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The process by which illness originates, develops, and ends. The study of pathomechanism focuses on the laws by which illness arises and the body reacts to it. The origination, development, and outcome of disease are closely related to the strength of the patient’s right qì, the nature of the disease, the severity of evils, and the affected part or parts of the body. When disease evils affect the body, right qì engages in a struggle to eliminate them.

The discussion below focuses on general pathomechanisms associated with functional disturbances with a focus on the struggle between right and evil, on disharmony of yīn and yáng, and on internal evils. The pathomechanisms specific to qì, blood, and fluids are discussed in qì, blood, and fluids pattern identification and bowel and visceral identification. Those of external evils are discussed under externally contracted cause.

Why Study Pathomechanisms?

Understanding pathomechanisms is of crucial importance for gaining skill in treatment. Chinese medicine is renowned for its principle of identifying patterns as the basis for determining treatment (辨证论治 biàn zhèn lùn zhì). However, disease patterns only refer to the state of the patient at any given time. Patterns change constantly and to understand their changes, the practitioner must understand pathomechanisms. As a picture of an ailing patient’s condition at a given point in time, a pattern represents a synchronic view. The pathomechanism, by contrast, is the progress of a condition through time. It represents the diachronic view. A patient’s condition can be fully understood only when the synchronic and diachronic views are combined.

Because pathomechanisms follow distinct laws, understanding them helps practitioners to determine how the condition will develop in the future so that treatments can be devised to prevent negative developments. The Nèi Jīng stresses the principle of treating disease before it arises (治未病 zhì wèi bìng), in other words, nipping illness in the bud and thereby preventing further developments. To do this, the practitioner must be able to discern pathomechanisms amid the confusing welter of presenting symptoms.

Patterns are the basis for treatment, but they are often difficult to identify. Since many symptoms may be seen in more than one pattern, it is often hard to tell what pattern or patterns the patient is presenting. Conditions presented by patients often do not correspond exactly to any of the finite number of disease patterns described in textbooks. The infinite variety of patterns encountered in clinical practice is often daunting for students. Furthermore, multiple patterns can appear at the same time. A person suffering from an external contraction, for example, has signs of the external contraction. However, the person may simultaneously also be suffering from a disorder of qì, blood, yīn, or yáng, which can influence the development of the external contraction.

For these reasons, students need to understand how symptoms arise and change. Instead of simply trying to match a group of presenting symptoms to a fixed pattern, it is useful to further discern the processes of change in a patient’s condition. By understanding the pathomechanisms that are operant in patients, it becomes easier to identify patterns in all their variations and combinations.

Modern Chinese medical diagnostics, as presented in PRC textbooks, center on pattern identification. From the 1950s, medical scholars writing textbooks included a wide variety of patterns with clear descriptions, obviously inspired by the notion that the more patterns that could be listed, labeled, and defined, the easier it would be for students to identify clinical conditions. In the past, by contrast, diagnosis did not involve the study of so many set patterns. To treat patients effectively, the practitioner had to understand the dynamics of their evolving conditions. Recently published Chinese-language textbooks now show greater emphasis on pathomechanisms, since pattern identification is insufficient in itself for effective clinical practice.

The development of pattern identification represents one of the most important developments in Chinese medicine in the modern era. This reached its apex with the Zhōng Yī Zhèng Hòu Jiàn Bié Zhěn Duàn Xué (中医证候鉴别诊断学 Chinese Medical Pattern Differentiation Diagnostics), which presents a total of 483 patterns. The new enlarged gamut of patterns, however, did not tumble out of the blue. Many of the terms used to name them are simply pathomechanical descriptions, that is, descriptions, not of states, but of processes occurring in the patient. While numerous patterns with signs clearly described may be useful in diagnosis and treatment, it is important to realize that the source of pattern identification lies in the processes of disease development—pathomechanisms.

The terminology of pathomechanisms overlaps with that of patterns to a certain extent. For example, ascendant hyperactivity of liver yáng is a pattern name, but it is also the final part of a process that begins with liver-kidney yīn vacuity. In China, modern textbook writers are encouraging a distinction between ascendant hyperactivity of liver yáng as pathomechanism and pattern ofascendant hyperactivity of liver yáng as a pattern name.

Multiple pathomechanisms may be operant in any illness and interact in different ways. Hence, the pathomechanisms are seemingly infinite in number. Nevertheless, many morbid states can be understood in terms of a few major parameters. The two most important ones are the struggle between right and evil, disharmony between yīn and yáng, and the emergence of internal evils. In the following paragraphs, we will therefore discuss the disease processes of disease of each of these categories, including the most common causes and most likely developments and complications that arise out of them. The many pathomechanisms that involve qì, blood, fluids, and the bowels and viscera will be discussed in later chapters on pattern identification.

Pathomechanism

The term pathomechanism is our translation of the Chinese 病机 bìng jī, which literally means disease mechanism/dynamic. Biomedicine also talks about the mechanisms of disease, which in Chinese are called 机制 jī zhì,literally mechanism-system. Many Westerners tend to think of Chinese medicine as being less mechanistic than biomedicine, but in the area of disease development, early Chinese physicians chose metaphors similar to those of modern medicine. It is interesting to note that the Chinese term for qì dynamic, 气机 qì jī, contains the same word 机 jī,meaning mechanism or dynamic. Pathomechanisms can be understood as the dynamics of disease (literally, the force by which diseases move through different stages in their development). Chinese medicine understands disease in terms of the complex and lively dynamic interaction of infinitely variable factors.

The laws of Pathogenesis (发病原理 fā bìng yuán lǐ)

Pathogenesis is the process by which illness arises. The main factors in the development of illness are right qì and evil qì on the one hand and yīn and yáng on the other. Right qì and evil qì represent the individual versus disease, while yīn and yáng are parameters that classify both disease evils and internal states of the body.

Right and Evil Qì (正气邪气 zhèng qì xié qì)

Right qì and evil qì are general parameters determining whether illness arises, how it arises, and what kind of illness arises. Not all illnesses are initially caused by external evils. Many illnesses are caused by internal imbalances in the body that cause evils to arise or allow external evils to take hold. Some illnesses and poor states of health are characterized only by imbalances. However, many illnesses do involve evil qì.

Evil Qì

Evil qì (邪气 xié qì) is any entity that causes disease. External evils are discussed under externally contracted cause. Suffice it here to recollect that they include the six excesses (wind, cold, summerheat, dampness, dryness, and fire), epidemic qì, worms, and internal products, such as phlegm-rheum and static blood. They also include evils corresponding to all six excesses except summerheat that arise internally. In a sense, evils also include excesses of the seven affects (joy, anger, worry, sorrow, fear, and fright), although these are rarely labeled as such.

Right Qì

Right qì (正气 zhèng qì) is the ability of the body to maintain and restore health. It includes the body’s ability for self-adjustment in adaptation to environmental changes and ability to resist evils of external and internal origin. It is dependent on the physical and functional integrity of all body parts and of yīn, yáng, essence, qì, blood, and fluids.

It is important to understand that right qì is not a diffuse, active substance powering activity in the body in the way that heart qì, ancestral qì, or defense qì are conceived. Rather it is the sum of both yīn and yáng aspects of the body in their ability to maintain health, resist disease evils, and recover from illness. Qì in the context of right qì means forces—the health-maintaining, health-restoring forces of the body. Any vacuity condition (yīn vacuity, yáng vacuity, qì vacuity, blood vacuity) can be understood as a vacuity of right qì. However, in practice, the term right qì is mostly used in the context of the body’s resistance to evil qì.

If a person is healthy, their right qì is strong, making it difficult for external evils to invade. The Sù Wèn (Chapter 33) states, For evil to encroach, qì must be vacuous (邪之所凑, 其气必虚 xié zhī suǒ còu, qí qì bì xū). The Líng Shū (Chapter 66) states, Come wind, rain, cold, or heat, unless there is vacuity, evils alone will not harm a person (风雨寒热, 不得虚, 邪不独伤人 fēng yǔ hán rè, bù dé xū, xiē bù dú shāng rén).

Right qì does not simply vary in strength; different aspects of it can vary too. Qì vacuity, blood vacuity, yīn vacuity, and yáng vacuity are various forms of right qì vacuity.

Evil Damages Right

Evil qì is called evil qì because it damages the right qì of the body.

• It can affect functions of the human body (e.g., external cold evil causes defense qì to become depressed and thus unable to perform its warming function).
• It can damage the physical integrity of body parts (e.g., heat toxin causing welling-abscesses or other sores) or yīn and yáng substances including essence, qì, blood, and fluids (e.g., heat evil damages the fluids).
• It can alter an individual’s constitution.

External evils usually first enter the body through the exterior. If they are undefeated, they may penetrate deeper into the body. In some cases, external evils may make a direct strike on the interior. Internal evils, naturally, arise in the interior. Both external and internal evils tend to affect function first and affect the physical substrates at a later stage. For example, wind-cold-damp entering the channels obstructs qì and blood, causing pain. In later stages, it can cause deformity of the joints. Only highly virulent evils cause immediate physical damage, such as heat toxin, which can cause erosion, putrefaction, and suppurative lesions.

Right Resists Evil

Right qì counters evil qì in the following ways:

It resists the invasion of external evils.When external evils attempt to invade the body, right qì fights to resist the invasion. When right qì is exuberant, it is difficult for evil qì to invade the body. The Sù Wèn (Chapter 33) states, For evils to encroach, [right] qì must be vacuous (邪之所凑，其气必虚 xié zhī suǒ còu, qí qì bì xū). After evil qì has invaded the body, right qì can muster itself to fight the evil, defeat it, and expel it from the body.

It can restore the body to health.After defeating the evil, right qì can repair the damage to the body and restore the body to health.

It contributes to determining the nature of the disease patterns caused by the evil.When in the struggle between right and evil, right qì and evil qì are both strong, a repletion pattern arises. When the evil is exuberant and right qì is weak, then a vacuity-repletion complex arises.

Illness is the Product of Interaction Between Right and Evil

Many illnesses involve a confrontation between right and evil qì. Many illnesses that start with an insufficiency of qì, blood, fluids, essence, yīn or yáng give rise to internal evils that contest right qì.

A confrontation between right and evil causes illness only when right qì is insufficient or when evil qì is so powerful as to defy the resistance of right qì. The relative strengths of right and evil therefore determine whether an individual succumbs to an evil, and if so, how severely the individual is affected.

When an evil causes illness, the nature and location of the disease and the patterns it manifests in depend not only on the nature of the offending evil but also on the specific strengths and weakness of right qì. When cold evil enters the body, it gives rise to cold signs, just as when heat evil enters the body, it normally causes heat signs. However, the strength of right qì also exerts an influence. If right qì is strong and puts up a fight, then an exterior cold repletion pattern of aversion to cold and absence of sweating with a tight floating pulse develops. If right qì is weak, the cold can make a direct strike on the interior, which damages the stomach and spleen and causes vomiting and diarrhea with clear thin vomitus and stool, cold pain in the stomach duct and abdomen, and long voidings of clear urine.

Relative Strength of Right and Evil

Vacuity and repletion are not a simple binary method of categorizing a disease condition. The relative strength of right and evil can vary infinitely.

Exuberance of both right and evil causes repletion: When a potent evil encounters the powerful resistance of right qì, the result is repletion pattern, marked by the swift development of pronounced signs. Here are some examples:

• When a strong healthy patient contracts wind-cold that fetters lung qì, he suffers from heat effusion, aversion to cold, headache and generalized pain, cough and panting, and a pulse that is tight, floating, and forceful.
• If the wind-cold is very powerful, it can pass into the interior and transform into heat, giving rise to exuberant yáng míng (yáng míng) heat binding in the digestive tract, manifesting as constipation, abdominal fullness, and in some cases delirious raving (yáng míng (yáng míng) bowel repletion pattern).
• When a strong healthy individual eats too much rich food (dietary intemperance), he is likely to suffer from fullness and discomfort in the abdomen, but without any vomiting or diarrhea that would relieve the condition.

Debilitation of right qì gives rise to vacuity: Vacuity of right qì without evil is mostly seen in elderly people, in patients suffering from constitutional insufficiency, or in people who have suffered enduring illness. In vacuity of right qì, broad distinctions are made between yīn, yáng, qì, and blood vacuity. Finer distinctions are made depending on where the vacuity is located among the bowels and viscera.

Evil exuberant and right vacuity causes vacuity and repletion: This arises under two circumstances.

• Repletion preceding vacuity: One is when both right and evil remain exuberant for a long time, and right qì is gradually damaged by the evil. This happens in yáng míng (yáng míng) bowel repletion patterns when the evil remains exuberant and gradually damages yīn humor, causing heat bind with damage to yīn. Note that heat bind (热结 rè jié) refers to constipation from binding in the intestines. Heat is said to bind the stool, i.e., dry and compact it.
• Vacuity preceding repletion: The other circumstance is when right qì is insufficient before the disease develops and is therefore easily further damaged by the disease evil. For example, in the course of warm disease, damage to yīn liquid by warm evil mostly fits this category. Qì stagnation, blood stasis, phlegm-rheum, and water swelling often develop as a result of chronic conditions of qì, blood, bowels, and viscera.

Root and Tip

In complex conditions, such as an exuberant evil with right vacuity, a distinction is made between the primary and secondary aspects of conditions, which are called root and tip (标本 biāo běn) respectively. Root and tip are defined in terms of the following parameters:

• Right qì and evil qì: Right qì is the root of a condition; evil qì is the tip. Remember, for evils to encroach, [right] qì must be vacuous.
• Cause versus symptoms: The cause of the illness is the root, while the symptoms it displays are the tip.
• Prior conditions versus new conditions: Prior conditions, that is, previous illnesses or conditions appearing first in the present illness, are the root, while more recently appearing conditions are the tip.
• Upper body versus lower body: Lower-body conditions are the root, while upper-body conditions are the tip.

Root and Tip
Root (本 běn)	Tip (标 biāo)
Right qì	Evil qì
Cause of illness	Symptoms
Prior conditions	New conditions
Disease in the lower body	Disease in the upper body

The distinction between primary and secondary conditions is important end devising an effective treatment strategy. Unfortunately, the root and tip scheme, in itself lacks utility, since the parameters are sometimes conflicting. In the case of evil exuberance and right vacuity causing vacuity and repletion discussed above, how the vacuity and repletion are classed varies on which parameter is applied. In terms of right qì verses evil qì, the vacuity is the root, while the repletion is the tip. However, in terms of prior conditions and new conditions, only in vacuity conditions preceding repletion conditions is the vacuity classed as the root, while in the repletion conditions preceding vacuity conditions, the repletion condition is the root.

Although root and tip provide convenient labels, their specific meaning must be defined according to the context in which they are used. Practical distinctions between primary and secondary aspects of illness, such as vacuity complicated by repletion and repletion complicated by vacuity, are discussed below under Vacuity and Repletion Complexes.

Yīn and Yáng (阴阳 yīn yáng)

Since yīn-yáng is a system of universal correspondences that is applied in all realms of medicine, yīn and yáng are used to categorize not only components and substances of the body but also evils invading the body from outside or arising from within―in other words, both right qì and evil qì.

The fundamental principles of yīn and yáng in pathology are that when yīn prevails, there is cold (阴胜则寒 yīn shèng zé hán) and when yáng prevails, there is heat. (阳胜则热 yáng shèng zé rè). By the principle of like qì seek each other (同气相求 tóng qì xiāng qiú), yáng evils (wind, fire, summerheat, dryness) merge with the yáng qì of the body to create an overall yáng surfeit, while yīn evils (cold, dampness) enter the body and merge with the yīn qì of the body to create a surfeit of yīn.

Because, as has just been explained, right qì is the aggregate of the health-maintaining forces of the body and includes yīn, yáng, qì, and blood, the development of disease in the body is not conditioned by the nature and strength of any offending evil alone but also by the specific state of right qì. External cold is more likely to cause illness when the body’s yáng qì is weak. External heat is more likely to cause illness if the yīn qì of the body is weak.

Factors Influencing Pathogenesis (影响发病的因素 yǐng xiǎng fā bìng de yīn sù)

The external environment is an individual’s living and working environment, including weather and geographical features, working conditions, and living conditions. The internal environment is an individual’s constitution and mental state. The inner environment largely determines the strength of right qì, while the external environment is largely associated with disease evils. However, the external environment can also affect right qì.

Geographic Features

These include climate and quality of earth and water, and in some areas high altitude. For example, the north of China has cold winters, so illness caused by cold evil is common. The south-east coastal region is warm, so warm diseases, damp-heat conditions, and sores are prevalent. Low-lying reaches of rivers, lake regions, and marshlands tend to cause water-damp. Some areas have poor earth and water. For example, regions far from the ocean and mountainous areas often lack iodine, and so goiter is more prevalent there. Finally, those who travel beyond their home region often experience acclimatization difficulties (水土不服 shuǐ tǔ bù fú) that can lower their resistance to external evils.

Weather

Different weather conditions are an important factor in illness.

Disease evils are prevalent at different times of the year. For example, in most parts of China the weather in spring is normally warm and windy, and so wind-warmth is common in spring; the weather in summer is hot and often damp, and summerheat-heat and summerheat-damp is prevalent in summer; autumn is dry, and hence dryness disease is most common in autumn; winter is cold, and so cold diseases are most prevalent in winter.

Finally, sudden changes in the weather and untimely types of weather are difficult for the body to adapt to. They can make the body susceptible to external evils and weaken right qì.

The incidence of contagious diseases is also to some degree seasonally related. For example, measles, whooping cough, and common cold mostly occur in the winter and spring, while dysentery mostly afflicts people in the summer.

Living and Working Conditions

Poor living and working conditions can affect health greatly.

• People who live in cold and damp conditions are susceptible to cold-damp. This makes them not only prone to impediment (bì) disease but also damages their right qì.
• People who work outdoors in cold winter weather may be susceptible to wind-cold or even frostbite.
• Farmers 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.
• People who live in densely populated areas are prone to diseases caused by epidemic qì that spread from person to person.

Constitution

Constitution is a complex combination of congenital factors, acquired factors, and age factors that influence health greatly (see constitution). People who are naturally endowed with good health, who eat well, and who exercise regularly have firm bodies and strong right qì that resists illness. People who are sickly from birth, fail to eat well, and do not get regular exercise, have weak right qì and are prone to illness. People’s constitution tends to weaken with advancing years.

Different constitutional types are prone to different illnesses, as the following examples show:

• People with yáng-biased constitutions (lean firm bodies) are susceptible to fire and easily develop taxation cough.
• People with yīn-biased constitutions (flabby bodies) suffer from cold diseases. They are prone to dampness and phlegm-rheum, as well as wind stroke.
• Individuals whose exterior qì tends to be weak are prone to contraction of wind-cold and wind-heat.
• People with weak stomachs and spleens are susceptible to food damage.

Affect-Mind States

Mental and emotional factors have a direct bearing on health. When a person is happy and optimistic and can successfully cope with the problems of everyday life, qì and blood remain in harmony, the bowels and viscera function in coordinated fashion, and right qì maintains its vigor. Conversely, people prone to emotional ups and downs or failure to stand up to the pressures and challenges of life suffer from anger, frustration, and worry. People engaged in mental work are given to excessive thought and preoccupation. These negative mental states affect the health of qì and blood, impair the functioning of the bowels and viscera, weaken right qì, and increase susceptibility to disease evils.

Types of Pathogenesis (发病类型 fā bìng lèi xíng)

Depending on the nature of the evil and the state of right qì, different chronological types of pathogenesis are distinguished.

Sudden Emergence

A sudden emergence (猝发 cù fā) is swift initial development of an illness. It occurs as a result of the following causes:

• Exuberant evil qì, such as external evils, invading the body of an individual whose right qì is strong and puts up an immediate fight.
• Contagious diseases that spread quickly.
• Sudden emotional changes that cause counterflow and chaotic movement of blood.
• Poisonous substances and snake or insect venom that enter the blood immediately.
• Physical injuries, such as knocks and falls, burns and scalds, incised wounds, frostbite, electric shocks, and bullet wounds.

Gradual Emergence

A gradual emergence (徐发 xú fā) or slow emergence (缓发 huǎn fā) is a slow development of a disease. It results from the following causes:

• Excessive thought and preoccupation, which slowly damage the heart and spleen.
• Sexual intemperance, which gradually wears essential qì and causes vacuity taxation (severe vacuity patterns).
• Dampness, which, being sticky and stagnant, often affects the body slowly.

Delayed Emergence

A delayed emergence (伏发 fú fā) is one in which the patient falls sick some time after contracting the evil. In such cases, the evil is called a latent qì (伏气 fú qì). Lockjaw (tetanus) and rabies, which result from wounds and dog bites respectively, are associated with an initial period of latency. Latent summerheat (伏暑 fú shǔ) and latent qì warm disease (伏气温病 fú qì wēn bìng) are externally contracted febrile diseases that lie latent in the body before emerging at a later time.

Remittent Emergence

Periodic reoccurrence of an illness is called remittent emergence (间发 jiān fā). Normally patients have no signs, but when their right qì weakens or certain conditions or stimuli arise, the illness becomes manifest. Remittent emergence is associated with diseases such as malarial disease, epilepsy, and wheezing and panting. Classic examples of remittent emergencies are conditions that arise during menstruation and disappear after it has ended, e.g., headache, vomiting of blood or nosebleed, and puffy swelling.

Secondary Emergence

A secondary emergence (继发 jì fā) is the appearance of a new condition as a result of the primary disease. An example is mother-of-malaria, (疟母 nǜ mǔ), which is splenomegaly occurring as a result of enduring malarial disease.

Relapse

The reappearance of an illness after a short time or a long time is called relapse (复发 fù fā). Relapses can occur when residual evils remain after the first episode ends, when right qì is weak, and/or when the illness is triggered by a new contraction of evil. The more frequent relapses are and the shorter the intervals between them, the poorer the prognosis. Relapse is classified according to cause:

• Food relapse (食复 shí fù): Relapse due to dietary irregularities, such as voracious eating and drinking or excessive consumption of liquor.
• Taxation relapse (劳复 láo fù): Relapse due to excessive physical taxation, sexual taxation, or taxation of the spirit.
• New contraction relapse (重感致复 chóng gǎn zhì fù): Relapse caused by a new external contraction.
• Medication relapse (药复 yào fù): Relapse caused by inappropriate medication.
• Spontaneous relapse (自复 zì fù): Relapse for no apparent reason.

Exuberance and Debilitation of Right and Evil (正邪盛衰 zhèng xié shèng shuāi)

Some illnesses take the form of simple vacuity or repletion. However, many conditions are vacuity-repletion complexes, which take the form of vacuity complicated by repletion or repletion complicated by vacuity. When right or evil is very strong or weak, vacuity-repletion conversion arises or a condition of true or false vacuity and repletion develops.

Vacuity and Repletion (虚实 xū shí)

Vacuity and repletion (虚实 xū shí) are defined in the Sù Wèn (Chapter 28) in the following way: When evil qì is exuberant, there is repletion; when essential qì is despoliated, there is vacuity (邪气盛则实, 精气夺则虚 xié qì shèng zé shí, jīng qì duó zé xū). Here, essential qì means the body’s resources and potential power for maintaining health. Right qì is the manifestation of essential qì in preventing illness.

Repletion

Repletion (实 shí) is a state in which evil qì is exuberant and right qì is relatively strong and able to fight it. Repletion patterns are marked by signs of evils, such as the six excesses, phlegm, food, static blood, or water lodging in certain locations. In externally contracted febrile disease, they typically occur in the early and middle stages and are of short duration. By contrast, when caused by phlegm or static blood developing out of vacuity patterns, they tend to develop slowly and are of longer duration.

A typical example of a repletion pattern is the exuberant heat stage of externally contracted febrile disease manifesting in yáng brightness (yáng míng) disease. This can take either of two forms. One is a yáng brightness (yáng míng) channel pattern, which manifests in great heat effusion, great sweating, great thirst, and a large pulse, a set of signs that known as the four greats (四大 sì dà). The other is a yáng brightness (yáng míng) bowel pattern, marked by constipation with abdominal distension and fullness that feels hard to the touch and refuses pressure, accompanied by late afternoon tidal heat effusion, delirious speech, and slight sweating from the extremities. At this stage, the evil is exuberant, but right qì has still not been greatly damaged.

Vacuity

Vacuity (虚 xū) is insufficiency of right qì. It occurs as a result of constitutional weakness, enduring illness, or major illness, such as with great sweating, great vomiting, or great diarrhea. Vacuity patterns manifest in signs that indicate impairment of bowel and visceral function.

In febrile disease, vacuity of right qì encourages the initial invasion of evil qì. However, pronounced vacuity patterns usually only make their appearance in the advanced stages, when evils have caused severe damage to right qi.

In internal damage and miscellaneous diseases, vacuity patterns resulting from numerous factors such as diet, imbalance of activity and inactivity, and repeated illness usually develop slowly.

Vacuity patterns are generally characterized by lassitude of spirit and fatigued body, lusterless complexion, heart palpitation, shortness of breath, spontaneous or night sweating, or vexing heat in the five hearts, or fear of cold and cold limbs, and a pulse that is vacuous and forceless, indicating damage to qì, blood, yīn, or yáng. For example, when a woman with severe flooding and spotting loses a large amount of blood, she presents signs such as somber-white or withered-yellow complexion, lassitude of spirit, heart palpitation, shortness of breath, pale tongue, and a pulse that is weak and forceless or floating, large, and forceless under heavy pressure.

Vacuity-Repletion Complexes (虚实错杂 xū shí jiā zá)

Vacuity-repletion complexes (虚实错杂 xū shí jiā zá) are characterized by the simultaneous existence of both vacuity and repletion. These conditions arise either

• when disease evil manifesting in a repletion pattern persists for a long time and gradually damages right qì (repletion causing vacuity) or
• when vacuity of right qì encourages the contraction of external evils or allows pathological products, such as water-damp, phlegm-rheum, or static blood, to arise in the body (vacuity giving rise to repletion).

Vacuity-repletion complexes commonly result from failure to provide appropriate treatment or from inappropriate treatment.

When a vacuity-repletion complex arises, one of the components is invariably more pronounced than the other. Hence, we distinguish between vacuity complicated by repletion, in which the vacuity is more pronounced, and repletion complicated by vacuity, in which the repletion is more pronounced. The second pattern to arise is initially less marked than the first, but in time it can become the dominant element in the complex.

In vacuity-repletion complexes, the vacuity and repletion patterns are typically located in different places, e.g., exterior repletion and interior vacuity; exterior vacuity and interior repletion; upper body repletion and lower body vacuity; upper body vacuity and lower body repletion. For example, kidney yīn vacuity can cause liver yīn vacuity, upsetting the balance with liver yáng and causing ascendant hyperactivity of liver yáng. This forms a pattern of upper body repletion and lower body vacuity.

Repletion Complicated by Vacuity

Repletion causes a secondary pattern of vacuity when the evil qì damages right qì. This is called repletion complicated by vacuity (实中夹虚 shí zhong1 jiā xū).

Vacuity versus Deficiency

The word 虚 xū is often translated as deficiency. In Chinese, vacuity is sometimes contrasted with a term of similar meaning, 不足 bù zú,insufficiency. While insufficiency describes a lack of substance or aspect of the body, vacuity emphasizes the state of the whole body as affected by insufficiency. Thus, when we say heart qì vacuity, we mean not only the insufficiency of heart qì itself but also the relative emptiness of the whole body as affected by an insufficiency of heart qì. Vacuity expresses the dynamic holistic view of sickness better than deficiency, which simply means insufficiency, i.e., the lack of a substance. Interesting are the uses of 虚 xū outside the description of patterns. There are vacuous and replete pulses, which feel empty and full, respectively. There is vacuity puffiness and vacuity fullness. The lung is described as a vacuous organ because of its sponginess. Immense confusion can arise when the term deficient is used in combination with heat or cold. Vacuity heat, which is heat attributable to yīn vacuity, makes no sense expressed as deficient heat. The same applies to deficient cold. The choice of vacuity conforms with a decades-long trend toward translations that more accurately reflect the original concepts.

In externally contracted febrile disease, this is observed when repletion heat causes damage to liquid or damage to both qì and yīn. When heat evil is intense and causes high fever, sweating, constipation, a red tongue, and rapid pulse, this is a repletion heat pattern. If we also see a dry tongue, thirst with large fluid intake, and short voidings of reddish urine, this means there is damage to liquid. If we find the patient further displaying shortness of breath or panting and lack of strength, we know they are suffering from damage to qì and yīn.

In miscellaneous disease, repletion complicated by vacuity is observed, for example, when stagnant qì and static blood bind in the abdomen to form hard concretions or accumulations, while at the same time, damaging right qì and causing gradual emaciation.

Different evils cause damage to different aspects of the body. This makes it relatively easy to predict developments in patient’s condition.

• Exuberant heat damages liquid.
• Severe cold damages yáng qì.
• Exuberant dampness encumbers the spleen.
• Dryness damages lung qì.

Vacuity Complicated by Repletion

Vacuity gives rise to repletion when it allows external evils to be contracted or when it fosters the development of internal evils. This is called vacuity complicated by repletion (虚中夹实 xū zhong1 jiā shí). Different vacuities encourage susceptibility to different evils, so developments are often predictable. For example,

• Any insufficiency of qì, blood, yīn or yáng can reduce a patient’s ability to resist external evils, they become susceptible to externally contracted disease.
• When yáng is depleted, then internal cold arises or susceptibility to cold evil increases.
• When yīn is depleted, internal heat arises or susceptibility to warm-heat disease evils increases.
• When qì vacuity deprives the blood of adequate propulsion, blood stasis arises.
• When the warming and transforming action of yáng qì is affected, water-damp and phlegm easily arise within.
• Spleen-stomach vacuity patients in whom the intake and transformation of grain and water is affected are susceptible to damage by intemperate eating, giving rise to center vacuity with food stagnation.

Vacuity-Repletion Conversion (虚实转化 xū shí zhuǎn huà

In the process of disease, we sometimes see a condition of vacuity giving way to one of repletion and vice versa. This is called vacuity-repletion conversion (虚实转化 xū shí zhuǎn huà).

Repletion Converting into Vacuity

In an illness in which evil qì is exuberant, factors such as weak health, inappropriate treatment, and/or failure to give appropriate treatment can easily give way to conditions in which the evil qì has disappeared, leaving right qì and bowel and visceral function severely damaged. Here, right qì has spent its last on fighting the evil. This is called repletion converting into vacuity (由实转虚 yoú shí zhuǎn xū).

For example, in externally contracted disease, when an exterior repletion pattern (exterior cold or exterior heat) is inappropriately treated or the patient is very old and weak and their right qì can only mount brief resistance, the original repletion pattern can convert into a vacuity pattern characterized by signs such as emaciation, reduced heat, lusterless complexion, shortness of breath, and lack of strength. This is repletion converting into vacuity. Note that this is different from a vacuity-repletion complex because the repletion pattern has disappeared altogether. In such cases, treatment focuses on addressing the vacuity.

In warm disease, repletion converting into vacuity is seen when warm-heat evil severely damages yīn, so that in the advanced stages (blood patterns), there is both residual heat attributed to the external evil and heat arising from the damage to yīn that it causes. Here, yīn vacuity is identified by heat effusion in the evening that abates by the morning and by vexing heat in the five hearts.

Vacuity Converting into Repletion

A vacuity pattern causing a severe repletion pattern is sometimes called vacuity converting into repletion (由虚转实 yoú xū zhuǎn shí). In fact, this is the same as vacuity complicated by repletion, because the underlying vacuity does not disappear.

True and False Vacuity and Repletion (虚实真假 xū shí zhēn jia3)

Normally, vacuity and repletion have specific manifestations that make them easily differentiable. Under some circumstances, however, vacuity may manifest not only in vacuity signs but also in false signs of repletion. Similarly, repletion may manifest not only in repletion signs but also in false signs of vacuity. In practice, such instances of true and false vacuity and repletion (虚实真假 xū shí zhēn jia3) must be clearly identified, otherwise grave errors of treatment may be made that are often described as evacuating vacuity and replenishing repletion (虚虚实实 xū xū shí shí), that is, wrongly treating vacuity with evil-dispelling medicinals or treating repletion evils by supplementation.

True Vacuity and False Repletion

True vacuity and false repletion (真虚假实 zhēn xū jia3 shí) most commonly arises when right qì vacuity is severe, qì and blood are insufficient, and organ function is poor. For example, spleen vacuity normally manifests in reduced eating, fatigue and lack of strength, a tender-soft enlarged tongue with a moist fur, and a pulse that is vacuous and forceless. However, if at the same time there is severe abdominal fullness, distension, and pain, these are false repletion signs. Although there is fullness and distension, this abates periodically and is therefore unlike the unremitting fullness of a repletion pattern. Although there is pain, this is relieved by pressure, unlike the abdominal pain of repletion patterns that refuses pressure.

True Repletion and False Vacuity

True repletion and false vacuity (真实假虚 zhēn shí jia3 xū) usually stems from heat binding in the stomach and intestines, phlegm and food congestion, damp-heat brewing internally, or large concretions and conglomerations, all of which cause obstruction in the channels that impedes the flow of qì and blood, thereby giving rise to vacuity signs. For example, when heat binds in the stomach and intestines, giving rise to intense interior heat, there will naturally be constipation, abdominal fullness, hardness, and pain that refuses pressure, as well as late afternoon tidal heat effusion, delirious speech, and a dry yellow tongue fur. If at the same time there is listlessness of essence-spirit, no desire to talk, and fatigued limbs, these are false signs of vacuity. Signs of false vacuity are often slightly different from signs of true vacuity. Despite no desire to talk, when the patient does talk, their voice is strident and their breathing rough. Although the limbs seem fatigued, they regain their strength after a little exercise.

Yīn-Yáng Disharmony (阴阳失调 yīn yáng shi1 tiáo)

Any illness, whatever the cause, can be understood in terms of yīn-yáng disharmony (阴阳失调 yīn yáng shi1 tiáo). When external evils invade the body, they affect the yīn-yáng balance. Cold and dampness are yīn evils, while wind, summerheat, fire, and dryness are yáng evils. When these evils enter the body, they disturb the harmony of yīn and yáng. Yīn evils tend to damage the body’s yáng qì, while yáng evils tend to damage yīn-blood and the fluids.

The basic principles of yīn-yáng disharmony aare when yīn prevails, yáng ails; when yáng prevails, yīn ails and when yáng is vacuous, yīn becomes exuberant; when yīn is vacuous, yáng becomes exuberant. Here, we take a closer look at these principles and further discuss yīn and yáng damaging each other, yīn-yáng block and repulsion, yīn-yáng conversion, and collapse of yīn or yáng, all of which are progressions of yīn-yáng surfeits and deficits.

Yīn-Yáng Surfeits and Deficits (阴阳盛衰 yīn yáng shèng shuāi)

Yīn-yáng surfeits (阴阳偏盛 yīn yáng piān shèng) are imbalances of yīn and yáng arising as a result of either yīn or yáng becoming stronger than its counterpart. Yīn-yáng deficits (阴阳偏衰 yīn yáng piān shuāi) are imbalances resulting from either yīn or yáng becoming weaker than its counterpart. Together, these are called yīn-yáng surfeits and deficits (阴阳盛衰 yīn yáng shèng shuāi).

Yīn-Yáng Surfeits (阴阳偏盛 yīn yáng piān shèng)

Although yīn and yáng classify many aspects of physiology and pathology, their major expression in the human body is in heat and cold. When there are surfeits of yīn or yáng, cold and heat invariably arise. Hence, an important pathomechanical principle is when yáng is exuberant, there is heat; when yīn is exuberant, there is cold. Surfeits of yīn and yáng manifest in repletion patterns.

When Yáng is Exuberant, There is Heat

When yáng is exuberant in the body, the warming and propelling functions of the yáng qì of the body become hyperactive. Because heat is the main manifestation of this, it is said: When yáng is exuberant, there is heat (阳盛则热 yáng shèng zé rè). Exuberant yáng damages yīn, hence the Sù Wèn (Chapter 5) says, When yáng prevails, yīn ails (阳胜则阴病 yáng shèng zé yīn bìng). This is also expressed as when yáng is exuberant, yīn is vacuous (阳盛则阴虚 yáng shèng zé yīn xū). Because this condition arises out of exuberance of yáng rather than insufficiency of yīn, it is called a repletion heat (实热 shí rè) pattern.

Pathogenesis: Yáng exuberance arises in several different ways.

• Externally contracted yáng evils: Yáng exuberance can develop when yáng evils enter the body. By the principle of like qì seek each other, yáng evils merge with the yáng qì of the body to create an overall yáng surfeit. Thus, when warm-heat (wind-heat, warm evil, summerheat) yáng evils invade the body, they cause the warming and propelling actions of yáng qì to become hyperactive and give rise to heat.
• Externally contracted yīn evils entering the interior and transforming into heat: Yáng exuberance may also arise when externally contracted yīn evils transform into heat under the influence of a constitutional or nascent internal exuberance of yáng qì.
• Miscellaneous evils: Yáng exuberance may also arise when stagnant qì, static blood, phlegm, or food accumulation depress the body’s yáng qì and cause it to transform into fire.

Exuberance and Prevalence
Both these terms appear in classical descriptions of yīn and yáng. The Chinese for both terms is pronounced in the same way. However, there is a difference in meaning. Exuberance (盛 shèng) means copiousness and strength, while prevalence (胜 shèng) emphasizes the predominance of yīn or yáng over the other.

Manifestations: The manifestations of exuberance of yáng qì can be summed up in four words: heat, movement, redness, and dryness (热动红燥 rè dòng hóng zào).

• Heat: Heat manifests in heat effusion. (Mild heat effusion can result from wind-cold, where it is attributable to the struggle between right and evil.) Heat effusion naturally gives rise to sweating.
• Movement: Heat causes increased movement and activity, which manifests in vexation and agitation with a rapid pulse.
• Redness: It stimulates the movement of blood, causing a red facial complexion and red tongue. Localized red swellings are also a sign of yáng exuberance.
• Dryness: Heat causes the body to sweat and stimulates qì transformation so that there is thirst with increased intake of fluids, short voidings of yellow or reddish urine, dry stool, and dry yellow tongue fur. Note that sweating, which makes the skin moist, is a feature of heat patterns, which are otherwise characterized by dryness. Sweating is a cause of dryness.

As the exuberance of yáng qì increasingly damages yīn qì, signs such as thirst, short voidings of reddish urine, and dry stool become more pronounced. In diagnosis, it is important to establish the degree of damage to yīn, as visible from the tongue fur, fluid intake, urine, and stool.

Heat Effusion vs. Fever

The Chinese term 发热 (fā rè) roughly corresponds to the English fever. However, in Chinese medicine, it often denotes sensations of heat that may or may not be associated with an elevated body temperature, as measured with a thermometer. Hence, for the sake of accuracy, we usually translate the term as heat effusion. However, the term 高热 gāo rè, which frequently appears in modern Chinese texts, is translated as high fever. The traditional term for this concept is 壮热 zhuàng rè, vigorous heat [effusion].

When Yīn is Exuberant, There is Cold

Yīn exuberance is a condition in which yīn evils in the body weaken the propelling, warming, and transforming functions of yáng qì, giving rise to repletion cold. Because cold is the manifestation of ailing yáng, it is also said: When yīn is exuberant, there is cold (阴盛则寒 yīn shèng zé hán). Exuberant yīn damages yáng, hence Sù Wèn (Chapter 5) says, When yīn prevails, yáng ails (阴胜则阳病 yīn shèng zé yáng bìng). This is also expressed as when yīn is exuberant, yáng is vacuous (阴盛则阳虚 yīn shèng zé yáng xū). Because this condition arises from exuberance of yīn rather than insufficiency of yáng, it is called a repletion cold (实寒 shí hán) pattern.

Pathogenesis: Yīn exuberance results from contraction of cold or dampness or from excessive consumption of raw or cold foods. The yīn evils merge with the yīn of the body to produce a yīn surplus that manifests in cold signs.

Manifestations: The manifestations of yīn exuberance can be summed up in the words cold, stillness, whiteness, and moistness (寒静白湿 hán jìng bái shī). These are the same categories of signs that characterized yáng deficits. However, yīn surfeits differ by also being characterized by an additional category, contraction (收 shōu).

• Cold: Cold manifests in cold signs, such as aversion to cold, fear of cold, cold limbs, desire for warm food and drinks, and a desire to keep well-covered.
• Stillness: Patients often lie in curled-up posture to preserve heat. Their desire to engage in physical activity is reduced. Cold notably also slows down the movement of qì and blood, causing pain in the head, nape, limbs, or stomach duct and abdomen (when there is stoppage, there is pain).
• Whiteness: Because cold reduces activity in the body and causes contraction of the blood vessels, it reduces blood flow, the pulse becomes slow, the facial complexion becomes white, and the tongue body becomes pale.
• Moistness: Because cold reduces qì transformation, the fluids are insufficiently warmed and transformed. This gives rise to a white glossy tongue fur, a runny nose with clear snivel, and long voidings of clear urine. The Sù Wèn (Chapter 74) states, All disease with watery humors that are clear, pure, and cold is ascribed to cold (诸病水液澄澈清冷, 皆属于寒 zhū bìng shuǐ yè chéng chè qīng lěng, jiē shǔ yú hán). When the spleen is affected, the patient suffers from sloppy stool and even diarrhea. The failure to transform water-damp properly can give rise to dampness, cold-damp, phlegm-rheum, and water swelling patterns.
• Contraction: Cold causes contraction and tension. Contraction of the interstices prevents sweating. Contraction of the sinews causes stiff nape or hypertonicity of the sinews. Contraction of the blood vessels causes the pulse to be tight or sunken. Note that absence of sweating is a feature of cold patterns, which are otherwise characterized by moistness.

Generally, cold limbs, abdominal pain, clear urine, and sloppy stool or diarrhea are signs indicating that the cold evil has damaged yáng qì.

Yīn-Yáng Deficits (阴阳偏衰 yīn yáng piān shuāi)

Deficits of yīn and yáng are yīn-yáng imbalances which arise through debilitation of the body’s yīn essence or yáng qì. When yáng qì fails to restrain yīn essence, vacuity cold arises. When yīn essence fails to restrain yáng qì, vacuity heat arises. This is summed up in the principle when yáng is vacuous, there is cold; when yīn is vacuous, there is heat.

When Yáng is Vacuous, There is Cold

When yáng qì weakens or is damaged, its warming, propelling, and transforming powers are diminished. As a result, yīn qì becomes relatively stronger. This is expressed as, when yáng is vacuous, yīn becomes exuberant (阳虚则阴盛 yáng xū zé yīn shèng). Because cold is the main manifestation of this yīn-yáng disharmony, the idea is also expressed as when yáng is vacuous, there is cold (阳虚则寒 yáng xū zé hán). This kind of cold is called vacuity cold (虚寒 xū hán).

Pathogenesis: Yáng vacuity is the result of earlier heaven (constitutional) insufficiency, later heaven lack of nourishment, taxation fatigue, enduring illness, or excessive use of cold-cool heat-clearing fire-draining medicinals.

Locus: The kidney is the root of yīn and yáng of the entire body. Yīn vacuity and yáng vacuity are essentially kidney yīn vacuity and kidney yáng vacuity. Yáng vacuity very often affects the spleen. Digestive disturbances with cold signs constitute spleen yáng vacuity. Liver yáng is mainly subject to superabundance rather than insufficiency, and lung yáng rarely figures in discussions of lung disease patterns.

Manifestations: The manifestations of yáng vacuity include cold signs such as bright-white facial complexion, fear of cold, cold limbs, a pale tongue, and a slow pulse. They also include vacuity signs such as desire for quiet, dullness of essence-spirit, and lying in curled-up posture. Because yáng vacuity affects qì transformation in the kidney, there are also long voidings of clear urine. The sloppy stool of spleen qì vacuity is superseded by the more severe condition of clear-grain diarrhea (diarrhea characterized by stool containing undigested food).

Yīn-Yáng Surfeits and Deficits
	Surfeits Acute, constant, generalized signs	Deficits Chronic, intermittent, localized signs
	Yīn Prevailing (Repletion Cold)	Yáng Vacuity (Vacuity Cold)
Cold	Aversion to cold; cold limbs	Fear of cold; cold limbs
Stillness	Liking for quiet lying in curled-up posture, slow pulse, pain	Liking for quiet lying in curled-up posture, forceless pulse
Whiteness	Somber-white complexion; pale tongue with white fur	Bright-white complexion; pale tongue.
Moistness	Absence of thirst; diarrhea	Long voidings of clear urine; diarrhea with undigested food in the stool; puffy swelling>
	Yáng Prevailing (Repletion Heat)	Yīn Vacuity (Vacuity Heat)
Heat	Vigorous heat effusion (high fever); sweating	Tidal heat; vexing heat in the five hearts; night sweating
Movement	Vexation and agitation; rapid, large, forceful pulse	Heart vexation; rapid, fine, forceless pulse
Redness	Red face, red eyes, red tongue	Reddening of the cheeks; red tongue with little fur
Dryness	Thirst with desire to drink; constipation; scant voidings of reddish urine	Dry throat and mouth; constipation; scant voidings of yellow urine

Yáng vacuity develops internally, among the bowels and viscera, but it also manifests by failing to reach the periphery of the body making defense yáng of unable to warm and protect the exterior and causing a bright-white complexion and, fear of cold, cold limbs, and susceptibility to common cold. Hence, for these reasons, the Sù Wèn (Chapter 62) says, When yáng is vacuous, there is external cold (阳虚则外寒 yáng xū zé waì hán).

When yáng vacuity grows severe, it can give rise to what is called exuberant internal yīn cold (阴寒内盛 yīn hán neì shèng), which is marked by more severe cold signs. Clear-grain diarrhea (diarrhea with undigested food in the stool) becomes more pronounced, while the cold becomes severe enough to cause abdominal pain. In addition, other yīn evils―water-rheum and internal dampness―become more pronounced and more closely associated with cold. Such conditions are understood to be vacuity-repletion complexes.

Comparison: Yáng deficits are similar to yīn surfeits. However, while yīn surfeits are characterized principally by pronounced cold signs, yáng deficits are characterized by a greater prominence of vacuity signs. Yīn surfeits are acute and associated with a trigger event (e.g., catching cold), while yáng deficits develop gradually.

When Yīn is Vacuous, There is Heat

When yīn is vacuous, it fails to restrain yáng qì so that yáng qì becomes relatively stronger than yīn essence. This manifests as increased warming and activity in the body. When yīn is vacuous, yáng becomes exuberant (阴虚则阳盛 yīn xū zé yáng shèng). Because heat is the main manifestation, this is also expressed as: when yīn is vacuous, there is heat (阴虚则热 yīn xū zé rè). This kind of heat is called vacuity heat (虚热 xū rè).

Pathogenesis: Yīn deficits are attributable to constitutional insufficiency or to the wear and tear of advancing years that increases after a person reaches their prime. They can also result from wear on yīn humor through enduring illness. They may also result from taxation fatigue and poor diet. In some cases, they are traceable to blood vacuity. Not uncommonly, they can arise when excesses among the seven affects cause the formation of fire, which scorches yīn essence. Note that internal fire can take the form of vacuity fire or repletion fire (seeinternal evil).

Locus: Because kidney yīn is the root of the whole body, yīn vacuity is largely associated with kidney yīn vacuity. The heart, lung, and liver are all susceptible to yīn vacuity.

Manifestations: Vexing heat in the five hearts (soles, palms, chest), postmeridian tidal heat, steaming bone tidal heat effusion, red face or tidal reddening of the cheeks, night sweating, emaciation, dry pharynx and mouth, red tongue with scant fur, and a pulse that is fine, rapid, and forceless. In heart yīn vacuity, these signs combine with disturbances of the spirit such as heart vexation and agitation. In lung yīn vacuity, they accompany respiratory disturbances, and in liver yīn vacuity, they accompany head and eye, liver channel, and sinew signs.

The heat signs in such cases simply reflect yīn vacuity leaving the normal power of yáng qì unchecked. This is described as yīn vacuity with heat (阴虚有热 yīn xū yoǔ rè), yīn vacuity with internal heat (阴虚有热 yīn xū neì rè), or simply vacuity heat (虚热 xū rè). The heat is described as internal since it arises in the interior of the body and remains focused there.

A feature of vacuity heat is that signs are limited in intensity, to certain locations, and to certain times of the day. Heat effusion is mild (limited intensity). It often manifests in vexing heat in the five hearts (heat confined to palms, soles, chest). The heat reaches the outside of the body in the latter part of the day, when yīn is weakest, so it takes the form of tidal heat (limited time of day), tidal reddening of the cheeks (limited location and time), and night sweating (sweating limited to the time when the body rests).

The tidal heat is sometimes called steaming bone tidal heat, reflecting how the heat is felt to come from the interior of the body. For these reasons, the Sù Wèn (Chapter 62) says, When yīn is vacuous, there is internal heat (阴虚则内热 yīn xū zé neì rè).

In severe cases of yīn vacuity, however, not only is yáng qì left unconstrained, but fire-heat arises internally, causing headache, dizziness, and pronounced redness of the face and eyes. This is vacuity complicated by repletion. It is often referred to as yīn vacuity with effulgent fire (阴虚火旺 yīn xū huo3 wàng). Because this intense kind of fire rises to manifest in upper body signs, it is often also described as vacuity fire flaming upward (虚火上炎 xū huo3 shàng yán).

Yīn vacuity with internal heat can result from repletion conditions. It can develop when repletion heat exacerbates the yīn vacuity internal heat and causes further depletion of yīn. This is notably seen in blood-aspect patterns of warm disease. Damp-heat can also conjugate with yīn vacuity, giving rise to yīn vacuity and damp-heat (阴虚湿热 yīn xū shī rè).

Comparison: Yīn deficits are similar to yáng surfeits. However, the heat signs differ markedly. Yáng surfeits are marked by pronounced heat signs, whereas yīn deficits are marked by milder heat signs: mild rather than vigorous heat effusion; heat sensations rather than fever that can be measured with a thermometer; heat effusion only in the latter part of the day; heat confined to the five hearts. The red facial complexion may be confined to the area of the cheekbones.

One apparent exception to this is tidal heat, which may also occur in the repletion heat pattern of yáng ming2 (yáng ming2) bowel patterns, where there may be late afternoon tidal heat, meaning heat effusion present throughout the day that peaks in the late afternoon. This is similar to the tidal heat of yīn vacuity, but in this case late afternoon tidal heat is explained by the fact that yáng ming2 (yáng ming2) channel qì is most effulgent in the late afternoon watch (3–5 pm). Note effulgence of yáng ming2 (yáng ming2) in the late afternoon does not conform to the scheme of exuberance and debilitation described in the context of the sequence of flow of qì through the channels in channels and network vessels.

Signs of Yīn-Yáng Surfeits and Deficits

Numerous signs directly or indirectly reflect yīn-yáng surfeits and deficits.

• Yáng surfeits (exuberance of yáng) and yīn deficits (debilitation of yīn) are marked by heat, movement, redness, and dryness (热动红燥 rè dòng hóng zào).
• Yīn surfeits (exuberance of yīn) and yáng deficits (debilitation of yáng) are characterized by cold, stillness, whiteness, and moistness (寒静白湿 hán jìng bái shī). Yīn surfeits may also be marked by contraction (收 shōu).

Surfeits (repletion patterns) are marked by acute, constant, and generalized signs, while deficits (vacuity patterns) are marked by chronic, intermittent, and localized signs.

Yáng Surfeits and Yīn Deficits: Heat, Movement, Redness, and Dryness

Heat effusion, fever (发热 fā rè): Fever and/or heat sensations. Note that发热 fā rè is often translated as fever. Heat effusion is a literal translation of the Chinese term, intended to avoid the assumption of elevated body temperature, which is not always the case.

Heat effusion is usually a sign of heat, but not always. When external evils invade the body, heat effusion is accompanied by aversion to cold. Even cold evil can give rise to mild heat effusion when defense qì rallies to combat it. However, in such a case, the aversion to cold is far more pronounced.

The term high fever (高热 fā rè), borrowed from biomedicine, often appears in modern Chinese texts. Traditionally, a continuing high fever is called vigorous heat effusion or simply vigorous heat (壮热 zhuàng rè).

Slight heat effusion (微热 wēi rè) is low fever or mild heat sensation. It can occur in initial-stage external contraction before the fight between right qì and evil qì becomes intense. With pronounced aversion to cold, it can reflect wind-cold in the exterior. In the absence of aversion to cold, it may indicate yīn vacuity.

Tidal heat (潮热 cháo rè): Also called tidal heat effusion. Heat effusion occurring at set times of the day, like the ocean tides. The most common form is postmeridian tidal heat (see next item). Tidal heat in the morning may be associated with spleen-stomach qì vacuity. When heat gives rise to blood stasis as in warm disease, the heat effusion becomes more severe at night.

Postmeridian tidal heat (午后潮热 wǔ hòu cháo rè): Also postmeridian tidal heat effusion. Fever or heat sensation occurring in the late afternoon or evening. It most commonly indicates yīn vacuity. When the heat feels as if it is emanating from deep within the body, it is called steaming bone tidal heat (骨蒸潮热 gǔ zhēng cháo rè). In externally contracted disease, a fever peaking between 3 and 5 p.m., called late afternoon tidal heat (日晡潮热 rì bū cháo rè), occurs in yáng brightness (yáng míng) disease.

Vexing heat in the five hearts (五心烦热 wǔ xīn fán rè): Palpable heat in the palms, soles and center of the chest and is a sign of yīn vacuity. Vexing heat in the hands and feet (手足烦热 shǒu zú fán rè) has the same diagnostic significance.

Sweating (汗出 hàn chū): Sweating can be attributable to external evils in the exterior and transforming into heat and entering the interior; it may also be attributable to insufficiency or yáng qì preventing normal containment of fluids. It may also result from insufficiency of yīn humor. Distinction is made between two forms.

• Spontaneous sweating (自汗 zì hàn) is sweating at any time of day or night that results from external evils or insufficiency of yáng qì.
• Night sweating (盗汗 dào hàn) is sweating that occurs only during sleep and ceases on waking is called. It is usually attributable to insufficiency of yīn humor. The Chinese term literally means thief sweating in allusion to the fact that it occurs when the patient is unaware of it.

Heart vexation (心烦 xīn fán): A subjective feeling of unrest, described as being centered in the heart. This is a sign of vacuity heat or repletion heat affecting the heart spirit.

Vexation and agitation (烦燥 fán zào): A subjective feeling of unrest (heart vexation), together with pronounced physical fidgetiness (agitation). This is a sign of vacuity heat or repletion heat affecting the heart spirit.

Rapid pulse (脉数 mài shuò): A pulse that beats more rapidly than normal reflects the stirring action of heat. In repletion heat, the pulse is typically large and rapid; in vacuity heat, it is fine and rapid.

Red facial complexion (面色赤 miàn sè chì): A complexion redder than normal. The whole of the face may be red, as in repletion heat. See next.

Reddening of the cheeks (颧红 quán hóng): A red complexion limited to the area of the cheekbones. Like tidal heat, it usually occurs in the latter part of the day, and hence is sometimes called postmeridian reddening of the cheeks (午后颧红 wǔ hòu quán hóng). It is attributed to vacuity heat. See red facial complexion above.

Red tongue (舌红 shé hóng): A tongue that is redder than normal is a sign of repletion or vacuity heat. Crimson, the deepest red coloring is seen in severe repletion heat.

Thirst (口渴 kǒu kě): Desire to drink fluids. Thirst is most commonly attributed to heat. When heat is pronounced, the patient may desire cold fluids. Thirst without desire to drink much is a sign of blood stasis or phlegm-rheum preventing fluids from rising to the mouth.

Dry throat and mouth (咽干口燥 yān gān kǒu zào): Dryness of the throat and mouth often accompanies thirst and results from the damaging effect of heat on the fluids. When mild and chronic, it is a sign of vacuity heat.

Short voidings of reddish urine (小便短赤 xiǎo biàn duǎn chì); short voidings of yellow urine (小便短黄 xiǎo biàn duǎn huáng): Scant urine darker in color than normal. It is attributable to heat causing reduction of the fluids. Mild heat (e.g., vacuity heat) causes the urine to become yellower than normal, while severe heat (repletion heat) causes the urine to assume a deep tea-colored appearance, which is traditionally called reddish. Note that we say reddish rather than red, to avoid confusion with the bright-red coloration observed in bloody urine.

Nasal congestion with turbid yellow snivel (鼻塞流黄浊涕 bí sè liú huáng zhuó tì): Nasal congestion and runny nose are attributed to disturbances of lung qì’s diffusion caused by the presence of externally contracted evils. When the evils include heat, the nasal mucous is turbid and yellow.

Constipation (便秘 biàn mì): Constipation can appear in many disease patterns. However, it is most commonly a sign of repletion heat, insufficiency of yīn humor, or vacuity heat.

Emaciation (消瘦 xiāo shòu): Loss of body weight attributable to damage to the yīn qì of the body.

Yīn Surfeits and Yáng Deficits: Cold, Stillness, Whiteness, and Moistness

Aversion to cold (恶寒 wù hán): Cold and shivering not completely relieved by addition of clothing, bedclothes, or a heat source, observed mostly in external contraction exterior patterns. Aversion to cold is fundamentally a sign of externally contracted evils affecting the exterior and depressing the warming action of defense qì. It is most pronounced in wind-cold fettering the exterior and is milder in wind-heat invading the exterior.

Fear of cold (畏寒 wèi hán): A habitual feeling of cold in yáng vacuity patients.

Physical cold (形寒 xíng hán): Cold that is felt as a subjective sensation by the patient or that can be detected by the practitioner through palpation. It occurs in repletion or vacuity cold.

Cold limbs (肢冷 zhī leng3); cold extremities (手足冰冷 shǒu zú bing1 leng3): Any condition of palpable cold in the arms, hands, feet, and legs. A sign of repletion cold or vacuity cold.

Lack of warmth in the extremities (手足欠温 shǒu zú qiàn wen1): Mild conditions of cold limbs.

Reversal cold of the limbs (四肢厥冷 sì zhī jué leng3); counterflow cold of the limbs (四肢逆冷 sì zhī nì leng3). Pronounced cold of the extremities up to the knees and elbows. It is typically observed in critical conditions called yáng collapse. It may also occur in block and repulsion patterns discussed further ahead.

Curled-up lying posture (向里蜷卧 xiàng li3 quán wò): A posture adopted to preserve bodily heat. A sign of repletion cold or vacuity cold. A sign of repletion cold or vacuity cold.

Slow pulse (脉迟 mài chí): A pulse that is slower than normal reflects the slowing action of cold. However, not all cold conditions manifest in a slow pulse, and a slow pulse does not necessarily reflect cold.

Headache (头痛 toú tòng): Any pain in the head. It can be due to numerous causes including externally contracted wind-cold.

Generalized pain (身痛 shen1 tòng): Pain felt throughout the body, notably the limbs and neck. It is due to external contraction of wind-cold, to dampness lodged in the fleshy exterior, or stasis obstruction of the network vessels. Cold, dampness, and static blood are all yīn evils that can obstruct qì and blood. When there is stoppage, there is pain.

White facial complexion (面白 miàn bái): A white complexion is mostly indicative of vacuity, of cold, or blood loss. It includes the following:

• Bright-white complexion (面色㿠白 miàn sè huáng bái), which is a very white complexion; a sign of yáng vacuity.
• Somber-white complexion (面色苍白 miàn sè cang1 bái), a white complexion with a slight tinge of green-blue; a sign of yáng collapse, fulminant desertion of qì and blood, or exuberant internal yīn cold.
• Pale-white facial complexion (面色淡白 miàn sè dàn bái), one lacking in color (as distinct from a bright-white or somber-white facial complexion); a sign of blood vacuity.

Absence of thirst (口不渴 kǒu bù kě): Absence of normal desire for fluids. Absence of thirst or intake of warm fluids in small amounts indicates a cold pattern. In cold patterns, normal sweating is reduced, and diminished fluid loss can be compensated for with reduced fluid intake.

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 as a result of depletion of blood and fluids. In this case, there will be pronounced heat effusion and dryness of the skin.

Runny nose with thin clear snivel (流清涕 liú qing1 tì): Runny nose is attributed to disturbances of lung qì’s diffusion caused by the presence of externally contracted evils. When the evils include cold, the nasal mucus is thin and clear.

Long voidings of clear urine (小便清长 xiǎo biàn qing1 cháng): When there is cold, sweating is reduced so that the amount of fluid in the body tends to increase, causing urine to increase in volume and appear pale in color.

Diarrhea (泄泻 xiè xiè): Increased fluidity of the stool and frequency of defecation. Diarrhea occurs in many different patterns. It figures most prominently in vacuity and repletion cold patterns as a result of yáng qì failing to warm and transform water-damp. It may also result from damp-heat and food damage.

Obesity (肥胖 feí pàng): The state of being fat or overweight. People who are overweight and whose fat is soft to the touch (flabby) are usually found to suffer from insufficiency of yáng qì and very often consequent phlegm-damp (yáng qì failing to deal with accumulating fluids).

Stiff nape (项强 xiàng jiàng) is stiffness and discomfort in the back of the neck. In externally contracted disease, it may occur as a result of wind-cold or wind-damp, by damage to liquid by evil heat, or by wind toxin entering wounds (lockjaw). In liver disease, it is a sign of liver yáng transforming into wind.

Hypertonicity of the sinews (筋脉拘挛 jīn mài jū luán): Also called hypertonicity of the limbs (四肢拘急 sì zhī jū jí). Tension in the sinews marked by inhibited bending and stretching. It is attributed to liver blood vacuity; cold-damp; damp-heat; external contraction of wind-cold; exuberant heat; yáng collapse and humor desertion.

Tight pulse (紧脉 jin3 mài): A pulse that is taut and very forceful, like a tightly pulled and twisted rope. Indicates cold, pain, and abiding food (enduring food accumulation). In cold patterns, it results from contraction of the blood vessels.

Yīn-Yáng Block and Repulsion (阴阳格拒 yīn yáng gé jù)

Yīn-yáng block and repulsion (阴阳格拒 yīn yáng gé jù) patterns are extreme forms of yīn and yáng surfeits or deficits. They include exuberant yīn repelling yáng and exuberant yáng repelling yīn. They occur when yīn or yáng is extremely exuberant (or its opposite is extremely vacuous) and causes congestion in the interior (the so-called block) so that yīn and yáng tend to separate and become concentrated in different parts of the body (repulsion). Yīn-yáng block and repulsion patterns are patterns of true heat and false cold or of true cold and false heat.

Exuberant Yīn Repelling Yáng (True Cold and False Heat)

Exuberant yīn repelling yáng (阴盛格阳 yīn sheng4 gé yáng) arises when yáng qì is extremely vacuous and or yīn cold is excessively exuberant, and yáng qì is repelled to the exterior or the upper body. This is a pattern of true cold and false heat (寒热假真 zhen1 hán jia3 rè) characterized by true internal or lower body cold with false external or upper body heat.

Pathogenesis: Exuberant yīn repelling yáng arises as a result of constitutional yáng vacuity and damage to yáng qì from enduring illness. It reflects severe advanced-stage vacuity cold.

Manifestations: The true cold is reflected in reversal cold of the limbs, clear-grain diarrhea, long voidings of clear urine, pale tongue with white fur, and a pulse that is faint and fine, on the verge of expiration.

The false heat is reflected in absence of aversion to cold (but a need to keep covered) and cheeks a floating-red color as if dabbed with rouge (两颧泛红如妆 liang3 quán fàn hóng rú zhuang1). Instead of the faint fine pulse, there may be a large pulse without root, i.e., one that is large (the vessel feels thick) and that is forceless or undetectable at the deep level when heavy finger pressure is applied.

Repelled yáng and upcast yáng: Exuberant yīn repelling yáng can further be divided into repelled yáng and upcast yáng, although the two very often occur together.

• Repelled yáng is true interior cold and false exterior heat. The exuberant yīn repels yáng to the exterior, so there is no aversion to cold.
• Upcast yáng (戴阳 dài yáng) is lower body cold and false upper body heat. Here, exuberant yīn repels yáng to the upper body, giving rise to fluctuating red patches on the cheeks that gives them the appearance of having been dabbed with rouge. This is sometimes described as vacuous yáng floating upward.

Exuberant Yáng Repelling Yīn (True Heat and False Cold)

Exuberant yáng repelling yīn (阳盛格阴 yáng sheng4 gé yīn) is extremely exuberant yáng heat deep within the body that repels yīn qì to the outside of the body, causing a pattern of true heat and false cold (真热假寒 zhen1 rè jia3 hán), characterized by true internal heat and false external cold.

Pathogenesis: Exuberant yáng repelling yīn usually arises when patients with a yáng-biased constitution contract heat evil, which passes into the interior and swiftly develops into intense fire. The heat evil blocks the body’s yáng qì, preventing it from reaching the exterior. It represents an advanced stage of externally contracted febrile disease.

Manifestations: True heat is reflected in vexing heat in the heart and chest, scorching heat in the abdomen felt on palpation, dry mouth, and a red tongue with scant liquid. The false cold is reflected in reversal cold of the limbs. In such conditions that reversal cold of the limbs is called heat reversal (热厥 rè jué).

Detriment to Yīn or Yáng Affecting its Opposite (阴阳互损 yīn yáng hù sun3)

Detriment to yīn or yáng affecting the other (阴阳互损 yīn yáng hù sun3) means that severe damage to yīn can spread to yáng and severe damage to yáng can spread to yīn. This is a progression of yīn-yáng deficits.

When either yīn or yáng weakens, the first effect it has is to leave its opposite unrestrained and relatively stronger. This is the principle that when yáng is vacuous, there is cold; when yīn is vacuous, there is heat. However, as the vacuity of yīn or yáng becomes more severe, it can have the reverse effect on its opposite. It causes it to weaken too, creating a condition of dual vacuity of yīn and yáng. This pathomechanism is based on the principle that yīn and yáng are rooted in each other, i.e., they are interdependent.

The kidney is the residence of fire and water, it stores the true yīn and true yáng within and is the root of the yīn and yáng of all the bowels and viscera. Whenever yīn vacuity or yáng vacuity in any of the bowels and viscera reaches a certain point, it is bound to affect kidney yīn or kidney yáng. This is summed up in the principle that enduring illness affects the kidney. Furthermore, when kidney yīn or kidney yáng vacuity reaches a certain degree, it causes vacuity in its opposite too, creating a condition of dual vacuity of kidney yīn and yáng. Thus, detriment to yīn or yáng affecting its opposite invariably involves the kidney.

Because qì and blood stand in a yīn-yáng relationship, in theory, the term detriment to yīn and yáng affecting its opposite could theoretically refer to qì failing to engender blood or blood failing to nourish qì. However, in practical usage, the term is never used in this way.

Detriment to Yīn Affecting Yáng

Depletion of yīn humor affects yáng qì either by causing insufficient production of yáng qì or by depriving yáng qì of its support, so that it disperses and dissipates. This is called detriment to yīn affecting yáng (阴损及阳 yīn sun3 jí yáng). Seminal emission, night sweating, and loss of blood often severely damage yīn essence, which, by the principle that detriment to yīn affects yáng, can give rise to yáng vacuity characterized by spontaneous sweating, fear of cold, and clear-grain diarrhea. Detriment to yīn affecting yáng results in dual vacuity of yīn and yáng manifesting in the simultaneous presence of vacuity cold and vacuity heat signs, as when fear of cold and lying in curled-up posture appears together with heat in the five hearts or dry pharynx and mouth with desire for warm drinks. In such cases, the vacuity heat signs are more pronounced than the yáng vacuity signs.

Note that yīn vacuity and yáng vacuity can exist at the same time when they are located in different places. The Sù Wen4 (Chapter 62) says, When yáng is vacuous, there is external cold (阳虚则外寒 yáng xū zé wài hán) and When yīn is vacuous, there is internal heat (阴虚则内热 yīn xū zé nèi rè). Yáng vacuity tends to be focused in the outer body, while yīn vacuity tends to affect only the inner body. In detriment to yīn affecting yang, the vacuity heat is in the inner body while the vacuity cold is in the outer body.

Detriment to Yáng Affecting Yīn

When depletion of yáng qì affects the production of yīn humor, it gives way to dual vacuity of yīn and yáng. This is called detriment to yáng affecting yīn (阳损及阴 yáng sun3 jí yīn). For example, insufficiency of yáng qì often manifests in impaired qì transformation that causes water qì (pervasive surplus fluid) to collect and spill out to the surface of the body to produce puffy swelling. When the yáng vacuity becomes severe, it affects yīn humor, so that in addition to water swelling, the patient becomes emaciated and suffers from vexation and thirst, and, in severe cases, tugging and slackening (clonic spasm). Detriment of yáng affecting yīn is dual vacuity of yīn and yáng with the simultaneous presence of vacuity cold and vacuity heat, but with the emphasis on the former.

Yīn-Yáng Conversion (阴阳转化 yīn yáng zhuǎn hua4)

Yīn-yáng conversion (阴阳转化 yīn yáng zhuǎn hua4) means yīn converting into yáng or yáng converting into yīn.

Yīn Converting Into Yáng

When in the course of an illness a yīn pattern is replaced by a yáng pattern, this is yīn converting into yáng (由阴转阳 yoú yīn zhuǎn yáng). This sometimes happens in externally contracted febrile disease when, owing to a yáng-biased constitution or inappropriate treatment, initial-stage signs, such as severe aversion to cold with mild heat effusion, headache and generalized pain, pain in the joints, nasal congestion and runny nose, absence of sweating, cough, a thin white tongue fur and a tight floating pulse, give way to repletion heat signs, such as high fever, sweating, heart vexation, thirst, a red tongue with yellow fur, and a rapid pulse. This is an exterior repletion cold pattern converting into an interior repletion heat pattern.

Yáng Converting into Yīn

When in the course of an illness a yáng pattern is replaced by a yīn pattern, this is yáng converting into yīn (由阳转阴 yoú yáng zhuǎn yīn). This sometimes happens in externally contracted febrile disease when, owing to inappropriate treatment or excessively exuberant heat toxin, the initial-stage signs, such as vigorous heat effusion, thirst, cough and chest pain, and a red tongue with yellow fur caused by exuberant heat evil, suddenly abate, and the body temperature abruptly plummets so that the heat signs are replaced with exuberant yīn cold signs, such as reversal cold of the limbs and dripping sweat. This is exterior repletion heat converting into interior vacuity cold.

Yīn-Yáng Collapse (亡阴亡阳亡 wáng yīn wáng yáng)

Yīn and yáng collapse are sudden severe losses of yīn humor or yáng qì that threaten the patient’s life. These are acute, critical forms of yīn and yáng deficits. They occur in what biomedicine calls shock.

Yáng Collapse

Yáng collapse (亡阳 wáng yáng) is the sudden failure of general functions of the body that in Chinese medicine is understood as fulminant desertion of yáng qì. Yáng collapse results from:

• exuberant evil that right qì is powerless to resist (most common cause);
• constitutional yáng qì vacuity and excessive taxation fatigue; or
• acute vomiting, diarrhea, sweating, bleeding, or excessive use of sweating, ejection (emesis), and precipitation (purgation) in treatment.

Manifestations: The main signs are great dripping sweat or pearly sweat, counterflow cold of the limbs, exhaustion of essence-spirit, indifference of spirit-affect, and in severe cases clouded spirit, muttering, and faint pulse on the verge of expiration. The severe sweating reflects the loss of yáng qì’s retentive action. The essence-spirit signs reflect yáng qì failing to nourish the heart spirit.

Yīn Collapse

Yīn collapse (亡阴 wáng yīn) is a sudden severe loss of fluids that leads to severe functional failure. Compare humor desertion described under fluid depletion.

Pathogenesis: It results from the following factors:

• extremely exuberant fire-heat evil causing high fever and great sweating, which in turn causes severe damage to yīn humor;
• summerheat strike causing great dripping sweat that damages fluids; or
• sweating, vomiting, or diarrhea in patients who have suffered from continual slight heat effusion (low-grade fever) that has gradually damaged yīn humor.

Manifestations: The main signs are incessant sweating with hot sticky or oily sweat, warm limbs, thirst with desire for fluids, vexation and agitation or clouded spirit, muttering, and a pulse that is fine, rapid, and forceless or surging, large, and forceless under pressure. In patients who have been suffering from chronic illness, the body may be emaciated with wrinkled and folded skin and sunken eyes.

Relationship Between Yīn Collapse and Yáng Collapse

Because yīn and yáng are rooted in each other, yīn collapse and yáng collapse are mutually conducive.

• When yīn collapses, yáng qì is deprived of its support and floats astray. This pathomechanism is called yáng deserting with yīn.
• When yáng collapses, fluids are no longer produced. This is called yīn deserting with yáng.

In practice, yáng collapse mostly occurs as a result of yīn collapse when extreme loss of yīn humor deprives yáng of its support. Yáng deserting with yīn is therefore much more common than yīn deserting with yáng.

Note that the patterns of qì deserting with the blood and qì deserting with liquid are similar to yáng deserting with yīn (see qì deserting with blood).

Severance of Yīn and Yáng (阴阳离决 yīn yáng lí jué)

Yīn and yáng are rooted in each other. When they are cut off from each other or deprived of each other, they separate and expire, and the individual dies. This is meant by when yīn and yáng are severed, essential qì expires (阴阳离决, 精气乃绝 yīn yáng lí jué, jīng qì nǎi jué).

Pathomechanisms of Internal Evils (内邪病机 nèi xié bìng jī)

All the six excesses except summerheat have counterparts that arise internally. Hence, these are often referred to as the five internal evils (内生五邪 nèi shēng wǔ xié) or simply internal evils (内邪 nèi xié).

Internal Wind (内风 nèi fēng)

Internal wind (内风 nèi fēng), also called wind qì stirring internally (风气内动 fēng qì nèi dòng), results from severe yīn-yáng imbalances characterized by yáng exuberance or yīn vacuity and manifests in abnormal movement or non-movement of the sinews. Since the sinews belong to the liver, internal wind is understood to be a liver disorder, hence the Sù Wèn (Chapter 74) states, All wind with shaking and dizzy vision is ascribed to the liver (诸风掉眩, 皆属于肝 zhū fēng diào xuàn, jiē shǔ yú gān). Hence, internal wind is called liver wind stirring internally.

Internal wind arises in the following ways:

• Extreme heat engendering wind:Externally contracted heat evil in children that manifests in high fever can transform into wind, causing convulsions and arched-back rigidity, a condition known as fright wind.
• Liver yáng transforming into wind:Ascendant hyperactivity of liver yáng can transform into wind, causing dizziness and unsteady gait or even wind stroke marked by hemiplegia, deviated eyes and mouth, and in some cases numbness and tingling.
• Blood vacuity engendering wind and yīn vacuity stirring wind: Blood vacuity and yīn vacuity depriving the sinews of nourishment and disrupting the movement of qì and blood can give rise to mild forms of internal wind manifesting in mild spasms or tremor. This pathomechanism is reflected in a maxim of treatment: to treat wind first treat the blood; when the blood moves wind naturally disappears (治风先治血, 血行风自灭 zhì fēng xiān zhì xuè, xuè xíng fēng zì miè).
• Phlegm and stasis engendering wind: Some modern Chinese texts include phlegm obstructing the network vessels causing blood to stagnate and cause chaotic movement of qì that results in liver wind stirring internally, which in turn results in stroke. This is attributed to fondness of sweet and fatty foods giving rise to phlegm or obesity with qì vacuity giving rise to copious dampness and phlegm. The formulation of this pathomechanism seems to have been influenced by the biomedical understanding of stroke.

Internal Wind Diseases

Internal wind figures in wind stroke, fright wind, and epilepsy.

Wind stroke (中风 zhòng fēng): A disease characterized by the sudden development of deviated eyes and mouth, stiff tongue and sluggish speech, and hemiplegia, sometimes heralded by sudden collapse and loss of consciousness, from which recovery may not be total. The classical form corresponds to what we call stroke (apoplexy, cerebrovascular accident). Mild forms in which there is only deviated eyes and mouth correspond to facial paralysis (Bell’s palsy) in biomedicine.

Originally ascribed to externally contracted wind evil, wind stroke was later attributed in many cases to internal causes, primarily liver wind stirring internally, which arises most commonly when insufficiency of kidney and liver yīn fails to keep liver yáng in check so that liver yáng becomes hyperactive and transforms into wind. Phlegm is invariably a factor in wind stroke too, so the cause of the disease is often described as wind-phlegm. Blood stasis may also be a factor.

Fright wind (惊风 jīng fēng): A disease of infants and children, characterized by convulsions and loss of consciousness.

Acute fright wind: An externally contracted febrile disease in infants and children characterized by clenched jaw and convulsion of the limbs. It is attributed to extreme heat engendering wind resulting from external contraction of warm evil. The disease starts with vigorous heat effusion with vexation and agitation, red face and limbs. When the warm evil causes phlegm congestion and qì stagnation, there is oppression in the chest and hasty breathing. As heat engenders wind, clenched jaw, the first sign of fright wind, appears. If the condition worsens, convulsion of the limbs, rigidity of the neck and nape, and arched-back rigidity appear.

Chronic fright wind: A disease in infants characterized by intermittent mild convulsions associated with pale-yellow facial complexion or a mixed green-blue and white facial complexion. In most cases, heat effusion is absent. It is attributed to liver exuberance and spleen vacuity.

Internal Wind Patterns

Internal wind occurs in repletion and vacuity patterns:

Liver yáng transforming into wind (肝阳化风 gān yáng huà fēng): Ascendant hyperactivity of liver yáng with sudden stirring of wind, in severe cases with clouding collapse and hemiplegia (wind stroke).

Extreme heat engendering wind (热极生风 rè jí shēng fēng): High fever and clouded spirit with convulsions, rigidity of the neck and nape, arched-back rigidity, upward-staring eyes, and clenched jaw (fright wind).

Blood vacuity engendering wind (血虚生风 xuè xū shēng fēng): Tremor; twitching of the flesh; inhibited bending and stretching; dizziness; tinnitus; liver blood vacuity signs.

Yīn vacuity stirring wind (阴虚动风 yīn xū dòng fēng): Wriggling of the extremities; dizziness; tinnitus; liver yīn vacuity signs.

Blood dryness engendering wind (血燥生风 xuè zào shēng fēng): Dry skin or encrusted skin with itching and scaling. It is attributable to any of several causes: enduring illness wearing the blood; depletion of essence and scantness of blood in advancing years; insufficient blood production stemming from poor nutrition; or static blood binding internally, preventing new blood from arising.

Internal Cold (内寒 nèi hán)

Cold also arises internally from insufficiency of yáng qì. This is called internal cold (内寒 nèi hán). This has already been discussed in detail in the contexts of yīn-yáng deficits above.

Internal Cold Patterns

The most common patterns attributed to vacuity cold arising internally are the following:

Heart yáng vacuity (心阳虚 xīn yáng xū): Heart palpitation or fearful throbbing; stifling oppression and possibly pain in the chest; yáng vacuity signs (vacuity cold). This develops from heart qì vacuity.

Spleen yáng vacuity (脾阳虚 pí yáng xū): Continual cold pain in the stomach duct and abdomen that likes warmth and pressure; signs of vacuity cold. It develops from enduring spleen qì vacuity; excessive consumption of raw and cold foods or excessive use of cold and cool medicinals; or kidney yáng vacuity depriving the spleen of warmth.

Stomach yáng vacuity (胃阳虚 wèi yáng xū): Continual cold pain in the stomach duct relieved by warmth and pressure; vacuity cold signs. It is caused by raw and cold foods, spleen vacuity affecting the stomach, or enduring illness.

External Cold and Internal Cold
		Pathomechanism	Clinical Manifestation
External Cold	Cold Damage	External contraction of cold evil, fettering defense yáng.	Aversion to cold, heat effusion, absence of sweating, headache and generalized pain, joint pain, a pulse that is floating and tight.
	Cold Strike	Cold evil directly striking the center, damaging the spleen and stomach, and affecting upbearing and downbearing.	Cold pain in the stomach duct and abdomen, vomiting and retching, decreased food intake, rumbling intestines, diarrhea (usually with aversion to cold and with headache and generalized pain).
Internal Cold		Yīn cold arising internally from insufficiency of yáng qì, with loss of warming and qì transformation.	Fear of cold, cold limbs or counterflow cold in the limbs, vomiting of clear water, clear-grain diarrhea, fatigue, localized cold pain.

Kidney yáng vacuity (肾阳虚 shèn yáng xū): Cold aching lumbus and knees; poor reproductive functions (impotence, infertility, low libido); profuse urination at night; yáng vacuity (vacuity cold) signs. It results from: constitutional yáng vacuity; general debilitation stemming from advancing age; enduring illness damaging yáng (as spleen or heart yáng vacuity affecting the kidney); sexual intemperance.

Large intestine vacuity cold (大肠虚寒 dà cháng xū hán). Uncontrollable diarrhea (efflux diarrhea) and fecal incontinence; vacuity cold signs. It mostly results from enduring diarrhea or dysentery that fails to be treated adequately.

Internal Dampness (内湿 nèi shī

Internal dampness (内湿 nèi shī) arises when, owing to impaired qì transformation, fluids are not distributed and discharged from the body as normal and instead collect in the form of water-damp. Internal dampness is related to the lung, kidney, but chiefly to the spleen. Hence, the Sù Wènstates that All dampness with swelling and fullness is ascribed to the spleen.

Internal dampness arises in the following ways:

• inability of the spleen’s yáng qì to warm and transform fluids and causing them to gather into water-damp;
• excessive consumption of raw or cold foods that damages the spleen’s yáng qì;
• excessive consumption of rich sweet and fatty foods or alcohol that tends to clog the action of the spleen and produce dampness.
• Internal heat.

Pathomechanisms-InternalDampness

Although external dampness often lodges in the fleshy exterior or in the channels, it can also affect the spleen. In this regard, external and internal dampness are mutually conducive. External dampness can damage the spleen, causing damp turbidity to arise from within. Conversely, internal dampness, being associated with spleen qì vacuity manifesting in the spleen’s failure to move and transform water-damp, can make the patient more prone to contraction of external dampness. Internal dampness, like external dampness, gives rise to repletion patterns (vacuity complicated by repletion). Hence the two are poorly distinguishable. Furthermore, both external and internal dampness affecting the spleen are treated in the same way, notably by fortifying the spleen and percolating dampness, using agents such as fú líng (Poria). Hence, whether the dampness is of internal or external origin is irrelevant in the context of the spleen. What matters more in the diagnosis and treatment of dampness patterns is where the dampness is located.

Dampness affecting the spleen tends to develop either with heat or cold. When the cause is spleen yáng vacuity or excessive consumption of cold and raw foods, cold-damp is the result, while excessive consumption for sweet and fatty foods or the presence of internal heat produces damp-heat.

Dampness forming with cold (湿从寒化 shī cong2 hán huà): Spleen yáng vacuity (spleen qì vacuity with cold signs) in the absence of any heat-producing influence causes dampness to form with cold, creating cold-damp patterns. Cold-damp refers to dampness encumbering the spleen accompanied by cold, which is attributed to yáng vacuity. It is marked by abdominal distension, diarrhea, heavy-headedness or heavy cumbersome limbs, and in some cases, water swelling, together with fear of cold and cold limbs.

Dampness forming with heat (湿从热化 shī cong2 rè huà): Rich sweet and fatty foods tend to clog the action of the spleen and produce dampness. They also produce intense stomach fire. The dampness and heat exacerbate each other. Spleen-stomach signs include glomus and oppression in the stomach duct, aversion to food, retching and vomiting, markedly yellow urine, and sloppy stool.

Because dampness is heavy and turbid, it can cause heavy-headedness and heavy cumbersome limbs. It carries heat down to the lower body to affect the large intestine, bladder, genital area, and lower limbs.

When the heat gives rise to heat effusion, the obstructive nature of dampness makes it take the form of generalized heat failing to surface or fluctuating generalized heat effusion that is unrelieved by sweating. Dampness trapping heat within the body accounts for itchy skin and exudative skin conditions.

Liver, bladder, and large intestine

• Both spleen damp-heat and cold-damp obstruct the qì dynamic and affect the liver’s free coursing, causing jaundice. Damp-heat in the liver channel can also give rise to yellow vaginal discharge.
• Damp-heat can pour downward to affect the bladder, large intestine, genital regions, or lower limbs. This results in any of the following conditions: damp-heat strangury; damp-heat diarrhea or dysentery with pus and blood in the stool; genital itching or sores; yellow vaginal discharge; or sores of the lower limbs. Conditions of this kind are attributed to the heaviness of dampness carrying heat downward.

Phlegm-rheum: Dampness can gather and concentrate to form phlegm or rheum. When there are signs of both dampness and phlegm, the condition is attributed to phlegm-damp.

Internal Dampness Patterns

The most common patterns attributed to dampness arising internally are as follows:

Cold-damp encumbering the spleen (寒湿困脾 hán shī kun4 pí): Distension and pain in the stomach duct and abdomen; nausea and vomiting; sloppy stool; signs of cold-damp collecting internally. It develops from insufficiency of spleen yáng vacuity; contraction of external dampness; consumption of raw and cold foods.

Damp-heat brewing in the spleen (湿热蕴脾 shī rè yun4 pí): Glomus and distension in the stomach duct and abdomen; nausea and vomiting; bitter taste in the mouth; aversion to food; signs of damp-heat brewing internally. It develops from externally contracted damp-heat or from excessive consumption of fatty or sweet foods or alcohol.

Bladder damp-heat (膀胱湿热 páng guang1 shī rè): Urinary urgency; frequent urination; inhibited urination with scorching pain in the urethra; damp-heat signs. It results from externally contracted damp-heat or from dietary irregularities causing internal damp-heat that pours down into the bladder.

External Dampness and Internal Dampness
	Pathomechanism	Clinical Manifestation
External Dampness	Dampness damaging the fleshy exterior	Aversion to wind or cold; heat effusion; heavy cumbersome head and body; aching of the limbs
	Dampness stagnating in the channels (impediment)	Heaviness and pain in the joints; inhibited bending and stretching
Internal Dampness	Spleen failing to move and transform, causing water-damp to gather; external dampness	Slimy taste in the mouth; poor appetite; oppression in the chest; nausea and vomiting; distension and fullness in the stomach duct and abdomen; heavy cumbersome head and body; diarrhea; turbid urine; vaginal discharge; water swelling

Liver-gallbladder damp-heat (肝胆湿热 gān dan3 shī rè): Distending pain in the rib-side, aversion to food, abdominal distension, yellowing of body and eyes, genital itch with signs of damp-heat. It results when dampness of external or internal origin combines with heat to form damp-heat that binds in the gallbladder.

Internal Dampness Diseases

Jaundice (黄疸 huáng dan3): Jaundice is a disease characterized by generalized yellowing of the skin and whites of the eyes (sclerae). It arises when contraction of external evils or dietary irregularities cause damage to the spleen and stomach and give rise to damp evil. The damp evil obstructs the center burner and affects the liver and gallbladder. This causes the bile to deviate from its normal path and spill into the blood, and from the blood into the skin. Jaundice can take the form of yīn yellowing (also called yīn jaundice) or yáng yellowing (also called yáng jaundice), depending on whether the dampness forms with cold or with heat.

Damp-heat strangury (湿热淋 shī rè lin4): Often referred to simply as heat strangury (热淋 rè lin4). Dribbling urination (frequent, short, rough voidings) with scorching pain in the urethra and tension in the smaller abdomen (lower abdomen). In some cases, there is pain stretching into the lumbus or abdomen. Damp-heat strangury may be caused by dampness and heat either of external or internal origin. Distinction is made between heat strangury, stone strangury, blood strangury, and unctuous strangury. Pathomechanisms and signs differ according to the type of strangury. Strangury is most commonly caused by damp-heat, but other causes exist.

Internal Dryness (内燥 nèi zào)

Internal dryness (内燥 nèi zào) is insufficiency of fluids and is commonly referred to as, damage to liquid. However, the term often denotes depletion of fluids affecting blood and essence, marked by emaciation, dry skin, vexing thirst, dry retching, bound stool, amenorrhea. A specific form of internal dryness is a form of blood vacuity called blood dryness, which manifests in emaciation, rough dry skin, in serious cases encrusted skin, itchy skin, brittle nails, lusterless hair, hard stool, and dry tongue. See qì, blood, and fluids pattern identification.

External Dryness and Internal Dryness
	Pathomechanism	Clinical Manifestation
External Dryness	External contraction of dryness evil causing non-diffusion of lung and defense qì	Aversion to cold, heat effusion, headache, floating pulse, dry pharynx and mouth, dry cough with scant phlegm that is sticky and difficult to expectorate, short voidings of scant urine
Internal Dryness	Depletion of fluids affecting blood and essence	Emaciation, dry skin, vexation and thirst, dry retching, bound stool, amenorrhea

Internal Fire and Internal Heat (内火内热 nèi huǒ nèi rè)

Fire and heat may also arise internally. This is internal fire (内火 nèi huǒ) or internal heat (内热 nèi rè). There are repletion and vacuity forms.

Internal repletion fire (repletion heat) is marked by acute, constant, and generalized signs of heat, movement, redness, and dryness: heat effusion and sweating (usually throughout the day); vexation and agitation with a rapid pulse; a red complexion; thirst, dry mouth, and desire for cold fluids; short voidings of reddish urine. It arises in the following ways:

• Exterior evils transforming into heat and, in the process, passing into the interior.This occurs, for example, in cold damage greater yáng (tài yáng) exterior patterns, when defense qì fails to expel the cold evil and allows it to lie depressed. Under these circumstances, the cold transforms into heat and forces its way into the interior. This is seen when the original greater yáng (tài yáng) exterior signs (aversion to cold and a floating pulse) give way to a yáng brightness (yáng míng) disease pattern characterized by high fever and constipation.
• Externally contracted warm-heat evils penetrating the interior.These are sometimes considered to be internal heat, even though, unlike cold transforming into heat, the heat is the same in nature as the originally invading evil.
• Affect-mind disturbances causing liver qì to become depressed and transform into fire (liver fire), which flames upward to cause upper-body fire signs.
• Phlegm, static blood, food accumulations, and worm accumulations lying stagnant and giving rise to heat.
• Hyperactivity of yáng qì may also be a predisposing factor for the development of internal fire.

Vacuity heat (vacuity fire) manifests in chronic, intermittent, and localized signs of heat, movement, redness, and dryness: tidal heat effusion and night sweating; heart vexation; a rapid fine pulse; reddening of the cheeks; dry mouth, short voidings of yellow urine. It results from yīn vacuity, as previously described under pathomechanisms. Vacuity fire is synonymous with vacuity heat, that is, heat from yīn vacuity, but refers to more intense heat and is often referred to as yīn vacuity with effulgent fire. See note below on Terms Denoting Fire-Heat Arising Internally.

Important Distinctions

Repletion fire, depressed fire, vacuity fire, floating yáng must be carefully distinguished because they require different methods of treatment.

External Fire and Internal Fire
	Pathomechanism		Clinical Manifestation
External Fire-Heat	External contraction of wind-fire evil		Initially, heat effusion with aversion to cold, headache and a floating pulse. Later, vigorous heat effusion, heart vexation, thirst, and a pulse that is surging and rapid.
Internal Fire-Heat	Repletion fire	Hyperactivity of yáng qì of the bowels and viscera	Internal heat with heart vexation, thirst, reddish urine, bound stool, red tongue, rapid pulse	Repletion heat signs in the heart, lung, liver, gallbladder, or stomach, a tough red tongue, and a pulse that is rapid and forceful.
	Vacuity fire	Yīn vacuity causing internal heat		Vexing heat in the five hearts; insomnia; tidal heat, night sweating, red tender-soft tongue with scant fur, and a pulse that is fine and rapid.

Repletion fire: Dis eases caused by heat or fire evil manifest as repletion heat (or fire) patterns and are therefore treated with cold and cool agents that clear fire or drain fire.

Treatment of Depressed Fire

Depressed fire cannot be effectively eliminated with cold and cool agents alone. Depressed fire is treated by effusion, which means that by effusion fire is dispersed and heat discharged by effusing sweat, outthrusting papules, and resolving phlegm-damp. This calls for outthrusting or upbearing dispersion to allow the heat out of the body. Where phlegm-damp is a factor, agents that resolve phlegm-damp are needed. Outthrusting agents include cōng bái (Allii Fistulosi Bulbus), dàn dòu chǐ (Sojae Semen Praeparatum), zhī zǐ (Gardeniae Fructus), lián qiào (Forsythiae Fructus), niú bàng zǐ (Arctii Fructus), and chán tuì (Cicadae Periostracum). Agents that resolve phlegm-damp include xìng rén (Armeniacae Semen), bái dòu kòu (Amomi Fructus Rotundus), chén pí (Citri Reticulatae Pericarpium), and jié gěng (Platycodonis Radix).

Depressed fire: Repletion fire also includes depressed fire that may arise under the following conditions:

• when fire is enveloped by an external evil (e.g., a cold enveloping fire), meaning when there is an unresolved exterior pattern together with exuberant internal heat manifesting in symptoms such as a red, sore throat;
• when there is deep-lying, internal heat prior to maculopapular eruption; orwhere phlegm or damp complications cause binding of phlegm and fire and dampness trapping hidden heat (湿遏热伏 shī è rè fú) characterized by glomus in the chest, and heart vexation.

Floating yáng (阳浮 yáng fú): Vacuous yáng floating astray (虚阳浮越 xū yáng fú yuè), which is sometimes called floating fire (火浮 fú huǒ), must be distinguished from true fire-heat. This usually occurs in yáng collapse vacuity desertion and is marked by red facial complexion, agitation, and thirst with desire for fluid. Although these are signs of heat, all other symptoms indicate cold attributable to yáng vacuity. Careful observation reveals that since the thirst is allayed by intake of fluid and the complexion has the floating-red characteristic of upcast yáng patterns, the heat signs are false, and the vacuity signs are those of extreme yáng vacuity (yáng collapse). Floating fire is the manifestation of the floating of vacuity yáng that results from exuberant internal yīn cold.

Treatment of Floating Yáng
Floating yáng is treated with warm agents such as fu4 zǐ (Aconiti Radix Lateralis Praeparata), ròu guì (Cinnamomi Cortex), rén shen1 (Ginseng Radix), and gan1 caǒ (Glycyrrhizae Radix), which return yáng and conduct fire (yáng) back to its origin, combined with heavy agents such as long2 gu3 (Mastodi Ossis Fossilia), mu3 lì (Ostreae Concha), and cí shí (Magnetitum) that subdue yáng.

Terms denoting Fire-Heat Arising Internally

In the context of fire-heat arising internally, fire and heat often imply nuances. The specific connotations of fire-heat terms are as follows:

• Exterior evils (external evils in the exterior) passing to the interior are usually said to transform into heat, rather than fire.
• Excesses among the seven affects causing qì depression are usually said to give rise to fire formation rather than heat.
• Fire often connotes more intense forms of internal fire-heat. For example, stomach fire is more intense than stomach heat. The standard pattern name is intense stomach heat, but an alternate name is intense stomach fire. Similarly, yīn vacuity gives rise to heat, and this is called yīn vacuity with heat. However, when the heat it generates is of great intensity, it is often called yīn vacuity with effulgent fire.
• Fire also connotes heat among the bowels and viscera that affects the upper part of the body, notably the head and face. For example, liver fire flaming upward denotes liver fire manifesting in red face and eyes. Hyperactive heart fire is also expressed as heart fire flaming upward when it manifests in a red face, a red-tipped tongue, and mouth and tongue sores.

Internal Fire-heat Patterns

The most common patterns attributed to fire or heat arising internally are:

yáng brightness (yáng míng) patterns (阳明证 yáng míng zheng4): Repletion heat disease patterns arising when external evils (wind and cold) leave the exterior and pass into the interior, giving rise to high fever, sometimes with constipation. There are variations depending on whether the heat is confined to the yáng brightness (yáng míng) channel or affects the yáng brightness (yáng míng) bowels (stomach and large intestine).

Hyperactive heart fire (心火亢盛 xīn huǒ kàng sheng4): Also called intense heart fire (心火炽盛 xīn huǒ chì sheng4). Vexation and agitation (or even manic agitation and delirious speech); mouth and tongue sores; repletion heat signs (e.g., heat effusion). It develops from excesses among the seven affects, causing qì to become depressed and transform into fire; from excessive consumption of rich, fatty, and hot spicy foods; or from external fire invading the interior.

Phlegm-fire harassing the spirit (痰火扰心 tán huǒ raǒ xīn): A repletion pattern marked by deranged spirit and phlegm-heat signs. It is seen in mania, that mental disease marked by manic agitation or externally contracted disease marked by clouded spirit with delirious speech. It develops by concentration of fluids either by externally contracted heat evil or by fire resulting from transformation of depressed qì.

Liver fire flaming upward (肝火上炎 gan1 huǒ shàng yán): A repletion fire pattern marked by dizzy head, distending pain in the head, scorching pain in the rib-side, and impatience, agitation, and irascibility, together with repletion fire signs. It stems from depressed liver qì transforming into fire; from excessive consumption of hot-spicy, fatty foods, sweet foods, alcohol, and smoking, which all foster fire formation; externally contracted heat; and/or from liver yīn vacuity.

Heart yīn vacuity (心阴虚 xīn yīn xū): Heart palpitation; heart vexation; insomnia; profuse dreaming; yīn vacuity signs (vacuity heat). It results from enduring illness; from excessive sweating, vomiting, or diarrhea; from damage by fire resulting from depressed qì; from lung, liver, and/or kidney yīn vacuity causing damage to heart yīn.

Lung yīn vacuity (肺阴虚 fèi yīn xū): Dry cough with scant sticky phlegm or no phlegm; yīn vacuity signs. It stems from dryness or heat evil assailing the lung; from contraction of pulmonary consumption; from smoking, alcohol, and hot-spicy dry foods; and/or from enduring cough or other enduring illness damaging lung yīn.

Kidney yīn vacuity (肾阴虚 shen4 yīn xū): Aching lumbus and knees; seminal emission; scant menstruation; dizziness; tinnitus; yīn vacuity (vacuity heat) signs. It results from enduring illness affecting the kidney; from damage to yīn in the advanced states of warm-heat disease; from excessive consumption of warm and dry medicinals; and/or from sexual intemperance.

##pathway of qì@@气道 |〔氣道〕@!!qì dào@@

Any way or course traversed by qì.

Etymology

Chin 气 qì, qì; 道 dào, path, way, Dao.

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