctor should listen to patient's complaints, and grasp the main character of the disease from the complaints. Then according to the TCM theories, based on the holistic philosophy, the doctor should question the main complaint intensively and the other symptoms all-side. The center should be put on the main complaint and all aspects should be asked. If no center, the key of disease could not be grasped. No all-side questioning, some disease data will be neglected. In long time clinical practice, ancient doctors accumulated rich experiences. For example, the "formula for describing disease" put forward by Yu Chang in his Critical Study is the brief summary of interrogation procedure.
4. The doctor shoujld be serious and patient, and be good at thinking and arasusing patients. But the intetional guide which will make patients to provide demanded , data for diagnosis should be prohibited in case the patients answer questions without thinking and just chime in with doctors that lowers the reliability of clinical data. Some patients may hide the truth or exaggerate the state when describing disease. Doctor should make judgment cautiously in combination with other diagnostic methods.
Section 2
The Content of Interrogation
I. General Data The first part in interrogation is the name, age, sex, occupation, birth place, na97
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tionality, address and marriage state of the patient, and the 24 solar-terms of the disease onset, etc. And the visit date and admission date should also be recorded in the medical history. Li Chan said: "In middle age, the body can bear the disease; in old, the diseases are complex and the primordial qi could not bear diseases; in female, those have less pregnancy have still exuberant qi and blood, those have many times of pregnancy and are old should be treated by tonifying rather than destroying. " H e pointed out that the age and sex relate to the disease type and syndrome differentiation. The nationality, occupation and marriage state are closely related to some diseases. For example, hepatic echinococcosis is seen in pastoral area; the rheumatism is frequently seen in coal miner; postpartum disease is only seen in women after delivery. The birth place and address could also influence the health. T h e natural environment and climate are different in difference areas. Internal Classic clearly pointed out that in different areas, the diseases are different. T h e date of disease onset is helpful to syndrome differentiation. Wu Hegao pointed out: "To know the year is to know the movement of five elements. T o know the month is to know the seasons. The disease should be treated on this background. " When treating the epidemic encephalitis B, Pu Fuzhou made different syndrome differentiation and used different herbs according to the different years, and got very good curative effect. That demonstrates the influence on diseases corning from movement of five elements.
PI. Life Style and Process Internal Classic mentioned that when making a diagnosis, one should question the life history and life style. The life style is related to diseases. Among it, the diet, mental activity and regular daily life are the most important.
I. Diet When visceral qi is relatively excessive or declined, there will be preference or addiction to food. The yin prevalent viscera lead to preference to hot or pungent food, while the yang prevalent viscera to preference to cold and uncooked food. So the preference or addition to food means the different prevalence in viscera that makes the body susceptible to some diseases. For instance, the addition to alcoholic drinking, meat, rich food often relates to the disorder of phlegm or dampness; the over intake of cold or uncooked food leads to diarrhea. The judgment of visceral yin-yang prevalence is listed in table 5. 98
Table 5 The Judgment of Visceral Yin-Yang Prevalence digestion
stool
d'isease
visceral qi
like cold food.
good
consti-
exorbitant
Yang preva-
if take hot or
appetite
pation
yaw syndrome
lent
there are dry
easy to
even for
the
vis-
throat, burning
be hungry
several
d'iseases
cera
pain in mouth,
days there
tend to
stomach discom-
is a
transform
fort with hot
defecation
into heat yin syndrome
insufficient
type
food intake
stomach
pungent food,
feeling like warm food,
poor
loose
yin preva-
if take cold,
appetite
stool
lent
abdominal
if eating
the
even yang
vis-
discomfort,
more, there
diseases
deficiency
cera
even diarrhea
will be
tend to
of both
indigestion
transform
spleen and
into cold
kidney
there are
no preference
the
spleen
normal
normal
the spleen
normal
and stomach
people
function well
2. Mental State Elementary Medicine said: "One should ask if the patient is in a favorable state of life or not. In a favorable state, the disposition is good and the qi and blood are in harmony. While in an unfavorable situation, the mood is bad and the qi and blood are in stagnation. "Internal Classic had also pointed out that the bad mood can lead to many diseases. So in interrogation, the temperament in ordinary time and the relation between mood and the disease should be questioned carefully.
3. Living Style The irregular life is often the cause of disease. So ancient doctors took the fatigue and over exertion as the main cause of endogeneous diseases. Plain Questions made a living time table and pointed out that the irregular life style can result in many kinds of diseases.
111.Family History and Anamnesis The statement about communicable diseases have existed from ancient time. For example, in Cui9s Informal Record, the pulmonary tuberculosis was described as an infectious disease which spreaded am'ong people regardless of young and old, and even more serious in the women and children. The ancients knew that some diseases could spread among people for a long time. In addition, some diseases relate to hereditary factors. So the questioning of family history is helpful to diagnose of infectious diseases and hereditary diseases. The anamnesis is closely related to the onset and development of present disease. For example, abdominal pain can be the presymptom abdominal mass; palpitation usually belongs to the prodromal symptom of heart disease; stomachache, stranguria and parasitosis are characterized by repeated attack and remission. So it is necessary to know the past disease history clearly by questioning. In addition, the marital history and childbearing history should also b e questioned because they have a close relation with diseases.
IV.Chief Complaint The chief complaints are the symptoms the patient feels the most obviously and painfully and the main cause for visiting a doctor. Though the symptoms of diseases are complicate and various, they can be divided into main and secondary symptoms. It is the key point for making correct diagnosis to question the disease condition intensively and purposely according to the main
f patient complains about epigastric pain, the doctor
may inquire the patient about the character, time pain, and the relation between the pain and diet and seasons according to the main
main complaints include a couple of symptoms in different times, the symptoms should be recorded in the order of their occurring time. For exaiiiple, "Tidal fever in afternoon for half a year, bloody sputum for three days" ; or "Palpitation and shortness of breath for five years, edema in lower limbs for half a monthJ', etc. T h e record should be done in clear and concise way. Sometimes the main complaint given by patient is not clear, the doctor should listen to patiently and then question intensively until getting a clear idea, and then write it down. 100
V. History of Present Disease T h e history of present disease is the main content of interrogation. It refers to the whole developing course from the onset up to now. It includes two parts: the disease process and present symptoms.
31. The Course of Disease When patient is consulting doctor, the doctor should ask about the circumstance, time, symptoms, sudden or not, cause and predisposing cause of the disease. and the development and the treatment process, etc. T h e time of onset is not only related to the five elements, but also to the chronic or acute condition of the disease. Generally speaking, the newly occurred disease usually belongs to exterior syndrome and excess syndrome while the old disease to interior syndrome and deficiency syndrome. Wang Donggao said: "The cause is the producing and source of disease. One should take pulse and ask about the symptoms after questioning the disease cause clearly. " T h e cause and predisposing cause must be inquired intensively. On the development and transmission of diseases, there are six meridian transmission in cold-attack disease and defensive-qi-nutrient-blood phase transmission in warm diseases. In endogenous miscellaneous disease, there are differences among the yin, yang, qi and blood diseases. And there are entering and exiting in skin diseases. If those are not inquired in detail, then there will be mistake in syndrome differentiation and other mistake will follow. T h e previous treatment which was effective or not, and how it effected on disease development should also be asked in detail. For example, if the cold herbs is proved useless to the condition, the hot herbs are helpful, the effects should be asked and distinguished in combination with the pulse and symptoms.
2. Present Symptoms The inquiring about present symptoms is the central point of interrogation. It provides the basis for diagnosis. Based on the statements of ancients and his own experiences, Zhang Jingyue, a famous doctor in Ming Dynasty, summed up the content of interrogation into the ten-questioning, namely "The first is to ask the cold and fever, the second the sweat, the third the head and limbs, the fourth the urination and defecation, the fifth the diet, the sixth the chest, the seventh the deafness, the eighth the thirst, the ninth the cause and the color to know yin-yang, and the *
101 *
tenth the odor and the vitality. " T h e doctors in later generations changed the last two aspects into "the ninth the old diseases, the tenth the cause. In women the mense and childbearing, and in children the pox and measles should also be inquired. These aspects of interrogation are quite valuable in practice, so they have "
been used since then. The contents of above mentioned ten-questioning are as follows :
11) Cold and Fever They are the common symptoms in disease course. Cold refers to the chilly sensation of patient. The chill which could not be relieved by putting on more clothes or warming oneself by the heater is called aversion' to cold. The cold sensation which can be relieved by putting more clothes or warming is called intolerance of cold (afraid of cold). The fever refers to not only the higher body temperature than normal body temperature, but also the self feverish sensation of whole body or local parts of the body in which the body temperature maybe is not higher than normal. The production of cold and fever is mainly determined by the nature of evil and the predominance of yin or yang of the body. Generally speaking, when evil causes diseases, the cold evil mainly leads to aversion to cold, but the cold evil can also transform into heat; tile heat evil mainly causes fever, but can also leads to pseudo-cold. When the disharmony between yin and yang causes diseases, the yang predominance usually produces out heat, the yin predominance produces inner cold, the yang deficiency leads to outer cold, and the yin deficiency to inner heat. T o inquire the details of cold and fever can help to infer the disease cause, distinguish the disease location, judge the disease nature, and know the condition of yin and yang of the body, then to provide a reliable basis for treatment. When questioning cold and fever, one should first clarify if there are cold and fever. If they exist, one should ask if the cold and fever are shown in the same time or not, then ask the characters of them such as the occurring time and lasting time, the seriousness and concomitant symptoms, so as to distinguish the nature. For example, the aversion to cold and fever in same time belongs to exterior syndrome, only the cold or fever belongs to interior syndrome, and the alternate chill and fever to half -exterior and half -interior syndrome.
A.Chill and fever: It
refers to the condition that patient has a sensation of
chill and a high body temperature by measurement in the same time. It is seen in the initial stage of exterior syndrome caused by exogenous evil. The chill and fever 102
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reflects the struggle between defensive qi and evils when evils invade the body and stay in skin and muscle. Because the evils are different in the category of yin-yang, the condition can be divided into three kinds:
a. More chi11 than fever: It is the condition that patient feels obvious aversion to cold with a mild rising of body temperature. It is due to exogenous cold evil attack. The cold evil is a yin evil. It wraps the body surface and impairs the yang, and seals the pore of skin. Then the defensive yang is obstructed and could not disperse. So there is a serious aversion to cold. The condition is frequently accompanied by headache and general aching, no sweating, floating and tense pulse, etc.
b. More fever than chill: It is a condition that patient has a feverish sensation and high temperature with slight aversion to cold. It is due to exogenous heat evil attack. The heat is a yang evil. When it causes disease, it makes the yang predominant, then the fever is severe. When wind-heat invades the exterior, the radiating nature of heat evil makes the pore opened, so there are sweating and slight chill. The condition is often accompanied by thirst, sore throat, floating and rapid pulse, etc. c. Fever with aversiiasln to wind: The patient has fever and aversion to wind. It is due to exogenous wind attack. The wind is a yang evil. It has the nature to open. When wind stays in the exterior, it makes the interstitial space between muscle and skin loosen and makes the defensive qi fail to consolidate the body, then there are sweating and cold sensation when meeting the wind. The severity of the chill and fever is helpful to infer the conditions of the genuine qi and the evil. In common condition, if the evil is weak and the genuine qi is strong, the fever and chill are both mild; when there is much evil and weak genuine qi, the aversion to cold is severe and the fever is mild; if the evil and genuine qi are both strong, the chill and fever are both severe.
B. The chill and fever separately: The patient has a sensation of cold without fever or there is only fever. They belong to interior syndrome. The fever without chill belongs to yang excess or yin deficiency while the chill without fever to yin excess or yang deficiency.
a. Fever without chill: There is fever but no sensation of cold. It belongs to interior heat syndrome. It can be classified into the following types according to the time, nature and concomitant symptoms.
Stlnennie fever: The condition of high fever without sensation of cold is called sthenic fever. It is seen in interior heat syndrome which is caused by the wind-cold 103 a
which enters interior and transforms into heat, or by heat evil in the interior. The genuine qi is strong and the heat is exorbitant. The heat evil steams the body and the disease is fulminant. The concomitant symptoms are profuse sweating, thirst and heavy drinking, vexation, flushed face, surge and rapid pulse, red tongue with yellow dry coating, etc.
Tidal fever: The fever waxes and wanes in a fixed time ljke the tide. The condition is called tidal fever. It can be divided into the following types according to the time, severity and concomitant symptoms. The first one is the tidal fever due to
yin deficiency. The fever occurs in afternoon or at night. The temperature is not high. The feverish feeling is characterized by hot sensation in five centers with vexation, even hot sensation like steaming from bone. It is usually due to yin deficiency which leads to yang prevalent relatively and produces endogenous heat. The concomitant symptoms are night sweating, hectic cheek, dry mouth and throat, red tongue, etc. The second one is the tidal fever of Yangming. The fever is high and reaches the highest point at 3 or 5 clock in afternoon. It is because the Yangming qi is on its duty in afternoon. It is often accompanied by abdominal pain and rigidity, constipation, etc. The third one is the tidal fever due to damp-warm. Its characters are the hidden fever (a condition when touching the skin of patient in short time, one feels just the mild fever; keeping touching for a long time, the one feels a scorch hot in the skin; and the patient is quiet), aggravated in afternoon, decreased a little after sweating but turned to the same degree as before sweating, being prolonged and refractory. It is frequently seen in damp-warm diseases resulting from the damp-heat in the middle. Because the dampness obstructs the heat to radiate out, the fever is hidden. The dampness is sticky and hardly cleaned away, so it is prolonged and refractory. T h e common concomitant symptoms are chest distress, nausea, heavy sensation in head and body, loose stool, sticky tongue coating, soggy pulse, etc.
Low grade fever: It is a condition of slightly higher temperature in chronic disease, or just a feverish sensation with normal temperature. It is usually seen in yin deficiency, qi deficiency in chronic disease, or infant heat stroke syndrome. The fever due to qi deficiency has a manifestation of low fever for long time which is aggravated in tiredness and relieved by rest. Its concomitant symptoms are shortness of breath, lack of strength, spontaneous sweating, etc. The low fever due to yin deficiency is similar to the tidal fever due to yin deficiency. The low fever in infant heat stroke syndrome is a fever lasting all summer with fatigue, thirst, little sweat@
104
@
ing, restlessness and poor appetite. and will disappear without treatment in autumn. Because the child is lack of qi and yin and belongs to the body of tender yin and tender yang, the body could not adapt himself t o the hot climate and leads to fever.
b. Intasilerance of cold without fever: T h e patient feels cold but no fever or feverish sensation. It belongs to interior cold. There are divisions of deficiency and excess of cold according to the severity, character and accompanying symptoms. T h e deficiency cold: Because the visceral yang and qi are weak and can not reach the muscle and skin, the limbs are not warmed, then the patient feels cold with cold limbs. There are concomitant symptoms like pale complexion, lying in curving position, slow and weak pulse, pale tongue. T h e symptoms can be relieved by putting on more clothes or warming by heater. T h e excess cold: Because cold evil invades viscera directly, the yang and qi are impaired. There is severe pain in the local part where the cold evil attacks. T h e pain is aggravated by pressing and relieved by warming. There may be contraction of limbs, vomiting and diarrhea, taut or tense pulse. C. Alternate chill and fever: T h e aversion to cold and fever occur in turn. It is
usually seen in half-exterior and half-interior syndrome. It is divided into two types.
a. Shaoyang syndrome: T h e alternate chill and fever are irregular of time. It is often accompaiiied by bitter taste in mouth, dry throat, distress in chest and hypochondrium and taut pulse. Its mechanism is that the invading evil could not enter the interior completely and the genuine qi could not expel the evil out. T h e genuine qi and the evil are locked. When the evil gets stronger or genuine qi is weaker, there is chill; while the predominance of genuine qi or declining of evil makes fever. T h e genuine qi and evil predominance in turn makes the alternate chill and fever.
b. Malaria: This is a condition of alternate high fever and chill. T h e occurring is on a fixed time. I t onsets every day, every other day, or every third day. T h e concomitant symptoms are severe headache, profuse sweating and thirst. T h e mechanism is that after entering the body, the malaria evil hides in the moytran, the part between the interior and exterior of the body. When entering, the evil struggles against the yin and makes chill and shiver; when exiting, it fights against the yang and makes high fever and sweating.
105
T h e attention should be paid to separating the exogenous from endogeneous diseases. It is a key point of syndrome differentiation. T h e exogenous disease is caused by the exogenous evil. It occurs suddenly and is characterized by simultaneous aversion to cold and fever. T h e aversion to cold could not be relieved by putting on more clothes or warming. T h e temperature of the dorsum of hand is higher than that of palm. T h e back is hotter than abdomen. I t is accompanied by other symptoms of exterior syndrome. If the symptoms in its initial stage are fever and aversion t o cold, sweating or not, general aching, it is an exterior syndrome. If the initial manifestations are fever, sweating, thirst, constipation, dark yellow urine, delirium, it is an interior heat syndrome. T h e endogeneous disease is due to internal injury of the viscera. T h e occurring is in a gradual way, the cold sensation and fever are in the same time. T h e feeling of cold can be relieved by putting on more clothes. When there is fever, the palm is hotter than the dosum of hand, the chest and abdomen are hotter than the back. And there are other symptoms which belong to internal injury. When asking about the cold and fever, the doctor should inquire about if the patient likes or dislikes the cold or hot things. Because of the difference of constitution, the preference to cold or hot is not the same. T h e patient in a relative cold constitution likes hot but is afraid of cold, and vice versa. In addition, when there are disorders of diet and pain, the doctor should question if the patient likes hot or cold drinking and food, and if the pain can be relieved or aggravated by cooling or warming. This is useful for judging the nature of disease.
2) Sweating T h e perspiration is body fluid which is evaporated and sent to the skin through the pores of body by the yang. Plain Questions pointed o u t : "The action that the yang puts on yin makes the sweating.
"
T h a t explains the genesis of
perspiration. When people take hot or pungent food, or do physical work, or undergo sudden emotional change, or put on too much clothes, there will be sweating and it is a physiological phenomenon. T h e normal sweat can harmonize the nutrient qi and defensive qi and moisten the skin. No sweating when it should sweat, sweating in a improper time, and over sweat,ing are all pathological reactions. No sweating when it should sweat is due to the following reasons: the first, the shortage of body fluid which could not produce perspiration; the second, the yang declination which fails to evaporate the fluid; the third, evil in the exterior obstructs the interstitial space 106
between skin and muscle. The improper sweating and over sweating
to syn-
drome of excessive evil or defensive yang deficiency. So the sweating relates closely to the nature of evil and the state of the genuine qi. When inquiring about sweating, whether there is sweating or not should be asked first, then the time, location, quantity. character and concomitant symptoms of sweating are inquired, so as to judge the disease location and nature.
No sweating: T h e phenomenon that in the time that it should sweat, but there is no sweat is called no sweating. The phenomenon in exterior syndrome means wind-cold in the exterior. The cold has an astringent character that makes the skin and interstitial space tightened. The fluid could not be sent out to skin to produce sweat. It is an exterior excess syndrome. There are other symptoms such as more cold than fever, asthma, headache, nasal obstruction, heavy body sensation, floating and taut pulse. In addition, no sweating can be seen in condition of body fluid insufficiency in endogenous diseases.
Sweating: T h e sweating means abnormal condition of sweat. It includes sweating in improper time, profuse sweating, or sweating with other pathological reaction. Many factors are involved in giving rise t o sweating. F o r example, the visceral
yang deficiency, or defensive yang inactivity which lets the interstitial space open and fluid escape out; the attack of wind-heat and summer-heat opens the skin and evaporates the fluid, then makes sweating. Also, the exorbitant interior heat can make profuse sweating. When differentiating syndromes according to sweating, the exogenous or endogenous diseases should be distinguished first. The exterior excess syndrome is characterized by no sweating because of the closed interstitial space, while exterior deficiency syndrome is by sweating because of the loose interstitial space. In endogeneous diseases, the yang or yin deficiency should be separated. The deficient yin fails to contain the yang, then there are sweating and fever. The deficient yang is unable to consolidate the body surface, so there is sweating with intolerance to cold.
A. Abnasrmallity on Sweating Character: a. Spontaneous sweating: The patient sweats in day time and the sweating is profuse when doing physical work. It is called spontaneous sweating. Because the qi is deficiency and defensive yang fails to consolidate the body, the interstitial space is loose, so the fluid goes out and makes sweating. Physical work consumes qi, the 107
body fluid goes out following the qi, so in this condition, the sweating is profuse. It is frequently accompanied by listlessness, fatigue, shortness of breath, indolence to speak, pale and corpulent tongue, feeble pulse, etc. If it is due to yang deficiency, there are intolerance to cold and cold limbs.
lo. Night sweating: The sweating occurs in sleep and stops on awaking. The phenomenon is called night sweating. It is mainly due to yin deficientcy. In physiological condition, the defensive qi enters the interior and moves in yin phase with the nutrient yin when sleeping. If the yin is deficient, the defensive qi could not enter the yin phase and wanders, the nutrient yin follows the defensive qi and goes out the body, that makes the sweat. When awakened, the defensive qi goes to the exterior part of body and controls the body surface, that prevents the body from sweating. The night sweating is accompanied by tidal fever, hectic cheek, dry mouth and throat, red tongue, thready rapid pulse, etc. In the condition of yin deficiency accompanied by qi deficiency, the night sweating can be found with the spontaneous sweating in the same body. That needs analysis in combination with the other symptoms. The theory that spontaneous sweating is due to yang deficiency while night sweating to yin deficiency should not be followed rigidly. Ancient doctors had made statement on this point. Zhang Jingyue said: "The spontaneous sweating may also belong to yin deficiency while the night sweating to yang deficiency. "
c. Profuse sweating: It is a condition of too much perspiration on skin which is a phenomenon of over evaporation of body fluid. The sweating can be classified into two kinds, the deficiency one and excess one.
If there are sthenic fever and profuse sweating with red complexion, thirst and liking cool drinking, red tongue, surge and rapid pulse, etc., it is an excess heat syndrome. The exogenous evils enter the interior and transform into heat. The exorbitant interior heat evaporates the body fluid and leads to profuse sweating.
If there is profuse cool perspiration with pale complexion, cold limbs, extinguishing pulse or floating scattered pulse without root, it is yang depletion syndrome which is caused by the sudden loss of yang. T h e yang fails to consolidate the body fluid and the body fluid gose out of the body. It is an extreme deficiency condition and maybe a fatal situation.
d. Yellow sweating: T h e perspiration is yellow. It is often accompanied by edema in head, face and limbs, heavy pain in all body, cold legs, dysuria, deep and slow pulse, etc. When diving or swimming just on sweating, the nutrient and defensive qi 108
are obstructed and the damp-heat steams in the internal, then there is
ell ow
sweating.
e. Fighting sweating: The patient shivers suddenly and then sweats all over the body. The condition occurs mainly in cold-attack diseases. It is the turning point of disease when the genuine qi fights against the evils. In that time, the evil is quite strong and the genuine qi is recovering. The genuine qi struggles with the evil, leading to fighting sweating. After sweating, if the fever abates, the breath is smooth, the pulse is weak but even, it is a good sign of recovering. While the disease condition is no change or even worse after sweating, it suggests deteriorating in which the genuine qi is defeated and the evil wins. If the body becomes cold and the pulse is extremely rapid or extinguishing, the patient is restlessness, that is fatal and the genuine qi is going to be exhausted.
If the fighting sweating is seen in surgical disease, one should take care for the pus-toxin attacking the viscera or tetanus.
f . Dying sweating: The sweating is constant and profuse. It is accompanied by spiritlessness, feeble breath, cold limbs, feeble pulse. In the condition, the primordial qi is escaping, the body fluid follows the primordial qi and makes sweating. It is a fatal condition of divorcing yin and yang and the yang escaping. It is called also the "depletion sweating". The dying sweating is seen in prolonged and severe disease. Plain Questions said: "There is dying sweating. Following the dying sweating is the death. " T h a t pointed out the dying sweating is a sign of dying.
B. Abnormality on Sweating Eocatiom: a. Hemihidrosis: There is perspiration in half of the body, maybe the left half, the right, the upper, or the lower. It is because the wind-phlegm or wind-dampness obstructs the whole or partial meridians of the half body and the qi, blood and body fluid could not distribute in the half body, then there is no sweating on the abnormal half of the body. It is seen in apoplexy, atrophy syndrome and paraplegia.
b. Head sweating: The sweating is seen only on the head or head and neck. The causes are the following four kinds. The first is the stagnated heat in upper-jiao which steams the head and makes sweating on head. The concomitant symptoms are flushed face, fidget, thirst, red tongue tip with yellow coating, rapid pulse, etc. The second is the damp-heat in middle-jiao which steams along meridians to head and leads to head sweating. It is frequently accompanied by the hidden fever, heavy body, chest distress, epigastric stuffiness, scanty urine, yellow and greasy coating, 109
etc. The third is the heat in blood chamber. Zhu Danxi said: "In condition of heat entering blood chamber, there are vexation and head sweating. " The fourth is the upwards floating of deficient yang. In prolonged disease condition, the body is weak and the yang is declined, the yin could not contain the yang, then the yang floats upwards and leads to head sweating. There are concomitant symptoms such as cold limbs, shortness of breath, feeble pulse'. If perspiration like oil is suddenly seen on head with dyspnea, it is an omen of yang depletion. Because the essential qi is exhausted and the yang and yin are divorced, the deficient yang escapes upwards to head, the body fluid escapes following the yang, then there is sudden head sweatIng.
c. Chest sweating: The sweat is seen only on the chest. It is due to over strain of heart. The worry impairs the heart and spleen and leads to deficiency of both the heart and spleen. The common concomitant symptoms are palpitation, poor appetite, abdominal distention, Lassitude, weak and thready pulse.
d. Sweating in the paam anad sole: The little sweat in palm and sole is normal. If the sweat is profuse, it is caused by the yin deficiency and yang hyperactivity, or stagnated heat in the spleen and stomach which evaporates body fluid and sends it to four extremities. In yin deficiency and yang hyperactivity conditions, there are concomitant symptoms of tidal fever, hectic cheek, vexation, red tongue tip with little coating, thready and rapid pulse. In condition of stagnated heat in the spleen and stomach, the concomitant symptoms are thirst, dry throat, poor appetite, constipation, dark yellow urine, red tongue with yellow coating, and rapid pulse.
e. Genital sweating: The profuse sweating in genital region belongs to dampheat in lower-jiao or kidney yang deficiency. Except the above aspects, the condition after sweating should be inquired. For example, the abatement of fever and smoothing of pulse after sweating means the relieve of exterior syndrome and is the sign of recovery. If the fever is abated slightly and rises high again after sweating, and the pulse becomes rapider, the tongue coating becomes yellow and dry, that means the evils have entered the interior. Some times, the sweating condition can be used to predict the prognosis. For example, Zhang Jingyue mentioned the six kinds of incurable conditions as follows: the first is the sweating with dyspnea; the second is the sweating with feeble pulse; the third is the severe general aching when sweating; the fourth is the profuse sweating making the hair wet; the fifth is the oil-like perspiration; the sixth is the pearl-like perspiration. Now, these conditions are not incurable, but they are still a
110
important.
3) Other Symptoms
Pain is the most common symptom in clinic. It can be in every part of the body. The pain in head, chest, abdomen and trunk is frequently encountered. The main aspects for inquiring about pain are the character and-location of pain.
A. Character of Pain The pain can be divided into deficiency and excess. The excess pain is characterized by sudden onset, severe and incessant pain, aggravated by pressing. It is caused by the affection of exogenous evils, qi stagnation, blood stasis, phlegm retention, parasitosis or food retention which obstructs the meridians and hinders the qi and blood movement. The deficiency pain occurs gradually and is dull and paroxysmal, and relieved by pressing. Besides the distinction of deficiency and excess, the pain character is different in accordance with the different cause and mechanism of disease.
a. Distending pain: The paroxysmal pain accompanied by distention in the same location is distending pain. It is caused by qi stagnation. T h e distending pain in epigastrium is due to the qi stagnation resulting from cold attack. The distending pain in chest and costal region is due to liver qi stagnation.
b. Slabbing Pain: The pain like being needled or prickled is called twinge or
stabbing pain. It is caused by the blood stasis. In this condition, the meridians are obstructed.
c. Colic pain: The severe pain as if the body being strangulated cut is named as colic pain. Because the solid evils obstruct vessels suddenly, qi and blood could not flow in vessel. That is the reason of colic pain. For example, the angina pectoris, one kind of the colic pain, is due to blood stasis in heart; the colicky pain in stranguria is due to the stone obstruction.
d. Retraction pain: The pain as if being pulled is called retraction pain. It is called also the radiating pain. The pain results from the malnutrition of tendons. Because the liver dominants tendons, the retraction pain relates mainly to liver diseases.
e. ScorclPilag pain: The pain just like being burned is called scorching pain or burning pain. The pain can be alleviated by cooling. It is mainly caused by the fire evil running in collateral.
f . Cold pain: The pain as if being frozed is cold pain or frozed pain. The pain 111
can be alleviated by warming. The cold evil in meridians or yang deficiency makes the viscera and meridians lack of warming and gives rise to the pain.
g. Hollow pain: The pain with feeling of vacancy is the hollow pain. It results from the deficiency of essence and blood which could not fill up the meridians,
la. Dull pain: The pain is lingering and mild. It is mainly caused by deficiency of qi and blood.
B.Location of Pain a. Headache The head is the confluence of all yang. The qi and blood in twelve meridians and 365 lines of collateral pour into the head. Therefore, all exogenous and endogenous diseases can lead to headache. There are divisions of deficiency and excess,of headache, If the course is short and the pain is serious and incessant, it is of excess syndrome. The paroxysmal headache with chronic course belongs to deficiency syndrome. The excess headache is caused by wind, cold, summer-heat, dampness, fire, phlegm or blood stasis which obstructs the meridians, or due to the heat evil which disturbs the orifice of head. If constant headache involves the nape and is accompanied by chill and fever, being aggravated by cold, it is due to wind-cold in the exterior. The headache with fever. sore throat and cough is caused by wind-heat. If the headache is due to interior fire, there must be symptoms reflecting the interior heat syndrome, such as fever, bitter taste in mouth, dry throat, vexation, flushed face, congestive eyes, dark yellow urine, dry feces, etc. Similarly, the headache due to phlegm is accompanied by symptoms of phlegm syndrome; the headache due to blood stasis by symptoms of blood stasis syndrome, and so on. The deficiency headache is mainly due to internal injury which leads to deficiency of qi, blood and body fluid and makes the brain empty. The lingering dull headache without chill and fever, aggravated by over-exertion, is due to qi deficiency in which condition the lucid yang could not go up to nourish the head. The headache with dizziness and pale complexion is due to nutrient qi and blood deficiency that leads to malnourished brain. Headache occurring in morning and stopping in evening belongs to yang deficiency, and vice versa. The different location of headache can indicate the meridians of disease. For example, headache in occiput radiating to nape is headache in Taiyang Meridian, because the Taiyang Meridian of Urinary Bladder goes from vertex into brain, then to nape, and goes down along the posterior head and nape to back: headache in fore*
112.
head is headache in Yangming Meridian, because the Yangming Meridian of Stomach goes through anterior margin of hair to forehead; headache in bilateral sides is headache in Shaoyang Meridian, because the Shaoyang Meridian of Gallbladder starts from lateral canthus and then goes along the bilateral side of head; the headache in vertex is headache in Jueyin Meridian, because Jueyin Meridian of Liver connects the eyes and the vertex; headache radiating to teeth and throat is headache in Shaoyin Meridian, because Shaoyin Meridian of Kidney goes along throat and tongue root. Headache with heavy sensation and diarrhea is headache in Taiyin Meridian, because the Taiyin qi flows rebelliously to head and leads to headache. Appendix : Dizziness Dizziness is also called vertigo. It means the dim and blurred vision and feeling of unsteadiness. The mild condition can be relieved by closing eyes and keeping calm for a moment. In the severe case, when looking, the patient feels surrounding things are whirling, and is unable to stand, even with nausea, vomiting, faint. In ancient time, there were two theories of "no phlegm no vertigo" and "no deficiency no vertigo". So the cause of dizziness can be classified into two groups. The dizziness of excess is caused by phlegm-dampness obstruction. The dizziness is accompanied by chest distress, nausea, vomiting with mucus. It is due to phlegm and dampness accumulating in the internal which makes the lucid yang fail to rise to head. There are three conditions of dizziness of deficiency. The first one is the ascendant hyperactivity of liver yang which is characterized by distending headache. flushed face, congestive eyes, bitter taste in mouth, tinnitus and taut pulse. The liver yang in hyperactivity goes upwards and transforms into wind. The wind disturbs the clear orifice. The second one is the deficiency of both qi and blood. The dizziness attacks after over-exertion or standing up suddenly. There are concomitant symptoms like pale complexion, palpitation and insomnia. It is due to the weak qi and blood which fail to nourish the brain. The third one is insufficiency of kidney essence. There are tinnitus, soreness and weakness of lower back and legs, seminal emission, poor memory etc. The insufficient kidney essence could not fill up the sea of marrow (brain) and that leads to dizziness. Symptoms of head also includes the distention and heavy sensation. Head distention is mainly due to turbid phlegm which covers the upper orifice. The heavy
sensation of head is often seen in brain deficiency. lnte?nal Classic said: "When 113 o
blood and qi is shortage, the head is heavy.
"
b. General Aching (Pantalgia) General aching is seen mainly in exterior syndrome of wind-cold or winddampness in exogenous diseases. The cold or dampness evil coagulates in meridians and obstructs the flow of qi and blood, that leads to pain. If infected by the exogenous pestilential toxin, the pain is severe and is accompanied by high fever, flushed face, and skin rashes. It is caused by the pestilential toxin which blocks the qi and blood. In internal injury diseases, if the disease implicates the bone, there is general aching. Pantalgia in prolonged disease results from the insufficiency and disharmo,ny of qi and blood. Appendix: Heavy Sensation of Wbole Body The heavy sensation of whole body relates to spleen deficiency and dampness. The heavy sensation with sleepiness, shortness of breath, lassitude, poor appetite and fatigue is due to insufficiency of spleen qi. The spleen qi is unable to produce essential material. That leads to malnourished muscle and limbs and to heavy sensation. The heavy sensation in head and all body with poor appetite, epigastric stuffiness, loose stool, greasy tongue coating is due to infection of dampness. The dampness is sticky and greasy and tends to encumber the yang and qi. The qi and blood disorder leads to heaviness.
e. Chest Pain The anterior part of the thorax is called chest. The chest belongs to upperjiao. It is the house of the heart and lung and the confluence place for pectoral qi. So, chest pain is mainly seen in diseases of the heart and lung. The heart yang deficiency, cold evil invasion, blood stasis, phlegm retention and the collateral damage due to fire can all make morbid flow of qi and obstruction of meridians in chest and lead to chest pain. Chest pain with distress, cough, asthma and expectoration of clear sputum is caused by the phlegm-dampness attacking the lung. The spleen deficiency leads to accumulation of dampness and phlegm which goes up and insults the lung. Chest pain with dyspnea, flaring nares, dark sputum and high fever is due to exorbitant heat in the lung. Because the exogenous wind-heat invades the lung, the lung fails to disperse and descend and is scorched. Chest pain with expectoration of pus and blood belongs to lung abscess. It is caused by the fire in lung which makes the flesh putrified and transformed into pus. 114
Chest pain with tidal fever. night sweating and hemoptysis belongs to lung yin deficiency in lung phthisis. The deficient fire burns lung collateral and gives rise to chest pain. Chest pain radiating to back and arm, or back pain radiating to chest is chest
blockage which results from the inactivity of yang in chest that leads to phlegm obstruction, or from the qi deficiency and blood stasis those lead to abnormal flow of qi and blood in heart vessels. The didtending pain in fixed region of chest with frequent sighs and irritability is due to qi stagnation and blood stasis which is caused by the emotional depression that leads to qi stagnation and then blood stasis. The stabbing pain in fixed region of chest with blue tongue or ecchymosis is due to blood stasis. The trauma makes blood stasis in collateral of chest. Stuffy chest with pain just below chest is chest block-up. In mild case, the pain is only at the region below chest and aggravated by pressing. In severe case, the pain is from chest to lower abdomen and the patient refuses even slight touch. It is accompanied by tidal fever in late afternoon.
Stuffy chest without pain, if accompanied by intolerance of cold, cough, foam sputum and slow pulse, is the cold stuffiness; if by aversion to hot, fidget, thirst, and rapid pulse, is the heat stuffiness; if by chest distress, uneven breath, frequent sighs and weak pulse, is the deficiency stuffiness; if by severe chest distress and profuse sputum and the patient beats the chest repeatedly, is the phlegm stuffiness. The hypochondrium refers to the bilateral regions of chest below the level of nipples. The inferior margin of ribs is called costal margin. The liver and gallbladder are located in right hypochodrium. The meridians of liver and gallbladder distribute in those regions too. So hypochondriac pain is mainly caused by diseases of the liver and gallbladder. For example, the distending pain in hypochondrium with frequent sighs belongs to liver qi stagnation which comes from the emotional depression. Burning pain in hypochondrium with vexation, irritability, flushed face and congestive eyes is due to blazing of liver fire which scorches the meridians. The fullness of chest and hypochondrium with alternate chill and fever belongs to Shaoyang diseases which is due to the combating between genuine qi and evils in the half-exterior and half-interior part. 115
The hypochondriac stabbing pain in a fixed location is caused by blood stasis in meridians resulting from sprain or falling down. Hypochondriac pain with epigastric distention, nausea, vomiting, yellow face and eyes belongs to jaundice which is due to damp-heat accumulation in the liver and gallbladder. Hypochondriac pain in one side with distention aggravated by cough belongs to suspending fluid-retention which is due to fluid-retention in hypochondriac region of chest.
e. Stomachache The upper half of upper abdomen is called epigastric region and is related to the stomach. The cold pain of stomach 'relieved by warming with intolerance of cold, cold limbs, vomiting of mucus is due to stomach cold. The cold evil which impairs stomach yang directly gives rise to the syndrome. I
The scorching pain of stomach with frequent hunger even after eating much food, foul odor in mouth and constipation is due to stomach heat. The exorbitant heat in stomach makes the hyperactivity of stomach to decompose food and consume up body fluid, then leads to the syndrome. The distending pain of stomach with belching aggravated by angry is due to liver qi stagnation which invades the stomach. The stabbing pain of stomach in a fixed location is due to blood stasis in the stomach which obstructs the meridians. T h e dull pain of stomach with likeness of being warmed and pressed, vomiting of water, decreased food intake is due to stomach yang deficiency, because the yang deficiency gives rise to cold and leads to a dysfunction of stomach to decompose food. The scorching pain of stomach with upset feeling, hungry without appetite, red tongue with little coating belongs to stomach yin deficiency, because the deficient yin leads to fire which disturbs the stomach. $
. Abdominal Pain
The lower half of the upper abdomen is called "big abdomen" and belongs to Spleen Meridian of Foot Taiyin. The medial part of lower abdomen is called "smaElli
abdomen" and is the region where the intestines, bladder, uterus and the meridians of spleen and stomach are located. The bilateral sides of lower abdomen is called
"junior abdomen" and is the region where the meridians of liver and gallbladder 116
pass through. The sudden onset of severe abdominal pain aggravated by pressing and food intake belongs to excess syndrome. T h e gradually occurrence of dull abdominal pain relieved by pressing and food intake is due to deficiency syndrome. T h e abdominal pain relieved by cooling is due to heat syndrome. That relieved by warming is due to cold syndrome. T h e pain surrounding the navel with stiff abdomen when palpating, thirst, vexation, fever and constipation belongs to fu-visceral syndrome of Yangming which results from the heat accumulating in the interior. T h e dull pain in "big abdomen" with poor appetite, likeness of being warmed, loose stool belongs to deficient cold of spleen and stomach in which condition the spleen fails in transportation and leads to undigested food in the body. The distending pain in "small abdomen" with scanty urine belongs to anuria or disuia which results from the dysfunction of urinary bladder. The stabbing pain in "small abdomen" with normal urine belongs to blood accumulation which is a syndrome of blood stasis in lower-jiao. The cold pain with pulling sensation in "junior abdomen" and radiating to genital region is due to cold coagulation in Liver Meridian in that condition the cold invades the meridian and makes the Liver Meridian contracted. The paroxysmal pain surrounding the navel with unfixed mass in abdomen is due to parasitosis. The pain in right lower abdomen aggravated by pressing belongs to intestinal abscess.
g. Lumbago The lower back is the house of kidney, so lumbago is mainly seen in kidney diseases. For example, the dull pain with weak back, seminal emission or premature emission, feverish feeling, constipation and dark yellow urine is mainly due to kidney essence deficiency which could not nourish the lumbus. The cold pain and heavy sensation in lumbus aggravated by cold or in cloudy climate pertain to colddampness which obstructs the meridians. The prickle pain in a fixed location of lumbus, even unable to turn, pertains to blood stasis which results in the blockage of meridian. If the pain implicates the upper back and nape, it is a disease of Foot Taiyang Meridian.
h. Pain of the Limbs
The pain of limbs a'nd joints is frequently seen in rheumatism due to exogenous wind, cold and dampness. Among them, that characterized by wandering pain is called migratory rheumatism. In this syndrome, the invasion is mainly made by the wind evil. Because the wind is good at wandering and changing, it leads a migratory pain. That characterized by severe pain is called painful rheumatism which is mainly due to the attack of cold evil. Because the cold is responsible for contraction and leads to coagulation of qi and blood, it makes the pain severe. That has a character of fixed location and heavy sensation and distention in the same limb is called fixed rheumatism which is mainly due to the dampness. Because the dampness has a character of sticky, turbid and heavy, the pain is in fixed location with heavy sensation. If the evils transform into heat due to staying for long, the joint is red, swelling and painful, and there are nodule and erythema in legs. It is the heat rheumatism.
4) Diet and Taste in Mouth By inquiring about the diet, we can know the prosperity and declination of the spleen and stomach. By the taste in mouth, we can know the viscera. The contents of inquiring about diet and taste in mouth include asking about the thirst and drinking, appetite and food intake and the abnormal taste in mouth.
A. Thirst and Drinking Thirst refers to the sensation of dryness in mouth. Drinking means the quantity of water being drunk. They are closely related. Generally speaking, if thirst, the patient drinks more than normal; while without thirst, the patient. does not like to drink. But the relation is not all the same. So the character, degree, quantity of water intake, preference to cold or hot water and the concomitant symptoms should be asked in order to distinguish syndromes. Water intake is one of the main source of body fluid. The feeling of thirst and the water intake are closely related to the wax or wane, and the metabolism of the body fluid. Through thirst or not and water intake we can know the nature of diseases and whether the body fluid is deficiency or in morbid metabolism. Zhang Jingyue said: "Thirsr or not can reflect the cold or heat o i the interior syndrome. The deficiency or excess can also be known from it.
"
a. No thirst: It reflects the normal body fluid. It is seen in cold syndrome or condition of no heat evil or deficient heat.
b. Thirst with profuse drinking and urine: If accompanied with much food intake and emaciation, it belongs to consumptive thirst disease; if with normal food *
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intake, it is the upper consumptive thirst. It is due to kidney deficiency or heart fire blazing. The kidney dominates water and controls the water gate. The kidney yin deficiency leads to yang hyperactivity, so the gate is opened more than being closed that leads to profuse urine and loss of body fluid, then there are thirst and big drinking. Thirst appearing after excessive sweating, drastic vomiting or diarrhea, or diuresis is due to over consumption of body fluid. In this condition, there is a need for supplement of body fluid.
c. Thirst but little drinking: The patient feels thirst and dry in mouth, but dislikes to drink or drinks little water. It belongs to mild loss of body fluid or disturbed metabolism of body fluid. It can be seen in syndromes of yin deficiency, damp-heat, phlegm, fluid-retention and blood stasis. Thirst but dislike to drink, accompanied by tidal fever, night sweating, hectic cheek, pertains t o y i n deficiency. Because the insufficient yin could not nourish the mouth, there is thirst; there is no excess heat to consume body fluid, the body fluid is slightly insufficient, so patient has not desire to drink. Thirst but little drinking, accompanied by heavy sensation of head and body, stuffy stomach, greasy tongue coating and hidden fever, belongs to damp-heat syndrome. Because the dampness produces heat and the heat impairs the body fluid, and because dampness obstructs the flowing and transforming of body fluid in middle-jiao, the body fluid fails to nourish the mouth, so there is thirst. Because the dampness obstructs the metabolism of body fluid, there is not desire to drink more. Thirst with preference to hot water, but could not drink more, or vomiting after drinking, accompanied by vertigo, cough, asthma, distention in chest, hypochondrium or epigastrium, gurgle in stomach, pertains to gastrointestine fluid-retention. The fluid-retention is a yin evil and impairs yang. The impaired yang could not transform body fluid into steam to moisten the mouth, so there are thirst and preference to hot water. Because the syndrome is a condition of morbid metabolism of body fluid without the deficiency of body fluid, patient drinks little. The fluid-retention makes stomach fail to descend, there is vomiting after drinking. If the patient is thirsty and only wants to rinse mouth without to swallow water, accompanied by blue tongue or ecchymosis in tongue and sluggish pulse, it is due to blood stasis. The blood stasis obstructs the qi movement. The body fluid could not be transformed into steam and be sent up, so there is thirst. It is a condition of morbid metabolism of body fluid without insufficiency of body fluid, so pa*
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tient dislikes to swallow water.
B.Appetite and Food Intake T h e stomach is responsible for receiving food and spleen for transformation and transportation. They are the acquired foundation of the body. Human body takes stomach qi as its root. So inquiring about the appetite and food intake can make us know the condition of spleen and stomach. That is important for judging the severity and the prognosis of the disease. T h e normal people liking cool food are yang-visceral people while those liking hot food are yin-visceral people. In patients, preference to cool food is due to internal heat while preference to hot food is due to internal cold.
a. Poor appetite: It is also called the "anorexia" . The patient loses the desire to eat, even becomes aversion to food. The frequently encountered conditions are: Poor appetite with little food intake, abdominal distention, loose stool, fatigue, pale tongue and weak pulse belongs to qi deficiency of spleen and stomach. It is caused by the dysfunction of spleen and stomach. It is seen in deficiency syndrome in prolonged disease or qi deficiency in ordinary time. Poor appetite with abdominal fullness, lassitude, loose stool and thick greasy tongue coating pertains to spleen encumbered by dampness. The dampness obstructs middle-jiao and makes the spleen fail to transport the food, so there is poor appetite. It is often seen in summer-heat attacking. Poor appetite with aversion to rich food, hypochondriac distention, yellow skin and eyes is due to damp-heat in liver and gall bladder. The accumulated damp-heat makes the liver fail in conducting qi. The stagnated wood over-restrains earth and leads to splenic dysfunction, so the appetite is poor. Aversion to food with abdominal distention, belching with fetid odor, thick and greasy coating belongs to food-injury. The over eating and drinking impair the spleen and stomach. The transporting and transforming functions of spleen are low, so patient feels aversion to food. The aversion to food in married women after stop of menstruation for several months, accompanied by vomiting and slippery pulse, pertains morning sickness. In pregnancy, the qi of Chong Meridian goes upwards rebelliously and makes stomach qi fail in descending. That leads to morning sickness. The severe cases should be treated with herbs of harmonizing and lowering down stomach qi and calming fetus. The mild cases belongs to normal reaction and can recover without treatment.
b. Overeratirag but still feeling hungry: The patient has an excessive appetite for 120
food and after a short time of meal the patient feels hungry again. The common conditions are : Overeating but still feeling hungry with thirst, vexation, foul odor in mouth, constipation, emaciation, red tongue and yellow coating is due to stomach fire. The stomach fire decomposes food rapidly and makes hypermetabolism, that leads to the symptoms. Overeating but still feeling hungry with diarrhea, emaciation is called "strong stomach and weak spleen". Because the stomach decomposes food rapidly, there are overeating and hungry; the spleen fails to transform and transport, so there is diarrhea.
e. Hunger without appetite: The patient feels hungry but dislike eating food or only eating a little. It is seen in stomach yin deficiency. There are concomitant symptoms such as upset and burning in stomach, red tongue with little coating, thready and rapid pulse, etc. The stomach yin deficiency leads to disturbance of deficient fire inside.
doFood addiction: The patient is addicted to some food or non-food things. It is called food addition. It is often seen as: Child is addicted to uncooked rice or soil and so on. If it is accompanied by distending abdominal pain, moving ball surrounding navel, emaciation, it is due to parasitosis. Because the unclean food leads to growth of parasite in body which causes spleen dysfunction and leads to special addiction to food. The addiction to sour food in married women after stop of menstruation, with nausea, rapid and slippery pulse, is due to pregnancy. It is not a symptom of disease but a physiological reaction. Symptoms relieved a little after taking food mainly belong to deficiency syndrome. Those aggravated by food can be seen in both deficiency and excess syndromes. The tiredness and sleepiness after meal are called "food drunk". It belongs to spleen and stomach deficiency. Inquiring about the dietary changes in the course of disease can help to know the developing tendency of diseases. If the appetite becomes better and food intake increases, it indicates gradual recovery of stomach qi; if the appetite turns to bad and the food intake decreases, it shows the declining of stomach qi. If the very poor appetite in a patient of chronic severe disease turns suddenly to good appetite and eating much, it is an omen of dying stomach qi and is called "removed middle-qi" . It pertains to false vitality. The stomach qi exhaustion will certainly lead to death. It 121 *
is a presymptom of death.
C.Taste in Mouth The taste in mouth refers to the morbid taste in disease. Because the morbid taste in mouth is often the reflection of visceral diseases, questioning the change of taste is helpful for diagnosing visceral diseases. In common condition, in the initial stage of exogenous diseases, the taste is usually normal and without aversion to food; in disease resulting from over exertion and improper food, patient often feels aversion to food and absence of taste. So, according to the diet and taste changes we can ascertain whether the disease is exogenous or endogeneous.
Tastelessness belongs to qi deficiency of spleen and stomach. Because of hypoactivity of spleen and stomach, the patient feels lack of taste and poor appetite and eating little.
Sweet taste in mouth with sticky feeling of mouth is due to damp-heat in spleen and stomach. The sweet enters spleen. When damp-heat invades spleen, the sweet is compelled and goes up to mouth, so there is sweet taste in mouth, and even with sticky feeling.
Sour taste: One of them pertains to heat accumulation in liver and stomach. The sour enters liver. When heat is in liver, the sour has to go up to mouth and leads to sour taste. Another is due to improper food intake. The improper food intake impairs the spleen and stomach and leads to food-retention in middle-jiao. Those makes the turbid qi in stomach flow up to mouth and leads to a sour taste and putrid odor in mouth.
Bitter taste: It belongs to heat syndrome in fire diseases and gallbladder-heat syndrome. The bitter enters the heart. The heart belongs to fire. T h e bile is bitter. So, fire blazing or bile overflowing due to gallbladder heat can produce salty taste in mouth.
Salty taste: It belongs to kidney disease and cold syndrome. The salty enters the kidney. The kidney dominates water. So, kidney diseases and cold-water flowing can all lead to salty taste in mouth. In addiition, the different addictions to food of some tastes are caused by diseases in different viscera. For example, liver disease produces addiction to sour food; heart disease leads to addiction to bitter food; spleen disease makes addiction to sweet food; in lung diseases, the patient is addicted to pungent food; and in diseases of kidney, the patient likes salty food. The difference of living and diet habit can also lead to addiction to some tastes. That could not be treated as diseases. *
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5) Defecation and Urination It refers to inquire about the changes of defecation and urination. The defecation is controlled directly by the large intestine, however it is also closely related to the transporting and transforming functions of spleen, the conducting function of liver, dispersing and descending functions of lung and the warming function of kidney fire. The urination is dominated by urinary bladder, and is related to the descending of lung, transforming of kidney and the regulating of triple-jiao. So, the defecation and urination are the important aspects for diagnosis. Zhang Jingyue said: "The defecation and urination are the outer showing of the body. No matter what diseases they are, they should be inspected so as to know the nature of disease.
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A. Defecation The normal people defecate every day or every other day. The defecation is smooth. The stool is moist and in certain form. There is no pus or blood, mucus, undigested food in it. The content of inquiring about defecation is the form and color of stool, the feeling and frequency of defecation.
a. Stool Form The dry stool in dark color is usually due to heat in large intestine. The extremely dry and hard stool is often seen in deficiency of blood and body fluid, after delivery of women, or not recovered qi and blood after severe disease. Loose bowel with shapeless stool is usually due to deficient cold in spleen and stomach which results in the dysfunction of transporting and transforming. The condition with hard stool first and loose stool then is due to dampness from spleen deficiency. Alternate dry and loose stool in irregular way is mainly due to liver stagnation with spleen deficiency, namely, the disharmony between liver and spleen. The stool with completely undigested food is caused by kidney yang declining which fails to warm the spleen yang. The yellow mucus stool is mainly due to damp-heat in large intestine or due to heat-fecaloma in intestine. In that condition there must be stiffness and pain in epigastrium or abdomen. The stool with partly digested food and putrid odor is mainly caused by improper food intake which leads to food retention. The pus and bloody stool with tenesnius belongs to dysentery.
beFrequency of Defecation
Constipation: less frequency of defecation, even per several days, with dry stool and difficulty to discharge, is called constipation. It is usually due to heat accumulating in intestines or the slowed transportation in intestines resulting from 123
insufficiency of body fluid. Constipation with high fever, abdominal distending pain, red tongue with yellow dry coating pertains to excessive heat syndrome. The heat consumes body fluid and accumulates in intestines, then leads to the syndrome. Constipation with pale complexion, preference to hot drinking, pale tongue, deep and slow pulse is due to cold. The cold accumulates in intestines and obstructs the flow of qi, then obstructs the moving of stool. Constipation with hectic cheek, tidal fever, red tongue and little coating, thready and rapid pulse belongs to yin deficiency. The deficient yin and body fluid could not moisten the intestines and lead to constipation. Constipation in chronic disease, aged people or women after delivery is mainly due to deficiency of both qi and body fluid. There is not enough body fluid t o moisten intestines, so, the stool is dry; the weak qi could not promote the movement of intestines, so the defecation is difficult. Those lead to constipation.
Diarrhea: It is a condition that the stool is watery and shapeless with frequent defecatioii. Diarrhea is mainly caused by the attack of exogenous evils, injury due to improper diet, yang deficiency of both spleen and kidney which make the water decend and dysfunction of intestines. The fulminant case of diarrhea usually belongs to excess or heat syndrome, and the chronic case to deficiency or cold. Diarrhea with loose stool, poor appetite, abdominal distention and dull pain in "big abdomen" pertains to spleen deficiency. T h e transporting function of spleen is impaired, so the water goes into intestines directly and leads to diarrhea. The patient feels abdominal pain at dawn, and then defecates with watery stool. After defecation the abdominal pain disappears. There is cold and sore feeling in lumbus and legs. It is due to the declining of life-gate fire which could not warm the spleen and leads to spleen dysfunction. T h e dawn is the time of weakest yang, so diarrhea occur Diarrhea with stuffy stomach, eructation with putrid odor, abdominal pain relieved by defecation pertains to food-impairment which is caused by the over eating or drinking, or contaminated food that impairs the spleen and stomach. When the retained food is discharged, the abdominal pain relieves. Diarrhea with abdominal pain relieved by defecation and depression belongs to the over-restrained spleen by stagnated liver. The stagnated liver qi invades the spleen and leads to diarrhea. G. CoBor
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off Sto~E1
T h e dark yellow stool is usually due to stagnated heat in intestines. Black stool like tar is due to blood stasis and is called "far bleedingJJ.Red blood in stool is called "near bleedingn. The red (blood) and white (pus) stool pertains to dysentery resulting from damp-heat in large intestine. The grayish white stool is seen in jaundice of damp-heat. T h e color of stool is often affected by the food and drugs. These should be asked carefully.
d. Feeling in Defecation Hot and burning sensation of anus: T h e hot and burning feeling of anus in defecation is due to damp-heat in large intestine which puts force on anus. Unsmooth defecation: The stool is loose and sticky, but difficult to be discharged completely. It is due to damp-heat in large intestine which makes qi flow obstructed. If accompanied by abdominal pain, it is due to stagnated liver which over-restrains the spleen and obstructs the qi flow of intestines. Tenesmus: Patient feels paroxysmal abdominal pain and heavy sensation in anus, and is always urgent to defecate. It belongs to dysentery. The damp-heat obstructs the qi flow of intestines and leads to tenesmus. Fecal Incontinence: The patient could not control the defecation and the stool is discharged out spontaneously. It is caused by prolonged diarrhea or physical declination in aged people. The qi deficiency of spleen or yang deficiency of both spleen and kidney leads to loss of control of anus. If it is caused by prolonged diarrhea, it is called "incontinence of diarrhea". Sagging feeling in anus: The patient feels something sagging from the inner body to anus. In sever case, prolapse of rectum occurs. It belongs to sinking of middle qi.
B. Urination The urine comes from of body fluid. The production of urine is closely related to the transforming functions of lung, spleen and kidney. A normal people passes urine 4 to 6 times in day time and 0 to 1 time at night. The amount of urine in a day is about 1500 to 2000 ml. The times and amount of urination are influenced by the drinking, air temperature, sweating and age. By questioning the urination, we can know not only the state of body fluid, but also the state of lung, spleen, kidney and urinary bladder. The morbid changes of urination include :
a. Amount of Urine The disease of excessive urine is attributed to kidney and mainly due to kidney *
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a
yang deficiency which fails to, transform body fluid and body fluid flows down. For example, the clear and profuse urine with intolerance to cold belongs to cold syndrome of kidney yang deficiency. In cold condition, the body fluid is not consumed and has to flow down to become urine, so the urine is clear and profuse. If it is accompanied by thirst, drinking a lot of water, it belongs to consumptive thirst which is caused by kidney yin deficiency that makes more opening than closing of the water gate. T h e scanty urine can be caused by exorbitant heat, or over sweating, vomiting and diarrhea, which consume the body fluid. It is often seen in yang deficiency of lung, spleen and kidney because of being unable to transform body fluid and lead to water-dampness retention. The urine of the former is dark yellow. T h e latter is accompanied by edema. b. Frequency of Urination T h e frequent urination with urgency and dark yellow urine in small amount belongs to stranguria which is caused by the damp-heat in lower-jiao that leads to dysfunction of urinary bladder. T h e frequent urination with clear urine pertains to failure of kidney qi in consolidation. T h e increased nocturnal urination with clear urine is seen in late stage of kidney disease or aged people. It is due to kidney yang deficiency which could not control the water discharge.
Dysuria and Anuria: T h e dysuria is a condition of urination in a way of dripping due to difficulty in passing water. T h e anuria refers to absence of urine discharged even though there is an urge of urination. Those of excess are due to the obstruction of urinary bladder which is caused by damp-heat pouring down to urinary bladder, or by stone and blood stasis. Those of deficiency are due to kidney yang deficiency that leads to dysfunction of urinary bladder.
e. Color s f Urine T h e color of urine is related to the cause and nature of disease. T h e normal urine is light
ell ow
and transparent. T h e yellow urine belongs to excessive heat
and the clear urine to deficient cold, T h e turbid urine is mainly due to damp-heat pouring down or turbid essence discharged. T h e red urine pertains to collateral impairment due to heat. T h e profuse milky urine with drinking a lot of water belongs to consumptive thirst. T h e clear urine in exogenous disease means the evil has not yet entered the interior. If urine becomes clear in warm diseases, it means the dis0
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0
eases will be cured. Some drugs can change the color of urine. That should be inIn jaundice, the color is an index of change of disease. The Secret Record of an
Official said: "Soaking a little cloth in the urine got at night. Recording the change of the color of the cloth every day. The gradually fading of the color means the cure of disease. " According to the record, the diagnostic method of observing color of urine appeared in the 4th century. It is the earliest record of experimental diagnosis in the world. d. Feeling in Urination
The urethral pain when urination with feeling of urgency, difficulty and burning belongs to stranguria which is caused by damp-heat which pours down to urinary bladder and leads to dysfunction of urinary bladder. T h e hollow pain after urination is mainly due to declining of kidney qi. T h e dripping of urine after micturation pertains to kidney qi failing to consolidate urine. It is frequently seen in aged patients.
Urinary incontinence is the loss of control of urination in conscious state and the urine is discharged spontaneously. It belongs to kidney qi failing to consolidate urine and dysfunction of urinary bladder in containing urine. If it is in coma or delirium, it is a fatal sign of expiring kidney.
Enuresis is the spontaneous micturition in sleep with good control of urination in awoken state. The enuresis in child is due to immature or kidney qi insufficiency. That in adult is due to kidney qi failing to consolidate urine, deficient cold in lower-jiao or primordial qi deficiency.
6 ) Sleep The state of sleep is related to the movement of defensive qi and the variation of yin and yang. It was pointed out in Spirit Pivot: "The hiding of yang and flourish of yin lead to sleep; while the hiding of yin and flourish of yang lead to awakening. " That is to say, the defensive qi moves in yang meridians in day time and keeps the body awaked; at night the defensive qi enters yin meridians and makes body sleeping. When diseases makes the disharmony between yin and yang, the prevalent yang and declined yin lead to insomnia and the prevalent yin and declined yang to sleepiness. When inquiring about sleep, the sleeping time,-state of sleeping and the concomitant symptoms are the main points.
Insomnia is named "sleeplessness" too. It refers to the difficulty to get to sleep and being easy to be awaked, even no sleep all night. There are four frequently encountered types as follows. a. The patient is difficult to fall asleep and can only keep asleep for a short time. It is accompanied by vexation, profuse dream, tidal fever, night sweating, sore and tired waist and limbs. That is due to disharmony between the heart and kidney. The disharmony is caused by exorbitant heart fire and insufficient kidney water. Those result in the loss of exchange between the heart and kidney. The insufficiency of water, fire blazing, yin deficiency or yang exorbitance disturbs the mind in heart. b. The patient is easy to get to sleep but easy to be awaked. After awaked, the patient is hard to get to sleep again. The concomitant symptoms are palpitation, poor appetite, lassitude, pale tongue and weak pulse. It pertains to deficiency of both heart and spleen. The worry and pensiveness impair the spleen, T h e spleen could not transform and transport the food essence. Then the blood supply is not enough. The heart is lack of blood and the mind in heart is malnourished. The insomnia is caused. c. The patient is frequently awaked by fright. The concomitant symptoms are vexation, timid, bitter taste in mouth, vertigo, chest distress, nausea and vomiting. It
pertains to gallbladder stagnation with phlegm disturbance. The emotional de-
pression transforms into fire and produces phlegm. The phlegm and fire disturb the gallbladder. The gallbladder is a clean organ. If disturbed, it will lose its calm, leading to insomnia. d. The patient is restless and sleepless at night. The concomitant symptoms are epigastric stuffiness, belching, abdominal distention, thick and greasy coating. It belongs to food retention. The improper diet impairs, the spleen and stomach and the stomach qi can not descend. The turbid qi goes up and disturbs the mind in heart, then leads to insomnia.
B.Sleepiness The sleepiness is also called somnolence. The patient feels tiredness and sleepy;Although having a long time sleep, the patient still feels lack of sleep, even can not help falling asleep at any time and place. There are four frequently encountered types. a. Sleepiness with dizziness and heavy sensation of head and body, abdominal distention, loose stool, poor appetite, greasy coating and soggy pulse belongs to a
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damp-phlegm encumbering the spleen. It is due to the infection of summer-heat, or dampness accumulation in ordinary time that leads to dampness encumbering the spleen. The lucid yang fails to ascend. The head looses its nutrient. Then there is sleepiness. b. Sleepiness aggravated after meal with poor appetite, fatigue and shortness of breath pertains to spleen qi deficiency. He Xichi said: "Drowsiness after meal is due to spleen deficiency. The spleen can not transport food. That leads to the static state of body. If quiet, one feels drowsy. "Because of the qi deficiency of spleen, the lucid yang could not go up to supply the head and that leads to sleepiness. c. Sleepiness in a weak body with intolerance to cold and lying down in curved position belongs to yang deficiency of both heart and kidney. It is seen in aged patients or Shaoyin syndrome in cold-attack diseases. The yang deficiency leads to yin cold and lower function of the body. Those lead to sleepiness. d. Lethargy or stupor with delirium, high fever at night, crimson tongue, rapid pulse, or eruption pertains to heat in pericardium, nutrient-phase or blood-phase syndrome in warm diseases. The extreme heat encumbers the mind and leads to lethargy. '3) Women Diseases
Women are characterized by the menstruation. vaginal discharge, pregnancy and childbirth in physiology. So, there are special diseases in women. The diseases suffered by women are frequently related to the above mentioned physiological characters. For women patients, these aspects should be questioned in diagnosis.
A. Menstruation Menstruation is an unique physiological phenomenon of mature women. The menstruation begins in 14 years old in a healthy woman. The first menstruation is called menophania. The menses appears once a month (exactly once for each 28 days). The ancients described its appearing as the wax and wane of the moon or
.
tide. So it was also called "month-signalpor "month-water" The lasting time is 3 to
7 days. The blood of menses is dark red, moderate in thickness, without solid blood. The amount of menses blood is about 50 to 100 ml. In about 49 years old, the menstruation finishes. That is called menopause or menostasis. During or before the mense, the woman can feel slight distending pain in breasts, sagging distention in lower abdomen, soreness in lumbus, tired limbs and vertigo, etc. The symptoms can disappear spontaneously after mensetruation. In few young women, the menses could not appear in the fixed time after menophani129
a*It is due t o weak kidney qi which is unable to fill up the Chong and Ren Meridi-
ans. When near the menopause age, there may be vexation, dizziness, palpitation, hot flash in face and insomnia. They are not serious and can disappear spontaneously and need not treatment. The menses appearing once each two months in a healthy woman are called "bimonthly menstruation" . The menses once each three moiitli are called "seasonal menstruation". The menstruation once a year are called "annual menstruation". That is no menses all life but can be pregnant is called "hidden menstruation". In pregnant and breast feeding period. there should be no menstruation. The regular menses in a pregnant wpmen is called "pregnancy menstruation". The menses is seen in some breast feeding women. Those are special physiological phenomena and do not belong to diseases. Inquiring about the menses is the indispensable content for diagnosing diseases of woman patient. The circle, amount, color, quality of menses and concomitant symptoms should be asked in detail. If necessary, the date of last menstruation, meiiopharia and menopause should be asked for diagnosis.
a. Irregular menstruation: It refers to the disorder of menses in their circle and is often accompanied by the morbid changes of the color, amount and quality of the menses blood.'It is divided into three type: preceded menstruation, delayed menstruation and irregular menstruation. Preceded menstiuaticpn: The menses circle is shortened by more than seven days. If the blood is bright red, thick and profuse or is normal, it is mostly due to the heat in blood which results from heat evil invasion. The heat makes the blood loss of its control. If the blood is light red, thin and in large amount, it is caused by qi deficiency. The weak qi could not confine blood within vessels and blood flows out of the vessels. Delayed mewstruatioaa: The menses circle is enlarged by more than seven days.
If the blood is light colored, thin and little in amount, it belongs to blood deficiency. The blood is too little to fill up the Chong and Ren Meridians. If the blood is dark purple with ciots and iittie in amount or is normal, it is due to cold which coagulates the qi and blood. If the blood is deep red with clots and scanty, it belongs to blood stasis resulting from qi stagnation.
Irregular menstruation: The menses is sometimes preceded and sometimes delayed, The difference between two linked circles is more than seven days. If the blood is purple with clots in it, the amount changes little or none, and accompanied 130
by distending pain in breasts, it is due to qi stagnation resulting from liver dysfunction. If the blood is light red and thin, it belongs to deficiency of both spleen and kidney which leads to dysfunction of Chong Meridian and Ren Meridian. If there are clots in the blood and with dysmenorrhea, it is due to blood stasis.
b. Dysmenorrhea: The abdominal pain, even unbearable, happening in menstrual or premenstrual period or after menstruation is called menstrual abdominal pain or dysmenorrhea. The distending pain in lower abdomen happening before menstruation and relieved after menstruation belongs to excess syndrome. It is due to liver qi stagnation resulting in obstruction of blood circulation. T h e dull pain in lower abdomen after menstruation with sore lumbus and legs pertains to deficiency syndrome which is caused by insufficiency of qi and blood, or kidney essence deficiency, those lead to malnourished Chong Meridian, Ren Meridian and uterus
. If
cold pain in
lower abdomen happens in menstrual period and is relived by warming, and the blood is dark purple, it belongs to cold syndrome. The cold evil coagulates blood in meridians and leads to contraction of uterus that leads to the pain.
c. Amenorrhea and scanty menses: If the menses dose not come in a mature woman, or the menstruation stops for more than three months, it is amenorrhea. The former is mainly due to congenital deficiency that leads to dysfunction of Chong and Ren Meridians. It should be distinguished from the "hidden menstruation". T h e latter can result from many causes such as blood stasis, liver qi stagnation, blood deficiency, kidney essence deficiency, etc. The cause can only-be identified by inquiring about changes before amenorrhea and other symptoms. In addition, amenorrhea should be distinguished from the menses stop due to pregnancy, breast feeding and menostasis by asking about the date of the last menstruation and the age. The scanty menses refers to the condition that menses blood is less in amount than that of average. It could be caused by insufficiency of essence and blood, phlegm, dampness, blood stasis and cold, etc. dl. Metrorrhagia and metrostaxis: The massive vaginal bleeding is called metr-
orrhagia. T h e constant vaginal bleeding in a small amount is called metrostaxis. They are related to each other. It is said: "The metrostaxis is the begin of metrorrhagis and the metrorrhagis is the serious case of metrostaxis.
"
If the blood is dark red with clots, it is mainly due to heat, That in pink and without clots is often due to impairment of Chong and Ren Meridians, or failure of a
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spleen to confine blood in vessels resulting from sinking of the middle qi.
B.Vaginal Discharge There is little odorless white mucus in the vagina of healthy women. If it is too much or in abnormal color, quality and odor, it is morbid. The white, thin and odorless vaginal discharge in a large amount is called Leuk-
orrhea or white vaginal discharge. It pertains deficient cold syndrome and is due to cold-dampness pouring down which is caused by spleen deficiency. The yellow, thick, fetid vaginal discharge in a large amount, accompanied by genital itching, is called yellow vaginal discharge. It is due to damp-heat. The dampness produces heat and flows down to lower-jiao. That leads to the yellow vaginal discharge. The red and thick vaginal discharge with slight fetid odor is called red vaginal
discharge. It is caused by depression. The depression makes liver qi stagnation which transforms into heat. The heat impairs the collateral and blood goes out. The red vaginal discharge in a large amount after menopause or multicolored discharge with putrid odor is likely due to cancer. A thorough examination should be carried out.
C.Pregnancy In a married woman, if the menstruation stops and there is no other abnormal sign, and the pulse is slippery, it may be of pregnancy.
Morning Sickness: It is characterized by aversion to food, nausea and vomiting, even unable to eat in a pregnant woman. If it is accompanied by fatigue, tastelessness and abdominal distention, it is due to stomach qi deficiency in ordinary time. After pregnancy, the qi of Chong Meridian lashes upwards and makes the stomach qi disharmony. If it is accompanied by depression, irritability, bitter taste in mouth and acid regurgitation, it is often due to liver stLgnation which transforms into fire. The fire invades the stomach. If it is accompanied by epigastric stuffiness, nausea and vomiting of mucus, it is due to phlegm which leads to stomach disharmony.
Pertuirbationa of fetus: The frequently perturbing of fetus and sagging pain in lower abdomen means threatened abortion. It is caused by the spleen deficiency, and/or anger which injures the liver, trauma or sprain, or affection of the windcold, etc. It is the predromal symptom of miscarriage.
Leakage of fetus: It is characterized by vaginal bloody fluid leaking in pregnant woman with lumbago, sagging pain in lower abdomen. It is also named &leaking a
132
uterus". If it is not treated in time, the abortion is unavoidable.
If the leakage of fetus is accompanied by dark complexion, vertigo, tinnitus and frequent urination, it is due to kidney deficienct failing to consolidate the Chong and Ren Meridians. If it is accompanied by pale and lusterless complexion and fatigue, it is due to qi and blood deficiency which could not afford the fetus. The leakage of fetus after falling or sprain is due to the impairment of Chong and Ren Meridians.
Eelamptism: It is characterized by lock jaw, stiff back, even opithotonus, convulsion, coma which are relieved after a moment and repeated attack. It is also called "pregnant epilepsyJ'or "fetal epilepsy" and is due to wind-phlegm which goes up with fire.
Pregnant edema: The edema starting from feet and developing to whole body in pregnance with scanty urine, chest and abdominal distention is named pregnant
.
edema or "fetal qi" It is due to deficiency of the lung and spleen.
D. Symptoms after Delivery a. Lachiorrhea: The dripping of bloody vaginal secretion lasts for more than 20 ,
days after childbirth is called lochiorrhea.
If it is characterized by massive thick lochia in deep red with flashed face, thirst, constipation and yellow urine, it is caused by blood heat.
If the lochia is purple with clots, accompanied by prickle pain in lower abdomen aggravated by pressing, bluish purple tongue or ecchymoses, it is due to internal blood stasis.
If the lochia is profuse, light red and thin, accompanied by fatigue and shortness of breath, it is due to deficient qi sinking.
b. Postpartum fever: The fever after delivery can be caused by the interior affection of the exogenous evil, internal fire blazing or fire due to yin deficiency, etc. Postpartum fever with symptoms of exterior syndrome like chill and headache is caused by exogenous evil. The high fever after delivery with vexation, thirst and drinking cold, constipation and yellow urine is due to internal fire blazing. Postpartum lower fever with abdominal dull pain, dizziness, pale complexion and dry stool is due to yin deficiency which leads to internal heat.
8) Disease in Children It is difficult to question children because of their inability to describe the dis133
ease condition clearly by themselves. T h e disease condition is obtained by inquiring the parents or nurse of the child. T h e special characters of child in physiology and pathology should be inquired besides the other aspects of interrogation. T h e children are characterized by tender viscera, rapid growth, tender yin, tender yang, and immature nerve system. So the diseases of children are characterized by sudden onset, changeability and tending to be deficiency or excess. When asking about disease of children, the following aspects are important. a, The condition after birth: T h e diseases of new-born (the child of not more
than one month after birth) are mostly related to the congenital factors or childbirth. T h e questioning should be put mainly on the body condition of the mother, the nutriture and health status of the mother in pregnancy; If there is difficult labor or premature labor, the nutriture and health status of the mother in breast feeding period are also asked. Those are helpful for knowing the condition of the child. Children grow rapidly below 3 years old and need a lot of nutrient. So the diseases of children are closely related to the nutrition and function of spleen and stomach. T h e feeding and developing condition should be asked.
b. The history of vaccination, ilrafectiasus diseases and the contact with
infeetilous diseases: When a child is more than six months old, the congenital immunity is lost and the acquired immunity has not developed. So the immunity in this period is weak and child is easy to suffer infectious diseases such as chickenpox and measles. For that reason the history of vaccination, infectious diseases and the contact with infectious diseases should be known. If the child has suffered some infectious disease that leads to eternal immunity, the disease should be excluded when diagnosing. T h a t is helpful for quick diagnosis.
c. %he special causes of children diseases: Because the nervous system of children is not fully developed and the temperature regulating function is poor, the
Because of the weak spleen and stomach with lower digesting function, . . diseases of vomiting, diarrhea, abdominal distention or n;alni;:r;:;on are freil~eailji resulting from the improper diet. So the feeding and food intake should also be inquired. Because the adaptive capacity of children to the circumstance is subnormal, the children are apt to suffer exogenous diseases. So the living condition of the children should be questioned.
Chapter 5
Palpation
Palpation includes pulse examination and body pressing-touching. They are diagnostic methods that doctor uses his tactile sensation of fingers and palm to touch patient's body to get diagnostic data. Pulse' examination is to feel the pulse while body pressing-touching is to touch and press the different parts of patient's body such as skin, hands and feet, chest and abdomen and so on.
Section 1 Pulse Examination Pulse examination is to judge diseases by means of using doctor's fingers to palpate patient's pulses which are shown in the superficial arteries. It is an unique diagnostic method of TCM. All ancient doctors paid great attention to it. Pulse examination is also named pulse-palpating, pulse-feeling, pulse-touching, pulse-reading or pulse-taking, etc. Pulse-taking is a common used term among them. Yang Shangshan gave the terms a clear statement in his Comprehensive Notes to the Yellow Emperor's Internal Classic: "Taking is to cut. Touching pulse by hand to separate the favorable condition from unfavorable condition of diseases is cutting. Searching pulse is to take pulse by two hands. T h e doctor can focus his mind on pulse beating. So we call it reading and searching pulse.
"
According to that
statement, pulse-taking is to touch pulse by hands and then to understand and judge the disease condition through the process of comprehension. T h e Chinese character
'a$"
was written as "J@" in ancient time. Its meaning is
that pulse flows like water flowing. After Song Dynasty, it was written as "jJ$". The Hejian's S i x Books gave an explanation of it: "The character is composed of the flesh (/%J) and forever
(7k).When
body gets the genuine qi, the blood, flesh.
tendons and bone will growth prosperously. T h e growth depends on the qi. It can make body last for long. So the character is written as flesh and forever.
"
T h e substance of pulse is the blood and the power of pulse is the qi. Because the heart dominates blood and vessels, the heart pumps qi and blood into all parts of the body through vessels. The qi and blood circulate incessantly. They enter zang and fu-viscera inward and reach limbs and skin outwards. Besides, the qi and blood circulation also depend on other viscera which coordinate the heart. T h e lung 135
meets all vessels. The qi and blood circulating all over the body should converge into the lung. Because the lung dominates qi. The blood circulation depends on the dispersing of lung qi. T h e spleen and stomach are the source of qi and blood. The spleen also controls blood flow. The normal flow of blood needs the controlling function of the spleen. The liver stores blood and is in charge of conducting. It regulates the circulation volume of blood. The kidney stores essence. The essence can transform itself into blood. It is one of the basic material for blood production. The essence can also change into qi. It is the root of yang-qi and the source of all energy of the body. And only through the vessels, all visceral qi can play its role fully in all parts of the body. Therefore, we can know the visceral state and the disease condition by means of pulse-taking. T o sum up the ancient documents, the significance
of pulse examination is as follows:
A. T o recognize the exterior and interior of disease: Although there are many kinds of diseases, they c a n be classified into the exterior and interior syndromes as the location of disease. The level of pulse can reflect the depth of disease location.
If pulse is floating, the disease is usually in the exterior. While pulse is deep, the disease is in the interior. B. T o judge the deficiency and excess: T h e deficiency and excess refer to the balance and increasing or decreasing of the genuine-qi and the evil in the combating. Xu Lingtai said: "The main point of deficiency or excess can not be out of the pulse. " The weak pulse such as thready pulse and feeble pulse shows the deficiency syndrome of the genuine-qi shortage, while the strong pulse like slippery pulse and surge pulse exhibits the excess syndrome of exorbitant evils.
C. T o ascertain nature of disease: The nature of disease can be divided into types of cold and heat. Their treatment principles are quite different. The rate of pulse beating can reflect the nature of disease. For instance, slow pulse usually belongs to cold and rapid pulse is mainly due to heat.
D. T o identify cause of disease: Doctors of TCM pay attention to seeking disease cause when making diagnosis. One of the main aims of syndrome differentiation is to find disease cause. By means of pulse-taking, sometimes, we can find out the disease cause. For example, in cold-attack diseases, if the pulse is floating and tight, it is due to cold evil; and if the pulse is soft, the cause is wind. In endogenous diseases, if the pulse is slippery, it is often caused by phlegm; and if pulse is uneven, blood stasis is suggested.
E. T o inspect the disease mechanism: The development and change of a disease 136
*
bring some difficulties to the treatment. The advantage of treating disease according to syndrome differentiation lies ir. the corresponding change of treatment method to the syndromes which are recognized in time. Pulse condition can reflect the changes of disease to a certain degree. For example, if the pulse in left guan portion is taut and that in right guan is weak, it means the exorbitant liver over-restrains the spleen. When this pulse conditions are shown in a patient suffering from liver disease, we should inspect not only the liver, but also the spleen. Therefore, the treatment can be adjusted according to the changing condition of disease.
F. T o predict the prognosis: Pulse taking is important for the inference of prognosis. For instance, when disorders of blood and qi precede the appearance of symptoms, the pulse changes first. At that time, the latent disease can be predicted by pulse reading. So, treatment can be applied in time. From paradoxical pulses or intermittent pulses, we know the disease is severe and the prognosis is not good. The appearance of soft pulse in chronic disease means the restoring of stomach qi and recovering of disease. The yang pulse like surge and strong pulse in severe case or deficiency condition means the critical condition due to exorbitant evil and declined genuine-qi, and a bad prognosis. Since ancient times, doctors have been paying great attention to pulse-taking and rich experiences have been accumulated. Nevertheless, there is limitation in pulse-taking. It should be applied in combination with other examining methods. Then correct diagnosis can be made. Generally speaking, pulse condition and syndrome are identical. For example, strong pulse presents in excess syndrome and weak pulse is found in deficiency syndrome. But there are also pulses which are not corresponding to the symptoms. At that time, we have to make diagnosis by attending to one aspect of them and neglecting the other aspect. In a word, only by combining pulse-taking with other diagnostic methods, we can improve the accuracy of diagnosis. It is just as Xu Lingtai said: "When we inspect the pulse and other symptoms separately, the benign or malignant could not be known. When combining all them, from the compatibility or not, the benign or the malignant can be ascertained. "
I. Locatiabns for Pulse Examination There are different locations for pulse taking. Three locations had been used, namely whole body selection, three-part selection and cunkou pulse location.
1.Whole Body Method T h e method of pulse location selection is recorded in the Internal Classic. It selected pulse locations in head (upper), hand (middle) and foot (lower). Each one is composed of three spots: the heaven, human and earth. So, the method is called "three parts and nine spots method". According to Internal Classic, if the disease occurs in a meridian, the qi movement in the meridian will be abnormal. So, we can diagnose disease by finding out the pulse different to the pulses of other locations. And then from the abnormal meridian we can know which viscera is affected. T h e three parts and nine spots are demonstrated in the following picture in detail.
Picture 6 @the upper part (Cunkou)
@upper (Taiyang) a m i d d l e (Shenmen)
'Ifline WEmoEe Body Pulse Selection
@middle (Ermen) @lower (Hegu)
Blower (Juliao) @the lower part
@middle (Qimen, Chongyang)
@the middle part
@upper
@upper (Wuli, Taichong)
@lower (Taixi)
O n feeling of those spots, internal Classic pointed out: " T o inspect the pulses in nine spots, the only one pulse smaller than others is abnormal, that larger than others is abnormal, that rapider than others is morbid, that slower than others is morbid, that hotter than others is abnormal, that colder than others is morbid. " That is to say, if only one pulse is different from others, the disease in the corresponding meridian can be confirmed. The more the abnormal pulses are found, the more severe the disease is. For example, the disease with abnormal pulse in three spots is more severe than that with abnormal pulse in only one or two spots. In the three parts, the middle and lower parts are more important. It was said: "The sudden slowed and accelerated rate of pulse in the middle part is the sign of dying.
"
In
critical cases, the pulse of lower part is more important. If all the pulse is abnormal, it was considered as the dying portent in ancient times. Because the method is over-elaborate and complex, and its diagnostic value is not more than that of other two methods, it is seldom used now.
2. Three-Bart-Method The method was mentioned in both Intel-nal Classic and Treatise on Cold-Attack. The Spirit Pivot said: "The cunkou pulse corresponds to the middle and the renying pulse to the exterior. " Treatise on Cold-Attack said: "If not taking renying and fuyang pulse as the reference for diagnosis. " This method appeared after the whole body selection method. It was listed as a normal diagnostic method in Eastern Han Dynasty. The pulse-feeling is applied to the three parts, the 7-enying, cunkou and fuyang. In fact, this method is the simplification of whole body method. It chooses one spot from each part. The spot of upper part is renying which is a point of Foot Yangming Meridian and is located at the pulsing place lateral to adam9s apple. By feeling it, we can know state of all yang-qi, fu-visceral qi or stomach qi. The spot of middlepart is cunkou which is on the line of Lung Meridian of Hand Taiyin and is located at the pulsing place of radial artery just above the wrist. The cunkou pulse can show all the yin-qi, zang-visceral qi or the qi of twelve meridians, because the lung dominates the qi of whole body. The spot of lower part is fuyang which is a point of Foot Yangming Meridian and located at the pulsing place on instep. It shows the state of stomach qi. In addition, while feeling fuyang pulse, some doctors also feel the pulse of taixi point of Foot Shaoyin Meridian to detect if congenital qi and acquired qi are both exhausted. The three-part method is also complicated by comparing with cunkou method. 139
So it is seldom used except when no pulse in cunkou spot, in that time, the fuyang,
t a i x i and renying pulses are felt.
3. Cunkou Method The method was first recorded in Internal Classic and discussed detailedly in
Medical Problems. It was widely used after that. It is considered as the further simplification of whole body method of pulse-taking. It is formed gradually by summarizing pulse-taking experience for long times. In Spirit Pivot, it was mentioned that the pulse of renying and cunkou had the same changes, "pulsing in the same time and shaping the same shape just like pulsing on the same cord. " That is to say, in that time, the unified pulse beating of all the pulse location had been found. Therefore, the later generations turned from the complicate to the simple method and inspected the only one pulse, the cunkou pulse, to know the disease of whole body. This method has been used since then and becomes one of the main diagnostic methods of TCM.
1) The Basis for Guakoa P~~l~Ise-Taking The cunkou pulse refers to the pulsation place of radical artery behind wrist. As to why it is called cunkou, Medical Problems gave out an explanation. "The length from thenar to the styloid process of radius is one cun. So it is called cunkou (a cun length opening of vessel). " The basis of inspecting cunkou pulse was discussed in Internal Classic and
Medical Problems. The Internal Classic said: "The stomach is the sea of food and the grand source of all fu-viscera. When food in five flavor enters mouth, it is stored in stomach to supply five visceral qi. Qikou (note: cunkou) belongs to Taiyin. Thus all visceral qi comes from stomach and is shown in qikou.
"
The spleen
and lung are both of Taiyin. Qikou belongs to Hand Taiyin. The Spleen Meridian is also named Taiyin. So, the qikou can reflect the condition of spleen and stomach. Because the spleen and stomach are the source of qi and blood and can enrich the other viscera, the qi of five-viscera and six fu-viscera can be reflected in cunkou pulse through the change of spleen qi and stomach qi. The First Problem of Medical
Problems said: "The cunkou is the great convergence of vessels and the puise of Hand Taiyin Meridian. The nutrient and defensive qi flows 25 circles in yang and
25 circles in yin. It is called a whole circle. At the each end of a whole circle the qi arrives at cunkou. The cunkou is the beginning and end of all movement of visceral qi. So pulse should be felt in cunkou.
"
According to the basic theories of TCM, be-
cause the lung dominates the qi of whole body and meets all the vessels, the 140
,
changes of all vessels can be shown in cunkou. Therefore, by feeling pulse in cunkou, we can know all diseases in viscera. The Internal Classic and Medical Problems supplement to each other on this aspect. Besides, the Lung Meridian begins from the middle-jiao, so there is a close relation between the lung and the spleen and stomach. All the visceral changes can be reflected in cunkou pulse.
2) The Divisions of Cupkkou and Their Correspoltading Viscera A. The Divisions of Cunkou The cunkou can be divided into three portions, the cun, guan and chi. The division method stems from Medical Problems. In Internal Classic, only the chi and cun are mentioned. In Treatise on Cold-Attack, there is no division of cunkou. In Medical Problems, though there are the names of three portions and their corresponding viscera, how to divide the three portions is absence. Until Jin Dynasty, Wang Shuhe defined the dividing method in his Pulse Classic. It was said in the first volume of Pulse Classic: "That behind cun and in front of chi is called guan. The guan is the bounder of yang and yin. The yang (cun) gives 3 fen (an ancient unit of length which is equal to 1/10 cun) and the yin (chi) gives 3 fen to it (guan)
.
"
So the guan
is 6 fen in length. In Medical Problems, it is said: "The yin part is one cun ( an ancient un:t of length which is equal to 1/10 chi) in length. The yang part is 9 fen in length. The whole length of cunkou is 1 cun and 9 fen.
"
According to those state-
ments, the whole length of cunkou is 1 cun and 9 fen. In it, the yang part is 9 fen. After giving 3 fen to guan, the cun is 6 fen in fact. The yin part is 1 cun. After giving 3 fen to guan, the chi is 7 fen. In a word, the guan locates near the styloid process of radius and its length is 6 fen; the cun is the 6 fen part anterior to guan, the chi is the 7 fen part posterior to guan. B. The Corresponding Viseera of Three Portions In Internal Classic, both of 'the two chi reflect the kidney and abdomen; the part equal to left guan reflects the liver and diaphragm and the right one reflects the spleen and bone: the portion equal to left cun reflects the heart and Danzhong and the right one reflects the lung and c h e s t . ' ~ a s e don that, later doctors adjusted the relationship in some aspects. The relationship between three portions and viscera in Essential Books for Medicine written by Li Zhongzi is the example. The relation is as follows : Xu Chunfu gave out an explanation of this corresponding relation: "There are three portions of pulse, the cun, guan and chi. The cun models after heaven. The guan models after the human. The chi models after the earth. T h e cun can show the *
141
disease of upper body which includes chest, heart, throat, head and eyes. The guan can express the sickness of middle body including diseases of spleen, stomach, liver and gallbladder. The chi can reflect illness of lower body including diseases of lower abdomen, lurnbus, kidney, legs, knees, feet, large intestine, small intestine and urinary bladder. That relation is called "the upper shows the upper body and the "
lower shows the lower body.
"
Because the explanation is easy to understand, it
was accepted by many doctors. Left
Right
cun
heart and Danxhong
lung and chest
guan
liver and diaphragm
spleen and stomach
kidney, bladder and small intestine
kidney, life gate and large intestine
chi
The different opinions on the corresponding relation between viscera and three portions are listed in the following table. Table 5 The Different Correspasltllding Relations Between Three Portions and Viscera cun
chi
guan
L
R
L
R
L
R
Medical
heart
lung
liver
spleen
kidney
kidney
Problems
SI
LI
GB
stomach
UB
LG
Pulse
heart
lung
liver
spleen
kidney
kidney
Classic
SI
LI
GB
stomach
UB
TJ
Note : abbreviation in the table : LG: life gate; SI : small intestine; TJ : triple-jiao ; LI : large intestine ; 142
GB : gallbladder ; UB : urinary bladder ;
PC : pericardium; DP : diaphragm.
Besides, it was proposed that there was no need for division of cun, guan and
chi;and it was enough to distinguish the superficial level, the middle level and the deep level for diagnosis. Also, it was proposed that the left cunkou pulse should be corresponding to the heart, liver and kidney while the right one to the lung, spleen and life gate. That is used in emergency and critical conditions and can also be used in old, infant, patients or women patient after delivery.
11. The Method of Pulse-Reading
I. Selecting the Time The pulse-taking ought to be done at the time that patient and doctor are both relaxed. The chapter of Essentials of Pulse in the Internal Classic said: "The examination should usually be carried out at dawn. At that time, the yin has not moved and the yang not acted, the food has not been taken, the meridians have not been filled up, the collateral keeps smooth, the qi and blood keep in their natural state, therefore the morbid change is easy to recognize.
"
It pointed out the importance of
taking pulse in the time that patient is relax. Nevertheless, it is impossible to feel the pulse of all patients at dawn in fact. So, Wang Ji pointed out that doctors could do pulse examination at any time if needed, not only at the dawn, if only the the patient is calm. Or the pulse can be taken after the patient has a rest. By the way, the doctor should follow the principle of "keep vacancy and calm when taking pulse", so as to concentrate his attention on pulse-feeling.
2. The Posture
1) Posture of Doctor The doctor ought to sit upright and let the elbow and forearm being flat on the table. A suspended arm should not be used when feeling pulse. The doctor should avoid the position right opposite to the patient. The doctor should face the sides of patient. Zhou Xuehai pointed out that the doctor should avoid facing the patient's face directly when the patient is suffering from infectious disease or is a woman.
2) Posture of Patierrat The patient can sit or lie on his back with the forearm stretched on the table or bed on the same level of heart. The palm keeps upwards and the wrist is sus143
tained by a soft pad. Thus the pulse can be felt. If lying on one side, the arm below body is pressed, the qi flow will be obstructed. If palm keeps downwards, the wrist is twisted and the meridian will not be-in its natural state. If the hand is kept on the level lower than the level of heart, blood will pour down into and stay in the meridians of hand. If the hand is lifted, the qi will go up and the meridian becomes relaxed. If lying on the stomach, the qi is pressed and pulse becomes tired. If the body is in motion, the qi will move and disturb the pulsation. So, the body posture should not be neglected.
3. Butting Figures The best way for doctor to use his figures is to feel the patient's pulse in right hand by the left hand, and vice versa. The finger belly is used to palpate the pulse because this area is most sensitive. An ancient doctor said: "The flesh of index finger is sensitive, that of middle finger is not so sensitive, and that of ring finger is nearly numb. So one must use the flesh near tip where is called finger-eye or finger-belly to feel pulsation. If doing so, the pulse is clear distinguished just like thing is watched in a clear day. So the pulse examination is called also watching-pulse in ancient. " This shows that the ancient doctors stressed on using fingers. By the way, some ancient doctors pointed out that there were pulsations in doctor's fingers and the doctor should know that the pulsation in doctor's finger should not be taken as the pulse of patient. The beginner should well understand and distinguish the pulsation to avoid making mistake. When feeling pulse of adult patient, all the three fingers, the index finer, middle finger and third finger, should be used. About putting on fingers, first, the middle finger is put on the guan position which is at the medial side of the styloid process of radius, then the index finger is put on the cun position which is anterior to the guan position, finally the ring finger is put on the chi position which is posterior to guan position. The three fingers keep in a bow shape and the tips are at the same level with the finger-belly touching the pulse. Lu Ziyi said: "The three fingers are not of uniform length. One must make the tips and joints of fingers a t the same level when feeling pulse. " The distances between fingers are determined according to the patient's height. If the patient is tall with long arms, the finger ought to be put at a relative larger distance, and vice versa. The infantile arm is short and could not contain the three fingers. So the doc-
. 144 .
.
tor can put only one finger on cunkou pulse. It is not necessary to divide the three portions of the cunkou.
4. The Pressing Strength The doctor should put different strength on fingers to feel pulse at different levels. The pressing strength may be little, moderate or heavy. Hua Shou said: "The touching, pressing and seeking are the key points for taking pulse. Palpating in slight strength is called touching, palpating with heavy strength is pressing and palpating with moderate strength is seeking.
"
At the beginning of palpating,
touching is used to find the pulse in skin which belongs to yang and fu-viscera and is also the reflection of the heart and lung. Then seeking is used to detect the pulse in muscles which pertains to both the yin and yang, and reflects the spleen and stomach. Finally, the pressing is used to probe the pulse below muscles which be\
longs to yin and reflects the liver and kidney. In addition, another method, the sliding is used. It is to move fingers around the pulse position to detect abnormal changes of pulse. By sliding along vessel we can know whether the pulse is long or short, while moving fingers transversely we can find if the pulse is oblique-running or ectopic radial. There is difference between general touching and single touching. The general touching is to feel pulse by three fingers in the same time. Using this method, we get a whole itnpression about the pulse. The single touching is to feel pulse by only one finger. It gives us the visceral conditions respectively. Usually, the. general touching and single touching are used in combination so as to get clues as much as possible for diagnosis. The general touching is used firstly and then is the single touching.First, all the three fingers are put on cunkou with small strength, then with moderated force, and finally with the strong force. After that, the middle and ring finger are lifted a little. Only the index finger is used on cun portion with strength from slight to heavy. Finished that, the index finger is lifted a little and the middle finger is used to feel pulse of g u a n portion in the same way of using index finger. Finally, the middle finger is lifted and the ring finger is used to detect the pulse of chi portion in the same way of the other two fingers. Some doctors may do the single touching only by one finger which is moved from portion to portion. For example. Liu Lizhi in Song Dynasty used only the middle finger on the three portions. The results got from general touching and single touching are sometimes not identical. Judgment should be made in combination with other clinical data. a
145
5. Normal Breath One breath is an inhale and an exhale. The breath is used to count the beating number of pulse. In adult, the normal rate of pulse is 4 to 5 beats for one breath, the 3 beats for each breath is slow and 6 is rapid. Because the normal breath is used as the criterion time for pulse counting, the doctor must keep relaxed and adjust the breath to smooth to avoid mistake.
6. Duration The time for one pulse-taking is usually no less than the time of fifty pulse beats. Spirit Pivot said: "When taking pulse, one should count the pulsation number. If there is no intermittence in successive fifty pulsations, the qi can reach all the five zang-viscera.
"
That is to say, if there is not intermittence in pulse beating.
the prognosis is relative good. The duration of pulse-taking now is based on the discussion of Spirit Pivot. We should not take pulse in a careless way, because it concerns patient's life.
111,Normal Pulse Zhang Jingyue pointed out that only after one knew normal pulse, one could distinguish the morbid pulse. It is possible to recognize the pathological pulse only when the doctor have a deep understanding on the normal pulse. The normal pulse, also called common pulse or ordinary pulse, is characterized by the pulsation in all three portions which is 4 to 5 beats in one breath, neither deep nor floating, soft and forceful, and in equal intervals. T h e pulse is closely related to the internal and external environment. I t often changes along with the change of climate, surrounding, diet and emotions. If the changes do not cause diseases, the pulse corresponding to them is still within normal range because the pulse still has the characters of normal pulse, being full of stomach qi, being full of vitality and being rooted.
I.Being Full of Stomach Qi The Internal Classic said: "The stomach is the sea of food. T h e five flavors enter mouth and are stored in stomach to provide qi for five zang-viscera. So all visceral qi comes from stomach and is shown in qikou. " The theory about stomach qi in the pulse is from Internal Classic. T h e Spirit Pivot took the soft and moderate pulse as the pulse full of stomach qi. Based on that, Dai Qizong made an explana146
tion on the pulse full of stomach qi that: "The neither large nor thin, neither long nor short, neither floating nor deep, neither slippery nor sluggish, and in moderate force with describable vigorous state is the pulse full of stomach qi.
"
This descrip-
tion gives us the criteria for the pulse full of stomach qi. The body takes the stomach qi as its root. So the body with full stomach qi will live well, the body with little stomach qi will be ill, and the body without stomach qi will die. The pulse takes stomach qi as its root too. In the same way, the pulse with little stomach qi indicates the illness, that without stomach qi means death, and the pulse being full of stomach qi is the sign of health.
2. Being Full of Vitality The vessel is the house of blood. The heart dominates blood and stores the mind. When blood and qi are abundant, the mind is vigorous and healthy, the pulse is then full of vitality. Zhou Xueting said: with full vitality.
"
"
The moderate upstroke is the pulse
Because Zhang Jingyue discussed mainly the stomach qi in pulse
in his works, doctors in later ages considered that the characters of pulse full of vitality should be similar to those of pulse full of stomach qi. The pulse which beats in the way of moderate force and unified rhythm in a soft vessel is considered as being full of vitality. The vitality is basedon the essence, qi and blood. So the states of essence, qi and blood can be detected from the vitality in pulse.
3. Being Rooted The pulse with root is explained in two statements. T h e first is from Medial Problems. In the Fourteenth Problem, it was said: "The importance of chi portion to the body is just as that of root to the tree. Although the leaves fade, the tree is living when the root is good. While the pulse is with root which means the vital qi is still in the body, the patient can be safe.
"
In the Classic of Pulse, Wang Shuhe also
said: "Although pulse is not felt in the cun and guan portions, the pulse still pulsate at chi portion. Why do we worry about the death in such a condition?" He took the pulse in chi portion as the root. The second is that the pulse felt in deep level means being rooted, because ancients held that patient would die if pulse was without root in all portions. In fact the two explanations a r e not contradictory to each other. The kidney is the congenital foundation and all the activities of the body rely on kidney qi. The existence of kidney qi to the body is similar to the alive root to the tree. The tree without leaves is alive only if the root is alive. The body can also revitalized when pulse is rooted. The existence of kidney qi gives the pulse root. 147
T h e deep level and chi portion can both be the reflection of kidney qi, therefore both the two methods for detecting pulse root can be used. No matter what 111e pulse is, the pulse is rooted when pulsating in deep level even by forceful pressed or moderately pulsating in chi portion. The diseases can be cured. If all the pulse disappears in the deep level on the forceful pressing, or the pulse is feeble and extinguishing in chi portion, it is the pulse without root and the disease is critical. T o sum up, the stomach qi, vitality and root in the pulse are closely related.
,411 of them reflect the internal states of qi, blood, essence and vitality of the body. A slow foliceful and stable pulse means stomach qi in pulse which shows the excellent function of spleen and stomach. The slow but forceful pulse reflects the abundant qi and blood, and calm mind. The pulse beating in deep level or slow but forceful beating in chi portion means the root of pulse which exhibits the plentiful kidney essence and qi, The pulse changing within normal range can be affected by the following factors.
A. Exogenous Factsrs a. The -Seasons The pulse changes along with the seasonal changes. The changed pulse is called seasonal pulse. In spring, the pulse in all portions are somewhat taut. In summer, the pulse is slightly surge. In autumn, the pulse is floating a little. In winter, the pulse is relatively deep. All the changes are within normal range. If pulse changes contrary to those, it is sign of diseases.
b. Emvironment The normal pulse varies with the environmental changes. The ancients thought that the pulse in northerner was strong and that in southerner was gentle; and the pulse of people in the same district might vary due to the different living conditions or constitutions.
B. Endogenous Factors a. Sex Sun Simiao pointed out that the pulse in women was softer and slightly rapider than that of men,
b. Age The pulse in infant is 7 to 8 times in the time of one breath. In child of above 5 years, the pulse is normal when it beats 6 times in a breath. The pulse beating over
6 times is due to heat and that below 6 times is due to cold. The pulse of younger is =,
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=,
strong while that in the aged is little weak.
e. Constitution T h e pulse in a vigor body constitution is usually forceful. The pulse in a body of weak constitution is soft. The pulse in a tall body is long and that in a short body is short. The pulse in a fat people is deep and that in a thin one is floating. Those facts demonstrate the relation between pulse and constitution. Some special pulse conditions may present in normal people. For example, the six yang pulses, which are the surge or large pulses (a pulse condition characterized by thick vessel) in all portions, and six yin pulses, which are deep and thready pulse in all portions are found in healthy people. Those are due to special constitutions. In old people, the pulse should be weak, but some of them have a vigorous pulse, because the well built constitution. The pulse in a strong body should be forceful, but some pulses in strong persons are thready and moderate in all portions. That results from the quite character of the constitution.
d. Daily Life T h e emotional reaction, labor, rest and food-intake can all change the pulse. When emotion changes, the pulse changes too. The pulse of a worker is stronger than that of intellectual. After strenuous exercise. the pulse is rapid and surge. The pulse becomes rapid when having alcoholic drinking. The pulse is often surge after meal and becomes supple when hungry. Those changes should be distinguished from the changes due to diseases.
e. Physiiolfogical Variation The pulse is not located at cunkou but goes from chi portion to dorso-radial region obliquely. That is called oblique-running pulse. The ectopic radial pulse is located in the dorsal side of the radial bone right contrary to the normal pulse location. They can be found in one or two sides and are the physiological variation.
f . Pregnancy and Menstruation When women are in the menstrual or pregnant period, the pulses are changed. T h e changes will be discussed later.
IV. Morbid Pulse When disease occurs, the qi and blood vary too, so the pulse changes. The pulse in disease condition is called morbid pulse. The morbid pulses are different while the disease cause, location, mechanism and syndrome are not the same. The pulse condition is felt by the doctor's fingers. The pulse obtained differs from one doctor to another. So the pulse was classified into different kinds by dif149
ferent ancient doctors. There are 2 1 kinds of pulse in Internal Classic, 26 in Treatise on Cold-Attack, 24 in Classic of Pulse, 27 in Binghu9s Pulse Study and Mediation on the Three Fingers, 1 6 in Jingyue9s Complete Works, 28 in The Principle for Diagnosis, 29 in The Concise Content of Diagnostic Methods, 30 in Genuine Meaning of Pulse. 32 in Truth of Diagnosis and 38 in Records of Syndrome Differentiation. Now 28 pulses are clinically used. They are floating, deep, slow, rapid, weak, strong, slippery, uneven, long, short, surge, faint, tight, moderate, taut, hollow. tympanic, soggy, firm, feeble, scattered, thready, hidd.en, bouncing, running, knotted, regular intermittent and swift pulse. The pulses are defined in accordance with the shape, site, location, dynamic and rhythm of the pulse. The morbid pulses are discussed as follows.
A.Pulse Character The floating pulse is a pulse condition that the pulse is easily felt and at the full in the superficial level, and its force decreases slightly in the deeper level. T h e Binhu9s Study on Pulse described that "The pulse is abundant when felt by lifting and inadequate when felt by pressing. It is just like the wood floating in water. "
B. Disease Suggested a. Exterior Syndrome: The floating pulse suggests the exterior syndrome. The forceful floating pulse indicates the exterior excess syndrome while the weak floating pulse the exterior deficiency syndrome.
b. Deficiency Syndrome: The floating pulse can also be seen in yin deficiency syndrome of the consumptive disease or declining yang in critical case.
C. Analysis When exogenous evils invade the exterior of the body, the defensive-yang rises against the evil. The yang pushes the qi and blood to go to the exterior, therefore the pulse is mostly felt in the superficial level obviously
.
If the yin is deficient and the yin could not contain the yang, or the yang is too weak to match the yin, the yang will float on the body surface, so the pulse becomes floating and weak. In endogenous diseases, the floating pulse is a bad portent for the exhaustion of genuine qi. Binhu9sStudy on Pulse said: "It is terrible to meet the floating pulse in the chronic diseases. "
D. Similar Pulses The hollow pulse, tympanic pulse, scattered pulse and soggy pulse are similar to the floating pulse. @
150
E. Pulse Combinations T h e common encountered pulse combinations of floating pulse include floating and tight pulse which appears in cold-attack in Taiyang Meridian, floating and moderate pulse which is the sign of wind-attack in Taiyang Meridian, floating and taut pulse which suggests the phlegm or fluid-retention, floating and slippery pulse which indicates the phlegm or food retention, floating and sluggish pulse which means the deficient blood, and floating and short pulse which results from qi disease. . All pulses with the character of deep pulse could not be felt in combination with the floating pulse.
2. Hollow Pulse
A. Pulse Character T h e hollow pulse is similar to the leaf of green Chinese onion which is hollow. The pulse is characterized by wide and soft vessel when lightly touched, and hollow when seeking. On pressing, the edges of vessel are clearly felt, but the center is obscure.
B. Disease Suggested Loss of blood and yin depletion are suggested. So the pulse is usually seen after the massive bleeding or dehydration.
C. Analysis The pulse shows a solitary yang without yin. After loss of blood, the yin and blood could not fill up vessel and contain the yang-qi. The yang loses its dependence and goes to the out part of body. Although the pulse belongs to yang-pulse, it is not rooted, therefore it is a sign of heavy deficiency.
D. Pulse Combinations Rapid hollow pulse is seen in yin deficiency with bleeding. Slow hollow pulse is due to deficiency of both qi and blood. Hollow, slow and intermittent pulse indicates the phlegm retention and blood stasis in combination with deficiency of yin and blood.
3. Tympanic Pulse
A. Pulse Character The pulse is large (the vessel which is thicker and wider is described a s large), rapid and forceful when touching and hollow when pressing just like the feeling of touching the surface of a drum. The pulse gets its nsme from this charac151
ter.
B.Disease Suggested The pulse suggests blood deficiency and essence exhaustion. It is found in diseases of bleeding, seminal emission, abortion, metrorrhagia and metrostaxis.
C . Analysis The tympanic pulse is like the leather covering of drum. The large, taut and tense feature when touching is due to qi floating which is caused by the essence and blood deficiency. The cold in the exterior may also lead to the feature which .means the excess syndrome in the exterior. The hollow character at deep level is a sign of depletion of qi and blood.
D. Pulse Combinations Float ilig. tight and tympanic pulse suggests the extremely exorbitant evil in
the exterior. Slow tympanic pulse indicates the dangerous condition.
4, Scattered Pulse A. Pulse Character The "scattered" means inability to concentrate. The pulse is loose without force by touching. The boundary between vessel and flesh is vague. If seeking and pressing, the pulse disappears, so that the rate is hard to count.
B.Disease Suggested Scattered pulse suggests escaping of yang and floating of vital qi. I t is a dangerous portent for the dying visceral essence especially the kidney essence. Nevertheless, the pulse appearing in woman of third trimester of pregnancy is a presage for child birth. If the pulse is present in the second trimester of pregnancy, abortion may happen.
I
6.Analysis scattered pulse is not felt when pressing. It reflects that the congenital foundation is used up and the visceral qi is extinguishing out. The pulse is lack of power. So the pulse is scattered and vague at superficial level.
5. Soggy Pulse (Soft Pulse)
A. Pulse Character The pulse is floating, thready and soft. The upstroke is forceless. If pressed, the pulse becomes weaker and weaker like the cotton in water.
B.Disease Suggested 152
Dampness, deficiency of stomach qi, yin and blood are suggested. The pulse is usually present in diarrhea, spontarieous sweating, asthma and weakness.
C. Analysis The dampness depresses the vessels. The qi and blood are difficult to flow in vessels. So, the pulse is thready and soft. The qi, yin and blood deficiency makes the yang loss its dependence. The yang is floating. If the pulse disappears by pressing, the yang is expiring. While the existence of yang by pressing means the yang tends to meet yin. When the pulse is present in patient of chronic'disease or old patient, there is no danger with patient. If the pulse is present in young patient or a strong patient, the prognosis is not good.
D. Pulse Combinations Soggy and sluggish pulse indicates the loss of blood. The rapid soggy pulse means the damp-heat in the body.
A. Pulse Character The pulsation is not clear by touching. It becomes clear by seeking. When pressing, the pulse is forceful and the vessel is full. Pulse Classic described it as "weak by touching and strong by pressing. "
B. Disease Suggested a. Interior Syndrome: The forceful deep pulse indicates the interior excess syndrome. While the weak deep pulse suggests the interior deficiency syndrome.
b. Exogenous Aggression: The deep, rapid and tight pulse is a sign of wind-cold which encircles the body in the exterior. T h e deep and tight pulse but not rapid is due to exterior cold with heat in interior. It is a compound syndrome of both interior and exterior.
C. Analysis The evils accumulate in body. The qi, blood and yang are obstructed in the inner part of body and could not rise against the evil. So, the pulse is deep. If the pulse still beats under the heavy pressing, it may be caused by the abdominal mass.
If pulse beating becomes weaker and weaker by pressing, it is due to qi and blood deficiency which is unable to move in vessels.
D. Similar Pulses Hidden pulse, firm pulse and feeble pulse are similar to deep pulse.
E. Pulse Combinations Deep rapid pulse indicates the interior heat. Deep slow pulse suggests the in*
1530
veterate interior cold. Deep slippery pulse means phlegm or fluid retention. Deep sluggish pulse is due to blood stasis. Deep moderate pulse shows the cold-dampness. Deep thready pulse exhibits the qi deficiency. Deep faint pulse is a sign of heavy deficiency of both qi and blood. Deep taut or tight pulse is often present in pain syndromes in the heart or abdomen. Those belonging to floating pulse category could not be present in the same body at the same time.
A. Pulse Character The pulse is not felt when touching, seeking and pressing. Only by heavily pressing to bone, the pulse can be felt. The hidden pulse may be present in all the three portions or only in one portion.
B. Disease Suggested The hidden pulse indicates the interior syndrome. It marks thorough obstruction of qi and blood. The forceful hidden pulse is due to excessive hidden evil. While the weak hidden pulse is caused by expiring yang and is usually present in syncope, extreme pain, yang and yin depletion. The hidden pulse presenting in both hands with absent of fuyang and t a i x i pulses is a critical portent.
6.Analysis The excessive evil obstructs the yang and qi. The qi and blood could not flow into exterior part of body through vessels, so the pulse is extremely deep and forceful. If it is due to yang deficiency, the mechanism is that the yang is too weak to push the qi and blood to flow in the exterior body. Therefore the pulse is very deep and weak.
DoPulse Combina$ions Hidden pulse with regular intermittence is due to extreme heat which transforms into cold. The slow hidden pulse indicates the cold accumulation which is an extremely yin and means an exhausting qi.
8. Firm Pulse
A. Pulse Character The firm pulse is characterized by hard, firm and fixed vessel which is located in the deep level. The pulse is not felt when touching. By pressing, the pulse can be felt large, taut, long, hard and forceful. It is similar to deep pulse to some degrees.
B.Disease Suggested Q
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Q
T h e firm pulse indicates interior excess cold syndrome. It is usually found in abdominal mass, lumps and hernia. C. Analysis T h e firm pulse is located in the deep level, so it belongs to yin cold. The large, taut, long and firm vessels means mass in body. The firm suggests the evil is deeprooted and difficult to expel. The pulse is not present in deficiency syndrome. But if the evil stays in the body for a long time, the struggle between the right and the evil may exhaust the stomach qi, then firm pulse appears. In this condition, the firm pulse is a dangerous omen.
9. Slow Pulse A. Pulse Character The pulse pulsates 3 times for each breath and moves slowly. The pulse which pulsates less than 3 times for each breath can all be called slow pulse.
B. Disease Suggested a. Cold Syndrome: The slow pulse suggests the cold in viscera. The slow and forceful pulse shows the excess cold while the weak and slow pulse shows the deficiency cold.
b. Internal Heat or Abdominal Mass. C. Analysis The cold causes contraction. When cold invades the body, or deficiency yang pr\oduces cold, the qi and blood are stagnant. Then the qi and blood circulation in vessels slows down. so, the pulse beating is slow. If it is a condition of cold in body, the pulse is forceful; while it is a condition of yang deficiency, the pulse is weak.
If the evil transforms into heat and enters the interior, it may obstruct the meridians and slow the pulse. The slow pulse is forceful. For example, Treatise on
Cold-Attack recorded that slow pulse was present in Yangming Syndrome with slightly aversion to cold and excessive sweating. That is a condition of cold in exterior and heat in interior. And in the initial stage of warm-diseases, the pulse is often slow. So, not all the slow pulse in exogenous diseases is due to cold. The slow pulse can also be present in abdominal mass. So in endogenous diseases, the slow pulse is caused not only by the cold.
D. Similar Pulses The moderate pulse, sluggish pulse, regular intermittent pulse and knotted pulse are all the similar to slow pulse.
155
a
E.Pulse Combinations The floating slow pulse indicates the exterior cold while the deep slow pulse the interior cold. The slow and sluggish pulse means blood deficiency. The slow and slippery pulse is due to wind-phlegm or food-retention. The slow taut pulse is due to cold coagulation. The weak slow pulse is due to yang deficiency. The slow thready pulse means qi shortage. The slow faint pulse means heavy yang damage. Those of rapid pulses can not be present coincidentally with slow pulse.
10. Moderate Pulse
A*Pulse Character The pulse beats 4 times for each breath and moves smoothly.
B. Disease Suggested Wind or dampness attack or a recovering condition. C. Analysis
If the pulse is vigorous with equal intervals, and the pulses in three portions are the same, it is a normal pulse, The weak one is due to wind-attack in meridians or dampness in viscera. Because the dampness is sticky and easy to stay in vessels, it obstructs qi and blood flow. If the moderate pulse is present in patient suffering from prolonged or critical diseases, it is a sign of restoring of genuine qi. If the pulse of patients suffering from abscess, apoplexy or after delivery is moderate, the patients are easy to recover from the illness.
D. Pulse Combinations The floating moderate pulse indicates the wind-attack. The deep moderate pulse is present in cold-dampness syndrome. The thready and moderate pulse is due to qi deficiency. the moderate and sluggish pulse is due to blood deficiency.
P I . Sluggish Pulse (Uneven Pulse) A- Pulse Character The pulse is slow and not ular. The feeling of the pulse is uneven and sluggish just like that of scraping a bamboo with a little knife.
B. Disease Suggested The pulse indicates qi stagnation, blood stasis, phlegm or food retention, insufficiency of body fluid and blood deficiency. It is present in diseases of abortion, threatened abortion, seminal emission, spontaneous emission, abdominal mass. C. Analysis 156
a
T h e deficiency and excess should be distinguished in /the condition of sluggish ,
pulse. The deficiency is the blood or body fluid deficiency which could not fill up the vessel and lead to uneven flow of qi and blood in vessel. The excess is the qi stagnation, blood stasis, phlegm or food retention which stays in meridians and makes the blood flowing hard.
D. Pulse Combinations T h e deep sluggish pulse is due to blood stasis and essence insufficiency. The uneven and feeble pulse means the qi deficiency. The faint and sluggish pulse is present in blood deficiency. The thready and sluggish pulse indicates the exhaustion of body fluid. The strong and sluggish pulse suggests the blood stasis with excessive heat. The taut and sluggish pulse marks the qi stagnation.
312. Regular Intermittent Pulse
A. Pulse Character The pulse is slow and weak with regular intermittent. After intermittence, the pulse will wait a little moment and then continue beating.
B. Disease Suggested This pulse indicates visceral exhaustion or expiring spleen qi. It is a dangerous portent.
C. Analysis The declining visceral qi and blood could not form a successive flow in vessels, so the pulse is weak and the pulsation is missed frequently. In the Internal Classic, the pulse is considered as the omen of expiring spleen. The spleen keeps credit. The missed pulsation means the credit on pulse is lost which happens only when the spleen qi is absent. The extinguishing vital qi may also be shown in the pulse. But if the pulse is present in cold-attack disease, pregnancy, emotional change, trauma, apoplexy and pain disease, the condition need not be worried, because the pause is due to the evil obstruction.
D. Pulse Combinations
If the pulse is combined with surge pulse, it suggests the disease is in collateral. If combined with deep and thready pulse, it occurs in diarrhea. The rapid pulse with regular intermittence suggests declining heart qi. The faint pulse with regular intermittence indicates the exhaustion of body fluid. The slow pulse with regular intermittence is a sign of dying spleen qi. *
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*
I3 Knotted Pulse A. Pulse Character The pulsating is slow with irregular intermittence. After the missed beating, the pulse continues immediately.
B. Disease Suggested The pulse indicates the exorbitant yin, qi stagnation, blood stasis, phlegm retention, declining qi and blood.
C. Analysis The pulse missing is like a knot in a cord. All things slip along the cord will be stopped for a while and then can pass over it. The evil in vessel is like the knot in a cord. If the qi and blood is not sufficient enough to fill up vessels, the evil will insert itself into vessels and cause the pause. And after the evil passed, the qi and blood keeps flowing. The pulse then continues its beating. Because the qi and blood are deficient, the pulse is slow. It is a sign of excess in deficiency. It appears frequently in weak patient. If heat stays in blood, it will also make the pause. Nevertheless, the pulse can be found in the normal body. This is a congenital variation, but not a disease.
D, Pulse Combinations
If combined with floating pulse, it is due to cold in meridians. If combined with deep pulse, it suggests the evil retention is in viscera. If with slippery pulse, it indicates the phlegm or fluid-retention. While with weak pulse, it is the sign of qi and blood deficiency.
114 Rapid Pulse A. Pulse Character The pulse is rapjd'and beats 6 or 7 times for each breath.
B. Disease ~ u & e s t a. Heat: The forceful rapid pulse indicates excessive heat while the weak one indicates deficient heat.
b. Deficiency and Cold: If the pulse is rapid, floating and hollow, it suggests the floating yang is dispelled by exorbitant yin. If the pulse is rapid, deep and uneven, it shows the yin is exhausted in the lower,
C.Anal ysds The heat evil is blazing in body. The genuine qi does not decline, so it rises against the evil. The active genuine qi makes qi and blood move rapidly, therefore
the pulse is rapid and forceful. If the diseases last for a long time, the yin is deficient, the yang is only relatively strong, so the pulse is rapid but weak.
If the pulse is floating, rapid, large, weak and hollow when pressing, it is due to exorbitant yin evil compeling the yang t o float. If the pulse is rapid, thready, deep and weak, it is the sign of exhaustion of blood and essence which is seen in dying case of phthisis.
D. Similar Pulses The swift pulse, bouncing pulse, running pulse are similar to rapid pulse.
E. Pulse Combinations The floating and rapid pulse indicates exterior heat. The deep and rapid pulse suggests the interior heat. The slippery and rapid pulse means phlegm-fire. The thready and rapid pulse is a sign of yin deficiency. The taut and rapid pulse shows the liver fire. Those of slow pulses could not coincidentally exist with rapid pulse.
15 Swift Pulse A. Pulse Character The pulse is more rapid and pulsates more than 7 times for each breath. It is the extreme condition of rapid pulse.
B. Disease Suggested The forceful swift pulse indicates hyperactivity of yang and excessive heat. The weak swift pulse usually suggests the yin deficiency and phthisis. C. Analysis
The unrestrained exorbitant yang makes the pulse swift and forceful. It is present in extremely heat condition of cold-attack or warm diseases with exhaustion of yin, and is a critical sign. If the swift pulse is weak and becomes weaker by pressing, it is due to deficient yin which is unable to contain yang, and leads to yang floating outwards. If it is present in the late stage of phthisis, the patient is expiring. If the pulse is in normal shape, the stomach qi is still in pulse, the patient can be resecured. The swift pulse due to frightening can recover spontaneously. The infantile pulse should be 7 times a breath.
D. Pulse Combinations The swift and surge pulse is present in disease characterized by fidget and chest distress. The swift and deep pulse is due to disease of abdominal pain. And both of them reflect the condition that the yin or yang will be exhausted. 159
16. Bouncing Pulse
A. Pulse Character The pulse is rapid and slippery. At the guan portion, the pulsation is forceful and is like a bean bouncing in vessels.
B. Disease Suggested The pulse suggests the condition of being frightened, disease of pain, fever and bleeding.
C. Analysis The bouncing pulse is a sign of struggle between yin and yang. When the yang acts, the sweating, pantalgia and palpitation happen. While the yin acts, fever and bleeding take place. If the pulse is floating and large, it is an excess syndrome. Pulse bouncing at chi portion is yin deficiency, while bouncing at cun portion is often a yang deficiency. If the bouncing pulsating is present in chi portion in pregnant women, it is a normal phenomenon.
D. Pulse Combinations The floating and bouncing pulse is present in exterior syndrome. The bouncing and feeble pulse is due to frightening. The strong and bouncing pulse is seen in rheumatism. The bouncing and hollow pulse means loss of essence.
17. Rapid Intermittent Pulse (Running Pulse)
A. Pulse Character The pulse beats rapidly with irregular intermittence.
BeDisease Suggested Yang hyperfunction, excessive heat, blood stasis, phlegm, food retention and qi rebellion are suggested.
C. Analysis That the yin could not keep up with the hyperactive yang, or the rebellious up flow of qi due to anger, leads to qi and blood rebellions in circulation. The qi and blood flow off and on. So the irregular pauses take place in pulsation. The yang and the heat make the pulse rapid. The phlegm, qi stagnation and food retention can obstruct the vessels and make intermittence. Sometimes, the pulse can be seen in cold syndrome. For example, the pulse can be seen in cold-attack disease with cold limbs. If the pulse is weak, it is due to deficiency.
D. Pulse Combinatiortns 160
a
If combined with surge pulse, it is a condition of exorbitant heat stay in meridians. If with small pulse, it is seen in the case of collapse in which the yin and yang could not supplement to each other.
318. Weak Pulse
A. Pulse Character The vessel is thick and soft. The pulsation is forceless either light touched or heavy pressed. When palpating, the vessel feels hollow.
B. Disease Suggested The pulse indicates deficiency syndrome. It can be present in all kinds of deficiency syndrome. It is also seen in summer-heat attack.
C. Analysis If yang and qi are insufficient, the pulse is lack of power. If yin and blood is shortage, the vessel is not well filled up. So all the deficiency may lead to weak and soft pulse. The summer-heat tends to take qi and body fluid away. So after the aggression of summer-heat, the body i s deficient, and the pulse becomes weak.
D. Similar Pulses Thready pulse, faint pulse, feeble pulse and short pulse are the similar pulses to weak pulse.
E. Pulse Combinations The floating and weak pulse means qi deficiency. The deep and weak pulse indicates declination of genuine fire. The slow and weak pulse suggests yang deficiency. The rapid and weak pulse is due to yin deficiency. The sluggish and weak pulse is present in blood deficiency. The taut and weak pulse shows the exorbitant wood with declining earth. The large and weak pulse marks the qi depletion.
19. Thready Pulse A. Pulse Character The vessel is thin and soft like a thread. The pulsation is clear even by pressing.
B. Disease Suggested The pulse indicates all kinds of deficiency and cold-attack, pain syndrome and dampness syndrome.
C. Analysis When qi and blood are abundant, the vessel is filled up. While qi and blood are *
161
insufficient, the vessel is not well filled up and becomes thin. If the body is suddenly attacked by cold, the qi and blood are suppressed in vessel, the pulse becomes thin. The dampness can encircle the vessel and make the vessel thin.
D. Pulse Combflrtnations T h e floating and thready pulse is present in yang deficiency. The deep and thready pulse suggests direct invasion of cold into viscera, or arthralgia. The thready and moderate pulse means dampness in the middle. The rapid and thready pulse is the sign of internal heat produced by yin deficiency. The thready and weak pulse is seen in the case of night sweating. The thready and tight pulse indicates cold in the body. The thready and taut pulse shows liver deficiency. The uneven and thready pulse shows blood deficiency.
20. Paint Pulse A. Pulse Character The vessel is extremely thin and soft. It seems to be felt or not be felt. If pressing, the vessel and pulse become vague.
B. Disease Suggested The pulse is a mark of yang exhaustion or heavy deficiency of qi and blood.
CeAnalysis T h e faintness is a sign of qi and blood insufficiency. Because the qi and blood are too weak to fill up and drive pulsating, the pulse seems to be felt or not felt. So, it is a sign of declination. Seeming not to be felt by light palpation shows yang decline. Seeming not to be felt by heavy pressing shows exhaustion of yin. If it is present in a prolonged disease, it is an omen of dying. If it is in a newly suffered disease, the disease is cur
D. Pulse Combinations The floating faint pulse indicates yang deficiency. T h e deep faint pulse suggests yin deficiency or diarrhea with abdominal pain due to visceral yang deficiency. The faint and sluggish pulse is present in loss of blood. The faint and taut pulse is seen in the case of convulsion.
21 Feeble Pulse A. Pulse Gharac$er The pulse is soft, deep and thin. It can only be felt in deep level be pressing. If more strength is put, the pulse is vague.
B.Disease Suggested Q
162
Q
The pulse indicates yang, qi and blood deficiency. Among them, the qi deficiency is mainly suggested. C* Analysis The superficial level can show the condition o f yang. Feebleness is a sign of yang and qi decline. Touching is used to feel the yang. That the pulse is not felt by touching gives the proof for yang declining. If the pulse is present with moderate pulse in conditions of loss of blood, after delivery, old patient, the stomach qi is still in pulse. If it is present in a physically strong body or sudden onset disease, the prognosis is not good.
D. Pulse Combinations The feeble and rapid pulse suggests loss of sperm or menorrhagia. The feeble and sluggish pulse indicates blood deficiency.
22. Short Pulse A. Pulse Character The pulse could not be felt in all the three portions. The pulse in can or chi, or both of them is absent.
B. Disease Suggested The short pulse indicates qi diseases, qi deficiency or stagnation. It can also be present in food or phlegm retention.
C. Analysis The exuberant qi makes blood circulating well. While the deficient qi leads to blood circulating hard. If qi is unable to conduct the flow of blood, pulse is short. If phlegm or food retention obstructs qi moving, the vessel is not stretched, the pulse is also short. It is pointed out in s o m r
classics that short pulse means qi disease.
DePulse Combinations The floating and short pulse indicates lung qi deficiency. The deep and short pulse suggests blood stasis or stuffiness in abdomen. The short, slippery and rapid pulse is due to phlegm or food retention. The short and hollow pulse is present in massive bleeding.
i
23. Strong Pulse
A. Puke Character The pulse is forceful in all the three portions no matter at what level. The vessel is full. It is the general name of all pulse full of power.
B.Disease Suggested
a. Excess Syndrome: It is present in the cases of exorbitant evil, blood stasis and fire blazing in which the fever, abscess, indigestion, constipation, mania and fidget are usually the main symptoms. b. The pulse sometimes may be present in deficiency syndrome. C. Analysis
,
The pulse is formed when evil is exorbitant and the genuine qi is also vigorous. The right fighting against evil fills up vessels and acts powerfully, so the pulse is forceful and filled up. Chen Yuangong said: "The excess does not refer to the genuine qi but the evils. The evils makes the genuine qi fill up in vessel.
"
If after a long time of disease, the genuine yin is used up, the solitary yang floats in the out part of body, the pulse can also be strong. This is a pseudo-excess sign. It was said in ancient times: "The strong pulse in a prolonged disease is a bad sign. " It is recorded in Synopsis of Golden Chamber: "After several years cough, if the pulse is weak, the patient can be cured; while the pulse is strong and large, the patient is expiring. "
D. Similar Pulses Taut pulse, tight pulse, long pulse, slippery pulse and surge pulse are similar to strong pulse.
E,Pulse Combinations The floating and strong pulse is present in exterior excess syndrome. T h e tight and strong pulse indicates the internal cold accumulation. The deep and strong pulse suggests interior excess syndrome. The surge and strong pulse is a sign of fire.
24. Taut Pulse
A. Pulse Character The vessel is long, straight and stretched like a string stretched on a violin.
B. Disease Suggested a. Diseases of liver and gallbladder, pain, malaria, phlegm and fluid retention. b. Consumptive disease or stomach qi exhaustion.
6.Analysis The taut pulse belongs to condition of yin hidden in yang. The pulse is caused by qi and blood rebellion. If evils stay in the liver, liver qi could not move normally and go into meridians. The rebellious qi fills up vessel and makes the pulse stretched and straight like a string of bow. The pulse is often present in the cases of malaria, diarrhea, hernia, rheumatism, abdominal mass, fever and chill, a
164
hypochondriac pain, etc.. which are all caused by exorbitant wood invading the weak earth. If it is caused by heat evil, the pulse is mainly taut and slippery; while by cold, it is taut and thready. The pulse can also be found in deteriorated cases. For example, most the pulse in mistreated cases of cold-attack disease is taut. In endogenous diseases, taut pulse is the main pulse, because most of the diseases involve the liver and spleen. The ancient doctors considered that the pulse in all t h r e e portions was a bad sign. But when the pulse is supple taut, the condition is not bad because the stomach qi is still in pulse.
D.Pulse Combinations The floating and taut pulse indicates sustained fluid retention. The deep and taut pulse suggests suspended fluid retention. The rapid taut pulse is usually due to heat while the slow one to cold.
25. Tight Pulse
0
A,Pulse Character The vessel is tight. The pulsation is swift and forceful. It feels like fingers on a tightened cord.
B. Disease Suggested Cold and pain syndrome.
C. Analysis The cold causes contraction. The cold in body makes the vessel contracted, so the pulse is tight. The pain syndrome is mostly due to obstruction. The obstruction in vessel tightens the vessel.
D. Pulse Combinations The floating tight pulse is a character of exterior cold. T h e deep tight pulse means interior cold. If combined with sluggish pulse, it is present in cold rheumatism. While with surge pulse, it suggests the abscess and ju.
26. Long Pulse A. Pulse Character The pulse is smooth and straight. The pulsation can be felt in not only the three portions but also over the usual position. The pulse can be normal or morbid.
B. Disease Suggested The pulse indicates all excess syndromes. It is usually present in excessive heat syndrome due to exorbitant heat-poison evil. 165 *
C. Analysis The long pulse is a sign of exuberant qi in normal condition. The normal long pulse is supple and moderately forceful. But if the pulse is too long and forceful, it is not normal and indicates the heat-poison or liver yang hyperactivity. In that condition, the patient may have a high fever and constipation. If the long pulse combines with other morbid pulse, it is certainly an abnormal pulse.
D. Pulse Combinations The floating and long pulse is present in exogenous disease or yin deficiency. The surge and long pulse is often found in patient of mental disorder. T h e deep and long pulse suggests the abdominal lump. The long and taut pulse indicates liver diseases. The slightly uneven and long pulse implies the recovery.
27. Slippery Pulse
A. Pulse Character Thewpulsemoves quickly and slipperily along vessel, just like a rolling pearl under skin. The vessel is plump.
B.Disease Suggested Phlegm, food retention and excessive heat are the main syndromes.
C. Analysis When excessive evil in the body, the genuine qi rises against the evil, the qi and blood are all mobilized, therefore the vessel is filled up and the qi and blood in vessel moves quickly. The pulse becomes plump and slippery. The slippery pulse in a woman may imply the pregnancy. The slippery pulse in a normal body means the plenty of qi and blood. If the pulse is large and slippery, it is abnormal. T h e slippery pulse in a very weak patient implies the loss of vital qi.
E. Pulse Combinations The floating and slippery pulse suggests od retention. The fire. The slippery and strong pulse means heat in the stomach.
28. Surge Pulse
A. Pulse Character The pulse is large and forceful like a flood flowing. The vessel is wide and thick. The coming of pulsation is strong and the leaving is quick.
B. Disease Suggested The pulse is present in excessive heat syndrome which is shown by fidget, ex*
166
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tremely thirst, mania, macular and papular eruption, and headache. It also indicates yang hyperactivity, stomach heat and abscess. The pulse is mostly seen in the fulminant stage of warm diseases.
@. Analysis The surge pulse belongs to fire. It is strong and wide and corresponds with the exorbitant qi in summer. When heat evil fills up all over the body, the genuine qi is mobilized, the qi and blood rush into vessel to fight against evil. So the vessel dilates and the pulse forms. If the pulse is present in deficiency syndrome, it is due to exposed genuine qi which escapes to the exterior. If the extremely excessive heat damages the yin, the yang has to float outwards, the surge pulse at that time shows that both yin and yang are out of their normal range. It is a sign of dying.
D. Pulse Combinations The floating and surge pulse means heat in the exterior. The deep surge pulse indicates heat in the interior. The surge and tight pulse suggests abscess. The surge and slippery pulse is due to phlegm-fire. The strong surge pulse shows the epilepsy*
Appendix: True Visceral Pulse and Paradoxicall Pulse
19, True Visceral Pulse The true visceral pulse refers to the pulse appearing in the case of zang-viscera1 genuine qi damage which is the final stage of diseases. Because the visceral essence and genuine qi are exhausted, the pulse changes strangely. The stomach qi, the root and vitality of the pulse are all absent. Plain Questions described the pulses. "The true liver pulse is extremely tense and could not be bent. It feels like a knife edge. The true heart pulse is hard and beating rigidly. The true lung pulse is large and hollow. It feels like a feather on skin. The true kidney pulse is extremely forceful. It feels like a stone hitting on finger. The true spleen pulse is alternately rapid and slow in an irregular way. All these pulses imply death.
"
2. The Paradoxical Puke Based on the theory of true visceral pulse and accumulation of experience, the theory of paradoxical pulse was raised. The theory summed up all the pulses without stomach qi, vitality and root. They are listed as follows:
A. Bubble Pulse The pulse is extremely floating and rapid. It can be felt just under the skin. 167
The pulse feels like the bubbles rising in boiling water which are numberless and stroke up but not down. The pulse is rootless. It is a sign of extreme heat in three yang and absence of yin. Because the loss of yin makes the qi uprooted and floating. While the qi dies out, the death comes.
B.Fish Swimming Pulse The vague pulse can only be identified on seeking. While touching, it is very faint. The pulsation is irregular and not clear. It is compared to the swimming fish in water. It is a sign of extreme cold in three yin and the expiring yang.
C.Flick-on-Stone Pulse The pulse is hard and rapid in the very deep level. The feeling is like the finger flicking on stone frequently. While on seeking, the pulse disappears. This pulse is the true kidney pulse which reflects the expiring kidney.
D. Rope-Untying Pulse The pulse is also in very deep level. It beats sometimes rapid and sometimes slow. The changing is irregular like untying knots in a rope. It indicates the exhaustion of both essence and blood or the expiring vital qi.
E.Roof -Leaking Pulse The pulse is very slow and irregular. The interval is long and not equal. It is compared to the leaking drops from the roof after rain. It suggests the dying stomach qi or the exhaustion of defensive qi and nutrient qi.
F.Shrimp-Darting Pulse The pulse is sometimes rapid and sometimes slow in the superficial level. And it beats sometimes clear and sometimes vague. Forceful pulsation may appear only one time occasionally. The pulsation is compared to the shrimp in water which moves irregularly and sometimes jumps to the water surface and then dives into deep water and hides in the water. The pulse is a portent that the mind is going to leave the body. ,@. Sparrow-Peeking Pulse The pulse is rapid and forceful with some 3 or 5 more rapid beatings which occur occasionally. The pulsation is in the deep level of tendons. It likes the sparrow which is pecking food. The pulse shows the malnutrition of meridians due to dying stomach qi.
H. Bean-Rolling Pulse The pulse is plump and short like a bean. The position of pulsation is not fixed. The feeling is just like the finger on a rolling bean. It is the true heart pulse 168
a
which means the exhausted heart and the wandering genuine qi.
1. Knife Pulse The pulse is hard, large and tense and all the same in the three portions. The pulsating is without rhythm. It feels like the finger putting on the edge of a large knife. I t is true liver pulse.
J. Confused Running Pulse The pulse is extremely rapid, thready and faint like the appearing of scattered eruptions in the measles. It shows the fatal condition of exhaustion of all qi and blood. All the ten kinds of paradoxical pulse are seen often in the dangerous disease conditions. Because the mortality is high in the patients with paradoxical pulse, so the pulse is also called "death pulse". Nevertheless, some ancients found that not all the patients died when the pulse was present. For example, Wang Gui said: "The shrimp-darting pulse and sparrow-pecking pulse belong to death pulse. The pulses are often present in the diseases of obstruction and rejection of qi and phlegm. But it should be known that the pulses are also seen in normal people occasionally or in the patients suffering from syncope and the pulse does not indicate the death on that occasion.
"
Xue Lizhai proposed that the diseases with paradoxi-
cal pulse be cured with Ginseng, Astragalus, Dried Ginger and Aconite. Now the medicine has achieved great progress. Most of the diseases with paradoxical pulse can be cured by proper and prompt treatment.
V.Key Point for Pulse-taking and Distinguishing Among Morbid Pulses The pulse-taking is the most complex and hardest to master among all the four diagnostic methods. Therefore, Xu Yinzong said that the pulse was profound and difficult to understand; and it was hard to express in language although one might know the meaning. "Only by extensive study, the mind will open and realize the meaning; and by the profound thinking, a thorough understand can be got. Then any sort of diseases and evils could not puzzle the doctor and escape from the treatment.
"
T o practice widely and think profoundly are very important for mas-
tering pulse-taking. The key points and distinguishing are very useful in conditions of complex diseases and pulses.
I. Key Points for Pulse-Taking The position, rate, shape and dynamic are the four key points of pulse. If knowing the points clearly, one can get full understanding on the 28 morbid pulses. 169
T h e first, the pulse position refers to the three portions and nine taking, namely the length and level of pulse appearing. That is helpful for grasping the disease location and deficiency and excess. The second, the pulse rate is the rhythm and beating number in a breath which is standard for judging slow, rapid, moderate, swift, knotted, running, regular intermittent pulse. Then, the pulse' shape is the vessel state. The slippery, uneven, taut, thready pulse and other pulses are identified mainly by this. The last one is the pulse dynamic. It is the state of pulse moving and power. By the four aspects, the pulse is recognized. But the morbid degree and pulse site should also be measured. The morbid degree, namely the mild or severe, is used to infer the seriousness of disease. And the pulse site is where the morbid pulse is present, in all the three portions or just the one portion. Knowing of these, the pulse-taking is completed.
2. Distinguishing Among Morbid Pulses Wang Shuhe said: "The theory of pulse is very sophisticated
....o*
.The shape of
pulse is difficult to distinguish. It is easy to understand but difficult to distinguish by palpating.
"
The distinguishing is done in the following two aspects.
1) Comparing The comparing includes two aspects. The one is to sort out the pulses according to the similarity among pulses. It is called sorting. The other is to separate the similar pulses by analysis. It is called discriminating.
AmSorting The morbid pulses are too many to remember. By sorting, they can be kept in mind in a simple way. The morbid pulses were grouped into two, four, six, seven or eight categories in ancient times. The classifications have their own advantages and disadvantages. The classification for six categories are often used. Now they are introduced as follows. a. Floating Category
All the pulses are characterized by clear in superficial level and decreased but not hollow when in middle and deep levels. It includes floating pulse, hollow pulse, tympanic pulse, scattered pulse and soggy pulse.
b. Deep Category The pulses of this category are characterized by clear pulsation in deep level and weakened in superficial and middle levels. The category includes deep pulse, hidden pulse and firm pulse. 170
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c. Slow Category The pulse of this category is slower than normal. I t includes slow pulse, moderate pulse, sluggish pulse, regular intermittent pulse and knotted pulse.
d. Rapid Category The category is characterized by rapid pulsation. T h e pulses in the category are rapid pulse, swift pulse, bouncing pulse and running pulse.
e. Weak Category Forceless pulsation is the common character of all the pulses in this category. T h e category is composed of weak pulse, thready pulse, faint pulse, feeble pulse and short pulse. %. Strong Category
T h e forceful pulsation is the common point of the category. Pulses in the category are strong pulse. taut pulse, tight pulse, long pulse, slippery pulse and surge pulse.
B.Discriminating Many pulses are very similar, so that they are often confused when taking pulse. We should know not only the similar point but also the differences among them.
a. The hallow shaped pulses : The hollow pulse is empty in the middle and clear in the edges of the vessel. The tympanic pulse is taut, large and rapid by touching and becomes faint by seeking and pressing. The weak pulse is slow, large and soft and becomes weaker just like being hollow when pressed.
b. The thready shaped pulses: The soggy pulse becomes very weak by pressing. T h e feeble pulse is absent by touching.
e. The forceless pulses: The faint pulse is found by touching but becomes vague by pressing. The weak pulse is clear in all levels. The thready pulse is clear but thin and it is stronger than faint pulse.
d. The intermittent pulses: The regular intermittent pulse pauses in a fixed interval. The knotted pulse is slow with irregular intermittences. The running pulse is rapid with irregular intermittences. The sluggish pulse beats irregularly and moves sluggishly. e. The countless pulses : The faint pulse is found by touching. The scattered
pulse is vague and the shape is not clear. 171
f . The pulses in deep level: The hidden pulse is found when palpating with heavy strength. The firm pulse is forceful, large, taut and long by pressing. The deep pulse is vague by touching and clear by pressing.
g. The rapid pulses: The rapid pulse beats 5 to 7 times a breath. T h e swift pulse beats more than 7 times a breath. The tight pulse is tense. R. The forceful pulses: The strong pulse is Iorceful in all levels. T h e surge pulse beats like the flood.
i. The plump pulses: The slippery pulse moves quickly and is plump in all three portions. The bouncing pulse is plump and rolling in only the guan portion.
j. The slow pulses: The slow pulse beats less than 4 times a breath. The moderate pulse beats 4 times a breath and moves smooth. k. The tense pulse: The thready and hard pulse like a string is taut pulse. The forceful and thick pulse is tight pulse.
2) Contrasting All things in the world belong to either yin or yang. The pulses are the same. By contrasting, the pulses with characters counter to each other are paired. It is helpful to remember. Floating pulse and deep pulse, slow pulse and rapid pulse, weak pulse and strong pulse, long pulse and short pulse, slippery and sluggish pulse, surge pulse and faint pulse, tight pulse and moderate pulse, bouncing pulse and hidden pulse, e ~ and firm pulse are all the paired knotted pulse and running pulse, s ~ a t t e r pulse pulses with inter-countered characters.
If the comparing and contrasting groups are fully understood and remembered, all the morbid pulses can be mastered. So one can do pulse-taking skillfully.
VI. Female Pulse and Infant Pulse
1.Female Pulse The women have their special and unique physiological and pathological changes. And women belong to yin while men to yang. Therefore, the female pulse is somewhat different from male pulse. The differences are listed as follows.
A. Pulse about Menstruation If the pulse becomes little large or surge in guan and chi portions of left cunkou without fever, abdominal distention and bitter taste, it implies the menstruation
in few days. If the pulse is slightly sluggish, or weak, or slippery in chi portion but normal in the other two portions, there will be a menstruation with trouble. 172
In amenorrhea, the deficiency or excess can be judged by pulse. If the pulse is slightly sluggish in chi portion, it is due to blood deficiency. While the slippery pulse in chi portion means the excess. In the condition of preceded menstruation, most the pulse is yang pulse. The pulse in condition of delayed menstruation is usually yin pulse. In conditions of metrorrhagia and metrostaxis, the slow and weak pulse suggests a good prognosis, while the slippery and strong pulse is a critical sign.
B. Pulse in Preglnaracy The Plain Questions held that if the pulsation in chi portion was more vigorous than that in cun portion, or the pulsation corresponding to the heart became vigor, the woman was pregnant. Some ancient doctors thought that the slippery and rapid pulse in chi portion was the sign of pregnancy. In it, if the left pulse is floating and surge, the fetus is male: while the right pulse is deep and strong, the fetus is female. Or the floating, large, slippery and strong pulse in left cun is the mark of male fetus, while the deep, slippery and strong pulse in the right cun is the sign of female fetus. The "off-meridian pulse" is present in the women who are going to delivery. T h e pulse is different in length and rhythm like the sparrow-pecking pulse or roofleaking pulse. In General Treatise on Causes and Sy?nptoms o f Diseases, it was recorded: "If the pulse of a pregnant woman is rapid and tight in chi portion, the delivery comes to happen.
"
The Presep-ved Medicinal Wo?-ds recorded: "There is
not pulsation at the bilateral sides of the end of middle finger. If pulsation appears in the places in a pregnant woman in combination with blurred vision and paroxysmal abdominal pain which becomes more and more severe and frequent, it is the very time for delivery.
"
In Internal Classic, the death or living of fetus is judged by pulse-taking. The sluggish pulse and tight pulse are considered as the omen of death fetus. Because the sluggish pulse and tight pulse are the sign of lack of essence, blood and yang. When those are deficient, the fetus is not supplied and warmed. After childbirth, the moderate and slippery pulse indicates the good condition of qi and blood. If the pulse is firm, large, taut, sluggish or not equal, the blood and qi are used up. Yet, the above mentioned pulses in women still require to be tested clinically. So the pulse should be used in combination with other methods to make diagnosis on woman's special changes.
\
2. Infantile Pulse In the Internal Classic, the pulse-taking for children is recorded. After that, doctors suggested that the pulse-taking should be replaced with observation of index finger collateral if the child is 3 to 5 years old; and the pulse-taking should be only used for the child more than 5 years old. Because the arm of child is too short to contain the three fingers, so the pulse-taking can be done with only one finger. The child more than 10 years old can be treated in the same way of the adult. The 28 morbid pulses are not suitable to describe the morbid pulses of child. Only the floating, deep, slow, rapid, weak and strong are used for child. The weak pulse means deficiency while the strong pulse is due to excess syndrome. The floating pulse indicates exterior syndrome. The forceful one is due to wind-heat while the weak one to interior deficiency. The deep pulse suggests interior syndrome. The vigorous one is due to phlegm or food retention. The forceless one is a sign of qi stagnation. The sapid pulse indicates heat syndrome or being frightened. The normal pulse rate is 7 or 8 times a breath for child below 5 years old; and is 6 for that of 5 to 10 years old. If the pulse beats more than those rate, it is rapid. The rapid and floating pulse indicates exterior heat, while the deep and rapid pulse suggests interior heat. The forceful one reflects excessive heat, while the flaccid one shows deficient heat. The slow pulse indicates the cold and deficiency. The floating and slow pulse is due to exterior cold and the deep one to interior cold or spleen deficiency. The forceful one implies pain condition while the weak one shows deficiency cold.
VHP. Compound Pulse and Solitary Pulse ply or complex. The compound pulse is the pulse condition that two or more morbid pulses appear in the same patient and in the same time. In the 28 morbid pulses, many of them are compound pulse. For example, the tympanic pulse is composed of floating pulse, taut pulse, rapid pulse and hollow pulse; the firm pulse is cornposed of deep pulse, strong pulse, taut pulse and long pulse. The compound pulse is only found in pathological condition. They were called "combined pulsesJ' by Xu Lingtai. The compound pulse may be composed of two pulses or more. The Diseases suggested by compound pulse are the combination of those of all o
174
component pulses. Taking the floating and rapid pulse as example, the floating pulse indicate exterior syndrome and rapid pulse suggests heat syndrome, then the rapid and floating pulse indicates exterior heat syndrome. There are three meanings of solitary pulse. The first is that some morbid pulses appear in one portion only. This kind of pulse suggests the same diseases indicated by the morbid pulse but only in the viscus corresponding to the portion. For example, the weak pulse only in left chi indicates kidney yin deficiency. The second is that some pulse corresponding to a viscus is present in all portions. The five zangviscera have certain relations to some pulses. The liver is related to taut pulse, the heart to surge pulse, the spleen to moderate pulse, the lung to floating pulse and the kidney to deep pulse. If pulse in all portions is taut and there are other symptoms related to the liver, it reflects liver diseases. The third is some morbid pulses in all portions. For example, the surge pulse in all portions is due to heat: the scattered pulse in all portions means death.
VlfHI. The Relation Between Pulse and Symptoms In most of the clinical conditions, a doctor could not make diagnosis only by the pulse, but also the comprehensive data. The relations between pulse and symptoms may be one or two of the following two kinds.
I.The Identiccall or Non-Identicall Relati on If the diseases/syndromes the patient suffers from (proved by symptoms) are among the diseases indicated by the pulse presented in the patient , the pulse and symptoms are identical, else they are not identical. If they are identical, the prognosis is relatively good, else the prognosis is bad. For example, the high fever in a patient abates after sweating, and the pulse becomes calm too, the pulse and symptoms are identical and the patient will recover soon; if the fever abates but the pulse is still very fast, they are not identical, the disease will develop further. Zhang Jingyue gave an excellent explanation on that: "In all excess conditions, the pulse should be vigorous; if the pulse is faint, sluggish, thready or feeble, it is a sign of deteriorated conditions. In all deficiency conditions, the pulse should be soft and supple; if it is surge, large, strong, slippery, floating or rapid, the prognosis is bad.
"
"In fulminant diseases, the floating, surge, rapid and strong pulses are relatively good signs. The faint, moderate, soft and feeble pulses in the prolonged diseases are also relatively good. If the pulse is on the contrary, the condition is bad. The identical pulse and symptoms are good to patient. " 175
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The ancient doctors accumulated rich experiences in the field. Some of the experiences are listed as follows. Exogenous febrile diseases should have yang pulse like rapid and surge pulse.
If the pulse is yin pulse like deep, faint, sluggish or small pulse, it is not good. In diseases of spleen damage by over stress, the pulse should be weak or feeble. If it is rapid with spontaneous sweating, the prognosis is bad. In diarrhea disease, the condition is good if the pulse is deep, small or feeble. The strong, large, floating and rapid pulses are bad signs. In fire or heat syndrome, the pulse should be surge and rapid. If it is faint, the condition is dangerous. In asthma, the pulse should be floating and slippery because the asthma is caused mostly by wind and phlegm. If pulse is deep and sluggish, the disease will deteriorate. In diseases of loss of blood, the pulse should be hollow or moderate. If it is large and rapid, the yang depletion may occur soon. In phthisis, the pulse should be faint or feeble. If the pulse is taut and rapid, it is the sign that the liver over-restrains the spleen or wood fire invades the metal. It is a deteriorating condition. The blood stasis belongs to excess solid evil, so the pulse should be large and strong. If it is deep and sluggish, the yang and qi become deficient and lose their ability to push blood. It is a hard situation because the offensive therapy for eliminating stasis could not be used straightly. In consumptive thirst disease, thereqis too much dry-heat in the body, so the pulse should be rapid and large. If it is thready, faint, short or sluggish, the prognosis is bad. The jaundice disease is mainly caused by damp-heat, so the pulse should be surge, rapid, floating and large. If it is faint or sluggish, the condition is severe. Id be floating, large, surge and strong. If it is deep, thready and faint, the condition is serious.
2. Choosing One from the Non-Identical Pulse and Symptoms The non-identity between pulse and symptoms may present in some occasions. For example, the yang pulse with symptoms related to yin, or pulse of excessiveness with symptoms of deficiency. The non-identity makes syndrome differentiation difficult. The causes of the non-identity include:
A.Sudden Onset 176
When evil invades the body and causes disease onset suddenly, the symptoms occur but the pulse is not changed in time, then the pulse and symptoms are not identical. Or the sudden occurred pain makes the qi and blood stagnated, then the flow in vessels could not reflect the true condition in body.
B. Mild Illness When illness is mild, the qi and blood are not involved, so the pulse is not changed. That is the malaise in body but not in pulse. Or in some cases, the pulse is changed, but the patient has not felt any discomfort. It is morbid pulse without disease in the body.
C . Internal Obstruction Sometimes, the phlegm, blood and food are staying in the body and obstructing the qi and blood flow, then the pulse may become vague which is like the pulse of severe disease of deficiency.
D. Coexistence of Diseases When many kinds of diseases are in the same body, or a disease occurs in the body with old diseases, the pulse will not be identical to the symptoms.
E. Constitutional Difference T h e pulse in a fat body is always deep, even though the exogenous disease attacks the body. On the contrary, the pulse in a slim body is usually floating even if there is interior disease in the body. The floating and rapid pulse may be seen in a yang predominant body even the disease belongs to yin, and vise versa. Since the pulse may be not identical to clinical symptoms, we should decide whether the pulse, or symptom can be used for diagnosis. The false expression should be neglected. About how to distinguish the true from the false, the ancients had not reached agreement. Zhang Jingyue9s opinion was more acceptable as follows. The key point is to identify which one is the aspect of deficiency. Because the manifestations of excess are often changeable, so the false excess manifestations are often seen. And the 'manifestation of deficiency is usually true. If the pulse belongs to deficiency and the symptoms to excess, the symptoms are false. While the pulse reflects excess and symptoms show deficiency, the pulse is false. If the faint pulse is found with fidget, the fire is certainly deficient. The abdominal distention with feeble pulse means the stomach deficiency. If the pulse is surge and rapid, but there is not fever and fidget, the pulse is false. The taut pulse without pain and distention could not be considered as internal excess syndrome. 177
a
Zhang Jinyue thought that there were only two kinds of conditions of nonidentity in deficiency and excess. The one is the acute heart pain or abdominal pain which is caused by cold evil attack or by food retention. In the conditions, the vessel is obstructed and the pulse becomes deep, slow intermittent or knotted pulse. The syndrome is excess and the pulse is of deficiency. So the pulse is false. The other is the cold limbs or chill with rapid slippery pulse. It is a condition of extreme heat like cold. The heat can be proved by the fidget and constipation. Except for the two conditions, all conditions else can be judged by the deficiency aspect as mentioned above.
Section 2
Body Palpation
The body palpation is to touch and press some parts of the patient's body to probe the cold or warm, dry or moist, soft or hard, tender pain, lump or other morbid changes for diagnosis. The ancient doctors applied not only pulse-taking but also body palpation to diagnosis. In the Internal Classic, Treatise on Cold-Attack, Synopsis of Golden Chamber, the body palpation was recorded. In it, the chest and abdomen palpation was taken as an important method for detecting the location and nature of disease. The functions of body palpation are: detecting the deficiency or excess by the patient's acceptance or rejection of pressing; identifying the cold or heat and the state of body fluid by touching skin; ascertain which one of qi and blood is involved in disease by pressing the chest and abdomen; making prognosis and judging the state of the genuine qi by touching the p u l s a t i o n in Xzili a n d a r o u n d navel.
I.Posture When doing hody palpation. the patient is x e q ~ i r e dto sit or lie s u p i ~ eWhen . palpating the chest and abdomen, the patient ought to lie on back and keep relaxed with legs stretched and hands laid aside. The doctor should stand by the right side of the patient. The right hand or both hands are used for palpating. When touching the deep part of abdomen, the patient is required to bend the legs to relax the abdominal muscle, so the deep part can be felt easily. 178
2. Manipulation There are three manipulations of body palpation, touching, seeking and pressing. The strength used in hand is increased from touching to seeking and to pressing just like that of pulse taking.
A. Touching: It is to touch the patient's body with the palm and fingers. The method is often used to touch the forehead, limbs, chest and abdomen. The main aim is to know the cold or warm, moist or dry, so as to know if the disease is an exogenous or endogenous disease, to find sweating condition, and to detect the states of yang and yin.
B. Seeking: The fingers are used to palpate patient's body with more strength than that used in touching. The method is mainly used in palpating the chest, abdomen, points, and swelling place. The purpose is to detect if there is pain and the shape, texture and size of the swelling. It can also find the condition of the genuine and the evil.
63. Pressing: T h e palpating is done with heavy force to probe if there is swelling or lumps in the deep part of abdomen. The visceral condition is also known by this method. When palpating, the three methods are used in combination. Generally, the touching is used first, and the seeking is the second, then is the pressing. T h e strength on hand is increased from one to one. The rough manipulation should be avoided. In winter, the doctor ought to get the hands warmed before doing palpating. Besides, the doctor should observe the patient's expression changes when doing pressing. Before examining, the doctor should tell the patient that the feeling during palpating be told to doctor, so the doctor can understand the condition. 11. The Main Content
The body palpation includes four parts. They are discussed as follows.
1. Palpating Skin It is to feel the cold or heat, moist or dry, and if there is any swelling in skin.
1) Detecting Cold and Heat: The skin temperature reflects the cold and heat of body. The heat is mainly due to excessive heat while the cold is usually caused by declining yang. When the skin is hot, we can know if the disease is in the exterior or the interior, or is excess or deficiency by the more careful palpating. If the skin is very hot *
179
*
on touching but becomes less hot when palpating for a little while, it reflects the heat in the exterior or the deficiency heat. While the skin is little hot on palpating and becomes very hot when keeping touching for a moment, the heat evil is in the interior. If the skin is not hot and the deep body is hot, it is a "bone steaming" fever or damp-heat in bone,
2) Detecting Moist and Dryness: The moist or dry skin reflects the state of sweating and body fluid. The moist skin shows sweating or sufficient body fluid, while the dry skin is the sign of no sweating or body fluid depletion. The moist and warm skin is found in syndrome of wind-heat attack of the exterior. The moist and hot skin is due to interior exorbitant heat. The moist and cool skin is seen in yang deficiency which is the result of excessive sweating or is the sign of yang depletion. The dry skin is due to no sweating. The dry skin in a strong body is seen in excess syndrome which may be cured by diaphoretic therapy. If the dry skin is accompanied by vexation and hot sensation in the five ceqters, or the skin is very dry, rough and squamous, it is the sign of body fluid depletion, yin deficiency or coagulated blood in body. In this condition, the diaphoresis is contraindicated.
3 ) Examining the Swelling: The edema and qi-swelling should be distinguished. When the skin is swollen, if a deep finger shape pitting is formed when it is pressed, and could not return to flat, it is edema which is caused by excessive water in body; if the pitting is formed by pressing but returns to flat soon after release the finger, it is qi swollen which is due to qi stagnatcy in the area.
4) Examining the Sore: It is to know if there is pus or not in the sore and what it belongs to. The hard, not hot sore with feeling of numb belongs to cold. The hot sore with pain pertains to heat syndrome. The flat swelling sore is due to deficiency while the high swollen sore to excess.
If the sore is hard and warm, it is most likely that there is no pus in it. While in the hot sore with soft peak and hard root, there is certainly pus. The pus in abscess in the deep part of muscle is judged by the "resonance" or
.
"non-resonance" The method is that the two hands are putting on two sides of the abscess separately, the one hand is tapping on one side, the other is feeling if there
.
is vibration. The vibration is the "resonance" If there is "resonance", there is pus in the abscess, and vice versa. The amount of pus can be measured by the area in which the vibration can be felt.
2-Palpating the Hands and Feet The main purpose of palpating the hands and feet is to survey the cold and heat, deficiency and excess of disease.
1) Surveying the Warm or Cool: The four limbs are the terminals of all yang. The temperature of the hands and feet reflects the state of yang and qi, and the development of disease. Generally speaking, the cold hands and feet belong to heat syndrome which is caused by yang deficiency and yin predominance; the hot hands and feet pertain to cold syndrome and reflect the yin deficiency or yang predominance. But the cold limbs can also be seen in excessive heat syndrome because the encircled yang fails to reach the extremities when the exorbitant heat evil wraps the yang. If the hands and feet are hot in a heat syndrome, it is a favorable case; while the hands and feet are cool, it is an unfavorable case and the disease is severe. It is valuable for judging the prognosis to survey the temperature of limbs. If the limbs are still warm in a yang exhaustion syndrome, the patient can be saved. While the limbs are cold, the prognosis is bad. In Treatise on Cold-Attack, it was said: "In Shaoyin disease, diarrhea is often seen. If the diarrhea stops and there are chill and curved lying, and the hands and feet are warm, the patient can be cured. " and "In Shaoyin disease, there are chill and diarrhea. If the limbs are cold, the patient is incurable. "
2) Discriminating the Interior from Exterior: If the dorsal part of hand is hotter than palm, the fever belongs to exogenous disease; while the palm is hotter than the dorsum, it pertains to endogenous fever. In addition, the comparing between the palm and forehead can also give proof for discriminating the exterior from interior. If the forehead is hotter than palm, it is an exogenous fever, and vice versa.
3 ) Palpating Child Hands: The cold finger tip indicates convulsion. The hot middle finger with normal other fingers is a sign of external wind-cold attack. The cold middle finger with normal other fingers is the sign of eruption in measles.
3. Palpating the Chest and Abdomen The soft or hard, the cool or warm of the chest and abdomen, and whether there is pain, distention, swelling and mass are the main aspects. The visceral state and evil nature can be found out by doing so. Internal Classic said: "The chest and abdomen are the external wall of viscera.
"
Yu Genchu, a famous doctor in Qing
Dynasty, also said: "The chest and abdomen play the same role for viscera as the 181
a
city wall for the city. They are the source of yin, yang, qi and blood. If you want to know the visceral state, the best way is to palpate the chest and abdomen. " The chest and abdomen are divided as the following. The upper part of trunk above the diaphragm is chest. The lower part below the diaphragm is abdomen. The bilateral sides of chest from axillary fossa to the costal margin are called
.
"hypochondrium" The little -region just below xiphoid process is called "below heart". The region between "below heart" and umbilicus is the upper abdomen. In the upper abdomen, the upper half is stomach region and the lower part is called "big abdomen". The abdominal part below navel is the lower abdomen. In lower abdomen, the middle part is called "little abdomen" and the bilateral sides are "junior abdomen.
"
(The division of chest and abdomen is illustrated in the picture.
Picture 7 Qepigastrium
)
The Division of Chest and Abdomen
@stomach
@junior abdomen
@)big abdomen @hypochondriurn
@little abdomen QXuli
The palpating order is from the upper to the lower, namely from chest to hypochondrium, to "below heart", to "big abdomen", to "little abdomen", and finally to the "junior abdomen". There are many manipulations for palpating chest and abdomen. Generally, the palpating is done from touching to seeking and to pressing. If necessary, the push-
ing-pressing and percussion are used.
11) Pabating the Chest The chest is the house of the heart and the lung. So we can know the conditions of the heart and the lung. The lifted anterior chest, if accompanying with asthma occurring by pressing, belongs to lung distention: if pain occurs when pressing, pertains to water accumulation in chest or qi clogged up in the lung. The chest pain radiating to back, shoulder and medial side of arm, aggravated by pressing, is cardiac pain. The X u l i is the main aspect for palpating chest. In ancient times, it was called "bouncing qi in X u l i . " The X u l i is located left nipple with apex beating. It is the meeting region.of all meridians. Zhang Jingyue considered the bouncing in XuZi as the heart beating and took the beating as the cause of deficiency. When patient suffering from palpitation, the bouncing in X u l i will certainly be abnormal. So it is an important method for detecting heart state. T h e heart is the supreme monarch of all organs and viscera. So palpating X u l i can also get a survey of whole body. In the critical condition or children disease, palpating X u l i is more important because the
cunkou pulse is difficult to palpate. In normal condition, the bouncing in X u l i is neither rapid nor slow in the moderate force and can be felt with fingers. That is the sign of abundant heart qi and pectoral qi in chest. In morbid condition, the palpating should be done in the following aspects.
A. Strong or weak: The feeble beating is due to pectoral qi deficiency. The too strong beating is the sign of escaping pectoral qi. If the beating is easy felt when touching and becomes weal; and difficult to feel when pressing, the qi is deficiency.
If the bouncing is in large region when touching and becomes beating in small region when pressing, it is due to blood deficiency. The extremely forceful beatsingin a large region and faint beating both indicate dangerous situations.
If the beating is so forceful that the fingers on it are lifted, and the sound can be heard, it is due to excessive fire in the heart and stomach. The forceful beating that can be easily seen in a women before delivery is not a good sign. If seen in consumptive diseases, it implies the deterioration of disease. The forceful beating after being frightened, or anger, or severe physical movement, but can recover after rest, is a physiological phenomenon. 183
B. The rate: The rapid beating with irregular intermittences is due to the slack middle qi. The slow beating is caused by heart yang deficiency. The regular intermittences for each 3, 4,5, or 6 beatings are due to evil retention. The ceased beating is the proof of death.
C. Thk beating region: If the beating is focused on the small area within a finger, it is "gatheringJJand is the sign of abundant genuine qi. In this condition, the disease is mild. If the beating is scattered in a large area, it is "scattered" and is the sign of slack visceral qi. The scattered beating with lifted chest and asthma is the omen of expiring heart qi and lung qi. The scattered and forceful beating is due to extreme heat which is usually present in exogenous febrile disease,,.food retention or in condition that the eruption will soon occur in disease of measles.
2) Pdpatiioltg of Hypochomdrium The right hypochondrium is the house of liver and gallbladder. The liver meridian distributes in hypochondrium of two sides. So, changes in hypochondrium reflect the diseases of liver and gallbladder.
A. Distention and pain: If the distending pain in hypochondrium is radiating to bilateral lower abdomen, it is due to liver qi stagnation. If the pain is aggravated by i,
pressing and is accompanied by hot hypochondrium, it is caused by liver fire. The swelling below costal margin with red skin and tender pain belongs to liver abscess. The hypochondriac pain alleviated by pressing is due to liver deficiency in which condition, this part is soft when pressing. The full sensation below costal margin is due to evil in the half-exterior and half-interior in exogenous disease or is due to liver qi stagnation in endogenous disease.
B.The lump: The lump below
costal margin with stabbing pain is due to blood
stasis. If the lump gives sound when pressed, it is fluid retention in it. If there is mask below right costal margin and the mass is rough, it may be liver cancer. The hard mass appearing after malaria is called "malaria mass.
"
3) Palpation of Abdomen The content includes the stomach region, big abdomen and lower abdomen.
A. Palipation s f stomach region: The stomach region reflects the diseases in stomach. In exogenous diseases, the changes are mainly the "chest blockageJ' and "stuffiness".
Distention and gain: The stomachache which radiates to the hypochondrium when pressing is due to liver attacking stomach. The prickle pain of stomach in 184
a
fixed location, aggravated by pressing, is due to blood stasis in stomach. The distending pain aggravated by pressing with belching of stale food is due to food retention. Sudden stomachache with chill is due to cold attack on stomach. The prolonged stomachache alleviated by pressing is due to qi deficiency.
"Chest blockage" : If there is a symptom of stomach distention and it becomes pain when pressed, the condition is named "small chest blockage. While the severe "
pain in chest and whole abdomen aggravated be pressing, even with bulged stomach region, is called "great chest blockage.
"
Stuffiness: The stuffiness refers to the feeling of distending and something clogged up in stomach. Although there is distending sensation in stomach, but there is no changes of the out shape. If the stomach region is soft when pressing, there is due to deficiency. While there is resistance or tender pain, it is an excess syndrome. If the stomach is distended with dull pain, and there is sound when pressed, it is fluid retention in the stomach.
B. Palpation of "big abdomen" : The big abdomen is the house of the spleen. So, abnormality in the region is closely related to diseases of spleen.
I
Cold and heat: If the abdominal wall is cool and the patient likes to be warmed and pressed, it is a cold syndrome. While the abdominal wall is warm and the patient likes to be cooled, it reflects heat syndrome. The cool abdomen in critical case means the dying yang. If it becomes warm after treatment, the yang begins to recover.
Soft and hard: T h e softness and hardness reflect the states of the genuine qi and the evil. If the abdomen is soft, the visceral qi is deficient. If the abdomen is too soft to resist finger, the viscera are exhausted. The hard abdomen reflects excessive evil in abdomen. In exogenous diseases, if the abdomen has not become hard, the evil has been in the exterior yet; while the abdomen becomes hard, the evil has entered the interior.
Pain: If the pain is alleviated by pressing, it belongs to deficiency; while aggravated by pressing, it pertains to excess. If the pain is around the navel and is aggravated by pressing, accompanied with constipation and dry feces, it pertains to dryness in stomach and intestines. Abdominal pain, with soft abdomen is due to spleen deficiency. Abdominal pain preference to be warmed and pressed is due to deficiency cold in the middle. If the abdominal distending pain appears after anger with rejection to pressing, or is accompanied with gas moving in abdomen when pressed, it is due to liver aggression to spleen. If the abdominal pain radiates to hypochondria
185
a
um, the pain is alleviated by heavy pressing but with rebound pain, it is due to spleen deficiency plus liver stagnation.
Distention: If there is a persistent abdominal distention which is tense and hard in palpation, and there are tenderness and dull percussion sound, it belongs to excess which is caused by firmly excessive evil such as dry feces, food retention, water or fluid retention. If the distention is paroxysmal and accompanied by resonance percussion sound, and the abdomen is soft, it pertains to spleen deficiency.
Mass: Attention should be paid to the shape, hardness, tenderness and movability, etc,
If the mass is persistent in a fixed place, and the shape is not changed when pressed, it is called mass which is due to blood stasis. While the mass is movable without fixed place and shape, and sometimes it disappears, it is called "gatheringJ' which is due to qi stagnation. The size and surface is useful for judging the prognosis. The large mass must existes for a long time. T h e rapid growth suggests a bad prognosis. The rough surface or irregular shape also means severe condition.
If the gathering is soft and sounds when pressed, it is the fluid retention. If the mass is hard, it is malignant. If the mass is movable, it is called "zheng" ; while the fixed one is named "jia". The jia will lead to consumptive diseases, tympanic diseases or ascites. The non-fixed gathering without fixed shape, and there is peristaltic moving in the gathering, it is the ball of roundworms. C. Palpating the lower abdomen: The lower abdomen belongs to lower-jiao. Its
morbid changes reflect the diseases of the kidney, urinary bladder, small intestine, large intestine and blood chamber.
a. The abdominal pulsation: The abdominal pulsation is found around the navel and is produced by the qi of Chong Meridian, Ren Meridian and the kidney. So the pulse can be used for probing the condition of Chong and Ren Meridians and the kidney. When palpating abdominal pulsation, the three fingers are put on abdomen and move around the navel. The pulse should be moderate in strength and rate. It reflects the adequate kidney qi. The followings are the main aspects for palpating abdominal pulsation.
Strong
(PP weak: An
over strong pulse means heat and deficiency syndrome.
The faint pulse indicates also deficiency syndrome. In exogenous diseases, if the 186
pulse is forceful, the heat evil is exorbitant; if the pulse becomes normal gradually with abating fever, it is a good sign. The faint pulse with cold body suggests the deficiency in life-gate.
Rate: If the pulse is more than 5 in a breath, it is due to heat. If the thready and rapid pulsation extends to upper abdomen, it is due to yin deficiency. If the pulsation beats only one time in a breath, the vital qi is on the declining. The hidden pulsation in very deep level is the sing of exhausted Chong Meridian and Ren Meridian. Beating region: The widespread pulsation with forceful beating in Xuli, even extending to chest and hypochondrium, is a sign of extreme deficiency of visceral essence and qi.
b. Pain: The distending pain in "small abdomen" aggravated by pressing, which is accompanied by dysuria, is due to water retention in urinary bladder. The cold pain in lower abdomen with diarrhea is due to deficiency cold in large intestine. The pain radiating to lumbus with hollow sensation when pressing lower abdomen is due to kidney deficiency. If the pain and lumps occur in lower abdomen in women with normal defecation, it is due to blood stasis in uterus. The pain in "small abdomen" aggravated by pressing with normal urination is due to blood stasis in exogenous disease, or heat in blood chamber in women which is accompanied menstrual disorder. T h e distending pain in left "junior abdomen", if with hard mass in it, is due to dry feces in intestines; while with hot abdomen and being aggravated by pressing, is seen in diarrhea due to damp-heat in large intestine. The pain with mass in the right "junior abdomen" is mainly the intestinal abscess.
4. Palpation of Acupoirrat
It is to detect the inner diseases by pressing and watching some acupoints and observing the reaction. The acupoint is the place where the qi passes through. So the interior diseases are often shown in reactions in some important points. T h e S p i n t Pivot pointed out: "If you want to know the disease, you can press some places. If the internal pain is alleviated, the place is the corresponding point. The method is simple and "
practical. The main morbid changes in acupoint are tender pain, sensitive skin and hardened nodule or cord-like nodule below the skin. o
187
The frequently used acupoints for diagnosing visceral diseases are the following. For lung diseases: Zhongfu
( L U 1) , Kufang (ST 1 4 ) , Qihu
(ST 13 ) ,
Yingchuang (ST 1 6 ) , Yuanye (GB 22), Yutang (RN 18) . For heart diseases : Juque (RN 14) , Danzhong (RN 17) . For liver diseases: Qimen (LR 1 4 ) , Ganshu (BL 1 8 ) , Taichong (LR 3 ) . For spleen diseases: Zhangmen (LR 1 3 ) , Shiguan (KI 1 8 ) , Shuifen (RN 1 9 ) , Liangmen (ST 21) . For kidney diseases : Jingmen (GB 25). Qihai (RN 6). Dantian (EX) For large intestine diseases : Tianshu (ST 25)
.
.
For small intestine diseases: Guanyuan (RN 4)
.
For gallbladder diseases : Riyue (GB 24) , Danshu (BL 19)
.
For stomach diseases: Weishu (BL 21). Chengman (ST 20), Shangqu (KI 1 7 ) , Zusanli (ST 36)
.
For urinary bladder diseases : Zhongji (RN 3)
.
In addition, the trial treatment by pressing acupoint can also contribute to the diagnosis. For example, a patient is suffering from upper right abdominal pain, if the pain can be relieved by pressing the two Danshu (BL 19) points, we can make a diagnosis of billiary ascariasis.
Section 3
T h e Modern Researches on Pulse-Taking
From 1950s9,pulse researches have been made in the fields of TCM, modern medicine, medical engineer and their combination fields. Some achievements had been gained. The main researches are as follows:
I.Objectifying of Pulse-Taking T h e fundamental condition for objectifying pulse-feeling is the pulse inspecting and measuring instrument. In recent years, engineers made many kinds of elect r o p ~ l s o ~ r a pby h using advanced electronic technique. Among them, Electropulso graph BYS-14 made by Beijing Medical Instrument Plant could record eletrocardiacgram and three sphygmograms in different parts synchronously. The sphygmograms could be used to distinguish floating, deep, slow, rapid, swift, taut, slippery, thready, faint, feeble, running, knotted and regular intermittent pulses, etc. In the seventies, the parameter measuring method of pulse graph was developed in Beijing College of TCM. By measuring parameters of pulse graph, pulses could be distin0
188
0
guished according to the analysis of parameters. The method improved the researches from qualitative to quantitative determination. In the beginning of the eighties, multi-factors analysis was used in Tianjin. According to this method, the pulse-feeling could be divided into eight components as follows: deep or superficial, thick or thin, strong or weak, frequency, rhythm, taut or soft, slippery or uneven, long or short. The discrepancy of pulse was due to the different constitution of those eight components. Electropulso graph MTY-A was made under the guide of this theory. It could record the width and amplitude tendency besides pressure wave. Afterwards, MX-5 multiple function electropulsograph was made. With the functions of MTY-A, it could also record the frequency tendency of pulse. 27 pulses could be distinguished by analysis of the four graphs. By using computer, the system analysed automatically. Other researches are also successful. For example, a multi could dimensional pulse information inspecting system was made out in Zhejiang University. Many kinds of pulse sensor and an instrument that could detect superficial artery movement and artery change of cross section were made out in Biomedical Engineering Institute, Chinese Academy of Medical Science.
The pulse curves drawn by electropulsograph is called sphygmogram. It should correspond to the feeling of doctor in taking pulse. The research program is as follows: First, a patient's pulse is selected by at least three TCM doctors separately. Second, if the pulse conditions recognized by doctors are identical, then the patient's pulse is drawn into sphygmogram. By this way, many sphygmograms are collected. Third, sphygmograms are classified into different types according to the pulse condition. Finally, in each type parameters are measured. By statistical analysis of the parameters, the typical sphygmogram and characteristic parameter values can be determined. Now typical sphygmograms corresponding to 1 2 pulse conditions have been set up. They are normal pulse, taut, slippery, floating, deep, slow, rapid, soft, sluggish, knotted, intermittent and running pulses. At present, the parameter measure is mainly carried out by visual method now. The break point, amplitude, time are determined this way. So discrepancy exists between different researches, the major aspects such as frequency, rhythm, force and width show no different. A-mong the parameters, the ratio between wave amplitude can be used to justify v a s ~ u l a relasticity and peripheral resistance. Some 189
discriminants that could improve the judgment of pulse have been set up.
III. Mechanism of Pulse Formation Many factors can affect pulse formation. They are the diastolic and systolic movement of aorta, artery and blood agitation caused by the heart ejection. The major wave in sphygmogram composes of ascending limb and descending limb. Prodicrotic pulse, dicrotic notch, dicrotic pulse could be parts of descending limb. The wave before dicrotic notch reflects the heart systole and the wave after the notch reflects the diastole. Cardiac contractility and ejection fraction affect the wave peak. Peripheral resistance can effect on the systolic wave. Artery compliance can also make a notable impact on pulse. Taut pulse and slippery pulse are studied more than others because they are frequently found in clinic and their characters in sphygmogram are constant. Their mechanisms of formation are mainly related to total peripheral resistance, cardiac output and artery compliance. The formation of taut pulse is mainly due to the increase of total peripheral resistance and decrease of artery compliance. The cardiac output is usually decreased. The formation of slippery pulse is mainly due to the dilation of peripheral vessel, slight increase of artery compliance, increase of heart rate and decrease of cardiac output. The formation of sluggish pulse relates to the decrease of myocardiac contractive force, resulting in decrease of cardiac output and reducing of circulation, decrease of artery compliance and increase of total peripheral resistance. The formation of hollow pulse relates to the reducing of effective blood volume and cardiac output. Besides, the formation mechanism of some other pulse had also been revealed.
PV*Glinieal Researches of Pulse The clinical research of pulse can be divided into 3 kinds as follows: A. By comparing different pulses with different syndromes in a disease, the identity and divergence between them can be found. B. Finding out the relationship between sphygmogram parameters and cardiac functions to help syndrome differentiation,
C. T o help the diagnosis and prognosis of some disease by comparing the patient's sphygmogram with some fixed pulse model. By means of analyzing the pulse of pregnant women, it is proved that in the first trimester, slippery pulse is a prevalent condition; while in the third trimester, 190
slippery and rapid pulse are popular. On delivering or aborting, slippery pulse disappears.
.
In upper digestive tract hemorrhage, if blood-loss is over 1500ml there will be a hollow pulse. This phenomena is corresponding to the traditional description of hollow pulse. Other researches also proved some traditional theories of pulse.
Chapter 6
The Eight Principle Syndrome Differentiation
The eight principle syndromes refer to those of yin and yang, exterior and interior, deficiency and excess, cold and heat which are paired into four contradictory groups. According to the clinical manifestations, all diseases can be classified into two categories, the yin and yang. In the aspect of location, they are classified into the exterior and interior; in the aspect of nature, they are divided into cold and heat; in the aspect of the relation between the genuine qi and evil, they are grouped /
into deficiency and excess. The eight principle syndrome differen tiation is applied to identifying the disease type, finding the crux of disease, predicting the developing tendency of diseases and guiding the treatment. The syndrome differentiation method was mentioned in Internal Classic and
Treatise on Cold-Attack, but not clearly described. In Ming Dynasty, Lou Ying said in Compendium of Medicine: "All the exterior and interior, the deficiency and excess, the cold and heat belong to yin and yang. " After that, Zhang Sanxi pointed out in the S i x Principles of Medicine that the main eight aspects are theyin, yang, exterior, interior, heat, cold, deficiency and excess, and all other factors such as qi, blood, phlegm and fire are included in the eight aspects. Zhang Jingyue said in Corn
plete Works of Jingyue: "Under the yin and yang are the exterior and interior, the deficiency and excess, the cold and heat. All diseases will be included in the six changes and the yin and yang. " He also said: "When diagnosing and treating disease, the first thing is to distinguish the yin and yang. That is the main principle of medicine. " He proposed firstly that the yin and yang were the two guiding principle and the exterior, interior, deficiency, excess, cold and heat were the six changes. The two principles could guide the six changes. In Qing Dynasty, Xu Lingtai called the six changes as six key points. Cheng Zhongling put the eight aspects in the same place and said: "All diseases can not be beyond the range of the cold, heat, deficiency, excess, exterior, interior, yin and yang. " There is not yet the term "eight principles" until Great Dictionary of Chinese Medicine written Xie Guan in 1920. After that, Zhu Weiju invented the term "eight principle syndrome differentiation" based on the theories of Cheng Zhongling. This term has been used up to now. Although each aspect of the eight principles has its unique content, they could not be separated from each other completely. For example, the disease of a patient o
192
a
can be both the exterior and interior syndromes, or half-exterior
& half-interior
syndromes. And in the exterior-interior aspect, there are exterior deficiency. exterior deficient heat, interior deficient cold, interior deficient heat, exterior excessive cold, exterior excessive heat, interior excessive cold and interior excessive heat. Moreover, there are complicated syndromes among the principles. So the syndrome differentiation should be made clearly so as to make correct diagnosis.
Section 1
Syndrome Differentiation on the Yin and Yang
T h e P l a i n Qzlestions said: " T h e calm yin and steady yang mean the good vitality. T h e divorce of yin and yang means the extinguish of vitality. " F r o m those statement, we know the dynamic balance between yin and yang was regarded as the standard of health by the ancients. When diagnosing, the pathologic change of yin and yang should be inspected first. Zhang Jingyue listed the yin and yang as the principle of medicine in his work. He said: "Although there are many theories of medicine, the one term that sums up all the theories is the yin-yang.
"
He also proposed that the exterior belongs to'
yang, the interior to yin, the heat t o yang and cold to yin. T h e yin and yang can stand for the exterior, interior, deficiency, excess, cold, heat, the upper, lower, qi, blood, moving and static state. All diseases can be classified into yin kind and yang kind. In fact, there are other contents like escaping of the yin and yang except for the six aspects. Because of that, it is still necessary to list the eight aspects in same level separately.
I. Wrra Syndrome and Yang Syndrome Plain Question said: "The prevalence of yin leads to yang diseases while the prevalence of yang to yin diseases. " T h e imbalance between yin and yang will lead t o diseases. T h e manifestations of yin and yang syndrome are different due to the difference of deficiency and excess. Internal Classic pointed o u t : " T h e yang deficiency leads to external cold; the yin deficiency to internal h o t ; the yang excess t o external hot: and the yin excess t o internal cold. " That is the general point for distinguishing yin syndrome from yang syndrome. Moreover, the differentiation of t h e yin and yang syndrome can be made in the following aspects.
I. The Speed of Disease Developing T h e yin syndrome develops slowly in both the onset and recovering. T h e onset *
193
and cure of yang syndrome are rapid.
2.The Change in the Daytime and Night The Classic on Middle Zang proposed that the disease condition of yang deficiency was mild in morning and severe in evening and vice versa; that of yang excess was mild in morning and vice versa. Because the yang acts in daytime, so symptoms of yang deficiency are relived in morning. The yin is strengthened at night, so the symptoms of yin deficiency become mild in evening. The excess yang is activated in daytime and the symptoms of yang excess are aggravated. T h e yin is stronger at night, so the symptoms of yin excess are increased in evening. If the paroxysm of disease is irregular and frequent, it means the insufficiency of genuine qi and the fighting between the genuine qi and the evil. In later generations, it was considered that the deficiency symptoms aggravated at night belonged to yin deficiency and that aggravated in daytime to yang deficiency.
3. Pulse Condition Floating, rapid, slippery, large and strong pulse belong to yang pulse, and the deep, thready, feeble, sluggish and weak pulse to yin pulse.
4. Symptoms Normal body feeling, vexation, fever, dry throat, liking to open eyes and to speak, scanty urine, dry stool or constipation pertain to yang syndrome. Heavy sensation of body, chill, liking to close eyes, indolence to speak, no vexation, no thirst, clear urine, loose stool or diarrhea pertain to yin syndrome. T h e differentiation of the yin syndrome and yang syndrome is listed in table 12. The yang syndrome refers to the general condition of yang exorbitant. T h e yin syndrome refers to the
in-cold syndrome
(in common saying, it refers to the yang
deficiency). So the above mentioned symptoms and pulses could not include all manifestations of yin syndrome and yang syndrome. The other symptoms are discussed in the ioiiowing sections. Besides, there are yang dominant constitution and yin prevalent constitution of human body. The yang dominant people need not thick clothes in winter, like drinking of water and have a bowel movement in several days. T h e yin prevalent people keep in thick clothes even in summer, and feel abdominal pain and diarrhea when eating cold food. When diagnosing, the doctor should inspects the yin and 194
yang constitution to avoid of making wrong diagnosis. Table 12 The Dlifferentiation of the Yin and Yang Syndrome methods
observation
auscultation olfaction
palptation
yin syndrome
flushed face, dry and chopped
pale or grayish complexion,
lips, liking opening eyes and
liking lying towards t o
light, fever with preference to
wall and curvedly, liking
cold, turning to outwards, vexa-
closing eyes, fatigue,
tion, red or crimson tongue,
listless,
yellow or black coating even with
pale, swollen and tender
cracks and prickles
tongue with moist coating
rough breath, asthma, loud voice,
weak breath, low voice,
I profuse speaking or raving, /
interrogation
yang syndrome
fetid odor in mouth and nose
1 calm and indolence to speak I
liking being cooled, thirst and
liking being warmed, no
liking cold drinking, constipation,
thirst, liking hot drinking,
fart with fetid odor, yellow and
tastelessness, poor appetite,
scanty urine
loose stool, clear urine
moist and hot skin,
dry and cold skin,
pain aggravated by pressing
pain relieved by pressing
rapid, large, slippery and
slow, small, sluggish and
excess pulses
weak pulses
IP. Yin Def icienncy and Uang Deficiency Each of the five zang-viscera has its yin and yang. So there are yin deficiency and yang deficiency in all the zang-viscera. The yin deficiency syndrome is that of yin and body-fluid shortage which leads to deficient fire in the interior. T h e yang deficiency syndrome is the that yang and qi insufficiency which leads to cold manifestations. T h e yin deficiency and yang deficiency are mainly the deficiency of the vital yin and vital yang, namely the deficiency of kidney yin and kidney yang. T h e kidney is responsible for the congenital foundation. Both of the improper innate development and afterbirth feeding can give rise to the insufficiency of kidney yang or kidney yin and lead to the following symptoms.
Kidney yin deficiency: hectic cheek, red lips, dry mouth and throat, tinnitus, fidget, vertigo, internal hot feeling like bone being steamed, night sweating, hot sensation in the five centers, nightmare, seminal emission, lumbago with sore legs,
constipation, yellow urine, red dry tongue without coating, rapid and weak pulse.
Kidney yang deficiency: pale complexion, shortness of breath, edema, spontaneous sweating, indigestion, lumbago with sore legs, impotence, spontaneous emission, scanty menses, loose stool or diarrhea at dawn, profuse clear urine,
e ale
lips,
corpulent and tender tongue, large but weak pulse. The treatment of yang and yin deficiency is definitely different from the that of yang and yin exorbitance. If it is the yang exorbitance, the bitter cold herbs are used to defeat the heat; while the yin exorbitance is treated by pungent and heat herbs to frustrate the yin. The yang or yang deficiency is treated by tonifying. So it is important to identify the deficiency or excess of the yin and yang to avoid the mistake of tonifying the excess and frustrating the deficiency.
111.Yang Depletion and Yin Depletion The depletion of yang or yin is the omen of critical condition and is an emergency for life. They are caused by over sweating, over vomiting, over using of purgation, or massive bleeding. As to which one of them occurs in what condition it is not certain, although the ancients such as Luo Qianfu held that the yang depletion happened mainly in over sweating and the yin depletion in over purgation. Because the perspiration is yin fluid, the yin will depleted following the exhaustion of sweat, then occurs the yin depletion. Though the purgation impairs yin, the yang depletion may happen following the yin exhaustion. The yin and yang have their roots in each other. When yang depletion happens, the yin may escape following the yang, and vice versa. But we should identify which of them is the key, so that the mistake in treatment could be avoided. Generally, the yin depletion frequently leads to yang depletion, while yang depletion seldom to yin depletion. In the severe stage of chronic diseases, the yin deficiency leads to yin depletion and the yang deficiency to yang depletion. Xu Lingtai proposed the differentiating method and importance for the yin depletion and yang depletion in Treatise on Yin Depletion and Yang Depletion. He said: "How to differentiate the yin depletion and yang depletion? The sweating in I
yin depletion is warm and saljty with aversion to hot, warm hands and foots, hot body, thirst and preference to cold drinking, rough breath, surge and strong pulse. Those are the manifestations. The sweating in yang depletion is cold and tasteless, with aversion to cold, cold limbs and body, no thirst or liking hot drinking, feeble breath, floating, rapid and hollow pulse. From those the syndrome can be identified.
"
196
*
Xu stated the method and the transformation between yin and yang depletion again in the his Huixi Medical Records. He said: "The yin.and yang depletion are similar but not the same. The one is characterized by feeble pulse, cold sweating like paste, cold limbs and moist tongue. The other is by surge pulse, hot and thin sweating, warm limbs and dry tongue. If the yin depletion is not treated effectively, the yang will go out of the body through sweating. That leads to the vital qi depletion, namely yang depletion. "His statement is still helpful at present time. T h e main manifestations of yang and yin depletion are:
Uang depletion: bluish complexion, feeble breath, intolerance to cold, no thirst, or thirst with preference to hot drinking, coma, cold limbs, oily cold sweating with no taste, moist tongue and feeble pulse. Yin depletion: coma or fidget, warm limbs and body, thirst and preference to cold drinking, profuse warm sweating with salty taste, dry crimson tongue, weak and rapid pulse. If followed by cold oily sweating, bluish complexion, cold limbs, hidden pulse, it is the secondary yang depletion. Table 13 Brief Differentiation of the Yin and Yang Depletion
yin depletion
sweating
limbs
other symptoms
tongue
pulse
profuse, hot
warm
coma or fidget, hot
dry, red,
rapid, surge
skin, thirst,
crimson
feeble when
salty, thin
deep pressed
preference to cold drinking oil-like, cold Yang depletion
cold
bluish complexion,
moist
feeble,
tasteless,
intolerance to cold
floating,
light thick
coma, no thirst,
hollow
liking hot drinking
Not only the severity of symptoms, but also the prognosis are different between the yin and yang depletion and the yin and yang deficiency.
A. The differences between yin deficiency and yin depletion : The yin deficiency is the syndrome of yin and body fluid shortage. Besides emaciation, dry throat, insomnia, vertigo and thready pulse, there are symptoms due to internal deficient fire, such as flushed face, tidal fever, fidget, hot sensation in the five centers, night sweating, red or crimson tongue, rapid pulse. The manifestations of yin depletion are severer than those of yin deficiency. There are hot sweating, coma, weak pulse when deep pressed, etc. 197
B.The dif f erenees betweeaa yaang deficielacy and yamg depletion : The yang deficiency is the syndrome of yang and qi shortage. Besides symptoms of qi deficiency such as shortness of breath, fatigue, listlessness, indolence to speaking, dyspnea and sweating on exertion, weak pulse, etc., there are symptoms of yang failure to warm body, such as intolerance to cold, cold limbs, no thirst or preference to hot drinking, clear urine, loose stool, pale and corpulent tongue. T h e yang depletion is the syndrome of yang extinguish or escape. Its manifestations are critical. There are cold thick sweating, pale complexion, cold limbs and body, curving lying, stupor or coma, extinguishing pulse.
IV. Uin Rebelaion and Yang ReltsellEiiasn The cold limbs belongs to rebellion. There are yin rebellion and yang rebellion. The manifestations of them are the following.
-
Yin rebellion: The main cause are cold evil staying internally , cold food or exogenous cold attack. The cold impedes the yang and qi to reach the limbs. In the initial stage, there are no fever and headache, but bluish complexion, cold body and limbs, curving lying covered with thick quilt, no thirst, profuse and clear urine, deep, thready and slow pulse. T h e syndrome is milder than yang depletion. The treatment is to warm the middle and restore yang. Table 14 The differentiation of the Uin and Uang Rebellion
I yin rebellion prevalence of cold, the yang is unable to warm the body
I yang rebellion I heat evils exorbitance makes the yang hidden in internal and could not reach the limbs
manifestation
cold limbs, aversion to cold,
cold limbs, hot chest and abdomen,
lying covered with quilt,
aversion to hot, thirst, gingival
quiet, no thirst, clear urine,
ulcer, fetid odor in mouth, fidget,
loose stool, pale tongue with
coma, delirium, deep yellow urine,
white slippery coating,
dry prickle tongue with yellow or
deep, slow or feeble pulse
brown coating, deep forceful pulse
Yang rebellion: It is due to affection of the exogenous climate evils or pestilential factors. There are fever and headache in the initial stage. Then the evil enters the interior and makes the yang stagnated which leads to cold limbs even cold body, and feeble pulse. In the same time, there are hot exhalation, gingival ulcer, 198
fetid odor in mouth, dry mouth and throat, extreme thirst, delirium, blackish yellow coating, prickle tongue, burning pain when urination, constipation or diarrhea. The cold limbs is relieved when fever is abated. The mild case can be cured with Cold Limbs Powder for activating the yang. The severe case can be treated by Chengqi Decoction to purge the heat and preserve yin.
Section 2
Syndrome Differentiation on Exterior and Interior
It is a method for distinguishing the endogeneous or exogenous diseases and for identifying the location and tendency of exogenous diseases. Most of the diseases in the outer part of the body and in mild condition are exterior syndromes. The diseases in the interior and in a severe condition are interior syndromes. Generally speaking, the diseases in the skin, muscle and meridian are called exterior syndromes; and the diseases in viscera, vessels and bone are interior syndromes, But the distinction is not absolute. For example, the frame of the body is the exterior and the viscera are the interior. In the range of body frame, the skin is the exterior and the bone and flesh are the interior. As for viscera, the fu-viscera are the exterior and zang-viscera are the interior. As to meridians, the Taiyang and Yangming are the exterior, the Shaoyang is the half-exterior & half-interior, the three yin meridians are the interior. Among them, the exterior can also be divided into exterior and interior, i. e . , the Taiyang-is the exterior within exterior and the Yangming is the interior within exterior. The interior can also be divided into exterior and interior, i. e . , the Taiyin is the exterior within interior and the Jueyin is the interior within interior, and so on. There is no strict boundary between the exterior and interior. The initial stage of some diseases may be exterior syndrome or interior syndrome. In some cases, the interior syndrome takes place after the exterior syndrome. In some other cases, the exterior syndrome transforms into interior syndrome. Some interior syndrome can be complicated by exterior syndrome. There are some cases partially in exterior and partially in interior. All those should be distinguished carefully.
I. Exterior Syndrome and Interior Syndrome The exterior syndrome is the initial stage of exogenous diseases which are caused by exogenous evils those invade the body by way of the skin, mouth and nose. It is characterized by short course and sudden onset. The syndrome is shown in chill and fever, headache, stuffy nose, cough, white thin coating, floating pulse. 199
All diseases characterized by these symptoms can be considered as exterior syndrome.
Half-Exterior & Half-Interior Syndrome : As for the location of the half-exterior
& half-interior syndrome, there are different opinions. One opinion (held by
Cheng Wuji) considered that the evils were in the Shaoyang which belonged half to exterior and half to interior. Another opinion thought the half-exterior and half-interior was the "moyuan".Wu Youke held this view. The manifestations are mainly the alternate chill and fever, and bitter taste in mouth, dry throat, dizziness, vexa-tion, nausea, fullness in chest and hypochondrium, poor appetite, taut pulse.
Interiop syndrome refers to the syndrome after evil entering qi-phase or Yangming Meridian, or to the internal attack by the hidden evils, or to the endogeneous diseases. In brief, the diseases belonging to neither exterior syndrome nor half-exterior
& half-interior syndrome are the interior syndrome. Table 15 Brief Diffferentiation on Exterior and Interior (in conditions of excess)
syndrome location
I interior syndrome I viscera
/ exterior syndrome / body surface
symptoms
fever
fever
aversion to cold
no chill
general pain and stiffness
no body pain
headache
seldom headache
stuffy nose
thirst & desire of drinking
normal eating, no chest and
nausea, vomiting, bitter
abdominal disorder
taste, poor appetite, abdo-
/ normal urination and defecation I minal distention and pain I normal mental state / constipation, diarrhea, I dark urine, vexation, pulse tongue
I
I insomnia,
I white thin coating
/ red, crimson. blue, purple
delirium
/ tongue with yellow or gray
I , ,
or black coating
The identification of exterior or interior syndrome should be done mainly on the basis of the symptoms. The pulse is only used as a reference. Zhang Jingyue 200 *
said: "Although the floating pulse belongs to exterior, the floating and weak pulse means yin, blood and qi deficiency. So not all the floating pulse indicates exterior syndrome. Though the deep pulse pertains to interior, in exterior syndrome in which evil bounds the skin and the pulse could not reach the skin, the pulse must be deep and tense. So the deep pulse is not all due to interior syndrome. In Treatise on Cold-Attack, the judgment of the Taiyang, Shaoyang and Yanglning syndrome is mainly on symptoms. That is the example.
PI. Syndrome of Both Exterior sand Interior Many of the diseases are both in exterior and interior. Those conditions are divided into two groups. T h e one is seen in exogenous diseases in which the exterior syndrome is complicated by interior syndrome, or the evils enter interior and remain some of them in exterior. T h e other, one kind disease is not healed yet and another disease takes place. For example, the patient is suffering from endogeneous disease, and is attacked by exogenous evil again; or suffering from exogenous disease and then impaired by improper diet or strain. In this condition, any symptoms can appear and the combinations are complex. For example, there are eight associations of the exterior and the interior in combination with deficiency and excess. They are the cold in both exterior and interior, heat in both exterior and interior, deficiency in both exterior and interior, excess in both exterior and interior, heat in exterior and cold in interior, cold in exterior and heat in interior, exterior deficiency with interior excess , and the exterior excess with interior deficiency. They are described as follows:
1. Cold in both exterior and interior: T h e cold in three yin with cold in exterior, or affection of exogenous cold in combination with the over taking cold food can cause this condition. There are symptoms like headache, general pain, aversion to cold, cold limbs, abdominal pain, vomiting, diarrhea and slow pulse.
2. Heat in. both exterior and interior: If there is heat hidden in internal and then the patient catches the warm evil, the condition takes place. There are fever, asthma, sweating, thirst with profuse drinking of water, vexation, delirium, constipation, scanty urine, red pricky tongue with dry and yellow coating, rapid pulse. 3. Cold in exterior and heat in interior: T h e cold evil is not dispelled and some of the evil transforms into heat and enters interior. Or heat in interior complicates the cold attack from outside. There are chill and fever, headache, pantalgia, thirst, fidget.
4. Heat in exterior and cold in interior: T h e patient with constitutional yang 201
deficiency catches the warm evil, or is in the initial stage of Shaoyin disease. There are fever, sweating, indigestion, loose stool, clear urine, corpulent tongue with slight yellow coating. If the exterior heat syndrome is treated by heavy cold herbs, the herbs may impair the yang and that will lead to the condition.
5.Excess of both exterior and interior: The unrelieved exterior cold syndrome complicates the food retention and leads to the condition. There are chill and fever without sweating, headache, pantalgia, abdominal distention, constipation, scanty urine, forceful pulse,
4. Deficiency of both exterior and interior: The deficiency of both qi and blood, or deficiency of both yin and yang may lead to this condition. There are spontaneous sweating, aversion to wind, dizziness, palpitation, poor appetite, loose stool, weak pulse. 7. Exterior deficiency with interior excess: The phlegm or food stagnates in interior and the exterior is not consolidated by qi. There are symptoms like spontaneous sweating, aversion to wind, abdominal distention aggravated by pressing, poor appetite, constipation and thick coating.
8. Exterior excess with interior deficiency : The patient with constitutional asthenia is attacked by exogenous evils may lead to the condition. It is characterized by aversion to cold, fever without sweating, headache, pantalgia, abdominal pain, poor appetite, vomiting, diarrhea, etc.
111.Entering and Exiting The entering and exiting refer to the transmitting process of evils in exogenous disease from exterior to interior or from interior to exterior. The direction of transmission is determined by the result of the fighting between the genuine qi and evil. The process that evil enters interior from exterior is mainly caused by the insufficiency of genuine qi, or the exorbitant evil, or the wrong treatment or nursing, which results in a situation of the genuine qi being defeated by evil. In this situation the evil enters the interior from the exterior. It marks the deterioration of diseases. The process that evil exits from interior to exterior owns to strong genuine qi, or proper treatment and nursing, that leads to the win of the genuine qi and the withdraw of evil. It marks the improvement of disease. So the entering or exiting of evil can indicate the developing tendency of diseases.
Evil entering interior from exterior: In exogenous diseases, whatever it is, the process can take place. When the manifestations of diseases are chill and fever, pantalgia, normal feeling in mouth, normal defecation and micturation, it means the evil 202
is yet in exterior and doesn't enter interior. If the chill and pantalgia disappear, and there are aversion to hot, bitter taste in mouth, nausea, vomiting, fullness in chest, thirst and drinking a lot, red tongue with yellow coating, it means the evil enters the chest. If there are vexation, insomnia, high fever, delirium, difficulty in drinking and eating, asthma, abdominal distention aggravated by pressing, constipation and dysuria, or abdominal pain with diarrhea, rapid and slippery pulse, it is due to the deeply entering of evil and is a severe condition.
Evil exiting
$0
exterior from interior: It is seen mostly in warm diseases. T h e
patient has interior syndrome with symptoms of fever, vexation, chest distress and abdominal distention. And then there are abated fever and vexation after sweating. eruption or miliaria alba. That means the outwards penetrating of evil and improvement. For example, the measles in child should be treated by dispersing evil which can make the evil in interior go out to the muscle and skin. If treated by cold method which will coagulate the evil in interior, there will be no proper eruption. T h e evil then turns into interior. T h e patient may die due to the dyspnea. So the method to induce internal evil to exterior is the key for treating measles. It must be pointed out that in the condition of evil exiting, there is no manifestation of exterior syndrome like chill and fever. If the manifestation of exterior syndrome appears, it is mostly due to the newly invasion of another exogenous evil. It belongs to syndrome of both exterior and interior.
Section 3
Syndrome Differentiation on Cold and Heat
It is the principle for distinguishing the disease nature. T h e evils can be divided into yin-evil and yang-evil. The genuine qi can be classified into yin-essence and yang-qi. In fact, the differentiation on cold and heat is to identify the wax and wane of the yin and yang. Zhang Jingyue said: "The cold and heat come out from the changes of yin and yang. The insufficiency of yin leads to yang prevalence which produces heat; while the insufficiency of yang leads to yin predominance which changes into cold. " In brief, the predominance of yang or invasion of yang-evil gives rise to heat syndrome, while the yang decline or yin-evil attack results in cold syndrome. T h e cold syndrome and heat syndrome can transform into each other. They can also be seen in the same patient and same time*Sometimes the true and false of them are difficult to identify. T h e cold and heat syndromes have their subdivision of exterior and interior, deficiency and excess. 203
I. Cold Syndrome and Heat Syndrome T h e cold syndrome is a syndrome shown in the body after the cold evil invasion or yang deficiency. T h e heat syndrome is a syndrome manifested in the body when heat evil, or heat produced by other evils in the body which leads to the struggle between genuine qi and evil, or yin and body-fluid deficiency. T h e symptoms of the same body in the different parts are quite different due to the difference of cold and heat. They are listed in the following table: Table 116 The Cold and Heat Manifestations body parts lips
symptoms due to cold
I 1
pale
I
throat
I
whole surface
/ I
moist
red or dry
/
dry
I
no thirst, or thirst with no
thirst and drinking cold
desire for drinking
preference of hot drinking
chill and liking being
aversion to hot, liking
warmed. curving lying
I
skin
I I I
I
mouth
symptoms due to heat
/ I
being cooled
I
cold, no sweating, pale
I
hot, sweating, red
I
head and body
aching
no pain.
mental activity
calm
vexation, delirium, mania
hand and foot
/
cold, bluish nails
I
warm, restless, red nails
urine
I
clear
/
scanty in yellow
defecation
I
loose stool, diarrhea
/
constipation or diarrhea
I
pulse
I
slow, deep
rapid, slippery
slippery coating in
tongue ; dry coating in
white, gray or black
yellow, gray or black
T h e manifestation of cold and heat are different from the syndrome of cold and heat. T h e former refers to the outer showing of diseases; the latter is the nature of diseases. In the common condition, the cold and the heat manifestations are the main basis for diagnosing cold and heat syndromes. But in complicated conditions. false cold manifestation or false heat manifestation may take place. Those should be carefully distinguished.
31. Excess Cold and Defic~iencyCold T h e excess cold syndrome is the condition due to the invasion of exogenous cold evil which encumbers the yang and qi. T h e cold evil belongs to yin-evil, therefore, the excess cold syndrome is taken as yin predominant syndrome. T h e
deficiency cold syndrome is caused by the decline of yang in body which is unable to prompt the qi and blood flowing. T h e two syndromes can be distinguished in the following aspects. Table 17
I
Distinguishing Points of Excess Cold and Deficiency Cold excess cold
I
deficiency cold
onset
sudden
slowly
symptoms
aversion to cold
intolerance to cold
cold limbs
cold limbs
/ dyspnea with profuse sputum
1
I by pressing
1 pressing
1 abdominal pain aggravated
shortness of breath with fatigue
I abdominal pain relieved by
constipation
loose stool, clear urine
pulse
deep, hidden, taut or tense
feeble, slow, deep and weak
tongue
bluish tongue with white,
pale corpulent tongue
thick and greasy coating therapy
dispelling evil by warming
tonifyiiig genuine qi by warming
2. Excess Heat and Deficiency Heat T h e excess heat syndrome is caused by the invasion of exogenous exorbitant evil which transforms into heat and fights against the genuine qi that leads to the manifestation of heat, or by the exorbitant visceral qi in some viscera or the extremely emotional disturbance which produces fire in the body. T h e heat and the fire pertain to yang, therefore, the excess heat syndrome is taken as a yang syndrome. T h e deficiency heat syndrome refers to the manifestation of heat due to the deficiency of yin, qi and blood. Zhang Lu proposed that the fever aggravated in day time and abating a t night with tasteless mouth was due to yang deficiency; the fever in afternoon relieved at night with normal sensation in mouth was due to yin deficiency: the irregular fever in day or at night was due to deficiency of both qi and blood of the spleen and stomach. T h e fever is seen mainly in yin deficiency. T h e ex@
205
.
cess heat and deficiency heat are distinguished in the following aspects. Table 118 Distiltaguishmerra&of the! Excess Heat and Deficiency Heat excess heat
aspect onset
/ sudden
characters
other symptoms
deficiency heat
I slow
fever with chill
intolerance to cold, or fever,
the dorsum is warmer than palm
the palm is warmer than dorsum
most of the fever is high
the fever is often low
the fever is constant
the fever is paroxysmal
the disease course is short
the disease is lingered
skin being felt hot as long
skin being hot only at
as being palpated
beginning of palpation
vexation, abdominal pain and
night sweating, bone
/ distention aggravated by
steaming, thirst, emaciation,
1 pressing, delirium, coma, shortness of breath, fatigue, constipation, yellow urine pulse
surge, rapid, slippery and strong
thready and rapid
tongue
red tongue with yellow coating
red tongue with little coating
/
I therapy
dispelling evil by clearing heat
or corpulent and tender tongue tonifying genuine qi by nourishing yin or invigorating qi
3. Differe~ntiationBetween Cold Syndrome and Heat Syndrome T o differentiate cold syndrome from heat syndrome could not rely on only one symptom, but on all manifestations of disease, so as to draw a corr-~f'conclusion.
/
The thirst or not, complexion, limbs, defecation, urine, tongue a d pulse are important for differentiating the cold and heat. The chill and preference to hot mean the cold; and vice versa. The thirst and preference to cold drinking indicate the heat and not thirst means the cold. The flushed face is due to heat and the pale complexion to cold. The hot hands and feet are due to heat and the cold limbs are to cold. The scanty yellow urine and constipation mean heat; and the profuse clear urine and loose stool mean cold. The rapid and slippery pulse is due to heat and the deep slow pulse is due to cold. The red tongue and yellow coating indicate heat; and the pale tongue and white coating indicate cold. From the above statements we may find that the cold syndrome belongs to yin predominance and is shown in the dysfunc-
tion of yanG the heat syndrome pertains to the yang predominance and is shown in the shortage of yin and body fluid.
11. Coexistence of Cold and Heat Besides the simple syndromes of cold and heat, there are combination syndromes of the cold and heat in the same'body. They include the cold and heat in the different parts of body respectively. The combination of cold and heat in the exterior and interior separately is described in the section 2 of this chapter. The combination of cold and heat in the upper and lower body: The heat in the upper is shown in headache, red eyes, dry mouth, sore throat, toothache, vexation, nausea, vomiting, preference to cold, black coating, etc. The heat in the lower is manifested by red swollen foot with pain, scanty urine, constipation, etc. The cold in the upper is shown in acid regurgitation, vomiting, belching with putrid odor, hiccup. indigestion, etc. The cold in the lower is manifested by abdominal cold pain, loose stool, diarrhea, enuresis, cold legs and feet, impotence, leukorrhea, etc. In the combination of cold and heat in the lower and upper, the symptoms of the upper and the lower are seen in the same time. The characters of the combination of cold and heat are the following: A. The coexistence of the manifestations of both cold and heat. B. It can be seen in any stage of any diseases.
C. Although there are differences in the seriousness and occurring order, they all reflect the nature of diseases.
111. Inter-Transfasrmatio~t~ Between Cold and Heat The cold or heat syndrome can change into each other in some conditions. The cold syndrome could transform into heat syndrome conforming to the predominant yang, if the genuine qi is exuberant and struggles against the evil. For example, a patient catches the cold, then appears the manifestation of cold such as aversion to cold, headache, pantalgia, no sweating, etc. When cold evil enters the interior and struggles against the genuine qi, it transforms into heat. The manifestations of cold disappear and those%f heat take place. There are fever, sweating, thirst, vexation, yellow coating, etc. Generally speaking, the transformation of cold into heat is mainly seen in exogenous diseases. If the yang is impaired and could not overcome the evil, the heat syndrome transforms into cold. For example, in exogenous diseases, the high fever which 207
o
leads to profuse sweating, or over vomiting or diarrhea, or the improper treatment or nursing consuming up the yang, then heat syndrome turns into cold. In endogeneous diseases, the yin and fluid exhaustion can involve the yang, then the heat syndrome changes into cold syndrome which is characterized by pale complexion, cold limbs, tiredness and feeble pulse.
IV.True and False of the Cold and Heat Plain Questions said: "Extreme cold produces heat and vice versa. " In the severe stage of diseases, the extreme cold and heat can show false manifestations. There are pseudo-cold in heat syndrome and pseudo-heat in cold syndrome. This time is critical to patient's life, any mistake will give rise to a fatal result. Generally speaking, the pseudo-manifestations are seen mostly in complexion, skin and limbs while the true manifestation in the tongue, pulse and inner body. T h e true pulse in cold syndrome is slow or weak; tlie true pulse for heat is forceful, slippery and rapid.
1.Pseudo-Heat in Cold Syadrabme This refers to the false manifestations of heat in extremely cold syndrome. It is also called "extreme water like fire" or "exorbitant yin repelling yang" . T h e condition can be caused by the cold invasion on a body of constitutional cold deficiency, or,'overuse of cold herbs wrongly which increases the yin up to an extreme state and the yin repels the yang to the outer part of body. It can also be caused by overexertion, emotional stress, drinking heavily or indulged in sexual intercourse which makes the yang deficiency and floating outwards. T fever, vexation, thirst, sore and swollen throat, maculae, constipation, scanty urine,
like cold water or drinking little. There are shortness of breath and fatigue, but not vexation. T h e rnaiiilae are srnall aiid i i ~light color. The dry stool is lollowed by j
loose one. T h e scanty urine is light yellow. T h e surge pulse is fprceless. T h e tongue is pale and tender with slippery coating. All tlie syniptoms reflect the syndrome of heat in skin and cold in viscera. T h e condition should be treated with hot herbs to restore the yang and save life, so that the genuine fire can be conducted into its normal position. T h e cold herbs are inhibited to use.
208
2.Pseudo-Cold in Heat Syndrome That refers to tlie false symptoms of cold in an extremely heat syndrome. It is called "extreme fire like water" or "exorbitant yang repelling yin" . If in cold-attack diseases, the excessive heat is treated wrongly with diaphoresis or purgation; or in warm diseases, the heat evil enters the interior, the excessive yang evil combats with the genuine qi and depresses the yang in the inner part. T h e yang could not reach and warm the external body, therefore the pseudo-cold symptoms take place. T h e more excessive the interior heat is, the more obvious the pseudo-cold symptoms are. T h e deeper the heat is, the colder the limbs are. T h e pseudo-cold symptoms include intolerance to cold, cold limbs, bluish nails, deep
01-
hidden pulse. Although feeling of cold, the patient dislikes thick
quilt. And there are symptoms like red eyes, dry lips, black coating, fetid odor in mouth, thirst and drinking of cold water, scanty urine in deep yellow, constipation or diarrhea of mixed dry and loose stool with fetid odor, burning pain in the anus. T h e deep pulse is forceful. All those shows cold in skin and heat in viscera. It should be treated with cold herbs to clear away heat. If warm herbs are taken, the fire is enforced, the condition will certainly get worse. Zhang Jiiigyue suggested that in the difficult condition for distinguishing the false from the true, "Give a little cold water to the patient, the patient of pseudoheat will refuse i t ; if drinking it, vomiting take place. So tlie patient should be treated with warm herbs. T h e patient of pseudo-cold will take it and feel comfortable. That should be treated with cold herbs. This is valuable experience obtained in "
practice and is helpful.
Section 4 Syndrome Differentiation on Deficiency and Excess The deficiency and excess are the principles for identifying the wax and wane of the genuine qi and evils. Plain Question said: "The predominant evil is excess and the loss of essential qi is deficiency. That is to say, the state of lack of genuine qi "
is deficiency and the existence of exorbitant evils is excess. Another chapter of
Plain Questions said: "The loss of blood or qi is deficiency; the exorbitant qi. or blood means excess. "Thereby, there are deficiency and excess of both the genuine qi and evils. Nevertheless, doctors in later generations all conformed tlie former statement. For example, He Xichi said: "The deficiency is about the genuine qi. It refers to the decline of the qi and blood. T h e excess is the exorbitance of evils, but o
209
not the exuberance of qi and blood. " In modern time, when making syndrome differentiation, the deficiency is the syndrome of lack of genuine qi, including the yin. yang, qi, blood, body-fluid and vitality of the body; the excess is the syndrome due to existence of evils. The central point of syndrome differentiation on deficiency and excess is to know the relative strength of the genuine qi and evils based on which developing tendency and prognosis can be concluded out. It is a guidance for treatment. The deficiency and excess syndrome can be found in simple and combined forms clinically. The deficiency syndrome could transform into excess syndrome, and vice versa. Being similar to the false of cold and heat, the false of deficiency and excess can also take place. When differentiating the deficiency and excess from each other, the exterior, interior, cold and heat should be taken into consideration comprehensively.
I. Deficiency and Excess Syndrome In Internal Classic, there are descriptions on five kinds of deficiency and excess. The five kinds of deficiency are thready pulse, cold skin, shortness of breath and diarrhea. The five kinds of excess are forceful pulse, hot .skin, abdominal distention, faint, constipation and oliguria. Based on the descriptions in Intel-nal Classic, doctors in later generations developed the classification of deficiency and excess. There were deficiency and excess of yin and yang, exterior and interior, cold and heat, qi and blood, and different viscera. Most of the exogenous diseases belong to excess syndrome. The excess syndrome is mainly seen in the initial and middle stage and is characterized by the short course of disease. The endogeneous diseases are mainly deficiency syndrome. The deficiency syndrome is frequently seen in the later stage of disease or in chronic disease and is characterized by prolonged course. But in endogeneous diseases, the visceral dysfunction could lead to qi stagnation, blood stasis, fluid or dampness retention, food retention and parasitosis. Those belong to excess syndrome. The deficiency and excess of the yin, yang, exterior, interior, cold and heat are explained in the previous sections. The deficiency and excess of qi and blood will be introduced in detail in the chapter of syndrome differentiation on qi and blood. The manifestations of common visceral deficiency and excess are described as follows.
I. The Common Manifestations of Deficiency and Excess The deficiency syndrome can be divided into yin, yang, qi and blood deficiency. 210
The excess syndrome varies to different natures and locations of evil. So the clinical manifestations of them vary and they are difficult to be described properly. The following aspects are the most common manifestations.
Facial appearance: The color is pale, sallow or rosy in deficiency and deep red or dark in excess.
Chill and fever: T h e cold limbs is due to yang deficiency; the feeling of hot in five centers with vexation is due to yin deficiency; aversion to cold is due to excessive cold; sthenic fever and tidal fever are due to excessive heat.
Sweating: Spontaneous sweating and night sweating belong to deficiency while no sweating and profuse sweating to excess.
Pain: The severe and incessant pain aggravated by pressing pertains to excess; the dull, paroxysmal pain abated by pressing pertains to(8eficiency.
Thirst: The extreme thirst and drinking a lot of cold water belong to excess. The thirst but drinking only little hot water is due to yang deficiency. Thirst without desire of water is due to yin deficiency.
Mental Activity: The listless state with feeble voice means deficiency. The vexation, mania and delirium with loud voice and rough breath indicate excess.
Chest: Palpitation and shortness of breath are of deficiency, while chest distress, asthma and gruff breath are of excess.
Defecation and urination: Loose stool, clear urine and incontinence of defecation or urination are due to deficiency. The constipation with abdominal distention and oliguria are due to excess.
Tongue: The tender tongue with little coating or no coating is of deficiency while the tough tongue with thick coating is of excess.
Pulse: The pulse lack of strength is of deficiency while the forceful pulse is of excess.
2. The Visceral Deficiency and Excess The treatise on five zang-visceral deficiency and excess proposed by Zhang Jingyue in his work Words Handed Down to the Devoted is cited in the following for reference. "As to excess syndrome, heart excess is mostly of fire and is shown in excessive laughing; liver excess is shown in pain in coastal and 'junior' abdominal region and irritability; spleen excess is shown in abdominal distention and heavy body; lung excess is characterized by rebellion qi of upper-jiao and shown in cough and asthma; kidney excess is mainly qi block in lower-jiao and shown in pain or disten@
211
tion or hot sensation in urination and defecation.
"
"As for the deficiency syndrome, heart deficiency is mainly the yang deficiency and is shown in the excessive grief; liver deficiency is shown in blurred vision, genital contraction and susceptibility to fear; spleen deficiency is shown in the disabled limbs, indigestion, abdominal distention and susceptibility to worry; lung deficiency is shown in the shortness of breath, weak respiration and dry skin; kidney deficiency is shown in the blockage or incontinence of defecation and urination, seminal emission, lumbago with inability of back to move, or muscular ache and atrophy.
"
In brief, deficiency syndrome can be classified into two main types: yin (blood) deficiency and yang (qi) deficiency. The yin deficiency includes the insufficiency of the essence, blood and body fluid. Among them, although the blood deficiency and yin deficiency belong to the same kind and have the similar symptoms like emaciation, palpitation and vertigo, the blood deficiency has no manifestations of heat while the yin deficiency is manifested by the symptoms of heat. There are other differences between blood deficiency and yin deficiency. For example, the complexion in blood deficiency is sallow or pale, while it is red in the zygomatic region in yin deficiency. Those should be noticed when making diagnosis. The yin (blood) deficiency should be treated by nourishing yin and supplementing blood. The yang deficiency can be divided into yang deficiency and qi deficiency further. Both of them have the common manifestations of deficiency. But the manifestations in qi deficiency is relatively mild and includes
110
symptom of cold. It is mainly located the
spleen and lung. The qi deficiency can develop into yang deficiency. The yang deficiency has an obvious feature of cold. The disease location is often in heart, spleen and strengthening the qi. Because the yin and yang have their roots in each other and the qi and blood share the same sour and not neglect any aspect. The excess syndrome can also be classified into two main kinds. The one is the invasion ol tlie exogenous evils wliicl-1 stay iii the body. The otliei- is the riscei-a! dysfunction and stagnation of qi flowing. At that point, the normal qi, blood, fluid and food transform into abnormal evil, such as, qi stagnation and rebellion, blood stasis, phlegm, fluid-retention, food retention, and so on. The therapeutic principle should be dispelling evils first and supporting the genuine qi secondly, so as to facilitate the recovery of visceral function.
11. Coexistence of Deficiency and Excess T h e coexistence of both deficiency and excess is frequently encountered. It includes tlie coexistence of deficiency and excess in tlie exterior and interior, in tlie upper and lower, and in the different parts of the body. T h e excess in the upper is manifested by chest distress, heavy head, stiff neck, sore throat, thick nasal discharge and spittle, poor appetite, etc. The excess in the lower is shown in the constipation, scanty urine, sore lumbus and legs, abdominal pain aggravated by pressing. T h e deficiency in the upper is characterized by the pale complexion or red zygomatic region, hoarseness, dyspnea, trembling in the upper body and palpitation. T h e deficiency in tlie lower is marked with loose stool, clear urine, incontinence of defecation or urination, difficulty in walking, and so on. T h e deficiency in tlie upper witli excess in the lower, or excess in the upper with deficiency in the lower is shown in combined manifestations of above mentioned symptoms. The coexistence of deficiency and excess in different parts of the body is demonstrated in the following example. T h e 280th item of Treatise on Cold-Attack said: "There is weak pulse witli normal defecation and urination in Taiyin disease. T h e dosage of rhubarb and peony in its normal treatment should be decreased because the stomach qi is weak and easy to be impaired. " That is a combined syndrome of coexistence of both deficiency and cold. The excess is in the spleen and the deficiency is in the stomach. I t is a syndrome of excess in spleen and deficiency in stomach.
HIH. Imter-Transformation Between Deficiency and Excess In some conditions, the deficiency syndrome can transform into excess syndrome, and vice versa. The deficiency syndrome may give rise to abnormal flowing of qi and blood, dysfunction of digestion, and inability of expelling evils which are the causes of some excess syndromes such as phlegm and/or fluid retention, food retention, qi stagnation and blood stasis. That is the excess syndrome caused by deficiency. T h e deficiency syndrome has not disappeared yet. So it is a syndrome of coexistence of deficiency and excess.
If the excess syndrome lasts for a long time, the genuine qi will be consumed although the evil is dispelled. All the yang, qi, yin and blood can be impaired. That is the transformation from excess into deficiency. There are shortness of breath, poor appetite, emaciation, asthenia, little coating, weak pulse. There is an example in the 397 item of Treatise on Cold-Attack: "After the relief of cold-attack disease, 213
there is weakness, shortness of breath, and nausea. That could be cured with Lophatherum and Gypsum Decoction.
"
Besides, the excess syndrome may also
cause deficiency. That is a condition of impaired genuine qi in combination with existence of evil. It is also a syndrome of coexistence of excess and deficiency.
Hv*
and Fd$gt of &heDeficiency and! Excess
The true and false should be distinguished in the aspect of deficiency and excess. In severe case, the pseudo-deficiency or pseudo-excess manifestations may occur just as that be pointed out in Internal Classic: "The doubled yang results in yin and the doubled yin gives rise to yang. "
1. The Pseudo-Excess in Deficiency Syndrome Li Zhongzi said: "There are manifestations of excess in extreme deficiency.
"
False manifestations of excess appear often in extreme deficiency. For example, there may be fever, abdominal distention, constipation, mania and eruption in the diseases caused by congenital deficiency, over-fatigue, over-drunk or indulgence in sexual activity. Those symptoms are similar to those of excess syndrome. In fact, they are caused by the qi stagnation. The distention is paroxysmal; the pain is relieved by pressing; the mania can be relieved by conversation; the pulse is weak when pressed. Besides, there are lusterless complexion, weak voice, fatigue and asthenia. All of them are really due to deficiency. If making a wrong diagnosis, the doctor will make the mistake of tonifying the excess and eliminating the genuine qi. It is said in the 205 item of Treatise on Cold-Attack: "The epigastric stuffiness and hardness in Yangming disease should not be treated by method of clearing away evil. If the method is applied on the patient, the patient will have severe diarrhea and die. "This is the warning given by Zhang Zhongjing.
2. The Pseudo-Deficiency in Excess Syndrome
Li Zhongzi also said: "There are manifestations of weakness in the great excess. '' That is to say, in extreme excess syndrome, some symptoms of deficiency may appear. For example, in exogenous diseases, if the evils accumulate in the viscera, the visceral qi could not carry out their functions, there are some symptoms of deficiency such as fatigue, indolence of speaking, poor appetite, vertigo, diarrhea, etc. But the movement is strong enough; the voice is loud; the food intake is sometimes not less than normal; there is diarrhea but patient feels relief after diarrhea; there is abdominal distending pain aggravated by pressing. Those are of the excess.
T a b k 119 Distinguishimg True from False s n Deficiency and EXCQSS I
I
I
diagnostic method
I I I observation I I I
deficiency
excess
pale or sallow complexion,
dry and cracked lips,
/ red in zygomatic region. 1 emaciation I fatigue, indolence of
I I strong I mania, vexation,
/
/
I speaking I shortness of breath. corpulent tongue little or no coating
true
I restlessness I asthma
smelling
/
I interrogation
palpation
observation
false
palpation
1
constipation, unsmooth defecation, yellow urine, micturation pain forceful pulse pain aggravated by pressing weakness, fever, red complexion, mania but calmed by conversation, pale tender tongue with little coating feeble voice of speaking and breath
feeble voice of breath but loud speaking fetid odor
listening and smelling
I II interrogation I
vertigo, palpitation, hot sensation in the five centers, bone steaming. cold limbs, spontaneous sweating, night sweating, less drinking, loose stool, clear urine, incontinence of defecation or urination, seminal emission, sore lumbus weak pulse pain relieved by pressing indolence of speaking, little but forceful movement purple tough tongue, thick coating
/
poor appetite but sometimes
red or purple rough tongue with thick coating fetid odor abdomi~ialdistension or pain, sthenic fever, tidal fever, aversion to cold, no sweating, thirst. drinking like a fish,
1
paroxysmal abdominal
1. eating no less than normal. / pain or distension,
I fatigue but relieved after rest 1 soft abdomen, thirst but 1 loose stool but feeling of / drinking little and hot water I
relief after defecation strong pulse pain aggravated by pressing
/
constipation weak in the deep level pain relieved by pressing
There was no unified opinion in ancient time about which clinical data could be used to distinguish the false from the true. Some doctors took the tongue as the basis. For example, Yang Bingliu said: "The true and false are identified according to the pulse. And the true and false of the pulse are distinguished according to the tongue. How can we find an excess syndrome but with corpulent tender tongue?"
Most of ancient doctors, such as Li Zhongzi, Zhang Jingyue, Tao Jiean and Xu Lingtai, took the pulse as the basis. Zhang Jingyue said: "The key point for distinguishing deficiency from excess is the pulse. The forceful and vigorous pulse means the true excess; while the pulse of no strength and vitality is of false excess. " I t should be pointed out that the opinions held by ancients are not reliable completely. We should integrate the opinions and the patient's condition to avoid making mistake.
Section 5
The Modern Research on the Eight Principle Syndrome Differentiation
In 1962, Chinese scholars proposed that the eight principles be the generalization of the reaction of the body to the pathological factors. Among them, the yin and yang were the hypofunction and hyperfunction of the body respectively; the cold and heat were the insufficiency or over generation of heat production respectively; the deficiency and excess were the functional changes of the body; and the exterior and interior were the diseases accompanied by metabolism disorder or not respectively. In the 1970s. on the research of pathological anatomy, somebody put forward that the exterior syndrome was mostly the inflammation in respiratory tract; the interior syndrome was due to the organic injury; the cold syndrome was the chronic inflammation in internal organs accompanied by the blood stasis, ischemia and edema of whole body or local part; the heat syndrome was mostly the acute inflammation with congestion or bleeding; the deficiency syndrome was mainly the degeneration or atrophy of the viscera and endocrine glands, the excess syndrome was mainly the acute inflammation, blood stasis and constipation. In the late 1970s, somebody studied the eight principles from the subcellular level. By observing more than 20 diseases, it was found that the plasmatic cAMP predominated in the yin deficiency, while the plasmatic cGMP was predominant in the yang deficiency, After treatment, they could be brought to the normal state. That suggested the changes of the cAMP and cGMP be one of the key points of the yin and yang deficiency. Besides, the researches were also carried out in the aspects of metabolism, glycolysis in red blood cells, oxygen utilization, ATP. T3, T4, and the neuro-endocrine system, especially the vegetative nerve-adrenal gland system. Those gave a partly explanation on the cold and heat.
Chapter 7
Etiological Syndrome Differentiation
Etiological syndrome differentiation is a dialectical method to research the cause of disease, its purpose is to eliminate pathogenic factors in order to heal the disease. Chen Yan in Song Dynasty divided pathogenic factors into three categories: endopathogenic factor, exopathogenic factor and non-exo-endo-pathogenic factor on the basis of Synopsis of Golden Chamber. He put forward: "The six evils are very often countered in the nature. They invades the body from meridians and further involve the viscera, so they are called exopathogenic factors. Seven emotions are common passion of human. They causes diseases in the viscera transmitting into limbs, so they are called endopathogenic factors. And improper diet, traumatic and injuries by insects and animals, incisive wound, injuries from falls, fractures, contusion and sprain are non-endo-exopathogenic factors. " T h e method mentioned above is still used in clinic today. T h e key of etiological syndrome differentiation is to find out the primary pathogenic factor, therefore, we can eliminate the evils from the body. Pathogenic factor in TCM not only indicates the primary cause of disease, but also includes pathological products in the body formed in the course of illness, such as blood stasis, phlegm retention. U p to now, pathogenic factors have already included six evils, pestilential evils, seven emotions, indigestion, malnutrition due to parasitic infestation, retention of phlegm and fluid, blood stasis, sexual overstrain, injury by insects and surgical trauma, own to development of later physicians to
Triple Etiology Doctrine of Chen Yan. Injury by insects, surgical trauma, retention of phlegm and blood stasis will be narrated in other chapters. I t should be pointed out that even if the diseases are caused by the same pathogenic factor, the syndromes may be varied individually with different temper, physique, environment, sex and age.
Section 1 Six Evils Wind, cold, summer-heat, dampness, dryness and fire are six natural factors which are actually six normal climatic variations. They become pathogenic factors to cause disease, when genuine qi is weak, or climate changes rapidly and violently, 217
I
the genuine qi can't adapt to them. When causing disease, they are named six evils. The pathogenic characteristics of six evils :
A. They are usually related to seasonal climate changes, especially drastic change. For example, in winter there are more diseases due to cold; in summer, more due to summer-heat.
B. Six evils can either attack body separately or simultaneously with two or more in combination. Fox example, wind, cold and dampness evils are usually combined as one pathogenic factor and cause rheumatism. Six evils may transform into and influence each other. For example, wind-cold may transform into heat; dampness may transform into heat or dryness after accumulation.
C.Exterior
syndrome is most often seen in the early stage of disease due to six
evils, and with the development of the disease, interior syndrome will appear. The common symptom is fever. The main treatment is eliminating evil. Owing to the limitation of ancient science and technique level, people couldn't understand the essence of pathogenic factor (bacteria, virus). They differentiated the syndrome only through various symptoms. Although six evils doctrine isn't perfect, it is still important in clinical practice today. Endogenous wind and endogenous cold in classic meaning aren't included in this scope.
I.Wind Syndrome Wind Syndrome is caused by wind evil. Disease due to wind evil occurs not only frequently in spring but also in the other seasons. Other evils, such as heat, dampness and cold, usually unite with wind evil, forming wind-heat, wind-dampness, wind-cold. So wind is foremost factor to cause disease
Clinical Manifestation: Fever, aversion to wind, sweating, stuffy and running nose, itching throat, cough, floating-moderate pulse, thin-white tongue coating.
Common Wind Syndrome (1) Wind Attack: The main symptoms are fever, aversion to wind, sweating,, stuffy and running nose.
(2) Winad Rheumatism: Its main symptoms are fever, aversion to wind, and migratory arthralgia.
(3) Wind Edema: The main symptoms are fever, aversion to wind, puffy face, edema all over the body, and scanty urine. (4) Rubella: The main symptoms are aversion to wind, itching skin without fixed places, reddish and bump after scratching, which are aggravated by catching *
218
*
wind.
(5) Apoplexy Involving Collateral: T h e main symptoms are numbness and wry face, salivation, hemiplegia.
(6) Tetanus: T h e main symptoms are rigidity of back. lockjaw, opisthotonos, and convulsion.
( 7 ) Leprosy: T h e main symptoms are maolarosis, depression of the nose bridge, ulcerous skin. Analysis: T h e -wind is a yang evil. Wind evil tends to invade the barrier of skin, to fight against defensive qi. T h e defensive qi fails to consolidate the skin and results in fever, sweating, and aversion to wind. The lung is in charge of respiration. Nose is the orifice of the lung. T h e throat is the tract of qi. When wind evil attacks this system, the flow of qi is obstructed, that is marked by cough. itching throat, and stuffy nose. Floating pulse and white tongue mean pathogenic factor in the exterior of the body. Wind evil, if attacks body in combination with heat evil, is shown in fever, sore throat, and floating-rapid pulse: when combined with cold evil, is shown in aversion to cold, pain all over the body, and floating-tense pulse; while combined with dampness evil, is shown in fever with peak in the afternoon, and migratory arthralgia. T h e lung is the upper source of the water in the body. T h e water flowing is obstructed when lung qi impaired, which is marked as puffy face, general edema. Wind evil, in combination with heat, fights against qi between muscles and skin, marked by itching and tumor. Wind evil invades meridians and results in muscular stiffness, numbness, itching, and wry face. Discussion of Meridians and Tendons of Spirit Pivot said : "Abnormality in Foot-Yangming and Hand-Taiyang Meridians manifests as muscular stiffness and wry face. Shen9s Work on the impel-tance of Life Preservation said: "Only the wind "
evil invades wound with rupture and causes tetanus. He believed that wind evil' invades wound, there would appear rigidity nape, lockjaw, and convulsion. When accumulating for long time, the evil spreaded over the whole body, resulting in sallow complexion, ulcerous skin, depression of the nose bridge, maolarosis.
"
T h e Pathogenic Characteriaics off Wind Evil: A. Wind is yang evil. Discussion of Taiyin and Yangming in Plain Questions said: "Yang is vulnerable to wind.
. . . Wind
evil usually attacks the upper parts of
the body. " So, head, surface of body and lung are always attacked firstly by the wind.
B. Wind evil is apt to migrate and change. So attacked by wind evil, the onset is rapid, the location of disease tends to be unsteady and migratory. Wind evil often combines with other evils to cause diseases from head to private part, from exterior to interior. C. Wind evil leads to mobility. There appear frequently tremor, convulsion,' vertigo, quiver of tongue and stroke fall.
IP. Cold Syndrome Cold syndrome is the disease condition caused by attack of cold evil. The cold is a yin-evil. The yang-qi can't come to surfaces to defend the body after attacked by cold evil. The syndrome has two categories. The one which is caused by attacked of cold in the exterior of body is called cold-attack, and the another, the cold-stroke is due to directly invasion of cold into viscera. Endogenous cold which results f r - ~ m insufficiency of yang isn't included in this scope. But endogenous cold and exogenous cold can influence each other. For example, a man with weaken yang-qi is easy to be affected by external cold, and the external cold attacks and damages yang-qi easily, which will lead to occurrence of endogenous cold.
Clinical Manifestations: Aversion to cold, fever, lack of sweating, headache. pantalgia, arthralgia, cough, asthma, cold limbs, vomiting with clear fluid, epigastric pain abated when warmed, borborymus, diarrhea, thin and white tongue coating, deep or slow or tense pulse.
Common Cold Syndrome (1) Cold-Attack: The main symptoms are aversion to cold, fever, anhidrosis, headache, heavy body, cough, asthma, tense pulse, white tongue coating.
(2) Cold-Stroke: The main symptoms are vomiting, borborymus and diarrhea, acute epigastric pain subsided by warming, cold limbs, cramps of the extremities, deep-tense or taut pulse, thick and white tongue coating. he main symptoms are pain and cramps of limbs, difficulty in bending and stretching, aggravated by cold.
Analysis: Cold evil invades the superficial part of the body, resulting in closed interspace of muscle, manifested as superficial excess syndrome, such as aversion to cold and anhidrosis. Defensive yang fights against cold evil, marked by fever. The lung is attacked by cold evil and leads to lung qi stagnated, marked by cough and asthma. Cold evil invades meridians and results in spasm, manifested by headache and pain of the whole body. Cold evil enters directly three yin meridians, impairs yang qi, disorders qi ascending and descending, and this is manifested by vomiting,
diarrhea, epigastric pain. Cold evil is coagulating and obstructing, marked as acute pain. Tense pulse, white tongue coating are manifestations marking the cold evil. Difficulty of bending and stretching of joints and arthralgia result from cold evil stagnated in joints.
Pathogenic Characteristics of' Cold Evil A. Cold evil is a yin evil and impairs yang-qi, so the qi in U. B. Meridian of Taiyang is always first attacked by cold. Body fluid flowing bases on the function of bladder. If bladder fails to order it, fluid will be stagnated, marked as vomiting and diarrhea. T h e Most Important Discussion in Plain Questions said: "All disorders with clear, cold fluid in body belongs to cold evil.
'
B. Cold evil is coagulating and obstructing, and those lead to blood and qi stagnated, marked as pain all over the body, anhidrosis, cramps tendons.
IHI. Summer-Heat Syndrome Summer-heat syndrome is caused by summer-heat evil. Summer-heat evil is a yang evil which is transformed from fire and heat. Summer-heat syndrome appears only by attacked of summer-heat evil in thk summer. In ancient, summer-heat syndrome had two categories, yin summer-heat and yang summer-heat. Shen Jinao considered that summer-heat syndrome occurring in a quiet state was the yin syndrome, called summer-heat-attack, and that the syndrome occurring in an active state was the yang syndrome, called sun-stoke. Zhang Jingyue put forward that the difference between yin summer-heat and yang summer-heat was that the former caught cold, the later caught heat in summer. T h e Zhang9s explanation is more reasonable.
Clinical Manifestation: Fever, flushed complexion, sweating. thirst, vexation, chest distress, I-lssitude, nausea, vomiting, dark urine, feeble pulse and red tongue.
(I) Summer-Heat-Attack: The main symptoms are fever, flushed complexion, thirst, irritability, chest distress, lassitude, dizziness, poor appetite, abdominal pain, nausea, loose stool, red tongue and feeble and rapid pulse.
(2) Sun-Stroke: It is heavier than summer-heat-attack, and manifested as flushed or dirty complexion, cold limbs, thirst, asthma, dribbling of cold sweating, sudden loss of consciousness, large feeble pulse or deep pulse.
( 3 ) Summer-Warm is a kind of disease with sudden onset. Qi phase syndrome may be seen first, shown in high fever, profuse perspiration. thirst irritability, yellow tongue coating, surge pulse. With the rapid development, qi and body fluid exhausted, apoplexy may occur.
(4) Summer-Heat Impairment: If the main symptoms are lassitude in summer, poor appetite, thin and weakness, called summer-heat impairment
.
Analysis: Plain Questions said that deficiency of qi and fever were due to summer-heat evil. Heat causes the pores to open, which is followed by heavy sweating and dispersion of yang qi, and is manifested by fever, flushed complexion, thirst, lassitude and dizziness. Heat disturbs mind in heart and results in upset. It tends to have chest distress and nausea because heat creates confusion in the chest. When heat moves down into the small intestine, it makes dark urine. Feeble pulse is due to deficiency of qi and sweating. Summer-heat consumes qi, marked by dirty complexion, asthma, thirst, cold sweating and cold limbs. Sudden unconsciousness comes from pericardium disturbance. The relation of summer-heat and dampness was discussed by physicians in Qing Dynasty. Ye Gui said: "The summer-heat will certainly accompany with dampness. " Shao Xinfu held the same opinion and said: "The body is a small cosmos, surrounded by summer-heat in the sky and dampness in the earth. The two evils often attack people simultaneously. " Wang Mengying in his Co??zpendiumon B
Epidemic Febrile Diseases said: "Summer-heat makes dampness heavier, but it doesn't indicate there must have dampness in the summer-heat. Summer-heat transforms from the sunshine, not the mixture of heat and dampness. " H e held that not all summer-heat accompanies with dampness.
If the disease is due to the combined affection of summer-heat and dampness, When heat is heavier than dampness, it is named summer fever, on the contrary, it is named dampness-warm disease. Summer-heat is liable to invade into heart-ying, resulting in the condition of orifice besieged by phlegm-heat. When the weak body with poor spleen and stomach is attacked by summer-heat, it is shown in the loss of weight and poor appetite.
Pathasgenic Characteristics of Surimmer-heat Evil : A. Summer-heat is a yang evil with natures of fire. It exhausts qi and body fluid, marked by fever, sweating, thirst, lassitude, dark urine, feeble pulse. Asthenic fire consumes qi and results in deficiency of qi, even yang-qi deliletion.
B.The
heart is in charge of fire. Summer-heat is a scorching fire. So summer-
heat evil is easy to attack the heart, resulting in upset, even unconsciousness and aphasia,
C. Summer-heat is often accompanied with dampness to attack body, marked by heavy limbs, poor appetite, chest distress and loose stool.
222
O
IV. Dampness Syndrome Dampness syndrome is caused by the affection of dampness. Shi Shoutang in his Origin of Medicine said: "Dampness and Dryness is the yin-yang in the world. " This shows how important is the dampness and dryness as seen by the ancient doctors. Dampness exists in the nature, and is in its most exuberant state in late summer. In that time, dampness tends to attack body. Exopathic dampness is usually related to conditions of living and working. For example, working around water, wading in water or being caught in rain, as well as damp dwelling conditions, and wet coats are all easy to lead dampness syndrome. T h e endogenous dampness is discussed in the chapter of visceral syndrome differentiation.
Clinical Manifestation: Fever, aversion to cold, sweating but without fever declining; aggravated in the afternoon, heavy head and body, chest distress, epigastric distention, slimy and greasy taste in the mouth, anorexia, loose stool, numbness of skin, ulcer and swollen, fixed pain of joints, scanty urine, whitish and turbid urine of man, leukorrliea in woman, soft and moderate pulse, thick and greasy tongue coating.
(1) Dampness-Injury: When the main symptoms are fever, aversion to cold, sweating without fever declining aggravated in the afternoon, heavy head and body, chest distress, poor appetite, nausea, thin and white tongue coating, soft and moderate pulse, the condition is called dampness-injury.
(2) Wind-Dampness: If the main symptoms are sweating, aversion to wind, shortness of breath, painful joints, dysuria, it is called wind-dampness,
(3) Cold-Dampness: If the main symptoms are chilly sensations, even in summer, painful joints, heavy sensations below waist, it is called cold-dampness.
(4) When the main symptoms are fever, pain and swollen of limbs, fever of partial body, distention and fullness in the abdomen, scanty and dark urine, it is called Dampness-Heat.
(5) When the main symptoms are fever which isn't too high, but aggravated in the afternoon, epigastric distention, poor appetite, lassitude, loose stool, it is called
Damp-Warm* (6) T h e symptoms of heavy limbs with pain, numbness, swollen and ulcer, belong to Dampness Arthralgia. Analysis: Dampness attacks the superficies of the body, resulting in dysfunction of defensive phase, and obstructing yang-qi, which is marked by aversion to 223
cold and fever. Dampness hindering heat to spread over is marked by sweating without fever declining. Owing to dampness the head is like wrapped, which is marked by feeling heavy of head. The disturbance of qi to ascend and descend, which is marked by chest distress, epigastric distention, scanty urine. Yang of spleen is besieged by dampness, leading to poor appetite, nausea, loose stool. The orifice of spleen is tongue, which is marked by greasy ta.ste in the mouth. The spleen has the function of nourishing limbs, but dampness turbid is retained in body. which is marked by heavy limbs. Dampness obstructs the circulation of blood, leading to numbness, ulcer, pain skin. Dampness is turbid and heavy, resulting in fixed pain. If dampness moves down into lower-jiao, which is marked by whitish and turbid urine of man and leukorrhea in woman. Thick tongue coating and soft pulse mean dampness is retained in the body.
Pathogenic Characteristks of Dampness Evil : A. Dampness is a yin evil which tends to obstruct functional activities of qi and impairs yang qi. So attacked by dampness, there are symptoms of feeling just like wrapped head, covered eyes, numbness, swollen skin, heavy limbs, chest distress, vomiting and/or nausea.
B. Dampness is viscous and lingering. Onset of the disease is slow and it is difficult to cure.
C. The symptom of turbid excreta and secreta can always appear because of the heaviness and turbidity of dampness.
V.Dryness Syndrome Dryness syndrome is caused by dryness evil. Although T h e Most I?npo?-tant
Discussion in Plain Questions said: "The treatment of dryness evil should be moistening, the better way to eliminate it is to take bitter and warm herbs, accompanying with sweet and hot medicine". Liu Wangsu in his Explo?-ation to Pathogenesis i n
Familiaf- Conversation, Etiology Based on Plain Questions put forward the concept of dryness syndrome which was divided into exopathic dryness and endogenous dryness. Yu Genchu divided exopathic dryness into cool dryness which was attacked by wind-dryness in late autumn, and was lighter than wind-cold in winter; warm-dryness was attacked by hot dryness, and was heavier than wind-warm in late spring. The endogenous dryness caused by excess of yang and deficiency of yin which result from blood and fluid exhaustion. It isn't included in six pathogenic factors.
Clinical Manifestation: Fever, anhidrosis, dry skin, mouth and nose, dry cough 224
without sputum or with viscous sputum, even blood-stained sputum, thirst, hypochondriac pain, dry tongue coating.
(1) When the main symptoms are fever, aversion to cold, headache, anhidrosis, dry skin, cough without sputum, thin and dry tongue coating. the syndrome is called Cool-Dryness.
(2) When the main symptoms are slight aversion to cold, fever, headache, anhidrosis, dry cough, viscous sputum, hypochondriac pain, thirst, upset, dry skin, scanty urine, red in the edge of tongue with yellow and dry coating, rapid pulse, the condition is called Warm-Dryness.
Analysis: Direct invasion of dryness evil to the body on the basis of deficiency of body fluid will cause warm-dryness syndrome which is similar to fluid inipairment in warm-hot syndrome, but more serious than it. Dryness invades the superficies of body, leading to fever, headache, slight aversion to cold appear. Dryness usually attacks lung first. Nose is the orifice of lung, so showing dry nose and throat. Dryness impairs lung yin and Lung Meridian, showing thirst. anhidrosis, dry cough and' blood-stained sputuni. Dryness exhausts body fluid which nourishes the skin and muscles, showing rough skin, scanty urine. Dry yellow tongue coating and rapid pulse mean dryness evil is retaining in the body. After attacked by cool-dryness, the defensive yang is obstructed, showing fever, aversion to cold, anhidrosis. Cooldryness makes lung dysfunction of descending and cleaning, which shows dry cough, dry skin and dry white tongue coating.
Pathogenic Characteristics of Dryness Evil A. Dryness prevails in autumn, so that the disease due to dryness mostly occurs in autumn. Lung prefers moisture to dryness, so that dryness tend to impair lung.
B. T h e manifestations of deficiency of body fluid, such as dry and rough skin, constipation, scanty urine, are due to dryness evil.
V1. Fire Syndrome Fire syndrome is caused by fire evil. Fire always replaces heat, but the symptoms of fire syndrome is more serious than those of heat syndrome. Fire syndrome may be caused by disorder of five emotions and fire evils. T h e mechanism of fire syndrome are two, affection by exogenous evil which is attacked by five evils transformed into heat or attacked directly by virulent fire evil; and internal damage which is due to improper diet and seven emotions.
Clinical Manifestation: Flushed complexion, fever, aversion .to heat, thirst, dea
225
siring for cool water, sore throat, irritability even coma, carbuncles and papule which are red, swelling, heat and pain, constipation, dark urine, red tongue with yellow fur, rapid pulse.
(1) When the main symptoms are flushed complexion, blood-shot eyes, fever, aversion to heat, thirst, irritability, constipation, scanty urine, restlessness even delirium, bleeding, papule, red tongue with yellow fur, forceful pulse, The syndrome belongs to Excess-Fire. ( 2 ) If the manifestations are carbuncles with local red, swelling, hot and pain, high fever, thirst, restlessness, red tongue and rapid pulse, the condition is called Virulent Fire,
Analysis: When fire evil retains in qi phase, it shows fever, aversion to heat, sweating, thirst, upset, constipation, dark urine,
ell ow
tongue fur and full-rapid
pulse. When fire evil further invades ying phase, it shows fever aggravated at the night, thirst with unwilling to drink, upset and insomnia, red tongue and rapid pulse may occur. Fire evils interferes mind in the heart, resulting in delirium. Fire evil forces the blood to go astray, leading to various bleeding symptoms, such as nose bleed, hematuria, hemafecia, macule and papule. When fire-heat accumulates in local part, resulting in flesh ulceration and blood spoiled:
Pathogenic Characteristic of Fire Evil: A. Fire tends to flare up, so a series of hot symptoms may occur in the disease due to fire.
B. Fire is a yang evil. It exhausts body fluid, even consumes genuine yin stored in viscera.
C. Fire tends to promote the production of liver wind and accelerate the flowing of blood. So convulsion, syncope and bleeding may occur.
D. Asthenic fire impairs qi, resulting in deficiency of qi, even scattering of yang-qi. Six evils cause diseases separately or simultaneously by two or more of them in combination. There are combinations of wind, cold, dampness and fire in spring, combinations of wind, summer-heat, dampness and fire in summer, combinations of wind, cold and dryness in autumn, and combinations of wind and cold in winter.
Section 2
Pestilential Evils
The disease due to pestilential evils is manifested as sudden onset, strong infectiousness, similar manifestations and severe conditions of illness. Physicians in 226
ancient had suitable knowledge of epidemic disease. Epidemic disease may occur in all seasons. Because disorder of six evils in the sky combines with damp-heat on the earth to form pestilential evils. It attacks body from nose and mouth and results in strong infection and epidemic.
Clinical Manifestation: Aversion to cold and then fever, head sweating, anxiety, delirium even coma, acute headache, dirty complexion like smoked, greasy fur like flour coating or dry thick yellow tongue coating and deep pulse.
(1) The disease with above mentioned symptoms is called pestilence. (2) The above manifestations accompanied by swelling and red face and nape stiffness is called smolllena-head pestijence.
(3) The disease being of above symptoms and accompanied by red, purple or black macule and papule is called epidemic eruptive disease. The patient with congestive, swelling and sore throat, bright red tongue with big red points is called
scarlet fever. The patient with sore throat covering whitish gray membrane, dysphagia and dyspnea, is called throat infections.
(4) The above manifestations accompanied by purulent and bloody stool, is called fuilmiinant dysentery.
(5) The above manifestations accompanied by getting yellow all over the body is called f ulminant jaundice.
(6) The above manifestations accompanied with red papule on the face, nape, hand and shoulder, soon changing into blister, and necrosis, is called cutaneous an-
thrax.
( 7 ) Manifestations of aversion to cold, fever, paroxysmal spasmodic cough with an inspiratory wheezing sound, highly infectious, mostly seen in children is called whooping cough. The differences between epidemic disease and exogenous febrile disease should be clear. Exogenous febrile disease is attacked from pores and hair first due to cold and without infection. Epidemic pathogenic factor is retaining in space between the pleura and the diaphragm through mouth and nose tract and is highly infectious. As for symptoms, exogenous febrile disease shows headache, sweating; epidemic disease manifests splitting headache, head sweating, macule and papule. When the two pathogenic factors enter stomach, decoction for potent purgation is used to lead them out. But exogenous febrile disease without evil root is treated by sweating and purgation. The treatment of epidemic disease should begin after it's festering and spontaneous sweating.
Epidemic disease locates between the pleura and diaphragm, so that both interior and exterior syndrome may appear, such as aversion to cold, fever and irritability. T h e evil is dirty and viscous, so that there is thick white tongue coating. With the evil passing through, meridians, muscles, throat, lung and intestines are all involved. Pathologic characteristics of epidemic diseases are severe conditions and infectious.
Section 3
Seven Emotions
Five zang-viscera have five emotions. Liver is related to anger, heart to joy, spleen to pensiveness, lung to worry and kidney to fear. It indicates that emotion disturbance due to stress coming from outside tend to affect the corresponding viscera, resulting in disease. For example, anger impairs liver, over-joy impairs heart. Plus grief and fright, there are seven emotions. In general circumstances, seven emotions belong to normal physiological activities, but when seven emotions are beyond normal range, the balance of yin-yang and qi-blood may be impaired.
Internal Classic said: "Excessive anger impairs yin. Excessive joy impairs yang. " "Grief exhausts qi. Fear makes qi sunk. Excessive anger consumes qi and blood, resulting in unconsciousness.
"
Clinical Manifestation: 1. Damaged by anger: anger, upset, headache, dizziness, vomiting, lienteric diarrhea, syncope, hematemesis and taut pulse.
2. Damaged by joy: over joy, irritability, lax mind, speaking incoherently and moderate pulse.
3. Damaged by w o r r y : edema, distressed, sighing, shortness of breath, poor appetite, constipation, scanty urine and uneven pulse. ,
palpitation, shortness of breath,
amnesia, speaking inarticulately, insomnia, abdominal distention, anorexia and knotted pulse.
5. D a ~ a g e dby grief: unhappy, =ad aiid slugyisil pulse. 6. Damaged by fear: disturbance, alternate pale and flushed face. acting like being
arrested,
muscular
flaccidity
and
cold
extremities,
spermatorrhea,
incontinence and deep pulse.
7. Damaged by fright: easy to be frightened, shortness of breath, palpitation. restlessness, insomnia with strange dream and taut pulse.
228 *
1
Analysis : Anger is related to liver and gallbladder which like smooth and spreading. Anger causes reversed flow of qi which is shown in dizziness and headache. Anger causes the blood rebellion which is manifested by hematemesis. Deranged qi leads t o unconsciousness. Liver qi attacks stomach and results in vomiting. Wood restricting earth gives rise to lienteric diarrhea. T a u t pulse means blockage of qi movement. Joy impairs heart. Discussion on the Impof-tant Basis of Vitality of Spirit Pivot said: "The deficiency of heart qi causes grief, while the excess of heart qi leads to over smile. " T h e man with excessive joy has lax mind, speaking articulately, upset and moderate pulse. Worry leads to abnormality of lung and spleen. Discussion on the I?npof-tantBasis of Vitality of Spirit Pivot said: "Worry causes qi stagnation which shows shortness of breath, asthma, dysuria. Long time stagnation may injury the function of spleen, which is marked by poor appetite, sluggish pulse.
"
Pensiveness is related to heart and spleen. Ancients believed that pensiveness originated from spleen and grew up in the heart. Excessive pensiveness impairs the mind and consumes blood, showing severe palpitation, amnesia, insomnia. Excessive pensiveness leads to stagnation of qi which impedes the transportation and transformation of spleen and is manifested by stuffy stomach and poor appetite. When spleen loses its function of keeping blood flowing normally, bleeding will happen. Grief is related to heart and lung. Spirit Pivot said: "Deficiency of heart qi leads to grief. " T h e emotion is also commanded by lung. Upset and restlessness may occur when both heart and lung are impaired. Grief consumes qi which commands the circulation of blood, resulting in sluggish pulse. Fear is related to diseases of heart, kidney, liver and stomach. Impaired mind, which is stored in heart, leads to fear. Fear is a response of kidney function. Liver is supported by kidney. Dysfunction of kidney disturbs normal liver function of storing blood, resulting in deficiency of blood, then fear occurs. Stomach is attributed to earth, kidney to water. Earth in excess restricts water. T h a t leads to fear. Internal Classic said: "Fear impairs essence of body and causes the sinking of qi. " S o there will appear fear, upset and loss of mind. Fright is related to diseases of heart, liver and stomach. Heart fails to command the mental activities when attacked by fright, showing restlessness and strange dream. Fright makes qi flow downward, which is marked by deep pulse. 229
Pathapgenic Characteristics of Seven Bmaptions : A. Resulting in internal damage. Seven emotions directly affect the corresponding viscera to bring about the dysfunction of five viscera. As Questions about Pathogens of Y a w n and Others in Spirit Pivot said: "Excessive grief, worry and sorrow will shake the heart, resulting in five zang and six fu-viscera being stirred in accordance.
"
B. Seven emotions mainly affect qi. For example, anger causes upward flow of qi, fright interrupts the flow of qi, fear causes sinking of qi. They also make qi stagnation, deficiency, and then deficiency of body fluid and various bleeding.
C. Seven emotions can cause disease separately or simultaneously. In fact, worry and pensiveness, fright and fear usually appear at the same time. Seven emotions are the response of function of zang-fu viscera. However, there exists relationships of generation, restriction, subjugation and reverse restriction among viscera. So the diseases caused by seven emotions are not limited in one viscera.
D. T h e diseases caused by seven emotions, except joy, are usually due to hyperaction, not deficiency.
Section 4 Improper Diet and Overwork
I.Food-Retention An appropriate amount of food supplies the nutrition to body. It is the basic conditions for human beings to maintain health. Overeating gives rise to diseases of indigestion, retention of food and stagnation of qi and blood. Dyspepsia is the first pathogenic factor to cause miscellaneous disea There is difference between food-retention and indigestion. Food-retention is due to damage of stomach and intestine by overeating. However, indigestion lies in qi stagnation resulting in food retention whether eating much or little and other pathogenic factors.
Clinical Mannifestation: Anorexia, eructation with fetid odor and acid, regurgitation, vomiting, nausea, abdominal distention, diarrhea or constipation, epigastric pain, heavy limbs, fever and sweating, headache, even abdominal mass, lean and naggard, slippery and rapid pulse, thick tongue coating.
Analysis: Five flavors supply nutrition for viscera, but overeating makes qi and blood stagnation. People in good health couldn't catch the disease. It is easy to be attacked while genuine qi isn't consolidated. 230
Over eating vegetables and fruits in bad health and excessive emotional stress can make food retention. T h e symptoms often appear among old man, children and postpartum in weakness, showing anorexia, nausea, belching, eructation. Accumulated food can transform into fire and damage genuine qi, which is marked by fever, sweating, headache, palpitation, even abdominal mass. Unhygienic diet and poisonous food may impair stomach, which is marked by colic in abdomen, vomiting and diarrhea. Over-drinking of wine, which is hot and poisonous in nature, will consume stomach yin, and result in diabetes, jaundice, phlegm-retention, distention of abdomen, dysphagia, abdominal mass, frequent vomiting, even death.
Pathogenic Characteristics of Food-Retentim A. Dyspepia mainly disorders the function of spleen and stomach. B. Accumulated food may transform into heat, called internal heat syndrome. But there only appears fever, headache, without pain of the whole body. Food preference, insufficient eating and unhygienic diet may break the balance of various nutrition and cause disease.
II. Overwork Li Dongyuan held that both improper diet and overwork belonged to internal injuries. Improper diet means over hunger or irregular intake of food. Over hunger impairs stomach while irregular food-intake the spleen. It is different from overeating. Physical overstrain consumes qi. Mental overstrain impairs blood. T h e final syndrome is yang-qi decline. Oversex impairs kidney and results in deficiency of yin and hyperactivity of fire. There is a saying "the flowing water is always fresh, the moving bolt isn't bit by insects.
"
So, too much rest also leads to diseases due to blockage of qi and
phlegm retention, which shows fat and shortness of breath.
Clinical Manifestations: Fever, headache, spontaneous sweating, irritability, shortness of breath, thirst, poor appetite, lassitude, heavy limbs and feeble pulse.
Analysis: Seven emotions, food-retention and overwork including oversex are internal diseases which have excess and deficiency, Above-mentioned symptoms are the main manifestations in all internal diseases. Overstrain or irregular daily life can impair genuine qi. Because the qi loses the motive power, lassitude and asthma appear. Deficiency of qi leads to hyperactivity of fire, and spleen (earth) is restricted and fails to nourish muscles, which is marked by fever, headache, spontaneous sweating, irritability, poor appetite, thirst and lassitude. 231
Oversex impairs kidney, resulting in whitish and turbid urine, impotence and symptoms of deficiency of kidney.
Section 5
Parasites and Surgical Trauma
1.Parasites Ancient physicians thought that parasites in intestines went upwards and downwards and made colic, and usually came out when coughing or vomiting. T h e important pathogenic factor for it is eating raw-cold food.
Clinical Manifestation: Pain from time to time, lean, lassitude, whitish patches on the face.
1. If the main symptoms are polyphagia, emaciation with sallow complexion, gastric upset, abdominal pain from time to time, vomiting fluid or roundworm, teeth grinding at night, white millets on the inner side of lips, whitish patches over face, easy to be hunger and heterorexia (raw rice, sand, tea) and large or small pulse, the condition is ascarides parasitosis.
2. Patients suffering from anus itching especially at midnight. And white minute linear oxyurids may be found around anus. There may be dull abdominal pain, poor appetite, and lean. It is called oxyuriasis parasitosis.
3. If the main symptoms are sallow complexion, lassitude, pain abdomen, diarrhea, itching anus, white band-shaped imaginal proglotids found in patient's feces or quits, knots below skin, epilepsy, thready pulse and pale tongue, the condition is called taeniasis.
4. If the main symptoms are edema, sallow complexion and palpitation, it is called ancylostomiasis. 5. If the main symptoms are sallow complexion, lassitude, poor appetite and visible superficial vein over abdomen, it is called schistosomiasis. Analysis: Parasites in intestines is due to eating raw-cold food. Parasites makes pain when moving. They disorders the function of transporting and transforming of spleen, resulting in vomiting, diarrhea, poor appetite. Lean, edema, palpitation and lassitude may occur because of blood and qi impaired. Hand-Yangrning Meridian enters into the lower teeth and curves round the lips, goes upwards to both sides of the wing of nose. Foot-Yangming Meridian starts from nose, enters into the upper teeth. Dampness and heat built up by parasites in stomach move along the meridians, disturb the functional activities of qi, shows whitish patches over face, grinding 232
a
teeth at night.
11. Trauma Surgical trauma includes incised wound, insect and beast bite and traumatic injuries. Although trauma has local wounded place, blood and qi must be attacked. For example, tetanus is due to invasion of wind evil from wounded parts, resulting in fever and chill from time to time, lockjaw, convulsion. The real reason of tetanus is deficiency of qi. It is considerate and important to think over meridians and viscera, not only to think about local wound.
Chapter 8 Qi-Blood and Body Fluid Syndrome Differentiation Qi-blood and body fluid syndrome differentiation is a diagnosis method which is used to distinguish various syndromes according to symptoms caused by disorder of qi-blood and body fluid. Qi, blood and body fluid are energy, and material base of vital activities. At the same time, they are products and symbols of living activities. The diseases of viscera will affect qi, blood and body fluid, and vice versa. It is necessary to combine qi-blood and body fluid syndrome differentiation with visceral syndrome differentiation in diagnosis.
Section 1 Qi Syndrome Differentiation Qi in different locations have different names. Pectoral qi is flowing in chest, stomach qi is stored in middle-jiao, genuine qi in lower-jiao, defensive qi is to protect superficies of body. Zhang Zihe said: "All diseases are due to disorder of qi.
"
Zhang Sanxi further put forward: "Qi in the sky and earth is normal in the nature. Diseases occur when the balance between sky and earth is broken. Human beings rely on qi in nature, seven emotions inside, and five elements movement outside. Qi is precious to man. It is originally one identity and is divided into nine categories when touching different places.
"
I. Deficiency of Qi Deficiency of qi is a syndrome that occurs when functions of zang-fu viscera have weakened.
Clinical Manilfestatisns: Shortness of breath, lassitude, dizziness, spontaneous sweating, loose stool, and bleeding. All these symptoms are aggravated after physical exertion. The tongue is corpulent and pulse feeble. AnsPysis: Overwork, prolonged disease, aging with weakness and improper diet all can cause deficiency of qi. Questions about Pathogens of Yawn and Others in Spirit Pivot said: "Deficiency of upper qi makes brain empty, manifested as tinnitus, dizziness; deficiency of middle qi leads to abnormality of urine and stool and *
234
borborymus; deficiency of lower qi causes muscular flaccidity, cold limbs and epigastric throbbing. " Qi deficiency is usually concerned to middle qi which locates in spleen and relates to lung. The middle qi deficiency shows indigestion and lassitude. When qi fails to go upwards to nourish head, there appear dizziness and corpulent tongue. Deficiency of pectoral qi leads to shortness of breath. Deficiency of defensive qi makes superficies weak, showing spontaneous sweating. Deficient qi is unable to command blood flow and shows bleeding, aggravated by exertion, and feeble pulse.
11.Qi Sinking Sinking of qi is included in deficiency of qi. The qi falling instead of rising.
Clinical Manifestations: Dizziness, lassitude, shortness of breath, fullness of abdomen, diarrhea, metrorrhagia and metrost axis, increasing amount of leukorrhea, prolapse of the rectum or uterus, pale tongue with white coating and feeble pulse.
Analysis: Deficient qi fails to go upwards to nourish head, then there is dizziness. In the severe case, just as Zhang Xichun said: "The falling of chest qi leads to shortness of breath or cessation of breath. It is a dangerous sign of dying. " Qi fails to ascend and is unable to restrain viscera, and shows various lower-jiao symptoms.
Appendix: Depletion of Qi Depletion of qi is a syndrome that happens when the genuine qi is running out and visceral function is exhausted.
Clinical Manifestations: Sudden faint, cold body, pale complexion with feeble pulse.
Analysis: The mechanism of above mentioned symptoms is the exhaustion of qi which is stored in viscera. Depletion of spleen qi leads to weak hand. Snoring means exhaustion of lung qi; closing eyes to liver qi, opening mouth to heart qi, enuresis to kidney qi. It is very difficult to cure while all symptoms appear.
111. Stagnatia~nof Qji Stagnation of qi arises from the blockage of functional activities of qi.
Clinical Manifestations: Oppression, distending pain in chest, hypochondrium and abdomen, belching eructation, fart, distention of breast, disorder of menstruation, urine and stool, and taut pulse. The above symptoms are aggravated by emotional stress. *
235
a
Analysis: The mechanism of qi stagnation is either due to disorder of emotions caused by liver failing to govern the flow of qi; or due to phlegm retention, improper diet, overwork and trauma. The clinical manif estations are different with different locations of blockage. Hua Xiuyun said: "Depression leads to stagnation of qi which is in physical body or viscera, resulting in different unsmooth flow. Qi does not have concrete shape, but it seems like a shape when assembling. For example, fullness in hypochondrium, epigastrium, abdomen. The main symptoms are local "
fullness and pain, subsided after fart or belching eructation. Stagnation in upperjiao shows epigastric fullness; that in middle-jiao shows abdomen pain; that in lower-jiao shows lumbago. Blockage of qi leads to abdominal mass inside, and results in edema outside. If there appear sudden faint with lockjaw, clenching of fists, it is called closure-syndrome of qi.
IV. Rebellion of Qi Rebellion of qi refers to disorder of qi in ascending and descending, resulting in upward flow of qi.
Clinical Manifestations : Belching eructation, suffocation, hiccup, qi which originates .from umbilical region going upward to throat and taut pulse. Analysis: Internal Classic said: "All about rebellion and going upward are related to fire. " Zhu Danxi also said: "Rebellion of qi results from heat-fire due to depress of qi is classified as yang.
"
The syndrome, which can be treated by decoction of twice cinnamomi and decoction of poria, cinnamomi, fructus a n d licorice, results from cold-qi reversing. Both heat and cold may cause rebellion of qi flow. When stomach qi is attacked by exopathogens, phlegm retention and dyspepsia, it ascends instead of descending, that is manifested by belching eructation, nausea, hiccup. Blockage of upper-jiao attacked by exopathogens or phlegm leads to asthma, suffocation, even coma. The cold evil moves along Foot Shaoyin Meridian, which starts from pantar surface of the little toe, ascends into throat and terminates at the root of tongue, and results in depression in chest and palpitation. When attacked by anger, liver qi rushes in throat and makes physical and functional depletion. In the severe case, coma occurs.
Section 2
Blood Syndrome Differentiation
Blood roots in kidney, comes from heart, generates in spleen, and is stored in *
236
liver and delivered by lung. Its function is to nourish and moisten the whole body. Lou Ying said: "Qi is the commander of blood. Blood activities are along with qi movement, such as ascending or descending. When qi is cold, the blood coagulates; while qi is heat, the blood moves. ''
I. Deficiency of Blood Deficiency of blood makes insufficient blood failing to nourish zang-fu viscera and the whole body. Deficiency of blood and deficiency of yin have the same symptoms, such as lean, palpitation, sleeplessness. There are differences by sallow complexion in blood deficiency and flushing of zygomatic region in yin deficiency.
Clinical Manifestatiom: Pale or sallow complexion, pale lips and nails, weakness and numbness of limbs, flaccidity, delayed menstruation or amenorrhea, pale tongue and thready pulse.
Analysis: Bleeding, weariness, hypofunction of spleen and stomach all consume blood, resulting in malnutrition of the whole body, which is manifested by sallow complexion and pale lips and nails. Deficient blood fails to supply nutrition to head, heart, tendons, meridians .Ilid sea of blood, the above-mentioned symptoms may occur.
11. Bleeding Syndrome Bleeding syndroiiie means that blood extravasats from the vessels.
Clinical Manifestations: Rhinorrhea, tongue bleeding, bleeding gums, hemoptysis, hematemesis, hematochezia, hematuria, metrorrhagia and metrostaxis and macule.
Analysis: Blood is the essence of yin-qi. It is not good to be disturbed. Blood commands nourishing qi. It is not good to be consumed. Heat accelerates blood flowing. Excessive fire makes blood flow disturbedly. Excessive emotions, overwork, over sex, exopathogens and improper diet may inspire fire to exhaust body fluid and yin: deficient cold of middle-jiao makes it failing to govern and results in qi sinking; excessive yin repels yang, which leads to fire failing to return its source and blood up. All of these give rise to bleeding. Not only epistaxis is due to weariness of primary qi and deficiency of yin which causes hyperactivity of fire, but also due to rushing up of excessive fire. Gum bleeding is due to fire in Meridian of Yangming. Tongue bleeding is due to fire in heart. Hemoptysis is due to heat retention in lung. Hematemesis comes from stomach. Heat in bladder and asthenic cold 237
in lower-jiao may cause hematuria. Hemorrhoid, diarrhea, and weak spleen lead to hematochezia. The disorder of Chong and Ren Meridians cause metrorrhagia and metrostaxis. Macule indicates heat is retained in ying phase.
HII. Blood-Heat Syndrome Blood-heat syndrome occurs when exopathogenic fire attacks stomach, bladder, blood-chamber and other viscera.
Clinical Manifestations: (1) Fever, which aggravates at night, thirst without polydipsia, insomnia, delirium, eruption, hematemesis, hematochezia, crimson tongue and rapid pulse; (2) pain and abdominal fullness, black stool and amnesia;
(3) chills, high fever like malaria, hypochondriac and epigastric distention and amenorrhea.
Analysis: Blood heat syndrome occurs when heat evil attacks ying phase which belongs to yin. So the symptoms are severer at night. Heat evil consumes ying-yin, which results in body fluid evaporated, showing thirst without polydipsia. Heat disturbs mind in heart, leading to delirium and insomnia. Heat accelerates the flowing of blood, leading to various bleeding. Abdominal pain, amnesia and black stool are due to heat retaining in stomach. Cramping in lower abdomen and incontinence of urine arise from heat blocking the bladder. Heat invades sea of blood giving rise to paroxysms of chills, high fever and amenorrhea.
HV.Blood Stasis Syndrome This syndrome is due to non-functional blood stasis which includes extravasated blood in tissue and stagnated blood in meridians and viscera.
Clinical Manifestations: Stabbing pain, which aggravates by pressing, fixed masses on the surface of body, blackish complexion, rough skin, dry hair, cyanotic lips and nails, dark purple tongue with ecchymosis and petechiae, sluggish pulse. Blood stasis of different locations has different symptoms. Stasis in liver shows stabbing pain, abdominal mass; stasis in heart shows chest distress and palpitation; in stomach shows hematemesis and blackish stool; in lung shows chest pain and hemoptysis; in uterus shows dysmenorrhea, amenorrhea and abdominal mass ; in superficies shows swollen masses in dark purple color with stabbing pain.
(1) When above symptoms are accompanied by dizziness, palpitation, insomnia and pale tongue, it is blood stasis with deficiency of blood. (2) When accompanied by cold limbs, which is subsided by warming, it is due to cold invasion meridians. 238
(3) When accompanied by blood-heat symptoms, it is blood and heat binding.
Analysis: Ancient physicians thought that accumulation of exogenous cold leads to obstruction of pulse. Exopathic disease, internal damage and trauma all can produce blood stasis through in forms of stagnation of blood and extravasting blood. Blood stasis has definite morphologic lesion which leads to stabbing pain aggravated by pressing, Blood stasis impairs body fluid resulting in fever aggravated at night. Blood stasis invades meridians which leads to continual bleeding with purple lumps. Blood stasis causes failure of nourishing which is manifested by rough skin, blackish complexion, dry hair and dark purple tongue.
V. Blood-Cold Syndrome This syndrome is caused by cold evil resulting in stagnation of blood as well as weakness of yang-qi.
i
Clinical Manifestations: Cold limbs, pain subsided by warming; dysmenorrhea, delayed menstruation with dark purple color clots, pale tongue and deep-slow-uneven pulse.
Analysis: Warmth accelerates the flowing of blood, however, coldness makes blood flow sluggish and blocked. Blockage leads to pain. Weakened yang-qi results in cold limbs; Cold evil invasion to uterus leads to delayed menstruation; Blood which is attacked by cold is unable to provide nutrients to tongue, showing dark purple color; Deep-slow-uneven pulse means yin cold evil retains in body and blood flows unsmoothly.
Section 3
Differentiation of Syndrome of Both Qi and Blood
Yang controls qi, and yin controls blood. They not only oppose but also contain each other. Deficient qi loses the function of warming, producing, consolidating and promoting of blood, which is manifested by insufficient blood, bleeding, blood stasis. Deficient blood fails to carry qi and provide nutrients for the movement of qi, which leads to deficiency of qi. Malnourished qi can transform into dry-fire. Depletion of blood gives rise to yang exhaustion. It is necessary to reinforce qi at the same time when blood is toned up, and vice versa.
1.Qi Deficiency and Blood Stasis Clinicall Manifestatiorrns:Shortness of breath, lassitude, spontaneous sweating, stabbing pain aggravated by pressing, ecchymosisin, tongue sluggish pulse.
Analysis: Deficient qi fails to promote the flowing of blood. There appear symptoms of deficiency of qi, soon symptoms of deficiency of blood occur.
11.Qi Stagnation and Blood Stasis Clinical Manifestations : stuffy chest, indigestion, swollen mass in abdomen with stabbing pain, irregular menstruation, distending in breast, purple tongue with ecchymosis, and sluggish pulse.
Analysis: Disorder of seven emotions due to stagnation of qi leading to a series of symptoms about depression of liver qi. With development of stagnation of qi, blood stasis forms, resulting in abdominal masses, stabbing pain and delayed menstruation.
IH. Deficiency of Both Qi and Blood Clinical Manifestations: Lassitude, shortness of breath, spontaneous sweating, pale or sallow complexion, palpitation, insomnia, dizziness, numbness of limbs, pale corpulent tongue and thready pulse.
Analysis: It is a deficiency of both blood and qi. Usually it is due to congenital insufficiency or acquired injury in daily life. Deficient qi fails to produce blood, which leads to deficiency of blood and vice versa. Deficiency of qi manifests as shortness of breath, lassitude, spontaneous sweating. Deficiency of blood shows sallow complexion, dizziness, palpitation, insomnia and numbness of limbs.
PV. Failure of Qi to Control Blood Clinical Maniffedations : Shortness of breath, lassitude, spontaneous sweating, pale and fresh tongue, feeble pulse and various bleeding.
Analysis: It refers to syndrome that deficiency of qi fails to govern blood. Blood can't exist without qi. In clinic, symptoms of qi deficiency appear first, then appear various bleeding, as hematemesis, metrorrhagia and metrostaxis. At last, collapse of blood and qi may happen.
V. Qi Depletion Resulting from Hemorrhage Clinical Manifestations: Heavy bleeding, pale complexion, profuse sweating, cold limbs, feeble breath, irritability, even syncope, pale tongue and thready pulse.
Analysis: It refers to syndrome of qi depletion brought about by hemorrhage, which usually caused by trauma, profuse metrorrhagia in delivery and other diseases. Qi will find nowhere to be attached and fails to go upward to nourish the
head, which is manifested by pale complexion and corpulent tongue. Depletion of qi and blood fails to nourish the mind, which is manifested by irritability and syncope.
Section 4
Differentiation of Body Fluid Syndrome
Body fluid comes from diet. It is subdivided into two categories. Jin is the fluid which is dilute. Part of it turns into sweat to the surface of body, others descend into bladder and being excreted as urine. Liquid (Ye) is the fluid which is thick. It is transported all over the body through triple-jiao. Body fluid has the function of moisturizing and nourishing. Body fluid pours into viscera, flows into pores and seeps into joints and spinal tube to provide nutrients for them. The disorder of body fluid has two aspects:
I. Deficiency of Body Fluid Sweating, vomiting, diarrhea, hemorrhage, loss of essence, yin deficiency and excessive yang all can lead to deficiency of body fluid which fails to moisten and nourish the body. All of dry symptoms come from excessive yang and insufficient yin. Hua Xiuyun said: "Dryness syndrome includes two categories, exopathic disease which arises from hyperactive wind-heat in later autumn and internal damage which is due to exhaustion of blood and essence. " Exopathic dryness has been discussed in the former chapter. Internal dryness is the following. Clinical Manifestations: Rough skin, dry hair, itching, polydipsia. diabetes, flaccidity, dysphagia, dry nose, scanty urine, and constipation. Analysis: The superficial cause of dryness syndrome is the in sufficiency of fluid, but the basic cause is the deficiency of qi and blood. The Law of Medicine said: "Manifestations of dryness syndrome are not uniform. Dryness in the exterior shows dry and wrinkled skin. Dryness in the interior makes depletion of essence and blood. Dryness of bloody fluid leads to decline of nourishing and defensive qi. It may show interior flaming and dried fresh. All theses varieties depend on which meridian the syndrome belongs to and is affected.
"
Lung connects Taiyin Meridian, and provides nutrient to skin and hair. If lung fails to clean and descend, rhagades, bleeding and itching will occur. When insufficient fluid fails to go upward to moisten, vital-yin is consumed, it shows dry nose and throat, polydipsia, diabetes. When tendons and joints have not been moistened, they become flaccid. Stomach without enough fluid leads to indigestion, even dys241
phagia. Insufficiency of fluid with hyperfunction of heat leads to constipation and scanty urine.
11. Retention of Body Fluid Retention of body fluid which results from the dysfunction of lung, spleen and kidney is divided into three kinds.
I. Edema Spleen has the function of transportation and transformation; lung controls dispersing and descending; kidney governs five-viscera and transports body fluid. So dysfunction of spleen, lung and kidney gives rise to fluid spreading over muscles and skins, edema may occur.
CIlinical Manifestations: Edema around the eyes, puffy skin, swollen head and abdomen, heavy limbs, cough, severe palpitation, coldness in loins, dark and scanty urine.
A. When edema is accompanied by fever, polydipsia, dark urine and constipation, it first appears in the upper parts with sudden onset, yellow greasy tongue coating, deep and rapid pulse, it is named yang-edema
BeWhen it is accompanied by cold limbs, no thirst, clear urine, loose stool, and it first appears below the waist with slow onset, white greasy tongue coating and deep slow pulse, it is named yin-edema. Analysis: Dysfunction of spleen, lung and kidney disturbs food to be transformed into nutrients, body fluid is obstructed. When body fluid retention spreads over the whole body. there appears edema all over the body, cough, asthma and palEdema in different viscera have different manifestations. Edema in heart diseases is accompanied by orthopnea and anxiety; that in liver diseases is accompanied by hypochondriac pain and ascites; that in spleen diseases is accompanied by ascites and heavy limbs; that in lung diseases is accompanied by general edema and dysuria; that in kidney diseases is accompanied by lumbago, emission, cold limbs and saiiow compiexion. The iater physicians distinguished edema through yin and yang, deficiency and excess after Li Shicai. He said in detail: "Yin-yang and deficiency-excess are necessary for differentiation". Yang syndrome leads to heat symptom which is related to excess. Yin syndrome leads to cold symptom which belongs to deficiency. The excessive syndrome due to exopathogenic factors and improper diet mania
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fests as edema first in interior, dark urine, constipation, slippery and rapid pulse, flushed complexion with asthma; The deficiency of syndrome due to excessive seven emotions and sexual overstrain shows edema first appearing in exterior, clear and profuse urine, loose stool, float thready pulse, pale complexion, shortness of breath. Edema is a severe condition in internal medicine. Black and swollen lips are due to liver disorder. Flat Quepen (supraclavicular fossa) is due to heart disorder. Bulging umbilicus is due to spleen disease. Flat foot is due to kidney disease. Flat back is due to lung disorder. All those indicate unfavorable prognosis.
2. Phlegm-Fluid Reteaation Phlegm retention is a pathologic and pathogenic product of body fluid metabolism in disease. Phlegm which is thick is different from fluid retention which 1
is clear.
(1) Fluid Retention Undigested food and drinking will transform into fluid retention. Hypofunction of spleen and stomach, deficiency of yang-qi combining with exopathogenic cold-dampness, improper diet, overwork and emotional factors can cause indigestion. There are phlegm-retention, pleural effusion, anasarca and fluid retention in the hypochondrium and epigastrium according to different places where phlegm retention stays. The basic mechanism of phlegm retention is excessive yin due to yang insufficiency. So, basic treatment is warming. The clinical characteristics are : a. Body fluid flows easily and makes sound of bubbles which is aggravated with action. Spirit Pivot said : "Fluid flows along the intestines, makes noise. Fluid retention under hypochondrium leads to pain while coughing.
"
b. All those with excretion of dilute liquid are named fluid retention because of fluid is dilute and clear. Zhang Jingyue said: "Fluid is a part of liquid in body. Vomiting of clear liquid and nausea with sound are fluid syndrome due to indigestion.
"
c. Patients with fluid retention always have the sensation of heaviness and fullness. Spirit pivot said: "Fluid retention in limbs leads to pain. Phlegm retention in hypochondrium results in stuffy chest.
"
d. Fluid retention obstructs the functional activities of yang-qi. When lucid yang doesn't elevate, it gives rise to dizziness. Blockage of lung qi leads to shortness of breath. Blockage of defensive qi leads to aversion to cold. Blockage of heart qi leads to palpitation. Obstruction of stomach-yang makes turbid yin rebellious and 243
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leads to nausea and vomiting. e. Slippery-taut pulse and white-greasy tongue coating with spittle. The common fluid-retention is following:
A.Phlegm-Fluid
Retention
Clinical Manifestations: Lean and water sounds along the intestines, in addition to above mentioned symptoms of fluid retention. Analysis : Yang-qi is impaired and turbid yin obstructs food from transforming into nutrients to nourish muscles and skin. So the liquid in food has the only way to flow along intestines, manifested by above-mentioned symptoms.
B. Hanging Fluid Retention (Blleurall Effusion) Clinicall Manifedations: Fluid retention below hypochondrium, pain after coughing, shortness of breath, asthma. Analysis: The passages of qi ascending and descending locates at hypochondriurn on both sides. When they are blocked by fluid retention, the syndrome occurs; C. Overflowing Fluid Retention (Anasarea) Clinical Martllifestations: Edema, heavy limbs, dysuria, fever, aversion to cold, anhidrosis, asthma. Analysis: Deficient spleen yang fails to distribute fluid. That gives rise to fluid spreading over the body, manifesting as edema, dysuria and general pain. If cold evil attacking results in superficies bound up and defensive qi blocked, there will be fever, aversion to cold. Obstruction of passage due to turbid yin leads to lung qi rushing upwards, showing cough.
D. Suspending Fluid Retention Clinical Manifestations: Cough, asthma, shortness of breath, inability of lying flat, puffy face, whitish sputum. Analysis: Fluid retention obstructs qi flowing, resulting in fluid flowing over the upper part, instead of descending into bladder. So cough, inability of lying flat and puffy face occur.
(2)Phlegm Syndrome Phlegm syndrome has different mechanisms. Hot lung qi due to deficiency of yin evaporates body fluid, congeals it into phlegm. Emotional stress may produce heat which burns body fluid. Invasion by cold-dampness or too much greasy food results in dysfunction of spleen and stomach. When deficiency of kidney qi fails to govern body fluid, the fluid spreads over. Six evils may cause spleen and lung confusion, and result in indigestion. All above mentioned may give rise to phlegm syn-
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drome. Phlegm extends all over the body through the meridians and collateral, brings about various symptoms, such as nausea, cough, fever, aversion to cold, dysphagia, diarrhea, palpitation, insomnia, fall and paralysis. There is the saying that "Strange diseases are due to phlegm.
"
Most diseases are related to phlegm. Phlegm and
blood stasis have the same origin, the body fluid. It is complicated when phlegm units with blood stasis to cause disease. Phlegm can be subdivided into two kinds, the visible and the invisible. Visible phlegm is shown in sputum, vomiting spittle, subcutaneous nodule and loose stool. It is easy to find. Invisible phlegm is manifested as insomnia, manic-depressive psychosis, blockage in throat, shortness of breath, abdominal distention, dizziness, palpitation and paralysis. It is difficult to distinguish. Common visible phlegm syndrome are following.
A. Wind-Phlegm This syndrome indicates that excessive phlegm results in apoplexy.
Clinical Manifestations: Dizziness, stupor, sudden fall, facial hemiparalysis, lockjaw, convulsion, paralysis, greasy tongue coating and slippery pulse.
Analysis: Too much greasy food and hyperactivity of yang-wind due to yin deficiency result in phlegm spreading over the body. When yang-wind disturbs head, dizziness and stupor occur. Meridian obstruction causes convulsion, facial hemiparalysis and paralysis. Phlegm-heat obstructs the clear orifice, delirium and coma may occur.
B. Heat-Phlegm This indicates phlegm binding with heat.
Clinical Manifestations: Fever, sore throat, blepharitis, severe palpitation, thick and yellow sputum, constipation, delirium, even madness, greasy and yellow tongue coating, slippery and rapid pulse.
Analysis: Heat evil or exorbitant interior yang boils body fluid into heat phlegm, which is manifested by yellow sputum and constipation, Fire flaming up to head causes blepharitis; phlegm-heat hoods the mind and leads to palpitation.
C. Cold-Phlegm Cold binds with turbid phlegm and they form cold-phlegm.
Clinical Manifestations: Chills, stabbing pain in joints, heavy limbs, white sputum, white greasy tongue coating, deep slow pulse.
Analysis : Deficiency of yang-qi fails to warm body. Yin-cold causes stagnation of qi and blood, resulting in above-mentioned symptoms. 245
D, Dampness-Phlegm Clinical Manifestations: chest distress, poor appetite, nausea, heavy body, lassitude and thick greasy tongue coating.
Analysis : Dampness evil or deficiency of spleen causes indigestion and fluid retention, manifested by poor appetite, and chest distress. Dysfunctional spleen fails to provide nutrients to limbs, which shows heavy limbs, lassitude and thick greasy tongue coating.
E.Dryness-Phlegm Phlegm syndrome combines with dryness is named dryness-phlegm.
Clinical M a n i f estatians : Sticky sputum, which is difficulty to cough out, sputum mixed with blood. dry nose and throat, thirst, constipation, dry tongue .and rapid pulse.
Analysis: Heat due to exopathic disease or internal damage evaporates body fluid, resulting in various dry symptoms, such as dry nose and throat, constipation and rapid pulse.
Section 5 Modern Research on Qi-Blood and Body--Fluid Syndrome Differentiation The achievements are focused on laboratory index of deficiency of qi and blood stasis syndrome differentiation. Since these studies are closely cooperated with clinic, the results are both theoretical and clinical valuable. Some of the traditional Chinese medicine theories about qi-blood have been proved experimentally. Injection of Ginseng and Astragalus extract to a body of inpartially the principle of qi promoting blood flowing. Ginseng and Pilose antler
for the theory that qi produces blood. Changes of laboratory indices of heart-lung function. digestion, endocrine glands, immunity in qi deficiency experiment have been, found: and also changes of
Mg, Zn, Gu, cyclic nucleoside, dopamine P-hydroxylase and a-antitrypsin in the blood have been found. The experiments on blood stasis concentrate on the change of blood-viscosity and blood-rheology. It is found that packed cell volume, globulin, b-lipoprotein, cholesterol, triglyceride, blood viscosity and coagulability, plasm content of fibrino246
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gem increase; fibrinolytic enzyme decrease; plasma recalcification time shortens and electrophoretic velocity of paltelet and RBC reduce; aggregation of platelet to reduction of ADP increases. Since the pathogenic factors of various blood stasis are different, there are corresponding differences of the syndromes. For example, platelet aggregation often occurs in myocardiac infarction and cerebral stroke, however, component of blood cell changing is always seen in burn and leukemia. The experimental research of qi-blood is important to clinic. For example, patients in coronary heart disease are classified as qi deficiency when hemodynamic changes are found through determining the period of ventricular contraction and blood rheology, but patients are classified as blood stasis when blood rheology changes.
Chapter 9 Visceral Syndrome Differentiation The theory of zang and fu-viscera is the core of fundamental theories of TCM. All the physiological functions and pathologic changes rely on the zang and fu-viscera. Hence, most of the occurrence and development of diseases are the results of zang and fu-visceral dysfunction. Based on the theory of zang and fu-viscera, the visceral syndrome differentiation is a dialetical method which analyze and synthesize the data from observing, listening and smelling, questioning and palpating which reflect the functional changes of viscera, t o define the location, to know the nature, to search the cause, to infer the pathological mechanism of disease and the wax and wane of genuine-qi and evils. It is the basis of all other syndrome differentiation methods. Tang Rongchuan said: "If a doctor doesn't know viscera, he could not distinguish the cause of disease and set up the principle of prescription.
"
Many syndrome differentiation methods can be used when we differentiate the syndrome. Each of them has its own character, but to determine the location and pathological mechanism of disease, we must use the visceral syndrome differentiation. It is because all pathogenic factors have to act on viscera to cause diseases, no matter what kinds of evils they are, exogenous six climatic evils or endogenous seven emotional factors. T h e therapeutic effects of medicine could give full play only through the viscera. Therefore. visceral syndrome differentiation has an irreplaceable position in clinical diagnosis and treatment. T h e symptoms after viscera are affected reflect the physiological and pathological changes of viscera. For every viscus is unique physiologically, the diseases and syndromes relating to different viscera are different. It is the theoretical basis of visceral syndrome differentiation to diagnose a syndrome on the basis of different physiological functions of viscera. When differentiating syndrome, the following aspects should be taken into consideration:
1. T h e nature and change of the viscus (including the meridian pertaining to it) : For example: the liver takes blood as its form and qi as its function; if liver blood is insufficient, there will be heat or inner wind; if the liver function is too strong, the exorbitant qi will transform itself into fire. T h e liver is characterized by growth and flourish, and likes being conducted and dispersed, otherwise, there will be disorder. T h e liver stores blood. Statically, blood returns to the liver; and dye
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namically, blood circulates in meridians. So diseases of blood are related to the liver.
2. T h e relationship between viscus and other organs and tissues: For instance, the liver dominates tendons and opens into the eyes. Nails are the surplus of tendons. Chong Meridian and Ren Meridian are subordinate to the liver.
3. T h e relationship between the viscus and other zang-fu viscera: For example, the liver and gallbladder are exterior-interior related. T h e liver is in a generating relationship with the heart and kidney, and in a restraining relationship with the lung and spleen, and so on. According to the three aspects above, we can find out visceral changes to provide evidences for syndrome differentiation. T h e content of visceral syndrome differentiation includes three parts: syndrome differentiation of zang-visceral diseases, syndrome differentiation of fu-visceral diseases, and syndrome differentiation of complicated visceral diseases. Among them, syndrome differentiation of zang-visceral diseases is the main part, because zang and fu-viscera can make impact on one another physiologically and pathologically, and in most cases, zang-visceral diseases can cover the fu-visceral diseases. Only the most common fu-visceral diseases are listed in this chapter.
Section 1 Syndrome Differentiation of Liver and Gallbladder Diseases When differentiating the syndromes of liver diseases, we should think over the following aspects :
(1) T h e nature and changes of the liver: T h e liver is a zang-viscus pertaining to the wood and wind. It can not only store 'shapely blood, but also conduct and disperse shapeless qi. It takes blood as its body and qi as its function. Its nature is growth and flourish. T h e liver likes being soothed and dispersed. The emotion of liver is anger. T h e liver governs stratagem and thinking. T h e soul is stored in the liver. T h e liver is the origin of tiredness. T h e ministerial fire is stored in it. Liver qi connects t o wind. T h e meridian of liver passes through external genitals and bilateral lower abdomen, then distributes in costal region, finally arrives head top. When diseases occur in liver, the following manifestations can be found: A. Symptoms related to "qi as its function" : If liver qi disperses too strong and flows transversely, there will be distending pain in hypochondrium, irritability and taut pulse. If liver qi fails to disperse, there will be depression and indifference. 249
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B. Symptoms related to "storing blood" : If liver blood is deficient, there will be pale complexion and lips, pale and dim nails, dizziness, loss of hair, numbness of limbs, muscular twitching, leanness, pale tongue, thready pulse, etc. If liver blood is stagnated, there will be stabbing pain and mass in hypochondrium, etc. C. Symptoms about "anger as its emotion" : When liver fire is flaming, there are irritability, easy to be angry.
D. Symptoms about "governing stratagem" : When liver 'is in disorder, there -
will be suspicious and hesitant.
E. Symptoms about "origin of tiredness" : When liver diseases happen, there are fatigue, or being easy to be tired.
F. Symptoms about "storing the soul" : If the liver could not store the soul, there would be insomnia, dreamy, frightened.
G. Symptoms about "storing ministerial fire" : If fire flaming up, there are head distention, hot sensation in face, conjunctival congestion, dry mouth with bitter taste.
He Symptoms about "connecting to wind" : The endogenous wind is caused by the ascending hyperactivity of liver yang, extreme heat or liver blood deficiency. The symptoms are vertigo, numbness of limbs, spasm, tongue tremor, etc. I. Symptoms about Liver Meridian: At the body parts in which Liver Meridian passes, there are symptoms as pain at head top. hypochondriac pain, and pain in bilateral lower abdomen, scrofula in neck or armpit, hernia, painful and swollen testis.
(2)The relationship between the liver and other organs and tissues:
The liver
opens into eyes and dominates tendons. Nail are the surplus of tendons. Chong and Ren Meridians are subordinate to the liver. So in liver diseases, there are symptoms as follows: A. Symptoms about eyes: Deficiency of blood and yin makes dry and uncomfortable feeling of eyes, blurring vision, night blindness; liver fire flaming up makes red and swollen eyes and daccyohea.
B. Symptoms about tendons and nails: When the blood does not nourish the muscle, there are muscular twitching, contraction, and spasm. Nails are surplus of tendons, most nail disorders pertain to blood deficiency. Knee is the house of tendon. When tendon is diseased, there is stiff knee. C. Symptoms about Chong Meridian and Ren Meridian: Chong dominates the blood sea and Ren dominates the placenta. Liver is the inherited basis for women. 250
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Disorders of genital system are due to liver disease.
(3) The relation between the liver and other viscera: The liver has an exterior-interior relation with the gallbladder, an inter-generating relation with the heart and kidney and an inter-restraining relation with the spleen and lung. Therefore, the following symptoms can be found in liver diseases. A. Symptoms about gallbladder involved in liver disease: About the "ministerial fire" : If the fire is excessive, there are head distention, conjunctival congestion, dry throat, bitter taste, jaundice, nocturnal emission; while the fire declines, there are vomiting, nausea and acid regurgitation. About decision-making function: timidness fightened, insomnia. About dominating the half-exterior and half-interior:
alternate chill and
fever. About Gallbladder Meridian: feeling of hot in ears, sudden deafness, migraine and hypochondriac pain.
B. Symptoms about the inter-generating relation between heart, kidney and liver : When water fails to generate wood, the liver yin deficiency follows kidney yin deficiency. When wood fails to generate fire, the liver qi or fire will disturb the heart, there will be chest choke, short breath, cardiac pain and heat syncope.
C. Symptoms about the restraining relation between spleen, lung and liver: Wood over-restrains earth. When excessive liver qi over-restrains spleen and stomach, there will be spleen-stomach symptoms. When liver qi is deficient and the wood can not soil the earth, there will be poor appetite and abdominal distention which reflect the dysfunction of spleen. Metal over-restrains wood. Liver disease occurs after lung disease. Excessive liver fire will injure the lung, i. e. , wood fire melts the metal, "the wood strikes the bell to ring. " so dry cough, flushed face, hypochondriac pain, even hemoptysis will occur. In summary, in liver diseases, the folaabwirrag symptoms are usually found c h i tally :
1) vertigo, migraine, parietal headache ; 2) eye disorder, such as ophthal moxerosis, blurring vision, night blindness, congestion ;
3) dry mouth and bitter taste in mouth;
4) ear disorder, such as hot flush of ear, tinnitus, heavy hearing: 5) alternate chill and fever; 6) pale nails or white macula in nail; 7 ) spasm, contracture, muscular twitching, numbness, stiff limbs:
8) distending pain or lump in hypochondrium or lateral lower abdomen, hernia;
9) impetuousness and irritability. depression, timidness and frightened, disturbed sleep ; 10) symptoms of blood deficiency;
11) symptoms of genital system; 12) jaundice ; 13) taut pulse and tongue manifestations.
1.Liver Qi Stagnation and Liver Qi Transversal Invasion T h e liver qi stagnation refers to the syndrome that liver fails to conduct and disperse and then the qi can not flow smoothly. T h e liver qi transversal invasion is a syndrome that liver is hyperactive in conduction and dispersion that leads to qi flowing transversely. Any factors, such as depression, which can make liver fails to conduct and disperse, can cause the syndromes.
Clinical Manifestations: Depression or irritability. Fullness or distending pain in the hypochondrium. Feeling of foreign body in throat. Some patients may suffer from neck goiter or abdominal mass. Other symptoms include poor appetite. dreaminess, frightened, distending pain in breast and irregular menstruation, pain in bilateral.lower abdomen. T h e pulse is usually taut.
If depression and fullness in hypochondrium are the chief complaints, the syndrome belongs to Biver qi stagnation.
If the chief complaints are irritability and distendi n g pain in hypochondrium or bilateral lower abdomen which are accompanied by dreaminess and frightened, the syndrome is Biver qi transversal invasion.
Analysis: When liver qi fails to conduct and disperse, it stagnates internally and causes emotional disorder as depression, chest choke, breast distention, foreign body sensation in throat, etc. T h e stagnated qi affects the middle-jiao, the wood doesn't regulate the earth that leads to abdominal stuffiness and poor appetite. Prolonged qi stagnation will put impact on blood circulation and water transformation which will produce phlegm and blood stasis. T h e goiter, abdominal mass are the manifestations of the phlegm and stasis. T h e Chong and Ren Meridians will lose 252
their harmony due to the failure of liver in regulating qi. Irregular menstruation and dysmenorrhea are their manifestations. T h e transversal invasion of liver qi causes irritability and hypochondriac pain. Because the mind is disturbed by liver qi, the sleep is disturbed by excessive dreams. When liver qi invades transversely. the exorbitant wood restrains the earth, attacks the spleen and stomach, there will be poor appetite and indigestion.
11. Liver Fire Flaming Up (Excessive Fire in the Liver and Galllbladder) T h e liver fire flaming up is a syndrome of liver fire going upwards rebelliously. It can be caused by stagnated liver qi. T h e stagnant qi can become fire. This is the condition of "excessive qi becoming fire. " Fury can also impair the liver and cause liver qi uprising, and then it becomes liver fire. Other emotional disorders can also produce fire and lead t o the syndrome. If heat evil invades the interior of the body, it may cause liver fire.
Clinical Manifestationas: Flushed face and red eyes, bitter taste in mouth, dry throat, tinnitus, deafness, dizziness, distending headache, fever, scorching pain in hypochondrium, irritability, profuse dreams or insomnia are the main manifestations. T h e stool is dry and the urine is scanty. Hematemesis, nose bleeding or hemoptysis may happen in some patients. Tlie tongue margin is yellow and the coating is yellow. Tlie pulse is taut and rapid.
Analysis: T h e excessive liver qi will turn into fire. Wang Xugao, a famous doctor in Ming Dynasty, said: "The flaring liver fire wanders about triple-jiao. It can cause disorders a t any part of the body. " There are two main aspects of the syndrome. T h e one is the excessive heat. T h e another is the flaming up of the fire, especially the sudden flaming up. T h e fire has a nature of flaming up. T h e liver fire goes up to hypochondrium along its meridian, and then to head, eyes, ears, etc. That causes scorching pain in hypochondrium, fever, flushed face. red eyes, dry throat, tinnitus, deafness, dizziness and distending pain of head. T h e liver fire affects the gallbladder, the bile overflows and causes bitter taste in mouth. Because the fire disturbs the mind, there are bad temper and bad sleep. T h e fire impairs collateral and forces blood t o flow uncontrollably, so there is bleeding. Dry mouth, scanty urine and dry stool are caused by yin and body-fluid impairment which are consumed by fire. *
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IHP. Ascending Myperaetivity of Liver Yang The ascending hyperactivity of liver yang is a syndrome of liver yang rising to the upper part of the body which is caused by. yin deficiency of the liver and kidney. While liver and kidney yin are insufficient, the yin is not able to check the yang, liver yang then goes up. That is a state of excessive in the upper and deficient in the lower. The five emotions are transformed into fire, then the fire boils the body fluid and yin and leads to the yin deficiency in lower-jiao. The water fails to nourish the wood. This is another mechanism of the syndrome.
Clinical Manifestations: The symptoms include distending pain in the head and eyes, vertigo, heaviness of head and lightness of feet, tinnitus, flushed face, rush hot feeling on face, dry throat, irritability and fidget, insomnia or dreaminess, sore and weak lumbus and legs. The tongue is red with little coating. The pulse is taut.
Analysis: The deficiency of liver and kidney yin results in disharmony between yin and yang. The liver yang is hyperactive and unlimited. The qi and blood go up with liver yang. Then, they causes distending pain in head and eyes, dizziness, tinnitus, flushed face, facial hot sensation, and dry throat. The excessive yang disturbs the mind. The mind and the soul could not keep inside, so the fidget, irritability, insomnia and excessive dreams take place. T h e lumbus is the house of the kidney and the knees are the house of tendons. Soreness and weakness occur in lumbus and knees because of the kidney and liver yin deficiency which could not fill up their house. Because liver yang is excessive in the upper body and liver and kidney yin is deficient in the lower body, the head is heavy and the feet is light. The tongue and pulse are the signs of excess of liver yang and insufficiency of yin. The syndrome of liver fire flaming up are similar to the ascending hyperactivity of liver yang in clinical manifestations. Both syndromes have symptoms of excessive yang. The differences between them are : the first, the main point of ascending hyperactivity of liver yang is the symptoms reflecting "excess in the upper, " such as distending pain in head and eyes, dizziness, hot flush, while the main aspect of liver fire flaming up is the symptoms of excessive fire, such as red eyes. bitter taste, dry stool and scanty urine; the second, the syndrome of ascending hyperactivity of liver yang is characterized by the symptoms of deficiency in the lower, i. e . , soreness and weakness of lumbus and knees, staggering gait and so on; finally, the syndrome of ascending hyperactivity of liver yang is formed in a relative long period and develops slowly, it belongs to the syndrome of deficiency in the root and excess in the branch, or excess in the upper and deficiency in the lower, while the syndrome of a
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liver fire flaming up has a relatively short history and develops rapidly, it belongs to excess syndrome.
IV. Lives BIloodi Deficiency It refers to the syndrome due to lack of blood in liver. The syndrome can be caused by innate defects, dysfunction of spleen and stomach, emotional disorders, chronic disease or bleeding. Clinical Manifestations: The complexion, lips and nails are all pale. Weak vision or night blindness is usually present. Other symptoms include vertigo, palpitation, insomnia, numbness of limbs, stiff joints, tremor or muscular twitching. In women patient, scanty menstruation or amenorrhea may happen. T h e tongue is pale and the pulse is thready. Analysis: T h e manifestations of liver blood deficiency are similar to those of blood deficiency syndrome. As a result of lack of blood, the withering occurs and is shown in sallow or pale complexion, pale lips, nails and tongue. Because the blood fails to nourish the upper body, dizziness is present. The palpitation and insomnia are the results of heart malnutrition due to blood deficiency. If meridians are lack of blood, there is numbness of limbs. When blood fails to nourish tendons, it gives rise to stiff joints. If blood sea is not filled up, the disorder of menstruation takes place. Because vessels are not filled up with blood, the pulse becomes thready. The liver opens into eyes and dominates tendons. Special symptoms of liver blood deficiency take place as follows: The first, if eyes are malnourished, the weak vision or night blindness is present: the second, when tendons is malnourished, the symptoms are tremor in limbs, muscular twitching and stiff joints.
V. Liver Yin Deficiency The syndrome is characterized by shortage of yin and body fluid in the liver. Most of the cases are caused by emotional disorder which makes stagnated qi transforme into fire. Liver yin is taken away by the fire. Some chronic diseases or warm diseases can also consume liver yin and lead to the syndrome. Clinical Manifestations: Vertigo, dry eyes and throat, tinnitus, facial hot flush, vexation and hot sensation in the five centers, tidal fever, night sweating, burning pain in hypocliondrium, twitching of limbs are the main symptoms. The tongue is red with little coating. The pulse is thready and taut. Analysis: The manifestations of liver yin deficiency are composed of the common symptoms of all yin deficiency and the characteristic symptoms of all liver disa
255
eases. The former are rush facial hot flush, tidal fever, fidget, feeling of hot in the five centers, night sweating, dry throat, red tongue and little coating. The latter are dizziness, tinnitus, dry eyes, burning pain in hypochondrium, twitching of limbs and taut pulse. The rapid and thready pulse means the yin deficiency leading to heat in the interior.
VP.Liver Wind Stirring Internally The liver wind stirring is a syndrome characterized by swinging symptoms like severe vertigo tending to fall, tremor and contraction. There are four types of it, namely wind transformed from liver yang, wind produced by extreme heat, wind produced by blood deficiency and wind produced by yin deficiency. The liver is a viscus of wind and wood. The hyperactivity of liver yang, or extreme heat, or yin deficiency, or blood deficiency all could produce endogenous wind. Because the wind is different from the exogenous wind, it is called endogenous wind. The wind has a nature of swinging and moving, so it is characterized by vertigo, tremor, contracture, etc. The Plain Questions pointed out: "Syndromes characterized by shaking and dizziness belong to liver. " I t refers to liver wind.
11. Wind Transformed from Liver Uang T h e syndrome is also named extreme yang (Jueyang) transforming into wind. Its mechanism is that wind phenomenon occurs suddenly on the condition of excess and unlimited liver yang existence. The hyperactivity of liver yang is due to the very deficient yin of liver and kidney which could not prevent liver yang from transforming into wind.
Clinical Manifestations: Severe vertigo tending to fall forwards, headache, stiff neck, tremor, staggering gait and unclear speech are the main symptoms. In a severe case, the patient may lose consciousness suddenly, the tongue becomes stiff, aphasia, wry mouth with distorted eyes and hemiplegia are also present. The tongue is often red and pulse is taut.
Analysis I The syndrome occurs often in patients who have an ascending hyperactivity of liver yang which results from liver and kidney yin failing to restrain liver yang. But some patients who have not history of liver yang hyperactivity could also suffer from this syndrome suddenly. Because the yang and wind whirling up, there is severe vertigo. Since the qi and blood go up to and obstruct in the upper body, headache happens. The malnourished tendons results in stiff neck and tremor. The wind whirling in the upper 256
and yin deficiency in the lower give rise to staggering gait. T h e yang and wind desiccate the body fluid to be phlegm, then wind carries phlegm t o the upper. T h e phlegm covers heart orifices and the mind could not work, so the patient loses the consciousness. T h e wind and phlegm obstruct collateral. the qi and blood are stagnant, that is the cause of wry face and hemiplegia. T h e red tongue reflects the yin deficiency and the taut pulse the liver disease.
2. Extreme Heat Producing Wind
0
It belongs to the liver wind syndrome caused by the extremely heat evil which transfers into the pericardium reversely during the course of exogenous febrile diseases. It often occurs at the extreme stage in the warm disease.
Clinical Manifestations : High fever, fidget, coma and stiff neck are the chief symptoms. In severe case, opisthotonus, lock-jaw, upward or straight staring eyes, spasm or convulsion are present. T h e tongue is crimson or red and the pulse is rapid and taut.
Analysis : T h e main manifestations consist of three parts : high fever, fidget and symptoms of liver wind. The heat evil in body causes high fever. T h e heat enters pericardium and disturbs the mind, then restlessness even coma occur. The heat scorches body fluid, so the tendons become tight, then appear the spasm, convulsion and stiff neck. T h e crimson tongue means heat in nutrient phase. The rapid and taut pulse reflects liver wind due to heat.
3. Blood Deficiency Producing Wind T h e syndrome is characterized by the malnutrition of tendons and meridians resulting in blood deficiency. It can be the result of prolonged disease or any kind of bleeding. T h e detail is described in the syndrome of liver blood deficiency.
4. Yin Deficiency Producing Wind It is a syndrome of liver wind due to liver and kidney yin deficiency. T h e syndrome can be seen in the later stage of exogenous febrile diseases. If the syndrome occurs in exogenous diseases, its detail can be found in the chapter of syndrome differentiation for exogenous disease. T h e syndrome in endogenous disease is discussed in the syndrome of liver yin deficiency.
Table
I LYTW
syndrome
.
The Differentiation of Liver Wind Stirring
d'lsease
heat
nature
excess in the upper and defi-
1 EHPW
I
excess heat
I YDPW
1 BDPW
heat
heat
deficiency
deficiency
twitching
numbness and
ciency in the lower main
severe vertigo,
symptoms
tremor, sudden
neck, opisthotonus,
tremor,
coma, wry face
upward or straight
twitching,
hemiplegia
staring eyes,
stiff joints
lock-jaw tidal fever,
pale complexion,
neck, stagger-
fidget, hot
nails and lips,
ing,
sensation in
dizziness,
other
headache, stiff
symptoms
high fever,
I slurred speech. I
I five centers,
I stiff tongue I
I red
tongue
taut
pulse
night sweating,
menstruation,
dry eyes and
amenorrhea,
throat,
palpitation,
I tinnitus red or crimson
taut, rapid
I tinnitus. scant I insomnia
red tongue
pale tongue
with little
with white
coating
coating
taut, thready
thready
EHPW: extreme heat producing wind. YDPW: yin deficiency producing wind. BDPW: blood deficiency producing wind.
VII. Retention of Cold in Liver Meridian It is a syndrome that cold evil stays in Liver Meridian. The syndrome is caused by cold affection. The syndrome is often seen in hernia diseases.
Clinical Manifestations:The cold pain in bilateral lower abdomen or genital or contracture of scrotum is the chief symptom which is aggravated by cooling and relieved by warming. Other symptoms include cold limbs, vomiting of clear mucus. The tongue coating is watery and white. The pulse is deep and taut.
Analysis: The Liver Meridian of Foot Jueyin goes through medial thigh and 258
*
genitals, and arrives at bilateral lower abdomen. The cold is a yin evil and possesses the nature of coagulation and contraction. When cold evil intrudes into meridian, the yang qi is checked, and qi and blood are stagnated, so the cold pain occurs in bilateral lower abdomen. The contraction of scrotum is the result of meridian contracting. The heat can counteract the cold, so the pain can be alleviated by warming. The cold causes water retention and the water in body causes vomiting of mucus. The tongue coating is the sign of cold and water in the body. The Ipulse indicates liver disease. The key point for diagnosis is the cold pain in bilateral lower abdomen or genitals.
VIII. Liver Qi Deficiency and Liver Yang Deficiency Liver qi deficiency and liver yang deficiency are both the syndromes of liver hypofunction. Congenital defect and prolonged diseases can result in those syndromes. In addition, if the liver qi stagnation lasts for long, it can damage the liver and yang and lead to those syndromes. The deficiency of liver blood or yin can also involve the qi and yang of liver and cause those syndromes. Table
The Differentiation Between Wetelmtion of Cold in Liver
Meridian (RCLM) , Liver Qi Deficiency (LQD) and Liver Yang Deficiency (L'ltlD) syndrome
RCLM
disease
cold
nature
excess
deficiency
deficiency
main
cold pain in bila-
hollow pain in hypo-
hollow pain in hypo-
symptoms
teral lower abdomen
chondrium, melancholy,
chondrium, melancholy,
and genitals,
timidness, tiredness,
timidness, indolence
contracture of
shortness of breath
to cold
LQD
LYD cold
scrotum, other
cold limbs, indo-
stuffy chest
stuffy chest
symptoms
lence to cold,
and epigastrium,
and epigastrium,
vomiting of clear
poor appetite
poor appetite,
mucus tongue pulse
watery and white coating deep and taut
cold genitals pale tongue with
pale tongue with
white coating
white coating
weak
feeble
,
Clinical Manifestations: The liver qi deficiency is shown in hollow pain in hypochondrium, melancholy, timidness, shortness of breath, listlessness, fatigue, 259
*
stuffy feeling in chest and epigastrium and poor appetite. The tongue is pale with white coating. The pulse is feeble. The liver yang deficiency has all the symptoms of liver qi deficiency and some other symptoms such as chill and cold limbs, cold genitals. The pulse is deep and feeble. Analysis: It is pointed out in Spirit Pivot that "liver qi deficiency leads to fear.
"
The Peaceful Holy Benevolent Prescl-iptions gave another word for it: "Liver deficiency produces cold. " These statements show deficiency and cold syndromes present in disease. In liver qi deficiency there are not only the symptoms of qi deficiency such as shortness of breath, tiredness, asthenia, pale tongue and feeble pulse. but also the special symptoms of liver diseases, i. e . , hollow pain in hypochondrium and timidness. On further developing, liver qi deficiency becomes liver yang deficiency, which is manifested as chill, cold limbs and genitals because yang fails to warm the body. Those syndromes are often seen with the qi or yang deficiency of spleen or kidney.
IX. Damp-Heat in Liver and Gallbladder It is a syndrome that dampness and heat evils accumulate in the liver and gallbladder. The syndrome can be caused by the inward invading of damp-heat or taking of too much rich food which transforms into damp-heat, or splenic dysfunction which leads to damp-heat due to dampness accumulation.
Cllinical Manifestations: The syndrome is shown in alternate chill and fever, bitter taste in mouth, distending pain in hypochondrium, poor appetite, nausea and vomiting. abdominal distention, constipation or non-smooth defecation, loose stool. dark and scant urine, red tongue with yellow and greasy coating, taut and rapid pulse; or jaundice, infrocostal lump, pain and hot swollen testis in some patients. In some female patients, the turbid leukorrhea and pruritus vulvae are the main problems. Analysis: When heat stays in gallbladder, the gallbladder qi goes up to the head, so the alternate chill and fever, and bitter taste happen. The liver fails to regulate and conduct qi, the qi stagnation takes place and gives rise to distending pain or lump below costal margin. The spleen and stomach can't work properly because of liver dysfunction, then poor appetite, nausea, vomiting, and abdominal distention occur. If the dampness is prevalent, the stool is loose; while the heat is prevalent, the bowel movement is uneasy and non-smooth. When the transforming function of urinary bladder is implicated, the urine becomes scanty and dark. The tongue and pulse reflect the existence of dampness and heat evil. 260
a
It is said in The Guide to Clinical Practice with Medical Records: "The dampness usually transforms into fire. Tlie heat stagnates in the interior and causes bile overflowing. T h e overflowing bile combined with turbid qi from stomach steams inside. They could neither go up nor down out the body..
. . So the
body skin and
eyes becomes yellow. " T h a t gives a clear explanation of jaundice due to damp-heat in liver and gallbladder. Because of damp-heat steaming, the bile doesn't flow in normal way but floods to skin, so skin and eyes become yellow. Liver Meridian goes through genital. If damp-heat pours down along Liver Meridian to testis and hinders the collateral, the painful swollen testis with hot feeling is then present. In women, the evil may pour down to vagina, that gives rise to turbid leukorrhea and pruritus vulvae. T h e key points for diagnosis are hypochondriac distending pain with yellow urine, red tongue and yellow greasy coating.
X. GallBbBadder Stagnatiasln due tap Phlegm Disturbance It is a syndrome that phlegm-heat disturbs gallbladder and results in gallbladder dysfunction. Emotional disorder which leads to qi stagnation is the main cause of the syndrome. T h e stagnant qi transforms into fire and produces phlegm in the body. Tlie fire in combination with phlegm gives rise to the syndrome.
Clinicall Manifestations: T h e symptoms include dizziness, tinnitus, bitter taste in mouth, chest distress, hypochondriac distention, timidness, insomnia and profuse dreams. T h e tongue coating is sticky and yellow. The pulse is taut and slippery.
Analysis: Zliang Zihe, a famous doctor in Jin Dynasty, said: "The gallbladder is responsible for courage. Fright and terror may impair the gallbladder.
"
T h e gall-
bladder is a clear fu-viscus. T h e turbid phlegm disturbs the gallbladder, then gallbladder qi flows non-smoothly and the gallbladder can not make judgment. So the patient becomes timid and suffers from insomnia or excessive dreams. Because the Gallbladder Meridian connects to head and eyes, when phlegm disturbs the upper along Gallbladder Meridian, it causes dizziness and tinnitus. If phlegm obstructs the middle, the spleen and stomach qi fail to ascend and descend freely, that results in nausea and vomiting. When the gallbladder fails to conduct and disperse, the bile goes up perversely and produces bitter taste in mouth. The qi and yang is obstructed in chest due to gallbladder failing in conducting and dispersing, so the patient feels chest distress and hypochondriac distention. T h e tongue and pulse reflect the existence of phlegm and fire in the body. T h e key points for diagnosis are palpitation due to fright, insomnia and yellow greasy coating.
Table
The DiffferentiatioaB among Liver Fire Flaming Up (LFF) , Ascending
Hyperactivity off Liver Yang (AHLU) , Damp-Heat in Liver and GallBladder (DHLG), Gallbladder Stagnation due to Phlegm Disturbance
(GSPD) and Liver Uin Def icieantcy (LUD) syndrome nature LFF
excess
/ heat
I
main symptoms
other symptoms
tongue
pulse
flushed face, red eyes,
bitter taste,
red in
taut
I vertigo, headache.
margins and
/ tinnitus. burning pain / irritability,
/ in hypochondrium,
I
/ dry throat,
with
/ excessive dreams.
constipation, scanty
insomnia,
urine, hemoptysis,
fidget
rapid
yellow coating
nasal bleeding, hematemesis AHLY
DHLG
heat
red face and eyes,
dry throat,
branch
dizziness, distending
irritability,
tongue
excess
headache, tinnitus,
excessive dreams,
with
root
heavy head with light
insomnia,
little
deficiency
foot, sore and weak
1 excess / heat I I I
lumbus and knees distending pain in
coating
/
/ alternate chill
/ hypochondrium, poor / and fever, bitter 1 appetite. nausea. I taste, abdominal
1 red
/ vomiting, yellow urine, / distention, 1 abnormal defecation, 1 lump below costal
taut
with
and
yellow
rapid
greasy coating
margin
jaundice, painful swollen testis, turbid
Gspcl /
I leukorrhea
I
excess
vertigo, tinnitus,
bitter taste,
heat
insomnia, timidness,
nausea, vomiting
fright, chest distress, LUD
I costal distention deficiency heat
taut
/ coating / and
I slippery
I
susceptibility to
I
greasy
I
hot flush of face,
dry throat, hot
red
taut,
dizziness, tinnitus,
sensation in the
tongue
thready
tidal fever, night
five centers,
with
and
sweating, dry eyes,
fidget, burning
little
rapid
twitching
feeling in hypo-
coating
chondrium
Section 2
Syndrome Differentiation of Heart and Small Intestine Diseases
When judging heart disease, the following aspects should be thought over.
(1) The nature and changes of the heart: The heart locates in the chest. It dominates the blood circulation. T h e mind stays in the heart. The monarch fire belongs to the heart. The heart matches joy in emotions. The heart takes the tongue as its out orifice and the face as its outward manifestation. The heart liquid is sweat. The Heart Meridian starts from the heart, then goes down into small intestine, and turns up, goes out to skin in axilla, and goes through medial side of arm into palm. Therefore, the manifestations of heart diseases are the follows. A. Symptoms about the blood circulation: shortness of breath, vertigo, palpitation, feeble or intermittent pulse, pale complexion, chest pain, numbness of arm.
B. Symptoms about monarch fire: fidget, insomnia, sore of mouth or on tongue, mania; or cardiac pain, bluish complexion and limbs.
C. Symptoms about the mind: palpitation, insomnia and poor memory, stupor, coma.
D. Symptoms about the sweat: excessive sweating. E. Symptoms of the region along Heart Meridian: hot palms and soles, stiff arm, chest pain.
(2) The relation between the heart and other tissues and organs: The tongue disorders like red tongue tip, "double tongue9'andstiff tongue, are related to heart disease.
(3) The relation between the heart and other viscera The heart has an exterior-interior relation with small intestine, an inter-generating relation with the liver and the spleen, and an inter-restraining relation with the lung and kidney. And the heart is located in chest with the lung. A. Symptoms about the small intestine: urination pain, frequent micturition, dribbling urination.
B. Symptoms about the lung involved : dyspnea, asthma, chest distress. T o sum up, the following symptoms are the most usually found in heart and small intestine disea$es : 1) palpitation; 2) vexation;
3) cardiac pain;
4) insomnia and excessive dreams; 5) poor memory; 6) delirium, coma; 7) intermittent pulse ;
8) red tongue tip or crimson tongue;
9 ) yellow urine with urodynia (urination pain).
I. Heart Qii Deficiency, Heart Yang Deficiency and Lms of Heart Yaag The heart qi deficiency is a syndrome of heart dysfunction. Congenital defect, aging, chronic diseases and over thinking can all cause the syndrome. The heart yang deficiency is the syndrome of heart yang on decline. The severe deficiency of heart qi, impairment due to cold evil, over sweating and purgation can lead to the syndrome. The loss of herrt yang is the separation of yin and yang due to sudden depletion of heart yang. Xu Lingtai said: "The sudden escape of yang results in dissociation of yin and yang. There are oil-like sweating and expiring pulse in all the six portions. Only the sudden occurred fatal condition like this can be called loss. " In the whole life span of human body, the yin and yang keep being tied together. If they are separated, thelife ends. The syndrome can be seen in all the critical or emergency diseases. If proper and prompt treatment is given, the patient can be rescued.
Clinical Manifestations : The heart qi deficiency is shown in palpitation, chest distress, shortness of breath, sweating, listlessness, and deteriorated by exertion, pale complexion, pale corpulent tongue and weak pulse. If it is accompanied by cardiac pain, intolerance to cold, cold limbs, pale and lusterless complexion, dark lips,
sweating, serious cold limbs, severe palpitation, feeble breath, stupor or coma, expiring pulse occuring suddenly, it is the condition of Loss of heart yang.
Analysis: On condition of heart qi deficiency, the heart is vacant which makes the mind unstable and leads to palpitation. The heart qi is unable to flow, so the chest is distressed and the breath is short. Sweat is the liquid of heart. The deficient heart qi could not consolidate the interspace of fresh and the superficies, so there is more sweating. The mind in heart is lack of supplement from qi, then the patient always feels fatigue. The body movement (exertion) consumes qi. After
movement, the qi deficiency is more severe, so all the manifestations are aggravated. The deficient qi fails to propel the blood to circulate, the blood could not reach the face and tongue in the upper body, so the complexion and tongue are pale. The blood circulation is lack of power, so the pulse is weak. The key points to make a diagnosis of heart qi deficiency are the palpitation, shortness of breath and listlessness.
In heart yang deficiency, the yang fails to warm and push blood, the vessel is paralyzed and blocked, so there is cardiac pain. The yang does not warm the skin and limbs, so the skin and limbs are cold. The abnormal blood circulation is also shown in pale lips, tongue and feeble or knotted pulse. The central points for diagnosing the heart yang deficiency are the heart qi deficiency plus the manifestations of cold. The loss of heart yang is the yang failing to hold the yin and a sudden escape of yang and qi. The yang and qi are insufficient, so there are palpitation, shortness of breath and feeble respiration. The yang escapes from the skin and fails to consolidate the exterior, so the sweating is profuse and thick. The mind escapes along with the loss of yang, so there is unconsciousness. There is no yang to warm body. so that the body is cold. The blood is stasis due to loss of motivation, the the lips and tongue are blue and the pulse is expiring. The key for diagnosis is the heart yang deficiency plus the yang depletion.
11. Heart Blood Deficiency It refers to the syndrome of lack of blood in the heart and the heart being lack of nourishment. The congenital defect, over mental activities, blood loss and chronic diseases can all result in the syndrome. Clinical Manifestations: pale or sallow complexion, pale lips and tongue, lusterless nails, palpitation, insomnia, poor memory, profuse dreams, thready pulse, etc. Analysis: The heart dominates blood. The deficiency of blood in heart leads to unstable mind which leads to palpitation. The blood is not able to nourish and fill up the head, face, tongue and nail, so they are pale and lusterless. The mind could not work normally, then there are poor memory, insomnia and dreaminess. The blood could not fill up vessels, then the pulse becomes thready. The key diagnostic points are the above mentioned symptoms, like palpitation, plus the blood deficiency syndrome. @
265
In. Heart Uin Deficiency The syndrome is the result of malnourished heart due to heart yin deficiency. It can result from over thinking and pensiveness which are the yang mental activities and tend to consume yin, or the yin consumption in warm diseases, or insufficiency of production of yin. The central diagnostic point is the palpitation with the yin deficiency syndrome.
Clinical Manifestation : palpitation, insomnia, excessive dream, tidal fever, fidget, hot sensation in the five centers, night sweating, hectic cheek, dry throat, red tongue with little coating, thready and rapid pulse.
Analysis: The yin fails to nourish the heart mind. The mind is unstable. So there is palpitation. The heart could not hold the mind in it. So insomnia and excessive dream take place. The fire of deficiency state in the interior leads to tidal fever, vexation and hot sensation in the five centers. In sleep, the yang enters yin and evaporates the body fluid to be sweating. The upwards floating of yang makes zygomatic region red. That the deficient yin could not flow to the upper leads to dry throat. And both the tongue and pulse reflect the deficiency of yin. Table
Distinguishing Heart Blood Defrieiency from Heart Yin Deficiellacy
common
tation, insomnia, excessive dream red zygornatic region
thready and rapid
IV.Blood Stasis in Heart It is the syndrome of blockage due to blood stasis in the heart. The syndrome is seen in the aged patients and patients suffering from chronic diseases. T h e deficiency of yang, phlegm retention, cold evil and qi stagnation all can cause obstructed flow of blood in heart and its vessels and lead to the syndrome. Q
266
Q
.
Clinical Manifestations: There are palpitation, chest distress, stabbing cardiac pain radiating to the arm, even to the hand, which is paroxysmal and aggravated by physical exertion. There are also cold limbs, sweating, curving lying, choking, purple lips and complexion, dark purple tongue or ecchymosis in tongue, intermittent pulse. In serious case, the pain is unstable, and there are coma and expiring pulse. Analysis: The cardiac pain is taken as the main complaint of the syndrome of blood stasis in heart. The pain is severe. It was described as "the pain just like the heart being stabbed" or "serious pain with cyanotic hands. The patient will die at evening if onset in morning, or die in morning if onset at evening" in Spirit Pivot. From this we can know the seriousness of the disease and the pain. Table
Pathogenic Differentiation of the Blood Stasis in Heart phlegm
cold evil
qi stagnation
palpitation, choking, paroxysmal stabbing cardiac pain radiating the common points
to arm or back, purple tongue or ecchymosis in tongue, thready or sluggish pulse. severe and
distending and related
the differences
It is due to that the insufficient heart yang is too weak to pump the blood. On this condition, the phlegm, cold evil and stagnated qi are apt to stay in heart and to hinder the blood circulation. Yu Chang said: "The exorbitant yin (evil) takes advantage of weak yang, then the cardiac pain of chest blockage takes place. '' The Heart Meridian begins in the heart, and goes to lung, then goes out from armpit and through medial arms to hand. Therefore, when blood stasis in Heart Meridian, the pain occurs from the chest and radiates to arm with choking. That the yang could not warm the heart mind leads to the palpitation. The yang could not warm and defense the body surface, so the body is cold and there is sweating. The cyanota
267
ic lips and tongue and knotted pulse reflect the blood stasis. If yin-cold is too exorbitant and compels the yang to escape, the mind leaves the heart, there is coma and extinguishing pulse. If the syndrome is related to the phlegm, the pain is compressive. The body is corpulent. There is excessive sputum. The coating is white and greasy. The pulse is deep and slippery. If related to cold evil coagulation, the pain is severe and attacks suddenly and abates in warming condition. There are intolerance to cold, cold limbs, pale tongue with white coating, deep and slow pulse or deep and taut pulse. If related to qi stagnation, the pain is distending and related to the emotional changes. There are pain in costal margin, taut pulse, pink or dark tongue.
V. Fire Blazing i n Heart It refers to the syndrome of excessive fire in the heart. The emotional stress, or six climatic evils, or the over-fatigue, or over taking of pungent food and rich food can all transform into fire and lead to the syndrome.
Clinical Manifestations : flushed face, dry throat, preference of drinking water, canker, vexation and hot sensation in chest, insomnia, turbid urine, pain in micturation, red tongue or tongue tip, yellow coating and rapid pulse; or spitting blood, nasal bleeding, hematuria; or mania, restlessness and delirium.
j ~ n a l ~ s iThe s : heart dominates fire. The excessive fire in the upper makes face red. The fire injures the body fluid and leads to dry mouth and drinking a lot. The fire blazing in heart makes hot feeling in chest. The heart opens into tongue. The fire flames up to the tongue and makes the tip of tongue red. "Abscess and ulcer with pain and itch are related to the heart. "Fire in heart leads to sore and ulcer of tongue. The fire goes down to small intestine and results in yellow urine, turbid urine or hematuria. The heart dominates blood. The heart fire compels blood flowing in uncontrolled way and leads to bleeding. The fire disturbs the mind and leads to insomnia, furthermore leads to mania and delirium. The tongue and pulse are both the reflection of fire. The key for diagnosis is the excessive heat syndrome in the heart and the related organs.
V1.Heart Disturbed by Phlegm-Fire It is the syndrome of mind disturbed by the phlegm and fire. The emotional stress and climatic evils t,ransform into fire and the fire boils down the fluid to be phlegm, then the syndrome forms. Exorbitant phlegm fire or exogenic heat can also cause the syndrome. 268
Clinical Manifestations: flushed face, fever, fidget, mania, restlessness, delirium, slurred speech, wheezing sound in throat, expectoration with yellow thick sputum, red tongue, rapid and slippery pulse. Or insomnia, vexation, incoherent speech, changeable emotions, strange behaviors, mania and aimless wandering.
Analysis: The exogenous heat evil is blazing in the interior, just like what Ye Gui said: "The warm evil is apt to attack the upper body. It invades the lung first and then enters the heart transversely.
"
The heat boils down body fluid to be
phlegm. The phlegm and fire in combination shut the pericardium. Because the mind in heart is covered inside, the patient is in coma and mania. The excessive heat leads to the red face and eyes, fever and vexation. The wheezing in throat and the excessive yellow sputum show the existence of phlegm inside. The evils invading the heart makes the tongue unable to move freely and leads to slurred speech. The red tongue and slippery pulse reflect the inside fire and phlegm. The main points for diagnosis are sthenic fever, coma and wheezing in throat.
Classic on Medical Problems said: "The doubled yang leads to mania. " Plain Questions said: "The restlessness and mania are due to fire. " In endogenous diseases, the emotional stress transforms into fire and boil down body fluid into :
phlegm. Fight between fire and phlegm disturbs the heart and results in mania. The evils break the peace of mind and cause the insomnia, fidget, incoherent speech, wandering and changeable emotions. There are two key points for diagnosing: the manifestations of heat and the morbid mental activities like insomnia and mania.
VIII. Phlegm Covering Heart Orifices It is a syndrome of heart orifices being covered by the phlegm. Prolonged dampness and qi stagnation due to depression can produce phlegm and result in the syndrome.
9
Clinical Manifestations : epigastric stuffiness, nausea, vomiting, stupor or coma, white greasy coating, slippery pulse. Or, depression, apathy (indifferent express i o n ) , dullness, dementia, soliloquy, abnormal behavior. Or sudden syncope with stridor, saliva dripping from mouth and convulsion.
Analysis: T h e dampness and phlegm retention lead to the rebellion of stomach qi. The adverse up flow of stomach qi causes epigastric stuffiness, nausea and vomiting. Phlegm in throat makes stridor. The phlegm shuts the orifices of heart and results in the loss of consciousness. The white greasy tongue coating and slippery pulse are the reflection of phlegm. The dementia and abnormal behaviors belong to depressive psychosis. They 269
are symptoms of abnormal mental activities. The depression gives rise to qi stagnation. The qi stagnation leads to phlegm. The phlegm covers the heart orifice and causes those symptoms. The liver qi stagnation is shown in apathy. The abnormal mental activities is due to the coverage of mind. The sudden syncope pertains to epilepsy. It is due to congenital defects, or being frightened, or splenic deficiency which leads to phlegm retention. The occasional upwards flowing causes the disease. The stridor and saliva dripping are the signs of phlegm. The sudden loss of consciousness with convulsion shows the covering of heart. The syndromes of small intestine are included in the zang-visceral syndromes. For example, the excessive heat in small intestine is included in the syndrome of fire blazing in heart. So they are not discussed here. Table
Differentiation of the Fire Blazing in Heart (FBH) , Heart Disturbed
by Phlegm-Fire (WDPF) , Phlegm Covering Heart Orifice (PCHO) syndrome
FBH
HDPF
PCHO
observation
flushed complexion
red face and eyes,
depression : abnormal
I sore and ulcer in I mouth with pain
/ yellow thick sputum, ' 1 behavior I mania : changeable
/ epilepsy : sudden convulsion
emotions and
.
behaviors
I insomnia listening
delirium
I red tongue with
tongue
pulse
Section 3
stupor, coma, sudden
mania
mania
mental
I
/ delirium, slurred I sp6&ch.stridor, / incoherent speech I red tongue with
yellow coating
yellow greasy coating
rapid
rapid and slippery
I
I wheezing sound in I white greasy coating
Syndrome Differentiation on Spleen and Stomach
The spleen and stomach diseases are judged in the following aspects. 270
a
(1) T h e nature of the spleen and stomach The spleen and stomach are located in the middle-jiao. The spleen governs the transporting and transforming food, while the stomach is in charge of receiving food. The spleen qi likes to ascend and the stomach qi likes to descend. They are the acquired foundation and the source of qi and blood. The spleen dislikes dampness. T h e spleen has a function of controlling blood. The Spleen Meridian begins at foot, and goes through leg into abdomen, then reaches the stomach, and continues to go up to throat and distributes below the tongue. The main symptoms of spleen and stomach disease are the following.
A. Symptoms of middle qi deficiency: fatigue, asthenia, shortness of breath, indolence to speak, preference of lying flat, and abdominal distention.
B. Symptoms of transporting and transforming dysfunction: poor appetite, indigestion, abdominal distention, diarrhea.
C. Symptoms about flow of spleen and stomach qi flow : vertigo, abdominal distention, sagging distention in lower abdomen, prolapse of rectum, belching, nausea and vomiting.
D. Symptoms about the dampness due to spleen: edema in eyelids or whole body, diarrhea, abdominal distention, jaundice.
E. Symptoms about spleen controlling blood: bleeding. F. Symptoms in regions of Spleen and Stomach Meridians: if disease occurs in Spleen Meridian, there are swollen neck, knee pain, hip pain; while diseases happens in Stomach Meridian, there are pain in forehead, sore throat, gingival pain, and nasal bleeding.
(2) The relation between the spleen and other organs The spleen governs muscle and flesh, and dominates limbs. It opens into mouth and has its outward manifestation on lips. So the following symptoms are present in spleen diseases : Loss of weight; aching limbs, weak limbs, heavy sensation of whole body; pale lips, swollen lips or choppy lip.
(3) The relation between the spleen and other viscera
A. The inter-generating relation with the heart and lung: the heart and lung diseases may be the cause or result of spleen diseases.
B. The inter-restraining relation with the liver and kidney: The liver often over-restrains the spleen. The spleen disease in its late stage usually implicates the kidney.
T o sum up, the following symptoms are usually found clinically in spleen and
stomach diseases : 1) poor appetite;
2) abdominal distention and pain; 3) diarrhea or loose stool;
4) constipation; 5) edema; 6) bleeding ;
7) belching, hiccup ; 8) nausea and vomiting.
I. Spleen Qi Deficiency It is the syndrome of weak spleen qi which does the transportation and transformation inadequately. Improper diet, over-fatigue, prolonged diseases and mistreatment can all give rise to the syndrome.
Clinical Manifestations : poor appetite, indigestion, abdominal distention aggravated after meal, bowl rumbling, diarrhea, tiredness, lack of strength, shortness of breath, heavy body, lassitude, edema, emaciation, pale tongue, weak pulse.
Analysis: The deficient spleen qi is not able to function, so the food is hard to , be digested and the appetite for food is poor. The food retention makes abdominal distention. When food is taken, the shortage of spleen qi is more obvious, so the distention is aggravated. The water is not transformed, and then becomes dampness. The dampness overflows into skin and leads to heavy sensation of all body, lassitude and edema. The dampness flows into intestines which results in bowl rumbling and diarrhea. Because middle qi is deficient, the patient feels lack of strength, tiredness and shortness of breath. The spleen qi fails to nourish the flesh, so the body becomes thin. The deficiency is also reflected in pale tongue and weak pulse. The central points of this syndrome are the poor appetite, abdominal distention and loose stool.
11. Spleen Qi Sinking It is the syndrome due to the fallure of the weak spleen qi in ascending. The improper diet, over-fatigue, prolonged diseases like diarrhea could result in the syndrome. Most of them develop from the spleen qi deficiency.
Clinical Manifestations: vertigo, shortness of breath, frequent sigh, feeble voice, indolence of speaking, heavy body, lassitude, sagging distention in abdomen
aggravated after meal; or loose stool, lingering diarrhea, even prolapse of rectum; or frequent urination, turbid urine; or prolapse of uterus; pale tongue with white coating, weak pulse.
Analysis: T h e spleen is healthy with its qi ascending. If the spleen qi is weak and sinks, the lucid yang is not able to rise, the patient feels vertigo. The lack of qi in chest causes shortness of breath, sigh, feeble voice and indolence of speaking. The deficiency of middle qi leads to abdominal sagging distention. Because the sinking qi is unable to keep and consolidate organs in their ordinary places, the sagging sensation in rectum, prolapse of rectum or uterus take place. The spleen is responsible for the distribution of essence. When spleen qi sinking, the essence could not be distributed normally. On the contrary, it flows into bladder, so the urine is turbid and micturation is frequent. The heavy body, pale tongue and weak pulse indicate the deficiency of spleen qi. The key point for diagnosis is the spleen qi deficiency plus symptoms of sagging.
111. Failure of Spleen to Control Blood It is the syndrome of inability of deficient spleen qi t o confine blood flowing within vessels. What cause spleen qi deficiency can all result in the syndrome.
Clinical Manifestations: bleeding, such as spitting blood, nasal bleeding, hemoptysis, hematochezia (blood in stool), hematuria, heavy menstruation, metrorrhagia and metrostaxis, subcutaneous hemorrhage; vertigo, shortness of breath, fatigue, lassitude, poor appetite, abdominal distention, loose stool, pale or sallow complexion, pale tongue and thready pulse.
Analysis: Blood is generated in spleen. The exuberant spleen makes all meridians filled up; and the weak spleen leads to hollow meridians. Blood is also controlled by spleen. The normal circulation of blood depends on the control of spleen. In spleen qi deficiency, the blood will flow unrestrainedly and flood extravascularly. The blood flooding in the upper leads to bleeding in upper body like spitting blood, nasal bleeding and hemoptysis. Blood flooding in the lower results in the blood in urine and stool. Blood flooding under skin causes subcutaneous bleeding. The unrestrained flowing in Chong and Ren Meridians leads to heavy menstruation, metrorrhagia and metrostaxis. The loss of blood makes the complexion pale and lusterless. The hollow vessel is shown in thready pulse. The spleen is too weak to transform and transport food, so there are poor appetite, abdominal distention and loose stool. T h e vertigo, shortness, fatigue and heavy body are due to insufficiency of qi and blood. The key point is the spleen qi deficiency plus the bleeding. 273
*
IV.Spleen Uang Deficiency The syndrome is present when spleen yang is declining. Too much cold or uncooked food and abuse of cold drugs can both take spleen yang away. In aged or chronic diseased patients, the spleen yang can be diminished. Thus the syndrome occurs.
Clinical Manifestations : Symptoms include cold limbs, chill, no thirst, abdominal distention after meal, poor appetite, cold sensation in abdomen, preference of hot food, abdominal dull pain liking warming and pressing, excessive saliva, loose stool and weariness. Edema may be present. The tongue is pale and corpulent with white slippery coating. The pulse is deep, slow and weak. Table Distinguishmcent Among the Deficiency Syndromes of Spleen
FSCB
SQS
SQD
syndrome
SYD
common
poor appetite, abdominal distention aggravated after meal, loose stool, weari-
symptoms
ness, indolence to speak, shortness of breath, pale tongue vertigo, sighing,
the different
I vertigo, pale or I cold limbs,
prolonged diarrhea prolapse of rectum, frequent urination, turbid
weak
pulse
weak
thready
deep, slow and weak
deficiency, spleen qi sinking, failure of spleen to control blood and spleen yang deficiency respectively.
Analysis: T h e wet earth of Taiyin is metabolized automatically when receiving yang. If spleen yang is insufficient, the spleen qi is unable to act. Becaus,e the yang fails to reach the four extremities, chill and cold limbs are present. The poor appetite is attributed to the dysfunction of spleen in transforming and transporting. When yang is deficient, cold takes place and the cold hinders the qi from moving.
274
a
Thus the cold and dull abdominal pain occurs. The yang could not transform water into fluid. The upwards overflowing of water results in excessive saliva in mouth; the outwards overflowing leads to edema; and the downwards overflowing gives rise to loose stool. The weariness, corpulent tongue with white slippery coating, deep, slow and weak pulse are the manifestation of yang declining. The key point is the coexistence of the manifestations of spleen dysfunction and deficiency cold. r-9'-
spleen qi sinking blood-failure of spleen to control blood yang-spleen yang deficiency
t
spleen deficiency
V. Spleen Encumbered by Cold-Dampness The syndrome is present when cold and dampness stay in the middle-jiao. All the improper diet, indulgence in cold and uncooked food, being exposed to cold and wet, caught by rain, living in humid room can result in the invasion of cold and damp evils which hinders the spleen yang. As a result of the invasion, the syndrome occurs.
Clinical Manifestations: dark yellow complexion, chill, no thirst, nausea, poor appetite, abdominal distention, heavy sensation in head and tiredness, loose stool, scanty urine. Jaundice may be present in a dark dusty yellow color. Woman patient may suffer from excessive leukorrhea. The tongue is pale with white greasy or white slippery coating. Pulse is soggy.
Analysis: When cold food and drink injure the yang of spleen and stomach and lead to indigestion of food, cold and damp evils stay in the middle. The dampness is then produced in virtue of the spleen dysfunction. The exogenous cold and dampness invading the body can also result in the syndrome. The yang is worn away. therefore chill is present. The dysfunction of spleen results in poor appetite and abdominal distention. The stomach qi is not harmonized and descending, which gives rise to the nausea. The cold coagulates qi and blood and has the result of abdominal pain. That dampness flows into upper body and leads to no thirst. The downwards flow of dampness produces loose stool and leukorrhea. The dampness has the nature of heaviness and descending. When it suffuses the whole body and spleen, it gives rise to the heavy sensation. The qi and blood are impeded by dampness. They could not nourish the face. Thus the face becomes sallow. That the bile overflows with dampness produces jaundice in dark yellow. The cold and dampness disturb 275
the function of bladder and lead to scanty urine. The soft pulse and pale corpulent tongue with slippery white coating are attributed to the cold and dampness. The key point for diagnosis is the presence of manifestations of both the spleen dysfunction and excessive cold. There are manifestations of spleen dysfunction and cold-dampness in the syndrome of spleen encumbered by cold-dampness and spleen yang deficiency. The differences between them are : The spleen encumbered by cold-dampness is caused by the exogenous cold which impedes the yang in the middle. The course is short. It belongs to excess syndrome. No manifestation of deficiency is present. The spleen yang deficiency is caused by the shortage of yang which leads to cold and dampness in body. The course is long. It pertains to deficiency syndrome but some manifestations of excess may be present.
VI..Stabmach Cold The stomach cold is a syndrome of cold evil in the stomach. The intake of cold food or direct invasion of cold evil can defeat the middle yang and lead to cold remaining in stomach. The syndrome is then present.
Clinical Manifestations: The sudden onset of severe stomachache aggravated by cooling and improved by warming and pressing is the main symptom of the syndrome. Other symptoms as vomiting of mucus, no thirst, bowel rumbling, loose stool, chill and cold limbs, pale tongue with white slippery coating, slow or taut pulse are present.
pain in stomach. When cold coagulates blood, the pain is severe. The heat can dispel cold and make qi and blood flow easily. So, the pain abates by warming. The food and drinking are not digested when stomach qi is abnormal and undigested food transforms into fluid-retention. The retained fluid goes upwards with the rebellious stomach qi and is vomited out. When fluid-retention is wandering in intestines. there is bowel rumbling. Because the yang is damaged by the cold evil, the body is cold. Thirst, loose stool, white coating and slow or taut pulse are the evidences of internal cold. The key diagnostic point is the stomachache with manifestations of cold.
Table
Distinguishment Among the Spleen Yang Deficiency (SYD) , Spleen
Encumbered by Cold-Dampness (SECD) and Stomach Cold (SC) syndrome
SYD
common
indolence of cold, thirstiless, abdominal distending pain, nausea, pale
symptoms
tongue with white slippery coating
different symptoms
edema poor appetite, excessive saliva, dull abdominal pain alleviated by warming and pressing, loose stool, cold body, fatigue, shortness of breath, indolence of speaking
pulse
deep, slow and weak
SECD
dark yellow face, jaundice, edema poor appetite, heavy body sensation, loose stool, excessive leukorrhea
soggy
SC
severe stomach pain abated by warming and pressing, vomiting of mucus, bowel rumbling, cold limbs
slow or taut
VII. Dattmp-Heat in Spleen and Stomacltn The syndrome is present in condition of dampness and heat evil in the middlejiao. It is caused by the indulgence in rich food or alcoholic which produces dampness and heat, or by invasion of exogenous dampness and heat. T h e dampness and heat stay in stomach and spleen in combination.
Clinical Manifestations: Fever, sweating, nausea, vomiting, poor appetite, abdominal distention, heavy body sensation, loose stool with difficulty in defecation and yellow urine are the usual symptoms of the syndrome. The jaundice in bright yellow with itching, or the lingering fever without abating after sweating may be present. The tongue is red with yellow greasy coating and the pulse is rapid soggy or rapid slippery.
Analysis: The dysfunction of spleen due to damp-heat is shown in the abdominal distention. The rebellion of stomach qi is marked by the nausea and vomiting. The heat in body gives rise to sweating. The dampness is sticky and is hardly dispelled even bp sweating. So, the fever does not abate after sweating. The dampness adheres to flesh and muscles makes heavy sensation. The evil goes down and makes loose stool and dark urine. The damp-heat acts on bile and makes bile overflowing. The bile with the evil stains the skin and produces jaundice. It is recorded in The
Distinguishing Among Miscellaneous Diseases: "The yellow stain due to damp-heat *
277
*
is dark like the being fumigated when the dampness is predominant, and is bright like the color of orange when the heat is predominant." The red tongue, yellow coating and rapid pulse reflect the heat. The greasy coating and slippery or soggy pulse are the signs of dampness. The central point for diagnosis is the manifestations of spleen dysfunction in combination with those of damp-heat.
VIII. Stomach Heat The stomach heat is the syndrome of fire blazing in stomach. The body of yang predominant constitution is liable to suffer from the syndrome. Too much pungent and fatty food and emotional stress may produce fire. The syndrome is present when fire invades stomach.
Clinical Manifestations: The syndrome is characterized by the burning stomachache with regurgitation of acid, excessive hunger even after big eating, fetid odor in mouth. There may be gingival swelling and pain, even bleeding. Constipation, dark yellow urine, red tongue with yellow dry coating and rapid pulse are usually present.
Analysis: The fire blazing in stomach scorches the meridians in stomach and impedes the flow of qi and blood. That gives rise to the burning pain in stomach. Because food is burnt away by fire, patient. always feels hungry even after meal. The thirst for cold drinking is due to lack of fluid which is caused by the fire. The turbid air goes up from stomach to mouth and gives the breath odor. The Stomach Meridian goes through gum. The fire goes up along meridian and leads to qi and blood stagnated in gum. So, gum swelling and pain occurs. If fire damages vessels, it causes bleeding. The insufficiency of fluid makes the dry and hard faeces. There ,
is no enough fluid to produce urine, so, there is scanty urine. The red tongue aiid rapid pulse are the marks of heat. The key diagnostic point is the stomachache in combination with interior excessive heat syndrome.
XI.Stomach Yin Deficiency The stomach yin deficiency is the syndrome of yin insufficiency in stomach. The prolonged stomach diseases which wears away the yin and fluid of stomach, or the febrile diseases in their late stages which takes away yin and fluid, or fire due to emotional stress, or over intake of pungent food can all develop into the syndrome.
Clinical Manifestations: The characteristic symptom is frequent hunger without appetite of food. Other symptoms are dull burning pain in stomach, retching, a
278
hiccup, stuffiness in stomach, dry mouth and throat, thirst, low voice of speaking and constipation. The tongue is red with little or no coating. The pulse is thready and rapid.
Analysis: The deficiency of stomach yin gives rise to the relative exorbitance of stomach yang which produces deficiency heat. The heat disturbs the stomach qi and makes stomach qi rebellious up. The hunger without appetite, burning pain and stuffiness in stomach reflect the deficiency heat and the rebellious qi flow. The retching and hiccup are due to up flaming of fire in stomach. The dry throat, drinking a lot and constipation suggest the insufficiency of body fluid. That the earth (spleen) does not help the metal (lung) makes the voice low. The tongue and pulse embody the deficiency heat. T h e hunger without appetite in combination with the manifestations of yin deficiency is the key point for diagnosis.
X. Spleen Yim Deficiency It is the syndrome of lack of yin in the spleen. Improper diet, over-fatigue and other factors can all cause the syndrome.
Clinical Manifestatioas: Anorexia, lack of saliva, dry mouth and throat but drinking only a little water, abdominal distention, hot sensation in skin, palms and soles, loss of weight, constipation and scanty urine are the symptoms of the syndrome. The tongue is red without coating or with exfoliative coating. The pulse is thready and rapid. Analysis: Gu Songyuan said: "The yin impairment of spleen is mostly caused by the over-fatigue.
"
Wu Tang said: "The cold-damp often damages the yang of
spleen while the damp-heat mainly impairs the yin of spleen. " T h e exogenous and endogenous factors can both lead to spleen yin deficiency. Chen Xiuyuan thought that the spleen belonged to Taiyin which was the first of three yin; so the treatment of yin deficiency should be focused on rectifying of spleen yin deficiency: and
if the spleen yin was enough which would supplement the yin in other viscera. From those, we can see the importance of spleen yin. Both spleen and stomach have their own yin. The spleen yin is mainly the nutrient and blood, and the stomach yin is mainly the body fluid. So the spleen yin deficiency is caused mainly by the endogenous causes which wear away the qi and blood. The stomach yin deficiency usually takes place in the late stage of warm diseases and is characterized by the loss of body fluid and deficiency heat. The spleen is responsible for the food transformation and transportation. The yin deficiency leads to splenic dysfunction which is expressed in anorexia. The lack of yin in upper o
279
body is shown in dry throat and scanty saliva while that in lower body is marked by constipation and scanty urine. The deficiency heat due to yin deficiency renders skin, palms and soles hot. The deficiency heat compels nutrient to go up, so the patient does not desire to drink. The dysfunction of spleen causes abdominal distention. The anorexia results in malnutrition of flesh and loss of weight. The anorexia with manifestations of yin deficiency is the key point for diagnosis. Distinguishment Among Damp-Heat in Spleen and Stomach (DEHISS),
Table
Stomach Heat (SN) , Stomach Yin Deficiency (STYD) and Spleen Yin Deficiency (SPUD)
SH
DHSS
syndrome
I
common
STYD red tongue and rapid pulse
I
points -
I poor appetite
-
diet
I
vomiting nausea abdominal feeling defecation
Yes
urination
deep yellow
observation other
stuffiness loose stool
heavy sensation of bodv yellow greasy
/
-
leven after meal. having a lot cold drinking regurgitation of acid burning stomachache constipation
soggy or slippery
.
1 hunger without /desire for food
retching, hiccup dull burning stomachache constipation
swelling gum, bleeding in gum fetid odor in
1 anorexia I no distention constipation scanty
yellow
I
I sweating,
pulse
excessive hunger
,jaundice in bright yellow fever without
coating
SPYD
emaciation
emaciation
dry mouth and / t o drink. feeble voice
yellow dry
little or no
rapid
thready
I hot sensation 1 in palms and
XI.Food-Retention in Stomach It is the syndrome of food retaining in stomach. Improper diet and weak spleen function may both cause the syndrome.
Clinical Manifestations: The symptoms includes distending stomachache, anorexia, belching with putrid odor, regurgitation of acid, vomiting of undigested *
280
*
food. Diarrhea, frequent fart, extremely fetid odor of faeces may also be present. T h e tongue coating is thick and the pulse is slippery.
Analysis: "When food intake is doubled, it injures the stomach and intestines. " T h e improper diet and the dysfunction of the spleen and stomach lead to food retained in the middle. T h e stagnated qi of the spleen and stomach gives rise to the epigastric distending pain. The rebellious stomach qi causes the anorexia, belching, regurgitation, and even vomiting. That the decayed food goes downwards leads to diarrhea with putrid stool. That the turbid qi in stomach acts on tongue upwards makes the coating thick. The slippery pulse is the sign of excess in the interior. The key diagnostic points are the epigastric distending pain, belching with putrid odor and acid regurgitation.
XII. Blood Stasis in Stomach It is the syndrome of blood stasis staying in stomach. The syndrome may result from the prolonged diseases of the spleen or stomach, internal cold or qi stagnation.
Clinical Manifestations: It is characterized by prickle pain in stomach aggravated by pressing and eating. The pain is fixed. Poor appetite, loss of weight, vomiting of black blood and tar stool may occur. The tongue is blackish purple or with ecchymosis. The pulse is uneven.
Analysis: The blood stasis in stomach obstructs the flow of qi and blood, so the stabbing pain occurs. The stasis in middle-jiao makes the food undigested, then there is no appetite. The decreased food intake causes malnutrition of flesh and loss of weight. If blood stasis damages the collateral, blood flows extravascularly, the bleeding then takes place. The purple tongue and ecchymosis are the signs of sta-
Section 4 Syndrome Differentiation on Lung and Large Intestine The following aspects are the focal points when differentiating lung syndromes :
(1) The nature of the lung The lung is in the chest and is the organ for respiration. It dominates the skin and opens into nose by the connection of throat. The lung is the upper source of water. The Lung Meridian begins in middle-jiao, goes through lung and out into 281
skin in axilla, then goes through arm into the end of thumb. The lung has an exterior-interior relation with large intestine. The symptoms of lung diseases include: A. Symptoms about the function of "dispersing and descending of qi" : shallow and rapid breath, feeble respiration, asthma, chest distress, cough, hemoptysis.
B.Symptoms
about the skin: symptoms of exterior syndrome and excessive
sweating.
C. Symptoms about the upper source of water: dysuria. D. Symptoms about the Lung Meridian: pain in superclavicular region, arm and shoulder pain.
(2) The relation between the lung and other organs A. T h e lung opens into nose, so nose disorders are found in lung diseases.
B.The
throat belongs to lung system, so itching, pain, swollen throat, hoarse-
ness and wheezing may occur in lung disease.
(3) The relation between the lung and other viscera A. The lung has an exterior-interior relation with large intestine. So, disorder of defecation may be present in lung diseases.
B. The
lung has an inter-generating relation with the spleen and kidney.
Therefore, the spleen diseases and kidney diseases may involve the lung, and vice versa. T o sum up, when lung disease occurs, the chief symptoms are chill and fever, cough and asthma. The symptoms include:
1) chill and fever; 2) cough;
5) chest distress or pain; 6) voice changes.
I.Lung Qii Defidency It is the syndrome of lack of lung qi. T h e chronic diseases, cough and asthma may take lung qi away and cause the syndrome.
Clinical Manifestations: The feeble cough and dyspnea, shortness of breath, thin and clear sputum, feeble voice of speaking and indolence of speaking are usually the main symptoms. Aversion to wind and spontaneous sweating are also frequently seen. The patient is susceptible to the cold. The tongue is pale and pulse is weak. Q
282
Q
Analysis: The asthenic constitution is easy to be attacked by cold through skin. T h e skin is connected to the lung. When evils invade skin, they will certainly enter the lung. If evils stay in the lung for long time, they injure lung qi. In prolonged diseases, the diseases involve the lung. The lung is in charge of the qi of whole body. So, symptoms are focused on impairment of lung qi. T h e cough and dyspnea without strength show the insufficiency of lung qi. T h e susceptibility to the cold, aversion to wind and spontaneous sweating are due to the failure of lung to consolidate the body surface in which condition, because the skin is loose, the evil is easy to enter the body and fluid is easy to go out from the body. The qi is inactive, so patient feels fatigue, indolence of speaking and the voice is feeble. The lung is the upper source of water and the container of sputum. When qi is deficiency, the water is difficult to transform and then becomes the watery sputum. Both the pale tongue and weak pulse are due to qi deficiency. The key point for diagnosis includes the feeble cough and dyspnea, shortness of breath and spontaneous sweating.
PI. Lung Yin Deficiency It is the syndrome of asthenic heat in body due to shortage of lung yin. The syndrome may be caused by the congenital defect, improper diet, over-fatigue, indulgence in sex, or the prolonged exogenous diseases in which the heat staying in lung takes the yin away.
Clinical Manifestations:The dry cough, or cough with little sputum or bloody sputum, hectic fever or tidal fever, fidget, hot sensation in the five centers, red zygomatic region, night sweating and dry throat are the main symptoms. The breath may be short and shallow. The voice is hoarse. The tongue is red with little coating. T h e pulse is thready and rapid.
Analysis: The typical symptoms of yin deficiency, such as dry cough, hemoptysis, hectic fever and night sweating, all belong to the symptoms of lung. The deficient yin leads to asthenic fire which boils down fluid to sputum. That is the cause of dry cough. The fire scorches the collateral and leads to bleeding. The yin could not arrive at the upper body, so the throat is dry. The body is not filled up, so it becomes thin. The cough will certainly wear away the lung qi and give rise to shortness of breath. The throat is connected to the lung. The deficient yin can not moisten the throat, so the voice is harsh. Both the tongue and pulse reflect the yin deficiency. T h e dry cough and symptoms of insufficiency of body-fluid are seen in both 283
lung yin deficiency and dryness evil attacking lung. The dryness attacking of lung is an exogenous attack and is mainly seen in autumn. It is characterized by the exterior syndrome in which the main symptoms are the slightly chill and fever. The lung yin deficiency is endogenous disease and is characterized by symptoms of yin deficiency, such as tidal fever, night sweating and emaciation. Nevertheless, it should be pointed out that the affection of dryness in lung can leads to lung yin deficiency if lasting for long. r
111. Wind-Cold Attacking Lung It is the syndrome of lung being encumbered by the exogenous wind-cold evil. The patient catches wind-cold from outside. The evils then enter the lung and encumber the activity of lung qi. Thus, the syndrome takes place.
Clinical Manifestations: The symptoms of the syndrome are cough with white thin sputum, chill and fever, chest distress, stuffy nose, muffled voice, headache and pantalgia. There is no sweating. The tongue coating is white and thin. The pulse is floating and taut.
Analysis: The exogenous wind-cold damages the defensive qi and makes the exterior stuffed, so there are chill and fever, headache, pantalgia and no sweating. The ancient classic said that the cold damaged the lung. The evil enters the lung and the lung is unable to disperse. Then the water and liquid can not be distributed and change into phlegm. The phlegm causes the cough with sputum and chest distress. The nose is the opening of lung and the throat is connected to the lung. The evil in the lung will affect the nose and throat, so the nose is obstructed and the voice becomes muffled. The key diagnostic point is the cough in combination with
PV- Gold in Lung It is the syndrome that cold evil invades the the lung. The cold attacks the lung directly without staying in the exterior and causes the syndrome.
Clinical Manifestations: The syndrome is shown in cough with white thin sputum, asthma, chill, cold limbs, pale tongue and slow pulse.
Analysis: T h e cold in the lung wraps up the yang-qi, so lung qi has to go up rebelliously. That leads to cough and asthma. The cold is a yin evil. It coagulates and transforms the fluid into phlegm which is expectorated out as sputum. The yang-qi is wrapped up and could not flow into limbs to warm -them, the limbs are cold. The cold slows down the flowing of qi and blood. That makes the tongue pale and pulse
284 *
slow. Both this syndrome and the syndrome of wind-cold attacking lung have cough with white thin sputum as their main symptom. The syndrome can be distinguished from the wind-cold attacking lung in the aspects of asthma, cold limbs, sudden onset but lasting for long, and no symptoms of exterior syndrome.
V. Phlegm, and FBuid Retention in Lung It is the syndrome of phlegm or fluid retention in the lung. The spleen qi deficiency and prolonged cough may bring about the syndrome. It is often evoked or aggravated by the catching of cold or dampness. Table
Distinguishment Among Syndromes of Wind-Cold Attacking Lung (WCAL), Cold in Lung E L > ,Fluid-Retention in Lung (FRL) and Phlegm in Lung (PL)
syndrome WCAL
CL
FRL
PL
chronic, paroxysmal,
chronic and paroxysmal
history
sudden onset
sudden onset
frequent
onset in winter
course
short
short
long
long
disease
excess
excess
deficiency in "root"
deficiency in "root"
and excess in "branch"
and excess in "branch"
white, thin and foamy
white thick
in large amount
in large amount
dyspnea without ability
dyspnea
sputum
white thin
white thin asthma
dyspnea
to lie down flat chill other
chill and
chill and
fever
cold limbs chest distress,
stuffy nose,
choke, wheezing
palpitation
symptoms no sweating, headache, pantalgia tongue pulse
pale tongue, white
white thin
pale tongue,
pale tongue, white
coating
white coating
watery coating
greasy coating
taut
slippery
floating and
slow
tense
Clinical Manifestations: The common symptoms are cough with excessive sputum which is white and easy to be expectorated out, chest distress, asthma, wheez285
ing, pale tongue and white coating. The phlegm in the lung is shown in thick sputum, greasy coating and slippery pulse. The fluid-retention in the lung is expressed by the foamy sputum, dyspnea without ability to lie down flat, palpitation, watery coating and taut pulse.
Analysis: The dysfunction in spleen qi deficiency leads to precipitation of water and dampness. The water and dampness then transform into phlegm which goes up into the lung. The prolonged cough may harm the lung. The lung fails to distribute water. The water accumulates in the lung, and then transforms into phlegm. The phlegm makes lung qi rebellious, which is characterized by the expectoration. If phlegm obstructs the air tract, choke, asthma and wheezing will take place. The phlegm is shown in thick sputum. If the water transforms into fluid-retention instead of phlegm, the sputum is frothy. That the fluid-retention stays in costal region and impedes air tract gives rise to qi rebellion which is marked by cough, orthopnea (dyspnea without ability to lie down flat), and palpitation. The tongue and pulse are the reflection of phlegm or fluid-retention. The key diagnostic point lies in cough and excessive sputum which is easy to be expectorated.
VH. Wind-Heat in Lung It is the syndrome that wind-heat evil invades the lung and the defensive qi is involved. The syndrome is caused by the exogenous wind and heat evils.
Clinical Manifestations: Its symptoms include cough with yellow thick sputurn, fever and slight chill, dry mouth, sore throat, stuffy nose with yellow turbid nasal discharge. The tongue tip is red. The coating is yellow and thin. The pulse is floating and rapid. cough. The heat boils down fluid into phlegm, so the sputum is yellow and thick. The combating between genuine qi and evil results in fever. Because the defensive qi is impeded, the patient feels slight chill. The wind-heat harms the fluid and leads to dry mouth. Impairment of qi flow in throat gives rise to sore throat. The nose is the opening of the lung. The obstructed lung qi produces stuffy nose. The windheat takes away the fluid and makes the nasal discharge turbid and yellow. The red tongue means the heat in the upper. The pulse indicates the exterior heat. The cough in combination with the exterior heat syndrome is the key for diagnosis.
VPI. Lung Clogged with Heat It is tHe syndrome that excessive heat blocks up the lung. All the evils can en-
. 286 .
,
ter the interior and transform into heat. If the heat is in lung, the syndrome is brought out.
Clinical Manifestations: Cough with yellow thick sputum, dyspnea, high fever, thirst, vexation, nares flaring, or chest pain with expectoration of purulent and bloody sputum are usually the symptoms of the syndrome. Constipation and yellow scanty urine are seen. The tongue is red with yellow coating and the pulse is rapid.
Analysis: The exorbitant heat in lung makes lung qi rebellious which brings about cough. The heat boils down fluid into phlegm, so the sputum is yellow and sticky. That the lung qi could not descend results in dyspnea. T h e high fever exhibits sthenic internal heat. The vexation is due to heat disturbing the mind. That heat sputum obstructs in air way gives rise to nares flaring. If heat invades collateral and obstructs the flow of qi and blood, and burns the flesh of the lung, there will be chest pain with expectoration of purulent and bloody sputum. The body fluid is evaporated away by heat, so the feces is dry and the urine is little in amount. Both the tongue and pulse are the signs of interior heat. The key diagnostic point is the combination of cough and interior heat syndrome.
VHHI. Dryness in Lung It is the syndrome of dryness evil invading the lung. T h e syndrome is seen in autumn. The dryness evil which may invade the body from environment or is produced by other evils, enters the lung and the syndrome takes place.
Clinical Manifestation: Dry cough or cough with little expectoration. In severe case, the sputum is bloody. Other symptoms include chest pain, fever, slight chill, little sweating, dry skin, mouth and nose. The urine is yellow and scanty. The tongue is dry and red with yellow coating. The pulse is rapid.
Analysis: The dryness is divided into warm-dryness and cool-dryness. They can all invade the lung. Both of them have the dry body, little sweating and symptoms of lung as the main symptoms. Warm-dryness attack and cool-dryness attack on constitutional yin deficiency patients can both result in the warm-dryness syndrome. Because evil attacks the exterior, there are fever and slight chill. Dryness damages the lung and absorbs the body fluid. Because of lack of fluid to moisten, the nose, skin, throat and mouth are dry and there is less sweating. The dryness damages the collateral in the lung, so the sputum is bloody. The tongue and pulse reflect the warm-dryness. The manifestations of cool-dryness syndrome is similar to those of wind-cold in lung. Yet, the dry cough, little sputum, dry nose, mouth and skin, white dry coat*
287
.
ing are the characteristics for cool-dryness syndrome. TabBe
Distinguishment Among Wind-Heat in Lung (WHL) , Fung Clogged with Heat (LGR) and Dryness in Lung (DL)
syndrome
WHL
LCH
DL
onset
mostly in winter and
mostly in winter and
mostly in autumn
season
spring
spring
cough
cough
cough
dry cough
sputum
yellow and thick
yellow and sticky
little and sticky difficult to expec-
#
torate, even bloody slight
chill
slight
fever
fever
high fever
fever
other
dry mouth, sore
thirst, nares flaring,
chest pain, little
symptoms
throat, stuffy nose,
vexation, chest pain,
sweating, dry skin,
yellow nasal discharge
pus and blood sputum,
nose and mouth,
constipation, yellow
yellow scanty
urine
urine
red tongue tip
red tongue
red tongue
yellow thin coating
yellow coating
yellow dry coating
floating and rapid
rapid
rapid
tongue pulse
IX. Damp-Heat in Large Intestine The syndrome takes place when damp-heat evil invades the large intestine. It is caused by the exogenous dampness and heat attack or eating dirty food.
CBinieal Manifestations: The syndrome may be manifested by the diarrhea with pus, blood and mucus in stool, frequent defecation, abdominal pain and rectal tenesmus, or by the fulminant watery diarrhea, or by diarrhea with unsmooth defethirst but drinking little, spasm and tenderness in lower abdomen. In severe case, vomiting and coma may happen. The tongue is red and the coating is yellow and greasy. The pulse is rapid and slippery.
Analysis: The damp-heat in large intestine is seen in diseases of dysentery, diarrhea and intestinal abscess. The damp-heat damages the collateral and burns the flesh, so there are pus, blood and mucus in stool. Damp-heat impedes qi flow. The f
qi stagnation causes abdominal pain and rectal tenesmus. The damp-heat goes down, furthermore, the large intestine fails to separate the clear from turbid, so the 0
288
0
turbid and the clear are discharged out in combination. That is the fulminant diarrhea. That the damp-heat impedes the large intestine makes the defecation uneasy. T h e internal exorbitant heat produces fever and sweating. The coexistence of damp and heat causes the thirst but drinking little. If evils goes up and involves the stomach and even the heart, there are vomiting and coma. If damp-heat enters blood, the blood in intestine will be transformed into pus. Tlius the intestinal abscess occurs, which is characterized by the spasm and tenderness in lower abdomen. The red tongue, yellow coating and rapid pulse suggest heat. The greasy coating and slippery pulse indicate the dampness. The key diagnostic point is the coexistence of diarrhea and symptoms of dampness and heat.
X. Def iciency-Cold of Large Intestine T h e syndrome is present when yang-qi in large intestine declines. The congenital yang insufficiency or damage of the yang-qi, too much cold or uncooked food, or prolonged diarrhea may cause this syndrome.
Clinical Manifestations: Bowel rumbling, dull abdominal pain, loose stool or diarrhea, incontinence of defecation, or difficulty (not enough force) in defecation, sagging feeling in anus, rectal prolapse after defecation are the main symptoms. T h e patient usually feels chill and likes being warmed. The body is cold. Listlessness, weakness and clear urine are often present. The coating is white. The pulse is deep or slow.
Analysis: The yang and qi deficiency makes the large intestine unc~ntrolledin its transmitting function. That is the cause for diarrhea, loose stool and incontinence of defecation. The large intestine is asthenic, so the defecation is incomplete. That blood is coagulated by cold gives rise to pain. The yang fails to warm body, therefore the body is cold. The qi deficiency brings about listlessness and weakness. The deficient qi could not keep the organ, thus the rectal prolapse. The tongue and pulse show the internal cold. T h e incontinence of defecation or difficulty in defecation with the symptoms of cold is the key for diagnosis.
XI. Loss of Large Intestine Fluid I t is the syndrome that the body fluid is insufficient and is not able to moisten the large intestine. The yin deficiency in aged patients, loss of body fluid after febrile diseases or chronic diseases, or yin and blood deficiency after delivery can all lead to the syndrome.
CliHiiicall Malmifestatioms:The feces is hard and difficult to excrete, The patient 289 0
0
loosens the bowel each time for several or even ten days. Dry mouth and throat, fetid odor in mouth and abdominal distension are usually seen. T h e coating is yellow and dry. The pulse is thready.
Analysis: Because body fluid is insufficient, the movement of intestines is slow. The large intestine could not transport the waste normally, therefore the waste stays in body which causes the constipation and abdominal distension. The turbid qi from feces goes upwards and gives fetid odor in mouth. The mouth and throat are not moistened, so they are dry. The tongue and pulse are the evidences for lack of body fluid. The constipation without manifestations of heat is the key for diagnosis.
Section 5
Syndrome Differentiation on Kidney and Urinary Bladder
The following aspects are main considerations for kidney diseases.
(1) The nature of the kidney The kidney belongs to water. It receives and stores yin-essence from other viscera. The kidney is the root of other viscera. The ministerial fire is governed by the kidney, which is a shapeless fire and goes over all the body. So the kidney is then a viscus of both water and fire. The kidney is the congenital foundation and is in charge of reproduction and development of body. The kidney also receives qi from the lung. The Kidney Meridian goes from foot to thigh, and into spinal cord. Because the kidney stores the genuine yin and genuine yang, the yin and yang match equally, and the water and fire coexist in it. Most of the kidney diseases are due to lack of essence and belong to deficiency syndromes. T h e following symptoms are usually found in kidney diseases.
A. Symptoms about the kidney yin and kidney yang: if the yin is deficient, there are tidal fever, bone steaming, night sweating, aching lumbus and knee, hemoptysis. While the yang is insufficient, there are intolerance to cold, cold limbs, bone pain and impotence,
B.
Symptoms
about
the
congenital
foundation
(
reproduction
and
development) : congenital defects, impotence, defective sperm, seminal emission, morbid menstruation, infertility, maldevelopment.
C. Symptoms about receiving qi : dyspnea or asthma with difficult inhaling and easy exhaling.
I
D. Symptoms about controlling urination and defecation: diarrhea, frequent 290
*
urination, incontinence of urination. E. Symptoms about the Kidney Meridian: heavy sensation, aching or pain in lumbus or legs. (2) The relation between the kidney and other organs The kidney governs the bone and produces the marrow which supplies the brain. The kidney opens into ears and has its outside manifestation in hair. The lumbus is the house of the kidney. So the following symptoms are found in kidney diseases. A. Symptoms about the bone: weak legs even difficulty in walking, vertigo, ringing in brain, poor memory; toothache and other tooth disorders.
B. Symptoms about ears : tinnitus and deafness. C. Symptoms about hair: withering hair or loss of hair. D. Symptoms about lumbus: sore and weak lumbus and knees, cold back. (3) The relation between the kidney and other viscera The kidney has an exterior-interior relation with the urinary bladder. If kidney function is impaired, the urination is abnormal. The kidney diseases can also lead to disorders in other viscera because they ,
have an inter-generating relation or an inter-restraining relation with one another. T o sum up, in kidney diseases, the IoEitlowiag symptoms are usually eacsuntered.
1. Lumbago, sore and weak lumbus and knees ; 2. Tinnitus and deafness;
3. Loss of hair, graying of hair;
4. Impotence, seminal emission, defective ejaculation and defective sperm which lead to male infertility:
5. Irregular menstruation, amenia, and infertility in women; 6. Edema; 7. Abnormal defecation and urination.
I. Kidney Yalrag Deficiency It is the syndrome of kidney yang declination. The congenital defect, aging, over-fatigue and indulgence in sex can all cause the syndrome. Clinical Manifestations: The lumbago, sore and cold lumbus and knees, intolerance to cold, cold limbs, blackish facial complexion, tiredness, weakness, pale tongue with white coating, deep and weak pulse are common symptoms of the syndrome. The following 1 or 2 grouped symptoms, such as impotence, seminal emis-
291
sion, spontaneous emission and infertility in male patients; or scanty mense, amenia and infertility in female patients: or poor appetite, loose stool, diarrhea at dawn; or clear urine, frequent night urination. enuresis and dripping after urination: or edema which is severe below waist and is deep sunken when pressed, dysuria, abdomi/
nal distention, palpitation, shortness o f breath, cough and dyspnea, can be present in patient,
Analysis: The kidney yang is also called vital yang and is the basis of all the yang in the body. The yang deficiency makes the body lost its warming, therefore patient feels cold. The lumbus is the house of kidney. If loses the nutrient from kidney, the pain and soreness occur in lumbus. The genuine color of kidney is black. The decline of genuine of kidney gives rise to blackish facial complexion. The mind is supplied inadequately, thus the spirit is low. The tongue and pulse reflect the yang deficiency. The declined life-gate fire leads to inability of sexual activity, therefore impotence is present. That the yang couldn't warm and control sperm gives rise to infertility and spontaneous emission. If the kidney yang could not consolidate the Chong Meridian and Ren Meridian, the excessive mense, metrorrhagia and metrostaxis will happen in female patients. If the yang deficiency leads to qi and blood stagnation or exhaustion of blood-sea, the menstruation is delayed or stopped. The weak yang could not warm uterus, then the woman is unable to be pregnant. Even though getting pregnant, abortion and premature delivery usually take place. Because the decline of fire which can not generate the earth. T h e disorder will occur in the spleen. The dysfunction of spleen causes poor appetite, loose stool, dawn diarrhea and incontinence of defecation. The water is out of control and goes urine and dripping of urine after urination may also be present. T h e water flows in-
the heart and lung, the palpitation, shortness of breath, cough and asthma are seen in patient. The yaiig fails to transform water in urinary bladder. The water stays in bladder and gives rise to anuria or dysuria. The key for diagnosis of the syndrome is the sore lurnbus and knees with manifestations of yang deficiency.
HI. Kidney Uin Deficiency It is the syndrome of lack of kidney yin. The congenital deficiency, indulgence in sex activities, emotional stress which transforms into fire, febrile diseases, chron292
o
ic diseases and mistreatment can all cause the syndrome.
Clinical Manifestations: The sore lumbus and knees, vertigo, tinnitus, listlessness, weakness, insomnia, poor memory, loss of hair, loss of teeth are present in patients suffering from the syndrome. The male patient may complain about the seminal emission and premature emission. T h e scanty menses or amenorrhea may be present in female patient. Other symptoms of the syndrome include loss of weight, hectic cheek, dry throat, tidal fever or hectic fever, fidget, hot sensation in the five centers and night sweating, dry stool and yellow urine. The tongue is red with little coating. The pulse is thready and rapid.
Analysis: The loss of genuine yin will certainly be shown in shape and appearance. The emaciation, weakness and loss of hair are the exterior changes of the yin deficiency. The bone is hollow due to yin deficiency, therefore the lumbus is sore and teeth are uprooted. The kidney water deficiency leads to heart fire active. The fire disturbs the mind and causes insomnia and listlessness. The sea of marrow is empty, so the memory is poor. The deficiency fire flaming inside brings out the vertigo, tinnitus and tidal fever. The yin and fluid could not moisten the body, so the throat is dry and the stool is dry also. The fire disturbance makes the sperm out of the chamber, therefore the seminal emission and spontaneous emission happen. The sea of blood is empty due to yin deficiency, so menstruation changes in women. The tongue and pulse reflect the deficiency heat in the body. The coexistence of sore lumbus or genital disorders with the symptoms of yin deficiency is the key for the diagnosis.
1x1. Kidney Essence Insuff idency The syndrome occurs when kidney essence is deficient. The congenital defect, improper diet, over-fatigue, prolonged diseases and over-sex render patient the syndrome.
Clinical Manifestations: Developmental retardation including delayed closure of fantanal, dwarfism, mental retardation, five retardation or five softness are the main symptoms in child. The sperm defect and male infertility, amenorrhea and infertility of female, senilism including prematural baldness, tinnitus, deafness, poor memory, trance, intelligence declining, fatigue and weakness are present in adults. The tongue is pink with white coating. The pulse is thready and weak.
Analysis: The essence is stored in the kidney. The state of essence determines asthenic or sthenic state of kidney qi. The deficiency of essence will involve the other viscera. The qi and blood are insufficient to provide nutrition to the body. 293
*
The bone is also lack of supplying. So the development of body is retarded. The deficiency of essence leads to hypofunction of reproductive organs, therefore the sexual function is decline. The kidney has the hair as the indicator for its brilliance. So the kidney essence deficiency brings about baldness. The teeth are the extending part of bone. If no essence to nourish them, the teeth will become loose and easy to be uprooted. The kidney opens into the ears and the brain is the sea of marrow. When essence is deficient, tinnitus, deafness, poor memory, trance and intelligence declining are present. Essence could not provide vitality, the spirit is low. The key diagnostic points are the developmental retardation, declined reproductive functions and the senilism.
IV.Unconsa~%fdation of Kidney Qii The syndrome is shown when kidney qi is weak and unable to perform the consolidating function. The kidney qi deficiency in the old and child, indulgence in sex activity, prolonged diseases can all lead to the syndrome.
Clinical Manifestations: The sore lumbus and knees, fatigue, weakness, frequent urination, dripping of urine after urination, frequent nocturnal urination, seminal emission or nocturnal emission in male, excessive thin leukorrhea in female are the usual symptoms of the syndrome. The severe case may show incontinence of urination or habitual abortion. The tongue is pale with white coating. The pulse is deep and weak.
Analysis: The kidney qi deficiency gives rise to fatigue, weakness and sore lumbus and knees. The kidney fails to control the urinary bladder, then the frequent urination, nocturnal urination and incontinence of urination take place. The kidney is unable to hold the essence, therefore the semen goes out uncontrollably. The Chong, Ren and Dai Meridians are loose, so excessive leukorrhea and habitual abortion are seen in female patients. T h e key point is the dysfunction of kidney or
V.Failure of Kidney to Receive Qi The syndrome is present when the deficient kidney qi could not conduct the qi to go back to the house of vitality. The prolonged cough or asthma involving the kidney can lead to the syndrome.
Clinical Manifestations: Sore and weak lumbus and knee, shortness of breath, dyspnea characterized by easy exhaling and difficult inhaling and aggravated on physical exertion, feeble voice, fatigue, sweating, chill with cold limbs are the usual 294
o
symptoms of the syndrome. The tongue is pale with white coating. The pulse is deep and weak. T h e serious case is shown in the severe dyspnea, excessive sweating, cold limbs, bluish facial complexion and floating pulse without root. The syndrome may also have dyspnea, flushed face, fidget, dry throat, red tongue and thready rapid pulse as its main symptoms. Table The Differentiation on Syndromes of Kidney Diseases syndrome common symptoms reproductive function
urination & defecation
other symptoms
tongue coating
KYAD
KYID
KEI
UKQ
They are all deficiency syndrome and manifested by sore lumbus and knees, mental and physical fatigue impotence, emission, infertility, emission, emission, premature amenorrhea, premature scanty emission, defected emission, mense, scanty menses sperm excessive infe;tility, or amenorrhea leukorrhea, amenorrhea habitual abortion loose stool, yellow polyuria, diarrhea urine, nocturnal a t dawn, dry stool, urination, nocturnal dripping after urination, urination, dripping incontinence after of urination urination blackish development vertigo, face, chill tinnitus, retardation and cold in child, insomnia, limbs, sore senilism bad memory, lumbus and hair and teeth loss, knee, edema, palpitation, emaciation, cough and hectic dyspnea cheek, tidal fever, hot feeling in five centers, night sweating pale red pale pale white little white white
FKRQ
dyspnea, feeble voice, chill and cold limbs, bluish or red complexion, fidget, dry throat
pale or red white
NOTE : KYAD: Kidney Yang Deficiency KEI : Kidney Essence Insufficiency FKRQ: Failure of kidney to Receive Qi
KYID: Kidney Yin Deficiency UKQ : Unconsolidation of Kidney Qi
Analysis: The lung is responsible for the exhalation and the kidney is for the inhalation. The asthma with feeling of difficulty in exhaling is due to diseases in the lung. The dyspnea with feeling of difficulty in inhaling is mainly due to kidney disorder. The chronic diseases, over sweating, loss of blood and over fatigue can wear kidney qi out. T h e qi then could not come back to the house of vitality. The yang loses its companion and support. Then the yang floats in the upper body. The syndrome thus appears. The kidney is the root of qi. If the kidney is unable to receive qi, so the qi does not come back into kidney and causes the dyspnea. The bone is malnourished due to qi deficiency of kidney. The qi fails to consolidate the body surface and gives rise to profuse sweating. The yang could not warm body and brings about the cold limbs and chill. T h e qi of the lung is involved, so the voice is feeble. If the yang and qi is severely depleted, the dyspnea, chill and cold limbs are severe; the complexion is bluish; the pulse is without root. Prolonged kidney qi deficiency may cause depleted kidney yin and the syndrome then turns into kidney deficiency of both qi and yin. This condition may also take place when kidney qi deficiency develops in constitutional yin deficiency patient. The yin deficiency and fire are shown in the flushed face, fidget, dry throat, red tongue and thready rapid pulse. The key for diagnosis is the dyspnea of easy exhaling and difficult inhaling
V11. Damp-Meat in Urinary Bladder The syndrome is present when damp-heat evil accumulates in the urinary bladder. The exogenous dampness and heat evils which enter bladder, or endogenous damp-heat produced by the improper diet can all flow down into urinary bladder, thus the syndrome takes place.
Clinical Manifestations: The main symptoms are frequent urination, urgency of micturation, burning pain in urethra. The urine is yellow. Fever, lumbago, bloody urine, or stone in urine may be present. The tongue is red with yellow greasy coating. The pulse is rapid.
Analysis: It is said in the Synopsis of the Gold Chamber: "The heat in lower-
. 296
*
jiao leads to bloody urine. It can also cause stranguria and anuria. The damp-heat "
in bladder makes dysfunction of bladder in transforming, so the urination is not smoothly. T h e evil obstructs the water passage and causes the pain. That the damp-heat suffuses all body gives rise to fever. The-damp-heat goes into kidney, there is lumbago. If damp-heat damages the collateral, the blood goes out of the vessel and forms bloody urine. If evil combines the decayed tissue to form the sand or stone, the sand may be discharged out from the urine. That is lithuresis. The steaming damp-heat makes the tongue red and the coating yellow. The key for diagnosis is the frequent urination, stranguria and yellow urine.
Section 6
Syndrome Differentiation on Compound Visceral Syndromes
The viscera are related to one another not only in physiological functions but also in the whole course of a disease. When disease occurs in some viscera, the other viscera can be involved and diseases then happen in those viscera. The syndrome involving more than one viscus is called compound visceral syndrome. When making syndrome differentiation, we should notice not only the frequent-encountered simple visceral syndromes but also the compound syndrome. When encountering compound visceral syndrome, what we should do first is to identify whether the diseases occur in the same time or not. Then we have to find out which viscus is the main one that disease takes place and which viscus is the secondary one, or the two viscera are equal important. After that, the causality and transmitting way among them should be recognized. In this way, the syndrome differentiation can be made precisely. The compound visceral syndromes are quite complicated. Only the most frequently-encountered compound syndromes involving two viscera are discussed as follows.
I. Qi Deficiency sf Both Heart and Lung The syndrome is present when the qi deficiency occurs in both the heart and the lung. The over-pensiveness or worriness, or prolonged cough or asthma, or congenital defect, or aging can lead to the syndrome.
Clinical Manifestations: Palpitation, shortness of breath, dyspnea, prolonged cough, chest distress, spontaneous sweating, fatigue and weakness. All the symptoms become worse when doing physical exertion. The complexion and tongue are 297
*
pale. The pulse is weak.
.
Analysis: Spirit Pivot said: "The pectoral qi keeps in chest to drive the pumping function of the heart and help the respiration. " The pectoral qi provides power for functions of both the heart and lung. The lung dominates qi and the heart is responsible for the blood and vessels. The qi controls blood and blood carries qi. All vessels meet in the lung. Thus, the heart and lung are closely related both physiologically and pathologically. When lung qi is weak, the pectoral qi is not fully produced, then pectoral qi is not able to drive blood circulation. While the deficiency of heart qi gives rise to blood stasis that can affect the functiop of the lung to distribute and descend. The syndrome is usually manifested by the abnormal breath and blood circulation. That the qi could not support the heart causes palpitation. The weak lung could not perform the function well, so patient feels shortness of breath. The qi could not be distributed by the lung and accumulates in chest, so the choke is felt. The rebellious results in cough and dyspnea. The loss of ability to consolidate the body surface of lung causes the spontaneous sweating. T h e disability of qi brings about the fatigue and weakness. The exertion consumes qi, so the symptoms deteriorate on physical exertion. The pale complexion and tongue are the reflection of inactive qi and blood. The weak pulse is the evidence for blood circulation without power. The key for diagnostic is the coexistence of palpitation, cough, dyspnea and symptoms of qi deficiency.
11. Deficiency of Both Heart and Spleen The syndrome is the combination of heart blood deficiency and spleen qi insufficiency. The over-pensiveness, improper diet, chronic bleeding, or prolonged diseases can all result in the syndrome.
Clinical Manif estationss : Palpitation, insomnia, excessive dreams, poor memory, dizziness, poor appetite, lassitude, weakness, abdominal distention and loose stool are the main symptoms of the syndrome. The subcutaneous hemorrhage, or scanty menses, or prolonged menstruation may be present. The complexion is sallow. The tongue is pale and tender. The pulse is thready.
Analysis: The heart dominates blood and stores the mind. The spleen produces and controls blood. The improper diet and chronic diseases lead to spleen qi deficiency. When spleen qi is deficient, the function of producing and controlling blood declines, thus the heart blood becomes deficient. The over-pensiveness wears out heart blood and qi. T h e deficiency of heart can
also implicates the spleen. So many causes can bring about the deficiency of both the heart and the spleen. The malnourished mind in the heart is shown in palpitation, insomnia, poor memory and excessive dreams. The blood could not fill up the brain, so dizziness occurs. The spleen dysfunction gives rise to poor appetite, loose stool and abdominal distention. T h e body is lack of nutrition, so patient feels lassitude and lack of strength. The qi and blood could not go to the upper, so the complexion and tongue are pale. The vessel is not filled up, therefore pulse becomes thready. If the spleen fails to confine blood within vessels, the blood flows into skin, then subcutaneous bleeding takes place. If blood goes out of body from Chong or Ren Meridian, bleeding from vagina occurs in female patient. If blood is not able to fill up Chong and Ren Meridians, the menses is scanty. The key for diagnosis is the coexistence of palpitation, insomnia, poor appetite and the bleeding.
I11. Blood Deficiency in Both Heart and Liver The syndrome is present when blood of both the heart and liver is deficient. Bleeding and over pensiveness may take blood away and cause the syndrome.
Clinicall Manifestations: The symptoms are the palpitation, poor memory, dizziness, insomnia, excessive dream, dry eyes, blurring vision, numbness in limbs, spasm, pale and lusterless complexion, lusterless nails and irritability. In woman case, amenorrhea or scanty menses may occur. The tongue is pale and pulse is thready.
Analysis: The mind is inadequately nourished by blood, so palpitation, poor memory, insomnia and excessive dreams take place. The malnourished tendons due to lack of blood in the liver is shown in numbness and spasm. The nails are the extending parts of tendons. They are also nourished inadequately and become lusterless. The lack of blood in brain brings about vertigo. The eyes without support of blood are dry and could not see things clearly. The malnourished tongue and face are pale. The liver loses its character of smooth moving and tender, therefore the patient is in bad temper. The blood fails to fill up vessels and Chong and Ren Meridians, the menstruation is lessened or ceased and the pulse becomes thready. The palpitation, poor memory, numbness, irritability and manifestations of blood deficiency are the key points for diagnosis.
IV. Yang Deficiency of Both Heart and Kidney The syndrome is present when the yang and qi of both the heart and kidney 299
are deficient. T h e constitutional yang deficiency patient is easy to develop into the syndrome. The fatigue and prolonged diseases can also cause the syndrome.
Clinical Manifestations : The palpitation, dyspnea, vertigo, dark complexion, bluish lips and nails, chill and cold limbs, scanty urine and edema especially in lower body are the main symptoms. The tongue is pale and corpulent or purple with white watery coating. The pulse is deep and faint.
Analysis: The heart is located in the upper body and is the fire-viscus. The kidney is the root of all the yang and qi. If the yang of the heart and kidney is coordinated with each other, it warms the viscera and whole body and propel the blood circulation. While the yang is deficient, the cold, blood stasis and water retention take place. The deficient yang is not able to transform the water in lower-jiao. The cold water will goes up and insults the heart. The insulted heart is shown in palpitation. If the lung is insulted, there are cough and dyspnea. The yang fails to warm body, so the body is cold. The yang could not push qi and blood to go up to the upper, therefore vertigo happens and the complexion and tongue lose their red color. T h e inactive blood is shown in bluish lips and nails. The water retention makes lessened urine. If the water flows into skin, edema is present. The deep and faint pulse reflects the severe yang deficiency. The key diagnosis point is the coexistence of palpitation, edema and symptoms of yang deficiency.
V.Disharmony Between Heart and Kidney The syndrome is present when the coordination between heart fire and kidney water is broken. The emotional stress, over pensiveness, indulgence in sex and yin insufficiency can all lead to this syndrom
Clinical Manifestations : Symptoms such as vexation, palpitation, insomnia, excessive dreams, vertigo, dry mouth, hectic cheek, tidal fever, night sweating, sore lumbus and knees and seminal emission are present. T h e tongue is red and p thready and rapid.
Analysis : The heart is in upper- jiao and the kidney in lower- jiao. The kidney yin must goes up into the heart to nourish the heart, so the heart fire can keep in normal. And the heart fire is required to go down to reach the kidney, so the kidney water will not be too cold. T h e exchange between the heart and kidney makes both the fire and water in balance. In diseases condition, the kidney yin is used up. The deficient yin makes heart yang relatively exorbitant. Many factors can also lead to excessive heart fire. The 300
fire goes down into the kidney and consumes the genuine yin. Or the fire will keep in the up and prevent the yang from going down to kidney. All those can bring about the disharmony between the heart and kidney. The deficient kidney water could not restrain heart fire. The fire will disturb the mind and give rise to vexation, palpitation, insomnia and excessive dreams. The kidney yin fails to nourish and fill up the bones, so the lumbus and knees are weak and sore. The head could not get enough supply, therefore vertigo takes place. The brain is hollow that leads to poor memory. The yin could not contain the yang. The floating yang makes the cheek red. The internal fire makes feeling of bone steamed. The fire compels body fluid out of body, so there is night sweating. There is no enough fluid in body, so mouth is dry. The fire disturbs the chamber of sperm and causes the emission. The tongue and pulse are the signs of yin deficiency. The key point for diagnosis is the coexistence of insomnia with symptoms of heart fire and kidney yin deficiency.
VI. Qi Def ieieney of Both Lung and Spleen It is the syndrome of qi deficiency in both the lung and the spleen. The prolonged cough or asthma, which leads to lung deficiency and finally involves the spleen, and improper diet, which impairs the spleen and implicates the lung, may bring about the syndrome.
Clinical Manifestations : Prolonged cough with excessive sputum, feeble voice, indolence of speaking, shortness of breath, weakness are present. They are deteriorated after exertion. Symptoms like poor appetite, abdominal distention and loose stool are also the main manifestations. Edema is seen in severe case. Thk complexion and tongue are pale. The pulse is thready.
Analysis : The spleen is the source of qi and the lung is the dominator of qi. The prolonged cough takes lung qi away. The lung then could not disperse and dominate qi properly, therefore the spleen qi is also encumbered and could not function well. If the improper diet impairs the spleen. The spleen could not produce qi, as a result the lung qi is implicated. Both of the above mentioned changes can result in the syndrome. When spleen and lung qi is deficient, the water and fluid metabolism is abnormal. The dampness and phlegm are formed in the body. The lung deficiency and spleen dysfunciton can both produce phlegm which is responsible for the chronic cough and excessive sputum. T h e feeble voice and shortness of breath are due to the qi deficiency of lung. The qi could not support the upper, so the complexion and tongue are pale. The dysfunction of the spleen 301
gives rise to the poor appetite. The inactivity of middle qi produces the abdominal distention. The downwards flowing dampness brings about loose stool. The lung is in charge of regulating water passage and the spleen is of transforming and transporting water. When their qi is deficient, the dampness and water retention take place, which overflow into skin and cause edema. The thready pulse is a sign of deficiency. The key diagnostic points are the cough, poor appetite, abdominal distention and loose stool plus the qi deficiency syndrome.
VII. Aggression on Lung by Liver Fire It is the syndrome that the lung is attacked by the rebellious fire in liver. T h e emotional stress which produces liver fire, or heat evil which invades the liver can both give rise to upwards flaming of fire in the liver. If the fire attacks lung, the syndrome occurs.
Clinical Manifestations : Burning pain occurs in hypochondriac region. Irritability, vexation, bitter taste in mouth, vertigo, red eyes are usually present. Cough with little thick sputum which is difficult to expectorate is the main symptom. Bloody sputum or hemoptysis is seen in severe case. The tongue is red with yellow coating. The pulse is taut and rapid.
Analysis: The lung qi is characterized by descending and the liver qi is by ascending. The coordination between them keeps the smooth flow of qi. If fire or heat in the liver makes the liver qi and fire moving upwards too much, the fire will attack the lung. The lung function is harmed and the syndrome forms. The liver is hyperactive and loses its harmony, so the patient is in bad temper. The Liver Meridian goes through hypochondriac region, so the rebellious qi and he fire goes up into head, therefore bitter taste, vertigo and red eyes are present. T h e
damages the collateral, the bleeding occurs. The tongue and pulse are both the indicators of liver fire. The key for diagnosis is the coexistence of hypochondriac burning pain, irritability and cough.
VIIT. Uin Deficiency of Both Lung and Kidney It is a syndrome of yin and body fluid deficiency in both the lung and kidney. The syndrome is caused by prolonged cough which impairs the lung and implicates the kidney, and over exertion or indulgence in sexual activity which makes the kid*
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ney exhaustion.
Clinical Manifestations: Cough with little sputum, bloody sputum or hemoptysis are usually the main symptoms. Other symptoms include dry mouth and throat, hoarseness, loss of weight, hectic cheeks, night sweating, tidal fever, sore lumbus and knees, seminal emission in male and irregular menstruation in female. The tongue is red with little coating. The pulse is thready and rapid.
Analysis: The lung is the upper source of water and the kidney is the root of all the yin and fluid in the body. The lung yin and kidney yin are supplemented to each other. That was called "inter-producing between the metal and the water" in ancient time. When the lung is impaired by prolonged cough, the lung could not send fluid down into the kidney. While the kidney declines, the kidney fails to provide the lung with yin and the lung is then implicated. Therefore the syndrome forms, The yin deficiency makes dysfunction of the lung, so dry cough is present. the deficiency fire damages the collateral, then bleeding is seen. There is not enough body fluid to moisten the upper, so the mouth and throat are dry. The throat is the gate of the lung and the place where the Kidney Meridian passes through. The lung and kidney yin deficiency makes sore throat and then the voice becomes harsh. The flesh is malnourished due to lack of yin, therefore the body becomes thin. The deficiency fire goes up and makes the cheeks red. While the fire dispels the fluid, there is night sweating. The fire in the interior gives rise to tidal fever. T h e lumbus is the house of the kidney. The hollow kidney is shown in ache of lumbus. If fire disturbs the chamber of sperm, the seminal emissions occurs. The lack of yin in the kidney makes the Chong and Ren Meridians abnormal, that gives rise to the irregular menstruation. The tongue and pulse are the signs of yin deficiency. The prolonged cough, ache of lumbus and seminal emission plus the yin deficiency syndrome are the key for diagnosis.
,
IX. Yalrag Deficiency of Both Spleen and Kidney The syndrome is shown when the yang is insufficiency in both the spleen and the kidney. The prolonged diseases of diarrhea or edema lead to deficiency involving spleen and kidney yang. Then the syndrome takes place.
Clinical Manifestations: The pale complexion, cold limbs, shortness of breath, indolence of speaking, lassitude, cold pain in lumbus or abdomen are the usual symptoms. In some cases the syndrome is characterized by incessant diarrhea with undigested food in the stool or dawn diarrhea. Others may present the edema with 303
dysuria, or even ascites. The tongue is pale and tender with white watery coating. T h e pulse is deep and weak.
Analysis: Kidney is congenital foundation while spleen is acquired foundation. They support each other in warming body and water metabolism.
If spleen yang declines and the spleen could not produce food essence to provide the kidney, the kidney yang will decline following spleen yang. While kidney yang .is deficient, the fire (vital yang) fails to support and warm the earth, the spleen yang will be implicated. In fact, either spleen yang deficiency or kidney yang deficiency can develop into the yang deficiency syndrome of both the spleen and the kidney if they last long time. T h e qi and blood is insufficient due to the lessened production from spleen, so the face is pale. The yang fails to warm the body, then the limbs are cold. The inactive qi causes shortness of breath, indolence of speaking and lassitude. The yang could not drive the qi and blood flow, therefore the lumbago or abdominal pain occur. The food could not be digested and absorbed without the spleen and kidney yang, so diarrhea happens. The water stays in the body because it could not be transformed or transported, so the edema takes place. In severe case, the water stays not only underneath skin, but also in abdomen, that is the ascites. T h e water can not be transformed into urine, so there is scanty urine. The tongue and pulse reflect the yang deficiency and water retention. The key diagnostic point is the coexistence of incessant diarrhea, edema, cold pain in lumbus or abdomen with deficiency cold syndrome.
X.Disharmony Between Liver and Spleen It is a syndrome that liver dysfunction leads to spleen dysfunction. The sy drome can result from the depression which harms the liver, and furthermore, the spleen; or from the improper diet and over-exertion which impair the spleen, the disorder implicates the liver further.
Clinical Manifestations: Hypochondriac distending pain, depression or irritability, poor appetite, abdominal stuffiness, loose stool, bowel rumbling and lots of gas are the usual symptoms. The patient may be urgent to move bowel on attack of abdominal pain, and after diarrhea the pain can relieve. The coating is greasy in white. The pulse is taut.
Analysis: The spleen dominates the food transportation and transformation. Its ascending functions is subject to liver function. The liver is in charge of regulating qi and can help the spleen and stomach in the qi movement. Emotional stress, espea
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cially depression and anger impair liver function. The spleen dysfunction occurs after liver disorder. While improper diet and over-exertion impair the spleen, the spleen qi stagnation may implicate the liver qi. From the two aspects, the disharmony between the liver and spleen is caused. The liver qi stagnation causes hypochondriac pain. The liver could not regulate the emotions, the patient may be depressed or irritable. T h e dysfunction of the spleen gives rise to poor appetite and abdominal distension. T h e dampness takes place due to spleen dysfunction and results in the loose stool, bowel rumbling and gas. After defecation, the qi gets released, so the pain is relieved. The greasy coating indicates the dampness. The pulse is due to liver disorder. T h e key for diagnosis is the coexistence of distending hypochondriac pain, poor appetite, abdominal distension and loose stool.
XI. Disharmony Between Liver and Stomach It is a syndrome that the liver dysfunction leads to disorder of the stomach function to descend and ascend. The sy8ndromeis caused by emotional stress which produces liver fire or by cold evil which invades the stomach.
Clinical Manifestations: The syndrome may be shown in distending pain in hypochondrium, belching, hiccup, stomach discomfort, acid regurgitation, vomiting, irritability or depression, yellow thin coating and taut pulse; or shown in vomiting of mucus, headache aggravated by cold, cold limbs, pale tongue with white watery coating, deep, taut or tense pulse.
Analysis: The liver is in charge of conducting and dispersing of qi. The stomach governs the receiving and descending food. The normal liver qi helps the stomach in descending. If depression makes liver qi stagnant, the liver qi may attack the stomach transversally, then thestomach function is disturbed. The Liver Meridian goes through the hypochondrium. If liver qi is stagnant in meridian, the distending pain will happen in the hypochondrium. The dysfunction of stomach brings about belching, hiccup, even vomiting. The stagnant qi produces fire. T h e fire disturbs the stomach, so acid regurgitation, stomach discomfort and yellow coating occurs. The liver could not relax the emotional stress, so depression or irritability is seen. The key diagnostic point is the coexistence of distending hypochondriac pain and the symptoms of stomach dysfunction.
If the syndrome is caused by cold evil, the cold may go along Liver Meridian to head. The cold obstructs the flowing of qi, so headache takes place. Because the pain is due to cold, so it is improved by warming and aggravated by cold. The cold 305
obstructs the movement of yang, the body is not warmed, so the limbs is cold. T h e tongue and pulse are the evidences of cold in the body. The key diagnostic point is the coexistence of headache, vomiting and symptoms of cold.,
XIB. Liver and Kidney Uin Deficiency The syndrome is composed of liver yin deficiency and kidney yin deficiency. The syndrome may be caused by declining kidney function in the aged, prolonged diseises, extremely emotional stress and indulging in sexual activity.
Clinical Manifestations: Vertigo, tinnitus, poor memory, insomnia, dry throat, hectic cheek, night sweating, vexation, hot sensation in the five centers, pain in costal region, lumbago and ache of knees, seminal emission in male or scanty menses in female are the symptoms. The tongue is red with little coating. The pulse is thready and rapid.
Analysis: l i v e r qi and kidney qi share the same source. The liver stores blood and the kidney stores essence. The yin of the liver and the kidney promotes each other. The surplus of liver yin is stored in the kidney. The abundant kidney yin supplies liver yin. That is called liver and kidney being from the same source. In "
"
disease condition, the shortage of liver yin can implicates kidney yin, and vice versa. The yin could not fill up the head, so vertigo and tinnitus are present. The brain is hollow, then the memory is poor. The mind is also malnourished, therefore insomnia takes place. The yin does not moisten the throat, so the throat is dry. The deficiency fire makes the cheek red and five centers hot. That the fire dispels fluid causes night sweating. The Liver Meridian could not get moistened, thereby, the pain occurs in hypochondriurn. T h e lurnbu; is not filled up due to kidney yin d ciency, so lumbus is weak and ache. When the fire disturbs the chamber of sperm, seminal emission happens. In women, the scanty menses is due to the hollow Chong
and Ren Meridians. T h e tongue and pulse are both due to yin deficiency. T h e key diagnostic point is the coexistence of hypochondriac pain, lumbago, seminal emissian and the yin deficiency syndrome.
Section 7
The Modern Research on Visceral Syndrome Differentiation
The researchers in Shanghai Medical University discovered that six diseases among which there were no inner relation could be effectively treated by TCM there
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apy of tonifying the kidney in late 50s. After that, they began to search the essen~ i a l sof the "kidney" in TCM. In experimental studies, they found that the 17-hydroxysteroid content in patients9 urine of kidney yang deficiency was lower than that of normal. Then, the circadian rhythms of serum cortisol level, metapyrone SU-4885 tests and ACTH test were done. Those tests could reflect the function of hypothalamus-pituitary-adrenal axis. The results proved that functional disorders of varying degrees existed in each links of the axis. T h e nationwide study on essentials of "spleen"has being done. T h e study was focused on spleen deficiency syndrome. The studies revealed that the "spleen" in TCM was not equal to that in modern medicine; it was the concept of not only in anatomy, but also in physiology and pathology; the "spleen"involved many systems of the body. For example, the spleen deficiency syndrome was seen in many diseases which might be characterized by the hypoactivity of digestive enzymes, hypofunction of digestive system, malabsorption of small intestine, disorders in gastrointestinal tract, dysfunction of vegetative nervous system, disorders of endocrine system, metabolic disturbance and/or defect in cellar immunity, etc. In addition, some pathological changes in morphology have been found. About the heart, the researches have being done from syndromes of heart qi deficiency, heart yin deficiency, blood stasis in the heart and disharmony between heart and kidney. Heart failure to varying degrees had been found in the patients suffering from heart qi deficiency. Besides, sympathetic hyperfunction, lessened '
serum 6-Keto-PGF12 and increased serum TXB2 might be present. In patients of heart yin deficiency, the increased serum tyrosine, 17-hydroxysteroid in urine and serum dopamine P-hydroxylase could be found. The increased serum thromboxane ii
AZ, Pplasma globulin and platelet factor IV were detected in patients of blood stasis in heart syndrome. The heart yin deficiency was characterized by increased catecholamine in urine, plasma cAMP and urine hydroxyproline. The urine 17-hydroxysteroid and catecholamine were decreased in syndrome of disharmony betweer. heart and kidney. As regards of researches on the lung, the syndrome of lung qi deficiency was studied. The syndrome was related to morbid changes of lung function, immunity. blood reology, vegetative nervous system, cAMP and cGMP, a n d , the energy metabolism, including hypofunction of immunity, decreased serum cAMP and rAT, parasympathetic hyperfunction, dysfunction of pulmonary ventilation, increased airway resistance, pulmonary emphysema, decrease of elasticity of pule
307
monary vessel, disturbance of pulmonary circulation. The researches on the liver were focused on the liver qi stagnation, disharmony between liver and spleen and the hyperactivity of liver yang. The results revealed that the syndromes of the liver were associated closely with the disturbance of nervous system, especially the vegetative nervous system. In syndrome of liver qi stagnation, the main change was the parasympathetic hyperactivity. T h e s ympathetic and adrenomedullary hyperfunction were related to the hyperactivity of liver yang. In syndrome of disharmony between liver and spleen, the serum CAMP was lessened and the cGMP was increased. The ratio of CAMP to cGMP was lowered which was enhanced in hyperactivity of liver yang and kidney yin deficiency. The blood reological change similar to that of blood stasis was shown in microciculation of nail fold when patient was suffering from liver yang hyperactivity or disharmony between liver and spleen. The contents of plasma angiotensin I1 and TXB2 were higher than normal in patients of liver yang hyperactivity. In addition, the HLAB15 was related to the disharmony between liver and stomach; serum copper in blood was decreased in syndrome of liver qi stagnation and liver yang hyperactivity.
Chapter 10
Meridian Syndrome Differentiation
It is said in chapter thirty-three in Spirit Pivot that "Internally, the twelve meridians are connected with the zang-fu viscera; externally, with the extremities and joints. " It is also said in chapter twenty-two in
Medical Problems
that "The
function of the meridians is to make qi and blood flow, help the balance between yin and yang and bring nutrients to whole body. " It means that the meridian has functions of connecting the organs and whole body and moving qi and blood. External disorders affect the viscera through the meridians, similarly, visceral diseases have local symptoms along the course of the meridian. Therefore, from the location of symptoms and their corresponding meridians, a foundation for diseases differentiation is provided. Meridian syndrome differentiation is based on the theory of meridians and summarizes the symptoms and interaction of disease of the viscera and meridians and their general regulation. It is different form syndrome differentiation based on the theory of zang-fu viscera although they are closely related. It gives detailed description about the symptoms expressing in the region along the meridians, such as local sensation changes as pain, fever and dysfunction like swelling, contraction and limitation of movement. The symptoms of the meridians include ones not only of local region along the meridians and their related organs but also general and psychologic symptoms. Therefore, meridian syndrome differentiation based on the theory of the meridians is different from syndrome differentiation based on the zang-fu theory about the descriptions of either local or systemic disorders, but they are complemented to each other. Meridian syndrome differentiation is very important for clinical diagnosis, especially for acupuncture, message and Qigong. T h e origin of meridian syndrome differentiation can be traced up to the early ages. There were a lot of descriptions of meridian diseases which included diseases of the twelve regular meridians, fifteen main collateral, muscles along twelve regular meridians and eight extra meridians in Spirit Pivot. These descriptions are still the theoretical basis for meridian syndrome differentiation until now. Meridian syndrome differentiation has been perfected gradually along with the development of TCM. In clinic, meridian syndrome differentiation of regular meridians and eight extra meridians are more useful than those of the fifteen main collateral and muse
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cles along twelve regular meridians because the fifteen main collateral are similar to the twelve regular meridians and the muscles along twelve regular meridians. Syndromes only include dyskinesia and associated pain.
Section 1 Syndromes of Twelve Regular Meridians The twelve regular meridians connect the.five zang-viscera and six fu-viscera internally. It is possible to know deficiency syndrome or excess syndrome of zang and fu viscera and their heat and cold natures by meridian syndrome differentiation. The relationship between the twelve regular meridians and their associated zang-fu-viscera are summarized in the chart as follows: Twelve regular meridians-and their associated zang-fu viscera Five elements :
Yin
Yang
metal
lung
Hand-Taiyin
large intestine
Hand-Yangming
earth
spleen
Foot-Taiyin
stomach
Foot-Yangming
fire
heart
Hand-Shaoyin
small intestine
Hand-Taiyang
water
kidney
Foot-Shaoyin
urinary bladder
Foot-Taiyang
(fire)
pericardium
Hand- Jueyin
triple-jiao
Hand-Shaoyang
wood
liver
Foot- Jueyin
gallbladder
Foot-Shaoyang
By meridian syndrome differentiation, the symptoms can be analyzed on the basis of the course of the meridians and the specific properties of their related viscera. For example, abdominal distention belongs to spleen disorders, since spleen meridian passes through abdomen; silly laughing pertains to heart disorders since heart is related with joy. In addition, disease is also related with that how much qi and blood there is in the twelve meridians. There is more qi and blood in the meridians of stomach and large intestine. There is more qi than blood in the meridians of gaiibiadder, kidney, heart, spleen, lung, and triple-jiao. There is more blood than qi in the meridians of urinary bladder, small intestine, liver and pericardium. For example, stomach meridian is rich of both qi and blood, therefore, its disease may have epistaxis; since triple-jiao meridian has more qi than blood, its disease shows sweating and the like. Meridian syndrome differentiation includes : *
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(1) Differentiation of deficiency and excess, cold and heat: The meridian of stomach is discussed in chapter ten in Spirit Pivot that: "Hyperactivity of qi leads to heat in the anterior part of body, if in stomach, there would be polyorexia and dark urine. Deficiency of qi leads to, cold in the anterior part of body, if in stomach, there would be distention. " I t is same as the meridians of lung, large intestine and kidney.
(2) Differentiation of diseases between Shidong (functional disease) and Suosheng (generated disease) : the diseases of the twelve regular meridians were divided into two kinds in chapter ten in Spirit Pivot. They were called as Shidong and Suosheng. After that time there had been different comprehension in successive dynasties. For examples, Yang Xuancao thought that Shidong was the diseases of qi and Suosheng was the ones of blood: Zhang Zhicong thought that the diseases caused by exopathic factors were belong to Shidong and the ones caused by endopathic factors were belong to Suosheng; Xu Lingtai thought that Shidong was the diseases of one meridian by itself and Suosheng was the ones by other meridians. All of these are not exactly. It is considered that Shidong and Suosheng are two kinds of the symptoms interrelated each other in the same system.
(3) Differentiation of Jue (perversion) and Jueni (perversion rebellion) of the meridian qi: it was discussed about the differentiation of Jue and Jueni of the meridians in chapter forty-five in Plain Questions. Jue syndrome (perversion) is a light deviation. It is divided into two types of cold and heat. The cold Jue syndrome is caused by deficiency of yang qi in the lower; the heat Jue syndrome is caused by deficiency of yin qi in the lower. There are different symptoms among six Jue syndromes. The symptoms of Taiyang Jue syndrome include swollen head with heaviness sensation, difficulty of movement and falling due to faint. The symptoms of Yangming Jue syndrome include depressive psychosis and madness, insomnia with restlessness due to abdominal fullness, hot flush of face and delirium. The symptoms of Shaoyang Jue syndrome include sudden deafness, swollen and hot cheek, hypochondriac pain and walking hardly. The symptoms of Taiyin Jue syndrome include abdominal fullness, distention of the epigastrium, constipation, loss of appetite, vomiting right after eating and inability to lie flat. The symptoms of the Shaoyin Jue syndrome include thirsty, dark urine, abdominal fullness and precordial pain. The symptoms of Jueyin Jue syndrome include pain and distention of the lower abdomen, dysuria, drowsiness, flaccid constriction of penis and hot sensation in the interior aspect of fibula. The Jueni syndrome (perversive rebellion) is a seri311
ous situation and caused by the evil qi reversing in the meridians to break the flow of yang qi. Either all three yin meridians or just the Heart Meridian of HandShaoyin has the Jueni syndrome to lead to death. The symptoms of Taiyin Jueni syndrome include spasm of leg and precordial pain radiating to abdomen. The symptoms of Shaoyin Jqeni syndrome include fullness due to deficiency, vomiting and diarrhea with undigested food in the stool. The symptoms of Jueyin Jueni syndrome include lumbago, fullness due to deficiency, difficulty in urination and delirium. The symptoms of Taiyang Jueni syndrome include sudden syncope, hematemesis and epistaxis. The symptoms of Shaoyang Jueni syndrome include dysfunction of flexion and extension of the waist and neck, acute appendicitis. The symptoms of Yangming Jueni syndrome include asthma, cough, fever, susceptible to fright, epistaxis and hematemesis.
(4) Differentiation of meridian-qi exhaustion : meridian-qi exhaustion means zang-fu visceral qi is finished while qi and blood stop flowing and leads to dissociation of yin and yang and then death. Exactly, differentiation of meridian-qi exhaustion is to diagnose a dying case. It is described fully in chapter sixteen in Plain Questions. Taiyang
qi exhaustion shows hyperphoria
with
fixed
eyeballs,
opisthotonos, chronic convulsion, sallow face and sweating of the dying. Shaoyang qi exhaustion shows deafness, flaccid paralysis, staring eyes and cyanotic pale. Yangming qi exhaustion is a case of twitching of eyelid and mouth, susceptible to fright, delirium, yellow complexion, rashness along Hand and Foot Yangming Meridians and numbness. Shaoyin qi exhaustion is a case of dark face, long and dirty tooth, abdominal distention and difficulty in urination and defecation. Taiyin haustion shows abdominal fullness
. dyspnea, vomiting and belching, flush
face caused by reversed flow of qi due to vomiting; In coordination between the upper and lower results in dark face and scorched skin and hair. Jueyin qi exhaustion is manifested by hot sensation in chest, dryness in pharynx, frequent urination, ve ation, shrinkage of tongues and testis. Referred to the descriptions in the chapter twenty-four in Medical Problems, they all mentioned symptoms of eyelids and dizziness in exhaustion of three yin meridians of hand and foot (There are also these symptoms of the eye in qi exhaustion of three yang meridians.
)
. In addition, There is greasy sweating in dying pa-
tient which means dissociation of yin and yang. So the symptoms of the eyes and sweating of the dying patient are used to diagnose the meridian qi exhaustion. In addition, pain, tenderness, sensitive spot, temperature or color changes, re*
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action of the skin appearing along meridians can help us to diagnose the diseases. For example, tenderness appears on the Feishu Point (UB 13) for the lung diseases , in
the region near Shangjuxu Point (ST 37) for acute appendicitis and on the Yan-
glingquan Point (GB 34) for cholecystitis.
I. Syndrome of Lung Meridian of Hand-Taiyin Symptoms: Chest distress, cough, asthma, pain in supraclavicular fossa, pain in the shoulder and back, aching along the anterior border of the medial side of upper extremities, thirst, vexation, aversion to cold and fever, sweating and frequent urination. Excess syndrome is manifested by stuffy chest, asthma and sweating; deficiency syndrome is manifested by lack of strength in breathing and dry sensation in the pharynx.
Analysis: Evil attack on the lung impairs the lung function in dispersing and descending. It leads to the hypofunction of the chest-yang and produces chest distress, cough and asthma. Failure in resistance results in chill, fever and sweating. Thirst is due to deficiency of the lung yin. Vexation results from that mind is interfered by heat. Frequent urination is caused by failure in controlling body fluid due to deficiency of the lung qi. Pathogenic factor staying in the meridian results in pain along Lung Meridian. Obstruction of the lung qi is marked by stuffy chest and asthma. Deficiency of the lung qi shows signs as lack of strength in breathing and dry sensation in the pharynx, because qi is unable to move the fluid.
XI. Syndrome of Large Intestine Meridian of Hand-Yangming Symptoms : Toothache, sore throat, thirst, epistaxis, swollen neck, yellow eye, cold and fever, pain in the anterior border of the shoulder and index finger. Excess syndrome is manifested by abdominal distention, flushed face and fever; deficiency syndrome is manifested by borborymus and diarrhea.
Analysis: Large Intestine Meridian of Hand-Yangming starts from the tip of the index finger, goes upward along the forearm, upper arm and shoulder. The branch from the supraclavicular fossa goes upward to the neck, passes through the cheek, enters the gum of the lower teeth, curves around the upper lip and crosses the opposite meridian at the philirum. From there, the left meridian goes to the right and right meridian to the left, to both sidesof the nose. In case of the Large Intestine Meridian disorders, the pathogenic factors staying in the meridian turns to the heat which will impair the body fluids. That will cause the symptoms along Large Intestine Meridian such as toothache, itching of the throat, dry mouth, epis313
o
taxis, yellow eye, swollen neck, aching along the shoulder, upper arm and index finger. Hyperactivity of the fire leads to abdominal distention, flushed face and fever. Deficiency of the fu-visceral qi causes deficiency cold manifested by borborymus and diarrhea.
BII.Syndrome of Stomach Meridian of Foot-Yangming Symptoms: Chill and fever, sweating, epistaxis, lip rash, facial paralysis, swollen neck, sore throat, pain and swollen knee and aching along Stomach Meridian like chest, breast, groin, thigh, musculus rectus fernoris, lateral border of tibia and instep. Excess syndrome is manifested by fever, sweating, polyorexia, mania and dark urine; deficiency syndrome is manifested by shivering and abdominal distention.
Analysis: Affection of Yangming leads to shivering and fever due to yin evil affecting yang-qi, and sweating due to heat of the stomach expelling and consuming body fluids. Foot-Yangming meridian starts from the lateral of nares. Passing through the nose, it enters the upper gum. Then it curves around the lips and descends along the neck. Its branch descends along the throat. The straight portion of the meridian goes downward through the supraclavicular fossa, passing through the nipple and Qichong Point (ST 30 ) , to Futu Point (ST 32 ) , reaches the dorsum of the foot along the anterior border of the lateral aspect of the tibia. So the disorders of the Foot-Yangming Meridian show as epistaxis, lip rash, facial paralysis, swollen neck, sore throat, aching in the region of the knee, Futu, the lateral of the tibia and instep. Excess syndrome of the Foot-Yangming leads to hyperactivity of endogenous heat, which results in high fever, sweating, mania, polyorexia and dark urine. Deficiency syndrome of the stomach-qi is manifested by shivering and abdominal distention.
IIV. Syndrome of Spleen Meridfan-of Fo
Symptoms: Rigidity of the tongue, anorexia, vomiting after eating, epigastric pain, abdominal distention, belching, diarrhea, jaundice, difficulty in movement, swelling in the medial of knee and thigh and impaired motion of the big toe. Excess syndrome is manifested by abdominal distention and sleepless due to dysphoria; deficiency syndrome is manifested by diarrhea, vomiting and borborymus.
Analysis: The Spleen Meridian of Foot-Taiyin starts from the tip of the big toe. It ascends along the anterior medial aspect of the knee and thigh up to the root of the tongue and spreads over its lower surface. Affection of Spleen Meridian leads 314
j to stiff tongue, swelling in the medial of the knee and thigh. Dysfunction of the spleen in transportation and transformation results in stagnation of qi in the interior and shows as anorexia, vomiting right after eating, abdominal distention. Failure of transportation of damp caused by deficiency of the spleen qi leads to diarrhea in cold syndrome and jaundice in the heat syndrome. Affection of the spleen results in difficulty of movement. Because the spleen dominates extremities and disorder of the stomach qi leads to sleepless.
V.Syndrome of Heart Meridian of Hand-Shaoyin Symptoms: Yellow eye, dry throat, drinking due to thirst, vexation, precordial pain, hypochondriac pain, pain along the posterior medial side of the upper extremities. Excess syndrome is manifested by fever; deficiency syndrome is manifested by absent-minded and melancholia.
Analysis: Monarch fire is the same as heart fire storing in the Hand-Shaoyin Meridian. Excess qi of the Shaoyin brings about heat syndrome and consumes the body fluids, which is manifested by dry throat, drinking due to thirst and fever. Vexation and precordial pain are caused by fire and heat disturbing the heart. Excessive heart fire leads to yellow eye because the heart connects with the eye upward. Pain is in the medial side of the upper extremities and hypochondrium where are the course of the Hand-Shaoyin Meridian. Deficiency of the heart qi causes grief which is showed by absent-minded and melancholia.
VI. Syndrome of Small Intestine Meridian of Hand-Taiyaaag Symptoms: Yellow eye, deafness, sore throat, swollen mandible causing stiff neck, pain of shoulder, upper arm, neck, and the posterior border of the lateral side of the upper arm. Excess syndrome is manifested by fever, vexation and aphtha; deficiency syndrome is manifested by aversion to cold and migraine.
Analysis: Small Intestine Meridian of Hand-Taiyang starts from the little finger, ascends along the posterior border of the lateral aspect of the upper arm to the shoulder. Via the neck and outer canthus, then it enters the ear. Evil attack of the Hand-Taiyang meridian is manifested by yellow eye, deafness, sore throat and pain of the upper arm. Fever is due to excessive heat caused by superfluous qi. More excessive heat disturbs the mind showed as vexation. Aphtha is due to flaring-up of the heart fire. Deficiency of the qi leads to aversion to cold and migraine.
VII. Syndrome of Urinary Bladder Meridian of Foot-Taiyalrag Symptoms: Fever, aversion to wind and cold, stiff neck or headache, tearing, yellow eye, malaria, hemorrhoids, mania, epilepsy, pain in the spine, lumbago, pain or impairment of motion along the meridian. .
Analysis: Chapter forty seven in Spirit Pivot said: "Urinary bladder corre-
sponds to skin and the interspace. " It means that the Urinary Bladder Meridian of Foot-Taiyang is responsible for the exterior of the body. When Foot-Taiyang Meridian is attacked by wind and cold, it is manifested by fever, aversion to wind and cold, headache with stiff neck. Yellow eye is due to excessive heat. Tearing is due to fighting between wind evil and vital-qi, and aching in the region of neck, spine, waist and thigh is due to blockage of the Taiyang Meridian. Since yang qi has the function of nourishing the tendons, its disorder leads to malnourishment of the tendons. It is said in the classic that hemorrhoids is caused by diarrhea due to the disorders of the tendons belonging to the Taiyang Meridian of Urinary Bladder. The evils affects internally to leads to malaria, epilepsy and mania.
WIIH. Syndrome of Kidney Meridian of Foot-Shaoyin Symptoms: Dark complexion, blurred vision, dry tongue, dry and swollen pharynx, orthopnea, vexation, fear, precordial pain, sleepiness, jaundice, dysentery, aching along the posterior medial side of the lower extremities and flaccidity with cold limbs. Excess syndrome is manifested by dragging pain between lower abdomen and low back, fever, dark urine and warm sole of the foot; deficiency syndrome is manifested by fear and palpitation. Analysis : The Kidney Meridian of Foot-Shaoyin starts from 'the interior side of the small toe and runs obliquely towards the sole. Then it ascends along the medial side of the leg and goes further upward along the poster-medial side of the thigh terminates at the root of the tongue. The branch springs from the lung, connects the heart and runs into the chest. Darkish complexion is due to failure of qi in ascending of the Shaoyin Meridian. Blurred vision is due to vital essence failing to ascend because the pupil is formed by vital essence of the bone. The kidney is responsible for storing the vital essence so that impaired kidney results in upward malnourishment , therefore, deficiency of the kidney yin leads to hyperactivity of the heart fire and a disturbance of the balance between water and fire, manifested by dryness tongue, dry, painful and swollen pharynx, fear, vexation, precordial pain
and jaundice. Dyspnea is due to abnormal ascending of the lung qi resulted from that qi of Shaoyin Meridian fails to coordinate with the lung qi. Orthopnea is due to qi of Shaoyin Meridian being failure in the lower while excessive in the upper. Deficiency of Shaoyin qi in the lower shows as flaccidity with cold limbs and dysentery. Aching in the posterior medial side of the thigh and spine is due to blockage of qi of Shaoyin .Meridian.
EX. S y n d r o m e of Pericardium Meridian of Maad-Jueyin S y m p t o m s : Flushed face, ell ow eye, silly laughing, palpitation with empty sensation, heat of the heart, vexation, pericardial pain, spasms of the upper extremities, swelling in the axilla, fullness in the chest and hypochondriac region.
Analysis: The pericardium stores ministerial fire. Its disorder has the symptoms such as fever, flushed face, yellow eye and palpitation with empty sensation. Silly laughing is due to heart diseases because the heart is related with joy. The Pericardium Meridian of Hand-Jueyin starts from the chest, emerges from the hypochondrium along the chest and down to the axilla. Then it runs down to the palm following the medial side of the upper limbs. Disorder of the Pericardium Meridian leads to spasms of the upper extremities, swollen axilla and fullness in the chest and hypochondrium.
X . S y n d r o m e o f Triple-Jiao Meridian o f Hand-Shaoyang S y m p t o m s : Deafness, pain in the outer canthus, swelling in the cheek, swollen and sore pharynx, sweating, pain in retroauricular region, shoulder and forearm and impaired movement of ring finger.
Analysis: The Triple-Jiao Meridian of Hand-Shaoyang starts from the tip of the ring finger, running upward between the 4th and 5th metacarpal bones along the dorsal side of the wrist to the lateral side of the forearm. Passing through the olecranon and along the lateral aspect of the upper arm, it reaches the shoulder. The branch arises from the retroauricular region and enters the ear. Then it emerges in front of the ear, crosses the previous branch at the cheek and reaches the outer canthus. The ministerial fire stored in the triple-jiao is so excessive in the upper that it leads to deafness and swollen and sore pharynx. The Shaoyang is a first yang which is the beginning of the yang, therefore sweating is in case of yang affecting yin. Disorders of this meridian also shows as pain in the outer canthus, swelling in the cheek and aching in the retroauricular region, shoulder, forearm and ring finger where are areas along Triple-Jiao Meridian. 317
XI.Syndrome of Gallklbladder Meridian of Foot-Shaoyang Symptoms: Alternate spells of fever and chills, sweating, bitter taste in the mouth, dusty complexion, dry skin, sighing, pain in head, lower jaw and outer canthus, pain and swelling in the supraclavicular fossa, failure of turning round due to pain in the hypochondriac region, sabre and beadstring scrofula, pain or impaired movement in the thigh, knee, the lateral side of the tibia and the fourth toe. Excess syndrome is manifested by abdominal distention, loss of appetite, dry pharynx, heaviness and ache of the head, aversion to cold and hypochondriac pain; deficiency syndrome is manifested by dizziness and syncope with flaccidity and when standing UP*
At~alysis:The Gallbladder Meridian of Foot-Shaoyang originates from the outer canthus, ascends to the corner of the forehead, then curves downward to the retroauricular region and runs along the side of the neck down into the supraclavicular fossa. From there it further descends into the chest. Then it continues to descend along the hypochondrium and lateral aspect of the thigh to the lateral side of the knee. Going further downward along the anterior aspect of the fibula all the way to its lower end Xuanzhong Point ( GB 39
),
it reaches the anterior aspect of
the external malleolus. Fever and sweating is due to the fighting between yin and yang. Hypofunction of the qi ascending of the Shaoyang results in bitter taste in the mouth, sighing. Failure of turning round is due to pain in the heart and hypochondrium. The Shaoyang is the beginning of yang so that ascending of the gallbladderqi impels other eleven viscera qi to ascend. As it is said in Treatise on Cold Attack that the growth of yang qi makes person have a bright color and face. In pathological condition, the Shaoyang Meridian qi is unable to ascend which shows as dusty complexion and dry skin. Sabre and beadstring scrofula is seen in case of stagnation. The arthralgia is due to the Shaoyang connecting with the kidney which domilower jaw, outer canthus, supraclavicular fossa, hypochondrium, thigh, knee, tibia and lateral malleolus where are all the areas along Shaoyang Meridian. Excess syndrome leads to qi accumulation manifested by abdominal distentien and loss of appetite etc. Deficiency syndrome leads to qi insufficiency manifested by dizziness and faint when standing.
XIP. Syndrome of Liver Meridian of Foot-Jueyina Symptoms: Lumbago, hernia in male, swelling in the lower abdomen in female,
dry pharynx, chest distress, vomiting, diarrhea, enuresis, retention of urine. Excess syndrome is manifested by epigastric distention and rigidity, hypochondriac pain, retention of urine and tending to be angry; deficiency is manifested by abdominal distention, diarrhea, melancholia, irregular menstruation and lumbago in female.
Analysis: Qi of the Jueyin Meridian comes from Shaoyang Meridian, so that their diseases have same symptoms, just like dusty complexion and less sheen in the face, dry pharynx and lumbago. Affection of Jueyin Meridian shows hernia in male and swelling in the lower abdomen in female. Because food digested by the stomach transforms into the essence which is transported to the liver and moves in the meridian. Dysfunctions of essence transportation due to the disorder of the liver shows i melancholia, irleads chest distress and vomiting. Deficiency of the l i ~ e r - ~ regular menstruation, diarrhea, enuresis and hernia. Excess syndrome is a case of retention of urine, hypochondriac pain, epigastric fullness and rigidity and easy to be angry.
Section 2
Syndromes of Eight Extra Meridians
The exuberant qi and blood of the twelve regular meridians are stored in the eight extra meridians and supply back to the twelve meridians, for nourishing the zang-fu viscera internally and connecting tissue externally. The eight extra meridians are different from the twelve regular meridians but exteriorly-interiorly related. They intersperse among the twelve regular meridians in order to strengthen the association among the meridians. The eight extra meridians gather in the lower-jiao which is related to the liver and kidney. For example, the Chong, Ren and Du Meridians all start in the lower abdomen and connect with the Kidney Meridian of Foot-Shaoyin; the Dai Meridian links the Chong, Ren, and Du Meridians and bind up all the meridians in the lower abdomen; the Yangqiao and Yangwei merge into Urinary Bladder Meridian of Foot-Taiyang which communicates with the kidney and the Yinqiao and Yinwei meridians merge into Kidney Meridian of FootShaoyin. As all of the eight extra meridians have relation to the kidney so they are thought to belong to the liver and kidney. In addition, as intersecting with the Stomach Meridian at the groin, the Chong Meridian is considered to belong to the Meridian of Y angming.
I. Syndrome of Du (6overnor) Meridian Symptoms :
Excess Syndrome: Stiffness and pain in the spinal column, opisthotonos, hernia which manifested by pain and difficulty in urination and defecation caused by rebellious qi from the lower abdomen to the chest, brain-wind due to wind accepting to Du Meridian, cold and pain in the low back and knee due to wind accepting the spine, or adult depressive psychosis, acute infantile convulsion, retention of urine and hemorrhoid.
Deficiency Syndrome: Dizziness, heaviness in the head, tremor, hunch back and flaccidity due to deficiency of the marrow. Weak mind, yawn, amnesia or feeblemindedness due to deficiency of mental activity. Impotence and spermatorrhea, infertility, enuresis, diarrhea due to insufficiency of the kidney yang.
Analysis: Primordial qi and body energy both originate from the region below the umbilicus. Du Meridian belongs to yang which starts from the uterus, running beside the Foot- Shaoyin Meridian and along the interior of the spinal column up to the vertex. Du Meridian is the sea of the yang meridians and governs all the yang meridians including the kidney yang, regulating the qi and blood of all the yang meridians. As above, its excess syndrome is caused by stagnated qi in the meridian and manifested by pain and stiffness of the lumbar and spine and failure of the motion. Its deficiency syndrome is due to decline of the yang, qi, essence and blood, manifested by symptoms of deficiency, cold and weak, such as enuresis, diarrhea, impotence, spermatorrhea, infertility. Du Meridian runs along the spinal column storing the medulla spinalis and up to the brain which is the sea of the medulla spinalis and the house of the mind. If the brain is normal, the body will be in the good condition and full of the vitality. In deficiency of the Du Meridian, the spine is unable to be nourished, resulting in the deficiency of the medulla spinalis and mind, manifested by heaviness in the head, dizziness, tremor, flaccidity, weak mind, amnesia and hypo-intelligence.
11.Syndrome of Ren (Conception) Meridian
Symptoms : Excess syndrome: Sharp pain in the navel, lower abdomen, pubic bone and pudendum, hernia in male and abdominal mass in female.
Deficiency syndrome: Woman's infertility of yin deficiency, habitual abortion, irregular menstruation, metrorrhagia and metrostaxis, vaginal bleeding during pregnancy. In male: impotence, infertility due to feeble sperm, less hair and beard: flaccidity due to lack of nourishment of tendons.
Analysis: T h e Ren Meridian starts from the inside of the lower abdomen and 320
a
through the perineum, goes anteriorly to the pubic region and ascends along the interior of the abdomen, passing through Guanyuan ( CV 4) up to Chengjiang ( CV 24), merges with the Du Meridian finally. The Ren Meridian is the sea of the yin meridians. It governs all the yin meridians and regulates the qi and blood of the yin meridians. The kidney yin is the fundamental yin so that it is important to the gfowth and development and reproduction of human body. The deficiency of the Ren Meridian leads to deficiency of the kidney yin, then affects the growth, development and reproduction. Ren also means pregnancy, it is responsible for pregnancy*
III. Syndrome of Chomg Meridian Symptoms: Reversed flow of qi with rushing from lower abdomen up to the chest and throat leads to vomiting, flushed face, metrorrhagia, metrostaxis, irregular menstruation, impotence, male infertility.
Analysis: Chong is the sea of the twelve regular meridians and five zang and six fu-viscera. It is also the sea of the blood. It is responsible for the congenital essence nourishing the yang upward and yin downward. Its function is to store the qi and blood of the twelve regular meridians. Moreover, as emerging with Stomach Meridian of Foot-Yangming in the region of the groin, the Chong Meridian is considered to belong to the Yangming. The Chong is full when the qi of the stomach is vigorous. When it is full, the sea of the blood is full, too, which keeps women's menstruation by nourishing the uterus, and promotes breast milk by nourishing the breast and makes men's sperm strong to fertilize. If Chong is deficiency, the sea of blood becomes empty so that the meridians and zang-fu viscera could not be nourished by blood. An upward adverse flow of qi shows reversed flow of qi rushing from the lower abdomen up to the chest and throat and vomiting (morning sickness is due to Chong Meridian affecting the stomach). Deficiency in the lower leads to metrorrhagia, metrostaxis, irregular menstruation and lochiorrhea in female; seminal emission, insufficiency of sperm and impotence in male. The Chong, Ren and Du Meridians are not isolated absolutely and were all called Taichong Meridian in ancient time, so the Chong and Ren Meridians together are responsible for reproduction. Affection of these meridians results in infertility, astysia of penis and less beard in male; acyesis and vaginal bleeding during pregnancy in female.
IV. Syndrome of Dai Meridian Symptoms :
Excess Syndrome: Abdominal distention, coldness and heaviness in the lumbar region, leukorrhea with reddish discharge, lumbago radiating to lower abdomen, swelling of the scrotum in infant.
Deficiency Syndrome: Vaginal bleeding during pregnancy, leukorrhea, flaccidity of lower limbs, weakness of the waist, and prolapse of uterus.
Analysis: The Chong and Ren Meridians which meet with the Yangming Meridian in the region of the genitals and converge on the Qichong point belong to the Dai Meridian and connect with the Du meridian. In order to nourish the lung and heart upward, the Taichong Meridian needs support by Dai Meridian. The Dai Meridian originates from the hypochondrium and goes around the waist like a girdle. The Dai Meridian has the function of binding up all meridians passing through the waist and abdomen, modulating the flow of the qi and blood. In affection of the Dai Meridian, stagnation of qi is due to the depression of the heart and spleen upward and deficiency of the kidney yin is due to the insufficiency of the liver and kidney downward. Hence, dampness stays in the body and down to the small intestine, showing as abdominal distention, heaviness and coldness of the waist like dipping in the water and leukorrhea with reddish discharge. Lumbago and abdominal pain are due to the evil staying the meridians. Pregnancy is controlled by the Ren meridian which depends on the maintenance by Dai Meridian. Hence Fu Shan said " The Dai Meridian maintains pregnancy. Deficiency of the Dai Meridian leads to functional failure manifested by vaginal bleeding during pregnancy". Deficient Dai Meridian is unable to control the qi by itself and results in sinking symptoms like vaginal bleeding during pregnancy, leukorrhagia, distention of the abdomen and waist with tenesmus, prolapse of uterus and weak lower limbs.
V.Syndrome of Uangwei and Uinwei Mesfdians Symptoms : Excess syndrome: When Yangwei Meridian is ill, there will be fever and chills, dizziness and asthma caused by hyperactivities of yang, pain or itching of muscle. When Uinwei Meridian is ill, there will be pain in the chest, heart and stomach. Stagnation of yin qi leads to chest distress and hypochondriac distention, pain in the lumbar region and pain in the perineum in female.
Deficiency syndrome: Amnesia, trance, weakness, faint, epilepsy leading to trauma, aphasia.
Analysis: the Yangwei Meridian connects with all the Yang meridians and Yinwei Meridian connects with all the Yin meridians. When the yin and yang hold toe
322
e
\
gether, the qi and blood of all meridians are reserved and coordinated and equilibrium between the yin and yang meridians is maintained. If not, the yin and yang meridians will fail to be in coordination and equilibrium, resulting in trance and faint. The Yangwei meridian dominates the exterior and Yinwei Meridian dominates the interior of the whole body. These two meridians dominate the exterior and interior and regulate the nutrient qi and defensive qi. Affection of these two meridians will result in disharmony between nutrient qi and defensive qi. Disease of the Yangwei Meridian leads to functional failure of the defensive yang-qi. Failure of superficial defence manifested by chills and fever and asthma due to obstruction of the yang-qi. Disease of the Yinwei Meridian leads to functional failure of nutri,
ent qi. Failure of governing the interior is manifested by pain in the region of the heart, chest and waist.
VP.Syndrome of Uangqiao and Yinqiao Meridians Symptoms : Excess syndrome: Affection of Yangqiao Meridian shows lower back pain, even stiffness, pain in the eye. Affection of Yinqiao meridian shows pain in the lower abdomen, lumbar region and perineum, stiffness of the foot and leg.
Deficiency syndrome: Dysphoria and insomnia or somnolence. In epilepsy, if the seizure is in the daytime, it is a yang deficient condition; if the attack is in the evening, it is due to yin deficiency condition.
Analysis: Qiao means vigorous and nimble. Yinqiao and Yangqiao Meridians start from the foot and are responsible for fast movement. Yangqiao Meridian runs a long the lateral aspect of the lower limb above the muscles where are the yang meridians. It links up six fu-viscera and is responsible for the superficies; Yinqiao Meridian runs along the medial aspect of the lower limb underneath the muscles where are the yin meridians. It links up five zang-viscera and is responsible for the interior. Qi of these two meridians communicate each other in order to harmonize yin and yang between the left and right sides.
Functions and Syndromes of the Eight Extra Meridians
I Meridian Functons governing all yang meridians, regulating the qi and blood of all the yang meridians, nourishing the brain governing all yin meridians, regulating the qi and blood of all the yin meridians,
Syndromes stiffness and pain of spinal column, diarrhea, impotence, spermatorrhea, enuresis, and infertility in deficiency; low intelligence, poor memory, flacciditv in deficiencv: / affecting the growth, menoxenia. infertility and hernia in male in deficiency
I spasm and contraction of genital: metrorrhagia, metrostaxis, lochiorrhea, leaking fetus and stertility in female; emission, impotence and less beard in male: abdominal distention, lumbago binding up all the meridians, Dai and abdomen pain, leukorrhea, securing the placenta vaginal bleeding Yangwei connecting with all the yang meridians fever, chills and asthma and merging with Du Meridian, dominating the exterior aching in the heart, chest and abdomen connecting with all the yin Uinwei meridians and merging with Ren Meridian and dominating the interior external symptoms as eye pain with Yangqiao dominating fast walking congestion and lumbago with stiffness and Yangqiao is in charge Yangqiao disorder : of the exterior and lumbago, abdominal pain, perineum pain; Yinqiao Yinqiao is in charge of stiffness below the knee; the interior, Yinqiao disorder : controlling the opening or closed eyes, somnolence in deficiency closure or eyes and sleeping cases ; opening eye, dysphoria and insomnia lin excess cases. -- the sea of the blood, in charge of reproduction
1
-
ion a~f$he Synadr vvhole body
sbdomen
mind
head
vexation
Lung Meridian sweating, of Hand-Taiyin thirst, fever and chills
:hest distress , :ough, asthma, shortness of ~ e a t h pain , in jupraclavicular fossa
eye, Large Intestine fever and chills, ell ow thirst, epistaxis , Meridian of sore throat toothache, Hand-Yangming swollen neck, flushed face
Spleen Meridian jaundice, limita- rigidity of tion of body tongue of Foot-Taiyin movement, anorexia, vomiting immediately after eating, belching
Co
N
U1 a
Heart Meridian drinking due to yellow eye of Hand- thirst, fever in excess, dry Shaoyin throat,
pain in shoulder iequent and anterior me- :ion dial side of arms
abdominal distention in excess case ; diarrhea and borborymus in deficiency case
Stomach Merid- fever and chills , epistaxis , facial mania lip ian of Foot- sweating, sore paralysis, rash, swollen throat Yangming neck
pain in the chest abdominal distention in the 3nd breast deficiency ; polyorexia
the sleepless due tc dysphoria in excess
vexation, mind- precordial pain, edless , melan- hypochondriac pain cholia
lefecation four extremities ~rination
and urina-
pain in the anterior border of the shoulder and index finger
pain and jark urine swollen knee, pain in the thigh, lateral side of tibia and instep
abdominal dis- swelling in the jiarrhea in defitention, epigas- medial of the :iency knee and thigh, tric pain limited movement of the big toe
pain in the posterior border of the medial side of arms
head
whole body
mind
chest
abdomen
four extremities
defecation urination
eyes, vexation Small Intestine fever, aversion yellow Meridian of to cold, sore deafness, aphthroat tha, swollen Hand-Taiyang mandible and stiff neck, migraine
pain in the neck, mandible, shoulder, the posterior lateral side of upper arm
Urinary Bladder fever , aversion headache, stiff mania ,epilepsy yellow Meridian of to wind and neck, cold, pain in the eyes ,tearing Foot-Taiyang spine and lumbago
impairment of hemorrhoid thigh9 pain in buttock, poppliteal fossa , fibia and foot
I
face , vexation fear, asthma , dyspdry darkish Kidney Meridi- jaundice, nea , precordial and blurred vision, sleepiness an of Foot- swollen pain, dry , tongue, sore throat Shaoyin thirst ,
Pericardium Meridian of Hand- Jueyin
flushed face, silly laughing , palpitation with empty sensavexation yellow eyes tion, pericardial pain, stuffy chest and hypochondrium
and
urine , dark pain in the spine dysentery and the posterior medial side of the thigh, hot, swollen foot with pain
spasms of arm, swelling in the axilla
whole body
head
mind
chest
abdomen
deafness ,pain in Triple- Jiao sweating, retroauMeridian of swollen and the ricular region, Hand-Shaoyang sore pharynx, swollen cheek, pain in outer canthus
Gallbladder fever, chills, Meridian of sweating, limitaFoot-Shaoyang tion of turning round, joints pain, less sheen of the body
defecation urination
and
pain in the shoulder and forearm, limited movement of ring finger
bitter taste in the mouth, dusty complexion, headache, pain in the lower jaw, outer canthus and supraclavicular fossa ,sabre and beadstring scrofula
Liver Meridian dry' throat, lum- dusty complexof Foot-Jueyin bago with limi- ion with less tation of bend- sheen ing
four extremities
pain in theabdominal dis-pain in the hypochondrium tention and poor thigh, knee , the and chest, fre- appetite in ex- lateral side of quent sighing cess the tibia and lateral malleolus ; syncope with flaccidity, failure to stand up when sitting in deficiency
irritability in the excess ; melancholia in the deficiency
chest distress, vomiting, epigastric fullness and rigidity, hypochondriac pain .
hernia in male ; swelling in the lower abdomen in female
diarrhea enuresis in deficiency ; retention of urine in excess
Chapter 11 Syndrome Differentiation of Exogenous Diseases Doctors of T C M , when making a diagnosis, put the stress on the differentiation of the exogenous diseases from endogenous diseases. Exogenous diseases refer to those caused by exogenous evils. The primary symptom is acute fever. There are some particular rules in clinical manifestations of exogenous diseases. For example, the pathogens usually transfer from the exterior into the interior of the body;and there are phases in the development and there are rules in the pathological changes. The key of treatment for exogenous disease should be put on eliminating the evils, this principle differs largely from that for endogenous disease. Exogenous disease, however, may lead to disharmony of yin and yang ,qi and blood of the internal organs ,and transform into endogenous disease. On the other hand ,endogenous diseases may lead to pathological changes of yin, yang, qi and blood, these changes often make patients vulnerable to exogenous evils. In addition,doctors should be aware of that exogenous diseases and endogenous diseases sometimes exist simultaneously. In some ancient medical literatures, exogenous diseases have a variety of names, such as cold attack wind attack, damp-warm disease, heat disease ,warm disease and so on. Afterward ,exogenous are divided into two categories :cold attack and warm disease. According to traditional view, they differ from each other in pathogens, route of invasion, pathogle,enesis,clinical manifestations, and mechanism of disease transformation and principle for treatment. The cause of cold attack is wind and cold, and cold is the primary. The evils enter the body from the interspace of the skin ,and then ,through the meridian an collateral, transfer from the exterior into the interior, from the fu-viscera into the zang-viscera. The pathology is characterized by excess of evils accompanied by in" "-
" .
.
. -
..
.
. . , . .
sufficiency of the genuine-qi. In three yang diseases ,the evils stay in the iu-viscera and they are excessive ;In three yin diseases, the evils invade into the zang-viscera
,
the cold transforms into heat ,and the genuine-qi becomes insufficient. As far clinical manifestations ,in Taiyang disease, they appear at the beginning of cold attack and belong to exterior cold syndrome. There is chill. In Shaoyang disease, the evil stays between the exterior and the interior ,and there is alternate attack of chill and Q
328
Q
fever. The evil will change to heat when it invades deeply,and then there are interior heat syndromes which belong to Yangming disease. When the disease transmits into three yin meridians, three yin diseases occur. The disease whose main symptoms are abdominal fullness, vomiting and diarrhea is Taiyin disease; the disease with thready pulse and somnolence as its main symptoms is Shaoyin disease ,and its pathology is deficiency of the heart and the kidney ;that whose main symptoms are alternate attack of fever and cold limbs is Jueyin disease, the pathology is liver deficiency. The types of transformation of cold attack include: transmission by the meridian orders , skipping-over transmission, exterior-interior transmission, combined diseases, complicated diseases, direct attack, and so on. The principle of the treatment for the three yang diseases is to eliminate the evils. A t the beginning of the disease 9to disperse the exterior cold ;secondly ,to harmonize the exterior and the interior ,or to clear away the heat ,or to purge the evils from the bowels. T h e principle of treatment for the three yin diseases is to invigorate the genuine-qi,mainly to warm the yang;sometimes it is also needed to nourish the yin and clear away the heat.
Warm diseases are a class of diseases caused by warm evil or heat evil, or by yin evils, such as cold and damp which have been transformed into heat; they are characterized by acute fever. The evils invade the human body through the nose or mouth, and transmit in turns from wei (defence) to qi, to ying (nutrition) and at last, to xue(b1ood) ;or invade the upper-jiao ,the middle-jiao and the lower-jiao successively. The pathgenesis of warm diseases can be summarized as excess of yang evils and consumption of yin ,mainly including fire transformation, dryness transformation, body fluid consumption, blood consumption, blood vessels damages and stirring of the endogenous wind. In wei or qi phase, the pathology is mainly consumption of the body f1uid;and the condition of disease in qi phase is more serious than that in wei phase. In ying or xue phase, blood consumption is the primary pathgenesis. And it also leads to yin deficiency ;the heart ,liver and kidney are often involved. The heat, when invading into the blood and. damaging the blood vessels, will make the blood escape from the vessels and leads to bleeding. Blood consumption and yin deficiency lead to endogenous wind symptoms of twitching or convulsion;this is because that the muscles and tendons are poorly nourished. At the beginning of warm-heat diseases, exterior heat syndromes appear, because the evils are in the wei phase, the diseases take place in the lung and the skin ,the symptoms are cough, sore throat, fever and slight chill. But in warm-heat diseases, the evils 329
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usually transform into heat in a short time,and the body f!ti'.' is easily consumed. When evil enters qi phase ,it is interior excessive heat syndromes and the lung and stomach are invo1ved;its appearances are similar to those of Yangming disease in cold attack. If the evil stagnates in the liver and the gallbladder ,or in the chest and diaphragm, the syndrome is then similar to Shaoyang disease. If the disease spreads into ying, the heart and the pericardium are involved with blood-heat syndrome, and the symptoms include macule ,pacule ,vexation or coma. Finally, when the disease spreads into xue phase, the heart, kidney and liver are involved, and an extremely serious blood-heat syndrome occur. The symptoms include high fever, coma ,convulsion which is due to stirring of the endogenous wind and bleeding which is due to fire and exhaustion of the yin. All of these symptoms are dangerous and emergent. As for the rules of spreading ,there is reversal spreading to the pericardiu m , the upper-jiao , the middle-jiao and the lower-jiao. At the beginning, the pathogens invade the upper-jiao ,the lung and the defence-qi are involved, the disease manifests as heat-syndrome of the lung, which is similar to wei syndrome. If the evil invade the pericardium, there appear blood-heat syndromes which resembles ying syndrome or xue syndrome ;this is a case of reversal transmission to the pericardium. If the evils invade the middle-jiao , t h e spleen and the stomach are involved, and there appear dampness-heat symptoms which are similar to qi syndrome. If the disease transmits into the lower-jiao ,the liver, kidney ,large intestine and urinary bladder are involved, the syndromes are then similar to ying and r u e syndromes. The principles of treatment include: diaphoresis for wei syndrome , clearing away heat for qi ~ y n d r o m e ~ d i s p e r s i nying-heat g back to the qi for ying syndrome, clearing away blood-heat and blood stagnation for xzle syndrome, for lest the blood is consumed by heat or by bleeding. Before Jin and Yuan Dynasty, most of the theories about exogenous diseases were consistent with the opinions of the Internal Classic and that of the Classic on Medical PI-oblems. In the Plain Que tions, the author stated thatb6allthe heat diseases belong to the realm of cold attack. "The 58th Problems of the Classic on Medical Problems also states thatb6Cold attack has five types :wind attack, cold attack, dampness-warm disease ,heat disease and warm disease. The symptoms of these diseases differ from one another. 99These theories attribute all warm diseases to the attack of cold evi1,and propose to apply the six meridian syndrome differentiation to differentiate these diseases ,to treat these diseases mainly with drugs hot in nature and pungent in taste ,in order to expel the cold evil. Liu Wansu, a doctor of Jin Dynasty, raised the doctrine that6'All a
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the six climatic factors tend to transform to f i ~ e ~ ~ , athatL6Febrile nd diseases must be treated as heat disease, rather than as cold disease. "His student, Ma Yuansu , pointed out more clearly: "Febrile diseases are always heat syndromes ,rather than cold syndromes; although the disease may transmit along the six meridians from the superficial parts of the body into deeper parts. "After this ,doctors9 knowledge changed gradually and an academic school of warm-diseases came into being. In syndrome differentiation, the wei-qi-ying-xue syndrome differentiation, which was initiated by Ye Tianshi ,and the triple-jiao syndrome differentiation, which was initiated by Wu T a n g , were formed. So there are three differentiation systems in diagnosis of exogenous diseases after Qing Dynasty: the six meridian syndrome differentiation, the wei-qi-ying-sue syndrome differentiation and the triple-jiao syndrome differentiation. Among them ,the six meridian syndromes differentiation is mainly applied in cold attack ,while the others ,in warm diseases.
Section 1 T h e Six Meridian Syndrome Differentiation The six meridian syndrome differentiation was initiated in Treatise on Cold Attack. This system applies Taiyang Yangming , Shaoyang , Taiyin , Shaoyin and Jueyin to analyze and conclude the pathological changes of cold attacks. I t , based on the clinical materials collected through the four diagnostic methods, i. e. observation, listening and smelling, inquiring and palpation, differentiates syndromes with the eight principles. At first, dividing diseases into yin and yang categories, and then, according to the level of the genuine-qi, the strength of evils, the development of the diseases and the rules of transmission, dividing diseases into six kinds: Taiyang disease, Yangming disease, Shaoyang disease, Taiyin disease, Shaoyin disease and Jueyin disease. The former three are called the three yang diseases; and the latter ,the three yin diseases. According to the pathological sites, the three yang diseases are exterior syndromes ;and among them, Taiyang is exterior syndrome, Yangming is interior syndrome, and Shaoyang is a syndrome between the exterior and the interior. Three yin disease are interior syndromes ;and among them ,Taiyin is exterior syndrome, Jueyin is interior syndrome, and Shaoyin is a syndrome between the exterior and the interior. As regarding to the relationship between the evils and the genuine-qi and the qualities of the diseases ,those with sufficient genuine-qi and excessive evils are three yang diseases, manifested as excessive heat syndromes. Most of the syndromes in which the genuine-qi is insufficient are three yin diseases ,manifested as cold syndromes of insufficient nature. *
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The six meridian syndromes are results of the pathological changes of the viscera and meridians. Among them, the three yang diseases reflect the pathogenesis of the fu-viscera ;and the three yin diseases reflect the pathogenesis of the zang-viscera. At the same time, the six meridian syndromes reflect the pathogenesis of the corresponding meridians. So the six meridian syndromes differentiation is related with viscera syndrome differentiation and meridian syndrome differentiation. The six meridian syndromes are strictly different from, and related t o , each other. If two or three diseases occur at the same time, it is called compound dis-
ease ;for example, Taiyang disease and Yangming disease compounded, Taiyang disease and Shaoyang disease compounded ,and the three yang diseases compounded.
If one meridian disease occurs after another meridian disease and the two is complicated ,it is called complicated disease. For example, Taiyang disease and Yangming disease complicated ,Taiyang and Shaoyang disease complicated ,and Shaoyang and Yangming diseases complicated. The six meridian syndromes may transmit. Transformation refers to instinct changes of phases in the development of diseases. The general rules by which the exogenous evils transmit along the six meridians are that they transmit from the exterior into the interior gradually and in the order of Taiyang ,Shaoyang ,Yangming, Taiyin, Shaoyin and Jueyin. These reflect a tendency of the diseases transmission from the exterior into the interior, from yang into yin, and to a state of more and more serious. Clinically, the six meridian syndromes sometimes do not transmit in the order mentioned above. There are certain specific types of transformation, for example :
(1) Meridian-Skipping-Over Transmission :Diseases transmitting not in the sequence of the six meridians but skipping over one or two of the
(2) Exterior-Interior Transmission :Transmission of diseases between the two meridians which are exterior and interior to each other;
( 3 ) Direct Attack: Evil directly attacks the three yin meridians not through the three yang meridians;the three yin meridian syndromes occur at the beginning of the diseases. That evils directly attack the Taiyin Meridian is commonly seen case. The conditions of diseases are more serious in the case of direct attack.
I. Tadyang Syndrome Taiyang controls the skin and acts as the shield of the six meridians. It can protect the body from evil invasion. Exogenous evils, when invading body, hurt Taiyang Meridian first. Taiyang diseases can be divided into meridian syndrome ,fu332
viscera syndrome and metamorphic type.
I. Meridian Syndromes of Taiyang The main symptoms are fever ,chill ,headache ,stiff neck and floating pulse. When the human body is invaded by wind-cold ,Taiyang is attacked firstly. At this stage of the disease, the defence-qi is hindered and fails to diffuse ;that leads to chill and fever. The Taiyang Meridian travels through the head and the neck; so when the meridian-qi is stagnated ,headache and stiff neck will occur. The evil is in the skin,the blood and the genuine-qi go there to combat it ,this results in floating pulse. These symptoms and pulse condition are the primary appearances of the meridian syndrome of Taiyang; and all the meridian syndromes of Taiyang have these appearances. Because patients differ physically ,pathogens differ in property, and the infections differ in seriousness ,the pathological changes and clinical manifestations of the meridian syndromes of Taiyang are different, and can be divided into two types: wind-attack and cold-attack. Taiyang syndromes are due to that cold-wind attack the skin, so the therapeutic principle is to relieve exterior syndrome with pungent-warm herbs.
A. Wind-Attack on Taiyang Clinical Manifestations :Headache, fever, sweating, aversion to wind, soft and floating pulse.
Analysis: This syndrome occurs usually when the skin is loose, and the defence-qi is attacked by kind. This leads to disharmony of the nutrient-qi and the defence-qi. Wind attacks the skin, then the defence-qi fails to protect the body, this leads to aversion to wind. Fever is due to that the defence-qi combats the evi1;The defence-qi fails to consolidate the skin ,therefore the nutrient-qi can't remain in the body ,sweating thus occurs.The Taiyang Meridian-qi is hindered by the wind, then headache occurs. Floating pulse is due to that the syndrome is in the exterior ;and moderate pulse is due to that the skin is loose and there is sweating.
B. Cold-Attack on Taiyang Clinical Manifestations : Chill and fever, headache and stiff neck, lumbago, arthralgia and general aching, asthma, aversion to wind, no sweating, floating and tense pulse.
Analysis :This syndrome is caused by that cold attacks the skin, the defence-qi is tightened and the nutrient-qi is hindered. Chill results from stagnation and impairment of the defence-qi;fever results from the fighting between the genuine-qi and the evil ,and stagnation of the yang-qi of the human body. Since cold is an evil 333
of yin and sticky in nature, the nutrient-qi ,when being attacked by cold, becomes stuck and fails to flow normally ,and this leads to headache and general aching. Additionally,cold is also contracting in nature ,so it makes the sweat pores closed and no sweating. The skin and the lung are correlated with each other ,so the closure of the skin may lead to lung-qi stagnation ,and asthma occurs. The floating pulse indicates that wind-cold is in the exteriorflense pulse is caused by cold. Wind-attack on Taiyang is also called exterior syndrome of deficiency type because there are sweating and moderate pulse. Cold-attack onTaiyang is also called exterior syndrome of excess type because no sweating appears and the pulse is tense.
2. Fu-Visceral Syndrome of Taiyang The exterior evils may ,if not be expelled, transmit along the meridian into the bladder and leads to syndrome of water retention or blood accumulation. For the treatment of water retention syndrome, water draining therapy is adopted; while for blood accumulation syndrome ,the treatment is to remove the blood stasis.
A. Water Retention Syndrome Clinical Manifestations :Dysuria ,slight fever, thirsty for water but throwing up while drinking, floating pulse.
Analysis: Dysuria results from retained water in the body. The exterior evil transmits into the bladder ,lowers the transformation function of the bladder. Under this condition ,the bladder can neither disperse fluid upward nor urinate the water downward, so there are symptoms such as thirsty, restlessness and dysuria. If there is excessive heat in the body, the patient will drink water and not throw it up. If only-slight heat is in the body ,the patient is unable to absorb water ,and the water stagnates in the stomach. Under this condition ,water in the stomach tends to ascend, the stomach will not accept water any more. So although the patient is
BeBlood Accumullation Syndrome Clinical Manifestations :Being manic or behaving in a manic way, hardness and fullness in the lower abdomen, normal urination, violet tongue or bluish-black marks on the tongue ,deep and uneven pulse.
Analysis :The evils in the Taiyang Meridian ,if not dispersed o u t , may invade along the meridian into the fu-viscera,the bladder ,and lead to stagnation of heat in the urinary bladder. The heat stagnates in the bladder but the urination remains normal, this manifests that the heat is connected with blood stasis. If the heat cause
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es bleeding ,and the blood does not accumulated i n the bladder, the heat will leave from the body through bleeding, the illness will be. cured by itself. If no bleeding occurs and the blood accumulates ,the heat will also accumulates in the lower-jiao (the lower portion of the body cavity). This pathological change gives rise to hardness of the lower abdomen. The patient behaves in a manic way ,but not mad, this is a manifestation of exterior heat. If the heat interferes with the mind, madness may occur. If the blood stasis remains in the body,a violet tongue or tongue with bluish-black marks will appear. The uneven and deep pulse is because the blood circulates unevenly.
3. Metamorphic Cases of Taiyaaag Usually, metamorphic cases of Taiyang take place when Taiyang diseases are not treated properly or not treated in time. Most of the metamorphic cases of Taiyang are caused by improper application of diaphoretic or purgative therapies. T h e metamorphic cases occur either to the predominant yang or to the predominant yin. The metamorphic cases of Taiyang are as follows:
A. Fullness Syndrome :This syndrome is characterized by fullness of the epigastrium, without pain. It is caused by heat which spreads from the exterior into the epigastrium when Taiyang disease is not treated in time or is erroneously treated with purgatives. T h e fullness is due to heat accumulation.
B. Block-up Chest Syndrome :This syndrome is characterized by hardness and pain of the epigastrium. It can be divided into severe case and mild case according to the depth where the heat stays. In mild case, the heat does not invade deeply yet, the pain remains in the epigastrium; while in heavy case, pain, fullness and hardness occur over the entire abdomen,the patient can not bear the touch on the abdomen. Block-up chest syndrome is due to the gathering of the evil which invades into the abdomen and the water which has not been transformed into sweating. It usually occurs when the exterior syndrome is not dispersed or is erroneously treated with purgatives.
C.Diarrhea: For
example, when Cinnamon Twigs Syndrome is erroneously
treated with purgatives, the exterior evil might invade into the interior and transform into heat ,and then there will be a complex of symptoms such as continuous diarrhea ,asthma and sweating',and irregular rapid pulse.
D. Jaundice: When the exterior syndrome is not dispersed in time, the evil might deepen and accumulate in the inner part of the body. Under this condition,if 335
no sweating and enough urination, jaundice will occur.
E. Running-piggy syndrome: This syndrome is characterized by a sensation of a forceful impulsive bumping up from the lower abdomen to the chest. It is caused by rushing cold and water injuring the heart. The predisposing causes are erroneous application of hot needle or profuse diaphoresis.
F.Epistaxis: This
syndrome is caused by accumulation of heat in meridian
when the exterior syndrome of Taiyang is not dispersed in time.
6. Heat in Blood Chamber: When a female patient during or at the end of menstruation catches cold, the evil might invade into blood chamber (womb) and make blood coagulation there. This pathological change leads to alternate fever and chill, which is lighter during daytime and heavier at night ,delirium at night, distention and fullness in the lower abdomen.
11.Sltamyang Syndrome Shaoyang syndrome occurs when the exterior evil is not removed and the genuine-qi is insufficient. The genuine-qi and evil fight each other between the exterior and the interior. The "pivot"can not work easily. The pathological changes take place neither in the exterior nor in the interior. They take place between the exterior and the interior, so the syndrome is called half-exterior
& half-interior syn-
drome.
Clinical Manifestations :Alternate fever and chill ,chest distress ,costal distention 9reluctant to speak and eat ,restless and nausea, bitter taste in mouth ,dry coating and dizziness. Analysis: The evil in Taiyang Meridian, if not be removed, may invade Shaoyang Meridian. On the other hand, the climatic evil may directly attack Shaoyang Meridian. Once the evil enters Shaoyang Meridian, which is located between the exterior and the interior, the genuine-qi will fight it. Chill occurs when the evil fights the yin of the body. Fever occurs when the evil-fights the yang of the body. Since the pathological changes take place in the half way between the exterior and the interior ,so chill and fever appear alternately. Shaoyang Meridian travels through the chest and hypochondrium. So, distention and oppression symptoms of the chest and costal region will occur when evil invades the meridian and makes the qi flow not smoothly. If gallbladder qi is depressed,it will invade the stomach,the patient is then depressed and reluctant to eat and drink. If the evil stays in the half way of the exterior and interior, usually there is vomiting which manifests the stomach qi rebellion. If the fire stagnates internally ,restlessness will occur. If gall, 336 *
bladder fire becomes exorbitant ,it will burn the five sense organs and lead to bitter taste in mouth, dry throat and dizziness. Huang Pumi said in the A
& B Classic o f
Acupuncture & Moxibustion : "The gallbladder is a storehouse of essence. the five zang-viscera and the six fu-viscera are dependent on it. The throat is also an organ which is controlled by gallbladder. Shaoyang Meridian originates from outer canthus, s o , when it is invaded by evil, bitter taste in mouth, dry throat and dizziness will occur.
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111. Yangming Syndrome Yangming syndrome represents the serious stage of combat between evil and genuine-qi. It usually occurs when Taiyang syndrome is not cured in time or is erroneously treated. The heat evil spreads into the interior ,consumes body fluid and makes dry and solid faeces. Sometimes ,the cold evil may invade Yangming Meridian directly and cause Yangming syndrome. Yangming syndrome can be subdivided into meridian syndrome and fu-visceral syndrome according to location of disease and symptoms. Meridian syndrome refers to that heat evil spreads over the the whole body, but there is no faeces in intestines. Fu-visceral syndrome refers to that heat and dryness make the hard faeces. in intestines with constipation. They are interior syndrome of excess type. The main therapeutic methods include cooling and purging. Cooling is applied to treating meridian syndrome, and purging is applied to treating fu-visceral syndrome.
1.Meridian Syndrome of Yangming Clinical Manifestations :High fever, profuse sweating, or sweating only on the hands and feet, heavy thirsty and drinking ,dry and yellow coating ,large and surging pulse.
Analysis: When the evil enters Yangming Meridian,the heat will be exorbitant in the interior and accumulate in the stomach. Since the stomach controls the limbs,so the heat in the stomach will make the body fluid ooze out on the four limbs and that leads to sweating on the hands and feet. The heat is exorbitant ,so there is high fever. The exorbitant heat acts on body fluid, then profuse sweating appears. And as a result, the body fluid is consumed, the patient then feels serious thirsty and desires to drink. Insufficient body fluid can't reach the upper part of the body and moisten the tongue ,so the coating becomes yellow and dry. T h e heat is exorbitant and the yang is predominant ,so the pulse becomes surging and large. 337
2. Fu-Visceral Syndrome of Uangmlng
Clinical Manifestations :Fever a n d sweating, tidal fever peaked at 3 : 00-7 : 00 p. m. ,abdominal pain and distention, tenderness of abdomen. The patient refuses to be touched on the abdomen. And there are symptoms of constipation with dry and hard faeces, fidget, stupor or delirium, yellow, thick and dry coating, or brown coating with thorns. The pulse is deep and forceful.
Analysis :The exterior evil spreads inward and transforms into heat. the exorbitant heat in the interior spreads outward, thus there appear fever and sweating all over the body. The meridian qi of Yangming becomes more vigorous at Shen,You and Xu (ancient time names ,equal to 3 :00-7 :00 p. m. ) ,so there is peak of fever at that time. The heart and faeces are combined into a whole one and hinder the flowing of Yangming fu-viscera, so there are abdominal pain and distention, and hardness and tenderness of abdomen,and constipation. The heat attacks the heart and leads to fidget. If the interior heat goes extreme ,stupor or delirium might occur. Body fluid is consumed by the heat , s o the stool is dry,and the tongue coating is dry and
ell ow. The heat
makes the pulse deep and forceful.
The typical clinical manifestations of the fu-visceral syndrome of Yangming can be summarized into four words :distention, fullness, dryness and excess. "Distention"means abdominal distention. " F u l l n e ~ s ~ ~ m e athe n s hardened abdomen. "Dryness"means the faeces in intestines is dry and hard. 6'Excess99meansthe combined solid evil (heat and faeces) fills up the bowels and the"excess"is manifested by constipation or heat-facaloma with watery discharge',abdominal pain aggravated by pressing ,deep and forceful pulse. Abdominal distention is caused by qi stagnation in bowel. Dryness and excess are the results of gathering of the solid evil. The qi stagnation and solid evil are the cause and result of each other. The treatment of this syndrome is to dispel the stagnation and the accumulation of the solid evil.
IV*Taiyin Syndrome Both the Spleen of Foot-Taiyin and Stomach of Foot-Yangming pour to middle-jiao ,and they are exterior-inrerior related and connected by meridians and coilateral. When disease occurs ,and under some circumstances, the disease of spleen may spread to the stomach and vice verse. However, Taiyin syndrome and Yangming syndrome differ in condition of deficiency and excess. Taiyin syndrome is deficient while Yangming syndrome excessive. There was a saying that: "The excess is of Yangming ,while the deficiency is of Taiyin. "This is to say that Taiyin syn338
drome is interior syndrome of deficiency nature and just the opposite of Yangming syndrome.
Clinical Manifestations : Abdominal distention, vomiting, poor appetite, diarrhea, paroxysmal abdominal pain, alleviated by warming and pressing, no thirst, pale tongue with white coating,slow and soft pulse.
Analysis :Taiyin syndrome may occur when the three yang syndromes are not properly treated and the spleen yang is impaired. Sometimes Taiyin syndrome is caused by cold which attacks the spleen directly. If the spleen yang is deficient ,the spleen will not transport food, then cold-dampness will stagnates in the middle, the ascending and descending functions of the middle-jiao become abnormal ,so symptoms such as abdominal distention and pain, diarrhea, vomiting and poor appetite occur. Since the syndrome is cold and deficient in nature, the abdominal pain is alleviated by warming and pressing, and the patient is not thirsty, the tongue is pale with white coating,and the pulse is slow and soft. If the syndrome transforms toward yang type ,the abdominal pain becomes severe and is aggravated by pressing. This syndrome should be treated with Ramulus Cinnamon plus Radix et Rhizoma Rhei Decoction. Abdominal pain and distention are the common symptoms of Taiyin syndrome and Yangming Syndrome ,but they are different in nature. In Taiyin syndrome, the pain and distention are paroxysmal, and the distention is more prominent than pain, the symptoms can be alleviated by warming and pressing, they are deficient in nature. While in Yangming syndrome, the distention is accompanied by hardness and pain, they are persistent and aggravated by pressing, they are excessive in nature.
V.Shaoyin Syndrome Shaoyin syndrome is a disease condition of heart and kidney. The heart is a zang-viscus of fire in nature ;while kidney is a zang-viscus of water in nature. Both of life. The Shaoyin Meridian possesses waheart and kidney are the ' ' r ~ o t ~ ~human ter and fire,it belongs to yin in the root and to yang in the branch. S o , when the Shaoyin Meridian is ill, both cold syndrome and heat syndrome may occur. Shaoyin syndrome appears at the most serious stage of cold attack ,it may be dangerous. In the Chapter of Shaoyin Disease of Treatise hn Cold Attack, dangerous syndromes are often discussed. The principal syndrome discussed in the chapter is deficiency syndrome, rather than excess syndromes. This is different from the other five meridian syndromes. However ,insufficiency of the genuine-qi may lead to excess of
evil. Shaoyin syndrome either manifests as yang-deficiency with yin-excess syndrome, which is cold syndrome of Shaoyin, or manifests as a yin-deficiency with yang-excess syndrome, which is a heat syndrome of Shaoyin and belongs to complication of Shaoyin syndrome or secondary syndrome of Shaoyin syndrome. The heat syndrome of Shaoyin results from that excessive yang transforming into heat. Generally speaking ,in Shaoyin syndrome ,cold syndrome of deficiency is more common than heat syndrome ,since cold syndrome of deficiency is the primary syndrome of Shaoyin.
I.Coad Syndrome of Shaoyin Clinical Manifestations : a. Aversion to cold, sleepiness, cold limbs, nausea without vomiting, no thirst or thirst but only desiring for hot drinking ,diarrhea with undigested food in stool, clear urine ,pale tongue with white coating ,deep and feeble pulse. b. Diarrhea with undigested food in stool, cold limbs, faint pulse, no chill, flushed face ,nausea and restlessness.
Analysis :This syndrome can be caused by direct cold attack on Shaoyin Meridian, deficiency of heart yang or kidney yang ,or improper treatment which impairs kidney yang. The insufficient yang is unable to warm the body,so the patient feels chill ,rolls his body ,and his limbs are cold. The patient tends to fall asleep because the yang is insufficient ,defence-qi remains in the yin without traveling in the yang of the body. Because the yang is deficient and the cold evil is exorbitant, there is no thirst. If the deficient yang fails to transform the body fluid, the body fluid could ing. The cold rushes upward and leads to rebellion of stomach qi, so the patient
with white coating,deep and feeble pulse are all the symptoms of yang deficiency ar,d .y;.,. excess. The dcficien: yang may be exhaiistid and escape from the body when the condition becomes serious further.
If interior cold is exorbitant ,it may expel the deficient yang outward to the superficies of the body ,and then pseudo-heat symptoms ,such as flushed face ,nausea,restlessness will occur. And at the same time,there are symptoms of real cold in nature ,such as diarrhea with undigested food ,cold limbs and faint pulse. 340
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2. Heat Syndrome of' Sltnaoyin
Clinical Manifestations :Dry mouth, dry or sore throat, fidget, insomnia, diarrhea with watery stool in greenish color ;or abdominal distention and constipation.
Analysis :The syndrome occurs usually when the heat evil is not dispelled and it consumes kidney yin ;or when exogenous evil invades Shaoyin Meridian of a patient who has yin deficiency,and the evil combines with the yang transforming into heat which consumes kidne,y yin (water in kidney). Since the heat is excessive and body fluid is consumed, there are symptoms of dry mouth and throat. Shaoyin Meridian penetrates the liver and the diaphragm, runs along the throat, connects with the root of tongue. So, when disease attacks Shaoyin Meridian ,sore throat occurs. The heat influences the mind,the water and the fire fails to help each other, then fidget and insomnia occur. The heat invades downwards the intestines and results in diarrhea. If the heat spreads into Yangming Meridian ,and the deficient kidney water could not moisten large intestine,heat fecaloma will occur with watery discharge in green color ,or there will be abdominal distention and constipation.
VI. Jueyin Syndrome It is said in Plain Questions that: "What is Jueyin? Qibo answers :The two yin terminates. "Gao Shizhong explained :"Yin changes from large to small and at last terminates. So there are large yin,small yin and terminal yin. The terminal yin is called Jueyin. "This means that Jueyin is the end of yin changing. Where yin terminates is just the beginning of yang. Jueyin syndrome is the last stage and also the crucial stage of cold attack diseases. Since the vital essence has been nearly exhausted, the yang and yin become disharmony, the main pathological mechanism is the mixture state of cold and heat, or the alternate attack of cold and heat. If the cold changes from extreme to mild, and the yang-qi becomes from deficient to sufficient ,the condition gets improved. But if the cold transforms into extreme further and the yang-qi is too weak to resist the evil, the pathological condition becomes more and more serious and the patient's life is dying. Sometimes the deficient yang still can fight the cold, although it is extreme ,under this condition, there will be a state of stalemate of yin and yang;and the disease manifests as a syndrome of combination of cold and heat.
Clinical Manifestations :Thirst, feeling of ascending air rushing up to epigastrium ,heartburn, epigastric pain, hunger but no appetite of food, cold limbs, diarrhea ,vomiting or vomiting with ascarids. a
341
'
Analysis: Jueyin syndrome occurs when the cold evil spreads into Jueyin Meridian, or directly attacks Jueyin Meridian, or the evil in other meridians which has not been treated properly invades into Jueyin Meridian. When Liver Meridian of Foot-Jueyin is invaded by evil, the liver is then unable to conduct, the ascendingdescending function becomes abnormal ,so symptoms due to disharmony of qi and blood and symptoms of combination of cold and heat appear. Jueyin dominates the ministerial fire. When Jueyin is ill, the air rushes up to epigastrium. The excessive fire consumes body fluid and thirst appears. The fire attacks the heart and leads to a hot and painful sensation in epigastrium. If the cold of deficiency nature exists in the body ,the patient is then unable to take food ,and vomiting or vomiting with ascarids will occur. Diarrhea will occur when the cold is in the intestines. The qi flow is congealed, the yin and yang can not connect with each other, these lead to cold limbs. In Jueyin syndrome, there are two kinds of cold extremities :cold and hot. Cold extremities of cold type has no fever, while cold extremities of hot type is caused by heat, so cold limbs and fever appear alternately. If fever persists for longer time than cold limbs does ,the disease is getting improved, while fever persists for shorter time than cold limbs does ,the disease is getting worse. In general, the main pathological changes of Jueyin syndrome include upper-heat with lowercold syndrome ,cold extremities syndrome ,and alternate cold extremities and fever syndrome.
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Section 2
Wei-Qi-Ying-Xue (Defence-Qi-Nutrient-Blood)
Syndrome Differentiation Wei-qi-ying-sue (defence-qi-nutrient-blood) syndrome differentiation is also a syndrome differentiation system for exogenous diseases. It was built up by Ye Tianshi, a doctor of Qing Dynasty. He completed the system on the basis of the medical achievements before him. It is a supplement to the six meridian syndrome differentiation, and it also enrich the content of exogenous diseases in diagnosis and treatment. Wei ,qi ,ying and xue refer to the four stages of the development of exogenous diseases. The exogenous evil spreads gradually from the exterior to the interior. The pathological location transmits from the superficial part into the deep part ,and the conditions of disease change from mild to serious. Ye Tianshi,on the basis of medical experiences before him (e. g. Wu Youke, etc. ),raised the doctrine that "Wei phase is followed by qi phase ,ying phase is followed by xue phase. When disease is in the wei phase ,diaphoresis therapy is proper ;in qi phase ,cooling is used ; when disease goes into ying phase, we can disperse the heat back to qi phase, and when disease spreads into xue phase, the treatment is to cool and activate the blood ,lest the heat causes bleeding and consumes blood. "This pointes out that the warm evil, when invading into the body ,spreads from wei phase into qi phase, then enters ying phase, and last the xue phase. The evil deepens gradually, the disease becomes heavier and heavier. As for pathological location ,wei phase syndrome is in the exterior and involves the lung and skin;qi phase syndrome is in the interior and involves chest, diaphragm, lung, stomach, intestines, gallbladder and so on. Ying phase syndrome is caused by the further invasion of heat evil and the location of disease involves the heart and pericardium. Xue phase syndrome is caused by the deepest invasion of heat into the liver and kidney, and its basic pathology is the blood consumption and bleeding. Those are the general rules of development of warm diseases. As for the order by which warm disease spreads ,generally speaking ,there are two basic types : sequential tsarasmission and reversal transmission. Sequential transmission refers to that the disease spreads in the order of wei phase ,qi phase, ying phase and xue phase. This order was described by Ye Tianshi. While reversal transmission refers to that the disease spreads other than the above order. Reversal transmission may occur under certain circumstances. 344
There were different theories in ancient China about the concept of reversal transmission. Some doctors, such as Zhang Xugu ,held that transmission from lung to heart directly was called reversal transmission. The theory was based on the description of Ye Tianshi that: "The warm evil attacks the body from the upper. It invades the lung first, and then spreads reversely into pericardium. "This indicated that the evil may spreads from wei phase into Lung Meridian, since defence qi ,
(wei) is communicated with the lung. Also the evil may spread from wei phase into ying phase, because the ying (nutrient qi) is communicated with the heart. This transmission is called reversal transmission to pericardium. The heart belongs to fire and lung to metal. Fire restrains metal. So, the transmission direction from lung to heart is thought reversa1:Some
other doctors, such as Wang Mengying,
held that: "Warm disease starts from upper-jiao and is in wei phase
o - e e e e
The
spreading of evil from wei downward to qi is called sequential transmission; while that from wei inward into ying is called reversal transmission. Sequential transmission is named in contrast to reversal transmission. "The reason by which a reversal transmission takes place is related to the situation of the patient and the nature of evils. T h e actual order by which disease transmits varies with the kind of evil, the severity of the infection,the condition of patient and the treatment given to the patient. This is what Chen Pingbo said: "Wind-warm'attacks the exterior of the body, the lung and stomach respond to it ;while wind-warm invades the interior, the lung and stomach are involved. "This indicates that wei phase and qi phase are separated absolutely. Since the wind belongs to yang, warm can transform into heat, wind and fire enhance each other ,the pathological process is variable. Usually when an exterior syndrome has not yet ceased,an interior heat has already initiated. Under this condition, the disease is in wei and qi phases simultaneously. In addition ,disease may begin at qi or ying phase, the heat is excessive ,no manifestations of wei phase syndrome can be found. Sometimes, the heat spreads widely and all the q i , ying and xue phases are involved. Under this condition, heat syndrome of both qi and xue,or of both qi and ying phases occurs. Sometimes the disease begins at wei phase and then spreads directly into ying phase,qi phase is not involved. This is just the so-ca11ed"reversa1 transmission into pericardium. "In clinical practice, doctors should flexiblely apply wei-qi-ying-xue syndrome differentiation according to the concrete condition of disease, rather than rigidly adhering to the principle of transmission. @
345
*
I. Wei Phase Syndrome Wei phase syndrome is the initial stage of warm disease, which is caused by exogenous evil attacking the exterior of the body. The pathology is that the exogenous evil attacks the skin ,the defence qi fails to consolidate the exterior. Since the lung controls skin and defence qi communicates with the lung, the lung will be involved when the exterior is attacked by evil. The defence qi is abnormal. S o , wei syndrome is usually accompanied by symptoms of Lung Meridian.
Clinical Manifestations :Fever, slight chill, red tip and margin of the tongue, floating and rapid pulse. Other symptoms, such as headache, slight thirst, cough, sore throat ,can be found.
Analysis: Warm-heat evil attacks the exterior of the body and makes defence qi disharmony and the lung fails to disperse and descend. Fever occurs when defence qi and the evil are fighting. Slight chill takes place when defence qi fails to consolidate the skin. T h e red tip and margin of tongue show the evil in the exterior. When defence qi is fighting against the evil ,the qi and blood circulation is accelerated ,so the pulse becomes rapid and floating. Headache is due to heat occupying in head. Thirst occurs because body fluid is consumed by the heat. Cough is due to dysfunction of lung to disperse. Throat and pharynx are the window of lung ,so sore throat may occur when lung is ill.
11.Qi Phase Syndrome The syndrome occurs when the warm-heat evil in wei phase is not dispelled,or the evil invades directly into the interior. In qi syndrome, the genuine qi is sufficient while the evil is exorbitant, they fight each other. The heat is predominant ,so a series of symptoms of heat appear. The types vary with the-location of evil. The syndrome can be subdivided into several types, i. e. heat congestion in lung, heat impairing chest and diaphragm, heat stagnation in gallbladder, excessive stomach
Clinical Manifestations :Fever without chill ,aversion to heat ,thirst and desiring for cold drinking, profuse sweating, red tongue with yellow coating, rapid pulse. In addition, the different types havk their own symptoms :
A. Heat congestfan in lung: cough, asthma, dyspnea, nasal flaring, pain in chest ,yellow sputum ,even wheezing and convulsion.
B. Heal impairing chest and diaphragm :restlessness, or indescrible vexation, chest distress, nausea. 346
C. Heat stagnation in gallbladder: bitter taste in mouth, hypochondriac pain, nausea, restlessness ,scanty yellow urine.
D. Excessive stomach heat :high fever ,profuse sweating ,extreme thirst and desiring for cold drinking ,surging pulse.
E. Heat in stomach and intestines: tidal fever, abdominal pain with distention and hardness, aggravated by pressing, constipation, or heat-fecaloma with greenish watery stool. T h e tongue coating is yellow, thick and dry, even in brown or black with thorn-like substance. Pulse is forceful.
F. Damp-heat stagnation :stuffy chest, abdominal distention, weak extremities, fatigue, scanty urine, soggy pulse.
Analysis: Fever occurs when genuine qi and evil are fighting. The heat is in the interior rather than in the exterior ,so there is not chill and the patient feels aversion to heat. Thirst occurs when body fluid is consumed by the heat. The heat steams interiorly ,so there is profuse sweating. The tongue picture and pulse condition show the interior heat.
A. Heat congestion in lung: Heat evil in lung makes lung qi fail to descend, then cough ,asthma and dyspnea appear. The nose is the window of lung, so there is nasal flaring. Heat evil stagnates in lung, the qi and blood could not flow smoothly, then the chest pain occurs. The fluid in lung is boiled up by heat ,it is transformed into phlegm, so there is
ell ow
sputum and wheezing. If the heat transforms into
inner wind, convulsion may occur.
B. Heat impairing chest and diaphragm :Heat evil stagnates in upper-jiao ,the chest and diaphragm are obstructed, then the mind is influenced, restlessness and vexation occur. Qi flows unsmoothly due to heat stagnation, this gives rise to nausea.
C. Heat stagnation in gallbladder :Shaoyang Meridian is located in hypochondrium. When heat obstructs in the meridian, the qi fails to flow smoothly, then hypochondriac pain occurs. When heat evil boils the bile, the bile overflows upward, there is a bitter taste in mouth. The heat attacks stomach, stomach qi flows rebelliously and nausea occurs. The heat gives rise to scanty and yellow urine since body fluid is consumed. D. Excessive stomach heat: The stomach is the sea of water and food ,and the source of qi and blood of all meridians. So ,heat evil in stomach may spread over to the whole body through twelve meridians. In this condition, high fever occurs and the patient feels aversion to heat. Heat evil burns in the interior ,forces body fluid outside, then profuse sweating appears, and therefore, body fluid is consumed, the *
347
patient feels thirsty and drinks much of cold. Surging pulse is the sign of exorbitant heat in the interior which accelerates the circulation of qi and blood.
E.Neat in stomach and intestines: Tidal fever peaked at 3 : 00-7 : 00 p. m. shows heat accumulation in the interior. Heat consumes body fluid and produces dry stool stagnated in large intestine. that causes constipation. It is just like a boat being unable to travel in a dry river. The dry feaces and heat obstruct qi flow and gives rise to abdominal distention and pain, even heat-fecaloma with watery discharge. The tongue picture and pulse condition signify the interior heat.
F.Damp-heat stagnation :Damp-heat -
stagnates in the interior and the yang-qi
in chest and abdomen fails to circulate normally, then fullness and distention of chest and abdomen occur. The spleen dominates wetness and the extremities, so when dampness stagnates in the interior, lassitude occur. Soggy pulse is due to dampness over spreading in vessels.
111.Ying Phase Syndrome Ying phase syndrome appears at the dangerous stage of warm disease which
signifies invasion of the warm-heat evil into the interior. The nutrient qi ( y i n g ) and the blood, which communicate with heart qi, are the essential nutrients for maintaining the human life. So, the primary pathology of ying syndrome is the consumption of nutrient qi and the disturbance of the mind. If the disease changes from ying phase outward to qi phase, the disease is improved, while if the disease spreads from ying phase inward into xue phase ,the disease is getting worse.
Clinical Manifestations: Fever peaked at night, restlessness and insomnia, slight thirst or no thirst, dim rashes under skin, purple tongue, thready and rapid pulse. If the evil spreads reversely into pericardium, there will be delirium or coma, sluggish tongue and cold limbs besides above symptoms.
Analysis :The heat invades into the yin part of the body and consumes the nutrient qi,so fever has its peak at night. Nutrient qi communicates with the heart the heat in ying phase will influence the mind,then restlessness and insomnia appear. The heat steams nutrient qi and the mouth is then moistened by nutrients ,so only slight thirst is found ,or the patient feels no thirst. The heat damages vessels, the blood overflows out from vessels, then rashes appear dimly under skin. Purple tongue means heat in ying phase. Thready pulse signifies deficiency of nutrient qi. If the heat is more exorbitant and spreads reversely into p e r i ~ a r d i u m ~ s t u p oorr coma will appear. If heat combins with phlegm stagnation in the heart, tongue then becomes sluggish, because tongue is the window of heart. The deeper the heat is 348
the more serious the obstruction of yang-qi is ,so cold limbs appear.
IV.Xue Phase Syndrome Xue phase syndrome is the last and most dangerous stage of the process of warm disease. It is usually transformed from ying phase syndrome. Since the heat deepens into the xue (blood) ,its primary pathology is hot blood overflowing and the inner wind produced by the heat. The liver stores blood, when heat invades blood (xue) ,the heart and liver are involved. The kidney belongs to water ,genuine yin is stored in the kidney. If the heat remains in the body for a long time ,it will surely consume genuine yin and impair the kidney. In xue phase syndrome, the heart ,liver and kidney are involved.
Clinical Manifestatiom : There are three main types of syndromes in r u e phase syndrome :overflowing of hot blood ,wind produced by heat in blood ,and consumption of genuine yin. ( 1)
Overflowing of hot blood :fever peaked at night, restlessness, madness or
unconsciouness
, rashes, spitting blood, apostaxis , hematuria , hemotochezia , en-
dometrorrhagia ,purple tongue and rapid pulse.
( 2 ) Wind produced by heat in blood :high fever, coma, convulsion, neck stiffness, opithotonus (contortion of the body and limbs) ,fixed eyes, lockjaw, purple tongue and rapid pulse.
(3) Consumption of genuine yin :tidal fever and hectic cheek in afternoon, hot sensation in the five centers, bone-steaming symptoms, dry mouth and throat ,palpitation, fatigue, deafness, sunken and faint eyes, twitching in limbs, hoarseness, emaciation, dry teeth, shrinkage in dry lips, dry purple tongue, rapid and weak pulse.
Analysis :Xue phase syndrome occurs when ying phase syndrome is not cured or the evil in qi phase invades directly r u e phase. Under this circumstance, the heat and the condition of disease are more serious than those of qi and ying phase syndromes. The heat disturbs the mind in heart, leading to fidget, coma or madness. The heat acts on blood circulation and vessels, so macula, rashes or bleeding appear. The heat, when being exorbitant, will consume blood, and blood is then deficient and unable to nourish the liver, this leads to endogenous wind. As a result, the tendons contract ,convulsion and opisthotonus appear. Laogong in the palm is an acupoint of Heart Meridian, and Yongquan in the pole is a point of Kidney Meridian. The heat may spread over along the two meridians ,leading to hot sensation at the five centers. Dry mouth and throat appear when body fluid is consumed. 349
Deafness occurs when kidney essence is not enough to nourish ears. When kidney essence and yin (water) are not enough to assist heart yin, heart yin is also insufficient, then the heart is malnourished and palpitation occurs. When kidney yin is exhausted ,as a result ,all yin of the body is insufficient, then sunken and faint eyes, and twitching limbs can be seen. Shrinkage of lips appears when the heart is involved. Contraction of tongue shows that spleen is involved. Hoarseness occurs when lung yin is in shortage. If whole body fluid is insufficient, the body becomes thin and dry.
Appendix :Modern Researches on Wei-Qi-Ying-Xue Syndrome Differentiation In regard to wei-qi-ying-xue syndrome differentiation, wei syndrome relates to the body's defensive and compensatory function qi syndrome mainly reflects disorder of physiological function and metabolism. Their clinical manifestations are obvious but reversible. Recovery can take place when the evil is expelled out. Ying syndrome reflects the deterioration of the disease and severe impairment of tissues and viscera. The symptoms become worse. Decline of immunological function, disturbance of water-electrolyte and acid-base balance ,even failure of organs are the main changes. Clinical studies have proved that the main pathological changes of wei syndrome appear at the predromal stage of acute infectious diseases, or at earlier symptom-appearing period ,and are characterized by inflammation of upper respiratory tract and neuro-vascular response. The local pathological changes of wei syn-
clouding tumefaction ,and dysfunction of internal organs. In ying syndrome, some special pathological changes of infectious diseases become serious further. In addition to those above ,the pathological changes are also characterized by obvious degeneration, necrosis, dysfunction of central nerve system, abnormal blood coagulation, and toxic injuries of several important organs, such as central nerves, heart, lung, kidney and liver. The responsiveness and defensive abilities of the body become weakened ,and there are also DIC. Generally speaking ,when the disease is in wei phase or qi phase, the main pathological changes are of function and
metabolism, including congestion, edema and degeneration of cells ;when the disease is in ying and xue phases ,the basic pathological changes are of degeneration and necrosis in certain organs and tissues ,and the corresponding dysfunction. 350
Table Fever and chill
whole body
Wei-Qi-Ying-Xue Syndrome Dif f erentiatim Diet
Defecation &
Mental State
Pulse
Tongue
floating
white and
Urination Ur,i phase fever and slight
chill or no chill
Qi phase
no sweating or
slight
slight sweating ,
thirst
thin, red
headache ,stuffy
tip and
nose, cough,
margins
sore throut
of the tongue
no chill, aversion sweating, cough,
thirst
yellow urine,
indescrible
surging ,
from white
vexation
or rapid
to yellow, red tongue
to heat ,or fidal
asthma ,abdominal
constipation ,or heat-
fever
distention and pain,
fecaloma ,burning
and forceful,
chest distress,
sensation
or deep
hypochondriac pain
around the anus
and forceful
Ying
fever peaked at
dim rash under
no
delirium or coma, rapid
crimson
phase
night
the skin
thirst
insomnia ,or
tongue
sluggish tongue and cold limbs macula or papula , various bleedings ,
helirium or coma, feeble, or spasm or thready and
purplish
sensation in five centers ,or fever
heavy palpitation,
twitch of limbs
rapid ,or
tongue,
taut and
less coating
Xue phase high fever, hot
peaked in after- deafness ,dry noon,
teeth, hoarseness,
flushed cheeks
emaciation
rapid
crimsom
Section 3
Triple- Jiao Syndrome Differentiation
Although triple-jiao syndrome differentiation was built by Wu Tang, actually, it was initialed in Ye Tianshi9s work which stated: 6 T h e disease due to seasonal evil of warm-heat nature should be treated according to triple-jiao. "In his book ,it was proposed to utilize pungent-cool' herbs to treat upper-jiao disease, bitter-cold herbs to treat middle-jiao disease ,and salty-cold herbs to treat lower-jiao disease. Wu Tang also said: "Use herbs as light as feather in nature to treat upper-jiao ,because only the light can rise there;use herbs with balancing action to treat middlejiao ,because middle-jiao can not get equilibrium without balance ;use herbs with heavy nature to treat lower-jiao,because only heavy herbs can go down to lower.
"
From this statement, we can find Ye's influence in it obviously. Wu ,based on Ye's wei-qi-ying-xue syndrome differentiation theory and the rules by which warm disease develops and spreads graised that the triple-jiao syndrome differentiation system should be applied as the principle of warm disease differentiation, and wei-qiying-xue syndrome can be included in triple-jiao system. According to Wu ,warm disease initiates in upper-jiao ,the lung and pericardium are involved ;the upper-jiao syndrome will transmit into middle-jiao if it is not cured ,and middle-jiao syndrome mainly involves the spleen and stomach; the middle-jiao syndrome can transmit into lower-jiao if the evil is not expelled,and the lower-jiao syndrome is located in liver and kidney. In fact ,the system is the concrete application of visceral syndrome differentiation in the field of exogenous diseases. Therefore, the triple-jiao syndrome differentiation can supplement the theory of wei-qi-ying-sue syndrome differentiation,and enrich the content of visceral syndrome different'
'
Warm disease is a general term for all the acute febrile diseases caused by warm-heat evil of the four seasons. The disease is different in clinical characters and types since the climate varies with seasonal changes ,the evils which tke patient catches are different. And there is also constitutional difference of responsiveness. According to the nature of disease ,the warm disease can be divided into two categories :warm-heat disease and damp-heat disease. i n spite of some common points, these two kinds of diseases differ from each other in main part. In damp-heat disease, the dampness is primary. Dampness is an evil of yin in nature. It usually damages the yang-qi and remains in wei and qi phases. In addition ,dampness is heavy, descending and turbid in nature. It usually spreads in triple-jiao. This is as Wu said : "Dampness 352
*
nee
when attacking the body, will impair the lung in upper-jiao ,
then the spleen in middle-jiao ,finally the kidney in lower-jiao. "Based on this ,some doctors held that the triple-jiao syndrome differentiation was mainly applied to the differentiation of damp-warm disease. It should be pointed out that doctors ,when applying the triple-jiao syndrome differentiati~n~should notice that the diseases do not always initiate in the lung of Hand-Taiyin, because the evils differ in nature and .the patients differ from each other. For example, when damp-heat diseases occur, the main pathogenesis is usually in the spleen of Foot-Taiyin. Another example is summer-heat disease which occurs usually with the symptoms of the liver of Foot-Jueyin or of the pericardiurn of Hand-Jueyin. This is just as Wang Mengying said :"Warm diseases can be differentiated in forms of triple-jiao syndromes, but this does not mean that warm diseases always initiate in the upper-jiao and then gradually transmit into the middlejiao and lower-jiao. Evil can hide in the interior of the body ,sometime it may initiate in the lower-jiao. The stomach is an organ where turbid things usually remains ; so damp-heat disease or epidemic disease sometimes occurs with the middle-jiao involved. Summer-heat with damp evil usually attacks the middle; summer-heat is fire ,fire and the heart correspond to each other, so summer-heat tends to attack the heart. All these conditions do not take place first in the meridian of HandTaiyin. "Additionally, middle-jiao syndrome or the lower-jiao syndrome may occur when the upper-jiao syndromes have not disappeared yet; the lower-jiao syndrome may take place when the middle-jiao syndrome has not subsided yet. Wu Tang ,in his work Treatise on Differentiation and Treatment of Warm Diseases, listed 11 kinds of warm diseases. They are wind-warm, warm-heat , warm pestilence, warm-poison ,winter-warm, summer-heat ,incubation of summer-heat
,
damp-warm, cold-damp, warm-malaria and autumn-dryness. The symptoms of these diseases differ largely from one another. As space is limited ,it is impossible to discuss all these diseases here. The common symptoms of triple-jiao syndrome are listed as follows:
11. Upper-Jiao Syndrome The upper-jiao syndromes mainly include the syndromes of the Lung Meridian of Hand Taiyin and the syndromes of the Pericardium Meridian of Hand-Jueyin.
31. Syndromes of Lung Meridian of Hand-Pfaiyimt
Clinical Manifestation :Headache, slight chill and aversion to wind, the skin temperature at chi-region being higher than normal ,fever and sweating, thirst or 353
*
no thirst but with cough; the fever being higher in afternoon,pulse being fast and large at both cun parts.
Analyses :The warm-evil enters the body from the mouth and nose. The nose acts as the window of the lung; the lung controls the defence-qi and correlates with the skin. When the lung is attacked by evils ,in the exterior ,the defence-qi will not function normally ,and in the interior, the lung fails to disperse. The evils stagnate in the lung, the fluid in the lung is consumed, then there are fever, sweating, thirst, cough and asthma.
2. Syndromes of Pericardium Meridian of Hand-J ueyin
Clinical Manifestation :Vague mind or coma, delirium, stiff tongue and cold limbs, purple tongue.
Analyses :The warm-evil ,when invading into the human body from the upper, attacks the lung firstly. If the evil in the Lung Meridian is not dispelled, it may transmit reversely into the pericardium. The heart controls the mind ;the pericardium functions for the heart ,so when the pericardium is attacked by evils ,the heart then fails to control the mind ,and symptoms such as vague mind and delirium,or unconsciousness, appear. The tongue is the window of the heart, when the pericardium is invaded by warm evil, the tongue will become stiff. If the evil deepens further and the heart-yang is stagnated and fails to distribute to the extremities, cold limbs occur. Purple tongue is the manifestation of exuberant heat.
HI. Middle-Jiao Syndrome T h e middle-jiao syndromes mainly include the syndromes of the Stomach Meridian of Foot-Yangming and syndromes of the Spleen Meridian of Foot-Taiyin. Wu Tang said :"Wind-warm ,damp-heat ,warm-pestilence ,winter-poison ,and winter-warm ,all these diseases manifest mostly as Yangming syndrome when they are in the middle-jiao ;while damp-warm ,when being in the middle-jiao ,often fests as Taiyin syndrome. Summer-heat-warm ,when being in the middle-jiao ,manifests half as Yangming syndrome and half as Taiyin syndrome.
"
1.Syndrome of Stomach Meridian of Foot-Yangming Clinical Manifestation :Aversion to heat ,no chill, tidal fever at 3 : 00-7 :00 p.
, flushed
m.
cheek and conjunctival congestion, hoarse voice, rough breathing,
thirst, sweating, constipation, difficulty in micturition, dry dark-yellow coating, even dark coating with thorn-like substances on the surface; surging and fast a
354 a.
pulse.
Analyses :Yangming belongs to dryness. So evils, when invading the Yangming Meridian, transforms into dryness. Warm-evil, when transmits into Yangming, sometimes manifests as invisible heat which spreads out all over the body, sometimes makes faeces dry and hard. Doctors can differentiate them from each other by observing whether there are abdominal pain, hardness ,distention and constipation, and by feeling the pulses. If the pulse is surging and large ,it is a meridian-heat syndrome of Yangming ;if the pulse is deep and vigorous, it is an interior excess syndrome of Yangming.
2. Syndrome of Spleen of Foot-Taiyin Clinical Manifestation : Tidal fever in afternoon without subsidence after sweating ,fullness of the chest and epigastrium, loss of appetite, nausea, heavy and tired limbs ,loose stool, greasy coating, soggy pulse and so on.
Analyses :Taiyin controls dampness ;so evil entering Taiyin often transforms into dampness and leads to damp-warm syndrome. Since the spleen is a zang-viscera of damp-earth in nature ,damp-warm evil tends to attack the spleen. The heat is hindered and the damp is s t a g n a t e d ~ s othere is insidious fever. Dampness is an evil of yin in nature and tends to become more exuberant in yin period ,so there is tidal fever in afternoon. The lucid yang is blocked, the damp in the spleen stagnated in the chest and epigastrium and not removed,this leads to fullness of the chest and epigastrium and nausea. There will be heavy and tired limbs because the spleen controls the four limbs and muscles. The turbid damp remains in the interior , s o soggy pulse and greasy coating appear; As the disease develops, the stagnated dampness transforms gradually into heat, then appearance of heat is getting obvious.
111. Lower-Jiao Syndrome The syndromes of the lower-jiao mainly include the syndromes of the Kidney Meridian of Foot-Shaoyin and the syndromes of the Liver Meridian of Foot-Jueyin. Warm evil tends to damage the body f1uid;so when warm diseases transmit into the lower-jiao ,liver-yin deficiency syndrome or kidney-yin deficiency syndrome is often found.
1. Syndrome of Kidney Meridian of Foot-Shaoyin
Clinical Manifestation : Fever and flushed cheek, hot sensation at the palms 355'0
and soles, bone-steaming sensation ,dry mouth and tongue ,restlessness and insomnia ,lumbago and soreness of the legs, tired mind ;weak and fast pulse.
Analyses :The kidney stores yin-essence. If the heat evil remains in the kidney for a long time, it will consume the kidney-yin, then there are fever, flushed cheeks ,hot sensation at the palms and soles ,lumbago and soreness of the legs. T h e yin is co~isumedand the body fluid is insufficient, so there are dry mouth and tongue. The kidney-yin is too deficient to nourish the heart ,and the heart fails to control the mind ,then tired mind ,restlessness and insomnia are found.
2. Syndrome of Liver Meridian of Foot-Jueyin
Clinical Manifestation :Twitch of the limbs, even spasm or convulsion, heavy palpitation, pain in the center of the chest, restlessness, unconsciousness, cold limbs ,atrophy of the tongue and testicles ;purple tongue ,weak and fast pulse.
Analysis: The liver is a zang-viscera of wind and wood in nature ,it needs to be nourished by the kidney-water. If the kidney-water is consumed and not enough to nourish the wood (the liver) ,endogenous wind will occur and symptoms mentioned above (e. g. twitch of the limbs, spasm or convulsion or syncope) appear. Spasm, which is recorded firstly in the Plain Questions ,refers to involuntary muscular contraction of the limbs, lockjaw, stiffness of the neck, contortion of the body and so on. Syncope refers to syndrome with the coldness of the limbs ,delirium or uncon/ ' -
sciousness. All the pathological changes due to exuberant heat-evil or deficiency of the genuine essence may lead to convulsion or syncope. Convulsion is usually caused by exuberant heat, while syncope is often due to endogenous wind of deficient nature. Here syncope occurs because that the warm-evil invades into the lower-jiao and gives rise to endogenous wind. Involuntary muscular contraction of the limbs is due to that the blood is too deficient to nourish the tendons. Heavy palpitation refers to an awareness of violent heart beats ,accompanied by a feeling of unsteadiness and hollowness. Among the eight extra-meridians ,Yinwei Meridian is subordinate to the liver and kidney,it flows into the heart. If the liver-yin and kidney-yin are consumed, the Yinwei Meridian is then lack of nutrients. Additionally, the water is too insufficient to balance the heart-fire, the heart-yin is also consumed ,so there are heavy palpitation ,pain in the central chest ,purple tongue with little coating ,weak and fast pulse ,and so on. The diagnostic significances of wei-qi-ying-sue syndrome differentiation system and triple-jiao syndrome differentiation system reside in that they can be applied to determining the pathological sites ,to analyzing the pathogenesis 9t0 realize
356
e
ing the spreading of diseases ,and to providing basis for the treatment. Between the two systems there are something in common as well as something in different. For example, syndrome of the Lung Meridian of Hand-Taiyin is similar to w e i syndrome ;the heat stagnation syndrome of the lung without exterior symptoms is approximately equal to qi syndrome. On the other hand, the lower-jiao syndromes ,in which the evils are in the liver and kidney ,differ from s u e syndrome. The former is n consumed by heat; a deficient syndrome in which the liver-yin and k i d n e ~ - ~ iare while the latter is a syndrome of excessive nature in which the blood escapes from the vessels because of the heat. Generally speaking, these two differentiation systems are correlated t o , and differ from, each other. So only when they are considered together in clinical practice, better diagnosis can be reached for exogenous warm diseases.
Chapter 1 2 Medical Record The medical record was called "case note" in ancient time and had a popular name of"pu1se record. "It is also called medical history or case history in modern time. It is the objective record of the whole process of inspecting patient, making diagnosis, analyzing disease condition, treating and nursing. Not only the clinical data but also the doctor's thought and action about the patient and diseases are recorded. It is the important basis for syndrome differentiation ,making therapeutic plan and predicting prognosis. It is also the main information for return visiting, transferring ,case report and discussing for patient. It may be the data for examining doctors and legal investigation in some occasions. I t is prerequisite for treating disease to record all the clinical data precisely and systematically. The medical record can provide valuable information for medical education because it records all important clinical data. The records can serve as models for students to do syndrome differentiation and lay out treatment plan. When summing up the TCM theories and the clinical treatment experiences ,it is important original data for clinical research. So,the medical record is very important for all aspects of medicine.
Section 1 T h e Attentive Items for Writing Medical Record 1. The record must be written seriously ,attentively ,objectively and precisely. The in-patient history should be done in 24 hours after the patient is admitted. The hospitalizing record for emergency condition should be done as soon as possible. The items should be filled in detail according to the objective facts. Never write record by inference or supposition.
2. The record should be written systematically and completely. The description about the symptoms should be accurate and clear. The main symptom should be described in detail. overlaborate and disorganized descriptibn should be avoided. The TCM terminology should be used,so as to show the TCM character.
3. The ink pen is required for writing record. The writing should be clear and neat. The language should be concise. The record will be invalid if altered ,clipped and pasted together. The sheet should be put in order. 359
4.The patient's name ,admission number and page number should be written on all sheets in record. The date should be written in standard form. The titles of an independent record should be written in the center of the line above the content.
5. At the end of each recorded content, the doctor who writes the record should sign his/her full name in regular script. When the senior doctor checkes and makes correction in red color ,the senior doctor should also sign his/her full name.
Section 2
The Contents of Medical Record
In the history Record, there were primitive case records. From t h a t , the medical record have become popular gradually. Some doctors, i. e. Li Chan, Wu K u n , Han Mao and Yu Chang ,had made their record forms. Some of them are similar to that of modern time. There are two kinds of medical records the out-patient record and in-patient record.
I.The Form and Detail of In-Patient Record I. General Items Name :
Sex :
Age :
Birth Place :
Nationality :
Marital State :
Occupation :
Employer (Organization)
Interrogating Time :
Reciter for disease :
Reliability :
Onset Season and Solar Term:
:
Address :
2. Data from Interrogation A. Chief Complaint This item records the symptom and its onset which are the chief suffering of the patient and the main reason bringing patient to medical attention. If they are composed of more than one symptoms, the symptoms should be recorded in the order of occurring time. This item should be concise and clear. The description in360
@
cludes the location ,character and time of the symptoms. The following description 66
High fever with chest pain and cough for two w e e k ~ ~ e x p e c t o r a t i nof g pus and
blood sputum for three days. "is an example of chief complaint.
B. Present History The whole course of present disease should be described around the chief complaint. The onset time, cause, predisposing cause, development, the character of chief complaint and the accompanying symptoms of the present illness should be recorded in detail. The description should be made in TCM terminology. The examinations ,treatment and the effect before consultation should also be recorded. The present symptoms are the major items. The present symptoms should be recorded focusing on chief complaint and in the order of theL6tenquestions". Some important aspects, for example, the diet, sleeping, defecation and urination, should be recorded even there is no morbid change. The degree, location and character of symptoms should be recorded accurately and completely ,so as to provide data for making a diagnosis. C. Alaamnesis (Past History) In the item, the past diseases, including infectious disease, trauma and operation ,and health condition are recorded. The diseases should be recorded in the time order. The onset time, lasting time, if there is complication, the result should be written down. Because the previous disease is related to the present disease to some degrees ,the present illness may be the continuous process of previous disease.
D. Personal History Personal history includes the birth place, the places patient has been,and the time he/she spents there,so as to know if it is possible that the patient suffers endemic disease or infectious disease. The living condition and working environment, the habit, the addiction to some food or drinking, the mental state and disposition all are the personal life. These may be the causes of disease or the factors affecting the development of disease.
E.Menstruatlo~a The age of menarche, the duration, the interval of the menstruation ,any pain, the date of nearest menstruation or age of menopause,and the color ,quality and quantity of the menses should.be written down if the patient is female.
F. Marital and-Obstetrical History The age of marriage ,the childbearing history and the health status of the husband should be written down. a
361
,
6,Family Hiistory The health status of the parents and children of the patient and if they are suffering some hereditary diseases or infectious illness should be recorded here.
3. Observation Data
A. General Status The content includes the mental state ,facial complexion, body shape and moving state of the patient.
B. Local Condition The shape, color, movement, deformation and other morbid changes of the head, face, eyes, nose, ears, lips, skin, gum, throat, nails, neck, chest, abdomen, back ,limbs and meridians are recorded in this item separately,
6.Excreta The quality, quantity and color of the sweating, vomitus, sputum, nasal discharge, tear, blood, pus and discharge from sore, defecation and urination are recorded hear.
D. Tongue The item records the morbid changes of the tongue and its coating including the vessels below the tongue.
4. Data from Auseufttation and Olfaction A. Sound: The record includes the morbid sounds of speech, cough, asthma, hiccup, vomiting, sighing, moaning and borborymus.
B.Odors :The
item records the morbid odors given off from the mouth ,sweat-
ing, sputum, vomitus ,feces and urine of patient.
5. Data From Palpation hypochondrium ,abdomen, trunk, limbs and acupoints is written down.
B.Pulse: The pulse in cunkou should be recorded in detail. The pulsation in cun, guan and chi of both sides should be written down respectively. Some times, the pulse in all three portions and nine takings is necessary. If the patient is in dangerous ,the renyin and fuyang pulses should also be palpated and recorded.
6. Analysis f s r Syndrome Difff eren$ia&ion This is to analyze the clinical data systematically and briefly according to TCM 362
a
theories. The analysis is done from the aspects of cause ,location ,nature and the development of the disease. T h e deduction should be reasonable, concise and on a \
sound ground. Many symptoms and signs appear when disease occurs. Those clinical data should be sorted out and analyzed to meet the requirement of syndrome differentiation. The following aspects are the focal points when analyzing and sorting out da-
ta. A. The chief symptom and accompanying symptoms :When the chief complaint is known, the accompanying symptoms are important. For example, when the chief symptom is abdominal pain, if accompanied by hard abdomen, fever, yellow urine, yellow dry coating ,deep and forceful pulse ,it is an excess syndrome of Yangming; if accompanied by chill ,clear urine ,white coating ,deep and slow pulse ,it is a deficiency cold syndrome of middle-jiao.
B. The positive symptoms and negative symptoms :The negative symptoms are as the same important as the positive symptoms when making differential diagnosis. For example, when differentiating Taiyang visceral syndrome, the morbid urination means qi-phase syndrome while the normal urination indicates the blood syndrome. In this case ,the negative symptom is the normal urination. C. The primary symptom and secondary symptom: The time order of symp-
toms is helpful for identifying the development of disease. For example, the fever and chill are present firstly, then the chill disappears and the fever becomes high, and excessive sweating and extreme thirst appear. That course demonstrates the disease transmitting from exterior to interior. Another example, if the mental depression and hypochondriac distention precede the poor appetite ,it suggests the liver disease implicates the spleen.
D. The symptoms relating to different viscera: By analysis the relation between those symptoms, the main location of disease can be found. For example, the chief complaint is asthma, other symptoms includes lower voice of speech ,shortness of breath, intolerance to cold, cold limbs, edema in feet, lumbago, pale tongue with white coating ,weak pulse. In this case, the asthma ,shortness of breath belong disease is in the kidney to symptoms of lung and others to kidney. So the"r00t~~of and the "branch"is in the lung. When making syndrome differentiation ,usually the order is as follows.
A. Distinguishing the exterior from the interior syndrome :By using the eight principle syndrome differentiation, the exterior syndrome can be ascertained. If it is 363
an exterior syndrome, it can be further analyzed by using six meridian syndrome differentiation, triple-jiao syndrome differentiation, defensive-qi-nutrient-blood syndrome differentiation. If it is not an exterior syndrome, it is an interior syndrome ,the visceral syndrome differentiation should be used further.
B. Identifying the nature of disease :It is to identify the cold and heat, the deficiency or excess.
C. Finding out the Location of disease :It is to judge the disease being in certain viscera or in certain meridians.
D. Searching the cause: If only the disease cause is clearly checked o u t , the disease can be cured fundamentally.
E.Explaining the development of disease :From the change of disease, the tendency of the disease can be found,so the prognosis and further treatment can be made out,
7. Diagnosis The diagnosis is the result of analysis. It includes the disease name and syndrome name. The cause ,location and mechanism of disease should also be included.
If there are more than one disease or syndrome name ,they should be listed according to the importance. They are listed as the following examples.
disease name
syndrome name Overfatigue damaging spleen yang ,the middle qi sink-
Diarrhea
ing Common Cold
-
wind-cold transforming into heat ,dysfunction of lung
I-lemoptysis
ql the wood-fire scorching the metal, the Lung Collater-
Jaundice
yin-jaundice ,cold-dampness retellti011 with blood staSlS
The diagnosis is a preliminary one. Whether it is corresponding to the fact ,it should be testified further. The response after treatment and the further development can testify the preliminary diagnosis. The wrong diagnosis is mainly due to the one-sideness in analyzing or due to the incomplete expression of disease. So the diagnosis should be reviewed continually. 364
,
8. Principle of Treatment and Therapy The treatment principle should be made out according to the syndrome differbe treated firstly; entiation. When the disease is emergent, the 66branch99should vvhile the disease is chronic, the"root9'should be treated. The therapy should also be recorded.
9. Prescription When the prescription is made according to a given formula ,the formula name should be written down. If the prescription is designed by the doctor, the name is not needed. The herbs should be listed in the fixed form: three or four herbs in one line, the dosage at the right lower corner, the preparing method at the right upper position ,the administration after the herbs in another line. The herbs should listed according to their role in the prescription, the main in the first, the secondary following the main.
,
10. Nursilrag The diet ,daily life and other nursing items are recorded hear.
11. Signature Finally,the doctor should sign his/her name to take the responsibility. T h e following is an example of in-patient record.
In-Patient Record Name :Hu Mumu
Sex :male
Age :46
Birth Place :Beijing
Nationality :Han
Marital State :married
Occupation :worker Employer (Organization) :No 4 Factory of Install Company Address :4 , Donsongnian Hutong ,Dongcheng District, Beijing Admission Date:3:30 P. M. ,Feb. 2,1982 Interrogating Time :5 :30 P. M. ,Feb. 2,1982 Reciter for disease :The patient himself Reliability :yes Onset Season and Solar Term: 3 days before Rain-Water
Data ff ram Pnterrogatiasn Chief Complaint : Fever ,chill and cough for 2 days ,pain in right chest for half a day.
History of Present 11Ihess: After exposing himself in cold, he felt headache ,nasal obstruction, heavy sensation in whole body, running nose with clear nasal discharge, cough, chill and slightly fever in Feb. 20. There was no sweating in that time. In the next morning, all the symptoms became severe. At 3 o'clock p. m., the shiver occured. So the patient came to our hospital to get treatment. In that time, the body temperature was 39 degree centigrade. The doctor made a diagnosis of common cold and prescribed Power for Common Cold, Co. Tablet of SMZ and Co. Amidopyrine Injection. Besides those medicines, the patient took ABC tablet. After that ,the fever and chill became more severe and aggravated at night. The breath became rough and vexation took place. In this morning, the patient felt pain in right chest. If breathing deeply ,the pain was aggravated. There were dark red sputum expectorated out. So the patient came to the emergency department of our hospital again. After that ,the patient was hospitalized.
Present Symptoms : Fever slightly abating after sweating, chill sometimes becoming shivering, flushed face, red eyes, headache radiating to nape, nose obstruction with yellow nasal discharge, cough with yellow sputum, slight rough breathing, radiating pain in right chest aggravated by deep breath, thirst liking cold drinking, pantalgia ,disturbed sleep, no defecation for 3 days, yellow scanty urine ,red tongue with yellow and slight greasy coating, floating rapid pulse in right cun portion, t a u t s1'lppery and rapid pulse in right cunkou.
Bast History : The patient was in good healthy status in ordinary times. No history of infectious disease and other chronic disease. No history of drug and allergy.
Others : The patient was born in Beijing. He had been in the northeast part of China, Suzhou City and Guangdong Province. The living condition was good. He was fond of hot and pungent food and drank a little. He smoked 10 cigarettes a day for more than 10 years. The disposition was sanguine. The patient got married in his 29 years old. His wife had a disease of chronic hemoptysis. They had a son and a daughter who were healthy. His mother was more than 70 years old and was 366
healthy. His father died in 1980 because of the disease of6'encephalomala'cia. 99
Observation : The general status: The eyes were vigorous. The mental activity was normal. The appearance was painful and tired. The body position and posture were free. The body was thin.
The local conditions : The hair was sparse and became gray with luster. The eyes were slightly sinking. There was no jaundice. The sclera was a little red. The pupils were equal and round. The nares was slightly flaring. The ears were red and moist. The lips were dark red and dry to be cracked. The teeth were normal. The throat was pink without swelling. The neck was soft without any lumps and nodule. The hands were keeping before the chest to protect the chest. T h e abdomen was normal. T h e back was normal. There was no deformation and edema in limbs. The skin was moist. There was no eruption found.
Excreta : The sputum was yellow and thick,easy to expectorate. There was little nasal discharge. Constipation. Yellow and scanty urine.
To~llglRe: The tongue body was normal. The color was red. The coating was yellow and slightly greasy.
A~seultatiioand OElf action : Sound :The speech was loud and forceful. The breath was rough and shallow. The sound of cough was resounding. No other abnormal sound heard.
Odor: There was slight odor in the mouth. No other abnormal odors were iound.
Pallpation : Skin :The skin was moist without shape change. The skin of forehead and forearm was hot. There was no swelling and lump found.
Chest and abdomen: The pulsation in Xuli was moderate. When pressing the right chest and upper abdomen,the patient felt severe pain. There was no mass in abdomen.
Pulse : cun left
taut ,slippery and
guan taut ,slippery and
chi taut ,slippery and 367
right
slightly rapid
slightly rapid
slightly rapid
floating, slippery
taut, slippery and
t a u t , slippery and
and rapid
slightly rapid
slightly rapid
The Summary of Clinical Data: Hu Murnu, male, 46 years old, worker. He was hospitalized at 3 : 30, Feb. 22, 1982,because fever 'and cough for 2 days and right chest pain for half a day. The disease was caused by exposing to cold. At the beginning, the patient felt headache, nasal obstruction ,running nose, slight cough, chill with slight fever, and no sweat. The next day, disease developed. In the afternoon, shiver appeared, the cough became frequent ,the sputum was yellow and turbid. The symptoms did not abate after taking APC. In this morning,the patient felt pain in right chest and expectorated dark red sputum. So the patient came to our hospital to get treatment. At that time', fever and chill, sometimes shiver, pantalgia, headache radiating to neck, nasal obstruction with turbid nasal discharge, rough breath, pain in right chest aggravated by deep breath ,sweating, thirst and like cold drinking ,no defecation for 3 days and yellow urine were the main manifestations of the disease. The tongue was red with yellow and slightly greasy coating. The pulse was slightly floating in left cun and taut, slippery and slight rapid in other portions. When pressing right part of chest and upper abdomewthere was obvious pain.
Analysis : Because the patient was thin and fond of hot and pungent food ,there was heat evil hidden in the body. T h e season was early spring, the cold qi was still strong and the wind was going to be prevalent. In that time ,the patient exposed himself -to cold,so he caught the cold-wind evil. The wind-cold in the exterior obstructed the defensive qi and yang ,so the headache, pantalgia ,fever and chill were present. The lung became dysfunction due to the evil , s o there was cough and nasal disorder. The evil produced heat and the heat entered the lung. The heat and phlegm obstructed the collateral of the lung,the qi and blood could not move,so the pain occured in right chest. T h e lung had an exterior-interior relation with the large intestine. The lung qi could not descend ,so the bowel losed its movement, then the feces stayed in the bowel. T h e body fluid was consumed by heat ,so the urine was yellow and scanty. The tongue and pulse were both the signs of heat and phlegm in body. The floating pulse in left cun meant the existence of evil in the exterior.
Diagnosis : - '.
Wind-Warm Disease Heat in Qi-Phase and Lung
7
I,
Treatment Principle : Dispersing wind and clearing up heat as the main strategy, Resolving phlegm ,dredging collateral to stop pain as the supplementary strategy
Prescription : T h e prescription was based on the formula of Powder off Eonicesa and
Forsythia in combination with Decoction of Ephedra, Apricot Kernel, Gypsum and Licorice. Ephedra 3g
Gypsum 30g
Forsythia log
Lonicera 12g
Peppermint 5g
Reed Rhizome 30g
Apricot Kernel log
Platycodon root log
Arctium fruit log
++
-
Luffa log Scutellaria root log Trichosanthes 30g ++ the herb should decocted 20 minutes before others were added into.
CcampatibiPity and Incompatibility : Keeping warmed, Avoiding cold. The uncooked and cold food and drinking should not be taken.
Nursing : Observation the sweating, pulse, facial complexion and breath attentively in case the high fever caused depletion of qi and yin.
Acupuncture : Selecting acupoints mainly on Foot Taiyang Meridian and Hand Yangrning Meridian to disperse wind and clear up heat.
Acupoints : Quchi (LI 11)
Hegu(L1 4 )
Fengchi (GB 20)
Dazhui (GV
14) Manipulation : Dispersion ;retaining the needle for 20 minutes. (omitted here) Doctor : (signification)
6 :20 P. M. ,Feb. 22 1982 o
369
II.The Form and Detail of Out-Patient Record The out-patient record is the record of the disease condition of the out-patient and ;he diagnosis and treatment the doctor makes. Because of the time limitation, the record is more simple than the record of in-patient. But the basic content is the same. T h e record should be concise and summered with main points emphasized. The whole process of diagnosis and treatment should be included in it. The requirement for writing an out-patient record is demonstrated as follows.
'
Genera8 Items : Name :
Sex :
Age : Nationality :
Birth Place : Marital State :
Occupation : . Address :
Employer (Organization) : Onset Season and Solar Term:
Visiting Date :
Departments :
No. of Out Patient:
Disease Condition : The chief complaint ,disease history,present symptoms and the date from examinations are written down in a concise way. If it is a return visit, the effect or disease change after the treatment given in the last visiting should be recorded.
Diagnosis The diagnosis of disease and syndrome differentiation are listed. If there is still time , a brief analysis should be made to support the diagnosis. The therapeutic principle, formula, drugs, dosage, preparing of herbs, administration and other matters relating to treatment should be written here clearly. The doctor signs his/her full name to end the record. The following is an example of out-patient record.
On&-PatientRecord in
Visiting Date :Aug. 3 ,1980
Series No. Name :Lu..
..
Marital State :married 370
a
. . . . TCM Hospital
Sex :female
Age :40
Birth Place :Jilin
Occupation :peasant
Add :Heilinzi ,Haide County
Cough and asthma for several years with prolapse of uterus in resent years. The patient had been suffering from cough and asthma for many years. Since last winter ,the disease had become severe and made the patient unable to lie flat. Aminophylline and Ephedrine have been token for relieving the ,disease. Now, the cough was severe ,there was yellowish thick sputum expectorated. The patient felt shortness of breath, palpitation, choke chest, dry mouth but dislike drinking, and difficult to fall into sleep. The stool was dry and the urination was frequent in little amount. When defecation and urination ,the uterus and rectum are prolapsed. The body was thin. Depressed appearance. The breath was rapid. The face was puffy and yellow. Edema was found in legs. The tongue was purple in its margin, the coating was white. T h e pulse was rapid and feeble.
Diagnosis : Cough, Uterus Prolapse Kidney Qi Deficiency with Lung Dysfunction At the beginning ,the disease was due to phlegm in the lung ,the lung did not function well, so there were cough and asthma. When disease developing, the lung qi became deficiency and implicated the kidney gradually. The kidney qi failed to control and support internal organs,so the prolapse of uterus and rectum was present.
Treatment The main principle was banking the earth to produce the metal and reinf0rcir.g kidney qi. The supplementary principle was to stop cough and relieve asthma.
Prescription Cordyceps 5g
Astragalus root 16g
Poria log
Glehnia root log
Schisandra fruit 8g
Prepared rehmannia 10g
Ass-hide glue log
Gingko nut 8g
Lepidium seed log
Platycodon root log
Fritillary bulb 8g
Scutellaria root 9g
2 dosage.
Administrati on Decoct with water. Take the decoction 2 times a day, morning and evening.
Nursing Avoiding wind and cold. Keeping rest.
Doctor : The following is an example for return visiting of the same patient in the above listed record. Aug. 6,1980
Internal Department
After taking herbs, the cough ,chest choke and edema were improved, the sputum was decreased. The uterus prolapse retracted back. Now the tongue was slightly red. The coating was thin and white. The pulse was deep and moderate. The prescription should not be changed because it was effective. Five dosages of the same prescription were given to the patient. Doctor :
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English-Chinese Collegiate Textbooks in Traditional Chinese Medicine for lnstitutions of Traditional English-Chinese Collegiate Textbooks in Traditional Chinese Medicine for lnstitutions of Traditional
Diagnostics of Traditional Chinese Medicine The Chinese Materia Medica Formulas of Traditional Chinese Medicine Traditional Chinese Internal Medicine Acupuncture and Moxibustion
gf-gq Chinese-English Dictionary of Traditional Chinese Medicine .
;.E$Egqi3& ISBN 7-5077-1271-0
