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A method of pattern identification that involves classifying four-examination data as interior exterior, cold or heat, vacuity or repletion, and yīn or yáng. This is the simplest and most general form of pattern identification, which in modern education in China forms the first stage of diagnosis.

After gathering data through the four examinations, the practitioner identifies a condition that can be explained by known pathomechanisms and hence treated effectively. Most symptoms have multiple causes, so the process of diagnosis involves explaining all symptoms in terms of the simplest coherent pathomechanical process or processes. Once the pathomechanisms are understood, the condition can be formulated in terms of disease patterns, which provide the basis for treatment.

Chinese medicine does recognize numerous specific diseases, some of which will be discussed in this and subsequent chapters. However, in clinical practice, the identification of a disease usually provides insufficient basis for treatment, since a therapeutic strategy can only be determined once the pathomechanism has been understood and a pattern or patterns have been identified. Identification of a disease does narrow down the diagnosis considerably, but in itself rarely provides an adequate basis for treatment.

Modern practice several different pattern identification schemes. The most general of these is eight-principle pattern identification, where the fundamental nature of the condition and its location are ascertained. Depending on the results of this, the practitioner advances to the more specific pattern identification schemes (described in the following chapters). For example, if by eight-principle pattern identification a heat pattern is detected, qì, blood, and fluids pattern identification will show how the blood or fluids are affected, while bowel and visceral pattern identification will determine what organ or organs are affected. If the heat arises as a result of an external evil, externally contracted disease pattern identification will identify what stage the disease has reached.

By eight-principle pattern identification (八纲辨证 bā gāng biàn zhèng), a patient’s condition is classified as exterior or interior, cold or heat, vacuity or repletion, and yīn or yáng. This is the most general of all the schemes for identifying patterns.

The notions of yīn-yáng, exterior-interior, cold-heat, and vacuity-repletion have been central concepts in Chinese medicine since the formative period. They were brought together as a system of analysis by Míng Dynasty physician Zhāng Jiè-Bīn (1563–1640), in commentaries on the Shāng Hán Lùn (伤寒论 On Cold Damage). The scheme was refined by successive physicians. The term eight principles (八纲 bā gāng) was first used by Zhù Wèi-Jú (祝味菊, 1884‒1951) in the Republican Period in the first half of the 20th century.

Eight-principle pattern identification is the most general of all the systems of pattern identification. No matter how complex a disease condition is, it can always be analyzed in terms of the eight principles. Yīn and yáng classify an illness by its most basic category. Differentiation of exterior and interior determines the depth of an illness. Differentiation of cold and heat determines the essential nature of an illness. By identifying vacuity or repletion, the relative states of right and evil can be gauged. Despite the simplicity of the scheme, exterior-interior, cold-heat, vacuity-repletion and yīn-yáng patterns can occur in numerous different combinations and are subject to numerous different changes.

Combinations and Complexes

A distinction is made between combinations and complexes on the basis of non-conflicting and conflicting principles. Cold and heat are conflicting principles because they cannot exist together in the same place, as in the exterior or interior, at the same time. Vacuity and repletion similarly cannot simultaneously exist in the same place. However, conflicting principles can exist together in different places, that is, in the exterior and interior.

Combinations (相兼 xiāng jiān): The concurrence of non-conflicting principles is called a combination. There are combinations of exterior or interior with cold or heat (exterior cold, exterior heat, interior cold, interior heat), of exterior or interior with vacuity or repletion (exterior repletion, exterior vacuity, interior repletion, interior vacuity), and vacuity or repletion with cold or heat (vacuity heat, vacuity cold, repletion heat, repletion cold).

Complexes (夹杂 jiā zá, 错杂 cuò zá): The concurrence of the conflicting principles cold and heat or vacuity and repletion are called complexes. Conflicting principles cannot exist in the same place at the same time, but they can appear simultaneously in different parts of the body. A commonly encountered example is exterior cold presenting simultaneously with interior heat. In complexes, it is important to determine which element is the root (the dominant element) and which is the tip (the secondary element). See root and tip.

Conversion (转化 zhuǎn huà)

Under certain conditions, conversion between opposites can take place. For example, exterior evils can enter the interior, or interior evils can be outthrust to the exterior. Cold patterns can change into heat patterns, and heat patterns into cold patterns. Vacuity can give way to repletion and vice versa.

True and False Patterns (证候真假 zhèng hòu zhēn jiǎ)

The practitioner also needs to pay attention to false phenomena. For example, a condition that is essentially a heat condition may not be immediately identified as such because of the presence of false cold signs. This is called true heat and false cold. There is also true cold and false heat, true vacuity and false repletion, and true repletion and false vacuity.

Exterior and Interior

The terms exterior and interior refer to parts of the body. The exterior is the skin and body hair, and the flesh; hence it is often referred to as the fleshy exterior. This fleshy exterior contains the interstices (sweat glands and pores), which regulate sweating, and the superficial parts of the channels. The interior includes the bowels and viscera, bones and marrow, qì and blood, and yīn and yáng (the latter in their sense of the fire-water duality of physiology).

Exterior-interior pattern identification involves determining whether the disease is located in the exterior or in the interior. Determining whether a patient’s condition takes the form of an exterior or interior pattern is most important because only externally contracted diseases (febrile diseases) in the initial stage manifest as exterior patterns.

Determining whether a patient’s condition takes the form of an exterior or interior pattern is most important because only externally contracted diseases can manifest in exterior patterns.

Disease of the exterior is generally mild. Disease of the interior is usually more serious. Exterior evils (external evils located in the exterior) entering the interior means that the disease is advancing. When this happens, even cold evil turns into heat. Evils that have penetrated the interior can move out to the exterior. This indicates that the disease is abating.

Exterior Patterns

In exterior patterns, the fleshy exterior is affected by disease. They generally indicate that the disease is in its initial stages and is relatively mild. The Jǐng Yuè Quán Shū (Jǐng-Yuè’s Complete Compendium, published in 1624) states, In exterior patterns, evil qì enter the body from outside… and An evil settling in the body must first abide in the skin and hair.

Exterior patterns typically occur in colds and flu or conditions presenting with similar signs. They appear in what biomedicine calls upper respiratory tract infections, as well as other acute infectious diseases in their initial stages.

Pathogenesis: Exterior patterns arise when external evils, such as the six excesses, enter the body through the skin and body hair or the nose and mouth.

Exterior patterns mostly occur in initial-stage externally contracted disease. Only very rarely do exterior evils that have entered the interior evils pass out to the exterior. Exterior patterns are usually of short duration, since the disease either abates or enters the interior.

External evils that have penetrated the exterior elicit a response from defense qì, the body’s own resistance to disease, to repel them. Defense qì mounts a struggle to expel them that results in heat effusion (fever) and often sweating. At the same time, the evil impedes defense qì’s action of keeping the exterior warm, so there is aversion to cold, the chill we experience in colds and flu.

Manifestations: Disease caused by any of the six excesses entering the body is characterized in the initial stages by aversion to cold or aversion to wind, heat effusion, headache, and a floating pulse. These are the classic exterior pattern signs.

Here, aversion to cold with heat effusion, that is, the simultaneous appearance of the two signs, is regarded as the hallmark of exterior patterns. In interior patterns, heat effusion and less commonly aversion to cold may occur, but never simultaneously. A floating pulse mainly indicates external evils in the exterior, but it may also occur in other patterns. However, with the simultaneous appearance of aversion to cold and heat effusion, it confirms the existence of an exterior pattern.

Aversion to wind or cold arises when external evils depress the interstices (sweat glands and sweat pores) in the flesh and obstruct the diffusion of defense qì. Heat effusion arises when defense qì is obstructed by an invading evil and struggles to repel it. The floating pulse, which is a pulse that can be distinctly detected at the superficial level with a light touch, reflects the exuberant evil in the exterior.

Differentiating Exterior and Interior Patterns
	Exterior Patterns	Interior Patterns
Cold & heat	Aversion to cold with heat effusion at the same time	Cold or heat signs but never simultaneous aversion to cold and heat effusion
Other signs	Headache, generalized pain, nasal congestion, runny nose. No pronounced disturbances of diet or spirit-mind	Absence of generalized pain. Signs of disturbance of bowel and visceral function
Stool & urine	Normal	Constipation or sloppy stool, short voidings of reddish urine or long voidings of clear urine
Tongue	White fur	Pronounced changes in the tongue and fur
Pulse	Floating	Sunken

In addition, headache and generalized pain (neck, back, and limbs) may also be experienced. These signs arise because of evil qì obstructing the flow of qì and blood in the channels. Remember that when there is stoppage, there is pain.

Many exterior patterns are marked by sweating. The severity of sweating is affected by the state of the fluids and qì.

Furthermore, given the close connection between lung qì and defense qì, external evils in the exterior (often referred to simply as exterior evils) often impair lung qì’s diffusion action, giving rise to nasal congestion, cough, sore throat, itchy throat, or sneezing. However, this is not always the case. Exterior evils never cause disturbances in any other bowels or viscera unless they pass from the exterior into the interior.

Exterior evils also manifest in a thin white tongue fur. However, since this type of tongue fur is within the normal range of a healthy tongue fur, it is of little significance.

Exterior patterns vary according to the nature of the offending evil and the strength of right qì. Distinction is made between patterns of exterior cold, exterior heat, exterior vacuity, and exterior repletion.

Exterior patterns are characterized by heat effusion, which can occur not only as a result of an external heat evil but also because the struggle between right qì and the evil generates heat. Furthermore, the actual body temperature was traditionally never measured. Therefore, identification of exterior cold and exterior heat patterns was always, and largely still is, based on the assessment of heat and cold signs.

Exterior Cold (表寒 biǎo hán)

Exterior cold patterns are usually caused by wind-cold evil. Cold evil is reflected in cold signs, while wind evil is reflected in the swift onset of the condition.

Exterior patterns are marked by pronounced cold signs with distinct aversion to cold. The pulse is floating and tight, while the tongue fur is thin, white, and moist. Cold in the exterior impedes flow in the external channels, giving rise to headache and generalized pain. This is because cold congeals and stagnates, impeding the movement of qì and blood. Hence, it is said, when cold prevails, there is pain. Runny nose with clear snivel and expectoration of clear thin phlegm are also common signs. These are attributed to impaired diffusion of lung qì and the damage to yáng qì in general. Remember, all disease with watery humors that are clear, pure, and cold is ascribed to cold.

Exterior Heat (表热 biǎo rè)

Exterior heat patterns are typically caused by wind-heat evil. The signs are pronounced heat effusion with mild aversion to cold (aversion to wind), and a pulse that is floating and rapid. Very often there is a painful red swollen pharynx and a slightly reddened tongue with a dry fur. Nasal mucus tends to be thick, turbid, and yellow as a result of the drying action of heat. Sometimes there is cough associated with the production of thick white or yellow phlegm.

Exterior Repletion (表实 biǎo shí)

Exterior patterns without sweating are called exterior repletion patterns. In most cases, these are exterior cold patterns caused by the contraction of an exuberant cold evil that obstructs defense qì, preventing it from opening the interstices (sweat glands and pores), so that there is no sweating. Defense qì is also unable to perform its task of keeping the exterior warm, so that there is aversion to cold. In such cases, defense qì is strong, but its action is hampered (depressed) by the exuberant evil.

Exterior Vacuity (表虚 biǎo xū)

Exterior patterns with persistent sweating and heat effusion are referred to as exterior vacuity patterns. Wind is a yáng evil that by nature is opening and discharging. It makes the interstices loose and open and defense qì insecure and unable to withhold provisioning-yīn (the source of sweat); hence there is sweating and aversion to cold. Exterior patterns are marked by a floating pulse. However, because in exterior vacuity there is sweating, provisioning-yīn becomes insufficient, the pulse is floating and moderate. In cold damage theory, this pattern is explained as disharmony between provisioning and defense, where defense qì is stronger than provisioning-yīn. This disharmony is described as strong defense and weak provisioning, although it is important to understand that the strength of defense qì is only relative to provisioning-yīn. See greater yáng (tài yáng) disease patterns.

Note that the term exterior vacuity also refers to lung-spleen qì vacuity with insecurity of defense qì that manifests in spontaneous sweating, fear of wind, and susceptibility to common cold.

Interior Patterns

The term interior pattern stands in opposition to exterior pattern and indicates that the disease is located in the interior. Interior patterns may result from one or more of the six excesses passing into the interior. They may also be caused by excesses among the seven affects (affect damage), taxation fatigue, or dietary irregularities that directly affect the bowels and the viscera, qì, blood, and fluids.

Interior patterns are varied by nature and are best defined as patterns that are not exterior. They occur in the mid-stages and later stages of externally contracted disease and in miscellaneous diseases (any disease other than externally contracted disease).

Pathogenesis: Interior patterns arise under the following conditions:

• when exterior evils (external evils in the exterior) pass into the interior and to give rise to an interior pattern;
• when external evils invade the bowels and viscera directly;
• when the bowels and viscera, qì, blood, yīn and yáng are disturbed by excesses of the seven affects (affect damage), dietary irregularities, imbalances of activity and inactivity, damage wreaked by severe or enduring illness, excessive sexual activity (sexual taxation), or the general wear and tear that increases with age.

Manifestations: Interior patterns are characterized by disturbances of the bowels and viscera.

Interior patterns may take the form of cold or heat patterns manifesting in numerous different signs, but never by the simultaneous presence of aversion to cold and heat effusion, which is the hallmark of exterior patterns.

Interior patterns include repletion heat, vacuity heat, repletion cold, and vacuity cold. Vacuity heat stems from internal causes, whereas repletion heat can stem from either external or internal causes. Interior cold differs in that repletion cold is only ever due to externally contracted cold striking the interior directly rather than to any internal causes.

Examples of repletion heat and vacuity patterns occurring when external evils enter the interior are provided in the next subsection.

Dual Exterior-Interior and Mid-Stage Patterns

Under certain circumstances, exterior and interior patterns appear simultaneously or can give way to each other. There are also patterns that are neither exterior nor interior, which are called mid-stage patterns.

Dual Disease of Exterior and Interior

The simultaneous presence of exterior and interior patterns is called dual disease of the exterior and interior. Such patterns can be divided into two kinds:

• Externally contracted disease with exterior evils entering the interior before the exterior pattern has resolved or externally contracted disease manifesting in an exterior pattern that is complicated by internal conditions, such as food damage or taxation fatigue.
• Interior patterns attributable to miscellaneous diseases that are complicated by externally contracted evils invading the exterior.

Dual disease of the exterior and interior is usually characterized by heat and cold or vacuity and repletion appearing together: exterior heat with interior cold, exterior cold with interior heat, exterior vacuity with interior repletion, or exterior repletion with interior vacuity.

Exterior Evils Entering the Interior

This occurs when an exterior pattern fails to resolve, and the externally contracted evils affecting the exterior then pass into the interior. This usually happens when right qì is weak, when evil qì is excessively exuberant, or when the patient has either received inappropriate treatment or failed to receive proper treatment. Such patterns can take many different forms.

Heat and repletion: If an exterior evil enters the interior and transforms into heat, the original exterior pattern gives way to one of heat effusion without aversion to cold, a red tongue with yellow fur, a rapid pulse, and short voidings of reddish urine. All these pronounced heat signs indicate interior heat. In severe cases, there may be tidal reddening of the face, aversion to heat, heart vexation, a rapid surging pulse, great sweating, and thirst, each of which indicates intense interior heat. Exterior evils penetrating the interior may also produce pain, distension, and fullness in the chest and abdomen, hard bound stool, a sunken replete pulse, and thick slimy yellow tongue fur. These signs are indicative of gastrointestinal heat-bind, an interior repletion pattern.

Developing a stage further, interior heat and repletion may be characterized by a crimson tongue, clouded spirit, and convulsions, as well as by maculopapular eruptions. These symptoms are indicative of evil heat penetrating provisioning-blood or the pericardium, or of extreme heat stirring wind. All are serious conditions.

Cold and vacuity: The passage of exterior evils into the interior may produce cold or vacuity, characterized by the absence of heat effusion, an aversion to cold, vomiting, chest pain, diarrhea, and absence of thirst. The tongue fur is white and moist, while the pulse is moderate and soggy. These signs indicate spleen yáng vacuity. In severe cases, there may be a somber-white facial complexion, sweating, cold limbs, lassitude of spirit, hypersomnia, and a faint fine pulse. These signs collectively indicate heart-kidney yáng debilitation, an interior (vacuity) cold pattern.

This is only a simple analysis of interior patterns. When interior patterns occur in externally contracted febrile diseases, it is also necessary to identify six-channel and four-aspect patterns (see externally contracted disease pattern identification. In internal damage and miscellaneous diseases, the wide range of patterns associated with the various organs and the variety of diseases and evils are such that eight-principle pattern identification must be followed by bowel and visceral pattern identification and qì, blood, and fluids pattern identification before treatment can be prescribed.

Interior Evils Passing Outward to the Exterior

Externally contracted evils that have entered the interior can be thrust out from the interior to the exterior. This happens when effective treatment is provided and the patient’s right qì is gradually restored.

An example of interior evil passing out to the exterior occurs in patients suffering from internal heat with vexation and agitation, cough counterflow, and oppression in the chest when the heat effusion abates, sweating begins, and the body becomes cool. Measles rashes and white sweat rash (miliaria) are also signs of interior evils thrusting out to the exterior.

Mid-stage Patterns (半表半里 bàn biǎo bàn lǐ)

Mid-stage patterns are externally contracted febrile disease patterns that fit neither the category of exterior patterns nor that of interior patterns. They are chiefly characterized by alternating heat effusion and aversion to cold, fullness in the chest and rib-side, heart vexation, no desire for food and drink, bitter taste in the mouth, dry pharynx, dizzy vision, and a stringlike pulse. The pathomechanisms of mid-stage patterns are discussed in detail under externally contracted disease pattern identification.

Since these are not exterior patterns, they cannot be treated by sweating. Because the evil has not completely penetrated the interior, the normal procedures for the treatment of interior patterns are also excluded. Instead, the method of harmonization is applied. The basic formula is xiǎo chái hú tāng (Minor Bupleurum Decoction), which outthrusts exterior evils and clears the interior.

Cold and Heat

Cold and heat are the principles by which the nature of a disease is identified. Cold patterns and heat patterns reflect the relative states of yīn and yáng in the body. Cold patterns reflect yīn exuberance or yáng vacuity; heat patterns reflect yáng exuberance or yīn vacuity.

It is important to understand that cold patterns should not be precisely equated with sensations of cold (fear or cold, aversion to cold) and that heat patterns should not be equated with heat effusion. Aversion to cold and heat effusion in exterior patterns are attributed to the struggle between evil and right. Aversion to cold appears in wind-heat exterior patterns and heat effusion occurs in wind-cold exterior patterns. When determining the presence of heat or cold, it is important to take all signs into account, not just these two.

Properly identifying a condition in terms of heat or cold is essential in the context of therapy. It is necessary for applying the dual treatment principle heat is treated with cold; cold is treated with heat.

Interior cold is not to be confused with internal cold. While internal cold is cold of internal origin, interior cold is cold in the interior rather than the exterior and attributable either to direct strike of external cold or to internal cold attributable to yáng vacuity. Interior cold can therefore originate internally or externally, while internal cold gives rise only to interior cold (never exterior cold). Similarly, interior heat is not to be confused with internal heat for the same reasons.

Cold Patterns

Cold patterns arise as a result of contracting cold evil or to damage to yáng qì by internal causes, or to excessive consumption of raw and cold foods. Signs care characterized by cold, stillness, contraction and tension, whiteness and moistness. Distinction is made between patterns of exterior cold, interior cold, vacuity cold, and repletion cold. Exterior cold was discussed under Exterior Patterns above. Here, the focus is on interior cold patterns.

Pathomechanisms of Cold Patterns

Cold patterns are the result either of (a) invasion of a yīn evil that obstructs yáng qì (when yīn prevails, there is cold) (b) insufficiency of yáng qì (when yáng is vacuous, there is cold).

• External contraction of yīn cold evil qì striking the interior directly;
• Consumption of cold or raw foods giving rise to exuberant internal cold; or
• Yīn exuberance attributable to yáng vacuity from internal damage or enduring illness.

Cold Signs and How They Arise

Cold: When yáng qì is obstructed by repletion cold evil or becomes insufficient and engenders cold, its yáng qì is lost, giving rise to signs such as aversion to cold, fear of cold; cold limbs; reversal cold of the limbs; lying in curled-up posture; desire to keep well-covered; desire for warm food and drinks.

Stillness

• Reduced physical activity: Lying in curled-up posture.
• Reduced qì transformation (physiological activity): Absence of thirst, sloppy stool, diarrhea, vomiting, long voidings of clear urine. See Moistness below.
• Reduced spread of qì: When yáng qì is insufficient (vacuity) or impeded by cold evil (repletion), its power to reach the exterior and extremities is reduced, hence the above-mentioned aversion to cold, cold limbs, and in severe cases reversal cold of the limbs.
• Reduced movement of blood: When qì fails to propel the blood adequately, the complexion and tongue become pale. The pulse may become slow. Severe cold can cause blood stasis.
• Pain: Cold impedes the flow of qì and blood, often giving rise to pain. Remember, when there is stoppage, there is pain.

Whiteness: Because cold slows down physiological activity and causes contraction of the vessels, it manifests in a white complexion and pale tongue.

Moistness: Because yáng qì fails to warm and transform the fluids, cold patterns manifest in clear copious fluids, notably a white glossy tongue fur; runny nose with clear snivel; expectoration of copious clear phlegm; long voiding of clear urine; sloppy stool or diarrhea. Moistness is also reflected in absence of thirst and the tendency to develop dampness, cold-damp, phlegm-rheum, and water swelling patterns. Remember, all disease with watery humors that are clear, pure, and cold is ascribed to cold.

Contraction: Contraction of the interstices causes absence of sweating. Contraction of the sinews causes hypertonicity of the limbs or stiff nape. Contraction of the blood vessels causes the pulse to be tight or sunken, and it exacerbates the reduced power of yáng qì to move freely and propel the blood. Contraction is mostly a feature of repletion cold patterns.

Patterns

Repletion cold: This arises when externally contracted cold evil strikes the interior directly or when consumption of cold or raw foods give rise to exuberant internal cold. It manifests in pronounced cold signs of physical cold and cold limbs green-blue facial complexion, and a pulse that is sunken and tight. Severe disturbances of spleen-stomach harmony may result in with fulminant pain in the stomach duct and abdomen, fulminant vomiting, or fulminant diarrhea. Fulminant (i.e., sudden and severe) cold pain in the stomach duct and abdomen exacerbated by exposure to cold and relieved by warmth. When cold and food obstruct each other in the stomach and intestines, constipation and abdominal distension may develop. When cold combines with phlegm to obstruct lung qì, panting with fullness in the chest may be observed.

Vacuity cold: Vacuity cold due to insufficiency of yáng qì is much more common than interior repletion cold and typically manifests in chronic conditions with long voidings of clear urine, clear-grain diarrhea (rather than fulminant diarrhea), pain in the stomach duct and abdomen relieved by warmth and pressure, and slow pulse (rather than a tight sunken pulse), along with physical cold and cold limbs and somber-white facial complexion. In severe cases of vacuity cold, yáng qì may be so weak that it recedes away from the extremities, giving rise to reversal cold of the limbs, a sign not normally observed in repletion cold patterns.

Since cold evil may damage yáng, and yáng vacuity may engender cold, the two forms of cold are interrelated. Accordingly, physical cold and cold limbs and somber-white facial complexion may be attributable to the debilitation of yáng qì and/or the presence of exuberant cold evil and so are common to both repletion cold and vacuity cold.

Heat Patterns

Heat patterns are caused by heat evil arising externally or internally or by insufficiency of yīn humor, and hence form either repletion or vacuity patterns. They are all characterized by heat sensations, movement, redness, and dryness, most commonly in the upper body. Distinction is made between exterior heat, interior heat, vacuity heat, and repletion heat. Exterior heat was discussed above under Exterior Heat Patterns. Here, the focus is on interior heat.

Pathomechanisms of Heat Patterns

Heat patterns are the result of (a) invasion of a yáng evil (when yáng prevails, there is heat), (b) the development of internal heat, or (c) insufficiency of yīn humor (when yīn is vacuous, there is heat). Specific factors are as follows:

• External contraction of yáng heat evil (repletion heat);
• Transformation of cold or dampness evils into heat, as when exterior evils pass into the interior (repletion heat);
• Excesses among the seven affects causing qì depression that transforms into heat or fire (repletion heat);
• Food accumulations that transform into heat (repletion heat);
• Taxation damage from overexertion, poor lifestyle, dietary irregularities, and sexual intemperance. These factors can damage yīn, giving rise to vacuity heat. They can all cause dysfunction of the bowels and viscera, hamper qì transformation, and give rise to phlegm, rheum, water, dampness, qì stagnation, blood stasis, and food accumulation, which may give rise to fire formation (repletion heat).

Heat Signs and How They Arise

Heat: Heat directly manifests in heat sensations: heat effusion, aversion to heat, and desire for coolness. The patient tends to lie supine with outstretched limbs to encourage heat loss.

Movement

Differentiating Cold and Heat Patterns
	Cold Patterns	Heat Patterns
Cold & heat signs	Aversion to cold and liking for warmth	Aversion to heat with liking for cold
Thirst	Absence of thirst	Thirst with liking for cold drinks
Complexion	Pale white	Red
Posture and spirit	Lying in curled-up posture, tendency to be inactive	Lying supine, vexation and agitation, tendency to be active
Phlegm and snivel	Clear or white, thin, and copious	Thick and yellow
Stool and Urine	Thin sloppy stool, long voidings of clear urine	Dry bound stool and short voidings of reddish urine
Tongue	Pale tongue with a white, glossy and moist fur	Red tongue with dry yellow tongue fur
Pulse	Slow or tight	Rapid or slippery

• Physical movement: Vexation and agitation, throwing off bedclothes, flailing of the limbs, etc.
• Movement of blood: Since heat stimulates the movement of blood, it gives rise to a red face, red eyes, red tongue, and rapid pulse.
• Upper body: Red face, red eyes, and red tongue are upper-body signs attributable to the fact that fire by nature flames upward and moves blood with it.
• Bleeding: Since heat can damage the blood network vessels and allow frenetic movement of hot blood, there may be vomiting of blood, coughing of blood, nosebleed, or subcutaneous bleeding.

Redness: Red complexion, red tongue, reddish urine, and red swollen sores are attributed to the increased movement of blood explained above.

Dryness: Because heat damages the fluids, there is thirst with fluid intake, scant urine, dry bound stool, dry tongue with little liquid, and a yellow tongue fur.

Sores: Fire toxin, a virulent form of external heat, gives rise to sores when it causes stagnation of qì and blood that results in putrefaction.

Patterns

Repletion heat: Heat patterns attributable to a prevalence of yáng are termed repletion heat patterns. These are characterized by a red face (redness of the whole face), red eyes, vigorous heat effusion (high fever), vexation and agitation, thirst with a liking for cold fluids, hard bound stool, and short voidings of reddish urine. The tongue is red or crimson with yellow fur, while the pulse is rapid and possibly large or surging. Severe heat can cause frenetic movement of blood that manifests in bleeding. Fire toxin can give rise to sores.

Vacuity heat: Heat attributable to insufficiency of yīn humor is termed vacuity heat and is characterized by heat effusion limited in severity, in body parts affected, and in the time of day it occurs, notably taking the form of slight heat effusion, reddening of the cheeks, vexing heat in the five hearts, postmeridian tidal heat, and steaming bone tidal heat. Vacuity heat is also marked by night sweating, dry throat and mouth, smooth bare red tongue, and a pulse that is fine and rapid. Bleeding due vacuity heat is rare.

Cold-Heat Complexes

A cold-heat complex is the presence of a cold and a heat pattern in two different parts of the body at the same time.

Upper-Body Cold and Lower-Body Heat

An example of this is when a patient suffering from a cold pattern of habitual cold pain in the stomach duct with vomiting of clear drool develops a heat pattern of short voidings of reddish urine and frequent urination. This is stomach cold with bladder heat. Another example is phlegm-rheum cough with cold signs occurring together with painful dribbling urination.

Upper-Body Heat and Lower-Body Cold

An example of this is seen in externally contracted disease inappropriately treated by offensive precipitation, causing incessant diarrhea and damage to liquid and humor. In such cases, the heat rises to the upper body to cause sore throat, expectoration of yellow phlegm or phlegm streaked with blood, while exuberant cold develops in the lower body, giving rise to diarrhea, cold limbs, and a pulse that is sunken and slow.

Exterior Cold and Interior Heat

Such patterns commonly arise when a patient habitually suffering from internal heat contracts external wind-cold or when external cold passes into the interior and transforms into heat before the exterior cold pattern has been resolved. Complex patterns of exterior cold and interior heat vary considerably. One frequently encountered scenario is aversion to cold with heat effusion, headache and generalized pain, panting, absence of sweating, and pulse that is floating and tight (exterior cold) with thirst and vexation and agitation (interior heat).

Exterior Heat and Interior cold

Such complexes typically arise when a patient habitually suffering from interior cold contracts wind-heat or when exterior heat is inappropriately treated by precipitation (purgation), which damages spleen yáng. In clinical practice, exterior patterns of heat effusion with aversion to cold, headache, cough, and sore swollen throat are often seen with interior cold patterns of sloppy stool diarrhea, lack of warmth in the limbs, and long voidings of clear urine.

When faced with cold-heat complexes, it is imperative to distinguish clearly between upper body and lower body patterns, interior and exterior pattern, the affected channels, and the bowels and viscera. It is also important to determine the relative severity of the different aspects of a condition, that is, to identify the tip and root of an illness so as to be able to decide which to treat first.

Heat and Cold Conversions

Cold-heat conversion includes cold patterns converting into heat patterns and heat patterns converting into cold patterns.

Cold Patterns Converting Into Heat Patterns

When a cold pattern gives way to a heat pattern and then disappears, this is a cold pattern converting into a heat pattern. This usually happens when the body’s yáng qì is exuberant, and cold evil transforms into heat under the influence of the yáng. It can also occur as a result of inappropriate treatment, such as the excessive use of warm dry medicinals.

A cold pattern converting into a heat pattern is typically seen when an exterior cold pattern that results from external contraction of cold evil and that is marked by aversion to cold with heat effusion, headache and generalized pain, absence of sweating, thin white tongue fur, and a tight floating pulse gives way to a heat pattern of vigorous heat effusion, thirst, heart vexation, a red tongue with yellow fur, and a rapid pulse. This occurs when the cold evil transforms into heat and enters the interior. The exterior cold pattern disappears, leaving only the interior heat pattern.

Heat Patterns Converting into Cold Patterns

When a heat pattern gives way to a cold pattern and then disappears, this is a heat pattern converting into a cold pattern. It occurs when evil is exuberant or right is vacuous, so that right fails to overcome evil. It can also be the result of inappropriate treatment that damages yáng qì.

This kind of conversion can take place either quickly or slowly.

• Slow conversion occurs, for example, when enduring heat dysentery causes increasing damage to yáng qì so that it gradually changes into vacuity cold dysentery.
• Rapid conversion is seen in a patient suffering from vigorous heat effusion and incessant great sweating when qì discharges with the sweat or excessive vomiting or diarrhea causes yáng to desert with liquid so that the original heat pattern suddenly gives way to a yáng collapse vacuity cold pattern. This is marked by a sudden drop in temperature, somber-white facial complexion, reversal cold of the limbs, and a faint pulse on the verge of expiration.

False Heat and Cold

When cold patterns and heat patterns develop to the extreme, signs of the opposite pattern sometimes appear. These conditions are called extreme cold resembling heat and extreme heat resembling cold. In such cases, the signs of the opposite pattern are false in the sense that they do not represent the root of the condition. Hence, these conditions are also known as true cold and false heat and true heat and false cold.

True Cold and False Heat (Extreme Cold Resembling Heat)

This is true internal cold with false signs of external heat. It is observed when a patient has generalized heat effusion, thirst, red face, and a large pulse but on further scrutiny is found not to be suffering from a true heat pattern but from a condition essentially attributable to cold.

• Despite the heat effusion, the patient needs clothing and bedding to keep warm.
• Despite the thirst, she only likes warm drinks in small quantities.
• Although the complexion is red, it is only a pinkish-red, like a dab of rouge on the upper cheek that drifts around.
• Although the pulse is large, it is forceless under pressure.
• Furthermore, there are distinct signs of severe cold such as reversal cold of the extremities, long voidings of clear urine, thin sloppy stool, listlessness of essence-spirit, and a pale tongue with white fur.

This condition is explained as exuberant internal yīn repelling yáng to the outer body. It is often called exuberant yīn repelling yáng.

True Heat and False Cold (Extreme Heat Resembling Cold)

This is true inner-body heat with false signs of outer-body cold. It is observed when a patient evinces signs resembling those of cold, such as reversal cold of the limbs and a sunken pulse, but on further scrutiny is found to be suffering not from true cold but from heat.

• Despite the reversal cold of the extremities, the body is scorching hot, and the patient refuses clothing and bedclothing.
• There is aversion to heat rather than aversion to cold.
• Although the pulse is sunken, it is slippery, rapid, and forceful.
• In addition, there are numerous clinical manifestations of heat: thirst with a liking for cold drinks, vexation and agitation, dry bound stool, short voidings of reddish urine, and a red tongue with yellow fur.

The reversal cold of the extremities and sunken pulse are false signs of cold that arise when intense internal heat depresses yáng qì and prevents it from reaching the outer body. Hence, the heat signs represent the true nature of the disease. Such conditions are called exuberant yáng repelling yīn. They are also called yáng reversal or heat reversal, that is, reversal cold of the limbs due to internal yáng heat obstructing the outward spread of yáng qì.

Distinguishing True and False

Two points help to distinguish between true and false.

Limbs, skin, and face signs are often false: The false signs usually appear on the periphery of the body (limbs, skin, face); the true signs as those related to the bowels and viscera, qì and blood, and yīn and yáng. The internal signs, the tongue, and the pulse provide an accurate picture of the condition. For example, it is important to observe whether the tongue is pale in color or red-crimson, whether it is moist or dry, whether there is thirst, whether the pulse is forceful or forceless, and whether there are long voidings of clear urine or short voidings of reddish urine.

Qualitative differences between true and false signs: Qualitative differences between as true signs and false signs are seen in red complexions and coldness of the limbs.

• When a red facial complexion is a sign of false heat, it takes the form of fluctuating pale-red blotches on the cheeks (often described as floating red). When a sign of true repletion heat, it manifests as redness of the whole face.
• When cold limbs are a sign of false cold, the patient does not want to be wrapped in clothing and bedclothing, and the chest and abdomen feel scorching hot to the touch. When they are a sign of true cold, the patient lies in curled-up posture and wants extra clothing and bedclothing.

n>def3,eight-principle pattern identification

Vacuity and Repletion

Vacuity and repletion reflect the relative states of right qì and evil qì. A vacuity pattern is one chiefly characterized by insufficiency of right qì. A repletion pattern is a condition marked by an exuberant evil being resisted firmly by the body’s right qì.

The Sù Wèn (Plain Questions, Chapter 28) states, When evil qì is exuberant, there is repletion; when essential qì is despoliated, there is vacuity.

Identifying whether an illness manifests in vacuity and/or repletion is of great importance in treatment since they are treated differently. Vacuity is treated by supplementing, while repletion is treated by attack. The wrong choice leads to replenishing repletion or evacuating vacuity, that is, treatments that exacerbate rather than relieve the condition.

Vacuity Patterns

Vacuity patterns are the manifestation of insufficiency of right qì. Remember that right qì is not a specific form of the active yáng qì in the human body; rather the term refers to all aspects of the body in their ability to maintain health and resist disease. It includes qì, blood, fluids, essence, and yīn-yáng.

Pathogenesis: Earlier-heaven insufficiency and later-heaven imbalance are both factors in the development of vacuity patterns. Of these, the latter is the more important and includes internal damage by excesses among the seven affects, dietary irregularities, excessive activity or inactivity, sexual intemperance, excessive childbirth, and enduring illness. The basic vacuity patterns are qì vacuity, blood vacuity, yīn vacuity, yáng vacuity, and vacuity patterns of the bowels and viscera.

Manifestations: Vacuity patterns are highly varied in nature.

• When yáng qì is insufficient, signs include a pale-white or bright-white facial complexion or a withered-yellow complexion, listlessness of the essence-spirit, fatigue and lack of strength, physical cold and cold limbs, spontaneous sweating, thin sloppy stool or efflux desertion (fecal incontinence), long clear voidings of urine or urinary incontinence, a pale enlarged tongue, and a pulse that is vacuous, sunken, slow, and forceless or weak. Signs differ depending on whether qì vacuity or yáng vacuity is more pronounced and on which bowel or viscus is affected.
• When yīn-blood is insufficient, signs include emaciation, vexing heat in the five hearts, night sweating, red tongue with little or no fur, and a pulse that is fine, rapid, and forceless. Signs differ depending on whether blood or yīn vacuity is more pronounced and on which bowel or viscus is affected.

Analysis: Vacuity patterns principally involve vacuity of the qì, blood, yīn, and yáng of the five viscera.

• Yáng qì vacuity mainly involves loss of warming and retentive functions.
• Yīn-blood vacuity mainly involves loss of the nourishing and moistening functions.

The numerous vacuity and repletion patterns are described qì, blood, and fluids pattern identification and bowel and visceral pattern identification.

Repletion Patterns

Repletion patterns are those characterized by an exuberance of evil qì. Causes can be divided into two kinds:

• Invasion of the body by the six excesses (wind, cold, summerheat, dampness, dryness, fire), epidemic, snake and insect poison, or other evils, giving rise to a fierce struggle between right and evil.
• Excesses of the seven affects, dietary irregularities, or taxation fatigue, which all cause dysfunction of the bowels and viscera, hamper qì transformation, and give rise to phlegm, rheum, water, dampness, qì stagnation, blood stasis, and food accumulations.

Differentiating Vacuity and Repletion Patterns
	Vacuity Patterns	Repletion Patterns
Duration	Long	Short
Constitution	Weak	Strong
Complexion	Pale-white or withered-yellow	Deep red or dull and stagnant
Cold	Fear of cold and cold limbs	Pronounced aversion to cold; severe abdominal cold pain
Heat	Vexing heat in the five hearts	Vigorous heat
Distension and pain	Mild, intermittent, relieved by pressure	Acute, persistent, exacerbated by pressure
Sweating	Spontaneous sweating (yáng vacuity) or night sweating (yīn vacuity)	No sweating or great sweating
Spirit	Lassitude of spirit and lack of strength, devitalized essence-spirit	Vexation and agitation or clouded spirit with delirious speech
Breathing and voice	Weak faint breathing, faint low voice, and laziness to speak	Rapid breathing, rough breathing, strident voice, talkativeness
Stool, urine	Sloppy stool, long voidings of clear urine	Constipation, short voidings of reddish urine
Tongue	Pale tender-soft tongue with little or no fur	Somber-tough tongue with thick slimy tongue fur
Pulse	Forceless	Forceful

Repletion patterns are highly varied because evils vary in nature, affect different parts of body and differ in strength relative to right qì. In general, new disease (disease of recent onset) and fulminant disease (disease of sudden and violent onset) mostly take the form of repletion patterns. Repletion patterns are also most commonly seen in people with a strong constitution.

Manifestations: Repletion signs are numerous. Among those most commonly observed are generalized heat effusion, vexation and agitation, oppression in the chest, rough breathing, phlegm-drool congestion, distension and pain in the stomach duct and abdomen that refuses pressure, constipation or fulminant diarrhea, tenesmus, and inhibited urination or rough dribbling voidings of urine. In severe cases, signs such as manic derangement, clouded spirit, and delirious speech may occur. In some cases, the tongue is somber and tough with a thick and slimy tongue fur. The pulse is replete.

Analysis: Many pathomechanisms are involved in the formation of repletion patterns. The main points are as follows:

• When evil qì harasses the heart, there is vexation and agitation. When it clouds the heart spirit, signs such as manic derangement or clouded spirit and delirious speech occur.
• When evil obstructs the lung, the diffusion and downbearing of lung qì are affected, manifesting in oppression in the chest and rough breathing, or phlegm-drool congestion.
• When repletion evil accumulates in the stomach and intestines, causing stoppage of bowel qì, there is abdominal distension, fullness, and pain that refuses pressure.
• When damp-heat brews and binds in the large intestine to disturb normal conveyance, there may be in fulminant diarrhea or tenesmus.
• When water-damp collects internally and hampers qì transformation, it causes inhibited urination or rough dribbling voidings of urine.
• When damp-heat pours downward to the bladder, there is rough dribbling and painful urination (strangury patterns).
• When fire develops in the liver, there is dizziness and distending pain in the head, red face and eyes, as well as impatience, agitation, and irascibility.
• The struggle between evil and right causes pounding in the vessels so that the pulse is replete and forceful.

Differentiating Vacuity and Repletion

It is important to be aware of the complexity of the symptomatology of vacuity and repletion. A given symptom or even a set of symptoms may occur in both vacuity and repletion patterns. For example, abdominal pain, constipation, and fear of cold and cold limbs may be attributable to either vacuity or repletion. To distinguish vacuity and repletion, it is helpful to adopt the following procedures:

• Carefully inspect the form of the body, the tongue, and the pulse.
• Listen to the sound of breathing and the voice.
• Inquire about the history of the disease.
• In the case of chest and abdominal discomforts, perform palpation to determine whether the patient likes or refuses pressure.

If the patient has a frail body, listlessness of essence-spirit, faint low voice and faint breathing, pain that likes pressure, and a pale tender-soft tongue with little or no fur, and a vacuous or weak pulse, the pattern is one of vacuity.

If the patient has a strong body, vigorous essence-spirit, loud strident voice, rough breathing, pain that refuses pressure, a somber and tough tongue with a thick slimy tongue fur, and a replete pulse, the pattern is one of repletion.

Vacuity-Repletion Complexes

When a patient suffers from vacuity of right in conjunction with repletion of evil, this is called a vacuity-repletion complex. We differentiate repletion patterns complicated by vacuity, vacuity patterns complicated by repletion, and vacuity and repletion equally pronounced.

Repletion Complicated by Vacuity

In this case, the main pattern is one of repletion, and the secondary pattern is one of vacuity. This most commonly occurs in repletion patterns in which right qì is damaged by the evil or by inappropriate treatment that fails to eliminate the evil or even directly damages right qì further. For example, in an interior repletion pattern with vigorous heat effusion, thirst, great sweating, heart vexation, and a red tongue with yellow fur, the intense internal heat can damage both qì and yīn so that the patient develops a pattern of dual damage to qì and yīn marked by vexing thirst, slight aversion to cold in the back, and a pulse that is floating, large, and forceless. The resulting condition is one of repletion heat with dual vacuity of qì and yīn, which is thus an example of repletion complicated by vacuity. Repletion complicated by vacuity can also occur when a person with a vacuity constitution suffers a new contraction of external evils.

Vacuity Complicated by Repletion

Here, vacuity is the main pattern and repletion is the secondary pattern. This is mostly seen in cases when a repletion pattern has persisted for so long that right qì is greatly damaged, even though the evil has not been fully eliminated. For instance, in the latter stages of warm disease, when there is depletion of the kidney and liver, there are signs such as persistent slight fever, with heat in the hearts of the palms and soles, dry mouth, and a dry crimson tongue without fur. In this situation, the evil heat has scorched the yīn of the kidney and liver, creating a condition chiefly characterized by vacuity. Vacuity complicated by repletion also arises when a person in a weak state of health contracts an external evil.

Vacuity and Repletion Equally Pronounced

Such patterns usually mean serious conditions. Vacuity of right qì and evil repletion are both pronounced. This occurs in severe evil repletion that persists for a long time and greatly damages right qì without abating. It also arises when a patient with severe vacuity of right qì suffers a severe external contraction. To give an example of the first pathomechanism, in a patient suffering from drum distension (ascites) with pronounced abdominal distension with green-blue veins suddenly appearing on the abdomen (caput medusae) and urinary and fecal stoppage, the presence of marked emaciation, inability to eat, and listlessness of essence-spirit indicates that vacuity and repletion are equally pronounced.

Vacuity-Repletion Conversion

In the course of illness, changes in the relative strength of evil and right can give rise to conversion between vacuity and repletion, where the original pattern of vacuity or repletion is replaced by its opposite.

Repletion Patterns Converting into Vacuity Patterns

When a repletion pattern appears first, is followed by the appearance of a vacuity pattern, and then disappears leaving only vacuity, this is called a repletion pattern converting into a vacuity pattern. It usually occurs when evil qì has settled in the body for a long time and, as a result of inappropriate treatment or failure to provide appropriate treatment, damages right qì. For example, if a repletion heat pattern of vigorous fever, thirst, sweating, and a pulse that is surging and large is inappropriately treated so that the illness persists, liquid and qì will be damaged. When the high fever abates, the patient is left emaciated with a desiccated white complexion, no desire to eat or drink, a peeling tongue fur, and a pulse that is fine and forceless. These signs indicate that repletion has given way to vacuity completely.

Vacuity Patterns Converting into Repletion Patterns

When, in an illness presenting as a vacuity pattern, the vacuity of qì and dysfunction of the bowels and viscera gives rise to phlegm, food accumulation, blood stasis, or water swelling, this is vacuity giving way to repletion. In such cases, the underlying vacuity is still present, but it is relatively insignificant compared to the more pronounced repletion. Examples of these are heart vessel obstruction and ascendant hyperactivity of liver yáng.

Yīn and Yáng

Yīn and yáng encompass a wide range of qualities: stillness/movement; inward/outward movement; downward/upward movement; heat/cold; moistness/dryness; redness/whiteness; dullness/brightness; poorly/easily detectable phenomena. In the body, yīn denotes yīn humor (yīn qì) and the tendency toward cold and quiescence, while yáng denotes yáng qì and the tendency toward heat and activity.

In the eight principles, yīn and yáng are the basic categories by which the other principles are classified. Exterior patterns are yáng, while interior patterns are yīn. Cold patterns are yīn, while heat patterns are yáng. Vacuity patterns are yīn, while repletion patterns are yáng. As such, yīn and yáng fail to describe practical clinical complexities accurately except for classic vacuity cold (a yīn pattern) and repletion heat (a yáng pattern). While, for example, a vacuity cold pattern is characterized by the yīn qualities of vacuity and cold, repletion cold is characterized by repletion (yáng) and cold (yīn), and hence terms of the eight principles is a yīn-yáng combination. For this reason, the terms yīn pattern and yáng pattern are not useful concepts, and hence are usually only used to denote vacuity cold and repletion heat.

In modern Chinese textbooks, discussion of yīn-yáng in eight-principle pattern identification variously addresses yīn vacuity and yáng vacuity or yīn exuberance and yáng exuberance. All include yīn collapse and yáng collapse patterns, even though these are both vacuity patterns. All these elements are discussed under pathomechanisms. Here we discuss yīn vacuity, yáng vacuity, yīn collapse, and yáng collapse by way of recapitulation, as well as yīn sores and yáng sores.

Yáng Vacuity (阳虚 yáng xū)

Description: Yáng vacuity manifests in habitual fear of cold; lack of warmth in the limbs; bland taste in the mouth and absence of thirst or else desire for warm drinks. Depending on the organs affected, other signs may be observed: lassitude of spirit and lack of strength; shortness of breath; spontaneous sweating; tendency to contract external cold evil; long voidings of clear urine or scant urine with puffy swelling; and sloppy stool. The complexion is pale-white. The tongue is pale and enlarged (sometimes bearing dental impressions)with a white glossy tongue fur. The pulse is sunken and slow, and forceless.

Pathogenesis: Yáng vacuity means depletion of yáng qì with loss of warming, functional activity, qì transformation (transformative functions such as the steaming action of the kidney), and retention functions. It manifests as vacuity cold. It arises as a result of the following factors:

• a yáng vacuity constitution;
• living in a cold environment for a long time;
• depletion of the life-gate fire in advancing years; and/or
• excessive consumption of bitter cold clearing and cooling medicinals.

Specific forms

• Heart yáng vacuity
• Spleen yáng vacuity
• Stomach yáng vacuity
• Kidney yáng vacuity
• Uterine vacuity cold

Further developments: Yáng vacuity can coexist with qì vacuity and develops from it. It can encourage the contraction of cold evil. In addition, it can give rise to the following:

• Qì stagnation
• Blood stasis
• Phlegm-rheum
• Dual vacuity yīn and yáng, which usually manifests as vacuity heat in the inner body (e.g., tidal heat, night sweating) and cold in the outer body (fear of cold, cold limbs).
• Severe yáng vacuity can give way to yáng collapse or exuberant yīn repelling yáng.

Yīn Vacuity (阴虚 yīn xū)

Also:

• Yīn vacuity with heat (阴虚有热 yīn xū yǒu rè) emphasizes the presence of mild heat.
• Yīn vacuity with effulgent fire (阴虚火旺 yīn xū huǒ wàng) emphasizes severe heat.

Description: Yīn vacuity manifests in emaciation; dry pharynx and mouth; slight heat effusion; postmeridian tidal heat effusion; reddening of the cheeks; vexing heat in the five hearts; night sweating; yellow urine; dry bound stool; red tongue with little fur; and a pulse that is fine and rapid.

Pathogenesis: Yīn vacuity is the depletion of liquid, humor, essence and blood making them unable to perform their moistening and nourishing functions and to counterbalance yáng qì. It results from the following factors:

• damage to liquid and humor by febrile disease;
• damage to yīn humor by enduring miscellaneous disease;
• excesses among the seven affects;
• sexual intemperance; and/or
• excessive consumption of drying warm or hot medicinals.

Specific forms

• Heart yīn vacuity
• Lung yīn vacuity
• Stomach yīn vacuity
• Liver yīn vacuity
• Kidney yīn vacuity

Combinations: Yīn vacuity can coexist with qì vacuity, blood vacuity, yáng vacuity, yáng hyperactivity, depletion of essence; and dryness evil.

• depletion of qì and yīn;
• depletion of yīn-blood;
• dual vacuity of yīn and yáng;
• yīn vacuity with hyperactivity of yáng (notably in ascendant hyperactivity of liver yáng).
• depletion of yīn and essence.

Further developments: Yīn vacuity can give rise to the following patterns:

• yīn vacuity with internal dryness;
• dual vacuity of yīn and yáng;
• yīn collapse;
• stirring of wind (liver wind stirring internally);
• qì stagnation;
• blood stasis;
• collection of water.

True and False Vacuity and Repletion

When either vacuity or repletion patterns develop to the extreme, signs of the opposite pattern sometimes appear. This situation is completely different from vacuity-repletion complexes, since the signs of the opposite pattern are false and do not require treatment but will disappear on their own when the root pattern, the true cause of the signs, is treated.

True Repletion and False Vacuity

When a patient who is suffering from great repletion suddenly presents signs of marked vacuity and emaciation, this is called true repletion and false vacuity. For example, when heat binds in the stomach and intestines and causes severe phlegm-food congestion, vacuity signs may appear, such as taciturnity, fear of cold, cold limbs, and a pulse that is sunken and hidden or slow and rough. Closer scrutiny shows that although the patient is taciturn, she has a strong voice and rough breathing. Although the pulse is sunken and hidden or slow and rough, it is forceful when pressure is applied. Although there is fear of cold and cold limbs, palpation of the chest and abdomen reveals scorching heat. In this case, the vacuity signs are attributable to repletion evil obstructing the channels, inhibiting the movement of qì and blood. This condition is traditionally described as great repletion with signs of marked weakness (大实有羸状 dà shí yǒu léi zhuàng).

True Vacuity and False Repletion

When an illness that is essentially one of vacuity manifests with signs that suggest repletion, this is called true vacuity and false repletion. This is seen, for example, when a patient who habitually suffers from spleen vacuity with poor movement and transformation presents with signs resembling repletion, such as abdominal distension and fullness, and a stringlike pulse. Although there is abdominal fullness, it sometimes abates, unlike the unabating abdominal fullness normally associated with repletion. Although there is abdominal pain, it likes pressure, unlike the repletion-type abdominal pain, which refuses pressure. Although the pulse is stringlike, it is forceless when pressure is applied. This situation is traditionally described as consummate vacuity with signs of exuberance (至虚有盛候 zhì xū yǒu sheng4 hou4).

Distinguishing True and False

There are four things to pay attention to:

Is the pulse forceful and spirited or not?You should be careful to take the pulse at both the superficial and deep levels. Very often the true nature of the disease is in the interior, while false signs are outwardly manifest, so when taking the pulse, it is important to apply pressure to feel the pulse at the deep level. If when pressure is applied, the pulse is forceful and spirited, this means that the pattern is a true repletion pattern. If it is forceless and spiritless, this means that the pattern is a true vacuity pattern. The idea of using the deep level of the pulse as the basis for judgment comes from Li3 Shì-Caí: As a general rule, when the signs provide insufficient evidence, the pulse should be taken into consideration. When the pulse [at first sight] provides insufficient evidence, one should take it at the deep level. The false signs all appear on the exterior; hence the superficial level of the pulse is false too. The true signs are the hidden ones, the ones that reflect the interior; hence the deep-level pulse is the one by which to identify the condition.

Is the tongue somber-tough or tender-soft and enlarged?A tongue that is tender-soft, enlarged, and pale-white indicates a true vacuity pattern. A somber-tough tongue that is hard and tight indicates a true repletion pattern.

Sound of breathing and voice: A strident voice with rough breathing usually indicates repletion. A timid low voice usually indicates vacuity.

How did the illness start and develop and what treatment was given before?A firm grasp of how the illness developed and responded to previous treatment helps to distinguish true and false signs.

Yīn Collapse Patterns

Yīn collapse (亡阴 wáng yīn) is a critical loss of fluids. Note that the terms collapse and desertion are close synonyms: collapse denotes critical vacuity; desertion suggests shedding of qì, blood, or fluids from the body.

Description: Sweating with hot sticky sweat that is salty to the taste and oily in consistency; generalized scorching heat, aversion to heat; vacuity vexation and agitation, or clouded spirit and delirious speech; thirst with desire to drink; wrinkled skin, desiccated teeth, sunken eyes; extremely scant urine or absence of urine; red face with parched lips, dry red shrunken tongue; and a pulse that is fine, rapid or racing, and forceless.

Pathogenesis: Yīn collapse patterns arise

• when extremely exuberant or chronic evil heat scorches yīn humor; or
• when massive bleeding, sweating, vomiting, or diarrhea seriously deplete yīn humor.

Analysis: When yīn is depleted, yáng floats, giving rise to sweating, hot flesh, and vexation and agitation. At the same time, yīn ceases to perform its moistening function, hence the tongue is dry, the lips are parched, the teeth are desiccated, the eyes are sunken, the tongue is red and dry, and the pulse is fine, rapid or racing, and forceless.

Yáng Collapse Patterns

Differentiating Yīn Collapse and Yáng Collapse
	Yīn Collapse	Yáng Collapse
Sweating	Hot sweat, salty in flavor	Cold sweat that is bland to the taste
Limbs	Warm	Reversal cold
Other signs	Hot flesh, hasty breathing, thirst with desire for cold drink, parched lips, dry desiccated teeth	Cold flesh, weak faint breathing, absence of thirst or desire for hot drinks
Tongue	Red and dry	Pale and moist
Pulse	Fine, rapid or racing, and forceless	Faint on the verge of expiration

Yáng collapse (亡阳 wáng yáng) patterns are the clinical manifestation of severe yáng qì vacuity desertion. This is often referred to as yáng collapse vacuity desertion (亡阳虚脱 wáng yáng xū tuo1) in Chinese literature.

Description: Somber-white facial complexion, cold dripping sweat that is bland to the taste, reversal cold of the limbs, weak faint breathing, and unclear spirit-mind or clouded spirit. The tongue is pale-white and moist. The pulse is faint and on the verge of expiration.

Pathogenesis: Yáng collapse patterns arise

• when extremely exuberant yīn cold leads to fulminant desertion of yáng qì;
• when massive bleeding, great sweating, or great diarrhea give rise to yáng deserting with yīn; or
• when poisoning, severe external injury, or phlegm-stasis obstruct the orifices of the heart, causing fulminant desertion of yáng qì.

Analysis: In vacuity desertion of yáng qì, the fleshy exterior becomes insecure, so cold clear thin sweat drips from the skin. Depletion of yáng qì causes the decline of functions, so that breathing is faint and weak, and the pulse is faint and on the verge of expiration. The loss of the warming function of yáng qì gives rise to a somber-white complexion and reversal cold of the limbs.

Yīn and Yáng Sores

Finally, in external medicine, a distinction is made between yīn and yáng sores.

• Sores without redness and with diffuse swelling, absence of heat, and clear, thin pus, or accompanied by generalized physical weakness are classified as yīn sores.
• Sores marked by pronounced redness, swelling, heat, pain, and thick pus, and associated with generalized repletion heat patterns, are classified as yáng sores, which are the more common.

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