One of the four examinations. The inquiry examination involves asking the patient about matters that cannot be investigated through the other examinations, such as sensations that only the patient is aware of (pain and other discomforts) or that are difficult for the physician to observe during a brief consultation (sleep, sweating, etc.).

Inquiry shapes the overall examination process. It accords the patient an active role in interpreting his or her condition and influencing treatment. Illness is thus determined in a cooperative process between the patient and the healer. Although the inquiry examination is come third in the traditional order of presentation, presumably because visible appearances and smells are often apparent on the practitioner’s first encounter with the patient, inquiry covers many of the preliminaries in consultation that in modern practice are dealt with by having the patient fill out a form before entering the consultation room. For this reason, many modern Chinese textbooks place it before the other three examinations.

Though important, inquiry nevertheless poses the problem of subjectivity. While inspection, listening and smelling, and palpation are relatively objective, the information provided by the patient in response to questions is not fully reliable, since it tends to be clouded by their own thoughts and fears and can therefore confound their judgment. Patients may be evasive if asked about negative emotions. Traditionally, it was recognized that although the patient must be questioned in detail regarding the condition, the information provided must be set against the picture presented by the other examinations. Accurate diagnosis depends on thoroughness and the correlation of all four examinations.

General

Consultation Preliminaries

Personal Data

Before consultation, patients should fill out a form asking their name, contact addresses, including telephone and email, usual place of residence, marital status, gender, age, occupation, and ethnicity. It should also include the name of anyone speaking on behalf of the patient (such as a parent in the case of a child). This information serves to identify the patient and facilitate future contact.

Age, gender, usual place of residence, and occupation are important because they can help determine what kinds of disease a patient is likely to be susceptible to. For example, children are prone to measles and chickenpox. Elderly people usually have vacuity patterns. People of middle or old age are more prone to wind stroke. Women and men have different reproductive functions, which are subject to various disturbances.

Chief Complaint

Establishing the chief complaint is a biomedical practice that has been adopted in Chinese medicine. The practitioner asks the patient what the chief complaint is, that is, what the main signs are that prompted him or her to seek medical assistance. The chief complaint should be recorded in a short phrase, such as runny nose and cough for three days or intermittent headaches for a month. The chief complaint may consist of one to three symptoms and should offer information on their duration. It usually allows the physician to grasp the nature and scope of the illness, as well as its severity.

Note that the chief complaint is always expressed in symptoms. It should not include diagnostic results such as disease names. Even if a patient presents high blood pressure as her first chief complaint, the practitioner should replace it with a description in terms of symptoms.

History of the Present Illness

The practitioner inquires about the onset and development of the present illness and whether prior medical assistance has been sought.

Present condition: Thorough inquiry aims to establish all of the symptoms a patient is suffering from at the time of consultation.

Times when signs occur: It is important to inquire if symptoms are relieved at any time of the day or in response to stimuli. For example, tidal heat effusion can occur at different times of the day depending on whether the cause is yīn vacuity or external evils, so it is important to establish the precise time of occurrence. Some symptoms, such as abdominal discomforts, may be related to emotional stimuli when caused by depressed liver qì. These may be relieved by belching or passing flatus.

Onset of illness: Ask about the time of onset and speed of onset, what factors the patient believes may have caused the illness, and what remedial actions, if any, the patient has taken. History of the present illness enables the practitioner to establish the pathomechanism, while the present condition provides the basis for disease identification and pattern identification.

Development of the illness: Note the main events in the development of the illness in chronological order to gain an understanding of the operant pathomechanisms. Exposure to specific environmental influences or types of food or drink may be important in judging conditions that subsequently arose. For example, consumption of cold foods may explain how abdominal pain arose.

Prior medical assistance: Ask whether the patient has previously sought medical assistance, and if so, what tests were performed, what their results were, what the diagnosis was, and what, if any, treatment was administered or prescribed, including medicines taken.

History of Past Illness

It is important to inquire about previous health and illness. This may provide some additional information about the patient’s constitution and pathomechanism of the present illness.

General health in the past: You should ask whether the patient has a strong or weak constitution and whether there is any susceptibility to disease. If the patient normally has a healthy constitution, the present condition may well be repletion; if the patient has a weak constitution, the present condition is more likely to be vacuity.

Contagious disease and inoculation: Ask about the patient’s history of contagious diseases, such as measles, diphtheria, malarial disease, and dysentery, and any inoculations. If you suspect a contagious disease, ask whether there have been any contagious diseases in the patient’s locality.

History of other illness: Ask the patient about other major illnesses in the past and whether they are still present. If a patient’s chief complaint is cough following contraction of wind and cold, it makes a difference whether the patient has a history of cough. If the patient continually has had coughs in the past, then this is probably closely related to the present illness.

Living Conditions, Work, and Lifestyle

Several aspects of the patient’s life are pertinent to medical inquiry.

Locality and environment: Ask where the patient lives and about the environmental and climatic conditions prevailing there, such as dryness or dampness.

• People living in warm and hot climates are susceptible to malarial disease, dysentery, warm-disease, and sores.
• People living in certain inland regions (now identified as lacking iodine in the water) are susceptible to goiter.
• People who live in damp climates or whose work brings them into frequent contact with water (e.g., paddy-field workers and fishermen) are prone to dampness-related diseases, such as impediment (bì) patterns. Cold and damp in particular can also damage right qì.

Occupation and exercise: Ask the patient about her occupation to find out how much manual and mental work is involved. Ask how many hours she works to determine whether she is overworked. Inquire about stress.

• Lack of exercise encourages qì and blood stagnation, fosters dampness, and blood stasis.
• Excessive exercise can damage yīn and body fluids.
• People who consistently overwork or whose work mostly involves use of mental powers are often sleep-deprived and suffering from yīn-blood vacuity.
• People with stressful jobs and lifestyles that cause frustration and anger or involve interpersonal tension may suffer from depressed liver qì.
• Work that involves physical strain, such as manual laboring or nursing, may suffer from musculoskeletal ailments, such as aching lumbus and knees or impediment (bì).
• People who work outdoors in cold winter weather may be susceptible to wind-cold or even frostbite.
• People who work outside in hot summer weather can get summerheat stroke.
• Miners are prone to lung disease.
• Many other working environments expose workers to air, water, and food pollution.

Diet

• Habitual consumption of rich, sweet, and fatty foods causes phlegm-damp.
• Hot spicy food gives rise to heat.
• Raw and cold food can give rise to cold and dampness.
• Irregular eating, excessive consumption of alcohol can cause stomach and liver disease.

Sexual relationships and childbearing: The practitioner may deem it appropriate to inquire of adult patients whether they are married or in a partnership. Stable relationships can provide psychological well-being, but marital and partnership tensions can affect health. It is important to ask female patients about when their periods started or ended, their menstrual cycle, whether they have given birth, how many children they have had, and about history of pregnancies (miscarriage or difficult delivery).

Inquiry about Temperament and Spirit-Mind

Spirit-mind refers to the mental and emotional state of the individual. Temperament refers to habitual states related to constitution. The two are hard to distinguish. Many states of spirit-mind are visually apparent. Many aspects of temperament and spirit-mind may become apparent through interaction with the patient, as well as through direct questioning.

As discussed in seven affects, excessive or enduring emotional and mental states are causes of disease. The five minds and seven affects (anger, thought, worry, sorrow, fear, and fright) can all have negative effects and contribute to clinical worry and depression, which are the most prevalent psychological disorders currently recognized in biomedicine. Many other specific mental states traditionally discussed in Chinese medicine are the result of the physical pathologies of the bowels and viscera.

Fatigue and lack of strength (身倦乏力 shēn juàn fá lì, 倦怠乏力 juàn dài fá lì); lassitude of spirit (神疲乏力 shén pí fá lì): Fatigue is weariness from bodily or mental exertion. Medically, it refers to an abnormal tendency to weariness. Lack of strength is the inability to perform normal movements, such as lifting and carrying heavy things. It is attributed to qì-blood vacuity or debilitation of yáng qì. It also occurs in dampness patterns. In terms of the bowels or viscera, it is usually seen in spleen, stomach, lung, and liver vacuity. Lassitude of spirit means lack of mental vigor. It has the same diagnostic significance as fatigue and lack of strength.

Emotional depression: People suffering from severe emotional depression (affect-mind depression) are likely to be suffering from depressed liver qì. Remember that depressed liver qì may cause or exacerbate phlegm conditions; it can also transform into fire. These changes may be reflected in the patient’s affect-mind condition.

Worry and fear: Worry and fear in severe cases that can make a patient afraid to stay in a room alone and that are accompanied by heart palpitation and hasty breathing usually occur in vacuity patterns. They are commonly caused by gallbladder qì vacuity and insufficiency of blood depriving the heart-spirit of nourishment.

Heart vexation: A feeling of unrest or irritability that is centered in the heart region. It indicates vacuity heat or repletion heat. In severe cases, it is associated with agitation (visible fidgetiness).

Impatience, agitation, and irascibility (急躁易怒 jí zào yì nù): A habitually agitated state of mind that manifests in an impatient attitude to others, rash behavior, and sudden flights of anger (fulminant anger). It is a sign of excessive free coursing and occurs in ascendant hyperactivity of liver yáng and in liver fire flaming upward. Note that patients may deny such mental states when inquired about them.

Forgetfulness: Poor memory. It is often accompanied by abstraction, which is absentmindedness and inability to focus attention. It is caused by depletion of heart blood depriving the heart spirit of nourishment, by insufficiency of kidney essence, or less commonly by phlegm turbidity harassing the upper body or static blood attacking the heart. It is seen in heart blood vacuity; dual vacuity of the heart and spleen; insufficiency of kidney essence; kidney yīn vacuity; and heart-liver blood vacuity.

Abstraction (恍惚 huǎng hū) : Absent-mindedness and inability to focus attention, often associated with forgetfulness. It indicates insufficiency of yīn-blood, yáng qì, or kidney essence. It can also be a sign of phlegm turbidity.

Susceptibility to fright (易惊 yì jīng): Susceptibility to fright is the tendency to be frightened or shocked easily. It is often associated with heart palpitation (see above) and with flusteredness (a feeling of nervousness and lack of composure). It results from insufficiency of qì and blood failing to nourish the heart, from fire or phlegm-fire harassing the heart spirit, or from failure of the gallbladder’s governing of decisions, making the heart spirit susceptible to fear and fright. It occurs in heart blood vacuity, hyperactive heart fire, phlegm-fire harassing the spirit, and in gallbladder qì vacuity, and dual vacuity of qì and blood.

Flusteredness (心慌 xīn huāng) : A state of agitation, confusion, or lack of composure associated with susceptibility to fright.

Indecision: Inability to make decisions. It is usually a sign of gallbladder disease.

Gallbladder timidity: Fearfulness and lack of courage to meet people or take action. It is usually a sign of gallbladder disease.

Inquiry about Sleep

Another aspect of spirit-mind is sleep. Sleep is related to the circulation of defense qì, to surfeits and deficits of yīn and yáng, to the state of qì and blood, and to the health of the heart and kidney. Normally, in the daytime, when defense qì moves through the yáng channels and yáng qì is strong, we are awake. During the nighttime, when defense qì circulates through the yīn channels, yīn qì is stronger, so we sleep. When defense qì remains in the yīn aspect for longer than normal, sleeping time may increase. However, sleep is affected by numerous factors. If qì, blood, yīn and yáng are in harmonious balance and the heart and kidney interact normally, we sleep well. When qì, blood, yīn, and yáng are in disharmony and the heart and kidney fail to interact, sleep patterns become abnormal. Sleep disturbances are all disturbances of the heart spirit, but the root cause is not necessarily heart disease.

Insomnia (失眠 shī mián)

Also called sleeplessness (不寐 bù mèi), insomnia is difficulty in getting to sleep, awaking during sleep and being unable to get back to sleep, or even being unable to sleep the whole night long. Most healthy people sleep for 7–8 hours, but the length of time people sleep depends on age and constitution. Older people tend to sleep less than younger people. Insomnia means sleeping for less time than normal for the individual and not feeling refreshed in the morning.

Insomnia is most commonly caused by heat or stomach problems. It occurs in heart blood vacuity; heart yīn vacuity; dual vacuity of the heart and spleen (insufficiency of heart blood and spleen qì vacuity); hyperactive heart fire; phlegm-fire harassing the heart; noninteraction of the heart and kidney; ascendant hyperactivity of liver yáng; gallbladder qì vacuity; residual heat in the final stages of warm disease; and stomach patterns involving severe disharmony of stomach qì.

• Vacuity insomnia is caused by yīn vacuity with effulgent fire, liver-heart blood vacuity, or heart-gallbladder qì vacuity.
• Repletion insomnia is caused by heart fire, liver fire, phlegm-heat, food accumulation, or static blood disturbing the heart spirit.
• When the stomach is in disharmony, there is unquiet sleep is an axiom that underscores the importance of stomach problems in insomnia.

Profuse dreaming (多梦 duō mèng): A tendency to dream more than often than normal. It often accompanies insomnia. When dreaming is profuse, it is often confused, hence the term profuse confused dreaming (多梦纷纭 duō mèng fēn yún) is a commonly used synonym. Profuse nightmares (惡夢紛紜 è mèng fēn yún) may be associated with liver fire flaming upward.

Hypersomnia (嗜睡 shì shuì)

Also profuse sleeping (多睡 duō shuì). Sleeping for extended periods and drowsiness in waking time. The patient may awaken when called, but easily goes back to sleep.

• Hypersomnia with clouded head and vision, oppression in the chest, glomus in the stomach duct, and heavy limbs is attributable to phlegm-damp encumbering the spleen, preventing the upbearing of clear yáng.
• Hypersomnia with devitalized essence-spirit (low mental energy) in the daytime, fear of cold, cold limbs, lying in curled-up posture, and liking for warmth (warm food and drinks, warm clothing) is attributable to debilitation of yáng qì.
• Hypersomnia after major illness reflects the body’s efforts to recuperate and indicates the healthy restoration of right qì.
• In externally contracted disease, hypersomnia is quite normal.
• Hypersomnia is pronounced in heat entering the pericardium or phlegm clouding the orifices of the heart.
• Desire only for sleep (但欲寐 dàn yù mèi) occurs in lesser yáng (shào yáng) disease of cold damage and is the result of debilitation of yáng qì. In this condition, it is difficult to tell whether the person is asleep or awake.
• Clouding sleep (昏睡 hūn shuì) is a more severe condition where the patient can be called out of sleep but cannot respond to inquiry properly. It means that the condition is critical.
• Drowsiness after eating (食后困顿 shí hòu kùn dùn) with fatigue and reduced eating or torpid intake is attributable to insufficiency of center qì and impairment of the spleen’s movement and transformation function.

Inquiry about Cold and Heat

When inquiring about cold and heat sensations, a major aim is to establish whether the patient suffers from only heat effusion or aversion to cold (fever or chills) or from both, since the simultaneous appearance of both is the criterion that determines an exterior pattern attributable to an external evil. If they do not occur together the condition forms an interior pattern attributable to numerous possible causes.

Heat

Sensations of heat and elevated body temperature fall into three basic kinds.

Heat effusion is used in this text in preference to fever as the translation for 发热 fā rè, since it includes subjective feelings of heat. Heat effusion has manifold significance, depending on its nature and accompanying signs.

Vigorous heat effusion (壮热 zhuàng rè) is a continuous pronounced heat effusion without aversion to wind or cold, equated with the biomedical concept of high fever (over 39°C/102°F). It occurs in interior heat and repletion patterns, e.g., yáng míng (yáng míng) disease. Many texts use the term high fever instead of this traditional term.

Slight heat effusion (微热 wēi rè) is a low-grade fever (which in biomedicine is defined as a body temperature of 37–38°C/99–100°F). It most commonly occurs in yīn vacuity but may also occur in qì vacuity or in qì depression transforming into heat.

Tidal heat effusion (潮热 cháo rè), or simply tidal heat, occurs like the ocean tides at set times of the day, such as afternoon, evening, or night. For diagnostic purposes, it is important to determine the time and whether the heat effusion only occurs or becomes more severe at that time.

• Yīn vacuity: Yīn vacuity tidal heat is the most common type of tidal heat. It can occur any time after midday (postmeridian tidal heat, 午后潮热 wǔ hòu cháo rè) or at night (nighttime tidal heat, 夜间潮热 yè jiān cháo rè) and manifests in slight heat effusion. When the heat feels as though it is emanating from the bones it is called steaming bone tidal heat effusion (骨蒸潮热 gǔ zhēng cháo rè). Tidal heat effusion occurs in yīn vacuity because after midday defensive yáng normally enters the interior, where it moves during the night, but when yīn humor is depleted, it is no longer kept in check, causing heat. This is often described as yáng failing to enter yīn (阳不入阴 yáng bù rù yīn), that is, failing to be enveloped and subdued by yīn. Yīn vacuity tidal heat can take the form of vexing heat in the five hearts, discussed below.
• Damp warmth: Pronounced postmeridian tidal heat with generalized heat failing to surface, that is, only felt on prolonged palpation, is called generalized heat failing to surface (身热不外扬 shēn rè bù wài yáng). It occurs in damp warmth conditions when the dampness prevents the heat from reaching the surface of the body and hence is described as reflecting dampness trapping hidden heat (湿遏热伏 shī è rè fú). This kind of tidal heat resembles steaming bone tidal heat above, but the accompanying signs are different. In damp-warmth, tidal heat is attended by glomus in the stomach duct and generalized heaviness, and a red tongue with a slimy fur.
• Warm disease with heat entering provisioning-blood: Heat effusion that worsens at night in warm disease is usually a sign of heat entering the provisioning-blood aspect. It is often described as generalized heat effusion more pronounced at night (身热夜甚 shēn rè yè shèn).
• Yáng míng (yáng míng) (yáng míng) bowel repletion: Heat effusion that worsens during the late afternoon watch of the traditional Chinese clock, i.e., 3–5 p.m. is called late afternoon tidal heat. It occurs in yáng míng (yáng míng) bowel repletion, because yáng míng (yáng míng) channel qì is most effulgent at that time, and this exacerbates the heat effusion.
• Qì vacuity: Heat effusion occurring at irregular intervals in patients suffering from fatigue and lack of strength is indicative of qì vacuity.

Vexing heat in the five hearts (五心烦热 wǔ xīn fán rè), which refers to palpable heat in the palms and soles with vexation and heat felt in the center of the chest, is a sign of yīn vacuity.

Heat vexation (烦热 fán rè) is a condition in which the patient feels hot and restless. It occurs with heat effusion. However, if the body temperature is slightly elevated, it indicates heat in the bowels or viscera.

Cold

Distinction is made between fear of cold, aversion to cold, and aversion to wind.

Fear of cold (畏寒 wèi hán) is intolerance of cold that can be relieved by adding extra clothing or bedclothes. The term physical cold is similar in meaning. It means that the patient has cold sensations and evinces signs objectively visible to the observer, such as wearing extra clothing or lying in curled-up posture. It is a sign of vacuity or repletion cold.

Fear of cold is often associated with lack of warmth in the extremities (手足不溫 shǒu zú bù wēn) or cold hands and feet which can be objectively felt by others. Hence, the combined terms fear of cold and cold limbs (畏寒肢冷 wèi hán zhī lěng) and physical cold and cold limbs (形寒肢冷 xíng hán zhī lěng) often appear in the literature. These signs arise because yáng qì is not powerful enough to fully warm the exterior of the body and the extremities. They are seen in any yáng vacuity or in repletion cold patterns such as cold stagnating in the stomach and intestines or cold stagnating in the liver vessel.

Aversion to cold (恶寒 wù hán) is often referred to as chills in English-language literature. Aversion to cold is a literal translation of the Chinese term. It is a sensation of cold that is not easily relieved by the addition of clothing or bedclothes and is often accompanied by shivering. This is the unique sensation of cold we typically feel when we have a common cold or flu. It occurs in external contractions, when external evils obstruct the outward movement of yáng qì.

Many Chinese texts also speak of aversion to wind (恶风 wù fēng), which is similar in meaning to aversion to cold but indicates a milder condition. It means that the patient is sensitive to wind and drafts but feels more comfortable when well wrapped up. Aversion to cold means that the patient tends to feel cold even when they cover up well. The distinction is of no significance beyond indicating the severity of the condition.

Shivering (战栗 zhàn lì, 振寒 zhèn hán): Trembling from cold is called shivering or cold shudders (寒栗 hán lì). In Chinese texts, it usually refers to violent shivering called rigors in biomedicine. It is basically the same as aversion to cold, but more severe. It occurs in warm epidemics and malarial disease. See also shiver sweating below under Inquiry about Sweating below.

Heat and Cold Occurring Together

Aversion to cold with heat effusion (恶寒发热 wù hán fā rè): Aversion to cold can occur with heat effusion. This happens when externally contracted evils enter the body and summon the resistance of defense qì. It is a major sign of exterior patterns. The heat is understood as a result of the struggle between evil qì and defense qì and does not necessarily mean that the invading evil causing the condition is heat.

• Heat effusion and aversion to cold occurring simultaneously at the onset of an illness is an exterior pattern caused by external contraction. The prominence of the two signs is important.
• Strong aversion to cold with slight heat effusion is observed in external contractions of cold evil (wind-cold). In such cases, the heat effusion may be very mild and subjectively almost imperceptible to the patient, although others may detect it by touching the patient’s forehead.
• Mild aversion to cold with pronounced heat effusion occurs in heat evil contractions (wind-heat). Heat effusion with aversion to wind is a sign of wind evil contraction.
• Alternating cold and heat (寒热往来 hán rè wǎng lái), that is, alternating aversion to cold and heat effusion, occurs in malarial disease and lesser yáng (shào yáng) disease.
• When heat effusion with aversion to cold gives way to unabating vigorous heat effusion (high fever) without aversion to cold indicates that the disease has penetrated the interior.
• Persistent but fluctuating high fever unabated by sweating with intermittent abhorrence of cold (see below) and heat vexation indicates intense evil heat in the interior that prevents yáng qì from reaching the exterior.
• Note that aversion to cold without heat effusion may occur in a severe illness when there is a sudden marked drop in body temperature. This indicates yáng collapse vacuity desertion.

Abhorrence of cold (憎寒 zēng hán): This is outer-body shivering with inner-body heat vexation arising when a deep-lying internal heat evil blocks yáng qì, preventing it from reaching the exterior.

Fear of cold with tidal heat: Fear of cold and cold limbs may be associated with tidal heat in dual vacuity of yīn and yáng. This occurs because yáng qì fails to reach the exterior, but yīn vacuity in the inner body causes tidal heat and heat in the five hearts.

Inquiry about Sweating

Sweat is produced from fluids and blood, and normal secretion is regulated by provisioning qì and especially defense qì. Sweating helps to disperse body heat. It is a normal consequence of a hot environment or exertion. In those suffering from illness, sweating reflects the state of the fluids and blood, as well as that of provisioning qì and defense qì.

Specific Types of Sweating

Sweating (汗出 hàn chū): Sweating is normal when attributable to warm environments and physical exertion. Abnormal sweating may be caused by (a) external evils in the exterior, (b) heat in the interior, (c) insufficiency of yáng qì preventing normal containment of fluids, or (d) insufficiency of yīn humor (yīn vacuity), when yīn fails to constrain yáng.

• Exterior patterns: Sweating occurs in greater yáng (tài yáng) wind strike patterns with wind evil and exterior vacuity. It is also seen in exterior heat patterns caused by wind-heat. Wind causes opening and discharge, making the interstices loosen and open. In exterior vacuity with defense yáng failing to keep the interstices closed, sweating is even more likely.
• Interior patterns: Sweating occurs in repletion heat patterns, yīn vacuity with internal heat, and yáng qì debilitation, and yáng collapse or yīn collapse patterns. Yīn vacuity manifests in night sweating, while yáng vacuity manifests in spontaneous sweating (see below).

Spontaneous sweating (自汗 zì hàn): Spontaneous sweating is a general tendency to sweat more than usual, especially after exertion. It is a sign of qì vacuity or yáng vacuity and is often attended by shortness of breath, lassitude of spirit and lack of strength, fear of cold, and a pale tongue and weak pulse. Yáng qì vacuity makes defense yáng unable to keep the interstices closed so that fluids escape from the body in the form of sweat. This is exacerbated by exertion. Note that the term spontaneous sweating is sometimes also used to refer to the sweating of external contractions.

Night sweating (盗汗 dào hàn): Night sweating, or, as it is called in Chinese, thief sweating, is sweating during sleep that ceases upon waking. It indicates yīn vacuity.

Great sweating (大汗 dà hàn): Great sweating means the production of large amounts of sweat. A distinction is made between repletion and vacuity. Repletion patterns are repletion heat. Vacuity patterns are yīn collapse or yáng collapse patterns.

• A yáng brightness (yáng míng) (yáng míng) channel pattern is marked by great sweating, great heat effusion (high fever), great thirst (with a desire for cold drinks), and a large surging pulse. These four signs are often called the four greats. It occurs in yáng brightness (yáng míng) disease in cold damage and qì-aspect patterns in warm disease.
• Yīn collapse manifests in incessant sweating with sticky and oily hot sweat. It is accompanied by heat effusion, thirst, rough breathing, and a pulse that is fine and rapid or racing. It is attributed to severe damage to yīn-humor with vacuity heat forcing the fluids to discharge.
• Yáng collapse is characterized by clear thin cold sweat that forms pearly droplets on the skin and drips off the body. Hence it is often described as great dripping sweat or cold sweat. It is accompanied by a somber-white complexion, reversal cold of the limbs, and a faint pulse on the verge of expiration.

Expiration sweating (絕汗 jué hàn): Great sweating in critical conditions is a sign of yīn collapse or yáng collapse. See great sweating above.

Cold sweating, cold sweat (冷汗 lěng hàn): Sweating in which the sweat feels cold. It is a sign of yáng collapse or fright. See great sweating above.

Hot sweating, hot sweat (热汗 rè hàn): Sweating in which the sweat feels hot. It is a sign of interior heat or yīn collapse. See great sweating above.

Pearly sweat (汗出如珠 hàn chū rú zhū): Clear thin sweat appearing as pearly droplets on the skin. See great sweating above.

Oily sweat (汗出如油 hàn chū rú yóu): When oily sweat starts streaming constantly from the skin in severe illness, this indicates yīn collapse. See great sweating above.

Great dripping sweat (大汗淋漓 dà hàn lìn lí): Severe sweating. Observed in yáng collapse, qì deserting with liquid, and qì deserting with blood.

Shiver sweating (战汗 zhàn hàn): Sweating after shivering is called shiver sweating. It occurs in patients with exuberant evil and weak right qì, when evil lies latent but fails to be eliminated. Shiver sweating is the manifestation of right qì attempting to rally its strength and engaging in a fierce struggle with evil qì. It is often seen in warm disease and cold damage. It represents a critical point in the disease. Abatement of heat effusion at this point indicates that evil qì is abating and right qì is recovering. If the heat effusion does not abate and there are signs such as vexation and agitation and a pulse that is urgent or racing, this signifies that the condition is worsening.

Yellow sweating (黄汗 huáng hàn): Sweating in which the sweat is yellow in color, staining the patient’s clothing and bedclothes yellow. This is often described as the color of water in which huáng bǎi (Phellodendri Cortex) has been decocted. It is a sign of damp-heat.

Sweating in Relation to Heat Effusion

Profuse sweating followed by abatement of heat effusion and calming of the pulse is a sign that right qì is expelling the evil.

Absence of sweating (无汗 wú hàn) is attributed to one of two factors. It occurs when external evils, notably cold, cause the interstices (sweat glands and pores) to contract and close. Here it is accompanied by pronounced aversion to cold and slight heat effusion. It can also occur with pronounced heat effusion and dryness of the skin as a result of depletion of blood and fluids.

Sweating that fails to abate heat effusion in externally contracted cold damage disease occurs in two situations:

• in exterior patterns with provisioning-defense disharmony preventing the expulsion of an exterior evil, characterized by spontaneous sweating with continual intermittent but not severe heat effusion with aversion to cold (see greater yáng (tài yáng) disease pattern; and
• in great qì-aspect heat patterns, where great heat effusion and great sweating are accompanied by aversion to heat and great vexation and thirst.

Localized Sweating

Sweating from the head (头汗 tóu hàn): Also sweating from the head only. This is sweating from the head or neck. Sweating from the head is a normal reaction to hot spicy food, hot drinks, or strong liquor creating a temporary exuberance of yáng qì. Pathological causes include the following:

• exuberant heat in the upper burner forcing liquid to discharge outward;
• center burner brewing damp-heat forcing liquid upward;
• original qì on the verge of desertion with vacuity yáng straying upward and causing liquid to discharge with yáng qì.

Half-body sweating (半身出汗 bàn shēn chū hàn), also hemilateral sweating. Sweating from one side of the body (right or left) or from either the upper body or lower body. The part of the body that is not sweating is the part affected by the illness. It mostly occurs in wilting disease, wind strike, and paralysis. It is mostly attributable to obstruction of the channels and network vessels by wind-phlegm, phlegm-stasis, or wind damp.

Sweating from the hearts of the palms and soles (手足心汗 shǒu zú xīn hàn): Slight sweating from the palms and soles is normal. Only when it is profuse is it pathological. It can be attributable to depressed heat in the yīn channels or dryness-heat in the yáng channels causing liquid to discharge outward. It may also be attributable to damp-heat in the center burner.

Sweating from the heart and chest (心胸汗出 hàn chū): Sweating from the region of the heart in the center of the chest is called sweating from the heart and chest. It is usually a vacuity sign and is seen in dual vacuity of the heart and spleen or noninteraction of the heart and kidney.

Genital sweating (阴汗 yīn hàn): Profuse sweating from the region of the genitals in either males or females is usually attributable to lower burner damp-heat.

Inquiry about the Head, Hearing, and Vision

The head contains the brain marrow and is an area densely covered by channel pathways. Most of the twelve channels and the eight extraordinary vessels, especially the yáng channels, pass through the head. Headaches and dizziness are among the common symptoms of illness, occurring in both externally contracted febrile disease and in internal damage and miscellaneous disease.

The ears are the orifices of the kidney. The eyes are the orifices of the liver. Hearing and vision problems are largely associated with these two viscera.

Headache

Headache can be categorized according to cause. Headache can occur in conditions caused by external contractions or in internal damage and miscellaneous disease and hence can take the form of vacuity or repletion patterns. It occurs in repletion patterns attributable to externally contracted wind, cold, dampness, or fire, phlegm turbidity, or blood stasis. It occurs in vacuity patterns involving depletion of qì, blood, or essence depriving the brain of nourishment. The nature and severity of headache and the precise location of the pain are all important factors in diagnosis.

Nature of the pain and sensations

• Headache of recent onset usually indicates exterior contraction.
• Enduring headache indicates internal damage.
• Severe headache usually indicates repletion.
• Dull headache usually indicates vacuity.
• Headache accompanied by heavy-headedness, often called head heavy as if swathed (头重如裹 tóu zhòng rú guǒ) is usually attributable to phlegm-damp clouding the upper body.
• Headache exacerbated by exposure to wind and cold usually indicates externally contracted wind-cold. Cold obstructs the movement of yáng qì, and when there is stoppage, there is pain.
• Headache exacerbated by warmth usually indicates ascendant hyperactivity of liver yáng.
• Headache on one side only is hemilateral headache (偏头痛 piān tóu tòng), commonly known as migraine. It appears in ascendant hyperactivity of liver yáng, in blood vacuity, and in blood stasis patterns.
• A persistent remittent, usually intense headache attributed to wind-cold or wind-heat invasions and obstruction of the channels by phlegm and static blood is called head wind (头风 tóu fēng) in traditional literature. Accompanying signs may include eye pain, loss of vision, dizziness, runny nose, numbness of the head, stiff nape, and nausea.

Headache according to patterns

• Externally contracted wind-cold: Headache sometimes reaching into the nape and back, with a tight feeling, exacerbated by wind and cold, with aversion to cold and heat effusion, pain in the joints, absence of thirst, thin white tongue fur, and a pulse that is tight and floating.
• Externally contracted wind-heat: Headache with a feeling of distension, exacerbated by exposure to heat, heat effusion and aversion to wind, red face and eyes, painful swollen throat, dry mouth and thirst, a red-tipped tongue, a thin yellow tongue fur, and a floating rapid pulse.
• Externally contracted wind-damp: Head heavy as if swathed, with a cloudy feeling and headache that is exacerbated by yīn-type rainy weather, accompanied by oppression in the chest, fullness in the stomach duct, torpid intake, heavy cumbersome limbs, scant urine, sloppy stool, a slimy white tongue fur, and a pulse that is soggy or slippery.
• Cold stagnating in the liver channel: Headache often taking the form of vertex headache (pain at the top of the head).
• Ascendant hyperactivity of liver yáng: Headache on both sides or vertex with dizziness.
• Center qì vacuity: Headache with an empty feeling in the brain.
• Blood vacuity and yīn depletion: Dull headache with dizziness.
• Blood stasis: Splitting headache with a possible history of trauma.
• Phlegm turbidity: Headache with clouded head, dizziness, oppression in the chest, glomus in the stomach duct.

Six-channel analysis: Headaches in different parts of the head can be analyzed in terms of the channels on which the affected part lies.

• Greater yáng (tài yáng) headache: Pain reaching from the head down the nape to the back.
• yáng brightness (yáng míng) headache: Pain in the forehead sometimes stretching into the eyebrow bone (the superciliary arch).
• Lesser yáng (shào yáng) headache: Pain on the sides of the head or the temporal region.
• Greater yīn (tài yīn) headache: Pain and heaviness in the head accompanied by abdominal fullness and spontaneous sweating.
• Lesser yīn (shào yīn) headache: Pain stretching into the teeth and deep into the brain.
• Reverting yīn (jué yīn) headache: Pain at the vertex stretching to the corners of the forehead, accompanied by a subjective feeling of counterflow qì ascent, with retching in severe cases.

Dizziness ( 头晕目眩 tóu yūn mù xuàn, 眩晕 xuàn yūn):

A subjective feeling of fogginess, often called clouded head (头昏 tóu hūn) or, in more severe cases, of whirling inside the head that is experienced even with the eyes closed, and visual disturbances. A distinction is made between dizzy head (头晕 tóu yūn) and dizzy vision (目眩 mù xuàn), although the two may be poorly distinguishable. Dizziness is attributed to insufficiency of qì and blood depriving the head and eyes of nourishment or to evils (fire, wind, phlegm-rheum, static blood) disturbing the normal movement of qì and blood. Because of its wide range of causes, dizziness appears in many disease patterns:

• Qì and/or blood vacuity: Dizziness with white facial complexion, lassitude of spirit and physical fatigue, pale tongue, and a fine pulse. Where qì vacuity is prominent, dizziness is often exacerbated by fatigue. Dizziness appears notably in heart blood vacuity, spleen vacuity qì fall, liver blood vacuity.
• Liver and/or kidney yīn vacuity: In both these patterns, dizzy head is accompanied by vacuity heat signs. In liver yīn vacuity, it appears with dry eyes and dull rib-side pain. In kidney yīn vacuity, it presents with aching lumbus, tinnitus, and seminal emission.
• Ascendant hyperactivity of liver yáng: Dizziness with a pronounced feeling of imbalance (such as felt on a boat) and accompanied by distension in the head, tinnitus, limp aching lumbus and knees, red face, bitter taste in the mouth, dry throat, red tongue with scant fur, and a pulse that is stringlike and fine. This type of dizziness is often exacerbated by anger.
• Liver fire flaming upward: Dizziness with distension in the head, vexation and agitation, irascibility, a red tongue, and a pulse that is stringlike and rapid.
• Wind-phlegm: Visual whirling suggests wind-phlegm harassing the upper body. In severe cases of liver wind stirring internally, patients may feel as if they are losing their balance, which is described as dizziness that threatens collapse (眩晕欲仆 xuàn yūn yù pū). This may portend wind stroke.
• Phlegm-damp or phlegm-rheum: Dizziness with heavy-headedness (often described as head heavy as if swathed), oppression in the chest, retching and nausea, and a slimy white tongue fur, as in cold rheum collecting in the stomach or rheum collecting in the chest and rib-side.
• Blood stasis obstructing the network vessels: Dizziness with stabbing pain.

Dizzy vision (目眩 mù xuàn): Also flowery vision (目花 mù huā). When the visual field appears to turn or move, as if one were on a moving boat or vehicle, or when flies appear to cross the eyes (mouches volantes), this is called dizzy vision. A distinction is made between vacuity and repletion.

• In vacuity patterns, dizzy vision usually arises as a result of spleen vacuity qì fall with clear yáng failing to ascend or of liver-kidney insufficiency with depletion of essence and blood, depriving the eyes of nourishment. It is often associated with lassitude of spirit, shortness of breath, dizzy head, and tinnitus, and most commonly occurs in the elderly, in people with weak constitutions, and in patients in a weak state of health attributable to enduring illness.
• In repletion patterns, dizzy vision arises when wind-fire harasses the clear orifices or when phlegm-damp clouds the clear orifices. It is often accompanied by red eyes, distension in the head, headache, or heavy-headedness.

Heavy-Headedness (头重 tóu zhòng)

A subjective sensation of heaviness and clouding of the head. Like heavy cumbersome limbs, it is a sign of dampness encumbering the spleen.

Head heavy as if swathed (头重如裹 tóu zhòng rú guǒ) is heavy-headedness often accompanied by headache and arises when externally contracted dampness evil or phlegm-damp of internal origin cloud the upper body.

Heavy head and light feet (头重脚轻 tóu zhòng jiǎo qīng): A feeling of top-heaviness. It occurs in ascendant hyperactivity of liver yáng and reflects the upper body repletion and lower body vacuity of this pattern.

Toothache (牙齿痛 yá chǐ tòng, 牙痛 yá tòng)

Pain felt in the teeth. Toothache is most commonly caused by tooth decay, a rotting away of the teeth. The ancient Chinese ascribed this to the work of worms. Where decay is absent, Chinese medicine attributes toothache to wind-fire, wind-cold, stomach heat, kidney vacuity, or qì vacuity.

Hearing

The main signs are tinnitus and deafness. The two are of similar diagnostic significance.

Tinnitus (耳鸣 ěr míng) is ringing or other sounds subjectively felt in the ear. A distinction is made between vacuity and repletion.

• Repletion: Tinnitus of sudden onset that is like the sound of frogs or the rushing sound of the sea on the shore (耳鸣如潮 ěr míng rú cháo) and that continues when the ears are pressed, the condition is one of repletion and is mostly associated with exuberant liver-gallbladder fire or phlegm-fire.
• Vacuity: Tinnitus that develops gradually, is faint like the sound of cicadas or mosquitoes and is relieved by pressure is ascribed to vacuity. It is usually attributable to liver-kidney yīn vacuity, ascendant hyperactivity of liver yáng, or insufficiency of kidney essence. It can also occur in spleen vacuity qì fall.

Deafness (耳聋 ěr lóng) is partial or complete hearing loss. Mild cases are known as hardness of hearing (重听 zhòng tīng). A distinction is made between fulminant deafness and gradual deafness.

• Fulminant deafness (暴聋 bào lóng) is sudden and severe deafness, as if the ears are plugged. It is associated with bitter taste in the mouth, headache, nasal congestion. It is attributable to liver-gallbladder fire rising to the head through the channels or to other evils affecting the lesser yáng (shào yáng) channel, which passes through the ears.
• Gradual deafness (渐聋 jiàn lóng) is of slow onset, usually in advancing years, and can affect one or both ears. It is caused by insufficiency of kidney essence or insecurity of kidney qì.
• Deafness can also be caused by streptomycin, especially in children.

Hardness of hearing (重听 zhòng tīng): Hardness of hearing is defective hearing, in which the patient either fails to perceive sounds clearly or hears them repeated. Distinction is made between vacuity and repletion.

• Repletion: Appearing suddenly, it usually forms part of a repletion pattern that arises when phlegm turbidity clouds the clear orifices or when wind evil attacks the ears.
• Vacuity: Developing gradually, it usually forms a vacuity pattern that arises when debilitation of kidney essence particularly in advancing years deprives the ears of nourishment.

Eyes and Vision

Eye pain (眼痛 yǎn tòng): Pain in one or both eyes is called eye pain. Severe eye pain usually indicates a repletion pattern. Mild eye pain usually suggests vacuity. Repletion patterns are more common.

• Distending pain in the head and eyes (头目胀痛 tóu mù zhàng tòng): A painful sensation of pressure in the head and eyeballs. It occurs in ascendant hyperactivity of liver yáng.
• Unbearable eye pain, with red face and eyes, bitter taste in the mouth, vexation, agitation, and irascibility is attributable to liver fire flaming upward.
• Red sore swollen eyes, with fear of light and copious discharge is a sign of wind-heat evil ascending to the eyes. It is mostly seen in fire eye (acute conjunctivitis or scleritis).
• Slight intermittent pain with dry eyes is usually attributable to yīn vacuity with effulgent fire.

Dry eyes (目干涩 mù gān sè): Lack of fluid to ensure the smooth movement of the eyelids. It is mostly attributed to liver yīn vacuity.

Tearing (流泪 liú leì): Also lachrymation.

• The presence or absence of tearing in children is important since crying without tearing indicates a relatively serious condition.
• Tearing on exposure to wind (迎风流泪 yíng fēng liú leì) is a sign of liver channel vacuity cold or liver channel wind-heat.
• Periodic tearing unassociated with exposure to wind is attributed either to liver-kidney depletion or to yīn vacuity with effulgent fire.

Itchy eyes (目痒 mù yǎng): Itching of the eyelids, canthi, or eyeballs. Severe itching is usually repletion. Itchy eyes like the crawling of bugs with fear of light (photophobia), tearing, and burning sensation are a sign of liver channel wind-fire. Slight itching is usually attributable to blood vacuity.

Flowery vision (目花 mù huā): See dizziness above.

Dizzy vision (目眩 mù xuàn): See dizziness above.

Clear-eye blindness (青盲 qīng máng): Gradual blindness that in severe cases can be total. It is attributable to insufficiency of the liver and kidney and depletion of essence-blood, combined with spleen-stomach vacuity preventing essential qì from reaching up to the eyes. It corresponds to optic atrophy in biomedicine. It is called clear-eye blindness because there is no visible obstruction in the pupil as with cataracts.

Night blindness (夜盲 què máng), also sparrow vision (雀目 què mù): Reduced visual acuity in poor light. People who suffer from night blindness have normal vision in the daytime, but as soon as dusk falls, their vision is unclear. It is usually attributed to liver blood vacuity or liver-kidney depletion with insufficiency of essence and blood depriving the eyes of nourishment. In Chinese medicine, night blindness is also called sparrow vision because sparrows see poorly in the dark.

Clouded vision (目昏 mù hūn) and double vision (視歧 shì qí, 视一为二 shì yī weí èr): Clouded vision, also called blurred vision (视物模湖 shì wù mó hú) is blurred vision is the inability to see objects clearly. Double vision is seeing one object as two. Both conditions are mostly caused by liver-kidney depletion with insufficiency of essence and blood depriving the eyes of nourishment. They occur in the elderly, in people with weak constitutions, and in patients in a weak state of health attributable to enduring illness.

Nose and Throat

Nasal congestion (鼻塞 bí sè) usually indicates an external contraction. When chronic in nature, it may be a sign of deep-source nasal congestion (鼻渊 bí yuān), which is persistent nasal congestion with turbid snivel, attributed to wind-cold, wind-heat, or gallbladder heat.

Itchy nose (鼻痒 bí yǎng) may be a sign of worm accumulation.

Sore throat (喉咙痛 hóu lóng tòng), painful red swollen throat (咽喉红肿痛 yān hóu hóng zhǒng tòng): Soreness of the throat is associated with redness and swelling and in severe cases hampers swallowing. Seeinspection (Inspecting Head, Face, and Neck).

Itchy throat (喉痒 hóu yǎng) is usually attributable to wind-cold impairing diffusion of lung qì. Less commonly, it is attributed to wind-heat invading the lung, dryness evil invading the lung, or lung yīn vacuity.

Plum-pit qì (梅核气 meí hé qì): A sensation of a foreign body present in the throat, which can be neither swallowed nor ejected, often associated with dryness, is called plum-pit qì. The intensity of the sensation fluctuates. It is attributed to liver qì depression, often with phlegm. Plum-pit qì is a literal translation of the Chinese term. It is synonymous with globus hystericus in Western medicine.

Inquiry about Body and Limbs

Inquiry about the body involves asking the patient about pain, discomfort, lumps, or other abnormal phenomena. Note that pain in the chest and abdomen is described in the next section.

Pain

Pain refers to acute sensations of discomfort, while aching refers to duller, often chronic sensations. Pain other than in the chest or abdomen takes the following forms:

• Localized pain is associated with damage to the skin, flesh, sinew, and bones as a result of external injury.
• Pain of fixed location (痛有定处 tòng yǒu dìng chù) is any pain that is continuously focused in a particular body part. It is associated with blood stasis and external injuries, where it is often described as stabbing pain (刺痛 cì tòng) or pain like the piercing of an awl (痛如锥刺 tòng rú zhuī cì). Duller pain of fixed location also occurs in impediment (bì) patterns with prevalence of cold and dampness (cold impediment and damp impediment).
• Pain of unfixed location (痛无定处 tòng wú dìng chù) is associated with qì stagnation. In the trunk rather than the limbs, it sometimes manifests as a scurrying pain (窜痛 cuàn tòng), where pain is felt to move from one place to another.
• Wandering pain (遊走疼痛 yóu zǒu téng tòng) is pain of fixed location affecting different appendages at different times. The term describes the pain of impediment (bì) attributable to prevalence of wind (wind impediment).
• Generalized aching pain (周身酸痛 zhōu shēn suān tòng) is pain experienced in the fleshy exterior (mainly limbs, neck, and back) or in the bones. It accompanies heat effusion and aversion to cold in exterior patterns.
• Joint pain (骨节疼痛 guān jié téng tòng) is pain in any joint. Enduring limb joint pain often exacerbated by damp weather is observed in impediment (bì) patterns. Pain felt in different joints at different times is a wandering pain, a sign of wind impediment.
• Painful red swollen joints (关节红肿痛 guān jié hóng zhǒng tòng) are observed in heat impediment. Joint pain of limited duration is observed in some externally contracted febrile disease patterns such as wind-cold exterior patterns and qì-aspect heat. Joint pain may also attend certain sores, such as streaming sores and red bayberry sores (syphilis).
• Limp aching lumbus and knees (腰膝酸软 yāo xī suān ruǎn) or limp aching lumbus and legs (腰腿酸软 yāo tuǐ suān ruǎn) often associated with lack of strength can appear in any kidney disease pattern. Remember that the lumbus is the house of the kidney, and that the knees are also associated with the kidney. Limpness of the legs and knees can easily be determined by ascertaining whether the patient has difficulty rising from a crouching posture by the strength of the legs alone.
• Cold painful lumbus and knees (腰膝冷痛 yāo xī lěng tòng) is a sign of kidney yáng vacuity.

Fatigued Limbs (肢倦乏力 zhī juàn fá lì)

Fatigue means an abnormal tendency to weariness. Lack of strength is the inability to perform normal movements, such as lifting and carrying heavy things. Fatigued limbs has the same diagnostic significance as general fatigue and lack of strength, which in many cases reflects impaired splenic movement and transformation giving rise to qì-blood vacuity, debilitation of yáng qì, and dampness patterns. Since the spleen governs the limbs, the fatigue is most prominently felt in the limbs.

Generalized Heaviness (身重 shēn zhòng)

is a subjective sensation of heaviness throughout the body. It is mostly attributable to the encumbering effect of dampness but may also be caused by wind and warm evils.

• Generalized heaviness is mostly attributable to disease of the spleen and stomach. When spleen qì becomes vacuous and fails to move and transform, the spleen can become encumbered by dampness, giving rise to generalized heaviness and fatigue, lassitude of spirit, and shortness of breath. Since the spleen governs the limbs, the sensation is mostly felt in the limbs and hence is often described as heavy cumbersome limbs (四肢困重 sì zhī kùn zhòng) or generalized heaviness and fatigued limbs (身重肢倦 shēn zhòng zhī juàn).
• Wind evil assailing the exterior can affect lung diffusion and downbearing, causing water to flood into the skin and giving rise to generalized heaviness and in severe cases puffy swelling.
• Warm heat evil damaging qì and yīn can also give rise to generalized heaviness.

Numbness and Tingling (麻木 má mù):

Numbness is loss of normal sensation. It is often associated with tingling, which is a slight prickly sensation, such as is produced by rough linen cloth. In liver disease, it is mainly attributed to liver blood vacuity depriving the network vessels of nourishment and giving rise to liver wind stirring internally; hence, it is often associated with hypertonicity of the sinews. Other causes include wind-cold, damp-heat, phlegm-damp or static blood blocking the channels and network vessels depriving the skin of nourishment.

Dry Skin

Itchy Skin (皮肤瘙痒 pí fū sào yǎng):

Itching is an irritation of the skin from which the sufferer seeks relief by scratching. It is chiefly associated with external wind, internal wind (blood dryness engendering wind), dampness, and heat. It is seen in dormant papules, genital itch, pudendal itch, foot qì sores, damp sores, lichen, and scab.

• Wind-damp: If scratching gives rise to vesicles that emit a watery discharge, the pattern is one of wind-damp.
• Wind-cold: Itching on the face, chest, neck, and hands, that refuses cold and likes warmthand is accompanied by a tight or moderate floating pulse is a sign of wind-cold.
• Dormant papules: Itching is also associated with dormant papules (瘾疹 yǐn zhěn), that is, wheals on the skin that come and go, called urticaria in biomedicine. These are mostly attributed to wind evil invading the skin or to accumulated heat in the stomach and intestines that fails to discharge through the bowels or thrust out through the exterior and becomes depressed in the skin.
• Damp-heat: Itchy skin when damp and exudative is attributable to damp-heat pouring downward. It is seen in foot qì sores (脚气疮 jiǎo qì chuāng, tinea pedis, referred to colloquially as athlete’s foot), damp sores, lichen, scab, some forms of eczema, as well as in genital itch.
• Blood heat: Itching that is exacerbated by heat and is accompanied by general heat signs is attributable to blood heat, which is most common in young people.
• Liquid depletion and blood dryness stemming from high fever, vomiting, diarrhea, and great sweating may manifest in dry itchy skin. This reflects blood dryness engendering wind.
• Blood vacuity: Itching that is more pronounced in the autumn and winter and is accompanied by a lusterless complexion, heart palpitation, insomnia, and flowery vision is a sign of blood vacuity, which is more common in older people.

Inquiry about Chest and Abdomen

The numerous discomforts of the chest and abdomen are associated with vacuity or repletion in the bowels and viscera.

Parts

For the purposes of diagnosis, the region of the chest and abdomen is divided into distinct parts. Parenthesized numbers referred to areas in the image below.

Chest (胸 xiōng): The part of the body encased in the rib cage (6).

Vacuous lǐ (虚里 xū lǐ): The apical pulse. (7)

Rib-side (胁肋 xié leì): The side of the chest from the armpit to the lowest extremity of the ribs, usually referring to the lower part of this region (6).

Abdomen (腹 fù) refers to the whole area of the abdomen. It includes the following items.

Region below the heart (心下 xīn xià): The small depression below the xyphoid process (the tip) of the sternum, also called pit of the stomach (1).

Stomach duct (脘 wǎn, 胃脘 weì wǎn): The part of the abdomen occupied by the stomach is called the stomach duct (2).

Greater abdomen (大腹 dà fù): The part of the abdomen above the umbilicus is called the larger abdomen. This term is not normally used in the diagnostic context (3).

Smaller abdomen (小腹 xiǎo fù): The part of the abdomen below the umbilicus (4).

Lesser abdomen (少腹 shào fù): The two lateral areas of the smaller abdomen (5).

Discomforts

Discomfort in the chest and abdomen includes the following:

Pain (痛 tòng): A discomfort that in severe cases elicits cries of anguish. Different forms of pain are discussed below.

Oppression (闷 mèn): A feeling of constriction and pressure in the chest caused by insufficiency of yáng qì or yīn evils. It may also be felt in the stomach duct when stomach downbearing is impaired.

Fullness (满 mǎn): A diffuse sense of expansion and pressure (as if the affected area were filled with gas or water) sometimes described as bloating.

Distension (胀 zhàng): Pronounced fullness that is palpable or even visible.

Glomus (痞 pǐ): The sensation of a lump or a pronounced feeling of blockage.

Palpitation (悸 jì): Perceptible throbbing, usually in the heart.

Vexation (烦 fán): A feeling of restlessness in the chest. It is often associated with heat, and this combined condition is referred to as heat vexation. Heart vexation occurs in both vacuity heat and repletion heat patterns. In severe cases, it is accompanied by agitation, that is, visible fidgetiness. This combined condition is called vexation and agitation.

Nature of Pain

Distinction is made between different pain sensations.

Distending pain (胀痛 zhàng tòng) is pain associated with distension (and also called distension and pain); it is attributed to qì stagnation or food stagnation.

Stabbing pain (刺痛 cì tòng), sometimes described as being like the piercing of an awl (痛如锥刺 tòng rú zhuī cì) or the cutting of a knife (痛如刀割 tòng rú dāo gē), is pain of fixed location that refuses pressure and is associated with blood stasis.

Cold pain (冷痛 lěng tòng) is pain exacerbated by cold and relieved by warmth. It is associated with the sensation of cold and is attributed to cold evil obstructing the network vessels or to insufficiency of yáng qì depriving the bowels and viscera or the limbs of warmth.

Scorching pain (灼痛 zhuó tòng) is pain associated with heat and occurs in certain heat patterns.

Dull pain (隐痛 yǐn tòng) is a usually continuous pain of mild intensity observed in insufficiency of qì and blood or in yīn cold arising internally.

Heavy pain (重痛 zhòng tòng) is pain associated with heaviness. It is mostly attributed to dampness.

Gripping pain (绞痛 jiǎo tòng) is intense pain as from a turning knife. It is associated with static blood, roundworm, or stones.

Scurrying pain (窜痛 cuàn tòng) in the chest and abdomen is attributed to qì stagnation (as in liver depression and qì stagnation).

Pulling pain (掣痛 chè tòng) is a pain that feels as though it is pulling from one place to another. It arises when the channel vessels are deprived of nourishment or obstructed due to stagnation and is usually associated with liver disorders.

Empty pain (空痛 kōng tòng) is attributable to insufficiency of qì, blood, or essence, depriving the bowels and viscera, sea of marrow (brain), or uterus of nourishment.

Qì pain (气痛 qì tòng) is pain associated with qì stagnation, that is, distending pain and pain of unfixed location (scurrying pain). A commonly encountered example of this is liver-stomach qì pain (肝胃气痛 gān weì qì tòng), which is pain in the stomach duct and rib-side due to depressed liver qì invading the stomach.

Stasis pain (瘀痛 yū tòng) is pain associated with blood stasis, that is, stabbing pain or gripping pain of fixed location.

Oppression in the Chest (胸闷 xiōng mèn)

This is a feeling of constriction and pressure in the chest. It is sometimes called chest tightness. It indicates that yáng qì is failing to move or that evils are causing obstruction. Oppression in the chest occurs in heart disease, notably heart yáng vacuity and heart vessel obstruction, in lung patterns involving phlegm, in spleen patterns involving dampness, and in liver patterns, notably depressed liver qì.

Stifling oppression and pain in the heart and chest (心胸憋闷疼痛 xīn xiōng bié mèn téng tòng) in the chest is the main sign of the traditional disease chest impediment (胸痹 xiōng bì), which is observed in what modern biomedicine classes as heart disease, pulmonary emphysema, and pleurisy. Chest impediment is a broad category of disease caused by vacuity, static blood, phlegm, and cold. It usually takes the form of heart yáng vacuity, fulminant desertion of heart yáng, or heart vessel obstruction.

Chest Pain (胸痛 xiōng tòng)

Also called pain in the chest. Any pain anywhere in the chest. It occurs in heart disease, lung disease, and liver disease.

In heart disease, chest pain, often called heart pain, is in the anterior of the chest at the position of the heart. The pain can radiate into the shoulder and along the medial side of the left arm. It is attributed to chest yáng failing to move in heart yáng vacuity or to the obstructive effect of phlegm, stasis, and cold in heart vessel obstruction patterns. Note that heart pain (心痛 xīn tòng) can refer to pain in the heart or pain in the region of the heart, including the region below the heart (the pit of the stomach). The term true heart pain (真心痛 zhēn xīn tòng) refers to pain in the heart itself (cardiodynia as attributable to myocardial infarction), but it is usually a disease name rather than a symptom name.

In lung disease, chest pain is associated with breathing disorders and is mostly attributable to phlegm turbidity causing obstruction or to fire damaging the network vessels of the lung. It is observed in intense lung heat or phlegm-fire congesting the lung, and sometimes in rheum collecting in the chest and rib-side. It is especially prominent in pulmonary welling-abscess.

In liver disease, chest pain is associated with distension and pain in the chest and rib-side and is seen in depressed liver qì.

In cold damage, pain below the heart with hard fullness that can be felt under pressure indicates chest bind (结胸 jié xiōng), which arises in cold damage disease when evil qì binds in the chest, causing pain below the heart with hard fullness that refuses pressure. It occurs when offensive precipitation is administered in greater yáng (taì yáng) and causes the exterior heat to fall into the interior to bind with water-rheum. It may also occur in greater yáng (taì yáng) disease progressing to yáng míng (yáng míng), where repletion heat combines with pre-existing water-rheum.

Heart Palpitation (心悸 xīn jì)

A a strong or rapid heartbeat that is subjectively felt by the patient and that is associated with susceptibility to fright (易惊 yì jīng) and flusteredness (心慌 xīn huāng). It is most commonly attributable to disease of the heart, specifically the heart spirit. It includes fright palpitation and fearful throbbing. It is considered a disease as well as a symptom.

• Fright palpitation (惊悸 jīng jì) is heart palpitation that is triggered by fright, fear, or other emotional stimulus, or that occurs in a patient who frequently experiences fright, fear, or other emotional stimulus.
• Fearful throbbing (怔忡 zhēng chōng) is pounding of the heart that is felt from high in the chest to low in the umbilical region, occurring in episodes less clearly related to emotional stimulus. It is more severe than heart palpitation and usually develops from it.

Pathomechanisms by which heart palpitation (fright palpitation or fearful throbbing) arises include:

• gallbladder depression with harassing phlegm (i.e., harassing the heart spirit);
• heart qì or heart yáng vacuity causing the heart to beat forcelessly;
• insufficiency of heart yīn or heart blood, depriving the heart spirit of nourishment;
• phlegm or blood stasis obstructing the heart vessels inhibiting the flow of blood;
• sudden fright in a patient suffering from heart-gallbladder qì vacuity;
• spleen-kidney yáng vacuity causing water to intimidate the heart.

Running piglet (贲豚 bēn tún): A sensation of upsurge from the lower abdomen to the chest and throat, accompanied by gripping abdominal pain, oppression in the chest, rapid breathing, dizziness, heart palpitation, and heart vexation.

Heart Vexation (心烦 xīn fán):

Heart vexation refers to a feeling of unrest or slight irritability focused in the heart region. Heart vexation commonly occurs in both vacuity and repletion patterns and is most closely associated with heart disease involving heat. In severe cases, it is accompanied by agitation, that is, increased physical movement. The term anguish in the heart (心中懊憹 xīn zhōng ào nóng) refers to severe heart vexation.

Rib-Side

• Distension and pain in the rib-side (胁肋胀痛 xié leì zhàng tòng), also called distending pain in the rib-side or distension and pain in the chest and rib-side, refers to painful fullness and distension in lower lateral parts of the chest. It is a sign of depressed liver qì.
• Scorching pain in the rib-side (胁肋灼痛 xié leì zhuó tòng): Pain with heat sensation in the chest and rib-side. When the pain is dull, it is caused by liver yīn vacuity; when acute, it is attributed to liver fire flaming upward.

Propping fullness in the chest and rib-side (胸胁支满 xiōng xié zhī mǎn), a term seen in older texts, denotes severe fullness and distension that makes the patient feel as though his chest is propped up.

Breasts

Distending pain in the breasts (乳房胀痛 rǔ fáng zhàng tòng) is distension and pain in the breasts. It usually occurs before or during menstruation and is a sign of depressed liver qì.

Stomach Duct and Abdomen

Distension and fullness in the stomach duct and abdomen (脘腹胀满 wǎn fù zhàng mǎn): Fullness means a subjective feeling of bloating. Distension means severe fullness or palpable or even visible expansion. Distension and fullness in the stomach duct and abdomen can be the result of spleen-stomach yáng qì vacuity, the presence of evils (such as food or dampness evil), or qì stagnation. It occurs in spleen qì vacuity, spleen yáng vacuity, food stagnating in the stomach duct, cold-rheum collecting in the stomach, or depressed liver qì invading the spleen or stomach.

A sagging sensation associated with distension, often referred to as sagging distension in the stomach duct and abdomen (脘腹坠胀 wǎn fù zhuì zhàng) or sagging distension in the small abdomen (小腹坠胀 xiǎo fù zhuì zhàng), is often a sign of spleen vacuity qì fall.

Glomus (痞 pǐ), also called glomus and oppression (痞闷 pǐ mèn) or glomus and distension (痞胀 pǐ zhàng), is a sensation of blockage and fullness in the stomach duct or below the heart. It is attributed to stagnation of the qì dynamic in the center burner, usually resulting from dampness, but sometimes from stomach qì vacuity. Note that some modern Chinese-language textbooks avoid the term 痞 pǐ altogether and replace it with distension.

Clamoring stomach (嘈杂 cáo zá): A discomfort in the stomach traditionally described as being like pain but not pain, and like hunger but not hunger. It is traditionally regarded as a disease name. It occurs in stomach yīn vacuity, intense stomach heat, liver-stomach disharmony, and worms accumulating in the intestinal tract.

Pain in the stomach duct and abdomen (脘腹疼痛 wǎn fù téng tòng) or abdominal pain (腹痛 fù tòng): Pain in the stomach duct or in the abdomen in general, usually with fullness. This arises when the spleen’s yáng qì is insufficient or when evils are present. Its significance is as follows:

• Pain that likes (is relieved by) pressure indicates vacuity (insufficiency of yáng qì).
• Pain that refuses pressure indicates repletion.
• Pain that likes warmth indicates cold.
• Pain that likes cold indicates heat.
• Pain limited to the stomach duct tends to indicate stomach disease;
• Pain felt in both the stomach duct and abdomen tends to indicate a spleen problem.
• Pain around the umbilicus usually indicates a sign of worm accumulation.
• Abdominal fullness or distension that is relieved by belching or passing of flatus means qì stagnation or food accumulation.
• Abdominal distension with periods of relief, that is accompanied by constipation is a repletion pattern.
• Vacuity distension (an empty kind of distension and fullness) with periods of letup and thin sloppy stool is a vacuity pattern.
• Rumbling intestines (腸鳴 cháng míng), also called borborygmus, occurs in food stagnating in the stomach duct, in cold strike (cold directly striking the interior in cold damage), center qì vacuity, and liver qì invading the spleen. See listening and smelling.

Distending pain in the lesser abdomen (少腹胀痛 shào fù zhàng tòng) is a sign of depressed liver qì in women. It is usually associated with distending pain in the breasts and with menstrual irregularities.

Scorching pain in the stomach duct (胃脘灼痛 weì wǎn zhuó tòng): A burning pain in the stomach itself. If the pain is intense, it is caused by intense stomach heat; if it is dull, it is caused by stomach yīn vacuity.

Signs of stomach heat: Attention should be paid to signs associated with stomach heat, especially when appearing together:

• scorching pain in the stomach duct;
• clamoring stomach;
• acid swallowing: Upwelling of acid that is swallowed before it can be spat out;
• immediate vomiting of ingested food; and
• swift digestion with rapid hungering.

Nausea and Vomiting

Nausea (恶心 ě xīn) is a discomfort in the stomach with an urge to vomit. It may be experienced by healthy individuals as a manifestation of revulsion to certain foods or repulsive sights. In Chinese medicine, it is sometimes described as upwelling and nausea (泛恶 fàn ě), emphasizing the upward movement of qì from the stomach, sometimes bringing stomach contents with it.

Vomiting (呕吐 ǒu tù) is the expulsion of food from the stomach. The two characters forming the Chinese term are sometimes distinguished as retching (呕 ǒu) i.e., dry retching, and vomiting (吐 tù), meaning the expulsion of food. However, in modern texts, this distinction is not usually made, and dry retching is specifically referred to as such (干呕 gān ǒu).

Nausea and vomiting or dry retching often indicate stomach qì ascending counterflow and hence mostly signs of stomach disease. They often occur in damp-heat brewing in the spleen when dampness affects the downbearing of stomach qì. They also occur in stomach cold, stomach heat, stomach yīn vacuity, liver-stomach disharmony, damp-heat brewing in the spleen, and in food damage (food stagnating in the stomach duct). They can also occur in external contractions such as wind-cold or summerheat. Dry retching is usually a sign of stomach yīn vacuity but can also occur in stomach cold.

• Sudden vomiting with diarrhea may be attributable to poisoning or sudden turmoil (cholera).
• Vomiting in the evening of food ingested the previous morning or vomiting in the morning of food ingested the previous evening is called stomach reflux (反胃 fǎn weì).
• Immediate vomiting of ingested food (食入即吐 shí rù jí tù) is usually attributable to stomach heat. It is seen in intense stomach heat, malign obstruction (恶阻 è zǔ), and dysphagia-occlusion (噎膈 yē gé).
• Dry mouth with desire to drink, but immediate vomiting of ingested fluid (水入则吐 shuǐ rù zé tù) is called water counterflow (水逆 shuǐ nì), which is attributable to water-rheum collecting in the stomach.

Acid swallowing (吞酸 tūn suān): Upwelling of acid fluid into the mouth that is swallowed before it can be spat out. It is caused by stomach qì ascending counterflow. It occurs not only in intense stomach heat but also in food stagnating in the stomach duct and in depressed liver qì affecting the stomach (liver-stomach disharmony).

Hiccup (呃逆 è nì) and belching (嗳气 aǐ qì), previously discussed in the listening and smelling examination, are also signs of stomach qì ascending counterflow.

Inquiry about Diet and Taste in the Mouth

Fluid intake, food intake, and taste in the mouth provide information about the state of the fluids and spleen and stomach functions (digestion and absorption) and about the presence of evils.

Thirst and Intake of Fluid

Absence of thirst: In illness, absence of abnormal thirst means that the fluids have not been damaged. It occurs in cold patterns, dampness patterns, and mild dryness patterns.

Thirst with large fluid intake: This indicates that the fluids have been damaged. It is seen in dryness patterns and heat patterns.

• Slight thirst with slightly increased fluid intake in patients with heat effusion and aversion to cold is seen in initial-stage warm heat contractions that have caused minor damage to liquid.
• Great thirst with desire for cold drinks in patients with vigorous fever, red face, and sweating indicates intense interior heat causing major damage to liquid. In such cases, thirst occurs with heart vexation, which is often described as vexation and thirst (烦渴 fán kě).
• Thirst with large fluid intake with copious urine, with a large appetite and rapid hungering, and gradual emaciation is a sign of dispersion-thirst.

Thirst without large fluid intake: This is mostly seen in yīn vacuity, damp-heat, and phlegm-rheum or static blood collecting internally.

Phlegm-rheum and static blood are yīn evils. They obstruct yáng qì so that it has less power to produce bodily fluids from ingested fluids and, more importantly, less power to deliver them to the upper body to keep the mouth and throat moist; hence thirst. However, phlegm-rheum and blood stasis, insofar as they are unassociated with heat, do not damage liquid; hence little desire to drink.

• Dry mouth and pharynx with reddening of the cheeks, night sweating, and a red tongue with little liquid are attributable to yīn vacuity.
• Thirst with generalized heat failing to surface (身热不外扬 shēn rè bù wài yáng), generalized heaviness and heavy-headedness, and a slimy yellow tongue fur is attributable to damp-heat. The heat creates thirst, but the dampness reduces the desire to drink.
• Thirst with desire for warm drinks in small amounts indicates phlegm-rheum collecting internally. Phlegm-rheum develops from insufficiency of yáng qì; hence the desire for warm drinks.
• Thirst with intake of fluids, but often with immediate vomiting after drinking, is attributable to water-rheum or phlegm-rheum collecting in the stomach. This is sometimes called water counterflow. Since ingested fluids are incompatible with the phlegm-rheum, they are ejected.
• Dry mouth with desire only to rinse the mouth, with a dark-purple tongue or stasis speckles on the tongue is attributable to static blood collecting in the inner body.

Appetite and Diet

Maintenance of a good diet is essential to health in general and is important for recovery from illness.

Poor appetite and reduced food intake: Chinese medicine has many different terms for this type of condition. No desire to eat (不欲食 bù yù shí), no thought of food and drink (不思饮食 bù sī yǐn shí), or no pleasure in eating (纳谷不香 nà gǔ bù xiāng) imply a lack of interest in food with a consequent reduction in food intake. In older texts, inability to get food and drink down (饮食不下 yǐn shí bù xià) implies severe inability to eat. Since practitioners are more concerned as to whether the patient’s food intake is sufficient, the terms reduced eating (食少 shí shǎo, 纳少 nà shǎo) and poor appetite (食欲不振 shí yù bù zhèn) are clinically more relevant concepts. In addition, there is torpid intake (纳呆 nà dāi), a term that reflects a disturbance of the stomach’s intake function and that in practice means no appetite because the person feels satiated even before mealtimes and tends to feel full as soon as they start to eat.

• No desire for food and reduced eating is normal in sudden illness of recent onset. In such cases, the return of appetite is a sign of recovery.
• Reduced eating is most commonly a sign of spleen-stomach vacuity. This is confirmed by other signs such as abdominal fullness, fatigue and lack of strength, withered-yellow complexion, pale tongue, and a pulse that is vacuous.
• Torpid intake with heavy head and body, glomus in the stomach duct or abdominal distension, and a thick slimy tongue fur indicates cold damp, phlegm-damp, or damp-heat, all traceable to damp evil encumbering the spleen.
• Hunger with no desire to eat (饥不欲食 jī bù yù shí) with reduced eating is a sign of stomach yīn vacuity.

Aversion to food (厌食 yàn shí) is a feeling of revulsion at the smell, sight, or thought of food. It may involve reduced eating, but often only applies to specific kinds of foods. It is a sign of food accumulation, damp-heat, or pregnancy.

• Aversion to food with belching of sour-putrid qì (gas), distension, fullness, and pain in the stomach duct and abdomen is a sign of food accumulating in the stomach duct.
• Aversion to greasy food (厌油 yàn yóu) with glomus in the stomach duct and abdominal fullness, vomiting and nausea, generalized heaviness, sloppy stool, and ungratifying defecation is usually attributable to spleen-stomach damp-heat.
• Aversion to food with distending pain in the rib-side, bitter taste in the mouth, and yellow urine, and yellowing of the body and eyes indicates liver-gallbladder damp-heat. In such cases, it may also specifically indicate gallstones.
• Aversion to food in the early stages of pregnancy is explained as counterflow ascent in the thoroughfare (chōng) and controlling (rèn) vessels affecting the harmonious downbearing of stomach qì. This is normal and usually passes. In severe and prolonged cases, where aversion to food is accompanied by nausea, vomiting, even immediate vomiting of ingested food, this is a morbid condition traditionally called malign obstruction (恶阻 è zǔ).
• The sudden return of appetite in a patient suffering from enduring or severe illness with reduced eating or inability to eat is a sign that spleen-stomach qì is exhausted. This is a manifestation of false spiritedness.

Swift digestion with rapid hungering (消谷善食 xiāo gǔ shàn shí), also called increased eating and rapid hungering (多食易饥 duō shí yì jī) is a marked increase in food intake and pangs of hunger shortly after eating.

• With bad breath and swollen gums, increased eating and rapid hungering indicates intense stomach heat with excessive ripening and rotting. The term swift digestion with rapid hungering often refers specifically to this condition.
• With emaciation, increased eating and rapid hungering indicates dispersion-thirst, which is mostly equivalent to diabetes mellitus.
• With sloppy stool diarrhea, increased eating and rapid hungering is a sign of a strong stomach and weak spleen. A strong stomach means excessive ripening and rotting that manifests in rapid hungering, while a weak spleen refers to a decline in the spleen and stomach’s function of moving and transforming grain and water, which manifests in sloppy stool. This is described in the Yī Xué Rù Mén (Gateway to Medicine, by Lǐ Chān 李梴, 1515): Ability to eat with inability to transform is spleen cold with stomach heat.
• Swift digestion and rapid hungering may appear with fright palpitation and profuse sweating in patients with goiter (swelling of the neck).

Increased eating (嗜食 shì shí, 好食 hào shí, 多食 duō shí) may indicate worm accumulation.

Predilection for certain foods may be related to health problems.

• Indulgence in sweet or fatty foods (恣食甘肥 zì shí gān feí) is traditionally associated with phlegm-damp, obesity, and dispersion-thirst. In the modern world, many processed foods contain hidden sugars. Canned and bottled drinks contain particularly large amounts of sugar.
• A predilection for raw and cold food easily damages the spleen and stomach.
• Excessive consumption of acrid hot and spicy foods can cause dryness-heat.
• Predilection for unusual foods in pregnancy is normal.
• Eating raw rice, earth, or paper in infants and children usually indicates worm diseases (parasites).

Irregular eating (饮食无时 yǐn shí wú shí) refers to deviation from a common pattern, such as three meals a day. It often takes the form of skipping meals and snacking. Irregular easing disturbs the normal rhythm of food intake and can damage the stomach and spleen.

Difficulty swallowing (吞咽困难 tūn yàn kùn nán) with a glomus (a feeling of blockage) in the chest and diaphragm as though food cannot pass down freely into the stomach and, in some cases, immediate vomiting of ingested food, is called dysphagia-occlusion (噎膈 yē gé), a serious condition attributed to depressed qì, phlegm turbidity, static blood, desiccation of liquid, and blood dryness causing a narrowing of the esophagus.

Taste in the Mouth

The taste that a patient has in the mouth when not eating food often helps in diagnosis. Healthy individuals normally have no particular taste in the mouth. This is called harmony of mouth. A particular taste in the mouth when not eating may have some diagnostic significance. The five flavors are associated with the five phases and hence with the viscera too: sour with liver-wood, bitter with heart-fire, sweet with spleen-earth, acrid with lung-metal, and saltiness with kidney-water. Tastes in the mouth may indicate morbidity of the associated viscus, but in practice they only partially reflect this scheme.

Bland taste in the mouth is usually a sign of spleen-stomach vacuity cold. It arises when a vacuous spleen fails to transform water-damp so that cold-damp floods up into the mouth. It is often associated with upwelling of clear water.

Sweet taste is associated with spleen disease since sweetness enters the spleen.

• A sweet taste in the mouth usually indicates damp-heat arising from excessive consumption of sweet and fatty foods or from externally contracted damp-heat brewing and binding in the spleen. In such cases, the tongue fur is yellow and slimy.
• A sweet taste in the mouth can also be attributable to spleen vacuity, in which case the tongue fur is thin and white and there is thin foaming drool in the mouth.

Sour taste in the mouth is often described as a sour-putrid taste. Closely related to a sour taste in the mouth are acid upwelling, acid swallowing, and acid vomiting. Acid upwelling is a welling up of acid. Acid swallowing is the welling up of acid that is swallowed before it can be spat out, and acid vomiting is the vomiting of acid fluid. These signs are associated with:

• food stagnation or
• liver-stomach disharmony arising when depressed liver qì running cross-counterflow to invade the stomach or when liver fire invades the stomach.

Bitter taste in the mouth most commonly indicates effulgent liver-gallbladder fire, liver-gallbladder damp-heat, damp-heat brewing in the spleen and in lesser yáng (shào yáng) disease patterns.

Salty taste in the mouth indicates yáng vacuity water flood (water swelling or phlegm-rheum attributable to kidney yáng vacuity). It may also occur in kidney yīn vacuity with effulgent fire.

Sliminess in the mouth is an uncomfortable sticky sensation in the mouth (not a taste). It is often associated with a thick slimy tongue fur and indicates damp turbidity, phlegm-rheum, or food accumulation.

• When occurring with a sweet taste in the mouth, it suggests spleen-stomach damp-heat.
• When occurring with a bitter taste in the mouth, it usually indicates liver-gallbladder damp-heat.

Astringent sensation in the mouth , such as experienced after eating unripe persimmons, is attributed to dryness-heat damaging liquid or exuberant bowel and visceral heat.

Inquiry about Stool and Urine

Inquiring about urine and stool is an indispensable part of the inquiry examination. It provides a valuable indicator of repletion, vacuity, cold, and heat.

Stool

Healthy individuals defecate once a day, but some may defecate as much as 2–3 times or as little as once in 2–3 days. Normal stool is pale brown, soft but formed, without blood or mucus, and evacuated with ease.

Frequency

Constipation (便秘 biàn mì) is defecation once in several or more days, at longer intervals than is normal for the patient. It is associated with difficult defecation (see below), often because the stool is dry, hard, and bound (highly compacted).

• Constipation with dry hard stool is mainly attributable to heat and repletion, although cold and vacuity are not uncommon causes.
• Constipation with fullness, distension, and pain in the abdomen occurring in externally contracted heat disease as a result of heat binding in the stomach and intestines is called heat constipation or heat bind, attributable to repletion heat.
• Constipation of sudden onset and repletion cold signs is observed in cold stagnating in the stomach duct.
• Dry bound stool without pronounced abdominal distension and pain results from depletion of liquid and blood and especially to insufficiency of intestinal humor. This is called vacuity constipation.
• Chronic constipation with fear of cold, cold limbs, and cold abdominal pain is attributed to kidney yáng vacuity.
• Chronic constipation with scantness of breath, laziness to speak, fatigued limbs and other qì vacuity signs is called qì vacuity constipation. It may be characterized by straining in vain to defecate or associated with prolapse of the rectum or prolapse of the uterus.

Diarrhea (泄泻 xiè xiè) is defecation more frequent than is normal for the patient. The stool is usually thin and sloppy (loose, not formed). It occurs in vacuity, repletion, cold, and heat patterns.

• Fulminant diarrhea (severe diarrhea with speedy evacuation) usually indicates repletion.
• Enduring diarrhea usually indicates vacuity.
• Diarrhea in which abdominal pain is relieved by defecation is most often caused by food accumulations.
• Bouts of diarrhea with abdominal pain unrelieved by defecation and brought on by emotional stimuli stem from liver-spleen disharmony.
• Diarrhea each day just before dawn or in the early morning, often heralded or accompanied by abdominal pain and rumbling intestines, is called fifth-watch diarrhea (五更泄 wǔ jīng xiè), which is a sign of spleen-kidney yáng vacuity. Fifth-watch diarrhea is also called dawn diarrhea (黎明泄 lí míng xiè), morning diarrhea (晨泄 chén xiè), cockcrow diarrhea (鸡鸣泄 jī míng xiè), or kidney diarrhea (肾泄 shèn xiè). It is more prevalent in males than females.
• Persistent diarrhea with fecal incontinence is called efflux diarrhea (滑泄 huá xiè). In severe cases, there may be prolapse of the rectum. It occurs in large intestine vacuity cold or spleen vacuity qì fall. Constituting a desertion pattern, it is sometimes called efflux desertion (滑脱 huá tuō).
• In intestinal heat bowel patterns, constipation may take the form of heat bind with circumfluence (热结旁流 rè jié páng liú), where thin stool flows past hard bound stool. The stool is blackish, foul-smelling, and watery.
• In older texts, diarrhea with undigested food in the stool is often called food diarrhea (飱泄 sūn xiè), which occurs in liver-spleen disharmony, where depressed liver qì affects the function of the spleen.

Consistency and Contents

• Stool containing undigested food is a condition often referred to as grain failing to transform. It occurs with diarrhea attributable to spleen-stomach vacuity cold or to kidney yáng vacuity.
• Stool that is sometimes sloppy and sometimes bound (溏结不调 táng jié bù tiáo) is usually attributable to liver depression and spleen vacuity. If it takes the form of bound stool followed by sloppy stool in a single defecation, it is attributable to spleen-stomach qì vacuity.
• Bloody stool means the passing of blood and stool at the same time (possibly with blood and stool mixed) or blood following stool, or just blood. It is mostly attributable to damage to the network vessels (small blood vessels) of the stomach and intestines. It can occur in damp-heat dysentery. Fresh blood in the stool may indicate hemorrhoids.
• Pus and blood in the stool with sticky stool indicates dysentery. Pus is the traditional description, but strictly speaking it is mucus. Dysentery is mostly due to damp-heat.

Abnormal Defecatory Sensations

Difficult defecation (便难 biàn nán): Difficulty passing stool is naturally associated with constipation. However, the term difficult defecation may refer to a distinct condition of difficulty in passing stool in which bowel movements occur every day (rather than once in several days, as in constipation), with soft rather than hard and bound stool, or without the abdominal discomfort associated with constipation. Difficult defecation may occur in large intestinal heat bind, damp-heat brewing in the spleen, spleen-lung qì vacuity, liver-spleen qì stagnation, spleen-kidney yang vacuity, and yīn vacuity with blood depletion. Note that difficult defecation (or constipation) stemming from spleen vacuity depriving the intestines of moisture is traditionally often referred to as straitened spleen (脾约 pí yuē).

Scorching sensation in the anus (肛门灼热 gāng mén zhuó rè): This is a burning sensation on defecation. It is mostly attributable to damp-heat pouring down into the large intestine, as occurs in dysentery, or to depressed heat causing distress in the rectum, as seen in heat diarrhea.

Scorching sensation in the anus (肛门灼热 gāng mén zhuó rè): This is a burning sensation on defecation. It is mostly attributable to damp-heat pouring down into the large intestine, as occurs in dysentery, or to depressed heat causing distress in the rectum, as seen in heat diarrhea.

Ungratifying defecation (大便不爽 dà biàn bù shuǎng): This is slow and inhibited defecation with a feeling of incompleteness after passing stool, as if more is to be passed. It is usually attributable to repletion patterns such as large intestine damp-heat, liver qì invading the spleen, or food stagnating in the intestines. It can also be a sign of spleen vacuity qì fall.

Tenesmus (里急后重 lǐ jí hoù zhòng): Also called abdominal urgency and rectal heaviness. This is a frequent urgent desire to defecate with a heavy sagging feeling in the rectum. It usually results from damp-heat binding in the large intestine causing stagnation. It is a major sign of dysentery.

Sagging in the rectum (肛门坠重 gāng mén zhuì zhòng): A heavy feeling in the rectum, sometimes heralding prolapse of the rectum, most commonly occurs in spleen qì vacuity resulting from enduring diarrhea or dysentery.

Fecal incontinence (大便失禁 dà biàn shī jìn): Loss of control over defecation resulting in involuntary loss of stool that in severe cases the patient is unaware of. It is sometimes called incontinent efflux (滑泄不禁 huá xiè bù jìn). It is mostly attributable to spleen-kidney qì vacuity or yáng vacuity. It is most common in the elderly and in enduring diarrhea or dysentery. If fecal incontinence occurs in a condition of recent onset or in patients suffering from clouded spirit or coma, it is usually attributable to damp-heat rather than vacuity.

Passing of flatus (矢气 shǐ qì): Expulsion of intestinal gas from the anus. This is not usually a sign of illness, although it may increase in frequency in stomach and intestinal disorders. Passing of flatus that relieves discomfort may indicate depressed liver qì or gastrointestinal qì stagnation.

Urine

According to biomedicine, healthy people produce 1000–1800 ml of urine a day and urinate 3–5 times in the daytime and 0–2 times at night. Volume and frequency vary according to fluid intake, temperature, sweating, and age.

Inquiry about urine and urination helps to determine the state of the fluids and the qì transformation functions of the bowels and viscera. Attention focuses on volume and appearance of the urine, frequency of urination, involuntary urination, and sensations experienced on urination.

The color and smells of urine and stool are covered in the inspection examination and the listening and smelling examination. This section focuses on the volume, frequency, consistency, and sensations during urination.

Volume

Increased volume: Long voidings of clear urine (小便清长 xiǎo biàn qīng cháng) are seen in vacuity cold patterns and in dispersion-thirst (diabetes mellitus). This is attributable to weakness of yáng qì (kidney yáng) and especially insecurity of kidney qì.

Reduced volume: This occurs in various febrile conditions and in water swelling (edema). It is caused by (a) reduction of fluids stemming from exuberant heat, sweating, vomiting, or diarrhea; (b) failure of lung, spleen, and kidney to process fluids adequately; (c) the obstructive effect of water-damp and phlegm-rheum. Commonly observed signs include the following:

• Short voidings of reddish urine (小便短赤 xiǎo biàn duǎn chì): Scant urine that is a deep tea cold, attributable to heat.
• Short voidings of yellow urine (小便黄短 xiǎo biàn huáng duǎn): Scant urine slightly darker than normal (but not as dark as reddish urine), usually ascribed to vacuity heat or milder forms of repletion heat.
• Short voidings of scant urine (小便短少 xiǎo biàn duǎn shǎo) with water swelling, attributable to kidney yáng vacuity. Here, the absence of change in color indicates the absence of heat.

Frequency

Profuse urination at night (夜间多尿 yè jiān duō niào), called nocturia in biomedicine, is getting up in the night to urinate more than once or twice. It is usually a sign of kidney yáng vacuity.

Frequent urination (小便頻數 xiǎo biàn pín shuò) with short voidings of reddish urine and urinary urgency indicates bladder damp-heat disturbing the qì transformation function. Frequent urination in enduring disease with copious clear urine and profuse urination at night is attributable to insecurity of kidney qì.

Dribbling urinary block (癃闭 long bì), also called urinary stoppage (小便不通 xiǎo biàn bù tōng), is a condition in which urine is reduced to a mere dribble and difficult to void. It is equivalent to anuria in biomedicine and is a sign of impaired opening and closing of the bladder stemming mostly from insufficiency of kidney yáng or sometimes from bladder damp-heat.

Involuntary Urination

Enuresis (遗尿 yí niào) is the involuntary loss of urine during sleep. It is usually attributable to insecurity of kidney qì. The term is synonymous with bed-wetting, although it usually refers to the pathological condition in adults rather than normal bed-wetting in infants and young children that occurs because their kidney qì has not gained its full strength.

Urinary incontinence (小便失禁 xiǎo biàn shī jìn) is involuntary loss of urine during the day. Like enuresis, it is a sign of insecurity of kidney qì but indicates a more severe condition.

Abnormal Urinary Sensations

Rough painful urination (小便涩痛 xiǎo biàn sè tòng) or scorching pain in the urethra (尿道灼痛 niào dào zhuó tòng) is mostly caused by damp-heat inhibiting the qì transformation function of the bladder. It mostly occurs in strangury patterns. Distinction is made between heat, blood, stone, and unctuous strangury according to presenting signs.

Urinary urgency (小便紧急 xiǎo biàn jǐn jí) is the sudden urge to urinate. It usually occurs with frequent urination. It is typically a sign of damp-heat.

Inhibited urination (小便不利 xiǎo biàn bù lì): Inability to achieve a full stream of urine. It is caused by disturbances in the movement of fluids or production of urine owing to insufficiency of yáng qì of the kidney, lung, and/or spleen. It may also be attributable to damp-heat or to qì stagnation with damp obstruction.

Dribble after voiding (小便余沥 xiǎo biàn yú lì) is failure of voluntary urination to terminate cleanly. It is attributed to insecurity of kidney qì causing bladder retention failure.

Stones in the urine (尿有砂石 niào yoǔ shā shí): Passing of small particles of calculus in the urine, usually associated with acute pain, and most commonly attributable to damp-heat is a sign of stone strangury (or sand strangury).

Inquiry about Men and Women

The differences between male and female humans are mostly related to reproduction. In Chinese medicine, reproduction is a function primarily of the kidney. However, gender-specific pathologies are related not only to the kidney but also to the other four viscera, as well as to evil qì. Disorders include reduced sexual function (male and female infertility, and male impotence) and in women menstrual disorders.

Men

Problems peculiar to males are disturbances of libido, impotence, premature ejaculation, seminal emission, scant semen, and frequent and persistent erections.

Excessive libido (性欲过强 xìng yù guò qiáng) is often attributable to kidney yīn vacuity with frenetic stirring of the ministerial fire (liver-kidney yīn vacuity with vacuity fire flaming upward).

Poor libido (性欲减退 xìng yù jiǎn tuì) in men or women is often attributable to kidney yáng vacuity.

Impotence (阳萎 yáng wěi): Also called yáng wilt. Impotence is the inability to gain an erection or sustain it for the full duration of intercourse. It is usually attributable to debilitation of the life gate fire (kidney yáng vacuity) occurring mostly in advanced years. Less common causes include liver-kidney vacuity fire, heart-spleen vacuity, liver depression and qì stagnation, and liver channel damp-heat pouring downward.

Premature ejaculation (早泄 zǎo xiè): Ejaculation shortly after insertion is called premature ejaculation. It is mostly attributable to frenetic movement of the ministerial fire or to insufficiency of kidney qì taking the form of a breakdown of the kidney’s general storage function (insecurity of kidney qì). It can also result from liver channel damp-heat, dual vacuity of the heart and spleen, or depressed liver qì.

Seminal emission (遗精 yí jīng): In the broad sense, seminal emission means any involuntary loss of semen (seminal loss). In the narrow sense, it means involuntary loss during sleep.

• Dream emission is seminal emission during the night associated with dreams of a sexual nature. This is the mildest form of seminal emission.
• Seminal emission without dreaming is involuntary loss of semen during sleep without dreams of a sexual nature. This is considered more severe than dream emission.
• Seminal efflux (滑精 huá jīng) is involuntary loss of semen during waking hours. It is the most severe form of seminal loss.

The causes of seminal emission are effulgent sovereign and ministerial fire, heart vacuity and liver depression, insecurity of kidney qì, noninteraction of the heart and kidney, and spleen vacuity qì fall. Generally, dream emission involves the sovereign (heart) and ministerial fires, while emission without dreaming and seminal efflux tend to be attributable to insecurity of kidney qì.

Scant semen (精少 jīng shǎo): Reduced volume of ejaculate is called scant semen. It is often associated with infertility (scant semen and infertility, 精少不育 jīng shǎo bù yǔ): Scant ejaculate and resulting inability to produce offspring. It is mostly a sign of insufficiency of kidney essence or kidney yīn vacuity. When the semen is cold to the touch and scant, this is called seminal cold (精冷 jīng lěng). It is attributable to kidney yáng vacuity.

Persistent or frequent erections (陽強 yáng qiáng; 阳强易举 yáng qiáng yì jǔ; 阴茎易举 yīn jīng yì jǔ): An abnormal tendency to experience long-lasting erections is called persistent erection or frequent erection. It is traditionally referred to as yáng rigidity, the word yáng referring in this context to the penis. Persistent erection is often accompanied by seminal loss, the combined condition being referred to as rigid center (強中 qiáng zhōng). Persistent or frequent erections are the result of kidney yīn vacuity with frenetic stirring of the ministerial fire (liver-kidney yīn vacuity with vacuity fire flaming upward), liver-gallbladder repletion fire, or liver-gallbladder damp-heat.

Women

Menstruation (月经 yuè jīng)

Menstruation begins at the age of 13–15 and ends at the age of 49–52. The normal cycle is about 28 days. The period of menstrual bleeding lasts for 3–5 days. The normal menstrual discharge is bright-red, neither thick nor thin, and unclotted.

All deviations from the norm are called menstrual irregularities (月经不调 yuè jīng bù tiáo). There are irregularities in the timing of menstrual periods, in the quantity of discharge, and in color and consistency. In addition, they may be accompanied by lesser abdominal pain, or distending pain in the rib-side, breasts, and lesser abdomen. Other signs may be associated with the menstrual cycle.

Menstrual irregularities, menstrual pain, amenorrhea (absence of menses), and flooding and spotting (heavy and light bleeding via the vagina other than in menstrual periods) are related to the supply of blood and to the movement of blood in the thoroughfare (chōng) and controlling (rèn) vessels. The spleen, liver, and kidney each play roles in both the supply and movement of blood. In addition, movement can be hampered by the presence of evils.

Spleen

• The spleen produces blood for menstruation.
• It controls the blood, preventing unnecessary loss.
• It warms and transforms fluids, preventing the development of dampness and phlegm that can hamper the flow of blood.

Liver

• The liver stores the blood, ensuring the supply of blood for menstruation;
• Its free coursing influences the flow of blood in the thoroughfare and controlling vessels.

Kidney

• The kidney governs storage, preventing the escape of blood.
• It stores essence, which is a component of the blood (essence and blood are of the same source).
• Kidney yáng provides warmth for the whole body, particularly the spleen.
• Kidney yīn counteracts the exuberance of kidney yáng.

Evils that affect the flow of blood

• Congealing cold attributable to yáng or repletion cold inhibits the flow of blood.
• Static blood attributable to depressed liver qì or congealing cold inhibits the flow of blood.
• Phlegm-damp attributable to disturbances of fluid metabolism, mostly related to the spleen but also to the lung and kidney, inhibits the flow of blood.
• Heat (blood heat) attributable to repletion heat (often from depressed liver qì transforming into fire) or yīn vacuity with effulgent fire hastens the flow of blood and causes or exacerbates bleeding.

Advanced menstruation (月经先期 yuè jīng xiān qī): When periods come earlier than normal by 8–10 days or more, this is called advanced menstruation. Causes include:

• qì vacuity preventing blood from being contained;
• blood heat attributable to evil heat or liver depression transforming into fire; or
• yīn vacuity with effulgent fire.

Delayed menstruation (月经后期 yuè jīng hoù qī): When periods come later than normal by 8–10 days or more, this is called delayed menstruation. Causes include:

• blood vacuity (stemming from insufficiency of spleen yáng qì failing to produce sufficient blood or from insufficiency of essence-blood) preventing the thoroughfare and controlling vessels from remaining full;
• qì stagnation and blood stasis, congealing cold and blood stasis, or phlegm-damp inhibiting the thoroughfare and controlling vessels.

Menstruation at irregular intervals (月经先后无定期 yuè jīng xiān hoù wú dìng qī, 乱经 luàn jīng): Also called chaotic menstruation. This is menstruation that is sometimes advanced and sometimes delayed, with periods coming 8–10 days (or more) earlier or later than normal, is called menstruation at irregular intervals. Causes include:

• liver depression and qì stagnation;
• kidney qì vacuity or spleen-kidney vacuity; and
• static blood causing obstruction and stagnation.

Profuse menstruation (月经过少 yuè jīng guò duō): Greater than normal menstrual discharge with menstrual periods of normal or excessive duration is called profuse menstruation. Causes include:

• blood heat damaging the thoroughfare (chōng) and controlling (rèn) vessels;
• qì vacuity preventing blood from being contained; and
• static blood or foreign matter causing obstruction in the uterus, damaging the network vessels of the uterus allowing blood to escape.

Scant menstruation (月经过少 yuè jīng guò shǎo): Lesser than normal menstrual flow with menstrual periods of normal or shorter duration is called scant menstruation. The causative factors are as follows:

• blood vacuity depriving the thoroughfare and controlling vessels of blood;
• insufficiency of essence-blood or dual vacuity of qì and blood depriving the thoroughfare and controlling vessels of blood;
• congealing cold, blood stasis, or phlegm-damp causing obstruction in the thoroughfare and controlling vessels (repletion).

Amenorrhea (闭经 bì jīng): Abnormal absence of periods for 3 months or more between menarche and menopause is called or amenorrhea. Cessation of the menses during pregnancy and lactation is normal. Causes of amenorrhea include:

• depletion of the spleen and kidney with dual vacuity of qì and blood;
• qì stagnation and blood stasis (liver depression and qì stagnation giving rise to blood stasis); and
• phlegm-damp or congealing cold and phlegm obstruction attributable to yáng vacuity.

Irregularities of color and consistency

• Pale and thin menstrual discharge is usually attributable to blood vacuity.
• Deep-red menstrual discharge that is thick in consistency is attributable to blood heat.
• Purple clotted menstrual discharge, usually accompanied by pain in the lesser abdomen, is attributable to congealing cold and blood stasis.
• Dark-red clotted discharge is attributable to blood stasis.

Menstrual pain (痛经 tòng jīng): Smaller abdominal pain associated with the menstrual cycle, usually during or around the time of menstrual periods, is called menstrual pain.

• Distending or stabbing pain in the smaller abdomen before or during menstrual periods is attributable to qì stagnation and blood stasis.
• Continuous pain during or after menstruation that is relieved by pressure results from dual vacuity of qì and blood.
• Dull or empty pain after menstruation (possibly with delayed menstruation) is ascribed to dual vacuity of qì and blood or to insufficiency of kidney essence depriving the uterine vessels of nourishment.
• Cold pain relieved by warmth is caused by congealing cold or yáng vacuity.
• Scorching pain in the smaller abdomen that refuses pressure with foul-smelling thick yellow vaginal discharge is attributable to damp-heat.
• Distending pain in the breasts before menstruation indicates depressed liver qì.

Flooding and Spotting (崩漏 bēng lòu)

Bleeding via the vagina other than in menstrual periods is called flooding and spotting. Flooding is severe, heavy bleeding; spotting is light bleeding. Flooding and spotting arise in three ways:

• insecurity of the thoroughfare (chōng) and controlling (rèn) vessels attributable to spleen-kidney qì vacuity (spleen failing to control blood and/or insecurity of kidney qì);
• heat damaging the thoroughfare (chōng) and controlling (rèn) vessels causing frenetic movement of hot blood.
• blood stasis causing damage to the network vessels and forcing blood to extravasate.

Vaginal Discharge (带下 dài xià)

A mild odorless white fluid normally keeps the vagina lubricated. Only copious discharge with unusual consistency, smell, and color is abnormal.

• Copious thin white vaginal discharge without malodor is usually attributable to spleen vacuity with dampness pouring downward.
• A foul-smelling thick yellow vaginal discharge that may be accompanied by pudendal itch is attributable to damp-heat pouring downward.
• A mixed red and white vaginal discharge with slight malodor is usually attributable to depressed heat in the liver channel or damp-heat pouring downward.

Prolapse of the Uterus (子宫下垂 zǐ gōng xià chuí)

Protrusion of the uterus out of vulva is called prolapse of the uterus or yīn protrusion (阴挺 yīn tǐng) and is usually attributable to spleen vacuity qì fall.

Infertility (不孕 bù yùn)

Inability to become pregnant between menarche and menopause is called infertility. In practice, a woman who fails to become pregnant within three years of unprotected sex is considered infertile. The causes include kidney vacuity, depressed liver qì, blood vacuity, phlegm-damp, blood stasis, or uterine cold. Uterine cold (胞寒 bāo hán) is marked by infertility with cold sensation in the smaller abdomen, physical cold and cold limbs, and delayed menstruation.

Pregnancy

When a woman’s periods suddenly stop, and her pulse becomes slippery, rapid, and flowing harmoniously, she may be pregnant. The most common problems in pregnancy are malign obstruction and stirring fetus.

Malign obstruction (恶阻 è zǔ): Aversion to food, nausea, vomiting, or even repeated vomiting with inability to eat constitutes malign obstruction, which is severe morning sickness. It occurs in three patterns.

• Stomach qì vacuity: If there is lassitude of spirit and fatigue, bland taste in the mouth, and abdominal distention, the cause is stomach qì vacuity with thoroughfare (chōng) and controlling (rèn) vessel qì ascending counterflow, disturbing the harmonious downbearing of stomach qì.
• Liver depression transforming into fire: If there is affect-mind depression and irascibility with bitter taste in the mouth and acid vomiting, the cause is liver depression transforming into fire with liver fire invading the stomach.
• Phlegm-turbidity ascending counterflow: If there is oppression in the stomach duct and torpid intake with vomiting of phlegm-drool, the cause is phlegm-turbidity ascending counterflow to disturb the harmonious downbearing of stomach qì.

Stirring fetus (胎动不安 tāi dòng bù ān): Sagging sensation in the smaller abdomen, aching lumbus, and spotting, the condition is called stirring fetus, a sign of insecurity of fetal qì, which may portend miscarriage.

• Kidney vacuity: Stirring fetus with dull stagnant facial complexion, dizzy head, tinnitus, and frequent urination indicate kidney vacuity failing to protect the thoroughfare and controlling vessels.
• Qì-blood vacuity: With a lusterless white facial complexion, lassitude of spirit, stirring fetus indicates qì-blood vacuity depriving the fetus of nourishment.
• External injury: Abdominal pain with bleeding without other signs of internal disturbance may be the product of external injury.

Postpartum

Lochia: The lochia is a bloody discharge that lasts for about 20 days after childbirth. If it lasts longer than this, it is called incessant flow of the lochia (恶露不尽 è lù bù jìn). This is due to qì vacuity, blood heat, or blood stasis.

• Qì vacuity: Incessant flow of the lochia attributed to qì vacuity manifests in copious pale lochia with withered-yellow facial complexion, lassitude of spirit and lack of strength.
• Blood heat: When attributed to frenetic movement of hot blood, the lochia is thick and dark red and accompanied by a red face, thirst, constipation, and reddish urine.
• Blood stasis: Clotted purple lochia with stabbing pain in the lesser abdomen that refuses pressure, and green-blue tongue with stasis speckles.

Postpartum heat effusion (产后发热 chǎn hòu fā rè): Persistent heat effusion after giving birth may be due to contraction of external evils, exuberant internal fire evil, or yīn vacuity with exuberant heat.

• External contraction: Postpartum heat effusion with aversion to cold and generalized pain is attributable to external contraction.
• Internal fire: With vigorous heat effusion, vexation and agitation, thirst with intake of cold fluids, constipation, and reddish urine, postpartum heat effusion is caused by exuberant internal fire evil.
• Yīn vacuity: With continual abdominal pain, dizzy head, white facial complexion, and dry bound stool, it is due to blood vacuity transforming into dryness and engendering heat.

Scant breast milk (缺乳 quē rǔ, 乳汁少 rǔ zhī shǎo): Insufficient mother’s milk to suckle the infant. It is attributed to postpartum depletion of qì and blood or to depressed liver qì, the latter being easily distinguishable by the presence of distention and fullness of the breasts. When there is hardly any or no milk, it is called breast milk stoppage (乳汁不通 rǔ zhī bù tōng, 乳汁不下 rǔ zhī bù xià).

Children

Children do not easily respond to direct questioning by unfamiliar people, so most of the information comes from the accompanying parent or caregiver.

Children grow and develop rapidly, but their bowels and viscera are still tender, as Chinese medicine says. They are susceptible to both vacuity and repletion conditions, which can develop rapidly.

Prenatal and Postnatal Conditions

Illness occurring within a month of birth is largely related to constitutional factors. Hence, attention should be paid to asking the mother about her course of pregnancy, whether the delivery was easy or difficult, whether the child was delivered prematurely, and about the relationship between the mother and child, particularly as regards feeding.

From the first to the third month, children normally develop rapidly and need adequate nourishment. However, their spleen and stomach are usually weak. If feeding is inadequate or inappropriate, they may easily develop vomiting and diarrhea, so it is important to ask about feeding practices. Furthermore, some children are prone to slow development, traditionally called the five limpnesses and five slownesses. Hence, the practitioner must ask about sitting, crawling, standing, walking, teething, and speech acquisition in order to determine whether development is proceeding normally.

Vaccination and Contagious Diseases

Neonates, especially those who are breast-fed, inherit and acquire their mother’s resistance to disease. Hence, in the first six months, illness is rare. From six months to five years of age, the immunity given by the mother declines, and the child relies on its acquired immune ability. In this period, it is easy for the child to contract diseases such as chickenpox or measles. In vaccinated children, the possibility of such diseases can usually be discounted even if the presenting symptoms might suggest them.

Cause of the Condition

When children become reliant on their acquired immunity, they become susceptible to weather factors and diet. Their resistance to disease is often weak, making them susceptible to external evils so that they often suffer from conditions marked by heat effusion with aversion to cold, cough, and sore throat. They are susceptible to acute fright wind (high fever with convulsions) and chronic fright wind (milder convulsions occurring after chronic illness). Because their spleens are weak, they are susceptible to food damage (tummy upsets) with vomiting, abdominal pain, and diarrhea. Infants are especially susceptible to fear and fright. Finally, family history of illness may be of importance in some cases.