The Art and Practice of Diagnosis in Chinese Medicine. NIGEL CHING

‘What Nigel Ching has achieved in this thorough and detailed study of
traditional Chinese diagnosis is to outline and explain clearly both the

methodology and, perhaps more importantly, the thinking behind it. It is
DIAGNOSIS IN Chinese Medicine

especially this that I am convinced will prove to be indispensable to both
students and interested readers.’
– from the Foreword by Jeremy Halpin, acupuncturist,
Zen-shiatsu therapist and teacher
The Art and Practice OF

This textbook on diagnosis in Chinese medicine is unique in its clarity and
accessibility.
Divided into two parts, it is a comprehensive diagnostic manual. The first
part explains how to collect and collate the information required to formulate
Nigel Ching
a diagnosis and is divided into four approaches: visual, palpation, interrogation
and listening/smelling. The second part describes the various diagnostic
models in Chinese medicine, including the Eight Principles; zangfu organ
patterns; the Six Stages, Four Levels and san jiao; the 12 regular channels
and eight extraordinary vessels; and the Five Phases.
Nigel Ching is a lecturer in Chinese Medicine and course director at the

Nordisk Akupunktur Uddannelse, Denmark. With over 25 years of clinical
experience, Nigel lectures widely in Scandinavia, Germany, the UK, Greece
and Finland and is the author of The Fundamentals of Acupuncture, also
The Art and Practice
Diagnosis
published by Singing Dragon.
OF in
Chinese Medicine
SINGING DRAGON
Nigel Ching
Fore word by Je re my Ha l pin
www.singingdragon.com
Cover design: Black Dog Design
The Art and Practice of Diagnosis
in Chinese Medicine
by the same author
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The Art and Practice of Diagnosis in
CHINESE MEDICINE
NIGEL CHING
Foreword by Jeremy Halpin
LONDON AND PHILADELPHIA

Disclaimer: The author and the publisher assume no responsibility for the
treatments carried out in relation to the instructions in this book.
English language edition first published in 2017
by Singing Dragon
an imprint of Jessica Kingsley Publishers
73 Collier Street
London N1 9BE, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.singingdragon.com
First published in Danish as Kunsten at diagnosticere med Kinesisk medicin
by Klitrose Publishers, Copenhagen, Denmark, 2009
Copyright © Nigel Ching 2017
Foreword copyright © Jeremy Halpin 2017
All rights reserved. No part of this publication may be reproduced in any material form
(including photocopying, storing in any medium by electronic means or transmitting) without
the written permission of the copyright owner except in accordance with the provisions of
the law or under terms of a licence issued in the UK by the Copyright Licensing Agency
Ltd. www.cla.co.uk or in overseas territories by the relevant reproduction rights organisation,
for details see www.ifrro.org. Applications for the copyright owner’s written permission
to reproduce any part of this publication should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work may
result in both a civil claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data
Names: Ching, Nigel, 1962- author.
Title: The art and practice of diagnosis in Chinese medicine / Nigel Ching.
Description: London ; Philadelphia : Singing Dragon/Jessica Kingsley
Publishers, 2017. | Includes bibliographical references.
Identifiers: LCCN 2016056990 (print) | LCCN 2016058175 (ebook) | ISBN
9781848193147 (alk. paper) | ISBN 9780857012678 (ebook)
Subjects: | MESH: Medicine, Chinese Traditional--methods | Diagnostic
Techniques and Procedures
Classification: LCC R601 (print) | LCC R601 (ebook) | NLM WB 55.C4 | DDC
610--dc23
LC record available at https://lccn.loc.gov/2016056990
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84819 314 7
eISBN 978 0 85701 267 8
Dedicated to my granddaughter ‘5316’, my parents
and all the family and friends between them.
If a man will begin with certainties, he shall end in doubts; but if
he will be content to begin with doubts, he shall end in certainties.
Francis Bacon 1561–1626
CONTENTS
Foreword by Jeremy Halpin . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
The Art of Diagnosis or How to Diagnose in Chinese Medicine . 17
Diagnostic prerequisites . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Western diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
The diagnostic process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Diagnostic models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Treating complex patients with many patterns of imbalances . . . . . . . . . . 34
Part 1: The Diagnostic Pillars

Introduction to the Diagnostic Pillars . . . . . . . . . . . . . . . . 36
Section 1: The Diagnostic Pillar: Visual Observation . . . . . . . . 39
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Visual diagnosis of a person’s shen . . . . . . . . . . . . . . . . . . . . . . . . 41
Visual diagnosis of the body shape and posture . . . . . . . . . . . . . . . . . 44
Visual diagnosis of a person’s movements . . . . . . . . . . . . . . . . . . . . 49
Visual diagnosis of a person’s clothing . . . . . . . . . . . . . . . . . . . . . 52
Visual diagnosis of the face . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Visual diagnosis of the eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Visual diagnosis of the area around the eyes . . . . . . . . . . . . . . . . . . . 65
Visual diagnosis of the forehead, the root of the nose and the area
between the eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Visual diagnosis of the nose . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Visual diagnosis of the ears . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Visual diagnosis of the lips . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Visual diagnosis of the mouth . . . . . . . . . . . . . . . . . . . . . . . . . 72
Visual diagnosis of the gums . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Visual diagnosis of the tongue . . . . . . . . . . . . . . . . . . . . . . . . . 73
Visual diagnosis of the hair . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Visual diagnosis of the body hair . . . . . . . . . . . . . . . . . . . . . . . . 96
Visual diagnosis of the throat . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Visual diagnosis of the chest and the back . . . . . . . . . . . . . . . . . . . 98
Visual diagnosis of the back . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Visual diagnosis of the limbs . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Visual diagnosis of the joints . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Visual diagnosis of the hands . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Visual diagnosis of the skin . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Visual diagnosis of veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Visual diagnosis of skin lesions . . . . . . . . . . . . . . . . . . . . . . . . . 109
Visual diagnosis of acupuncture points and channels . . . . . . . . . . . . . . 112
Visual diagnosis according to micro‑systems such as ear acupuncture . . . . . 113
Appendix to Section 1: Visual Diagnosis of Children . . . . . . . . . . . . 117
Section 2: The Diagnostic Pillar: Listening and Smelling . . . . . 124
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Auditory diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Auditory diagnosis of the person’s voice . . . . . . . . . . . . . . . . . . . . 126
The Five Phases in the voice . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Quality of the voice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Auditory diagnosis of other sounds coming from the mouth, nose and chest . . 138
Diagnosis of sounds from the abdominal cavity . . . . . . . . . . . . . . . . 141
Olfactory diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Section 3: The Diagnostic Pillar: Palpation . . . . . . . . . . . . . 148
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Pulse diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Palpation of the abdomen, including Hara diagnosis . . . . . . . . . . . . . . 183
Palpation of the thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Palpation of the skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Palpation of the hands and feet . . . . . . . . . . . . . . . . . . . . . . . . . 190
Palpation of acupuncture points, channels and micro-systems . . . . . . . . . 191
Section 4: The Diagnostic Pillar: Interviewing . . . . . . . . . . . 195
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Interviewing techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
The 10 questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
General questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Disease history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Energy levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Sweating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Thirst, appetite and taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Stools and urination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Heart, thorax and Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Skin, hair and nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
The ears and eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Enquiry that is specific to women . . . . . . . . . . . . . . . . . . . . . . . 241
Enquiry that is specific to men . . . . . . . . . . . . . . . . . . . . . . . . . 248
Enquiry with regard to the emotions and mental state . . . . . . . . . . . . . 251
Lifestyle and diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Part 2: The Diagnostic Models

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Section 5: Diagnosis According to the Eight Principles . . . . . . 261
Interior and exterior imbalances . . . . . . . . . . . . . . . . . . . . . . . . 263
Exterior imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Interior imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Hot and Cold imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Combined Hot and Cold patterns . . . . . . . . . . . . . . . . . . . . . . . 288
Xu and Shi imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Xu conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Shi conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Yin and yang imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Section 6: Diagnosis According to Xie Qi . . . . . . . . . . . . . . 305
Wind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Invasion of exogenous Wind . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Internally generated Wind . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Dampness and Damp-Heat . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Exogenous Dampness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Internally generated Dampness . . . . . . . . . . . . . . . . . . . . . . . . . 324
Summer-Heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Heat and Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Shi Heat and Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Xu Heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Dryness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Exogenous Dryness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Internal Dryness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Phlegm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Xue stagnation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Food stagnation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Section 7: Diagnosis According to Qi, Xue and Jinye Imbalances . 355
Qi imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Xue imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Jinye imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Section 8: Diagnosis According to Zangfu Organ Patterns . . . . . 393
Lung imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Large Intestine imbalance . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Stomach imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Spleen imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Heart imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Small Intestine imbalance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Urinary Bladder imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Kidney imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Pericardium and san jiao imbalances . . . . . . . . . . . . . . . . . . . . . . 577
Gall Bladder imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Liver imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 590
Section 9: Diagnosis According to the Six Stages,
Four Levels and San Jiao . . . . . . . . . . . . . . . . . . . . . . . 641
Diagnosis according to the Six Stages . . . . . . . . . . . . . . . . . . . . . . 642
Diagnosis according to the Four Levels . . . . . . . . . . . . . . . . . . . . . 669
Diagnosis according to San Jiao theory . . . . . . . . . . . . . . . . . . . . . 696
Section 10: Diagnosis According to the 12 Regular Channels . . . 712
Lung channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
Large Intestine channel imbalances . . . . . . . . . . . . . . . . . . . . . . . 715
Stomach channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . 716
Spleen channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Heart channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
Small Intestine channel imbalances . . . . . . . . . . . . . . . . . . . . . . . 718
Urinary Bladder channel imbalances . . . . . . . . . . . . . . . . . . . . . . 718
Kidney channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
Pericardium channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . 719
San jiao channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
Gall Bladder channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . 720
Liver channel imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
Section 11: Diagnosis According to the
Eight Extraordinary Vessels . . . . . . . . . . . . . . . . . . . . . . 722
Du mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723
Ren mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
Chong mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
Dai mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
Yin qiao mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
Yang qiao mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Yin wei mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Yang wei mai imbalances . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
Section 12: Diagnosis According to the Five Phases . . . . . . . . 729
Sheng phase patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Ke phase dominating patterns . . . . . . . . . . . . . . . . . . . . . . . . . 732
Ke phase ‘insulting’ patterns . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Appendix 1: Supporting the Treatment of the Patient through Yangshen . . 738

Appendix 2: The Energetic Properties of Certain Foods . . . . . . . . . . . 754
Appendix 3: Herbal Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . 758
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
FOREWORD
Another way of seeing things

One of the most important contributions that Chinese medical diagnosis has given
to the collective medical knowledge is the unique way it comprehends and describes
conditions of disease. Chinese medicine does not use polarised belligerent metaphors
that try to identify internal and external ‘enemies‘ that must be destroyed. Neither
does it see the body as a dissociated and isolated island on which this ‘war‘ is waged.
Chinese medicine’s focus is more on the constant adaptation to change.
To understand why this is so, it is necessary to understand the underlying
medical model, or the logical principles that form the basis for this approach. To use
a modern metaphor, the approach in this model focuses on ‘software data flow‘ and
not ‘hardware’, i.e. on what is happening inside and not on the physical structure.
The model is energy based; it is not an anatomical/physiological model. It does
not involve the study of dead bodies or the deconstruction of the body into ever
smaller components in an attempt to describe the whole. Chinese medicine always
sees everything in the context of the whole.
The Dao that can be named is not the Dao1

The attentive reader will note that all the diagnostic models in this book describe the
body’s response to change and not separate and arbitrary disease symptoms as such.
This is because the state of balance in the body is in a state of constant flux and
a skilled therapist will be able to track the signals that the body is emitting. In
this context, to name something is to fossilise it. People are not their ‘diabetes‘ or
‘migraine’. They are unique individuals whose conscious and unconscious responses
have brought them to this place. The art of diagnosis is to identify these unique
patterns of response in each individual. In other words, it is the patient who is
diagnosed and not the disease.
An exchange of stories
So what is diagnosis? In the late 1800s the meeting between the patient and
practitioner was called an ‘exchange of stories’. This is where the patient presents
their problem (‘story’) as best they can, based on their subjective experiences. They
can also present their story in more subtle and non-conscious ways, for example
their posture, movement and other factors that can be observed by the clinician.
Diagnosis, which is the subject of this detailed book, forms the therapist’s story
– the therapist’s interpretation and response to the patient’s history through the
filter of their knowledge and experience. It will include aspects such as observation,
palpation and the use of other senses, such as the sense of smell or noting the way the
11
The Art and Practice of Diagnosis in Chinese Medicine
person’s shen is manifesting, to expand the practitioner’s perspective of the whole. All
these factors are sorted in the diagnostic process through the various sub-models (the
Eight Principles, Four Levels, Six Stages, etc.) to differentiate the possible diagnoses.
This does not, however, mean that the diagnosis ends here. For example, it
is common to recheck the pulse diagnosis during the treatment to measure the
response. In fact, treatment and diagnosis are never separated. They are constantly
influencing each other and are two sides of the same coin.
When looking at new models such as this one, it is easy to drown in the volume of
cultural references that permeate it. What Nigel Ching has achieved in this thorough
and detailed study of traditional Chinese diagnosis is to outline and explain clearly
both the methodology and, perhaps more importantly, the thinking behind it. It is
especially this that I am convinced will prove to be indispensable to both students
and interested readers.
Jeremy Halpin
Acupuncturist, Zen-shiatsu therapist and teacher
Stockholm, June 2008
12
ACKNOWLEDGEMENTS
I would like to express gratitude to the practitioners and scholars of Chinese medicine
who have developed and documented this unique medical system. The world is a
much better place to live in thanks to their knowledge, wisdom and efforts. I am
deeply indebted to all of my teachers through the years, the authors of English
language Chinese medicine textbooks and the doctors and practitioners who I have
had the pleasure and honour of working with.
I would also like to thank the people directly involved in the genesis of the
original Danish version of the book. Primarily my thanks go to Ole Bidsted from
the Klitrose publishing house who published the original version of this and all my
other books. Thank you for your tireless idealism and enthusiasm in publishing
unprofitable but indispensable textbooks.
My gratitude and appreciation is also sent towards Singing Dragon for their
support and belief in my books. A special thanks to Claire Wilson, Jane Evans and
Victoria Peters.
Thanks to Aske Ching for tweaking the illustrations and making them presentable.
Thank you to the various students who have made valuable comments to the
book, both when it was still only in the form of teaching handouts and later on after
it was published in Denmark. There is a lot of proofreading talent gone to waste
out there!
Thanks to friends and colleagues who have helped with their encouragement.
I would particularly like to thank Wendy Norris for shelter, encouragement and
support, both before and during the writing of the original version of the book.
13
PREFACE
An experienced Chinese medicine doctor can often diagnose a patient before the
patient has even begun to tell the doctor what their disorder is. This may sound
fantastic, as if the doctor has supernatural abilities, something that only a few people
with special powers can do. This ability, though, depends on years of experience
and a thorough understanding of the body’s physiology and pathology. The doctor
will have consciously and subconsciously picked up on a myriad of small and
sometimes extremely subtle signs, such as the expression in the patient’s eye, the
facial complexion, the tone of the flesh, how the movement of the person is, how
their posture is, the strength of their handshake and whether the hand feels clammy
or dry, whether the hand is cold or hot and if it is warm whether it is the whole
hand or only the palm that feels hot, how their attire is, the smell of their body, the
sound of their voice, etc. All these individual small signs and signals will create an
overall impression in the doctor’s mind, enabling the doctor to identify the patterns
of imbalance that the patient is presenting with.
Charlie Buck once said that this ability which experienced Chinese doctors
possess is the same ability that a good ornithologist possesses. If a novice like me is
going to be able to identify a bird in my garden, the bird must stand still and I must
also have sufficient time to take note of the size of the bird’s body, its wingspan,
the colours in the plumage, the colour and length of the legs and beak, how it
moves and so forth. Furthermore, I must then compare this information with the
descriptions presented in an ornithology manual to see which bird it is that has
precisely these colours and characteristics. However, an experienced ornithologist
will immediately recognise which bird it is that is sitting on the bird table. An
experienced ornithologist will not only recognise the bird when it sits on the bird
table outside the window, but will also be able to identify the bird at a distance, even
when it flies quickly past. Where others will barely have noticed the bird at all, just
a few fleeting impressions will enable the experienced ornithologist to identify the
bird with certainty. This ability is the result of many years of experience of studying
the bird both through binoculars and with the naked eye, as well as having studied
pictures and read descriptions of the bird in ornithological manuals. This will have
resulted in an ability to recognise birds quickly from a minimum of signals.
This is also the case with an experienced Chinese medical doctor. The doctor
will have gathered sufficient information before the patient talks of their problem
to be reasonably certain of their diagnosis. The rest of the consultation is then
used to confirm the diagnosis and to identify the aetiology and whether there are
contributing patterns of imbalance.
This might give the impression that diagnosis goes from being analytical to
being simply intuitive, but this is not so. Diagnostic intuition is nothing other than
the rapid, subconscious analysis and interpretation of impressions and signals and
14
Preface
relating these impressions to all the previous experiences of these signs. At the same
time, these signs and impressions are subconsciously compared with the theoretical
knowledge that has been gleaned from books and teachers. The subconscious is much
quicker at analysing and sorting information than the conscious brain. Intuition is
therefore not a supernatural ability but something that most of us are capable of. It
just requires experience and a sound theoretical foundation.
What Chinese medical doctors have done over the centuries is to observe all
the changes that occur in a person when a person’s body is out of balance – both
which symptoms there are and what other signals the body emits in these situations.
They have been aware of the relationships between these symptoms and signs or the
patterns that they constitute. Chinese medicine developed methods to collect
and collate this information and these models systematically, and to classify and
differentiate the symptoms and signs so that an accurate diagnosis can be determined,
thereby creating a solid foundation for the treatment strategy.
The purpose of this book is to enable the practitioner to gather the necessary
information from the patient to make an accurate and correct diagnosis through the
use of traditional Chinese diagnostic methods.
The book is divided into two parts. The first part of the book is a summary of
the four diagnostic approaches or diagnostic pillars. This part of the book covers the
methods used to collect information from the patient – through observation and
palpation and by listening to and smelling the patient – and the information that can
be gathered through interviewing the patient. The clinical significance of what these
signs represent in Chinese medicine is also detailed and explained.
The second part of the book examines the various diagnostic systems or diagnostic
models used to classify and rationalise the information that has been collected
through the four diagnostic pillars. It is only by making an accurate diagnosis that
one is able to give the correct treatment to each individual patient.
As well as reviewing the various patterns of imbalance, this part of the book also
gives suggestions for their treatment. It is important to remember that the acupuncture
points and herbal formulas that are mentioned in the text are suggestions and not a
rulebook. Excellent results will also be obtained using other relevant combinations
of acupuncture or herbal formulas.
Furthermore, the acupuncture points suggested are just a starting point and
only some of the points listed will be used. These points will often be combined
with other points that are relevant to the individual symptoms or other imbalances
that are to be addressed concurrently. The herbal formulas presented should also
be modified in practice so that they are tailored to match the individual patient’s
presentation. It should also be noted that treatment with herbal prescriptions should
only be administered by practitioners who have a relevant herbal medicine training.
Acupuncture needles forgive mistakes, but herbal prescriptions can be merciless and
one can easily worsen a patient’s condition if the diagnosis and herbs do not match
each other. Furthermore, there is a risk that even if the prescription is suited to
the diagnosis, it can still create new imbalances in the body. Only when you have
15
learned what signs you should be aware of do you know how to intervene and adjust
the treatment in time.
It should also be made clear that this book is an analysis of Chinese medical
diagnosis as a complete system. This means that some of the diagnostic categories are
a reflection of life-threatening conditions that you will rarely meet in the clinic. Even
if you work exclusively with Chinese medicine, it is important not to forget which
signs and symptoms to be aware of in Western pathology and to know the limits of
your competence and when to send a patient on to a Western medicine doctor for
further examination or hospitalisation.
In keeping with Fundamentals of Acupuncture (Ching 2016), I have as far as
possible used Chinese words, such as qi, xue, xu, shi, shen, instead of an English
translation of these terms. The reason for this is that English words will usually either
be too specific, representing only one of the multiple meanings or interpretations of
the term, or they will not express the connotations that are present in the Chinese
character. Xue, for example, is something other and more than blood is in the Western
definition of the word. Furthermore, terms such as shen or qi cannot be adequately
translated into a single English word. These Chinese words are therefore written
in italics.
Furthermore, organ names, pathogens, pulse qualities, etc. are capitalised
when the Chinese understanding of this term is inferred. This is done in order to
emphasise that it is the Chinese medicine concept that is being referred to and that
the word is not to be understood in the usual definition of the word in English.
I hope that this book can help the reader to develop a systematic approach to
the diagnosis of their clients and that it gives the reader a thorough understanding
of how and why pathological changes arise in the body. This book will never be able
to replace practical instruction or teach the more tactile aspects of the diagnosis, but
it is my hope that the book can be a guide to what needs to be felt, seen, smelt or
heard and how these sensations are often experienced.
I am indebted as a practitioner, teacher and author to the Chinese doctors and
scholars who have developed the theories and methods that are described in this
book, as well as to the teachers and authors who have transferred this knowledge on
to me.
My hope is that I can be a medium or pathway so that their knowledge can be
of benefit to you and your patients.
Nigel Ching
Copenhagen
16
THE ART OF DIAGNOSIS
OR HOW TO DIAGNOSE IN
CHINESE MEDICINE
Before we even start to look at how to diagnose in Chinese medicine, it is appropriate

to consider the following questions.
• Why do we diagnose at all?
• What is the aim of the diagnosis?
• In what way are we going to use the diagnosis?
We use the diagnosis as one of several steps that must be taken when we want to
move from point A, which is a person who has some form of disorder or suffering,
to point B, which is the same person who no longer has a disorder or is no longer
suffering. Traditional Chinese Medicine (TCM)2 has a logical and linear approach
to enable the practitioner to get from point A to point B.
Patient with a problem Diagnostic techniques to reveal the

patient’s symptoms and signs Classification of these symptoms
and signs into the various diagnostic models Creation of an
appropriate treatment strategy Choice of relevant acupuncture
points and needle techniques, appropriate herbal formulas and
appropriate dietary and lifestyle advice Patient without a problem
By diagnosing and identifying the underlying pattern or patterns of imbalance, we

have not only a treatment strategy in relation to acupuncture and Chinese herbs,
but we have also created a foundation from which we can give relevant advice
to the client. This advice will often, but not always, have a direct relationship with
the aetiology of their disorder. When we know which patterns of imbalance are
present, we will also have an idea of the probable aetiology. These aetiological factors
can often still be a part of the person’s life. In this case, they are something that
must be altered if the patient is to have a long-term benefit from the treatment.
At the same time, when we know which other aetiological factors can negatively
affect the imbalance, we can also give the client advice with regards to these factors.
Chinese medicine usually diagnoses on two levels at the same time: bian bing
lun zhi (differentiation of symptoms and signs in relation to the disease category)
and bian zheng lun zhi (differentiation of symptoms and signs in relation to the
patterns of imbalance). Bian bing lun zhi is very similar to a Western medicine
diagnosis in that it classifies the symptoms and signs with respect to a specific disease
17
category, for example headache, menstrual cramps, vomiting, etc. Although the
bian bing diagnosis is characterised by the name of a specific disorder, it is still
important to remember that you must still think of this pathological process from
a Chinese medical perspective. This means that we must understand the disorder
through the pathomechanisms that have generated it. We must think of qi, xue,
Phlegm, zangfu, etc. and not through the lens of lymphocytes, antibodies and
hormone receptors. We do this even if the bian bing category has the same name
as a Western disease category.
Dizziness, for example, is a disease category in both Chinese and Western
medicine, yet the understanding of how and why dizziness arises is very different. In
both Chinese and Western medicine there are several causative factors and various
subcategories of dizziness. These pathomechanisms cannot simply be translated
from one system into another. Dizziness can, for example, be diagnosed in Western
medicine as being caused by a virus on the balance nerve. If we just translate this
into Chinese medicine, we may think that we have to expel invasions of exogenous
xie (pathogenic) qi. There will only be a few situations in which this would be a
relevant treatment strategy. Dizziness in Chinese medicine can arise from many
factors, such as internally generated Wind, xue xu or yin xu. Although the disease
names and the underlying aetiology can sound similar, the treatment focus will often
be decidedly different. This is because it is with the Chinese medical system that we
will be treating the disorder. There is a linear progression in all medical systems from
physiology, pathology and diagnosis through to treatment. Each stage is determined
by the previous stage and these stages cannot be separated from each other.
The bian zheng lun zhi approach to diagnosis is radically different from Western
medicine concepts. Bian zheng lun zhi is the classification of symptoms and signs in
relation to the various patterns of imbalance, such as Liver qi stagnation, an invasion
of Wind-Damp or shaoyin Stage Cold. Chinese medical diagnosis is not a choice
between either bian bing lun zhi or bian zheng lun zhi. For the treatment to be truly
effective, we must in reality use both differentiations. This can be illustrated with
the following example. The acupuncture point GB 20 and the extra point taiyang
(Ex-HN 5) are effective acupuncture points that can be used to treat headaches (bian
bing lun zhi diagnosis). This is because these acupuncture points move and circulate
qi and xue, as well as being able to drain xie (pathological) qi downwards from the
head. GB 20 and taiyang are not, though, indicated in the treatment of nausea, which
is a separate bian bing lun zhi diagnosis. The reason for this is precisely because the
actions of these points is in the head. If the headache was the result of Phlegm (bian
zheng lun zhi diagnosis), then St 40 and Sp 3 would be obvious points to combine
with GB 20 and taiyang. This is because St 40 and Sp 3 can transform Phlegm,
which in this case is underlying the headache. If, on the other hand, the headache
had arisen from an invasion of Wind-Cold (bian zheng lun zhi diagnosis), then
St 40 and Sp 3 would not be relevant, because they do not ‘open to the exterior and
expel invasions of xie qi’. St 40 and Sp 3 would, though, be relevant when treating
nausea (bian bing lun zhi diagnosis) if the nausea is due to the presence of Phlegm
18
The Art of Diagnosis or How to Diagnose in Chinese Medicine
(bian zheng lun zhi diagnosis). In this situation, these two points could be combined
with Ren 12 and Pe 6, as these points are effective in regulating Stomach qi so that
it descends. Ren 12 and Pe 6 are, however, not suitable for draining Phlegm down
from the head. It is for this reason that an adage in Chinese medicine states, ‘A single
ailment can have many causes; a single cause can result in many ailments.’
Western medicine trains practitioners to distinguish symptoms separately and
to understand them individually or as part of a particular disease or disorder. In
Chinese medicine it is the opposite. Here one is trained to try to see patterns in the
symptoms and signs and to see how these are related and what they can be an
expression of.
A Dutch lecturer, whose name I have unfortunately forgotten, once gave a good
illustration of the difference between the two systems’ approaches to analysing a client.
He said that the two systems both look at the same scene through a telescope. Western
medicine views the body through the focus of the telescope, so when you look through
it, you can, for example, see a hand. Western medicine can even see through the skin
and can zoom in on the tendons, the muscles and bones in the hand and how these
interact with each other. The telescope can zoom even closer in and see how the nerves
affect the muscle fibres and how various neurotransmitters can activate the nerves. It
can see into the cells themselves and see how the various components in the individual
cells operate. Chinese medicine reverses the telescope. Chinese medicine sees the same
hand, but it also sees what is going on at the same time. It observes that the hand
is on an arm that belongs to a woman, who is waving to her husband, whilst a train is
pulling out of a station. Both images are correct. To stop the hand moving, you could,
for example, sever the muscles and tendons, break the bone or inject a chemical that
disrupts the nerve signals. You could also, though, stop the train. Both approaches will
result in the same result: the cessation of the hand waving.
In Western medicine, the focus is on the physical causes and effects. In Chinese
medicine it is more the context and the relationship that are the most important,
and not the individual components. For example, migraine headaches, menstrual
pain, alternating diarrhoea and constipation, hypochondriac tension, a sensation
of having a lump in the throat, the voice having a slight staccato quality and the
pulse having a Wiry quality in the left middle (guan) position are not coherent
symptoms in a Western medicine perspective and they will be seen as being
expressions of several disparate disorders. Chinese medicine sees these symptoms
and signs collectively as a clear indication that the person is presenting with Liver
qi stagnation. Chinese medicine will therefore not treat these individual symptoms
separately but instead treat them as a single pattern. Chinese medicine will also try
to identify the underlying aetiology that has resulted in the development of Liver
qi stagnation, because the pattern of imbalance itself must also be seen in a context.
Imbalances do not arise by themselves.
The adage ‘a single ailment can have many causes; a single cause can result in
many ailments’ means, therefore, that there are no standard treatments for specific
diseases. There will, of course, be particular acupuncture points that are often used
19
in the treatment of certain ailments, but there will also be utilised acupuncture
points that treat the specific patterns of imbalance that have resulted in the disorder.
In order to do this, one must be able to differentiate the individual patterns of
imbalance from each other.
Patterns of imbalance can be differentiated according to various diagnostic
models. These models can be used individually and they can be used together. They
are, in fact, overlapping. Liver xue xu for example is both a diagnosis based on the
Eight Principles and a zangfu diagnosis, as well as being a diagnosis according to qi,
xue and jinye.
The bian zheng lun zhi diagnosis will not only identify the root cause of the
disease manifestation, it will also identify where or at which level in the body
the imbalance is. At the same time, it will give an indication of the relative strength
of the body in relation to the imbalance. For example, the diagnosis ‘invasion of the
Wind-Cold’ indicates that the imbalance is to be found in the taiyang aspect, which
means that it is in the exterior aspect of the body, and implicit in this diagnosis is that
there is a relatively strong pathogenic assault on the body – a shi or excess condition.
Liver xue xu diagnosis, on the other hand, indicates that the imbalance is in the
interior aspect of the body and that it is specifically the functioning of the Liver
that is disturbed. Liver xue xu further implies that xue is deficient, and therefore the
organ is weakened, so the Liver is xu or deficient.
A Chinese medicine diagnosis is the foundation of the treatment strategy,
i.e. how to restore balance in the body. The treatment strategy is already indicated
in the diagnosis. If there is an invasion of xie qi, xie qi must be expelled. If there is a
shi condition, then that which is shi must be drained, spread or expelled. If there is
a xu condition, then that which is xu should be tonified, nourished or strengthened.
By differentiating patterns of imbalance, the clinician is not only able to develop
an appropriate treatment strategy and thus utilise relevant acupuncture points
or herbal prescriptions, but also will have an idea of what the aetiology of the
imbalance could be. It is vitally important to remember that patterns of imbalance
are not the causes of the disease. Diseases are certainly manifestations of patterns of
imbalance, but the real causes lie in the aetiological factors that result in the pattern
of imbalance. This will be factors such as environmental influences, a person’s diet,
lifestyle or emotional influences.
Liver qi stagnation, for example, can manifest with the symptoms and signs
described earlier. However Liver qi stagnation is not the cause of these symptoms and
signs. Liver qi stagnation is, like all other patterns of imbalance, a related collection
of signs and symptoms. The pattern of imbalance is exactly this – a ‘pattern’ the
patient presents with. The underlying cause of the pattern in this case will often
be related to a person’s emotional situation. If we are able to recognise patterns, we
can have a logical idea of the underlying aetiology. When we have an idea of the
aetiology, we have an opportunity to give relevant advice to the client. This is in
reality the most important part of the treatment. By administering herbs or inserting
needles, we can rectify an imbalance and relieve its symptoms. By giving relevant
advice, we can help a person to prevent the imbalance from arising again.
20
To be able to detect which patterns of imbalance are present requires a

comprehensive and thorough diagnosis. This entails the gathering of large amounts
of disparate information from the client. This information has to be gathered
through several sensory organs at the same time. Gathering and processing so much
information simultaneously can appear to be overwhelming, but Chinese medicine
is very logical in its approach from having developed specific diagnostic models
and, especially, from having a very systematic approach to the collection of
this information.
This foundation for this systematic approach to the gathering of diagnostic
information was laid 2000 years ago in the classical text Nan Jing (The Classic of
Difficulties). This book initiated the diagnostic approach that we use to this day:
the four diagnostic pillars. In the book it says that one must first see and observe the
patient. Then you should listen to and smell the patient. Next you have to ask
the patient questions. Finally, you should palpate the patient. This requires that you
are systematic and logical, whilst being sensitive and aware. This is because much
of the information that needs to be gathered and utilised is something you have to
perceive through your fingers, nose, eyes and ears, rather than simply asking questions.
To observe and absorb this much information at the same time, you need to be
centred and focused when the patient comes through the door and free from all mental
distractions so that your senses are open and receptive. This is obviously easier said
than done when you are already behind schedule with your clients. Nevertheless, it is
important to try at all times to be as focused and present as much possible.
However, being sensitive and receptive is, in itself, not enough when diagnosing.
You also need to have an intellectual understanding of the material. You need to learn
which signs and symptoms you should be aware of and what these symptoms and signs
mean. This can done by learning either the various signs and symptoms and what
these are a manifestation of by heart, and what the pathomechanisms behind these
signs and symptoms are – how these symptoms and signs arose. Organising and
structuring our approach and the way we process this information means it becomes
more manageable and easier to access the relevant information. This frees you up
so you can be more intuitive. Intuition that is not based on a strong fundamental
understanding of theory will always only be speculation and guesswork.
Diagnostic prerequisites
A strong theoretical foundation and understanding
of Chinese medicine physiology and pathology
By having a solid understanding of both the Chinese medicine physiological and
pathological models, you will be able to understand the pathomechanisms (the
pathological dynamics) behind the various symptoms and signs.
Let us look at an example. The Stomach sends its qi downwards. When a person
vomits, this will be due to a rebellious movement of Stomach qi, which has sent the
21
contents of the Stomach upwards and out of the mouth. We do not yet know why
the Stomach qi is rebellious, but we know that Stomach qi is moving in the opposite
direction to the direction in which it should when the Stomach is in balance. We
know this, because we have studied the Chinese medicine physiological model and
we therefore know that the correct movement of Stomach qi is downwards. Having
also studied Chinese medicine pathology, we will already have several ideas of how
and why this disturbance of Stomach qi could have arisen. There could, for example,
be something that is blocking the Stomach qi from descending (such as exogenous
Cold, Phlegm, qi stagnation, xue stagnation or food stagnation). We also know that
Stomach qi could be too weak to be able to send the food downwards (Stomach qi xu)
or there may be Heat present, causing the Stomach qi to rise upwards (Stomach Fire or
an invasion of exogenous xie qi). This means that we can start looking for relevant
symptoms and signs that relate to these particular patterns of imbalance and we can
ask the patient relevant questions: Is there anything that provokes the vomiting? Is
there anything that ameliorates it? When and how did the vomiting start? And so on.
All these things will give an idea of why the person’s Stomach qi has become rebellious.
Observe and analyse deviations from the ‘norm’

A concept that is central to the art of diagnosis is the norm. The norm is that
which we expect to observe. It is that which we should observe when the body
functions perfectly and is completely harmonious. This condition is also known as
the utopian state!
If we constantly maintain a clear image in our minds of how the body should
be, we can recognise signs which indicate that the body is not in balance. At this
point, it is very important to be constantly aware of the crucial difference that there
is between what is normal and what is common. It is common to have a pale tongue
with teeth marks, a greasy yellow coating on the root and a red tip. This is seen in
a lot of people, perhaps the majority of Northern Europeans, but it is not what a
normal tongue should look like. A normal tongue should be pink, without tooth
marks and with a thin, pale, even coating.
We must train ourselves to spot deviations from the norm, and to think about
and determine what has caused the change.
There will often be nothing, or very little, to observe. The closer you are to the
norm, whether this is the strength and speed of a person’s voice, the colour of
the tongue or something else, the fewer signs of imbalance there will be to observe.
By observing the deviations from the norm, and by understanding
pathomechanisms behind these changes, you are in fact liberated from having to
learn long lists of symptoms and signs, as well as having to remember what these
signs and symptoms signify diagnostically. This is not the typical Chinese approach
to learning how to diagnose: in China, it is more common to learn things by
heart, which is also a valid way of learning the significance of the various signs
and symptoms. I personally think, though, that it is easier to learn and remember
22
the relevance of diagnostic signs and symptoms, by thinking of qi dynamics and

pathomechanisms. This also has the advantage that you become more flexible in your
thinking and comprehension of problems when they present themselves differently
from the textbooks.
By learning to understand the pathomechanisms, you become accustomed to
thinking: ‘This is not as it should be. How and why is it not as it should be?’ When
you have done this, you can start to figure out why something has deviated from
the norm.
As always, it is easiest to use an example. Normally, a person’s respiration is
gentle and rhythmic. If a person has difficulty breathing gently, quietly and
rhythmically, and if their respiration is very shallow, this is a sign that the Lung3 is not
descending and spreading qi as it should. We must then try and determine why the
Lung is not able to perform this function optimally. Is it because the Lung is qi xu? Is
it because there is a stagnation of qi in the upper jiao? Is there exogenous xie qi, such
as Wind‑Cold, obstructing the Lung so it cannot spread and descend qi? Is there
Phlegm in the Lung and the upper jiao that is blocking the qi? Has the person been
exposed to a shock, and qi in the upper jiao has become chaotic? This way of thinking
can be used with any symptom or sign. This approach also means that we then start
to look for other relevant signs and symptoms that may confirm our hypothesis.
Study and become adept at using the various diagnostic techniques

In order to practise Chinese medical diagnosis, it is a prerequisite that you have
learned the various diagnostic techniques – the observational skills required to be
able to utilise the techniques involved in the four diagnostic pillars. This means that
you must have learned to palpate the pulse, observe the tongue, palpate the channels
and interview the client. This is something that is taught in basic training, but it
requires constant practice to become adept at it. I often meet former students who
ask me for advice about a client they are treating. Unfortunately, when I ask about
the tongue and pulse diagnosis, it is not uncommon that the practitioner says that
they have not checked the pulse. When I ask why, the answer is that they think
it is difficult and they do not feel that they are competent enough to be able to
utilise the pulse. Learning diagnostic skills is no different from learning to play the
guitar or learning a foreign language. Some people have natural talents and they are
adept right from the beginning. These people will only improve with time if they
practise. Others, myself included, are less gifted. I could learn to play some simple
chords on a guitar if somebody showed me where to put my fingers. However, I
would never become a virtuoso who could play in a concert hall, although I might
become competent enough to sit around a fire and entertain my friends. However,
even this will take practice – a lot of practice! The same is true of pulse diagnosis,
tongue diagnosis, observation techniques and palpation. Diagnostic techniques are
something that must be practised every day or at least every time you have a patient.
You may well feel that you are not feeling or observing anything, but it is important
23
to keep on practising. It is often easier, when diagnosing, if you deconstruct the

process and analyse each aspect separately.
If we take the pulse as an example, you might ask yourself, whilst your your
fingers are palpating the patient’s artery: Is the rate of the pulse fast or slow? Does
the pulse feel strong or weak? Wide or narrow? Shallow or deep? Rhythmic or not?
Has the pulse got qualities that could be perceived of as being ‘Slippery’, ‘Choppy’,
‘Wiry’ or ‘Tight’? Are there variations between the individual pulse positions? You
can also reverse the process. If you know which patterns of imbalance are present in
a patient, you can search for the relevant pulse qualities and see if you can recognise
them in the patient’s pulse. When you have felt the same quality several times, you
may start to recognise this same quality in a new patient’s pulse.
Study the various patterns of imbalance

There are, unfortunately, no short cuts here. The various patterns of imbalance
should be learnt by heart. You should be able to classify the various symptoms and
signs you experience and categorise them into the various patterns of imbalance.
However, there is the loophole that I described above: if you have a firm grasp of
Chinese medicine physiology and understand the dynamics of the various forms
of xie qi (pathological qi) and other disruptive factors, you will be able to assess
which organs, substances or aspects of the body are affected and in what way. For
example, if a person freezes, especially suddenly, and they cannot get warm even
though they put on thick clothes and tuck themselves under a duvet, our thinking
will be as follows. We know that it is yang qi that heats the body, so if they had yang
qi xu – a condition where there is too little of the warming yang qi – the person ought
to be able to keep warm by putting on sufficient clothing or by tucking themselves
under a duvet. This is not the case here, so it is probably not a yang xu condition. If,
on the other hand, the person has been invaded by exogenous Wind-Cold, which
blocks the wei qi whose function it is to warm the skin, then even though they pack
themselves into warm clothes and bedding, they would still feel cold. Therefore,
this is probably a shi Cold condition – an invasion of exogenous xie Cold. Further
confirmation that their wei qi is being blocked by exogenous xie qi will be found if
the person does not sweat and has muscle aches. This is because all these signs either
relate to the functions of wei qi (warming the skin and controlling the pores) or they
are signs of a stagnation of qi in the exterior aspect of the body, where the wei qi
circulates (muscle aches). We know that the wei qi can be blocked by exogenous xie
qi and that Cold, due to its contracting dynamic, will cause the pores in the skin to
close. Cold will also inhibit the free movement of wei qi.
The other option is, of course, to learn everything off by heart. You can memorise
the various symptoms and signs that define the individual patterns of imbalance. By
studying the textbooks, we know that all of the above symptoms and signs can be
found in the diagnostic category ‘invasion of Wind-Cold’. This is similar to how a
computer works. The computer does not understand why the symptoms occur, but
24
it can nevertheless recognise a pattern when it is presented with a particular group

of symptoms and signs. This is because it has been programmed to recognise these
symptoms and signs as being representative of this pattern of imbalance.
An alternative approach is to learn the importance of the individual symptoms
and signs by heart. In the example above, when a person freezes, you can look at all
the possible imbalances that manifest with a sensation of cold or an aversion to cold.
You can then collect additional information to see whether the person has other
symptoms and signs that can confirm the presence of one or more of these patterns
of imbalance.
Experience
The main difference between an experienced practitioner and a novice with regards
to diagnosis is simply a question of experience. An experienced practitioner has
had more years to read books and study other practitioners’ case histories. More
importantly, the experienced practitioner has had more years of experience in
visually observing, interviewing, listening to, palpating and smelling patients and
subsequently comparing what they have read about in books with what they meet
in practice. This means that the experienced practitioner knows what is probable in
certain situations, but also has experienced situations where the opposite is the case.
An experienced practitioner has also learned to place more emphasis on certain
symptoms and signs than others in particular situations. Moreover, the experienced
practitioner, through practice and experience, just becomes better at recognising
characteristic signs of an imbalance in certain people. They have, however, also
become better at not latching onto, and sticking with, the first idea that comes to
mind. They have become more flexible in their approach.
In general, an experienced practitioner is often quicker at diagnosing a patient
than a novice. This is because the experienced practitioner does not need to think
for as long about things. When observing a symptom or a sign, the experienced
practitioner automatically know what questions they will subsequently ask or what
signs they should observe in this situation. They do not need to think about it. Neither
do they need to look things up in books or search the corners of their memory when
they want to find out what the various symptoms, signs and observations signify. It
is something that they just know.
Intuition
Another major difference between experienced and less experienced practitioners, is
how much they trust their intuition and, especially, how trustworthy their intuition
is. Intuition must be based on a solid theoretical understanding coupled with
practical experience, otherwise it is nothing more than just guesswork.
Intuition is one of the most important skills an experienced practitioner
possesses. Intuition, however, is nothing other than a person’s ability to let their
25
subconscious brain recognise and process the information that they, at some point,
have had to collect consciously and think about. Their subconscious brain can more
rapidly sort this information into useful conclusions than the conscious processes of
the mind can.
Western diagnosis
There can be a tendency amongst some practitioners to use a Western medicine
diagnosis as their starting point. A question that I often meet, both when I talk to
other acupuncturists and when I read online discussions is: Which acupuncture
points should you use to treat some Western named disorder? This raises several issues.
• Western diagnoses can be incorrect. There is a significant risk involved
in relying on another person’s diagnosis. It is not uncommon for a patient
to receive different diagnoses from different doctors. This is not a critique
of Western doctors, but a fact when different people subjectively analyse
objective material. If you treat according to another doctor’s diagnosis, there
is a risk that you will administer an incorrect treatment if the initial diagnosis
was wrong. This is only made worse by the fact that the Western medicine
diagnosis is based on a completely different physiological and pathological
model than that of the Chinese medicine diagnoses and treatments. I will
expand on this below. However, it is not only the Western medicine diagnosis
that we must be wary of. We should also be wary of Chinese medicine
diagnoses made by other acupuncturists or herbalists. I regularly receive
clients from other practitioners who want me to either treat their patient
with herbs or continue their acupuncture treatment. It is not uncommon
that my and the other acupuncturist’s diagnoses do not match. If I prescribed
herbs or inserted needles based on another acupuncturist’s diagnosis, I would
often be giving the patient the wrong treatment (assuming that my diagnosis
is correct). Likewise, if I gave an acupuncture treatment on the basis of a
Western doctor’s diagnosis, I cannot be sure that the doctor’s diagnosis was
correct in the first place.
• A Western medicine diagnosis is based on the Western medicine
physiological and pathological model. The acupuncture points that are
recommended in Chinese medicine textbooks for the treatment of certain
organs, bodily substances, pathological factors, etc. are usually selected based
on an understanding of the actions that they have in Chinese medicine. It
is not certain that they have the same effect when viewed from a Western
medicine analysis of their physiological actions. A very obvious example of
this is when a Western medicine diagnosis says that a person has a problem
with their spleen. It is far from certain that a point such as Sp 3 will have any
effect on the physical spleen in this situation. This is because the same pattern
of symptoms and signs in a patient will often not be diagnosed as a Spleen
26
pattern of imbalance in Chinese medicine. We need to translate diagnoses

to our own diagnostic models. It is only in this way that the treatment will
match the diagnosis perfectly. This also applies to other complementary
medicine diagnostic methods, such as iris diagnosis or a homoeopathic
diagnosis. In these cases, the diagnosis of organs and their functions will
again be based on another physiological and pathological model. Treatments
and the physiological and diagnostic foundation must match each other. We
would not expect a Western medical doctor to treat a patient based on our
diagnosis. They would immediately exclaim that what we are saying does
not make sense in relation to their way of understanding the body. Likewise,
we should not treat the body from a diagnosis based on a Western medicine
understanding of the body but through a Chinese medicine interpretation
of the symptoms and signs.
• The same disorders can have many causes. A Western diagnosis will always
be a bian bing lun zhi diagnosis. The foundation of Chinese medicine is the
differentiation of disorders both in relation to the disorder or disease and in
relation to the patterns of imbalance. This means that even if we diagnose
multiple patients with the same bian bing lun zhi diagnosis, we may well
treat each of these patients differently, precisely because their patterns of
imbalance or bian zheng lun zhi diagnosis are different.
In what way can we then use a Western medicine diagnosis?

As written above, a Western medicine diagnosis is basically a bian bing lun zhi
diagnosis that is based on a Western medicine understanding of the body. This
means that the Western diagnosis will often relate to aspects of the body that are
not found in the Chinese medicine model, such as hormones, neurotransmitters
or intestinal bacteria. We know that intestinal flora, for example, has many of the
functions that we relate to Spleen qi, but we also know that Spleen qi is much
more than just the functions performed by the intestinal flora. Similarly, the
intestinal flora also have functions that do not relate to Spleen qi. When we are
informed of a Western medicine diagnosis, we need to deconstruct this into its
component symptoms and pathological processes. We should then reconstruct
the individual symptoms and signs, as well as the pathological processes, into a
Chinese medicine diagnosis using a Chinese medicine understanding of the body.
Unfortunately, we cannot just say that oestrogen, for example, is equivalent to
Kidney yin and thereby treat an oestrogen imbalance with the acupuncture point
Kid 3. It may well be that the treatment will work, but not all of the functions of
oestrogen in the body can necessarily be interpreted as being Kidney yin. There may
well be individual processes that we will interpret differently, and if we are to treat
these processes then there may be a greater physiological effect if we warm Kidney
yang or move Liver qi or something else altogether. This is especially relevant if there
are other symptoms and signs that also point in this direction. What we must find
27
is a pattern – a relationship between the various symptoms and signs and how they
relate to the Chinese medicine model of health and illness.
A Western medicine diagnosis will give us an idea of which direction we should
look in. We can definitely examine the Western medicine diagnosis and try to analyse
the symptoms and the pathological processes that lead to these symptoms from
a Western medicine perspective, but we should always be thinking: How would
I interpret this from a Chinese medicine perspective? Which organs or types of
qi perform these functions? How could this process be disturbed, for example, by qi
stagnation, Phlegm, Heat, etc.? We should also look at the individual patient and
ask ourselves: Do they actually have these symptoms and signs? At the same time, we
need to correlate these symptoms and signs with all the other symptoms and signs
that the patient manifests. This is because Chinese medicine often places emphasis
on signs and symptoms that are not viewed as being relevant in a Western medicine
diagnosis of a disorder. This could, for example, be that the person talks rapidly and
gesticulates a lot with their hands whilst they are talking, indicating the presence of
Heat in the Heart.
The diagnostic process

As previously written, diagnosis is part of a process where we proceed from point A,
where a patient has a problem, to point B, where the same patient does not have a
problem any longer. This is most easily achieved by having a structured approach
where you are aware of what the aim of each step is. This is especially true in the
diagnostic part of the process.
The diagnostic process starts at the first contact

We start the diagnosis the moment we first see the patient or at the first moment
of contact that we have with the patient. This process can actually start even before
the patient enters the room, when we talk to them on the phone or read their email.
From the moment we are in contact with them, and certainly from the moment they
step into the room, we must constantly gather information from them and begin
to form a diagnostic hypothesis. We will subsequently continue to verify and check
this hypothesis in an attempt to confirm or refute our assumptions. We must then
constantly investigate all the various diagnostic clues that reveal themselves. At times,
it is something of a difficult balancing act. We must trust our first impressions. This is
because the first impression can often be of great diagnostic importance, especially as it
is at this moment that we are usually most intuitive and least rational in our thinking.
We must, however, simultaneously have and maintain a flexibility in our thinking and
our approach to the patient. We must not stubbornly cling to a diagnosis and thereby
become blind to the diagnostic signs that point in other directions. We must be aware
of the risk of interpreting symptoms and signs exclusively from the perspective of our
first hypothesis. It’s like being a detective. We must follow a hunch, but not become
blind to other possibilities or exclude other suspects.
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Have a structured approach

Having a structured approach is very important. Moving from the metaphorical
point A (the patient has a problem) to point B (the patient no longer has a problem)
is most easily achieved when taking deliberate steps, where you are conscious of
what you want to achieve with each individual step. A structured approach is also
important, because our clients often present us with many, varied and sometimes
conflicting symptoms and signs. It is therefore essential that you constantly have
a clear idea in your head of where you are going and what you want to know. You
must not let yourself be driven around like driftwood in a sea of symptoms and
signs. You must have a clear direction and deliberately paddle using your eyes, ears,
mouth, nose and fingers as oars and your theoretical foundation as a rudder. This
can be especially difficult when new pieces of information constantly keep emerging,
each of which must be investigated. You will have to travel down each diagnostic
track one at a time, but at the same time remember to come back and investigate the
remaining tracks. In these situations, having a pen and a piece of paper is invaluable,
so that you can jot down notes and key words whilst the patient is talking to make
sure you do not forget to investigate everything thoroughly. A good intake sheet
with boxes and rubrics that list various qualities is a diagnostic essential that enables
you to investigate all relevant areas thoroughly.
Complex patients, where there are many signs and symptoms, will always be a
challenge. Unfortunately, these clients are not uncommon. This is because many
of the clients who seek Chinese medicine are clients who have chronic conditions
that have not been helped in the conventional medical system. These conditions are
called ‘difficult to treat, knotty diseases’ in China. In these cases, there will typically
be many patterns of imbalances at the same time – at least six or seven – and often
in excess of ten patterns. There will also be a tricky mixture of xu and shi and Hot
and Cold imbalances. This means that there will be a myriad of symptoms and
signs to discern and decipher. These signs and symptoms will often be contradictory,
pointing in opposite directions at the same time.
There is a vast amount of information that we have to keep track of whilst
we diagnose. At the same time, we must be open and attentive on several levels,
both intellectually and intuitively. We need to listen to what the patient says and
at the same time listen to how they are saying it, what qualities their voice has,
how fast they talk and how structured their conversation is. We must observe their
appearance, their movements and their body language while we ask them questions
and mentally analyse their responses.
A structured approach is also important when interviewing clients who have a
tendency to take over the interview. There are definitely some clients who are more
difficult to interview than others. This is usually an important diagnostic sign in
itself. As the practitioner, we should try to maintain control of the conversation.
After all, it is us who is the therapist. When this control is challenged by the client,
we can try and interpret diagnostically why and how they cause us to lose control.
We must, of course, be conscious of our own patterns of imbalances and how these
29
might be involved in us having difficulty in controlling the interview. If it is not our

own patterns of imbalances that result in us losing control, then we can try to see
how the patient makes us lose our footing. For example, some patients with Heart
Fire will often be very garrulous and we will have difficulty getting succinct answers
to our questions. Patients with Phlegm-Heat blocking and agitating shen will also
often talk a lot and much of what they say may be completely irrelevant, because
Phlegm is blocking their shen. Liver qi stagnation patients may have a tendency to
want to control the situation and the conversation. Phlegm-Dampness patients may
be slightly confused and have difficulty keeping their focus, and so on. It can also be
difficult when patients have a lot of ideas about what is wrong and why they have a
disorder. These people tell you a lot of things that to us are not necessarily relevant
to the diagnosis. They could, though, have been treated by other acupuncturists or
have read things on the internet or in an acupuncture textbook and believe that they
know which Chinese medicine patterns of imbalances they are manifesting. It is
important that it is us who interprets the information we gather and the information
they tell us. What they conclude or what they have been told may not be correct. It
is important that it is us who makes the diagnosis.
A structured approach is more than just a checklist

As written above, all the information that we need to collect and process simultaneously
can be overwhelming and confusing, especially with a client who takes control of
the conversation. A well-designed diagnostic journal or intake sheet is a massive
help here. It ensures that we collect all the information that we need to use. A
diagnostic journal must never become a checklist where you just tick boxes. I have
often experienced in exam situations and school clinics that some students tend to
ask a question – often a yes or no question – and then they just move on to the next
question. Each and every answer we get is a springboard for further investigation. It
is a door that we should walk through to see if there is more information inside that
room. For each answer we get, or for each sign we observe, we must look for further
signs or ask clarifying questions. This is both in order to understand the mechanism
behind this sign or reply and to see if there are other symptoms and signs that these
are connected to. We must see whether the sign or the answer is part of a pattern. An
example could be that the patient has replied that yes, they do suffer from headaches.
We then need to know: When do they have headaches? How would they describe
the pain? Whereabouts in the head is the pain? What makes the headache better or
worse? When did they begin to suffer from headaches and what happened in this
period of time? We must ascertain what type of headache they have. If we have the
impression that the headache is possibly a manifestation of, for example, ascending
Liver Fire, we must then look for further signs of Liver Fire to confirm or refute our
hypothesis. Furthermore, we also know that many patterns of imbalance may be a
consequence of the other patterns of imbalance. We should therefore also investigate
whether there are signs and symptoms of these patterns.
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Use all four of the diagnostic pillars

If we have a structured approach, we should consciously utilise all four diagnostic
pillars. A skilled diagnostician will also utilise as much information as possible from
each pillar. A pillar is not just built from one or two blocks of stone, it also consists
of sand and mortar. Palpation is more than just pulse diagnosis, and observation is
more than just tongue diagnosis.
Furthermore, there can be a tendency to prioritise the diagnostic pillar of
interviewing or questioning the client. This is often at the expense of the other three
approaches. This is mainly due to the way we have been educated, since we started
in primary school when we were children. This has resulted in the development of an
intellectual bias. We feel secure and trust an intellectual approach based on questions
and verbal responses. It is relatively easy to translate a verbal response to intellectual
knowledge. This is something the education system trained us to do for more than
a decade. There are, however, a lot of pitfalls in this diagnostic approach. We must
be very conscious of what the questions are and how we ask them. We need to know
what their response implies. We also know that patients do not always respond
truthfully. It could well be because it is something that they are not conscious of.
Also, clients sometimes, for various reasons, deliberately answer misleadingly or use
words that you can interpret in a different way from them. More typically though,
they comprehend the question in a different way from the practitioner. For example,
if you ask a woman if she has regular menstrual periods, she may well answer yes,
even if her menstrual cycle is only 21 days long or is 35 days long. Another woman
might answer yes – it is regular, because it comes about once a month. The problem
for us is that ‘about once a month’ is not regular in Chinese medicine if it’s 25 days in
one month and 33 days in the next month. Similarly, regular bowel movements can
be interpreted by a client as being once every three days or four times each day. Some
of these problems can be minimised by having a good interview technique with
unambiguous questions and constantly ensuring that you have asked additional and
clarifying questions and not let yourself be satisfied with simple yes and no answers.
The fact that we are so conditioned to be intellectual by the education system
means that we actually have an intellectual handicap. We blindly trust our intellect at
the expense of our other senses. We must learn to retrain and hone our observational
abilities. This is also a challenge, because it is much easier to translate verbal responses
to intellectual knowledge that can be analysed and categorised than it is to transform
sensory information to something we can rationally analyse and intellectually classify.
Each of the four diagnostic pillars has their inherent strengths and their
weaknesses. These will be investigated in Part 1.
Conflicting information
It is, unfortunately, not uncommon for there to be a conflict in the information, and
thereby diagnostic conclusions, obtained from the different diagnostic approaches
or within the same aspect of the diagnosis. It is quite common, for example, for the
31
tongue to exhibit signs of certain imbalances, whilst the pulse manifests something
else and the patient’s voice and demeanour something else again. In reality, we must
not think of these discrepancies as being conflicts but more as puzzles to be solved.
These discrepant signals will usually just reflect different aspects of the diagnosis,
i.e. different patterns of imbalance, all of which are present at the same time. We
just need to understand how to separate them from each other and see whether they
interact with each other or are independent of each other. We must also be aware of
other factors that may have blurred these diagnostic signs, for example medicine, the
fact that the patient just ran up the stairs or that they are angry.
Time constraints
A major problem we have is a lack of time. It can take a long time to gather all the
information, especially when you are not experienced and therefore as quick to spot
what is relevant and important in this situation. This means that you have to either
allot an appropriate period of time to the diagnosis of clients or learn to prioritise
information and make sure that you have control of the dialogue with the client.
Different processes, different strategies

Some teachers believe that you should only investigate the patterns of imbalance
that are relevant to the specific disorder that you are asked to treat. This means that,
for example, you do not start asking questions about signs of a Lung imbalance, if a
person has chronic diarrhoea. Bob Flaws, an American author of numerous Chinese
medicine textbooks, is an advocate of this approach and considers that you must learn
all the relevant patterns of imbalance for the different bian bing lun zhi categories
and only investigate these when diagnosing a bian bing condition. Personally, I do
not agree with him. First, the relevant pattern of imbalances that can manifest with
a specific disorder can in itself be the consequence of other patterns of imbalance.
For example, Liver qi stagnation can be a consequence of Liver xue xu, which itself
may be a consequence of Spleen qi xu. It is important to understand the dynamics
involved in the genesis of the patterns of imbalance. I personally, therefore, do not
think that it is enough only to investigate the patterns that are relevant to the specific
bian bing lun zhi conditions.
Furthermore, the patterns of imbalance that are presently manifesting may be
precursors to other patterns of imbalance. It may therefore be relevant to investigate
whether these patterns of imbalance are evolving. Furthermore, it is not uncommon
to uncover other disorders through the diagnostic process that are more serious
than the disorder that the client has sought help for. It may be that the patient
is not aware that you could also treat this problem but would actually want this
problem addressed. For example, a patient may come to you because they want
to have treatment for their weak immune system, but through your thorough and
32
extended diagnosis you find out that they suffer from anxiety and insomnia, which
is something that is a serious problem for them.
Diagnostic models
It is an advantage to memorise the various symptoms and signs of all the various
bian zheng lun zhi categories, i.e. all the various pattern of imbalances. You can, of
course, look these up in your textbooks or on the computer, but this is much more
time consuming in the long run. Once you have learned the different diagnostic
models and categories, you can quickly recognise patterns in the symptoms and
signs that are in front you. The diagnostic models are templates that we can place on
top of all the information we have collected. We can then see if the information we
have gathered fits into a particular template.
Some diagnostic models are only used in specific situations, for example
diagnosis according to the three jiao or the Four Levels; others are used constantly
and in combination with other diagnostic models, for example diagnosis according
to zangfu and diagnosis according to qi, xue and jinye.
One of the typical mistakes that I made when I started was that I believed that
all the symptoms and signs that were listed as being representative of a specific
pattern of imbalance should be present. Often, we diagnose a pattern of imbalance
from the presence of as little as three or four key symptoms and signs. The trick is
to learn which of the various symptoms and signs are important and essential and
in which situations. Furthermore, I thought that the symptoms and signs that were
listed in the textbook were the only signs and symptoms that were manifestations
of this particular pattern. The signs and symptoms listed in textbooks are the most
probable symptoms and signs of this pattern. There will often be other symptoms
and signs that are not in the textbook but are created by this pattern’s qi dynamic.
When you suspect the presence of certain patterns of imbalance, you have to ask
yourself whether all the things that you are observing can be interpreted as being
manifestations of these patterns, even though they are not listed in the textbook.
This is where you really benefit from the hours spent studying Chinese medicine
physiology and pathology. These studies have, in reality, enabled you to determine for
yourself what symptoms and signs can be manifestations of a particular imbalance.
You are now capable of seeing a symptom or a sign in different context from that
described in the textbook.
Another mistake that I made was to think that when diagnosing a particular
disorder, the disorder was the result of either one or other of the imbalance patterns
that were listed as being the root of the problem. In reality, a disorder is usually the
consequence of multiple patterns simultaneously. For example, spontaneous bleeding
will very often be the result of Spleen qi xu, xue stagnation and Heat simultaneously.
Individually, these three patterns of imbalance may not have been sufficient to result
in bleeding in this patient. This can also sometimes be the reason that a treatment has
33
not succeeded. This is because you have not treated all the aspects of the problem. At
other times there will only be the one underlying pattern of imbalance.
Treating complex patients with many

patterns of imbalances
Keep it simple
When things seem complex and confusing, it is always a good idea to keep things
simple and only diagnose and treat what you are certain is present. The diagnostic
picture may well become clearer with time. The situation may seem daunting,
because there are so many symptoms and signs all mixed in with each other. This
is further complicated by the fact that some of these symptoms and signs are also
contradictory. In these situations, the diagnostic model of the Eight Principles is a
blessing. This is a solid rock that we can step back onto when we start to drown in
a rough sea of multiple symptoms and signs. We can simplify the whole situation
or the individual symptoms and signs momentarily and ask ourselves: Is this xu or
shi? Cold or Hot? Interior or exterior? Yin or yang? This can then be used as a
springboard to refine the diagnosis. If the diagnosis will not or cannot be further
refined, we can always treat the patient from these principles alone. If we treat only
from the Eight Principles, we can be reasonably confident that we will not harm the
patient, but, on the contrary, we will probably benefit them. This is despite the fact
that it would have been optimal to further refine the diagnosis.
Make inventory boxes and flowcharts

One technique that I utilised a lot in the beginning was to make inventory boxes
and ‘flowcharts’ on a sheet of paper. I distributed all the symptoms and signs of
the patient in various diagnostic boxes. The individual symptoms and signs could
usually be listed in multiple boxes. Boxes that had many symptoms and signs in were
probably relevant patterns of imbalances, whereas boxes with only one or two signs
or symptoms were less probable, especially if these symptoms and signs could be
seen and explained better in other boxes. However, it is important not to write off a
pattern of imbalance simply because there are only one or two signs or symptoms in
the box. This is because some signs and symptoms are definitive signs of particular
patterns of imbalance or these signs are simply the only two signs that are manifesting
at this point in time. When you have made these boxes, you can then see how the
dynamic is in this patient – how these patterns of imbalance affect and create each
other. You can also continue the exercise by including the aetiological factors.
34
Part 1
THE DIAGNOSTIC
PILLARS
INTRODUCTION TO THE
DIAGNOSTIC PILLARS
The first half of this book concerns itself with the so-called ‘diagnostic pillars’. These
pillars are all the information that can be gathered through visually observing, listening
and smelling, palpating and interrogating the client. The pillars are the systematic
approach that Chinese medicine has developed over the years to gather and analyse
all the information from a patient that has diagnostic relevance. The four pillars enable
the practitioner to construct as precise and solid a diagnosis as possible.
Through the use of the practitioner’s eyes, hands, ears and nose, as well as their
intellect, Chinese medicine has over the millennia developed a diagnostic system
that is both coherent and logical. This is because any change in the physiology of the
body will not only affect the functioning of the body, but it will also manifest with
tangible signs that can be seen, felt, heard and smelt. By systematically organising
the collection and categorisation of this knowledge, Chinese medicine has developed
a very precise and scientific diagnostic system. While modern Western medicine has
chosen to focus more and more on less and less, Chinese medicine historically chose a
different approach. Chinese medicine has focused on collecting as much information
as possible about a person. This includes not just the individual symptoms and signs
themselves, but also information about the person as an individual and the world
around them. By gathering as much information as possible, the picture becomes
more defined and precise.
In the beginning, the sheer volume of the information that is presented in the
following chapters can appear to be overwhelming and intimidating. The intention
is not that you should slavishly follow the contents of each chapter section by section
when diagnosing a client. Instead, you should train yourself to be aware of when
and how a patient differs from what is normal or to be expected, i.e. the norm.
There will always be an ideal norm – the norm being what we ought to see or hear,
all things being equal, if the body is physiologically harmonious – and then there is
the reality that is in front of us. This reality will be an aggregate of various deviations
from the norm. Each of these deviations will usually be linear movements away from
a midpoint. There will often be too little or too much of each individual variable.
Each norm or midpoint is, of course, itself variable and is dependent on many
factors, such as gender, age, season or time of day. It is, for example, normal to be
wide awake at three o’clock in the afternoon but not at three o’clock in the morning.
Whenever there’s a change in a person – a deviation from the norm in how they
look or smell or the sounds they emit – it will be a manifestation of an imbalance in
their physiology. Every sign and every change is significant. What Chinese medicine
has done is to document the systematic observation of how imbalances manifest
themselves and the diagnostic significance of these physiological changes.
36
Introduction to the Diagnostic Pillars
We must therefore constantly ask ourselves the following questions every time
we observe something in a patient.
• What should I expect to be seeing, hearing, smelling or feeling right now?
• In what way does this manifestation differ from the norm?
• Which mechanisms and dynamics could be the cause of this change?
• Which pathological process can be the cause of this dynamic?
• How can this be interpreted in Chinese medicine terms? What imbalance
and which pathological processes could be the cause of this manifestation?
Something imperative that is important to be constantly aware of is the crucial
difference between what is normal and what is common. Being common does not
make something normal. This is evident, for example, when considering the tongue.
Most of my clients present with tongues that are pale and swollen, with teeth marks
on the sides, a red tip and a greasy coating. Is this therefore a normal tongue? No,
this is a common tongue, manifesting signs of very common patterns of imbalance.
I have tried, wherever possible, to provide physiological explanations of how and
why changes in the body arise in pathological conditions. This is because I, personally,
think that it is easier to learn the diagnostic significance of these changes if you
understand how and why they have arisen, rather than just learning the signs and
symptoms by heart and blindly accepting that things are as they are. Furthermore,
by developing a comprehension and understanding of how changes occur, you will
be able to figure out why a body presents as it does without having to remember the
importance of all the symptoms and signs by heart.
Some signs and symptoms are, of course, more important than others; some
will be seen more frequently and others more rarely. However, I have chosen in this
part of the book not to weight some signs and symptoms as being more important
than others or as being ‘key symptoms’. Even though the signs and symptoms are
themselves objective, the diagnostic process itself is subjective. Some therapists
weight certain signs as being more important than others. I know from my own
experience that the signs and symptoms that I weight most now are somewhat
different from the ones that I weighted ten years ago. Where ten years ago I relied
much more on the interrogative approach to diagnosis, my focus is now much
more on the visual and auditive signs that the patient is manifesting. On the other
hand, a person trained in Japanese acupuncture will often place more emphasis on
palpable signs, and a Five Element acupuncturist may well focus more on smelling
and listening to the client. It is not because one area is more important than others.
All information has a value and ought to be involved in the diagnostic process. There
will, however, often be a personal and subjective weighting of which information
is deemed to be most relevant or reliable. What is crucial is to keep an open mind
whilst diagnosing. Even though there may be a clear sense of what the diagnosis is
from the outset or during the initial stages of the diagnosis, one must consciously
37
search for evidence that can confirm this thesis or assumption. It is also important
not to focus blindly on this thesis. This is because most signs and symptoms can
mean different things in different contexts. This is the core of Chinese medicine
and oriental philosophy in general. It is the context that the object is observed in
that provides the definition, not the object itself. A sign or symptom should be
comprehended as a part of a whole and it is this whole we are trying to determine,
not the individual components. This is the reason that the Chinese medicine
diagnostic process is so comprehensive and the reason that each of the four pillars
comprises of so many elements. It’s also why you have to use all four pillars together
and not neglect the use of any of them. A roof is only stable if there are four pillars
supporting it. A diagnosis is no different; it relies on four pillars. There are also some
aspects of these diagnostic approaches that are indispensable. They should not be
forgotten or omitted. This is especially true of tongue and pulse diagnoses, which
are such important cornerstones in their respective columns that the pillars, and
therefore the diagnostic roof, would be unstable if they are not present.
38
Section 1
THE DIAGNOSTIC PILLAR:

VISUAL OBSERVATION
Introduction
Visual diagnosis is something that people constantly utilise without necessarily being
aware of it. What you must learn, as a practitioner, is to refine this ability. When
someone who is angry or distressed enters a room, you are usually in no doubt about
their mood. Similarly, if a person is exhausted or has a heavy cold, you will usually
also pick up on this, both by seeing them and when talking to them. This is because
there is a multitude of signs and signals, some more subtle than others, that we pick
up on. We perceive and mentally record these signs without even thinking about it.
What we, as therapists, must do is refine this ability to observe relevant signs and see
them as part of a pathological pattern.
The above examples are, of course, fairly obvious and the signs are easy to spot,
but the difference between these examples and the signs that we encounter in the
clinic when interviewing clients is only a matter of degree. The signals are always
there. They’re just not always as pronounced. The trick is to refine and train one’s
perception. This is an ability that virtually everyone possesses, but they are not
accustomed to using it in such a refined way or, importantly, using it systematically
as part of a structured diagnostic system.
Visual diagnosis in Chinese medicine has two prerequisites: you must learn what
the different visual diagnostic signals are a manifestation of in a Chinese medical
context, and you must train your observational skills – your visual attentiveness. The
former is a matter of understanding and remembering how changes in the body’s
internal physiology will manifest on the exterior of the body. The latter requires
honing your visual awareness and focus so you are able to perceive these signals.
Something that is also vital when utilising visual diagnosis is good lighting. This
is especially relevant when observing the complexion in the face and the tongue. A
great many details can be overlooked because the lighting conditions are poor or
the signs can be misinterpreted because the light source causes the colours to have a
different hue.
What are the signs and symptoms that we will be looking for in this
diagnostic pillar? Which signals from the body should be observed and what is
the diagnostic significance of these signs?
In the moment a client steps through the door, we immediately start to form an
impression of the person. We do this based on their body shape, their posture, their
way of moving, the colours in their face, the complexion of their skin, the expression
in their eyes, their body language, how they sit down on the chair and much more.
39
During the diagnostic procedure, we actively observe specific areas of the body
– including the tongue, the fingernails and the skin. This is because certain aspects
of the body manifest a lot of relevant information that can give us vital information
about the patient – information that can often determine the diagnosis.
In Chinese medicine visual diagnosis, this information is utilised in a structured
manner. We consciously focus on and interpret the signals that are being radiated
by the patient. We process the information and relate it to our understanding of the
body’s physiology. Within the first three to four minutes, an experienced Chinese
doctor may well have determined the fundamental aspects of the diagnosis. The rest
of the consultation is then used to confirm and further refine the diagnosis.
Having said that, it does not mean that you should blindly adhere to your initial
diagnostic impression or solely approach the diagnosis using intuition. At times this
becomes a difficult balancing act. We must learn to trust the first impression we
have received. This is because this first impression can often be of great diagnostic
importance, especially because it is in this moment that we are often most intuitive
and least rational in our thought processes. However, we must simultaneously
maintain a flexibility in our thinking and our approach to the patient. Our mind
must not get stuck on a diagnosis and thereby become blind to the diagnostic
signs pointing in other directions. We must be aware of the risk of interpreting
symptoms and signs only from the perspective of our initial hunch. It’s like being
a detective. We must follow a lead, but not get stuck trying to pin the evidence on
our initial suspect.
Intuition without a theoretical foundation is nothing other than guesswork.
Intuition requires that you have a strong theoretical basis that you subconsciously
utilise. Most of us, at least to begin with, have to look systematically and consciously for
each visual sign. We must consciously ask ourselves questions whilst we observe the
patient: How is their facial complexion? How are their body movements? How do
they dress? And so on.
Later on you will begin to answer these questions subconsciously and just say to
yourself when you see a client: ‘Liver qi stagnation and Heart yin xu,’ without having
consciously thought about it.
Some diagnostic areas are more straightforward than others. Diagnosis of body
movements is usually fairly straightforward and can be observed from a greater
distance than, for example, the skin in the area around the eye. Several signs that
have relevance must be consciously sought out, for example skin lesions that are
covered by clothing. They will first be seen only when the relevant area is uncovered.
J. R. Worsley advises practitioners to set up their practices so that they can see
their patients when they arrive in their car and walk towards the clinic. This means
you will have time to see the client and their natural posture and body movements,
etc. without the client being aware that they are being observed (Worsley 1990, p.77).
As stated, good lighting is crucially important in visual diagnosis. You should,
whenever possible, take advantage of daylight. Unfortunately, this is often not an
40
The Diagnostic Pillar: Visual Observation
option because there is a building just opposite your window that blocks the light or
your client has come in the early morning or evening.
It is therefore a good idea to decide on what form of artificial lighting you will
be using in the clinic and then investigate how this source of light affects the various
colour tones. This can be done by initially observing the skin, tongue or other
aspect of the body in natural daylight and then observing the same area when it is
illuminated by the artificial light source and mentally noting the difference.
Visual diagnosis
Relative strengths of visual diagnosis
• Observation, together with auditory diagnosis, is the cornerstone of the
intuitive approach to diagnosis. Through these two approaches we can often
determine a substantial part of the diagnosis. We must learn to trust this
ability but at the same time not confuse intuition with guessing.
• When observing the client, we are not dependent on the client’s subjective
interpretation and presentation of their diagnostic signs.
• Visual diagnosis is central in the diagnosis of children.
Relative weaknesses of visual diagnosis

• Many of the visual signs are very subtle and thereby difficult to differentiate.
• There are almost too many signs, which can be overwhelming, making it
difficult to maintain an overview.
• The facial signs can be concealed by make-up.
Diagnostic tips
• Remember to notice petechiae and nevi whilst palpating and locating
acupuncture points.
• Remember to notice whether the skin is dry whilst palpating and locating
acupuncture points.
• Skin that is red or ruddy is a sign that Heat is present, at least in the local area.
• Skin that is purple is a sign of xue stagnation in the area.
• Discharges and exudations that are yellow or greenish are always a sign
of Heat.
Visual diagnosis of a person’s shen

Observation of the shen is probably one of the most important aspects of diagnosis.
Even though observation of the shen is something many people do without even
thinking about it, it is a good idea to be aware of what you are doing and subsequently
draw relevant conclusions from what you have observed.
We immediately start to form an impression of the patient’s shen from the first
point of contact. The state of a person’s shen is critical in determining the prognosis.
41
This is because shen is formed from jing, qi and xue. These are the material basis for the
more ethereal shen. For its part, shen is the exterior manifestation of these substances.
This means that the person’s shen will reflect the state of these vital substances and
the condition of the body that generates them.
If the person is healthy and their yin, yang, qi, jing, xue and zangfu are strong,
they will have a strong shen. If they are weak, or if xie qi (pathogenic qi) is virulent
and injuring the vital substances, their shen will be weakened.
Shen can be observed in a person’s eyes, face, hair, body movements, tongue and
breathing, as well as the way they act, react and interact with their surroundings.
Vitality is a key word here. When there is shen, there is vitality. If a person radiates
a vitality, there will still be a good prognosis, even if their symptoms are serious.
Contrarily, if the person lacks this radiance, the prognosis is poor. This is because a
lack of shen is a sign that the vital substances are injured and/or that xie qi is virulent.
If shen is strong, healthy and harmonious, there will be a shine and a sparkle to
the person’s eyes. The eyes will be bright. Conversely, a person’s eyes can seem dull
and lifeless if their shen is weak or blocked. If the person’s shen is agitated, their eyes
can seem very intense or they will be restless, their gaze darting around the room.
Because shen manifests in the eyes, a person with a healthy shen will be able to
look you directly in the eye and maintain prolonged eye contact. If the shen is out of
balance, you can have the sensation that even though you are looking them directly
in the eyes, there is no contact. They may have difficulty maintaining eye contact
because their eyes are darting around in various directions or they may maintain
eye contact but have dull and lifeless eyes. They may give the sensation that there is
no-one there, there is no vision coming out through the eyes or you are not able to
create a connection into them.
The skin of the face is another place where a person’s shen can be observed.
The skin in the face should have a faint glow. The facial skin should also be soft
and elastic. It should not be grey, dry or lifeless. There should be a vitality in the
skin. This is not dissimilar to the tongue. Both should appear fresh and have a
vibrancy. There should be the same vitality that you see in a live fish, not a fish that
has been lying on a fishmonger’s slab for a few days.
As stated earlier, shen is the external manifestation of the internal organs and the
vital substances. This means that a person’s body and their muscles can also reflect
the quality of their shen. A strong body with healthy muscle and strong bones will be
a sign that there is a strong foundation for shen, i.e. that their jing and xue are strong
and healthy. A person’s movements should be light and agile and their reflexes sharp.
This shows that shen is able to control the body, that the Emperor is in command
of his realm.
There is a close relationship and cooperation between the Heart and the Lung.
Shen can therefore also be observed in a person’s breathing. The respiration should
be calm, smooth and regular, indicating that the shen is in balance.
The concept of the shen encompasses both the concepts of the soul and the mind
in Western terminology. Most people can recall having seen someone in the street
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or on a bus and instantly recognising that the person is mentally deranged. Their
clothes, hair and body movements separate them from the crowd. If a person’s shen
is in balance, a person will have normal responses and behaviour in relation to
their surroundings. A person whose shen is imbalanced will often dress oddly. The
clothes may seem strange, unusual or disharmonious or just inappropriate for their
surroundings or the season. Their hair can be eye-catching and eccentric, and they
will act and behave in a way that arouses our attention. However, it is important
to remember that even though a person’s clothes and behaviour may seem odd or
different to what most people think of as normal, it may just be something that is
the norm within a certain subculture or ethnic group to which the person belongs
or it may be a conscious choice by the person.
Observation of shen
Strong shen that is in Shen that is weak or imbalanced
balance
Eyes The eyes are bright and have The eyes can seem either dull and lifeless or
a sparkle and a radiance too intense
Eye contact Good eye contact and the Poor eye contact and the person has difficulty
person is able to maintain maintaining eye contact
this contact Their gaze can be too rigid and staring, their
eyes can dart around the room or they may
shyly look away, because it is too intimidating
to maintain eye contact
Facial skin The skin has radiance and is The skin is dull and lifeless, possibly grey
soft and supple or matt
The hair The hair has shine and lustre The hair is dull and lifeless
Muscles and flesh Strong and solid body with Weak and lax body with poor muscle tone
good muscle tone
Body movements Agile movements with good Slow, uncertain movements with poor reflexes
reflexes
Breathing Calm and smooth breathing Superficial, irregular or rapid breathing
Clothes and hair Normal and harmonious Outlandish or odd clothes and hair
clothing and hair
Response to the The person acts and The person is either very apathetic or agitated
environment reacts normally with their The person reacts inappropriately to their
surroundings surroundings, saying and doing things that are
odd or inappropriate
False shen
Something that can be seen in seriously ill patients is that they can go from a state
where they are very exhausted and their shen appears to be extremely weak, possibly
even lacking consciousness, to suddenly brightening up. They may suddenly start
talking again and have a brightness in their eyes, their appetite returns and they get a
43
rosier colour returning to their face. This is ostensibly a positive improvement, but it
is actually the opposite. When a person is very weak and ill, recovery and returning
to strength should occur gradually. What is being observed here is ‘false shen’ and is
an indication that zheng qi is about to collapse and that yin and yang are separating.
These apparently benign signs are in fact manifestations that yang has detached itself
from yin and is no longer controlled, thereby rising upwards. This is a very serious
and negative sign.
Visual diagnosis of the body shape and posture

General shape and posture
Everyone is born with a certain constitution. The shape and form of a person’s body
can give an indication of their constitutional foundation, as well as the balance
between yin and yang in their body. A person with a strong and robust physical body
will usually also have healthy organs and strong qi. When there are imbalances in
this person’s physiology, they will tend to be shi in nature. In contrast, a person with
a weak and fragile body will tend more towards xu states of imbalance.
The body’s posture also expresses the distribution of qi in the body and whether
there are shi or xu conditions in certain organs. A person with too much yang qi will
often appear to be slightly distended or pumped up in the upper part of the body
with a barrel chest. Generally, it will look as if their muscles are slightly too tense.
Their legs will seem to be relatively insubstantial in relation to the upper body. This
will result in a V-shaped body. This is called a ‘taiyang’ body type. It is more typically
seen in men and people who are relatively yang, and the person will tend towards
yang shi imbalances.
Conversely, a person with relatively too much yin or with too little yang will tend
to become more pear-shaped. This is due to the accumulation of yin Dampness in
the lower part of the body or because yang is not lifting the qi upwards in the body.
This gives a more pear-shaped appearance. This body type is called a ‘taiyin’ type.
Where the taiyang body type’s muscles will often appear to be slightly taut and tense,
the taiyin type’s muscles will appear to be more flaccid or doughy and the skin will
be paler. This person’s movements may well be slightly slower and more ponderous.
Taiyin body types are more typical in women, and taiyin types will generally tend
more towards yang xu, Dampness and Phlegm.
The ‘shaoyang’ body type is mixture of the first two body types. In the shaoyang
body type the proportions of the upper and lower parts are more even and the
muscles will be neither too flaccid nor too tight. This is the healthiest body type
because yin and yang are harmonious.
A fourth body type is the ‘shaoyin’ body type. This person is very thin and sinewy.
They can often be slightly nervous or restless in their body movements. These people
tend to be yin xu and/or xue xu.
By observing the distribution of qi in the body, you can get an idea of how
long‑term influences have physically affected the body. When we see a person in
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front of us, we must ask ourselves: How is the qi distributed? Is there an impression
of there being too much or too little qi in general? Are there areas of the body where
there is relatively too much or too little qi? Are there areas where there appear to
be signs that Dampness or Phlegm are accumulating? Are there signs that yang qi is
ascending?
In general, a powerful body with strong muscles and bones is an indicator that a
person has strong jing and qi. Because their qi is strong, they will be more likely to
develop shi patterns of imbalance. A person with weak muscles and a more delicate
bone structure whose posture is more slumped will probably be qi xu and possibly
even jing xu. When these people get sick, their patterns of imbalance will tend to be
xu in nature.
Qi xu and yang xu tend to result in a slumped posture. There is an impression
that the qi is not lifting the body up and holding the person upright. The patient will
typically sit slumped on a chair and their back will not be straight or erect. On the
other hand, if a person is too rigid in their posture, it could indicate that they have
Liver qi stagnation. Liver qi stagnation will result in muscles that are tense, their lack
of flexibility on the mental and emotional level being reflected in their physique.
Liver qi stagnation and ascending Liver yang can also be seen in shoulders that are
raised and tense. This is due, not only to the ascending yang qi lifting the shoulders
upwards, but also because the neck region is a ‘bottleneck’, and if there is ascending
yang qi, the ascending qi will have difficulty passing through this narrow area and will
accumulate, creating neck and shoulder tension. The tension is further exacerbated
if there is already Liver qi stagnation creating a stagnancy of qi in the muscles.
A person with an excess of Damp-Phlegm can have a tendency to obesity or be
overweight. In particular, the Dampness will accumulate around the hips, buttocks
and the lower portion of the abdomen. This is due to the yin nature of Dampness,
which results in it seeping downwards. The muscles and skin can be loose and flaccid.
If there is Lung qi xu, the person may be hollow chested or have poorly developed
muscles in the thoracic region. An accumulation of Phlegm in the upper jiao will,
on the other hand, result in a person being barrel-chested. This is due to the Phlegm
blocking the movement of qi and causing qi to stagnate in the upper body.
A person with an excess of Heat in the body will have a more ‘open’ or ‘splayed’
posture. They will often sit with their legs and arms spread out to the sides. They will
spread their limbs outwards in a subconscious attempt to create a larger surface area
and thereby increase the dissipation of heat from the body.
A person who lacks physiological heat – a person who is shi Cold or yang xu –
may sit with their arms crossed or even wrapped around themselves, in an attempt to
reduce the loss of heat from the body. This posture is similar to, but slightly different
from, a person who is emotionally blocked or suspicious (blocked shen due to Liver
and Heart qi stagnation). They can also sit with a very ‘closed’ posture, with their
arms folded in front of the chest. However, this is not an attempt to maintain body
heat but is an external manifestation of their emotional rigidity.
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Body shape and posture

Observation Significance
Strong and sturdy body Strong constitution and qi. Good jing. Tends
towards shi imbalances
Weak and fragile body Weak constitution and qi. Weak jing. Tends
towards xu imbalances
Pear-shaped or ‘taiyin’ type Yang xu, Spleen qi xu, Damp-Phlegm
V-shaped or ‘taiyang’ type Yang shi
Thin and wiry or ‘shaoyin’ type Yin xu, xue xu
Even distribution between upper and lower Yin and yang are in balance
parts of the body or ‘shaoyang’ type
Slouching posture Qi xu or yang xu
Stiff and rigid posture Liver qi stagnation
Overweight or plump Phlegm-Dampness
Raised shoulders or tense shoulders Ascending Liver yang, Liver qi stagnation
Sitting with arms and legs spread Heat
Huddled around themselves Shi Cold or yang xu
Arms folded and rigid body Liver and Heart qi stagnation
Five Phase body shapes

Everyone is born with a constitutional body shape and form. This is the foundation
of their subsequent development. There are five primary body shapes in Chinese
medicine. These correspond to the Five Phases. However, it is rare that a person is
exclusively one shape alone. People are combinations of all Five Phases simultaneously,
but one or two phases may be dominant in relation to the others.
A person’s experiences in life, their diet, the diseases they’ve suffered, their
chronic patterns of imbalance, their environmental surroundings, etc. will all have
had a fundamental influence on the way that their body has developed and changed
through the years. This influence is particularly strong during childhood when the
body is still developing and qi is less stable and more easily affected.
In the Five Element acupuncture system, people are diagnosed with regard to
their constitutional types. The body’s fundamental physical appearance is used to help
to determine which phase is most dominant in the person’s constitution. The Five
Phase body differentiation can also be used to assess the seriousness of an imbalance.
It is better to have an imbalance that is congruent with the dominant constitutional
phase, rather than an imbalance that is characteristic of the controlling phase.
Huang Di Nei Jing – Ling Shu (The Yellow Emperor Classic – Spiritual Axis)
chapter sixty-four lists the following characteristics of the five constitutional types.
46
Wood type
• Sinewy
• Greenish skin colour
• Small head
• Long face
• Broad back and shoulders
• Straight back
• Small torso
• Tall
• Small hands and feet
• Intelligent
• Not physically strong
• Persistent when they work
• Tendency to worry
Fire types
• Ruddy skin colour
• Small head
• Thin face
• Wide back
• Well-developed muscles in the shoulders, back, abdomen and buttocks
• Curly hair
• Quick tempered
• Quick thinking
• Quick body movements
• Firm gait, and the body moves whilst they walk
• Can have a tendency to be anxious
47
Earth type
• Yellowish skin colour
• Rotund body shape
• Large head
• Round face
• Broad jaws
• Large abdomen
• Large thighs and calve muscles, strong legs
• Relatively small hands and feet
• Well-proportioned body
• Steady gait
• Raise feet slightly whilst walking
• Solid muscles
• Quiet and generous
• Not over-ambitious
• Easy to get on with
Metal type
• Pale skin colour
• Square face
• Small head
• Narrow shoulders and upper back
• Small abdomen
• Lean
• Fine bone structure
• Powerful voice
• Thinks quickly
• Honest and reliable
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• Quiet and calm, but solid

• Determined
• Good leader
• Quick, swift movements
Water type
• Dark complexion
• Wrinkled face
• Large head
• Angular jaw and chin
• Round and narrow shoulders
• Large abdomen
• Move the whole body when they walk
• Long spine
• Relaxed
• Loyal
• Attentive and sensitive
Visual diagnosis of a person’s movements

A person’s body movements are one of the first things, along with the shape of their
body and their posture, that we notice when they enter the room. It is important to
be aware of how they move, not only before they sit down in the chair, but also after
they have seated themselves. We should observe how much movement there is in the
body or whether there is a distinct lack of movement.
Heat and Cold will both have an influence on a person’s movements. The more
Heat there is, the greater the activity of qi and thereby the faster the movements
and the greater the amount of movement. A person with Heat will not only move
quickly, they will also tend to be more restless or just move their body more. A
person with a lot of Heat – both xu Heat and shi Heat – will have difficulty sitting
still because their qi is agitated. Their toes will tap, their arms and hands will
constantly be in motion and they will keep moving about on the chair. This is
usually noticeable in people with yin xu Heat. They will often be restless and nervous
in their movements, having difficulty sitting still. The difference between xu and shi
Heat can be seen in, amongst other things, the force of the movements. Shi Heat
49
will manifest with more powerful movements, because there is simply more qi. Yin
xu movements are typically more fidgety and nervous.
To gain an impression of how yin xu Heat movements can manifest, think
about how small children are in the evening, especially when they are overtired.
Their movements are not lethargic and slow, as would be expected when they are qi
xu, due to them being tired and exhausted. Instead, their movements are frenetic
and overexcited. The more tired they are, the more they run around and the more
excitable they become.
The dynamic nature of Cold is to contract and constrict. This thereby restricts
the movement of qi, leading to a lack of movement and slowness. The slowness is
accentuated by a lack of physiological heat, which can activate the qi and thereby the
body itself. There will be significant differences in the person’s movements, depending
on whether the Cold is shi or xu in nature. When there is yang xu, the movements will
be slower and more lethargic. This reflects that there is a lack of the yang qi that creates
activity. With shi Cold, the movements will also be slow, but the movements are not
weary, weak and feeble, but stiff and inhibited. This is because the lack of movement is
not due to a lack of qi but because qi is restricted in its movement by the Cold.
A localised invasion of Cold will affect the mobility of that area of the body.
Invasions of Cold are typically seen in the joints of the limbs, the lumbar region or
the shoulders and neck. These areas will be restricted in their movement and there
will also be stiffness and physical pain.
Xue stagnation can also result in a joint’s movements being inhibited and often
painful. This will manifest with rigidity and a reduced mobility of the joint.
Elderly people’s body movements are characterised by the decline in their yin,
yang, qi, xue and jing. This will manifest in movements that are slow and weak. This,
though, is not the only thing we see. Elderly people’s movements are also stiff and
inhibited. This is because there is an increasing stagnation of xue and Phlegm as
people get older. Typically, their movements will be stiffest in the morning and after
they have been sitting still for a while. They have difficulty getting up and moving
again, due to the stagnation.
Liver qi ensures that qi in general can flow freely and the Liver thereby ensures the
unimpeded flow of qi throughout the body and through all the muscles and tendons.
If Liver qi is harmonious, the person will have smooth and fluent movements. If
Liver qi has stagnated, the movements will be more uneven, clumsy and stiff. Liver
qi stagnation may also result in stiffness and a noticeable rigidity to the body itself.
The person may sit stiffly upright in the chair and there may be a conspicuous lack
of movement in their body. This will particularly be seen in the hands and facial
muscles, which will be noticeably immobile.
Qi xu and yang xu can result in a person’s movements being limp and weak, the
muscles lacking the energy to complete their movements. When the person enters
the room, they may drag their feet slightly. Their movements will seem lethargic and
will often be slow. Again, it can help to conjure a picture in your head. These are the
movements that you will also see when someone is completely exhausted.
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Dampness and Phlegm result in a heaviness in the body and this will be reflected
in the movements of the body, which will be lumbering and ponderous. The Phlegm
and Dampness can also block the joints in the limbs. The movements of these joints
then become stiffer and inhibited due to qi being blocked in its movement by the
Dampness and Phlegm. This will be more noticeable when the weather is damp or
humid and when the joint has been inactive for a while.
Clumsiness can arise either because there is a stagnation of qi, so the movements
of the body are uneven and rougher, or when there is Phlegm. Phlegm can block the
shen so that there is a poorer coordination of the body’s movements.
All of these movements are things that we should be picking up on as the patient
enters the room and sits down in the chair. We should also be conscious of their
movements whilst we interview them and again when they get up to walk over to
the treatment couch. We should constantly ask ourselves: What are their movements
like? Are they slow, quick or stiff? Do they drag their feet? How is the balance of
qi and where is it in their body? Is there a lot of body movement in general or is
there too little? Are the movements large or small, forceful or weak, rapid or slow,
smooth or jerky, stiff, heavy and ponderous? How much do they use their hands
when talking?
Do they sit too still and if so is it due to rigidity or lack of energy? Do they
fidget and move about in the chair? If they are fidgety, is this due to nervousness
or is it just excessive movement? We see this often in children, because children are
generally warm and tend to be yin xu. This means an excess of movement will have
more diagnostic significance in adults than it does in children, because the heat and
relative lack of yin is the norm in children but not in adults.
We should also note whether there are changes in their movements when they
talk about different subjects.
Body movements
Rapid Heat
Quick and nervous Yin xu Heat
Quick and forceful Shi Heat
Restless Heat
Slow and stiff Cold
Lethargic, weak and slow Qi xu, yang xu
Stiff and limited Cold, qi stagnation, xue stagnation
Clumsiness Liver qi stagnation, Phlegm
Heavy and ponderous Dampness and Phlegm
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Visual diagnosis of a person’s clothing

A person’s attire can relay useful information, but we must also pay attention to
factors such as fashion and the identity statements of subcultures.
One of the first things that we can focus our attention on is how much clothing
the person is wearing and how appropriate this is for the climate. This will give an
indication of Heat and Cold, from an Eight Principles perspective.
A person with an excess of Heat will usually be more lightly clad than others,
even if the weather is cold. This can be seen, for example, in alcoholics sitting on
park benches. Even in the midst of winter, they will often only be wearing a t-shirt
and a thin jacket, despite single-figure temperatures.
Conversely, a person with yang xu will often meet up in the clinic wearing a
thick jacket or a sweater, even in the height of summer when everyone else is walking
around in a t-shirt and shorts. You should always ask yourself: Is the clothing they
are wearing appropriate for the climate? Are they wearing too much or too little
clothing compared with other people? It is, of course, important that this judgement
is made from an objective perspective and not from your own subjective feelings. If
you yourself are yang xu, then you will also probably wear more clothes than others
and only notice a discrepancy in people who are more scantily clad than yourself. It
is therefore important to be conscious of your own patterns of imbalance.
Harmony
Our shen makes us conscious of what is normal and correct in any given situation.
Our shen makes us aware of, and thereby helps us conform to, what is expected
or normal in the society around us. When shen is disturbed, the person may have
difficulty conforming to this norm. The person will often say and do things that
other people find strange. This can be seen in their clothes. Shen-disturbed patients
may have a lack of harmony in their clothing. People with an extremely disturbed
shen – people who are mentally ill – can often be easily spotted on a bus or the street
because their clothes are disharmonious and to others look a bit weird. This is typically
exemplified in cartoons when depicting a person who is ‘mad’. Focusing on extremes
and looking at caricatures is useful training, as it helps us to tune our awareness so we
can spot the more subtle cases. This is useful, as many of the patients we see are not
‘over-the-edge wacko’ cartoon characters, but their shen is still disturbed or disrupted
in some way. These patients are definitely ‘normal’ in their own eyes, and often in
the eyes of those around them, but their shen can still be disturbed from our point
of view. They have deviated from the ideal ‘norm’. It can just be subtle differences
between what we expect and what we see, or it can be more extreme. We must ask
ourselves: Is this voluntary, through choice, or are they unaware of their appearance?
What we must be aware of is that many subcultures consciously choose to look
weird or different or just adopt a rebellious way of dressing. These individuals’ shen
are usually harmonious, because they are just conforming to a subset of normality,
rather than the normality of society. Often, they are more conformist in relation to
52
the narrow rules of their social niche than other people whom they perceive as being
normal and boring!
There is, of course, also a narrow line between genius and madman. It can often
be difficult to see the difference in their appearance.
Colours
Another aspect of a person’s clothing we can observe is colour. We can ask ourselves:
Is a patient predominantly and/or repeatedly dressed in just one colour?
A preference for a certain colour can be a tenuous sign of imbalance, as it is more
often fashion related and thereby of little diagnostic relevance. That said, xu and
shi pattern imbalances may affect a person’s relationship with certain colours. This
is because colours have an energetic resonance. If there is a certain organ or phase
that is xu, a person may have an attraction to the colour that is a manifestation of that
phase’s qi. A person with a Kidney xu condition, for example, may have a tendency
or an attraction to wearing clothes that are predominantly black or dark blue. This is
a subconscious attempt by the body to replenish its own deficiency of this particular
resonance of qi. A person with a shi condition, on the other hand, may have an aversion
to a certain colour because they already have too much of this type of qi in their body.
Drab colours and clothing

The brightness and vibrancy of a person’s clothes can reflect the quality of their
shen and qi. Young people often dress more brightly than older people, wearing
more vibrant colours and patterns. These clothes will also suit them better than if
somebody middle-aged wears the same clothes. This is because the clothes seem
more harmonious with the person wearing them. They match their qi. Many people
tend to dress more drably as they get older. They become more anonymous. This can
reflect the imbalances and developments that are common as a person grows older.
Xue xu, qi xu, yin xu, yang xu, jing xu, Phlegm and various stagnations will all mean
that the shen shines less brightly because it is either undernourished or blocked.
This reduced vibrancy can sometimes also be seen not just in their clothing, but
also with reduced sparkle in their eyes. The vibrancy of their clothes and their eyes
reflects the vibrancy of their qi. This, of course, is far from always the case. Some
elderly people do wear bright clothes and look harmonious in them. However, this
is usually a reflection of the quality of their qi and their shen.
Drabness can also be the complete opposite. It can be a manifestation of a shen
in perfect balance – the apparel and physical appearance no longer being of any
importance and clothing being just another ego attachment. That is why, like every
other sign, it must be viewed as being part of a larger pattern.
We also see many people whose marital relationship or life has become stuck
and non-giving become more and more drab or boring in their appearance. A
person whose life, and thereby peace of mind, has fallen apart, for example a man
53
whose wife has left him and who has emotionally imploded, may stop caring at
all about his appearance and often start to look dishevelled. This is a reflection of
emotional condition – the state of their shen. Even though this is common and
understandable, it is not an expression of a shen in balance, i.e. the ideal ‘norm’ from
a Chinese medicine perspective. Similarly, when some people stop caring about their
appearance, it is a reflection of them no longer caring about themselves and lacking
self-worth. This is, again, telling us something about their Heart and their shen.
A shen blocked by Phlegm and Dampness can sometimes manifest with confusion
and muddle-headedness. This can be reflected in the appearance, for example shirts
buttoned wrongly, different coloured socks, pockets hanging out or food stains on
their shirt.
It is not just aberrations from the norm that are manifestations of a pattern of
imbalance. Over-conformity can also be a relevant sign. The extreme tidiness and
pristineness of some people reflects their controlling attitude to everything in their life
and everything around them. This will often be seen in people with Liver imbalances.
The need to decorate themselves and conform to the latest fashion – the need to
belong and conform – is for some people a sign of their imbalances. Like so many
things in Chinese medicine, it is not the factor itself, for example the flavour, the
climatic influence, the emotion or whatever, that is the problem. It is the amount,
situation and context of the factor, in particular whether there is too little or too
much. Too much control and conformity or too little are both signs of imbalance.
This means that when the patient comes through the door, we might take note
of the clothing. Most often there is nothing to see or register. It is only when there
is something that sticks out that we take note, and even then we can’t necessarily use
the information but occasionally we can. This is no different from many other signs.
It is the aberrations that we look for and we only can use them when they appear
part of a pattern, unless they are very extreme or are a unique manifestation of a
certain pattern.
Finally, we must also take other factors into consideration when considering a
person’s attire. They may, for example, be on their way to or from work, where the
clothing is specified, or be on their way to or from a social function.
Clothing
Wearing lots of clothes Cold, yang xu
Wearing little clothing Heat
Disharmonious clothing Shen disturbed
Very pristine clothing Liver qi stagnation
Predominance of a particular Can be a sign of a xu condition in the zang organ that resonates
colour with that colour, but usually it is fashion related
Aversion to a particular colour Can be a manifestation of a shi condition in the zang organ,
which resonates with that colour
54
Visual diagnosis of the face

When we visually diagnose the face, we must note changes and distribution in the
colours on the face. We must also observe the moistness and the quality of the skin
and whether there is radiance.
Visual diagnosis of the face is fairly straightforward, as the face is not usually
covered by clothing. Furthermore, it is the face that we look at when we talk to
the client.
It is important though to pay attention to the lighting conditions in the room and
to take into account the fact that many women use make-up, which can shroud the true
colours of the complexion. Both of these factors can complicate the diagnosis. Some
therapists therefore ask their patients not to put on make-up before the consultation.
Account must also be made for the natural difference in skin colours between various
ethnic groups. A pale complexion, for example, will be darker in a person from Pakistan
compared with a Norwegian. The facial colours that a person is born with are called
their ‘guiding colours’. The colours that the face can manifest because of changes in
temperature, physical activity, mood swings, etc. are called ‘visiting colours’.
The colours of the face

Facial colours in relation to the Five Phases
There are different diagnostic levels or models for analysing the colours of the face.
Five Element acupuncturists place great emphasis on the client’s facial colours,
especially the area between eyes and temples. This can give an indication of which
constitutional type the person is. Furthermore, changes in facial colours can reveal
which element or phase is in imbalance.
The colours of faces in relation to the Five Phases

White Metal constitution or imbalance in the Metal Phase
Blue/black Water constitution or imbalance in the Water Phase
Red Fire constitution or imbalance in the Fire Phase
Green Wood constitution or imbalance in the Wood Phase
Yellow Earth constitution or imbalance in the Earth Phase
Some colours are more favourable and some are more serious, depending on the
phase that the colour represents. It is necessary to relate the colours to the sheng and
ke cycles. If the person manifests a colour in the face that resonates with the ‘mother’
phase, it is called a conforming colour and this is a positive sign. If they manifest the
colour that resonates with the ‘son’ phase, this is a slightly ‘conflicting’ colour and is
seen as being a negative sign. This, though, is not as bad as if it is a ‘contradictory’ or
very conflicting colour. A conflicting colour will be when the patient’s face manifests
the colour of the phase that should be controlled by the phase in the ke cycle. It is
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even worse when the patient manifests the colour of the phase that ought to be
controlling the phase of the patient or the phase that resonates with their disorder.
Conforming and contradictory colours in relation to the Five Phases

Earth Metal Water Wood Fire
Yellow Conforming Very Contradictory Slightly
contradictory contradictory
White Slightly Conforming Very Contradictory
Black or Contradictory Slightly Conforming Very
dark contradictory contradictory
Green or Very Contradictory Slightly Conforming
green/blue contradictory contradictory
(qing)
Red Conforming Very Contradictory Slightly
Facial colours in relation to the Eight Principles

The observation of the facial colour is also an important tool in more classical
Chinese medicine and TCM. The colours of the face can be used as an aid when
differentiating the Eight Principles. The colours of the face can help to reveal
whether there is an internal or external condition, whether the condition is xu or shi
or whether it is Hot or Cold. The colour of the face can also give an indication of
which types of xie qi are present.
The facial colour will normally match the underlying pattern of imbalance, for
example if a person has a Hot condition, then the face will be red or reddish. If it is
not, there can be various explanations. One of the most common reasons that the
colours in the face do not correspond to a pattern of imbalance is that the patient is
manifesting multiple patterns simultaneously, and not all the colours can manifest
at the same time. For example, a patient with shi Heat, Spleen qi xu and Liver qi
stagnation will not have all three colours simultaneously; most often, we only see one
colour. When the colour of the face is not consistent with what we expect to see, this
can be used as an aid to understanding the pathological dynamics that are taking place.
If we expect to see a dark colour because the person is manifesting xue stagnation but
their face has a pale colouration, this could tell us that the root of their xue stagnation
is a qi xu or xue xu condition. This will then influence our approach to treatment and
we may well utilise a different treatment strategy than we would if it were a purely
shi stagnation. The facial colours can also be affected by things such as the person’s
occupation, for example if they work outdoors. The change in the colour could also be
due to the weather, the season or the person’s emotional state.
There may also be situations in which there are conflicting signs of Heat and Cold
in the patient’s facial colour, their symptoms and the tongue and the pulse. This can
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be seen when there is ‘false’ Heat or ‘false’ Cold. False Heat and Cold arise when the
patient’s yin and yang are in the process of separating. This is always an ominous sign.
It is not only the colour itself that has a diagnostic significance. The intensity of
the colour, its depth and the radiance and moistness of the skin are also of relevance.
Intensity and depth of the colours

When diagnosing the face, we have to observe the qualities of the facial colours. The
colours will be more superficial in an exterior condition. There will be an appearance
of the colour almost floating on the surface of the skin without the colour having
any ‘root’ or depth. Interior conditions usually manifest with more deeply rooted
colours. These colours will have depth, appearing not to be lying on the surface of
the skin. A xu condition will result in weaker or more dilute colours. These colours
will not be as intense and concentrated as the colours in a shi condition, where the
colours are more substantial.
In addition to the intensity and depth of colour, moistness must also be taken into
account, as well as whether there is radiance or the colour seems dull, matt and lifeless.
Radiance
The facial complexion should have shen in the same way that the pulse and tongue
do. This means that the complexion must have radiance. The presence of shen is
always a good prognostic sign. Conversely, a lack of shen is always interpreted as a
negative prognostic sign.
Moistness
In the same way that Stomach qi gives the pulse a smooth and slippery quality and
the tongue a thin, rooted coating, Stomach qi ensures that the face and thereby the
complexion has a slight moistness. If the complexion appears to be matt, dry and
without lustre, it will be a sign that Stomach qi is injured and is not producing
sufficient jinye.
Face colour in relation to the Eight Principles

Superficial hue Exterior condition
Deep hue Interior condition
Weak, diluted colours Xu conditions
Strong, intense colours Shi conditions
Red and ruddy hues Heat
White, pale or blue hues Cold
Clear, bright colours Yang conditions
Matt and dull colours Yin conditions
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It is also necessary to note the distribution of the facial colourations. The individual
areas of the face relate to the various zangfu organs.
Normal colours
The normal colour will, as stated previously, depend on the person’s ethnicity.
Northern Europeans’ facial colour should be a mixture of white and a slightly red
colour. Adjustments to this base colour should therefore be made for different ethnic
groups. Despite differences in skin colours between the various ethnic groups, there
will still be the same dynamics and the same variations in facial complexion.
A slightly red colour indicates that there is sufficient Heart xue. The facial colour
should have lustre and radiance, indicating the presence of shen. The colour should be
‘subdued’. This means that it should not be too obvious. Huang Di Nei Jing – Su Wen
(The Yellow Emperor Classic – Simple Questions) chapter ten states that ‘the colour
should appear, as if it is being seen through a thin piece of silk’. This means that the
colour should be seen through the skin, i.e. the skin itself should not have the colour
and the colour should not appear to be lying on the surface of the skin.
The skin should be slightly moist and the

colour should have a slight lustre
The normal colour will be seen in a person who is healthy and in balance. If these
colours are seen in a person who is ill, this in itself will be a good prognostic sign.
This means that the disease has arisen recently and has not taken root. It indicates
that the disease has not injured qi, xue, jinye or zangfu yet.
Pathological colours
White
The white colour is seen when there is qi xu, yang xu, xue xu and Cold. The white
colour can be: dull and matt when there is yang xu; dull and pale or almost greyish
when there is qi xu; a sallow, wan white that is slightly yellowish and without
lustre when there is xue xu or sometimes Phlegm; an almost bluish white colour
when Cold is present.
Grey
A greyish white, sallow complexion that is slightly dry can sometimes be seen in the
face when there is Phlegm blocking xue from nourishing the skin.
Qing4 (green/blue), green

The green or green/blue colour is seen when there is pain, when there is a stagnation
of qi, especially Liver qi stagnation, or when Cold creates stagnation. It can also
sometimes be seen when there is Heart xue stagnation.
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Blue
The blue colour is often classified as being a shade of qing. It will usually be seen
when Cold stagnates xue. It can also be seen in the area between the eyebrows of
young children when there is Liver Wind. If the entire face of a pregnant woman is
bluish, this is a sign of xue stagnation and yang xu. This is an adverse sign.
Red
The red colour will always indicate the presence of Heat. Shi Heat will cause
the cheeks or the entire face to become red or ruddy, whereas xu Heat will result
in the cheekbones and the region around them becoming red. The red colour in yin
xu will also be thinner and look more like make-up brushed on to the surface of the
skin. Heat can also result in the eyes becoming red.
Black
The black colour includes a very dark complexion, as well as black. The dark
complexion will be a sign that there is Kidney xu, Cold, Damp-Phlegm or xue
stagnation. When there is Kidney yin xu, the skin will be dark and dry. When there
is Kidney yang xu, the skin will be dark and moist. Damp-Phlegm or Damp-Cold
can result in the area around the eye becoming dark. If the colour is very dark, then
there may be xue stagnation.
Yellow
The yellow colour is seen when there is xue xu, Damp, Damp-Cold and Damp-
Heat. Xue xu can result in the face being pale and wan with a slightly yellowish tinge.
Shen accompanies xue as it circulates around the body. If there is xue xu, the face will
therefore lack radiance and lustre.
The yellow colour resonates with the Earth Phase. When there is Spleen qi xu,
it can sometimes manifest with a yellowish hue in the facial complexion if there
is Dampness at the same time. Damp-Heat imbalances will also manifest with a
yellowish tinge to the face. Damp-Heat can arise when there are Spleen imbalances,
but also in other organs, for example jaundice is often seen when there is Damp-
Heat in the Liver and Gall Bladder. The yellow hue will often be seen in the facial
complexion, as well as the sclera of the eyes. The more Heat that there is present, the
brighter the yellow colour will be. If there is Damp-Cold, the complexion will be
darker and more smoky. If the face is dry and yellowish without radiance, there may
be pathological Heat in the Stomach or Spleen.
Purple
The purple colour is seen when there is extreme xue stagnation and poisoning.
As with the tongue, the purple colour is differentiated according to whether the
complexion is reddish-purple or bluish-purple. Heat can condense xue and thereby
59
stagnate it. This will be seen with a reddish-purple complexion. Cold will congeal
xue. In this case the facial complexion will be bluish-purple.
Facial colouration
Normal colour No disease or a disease of shorter duration and with a good prognosis
White Qi xu, yang xu, xue xu and Cold
Red Heat
Blue/green Pain, qi stagnation, Cold, Heart xue stagnation or Wind
Yellow Damp, Damp-Heat, Damp-Cold or Spleen qi xu
Black Kidney yin xu, Kidney yang xu, Damp-Cold, Damp-Phlegm or xue stagnation
Purple Xue stagnation or poisoning
Greyish Phlegm
Facial areas
In classical texts such as Huang Di Nei Jing – Su Wen and Huang Di Nei Jing – Ling
Shu there are descriptions of the facial areas and the internal organs that these areas
relate to. An imbalance in a zangfu can manifest with changes to the colours or
the skin in these areas. There are significant discrepancies between these two texts,
as well as between other sources, with regards to the diagnostic relationship of the
various areas of the face and the internal organs. Figure 1.1 shows the positions of
the zangfu organs in the face according to Huang Di Nei Jing – Ling Shu Difficulty
forty-nine, but, as written, there are many different interpretations of the diagnostic
significance of these areas.
Tics
Tics occur when there is internal Wind in the muscles. The Wind makes qi become
chaotic in its movement and thereby lose control of the muscles. The Wind will be
internally generated and will always be related to Liver imbalances. This also explains
why tics can often develop or worsen when a person is stressed or emotionally affected.
60
Lung
Heart
Liver
Gall Gall
Small Intestine Bladder Bladder Small Intestine
Kidney Kidney
Stomach
Large Intestine Large Intestine
Spleen
Stomach Stomach
U.B. / U.B. /
Uterus Uterus
Kidney Kidney
Figure 1.1 Positions of the zangfu organs in the face according

to Huang Di Nei Jing – Ling Shu Difficulty forty-nine
Visual diagnosis of the eyes

Before discussing the eyes as a diagnostic tool, it is important to state that it is
the Chinese medicine version of eye diagnosis that should be utilised in a Chinese
medicine diagnosis. Whilst iris diagnosis is an effective and precise diagnostic tool,
it should not be used as part of a Chinese medicine diagnosis. This is because iris
diagnosis is based on the Western medicine anatomical and physiological model.
This means an observation of an imbalance in the kidneys, for example, in iris
diagnosis does not necessarily mean that the Kidneys, as understood in Chinese
medicine, have an imbalance and need treatment. Conversely, one can imagine a
situation in which there is an obvious pattern of Kidney yin xu or Kidney yang xu
without this manifesting as a problem in the person’s physical kidneys, and therefore
this will not register with changes in the iris. It is important to keep the diagnostic
tools from different physiological and pathological systems separate, otherwise there
is a risk of formulating a treatment principle based on a false premise.
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There are many different aspects and levels to ophthalmic diagnosis. Most of us
have taken advantage of some of these, even before we started learning and practising
Chinese medicine. Chinese medicine has just taught us to focus our attention on
these signals and systematise the information that they give us.
Shen
One of the first things we determine, both consciously and subconsciously, on
meeting a person is how much vitality and radiance there is in their eyes. From a
Chinese medicine perspective, this will inform us about the person’s shen. In the
same way that we in the West say that the eyes are the windows of the soul, Chinese
medicine states that shen can be observed in a person’s eyes.
There are two definitions of shen that are relevant here: shen meaning vitality and
radiance and shen meaning spirit/mind/consciousness.
A person who is in good health will have eyes that are bright and sparkling. It
is possible to have direct eye contact with them and this will feel comfortable for
both persons.
A person with Heart qi xu will have difficulty maintaining, or feel uncomfortable
with, direct eye contact. This is because their shen is undernourished and they are
therefore often very shy; direct eye contact can feel too intense for them. It can also
seem as if there is just too little sparkle in their eyes; it can remind you of the eyes of
a person who is exhausted. The shen is simply not shining brightly enough.
It can also be difficult to have eye contact with a person who has Heart and Liver
qi stagnation, due to the lack of movement of their hun and shen. The difference
between this and the former situation is that a person with Heart qi xu will have a
tendency to look away and they will lower their gaze when you look directly into
their eyes. In a person with Heart and Liver qi stagnation, it will seem as if they are
staring inwards, are unable to look outwards and are locked within themselves. This
is reflective of their mental condition. Their hun, which normally looks forwards and
outwards, is inhibited in its movement by the stagnation, and the person can have
difficulty in seeing a future for themselves.
An over-active Liver can in turn result in a person having very intense, rigid
staring eyes. They stare at you and instinctively you want to look away from them
because their gaze is too intense and piercing. In this case, the hun is over-active. It is
very focused on a goal or its own individual vision of the future. This type of person
is used to being in control and getting their own way.
When Heat agitates the shen, it becomes restless and the person can be manic.
Their eyes will become restless and frenetic. This is because ‘hun follows shen in its
entering and exiting’. When shen is agitated and thereby over-active, hun is forced
to follows its movements. This results in eyes that are constantly shifting their point
of focus in the room.
When shen is obscured and blocked by Phlegm, it can have difficulty radiating
outwards, thereby creating a barrier in making contact with other people’s shen.
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The eyes will appear matt and blurry. The person will often have the feeling that they
are not fully present and in touch with the outside world. It is as if they are sitting in
a bell jar or there is a mist between their eyes and the outside world.
Observation of the eyes

Lack of eye contact Heart qi xu
Staring and piercing eyes Liver shi imbalances
Darting or restless eyes Heat agitating the shen
Blurry or matt eyes Phlegm blocking the shen
Lack of brightness Liver and Heart qi stagnation, Heart qi xu
The zones in the eyes

The eyes can be divided into different zones, as with the ears, feet and other parts
of the body. When there are colour changes in these areas of the eye, this can tell
us something about the corresponding zangfu organ. It is important to remember,
though, that the condition of other organs may also affect these areas. A condition
of Heat, even though it is not in the Lung, will make the sclera in the eye redden
and become bloodshot. Heat’s yang nature means that it will always rise upwards and
therefore all forms of Heat in the body can affect the sclera of the eyes.
The zones in the eyes

Zone Significance
The pupil The Kidneys
The iris The Liver
The sclera The Lung
The canthus The Heart
Lower eyelid The Stomach
Upper eyelid The Spleen
The colours in the eyes

Various imbalances can affect the eyes. Although the eyes, when taken as a whole,
relate to the Liver, the colours in the eyes can be affected by other organs and by
xie qi.
Heat, especially shi Heat, will make the eyes red. Heat is yang in nature and
therefore rises upwards. Systemic Heat, unless it is bound together with Dampness,
will always rise up to the upper part of the body and to the head. This is why it is
most often the head and not the lower part of the body that manifests symptoms
and signs of Heat.
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Heat manifesting with a redness of the eyes will often have its root in Liver Fire,
Stomach Fire or an invasion of exogenous Wind-Heat. The Heat can be so intense
that it affects the fluids in the eye. This will result in dryness as the body fluids
evaporate from the area or in an inflammation when the Heat is so intense that it
becomes ‘Toxic-Heat’.
Yellowish eyes result from conditions of Damp-Heat. Xue xu and xue stagnation
can also cause the eye to turn yellowish.
Less common, but still of relevance, are the colours green and blue. A bluish tinge
to the eyes may be a sign of Cold and greenish tinge may indicate Liver Wind.
Colours in the eyes

Red Xu and shi Heat
Yellow Damp-Heat, xue xu or xue stagnation
Blue Cold
Green Liver Wind
Inflammation and styes

Inflammation and styes in the eye have two main root causes. They can result from
an invasion of Wind-Heat or when Heat that has been generated internally rises
up to the eye. Often the Heat will have ascended from the Stomach via its channel
connection to the eyelid. The Heat can damage the fluids and be so intense that it
generates Toxic-Heat.
Tears and mucous in the eyes

In theory, sleep and secretions of mucous in the eyes can be observed by the therapist,
although this is not usually the case in practice because the person will often have
removed it before you meet them. This means it is best to ask the patient about
it instead.
In the same way that Phlegm can accumulate in the Lung or in the respiratory
passages, it can also accumulate in the corners of the eyes. This is because the corner
of the eye is a cavity in which there is a limited flow of qi. Fluids can stagnate in this
cavity and turn into Phlegm. This can be seen in the morning after the eyelids have
been closed for several hours, resulting in a lack of movement of qi in this area. A
person with a tendency to have Phlegm may often experience small blobs of mucous
in the eyes forming throughout the day.
Watering eyes can be due to the circulation of fluids in the area being disturbed
by exogenous xie qi or a Liver imbalance causing the movement of fluids in the eyes
to become chaotic. Liver imbalances that lead to the eyes watering can be both xu
and shi in nature. The tears may be spontaneous, but they will often arise when the
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eyes are exposed to wind or draughts. This is consistent with the fact that the Liver,
wind, the eyes and tears are all aspects of the Wood Phase in Chinese medicine.
Secretions and mucous in the eyes

Sleep and mucous in the eyes Phlegm
Watering eyes Liver imbalances, Wind-Cold or Wind-Heat
Styes and inflammation Wind-Heat, Stomach Fire
Visual diagnosis of the area around the eyes

The area around the eyes includes both the eyelids and the area just below the eyes.
Visible changes in the colour of the skin and in the moistness of these areas may be
observed. Attention should also be paid to the presence of oedema or puffiness in
the area around the eyes.
Colour
The colours most often observed in this area are black, green, blue/green, yellow,
red and white. Changes in skin colour will most often be fairly subtle – often only
a slight tinge.
Blackness of the skin around the eyes usually indicates a Kidney imbalance. The
colour in this case must be seen in relation to the moistness of the skin in the area.
If the skin is black and moist, then this can be a sign of Kidney yang xu. There may
well also be puffiness as a result of a slight oedema in the area. This will be due to
the inability of the Kidneys to transport body fluids away from the area. If the skin
is dry, there may be Kidney yin xu. A black colour can be easily confused with the
blue/green (qing) colour, therefore you should, as always, compare this characteristic
with the other signs and symptoms.
A dark, dusky colour around the eyes can also arise when Phlegm or Dampness
block the movement of qi and xue in the fine network of vessels in this area.
Blue/green and green around the eyes is usually a sign of Liver qi stagnation.
The difference between these two colours is an indicator of the degree of the Liver
qi stagnation that exists. Liver qi stagnation can result in xue not circulating in the
fine network of vessels as it should. Because the skin around the eyes is very thin and
almost transparent, it will be easier to see the stagnation of xue here than in other
areas of the body. The stronger the qi stagnation, the more xue will stagnate. The
blue/green colour indicates a stronger stagnation of qi than the green colour does.
A purple colour indicates xue stagnation.
Redness around the eyes is a sign of Heat, generally xue Heat. The redness can
also be a sign of Damp-Heat. In this case, the skin will often weep or flake as is seen
in fungal infections of the skin.
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Whiteness can be shiny, pale or pallid. A shiny whiteness around the eyes can be
seen in an invasion of Wind-Cold. Pale or pallid skin around the eyes is a sign of xue
xu. The sallow complexion here can almost be yellowish.
As is the case with the lips and the face in general, the use of make-up can negate
the diagnostic observation of these areas.
The colours around the eyes

Black and dry Kidney yin xu
Black and moist Kidney yang xu
Dark brown, dusky Phlegm or Dampness
Blue/green (qing) or green Liver qi stagnation
Redness Heat
White and shining Cold
White, dry and sallow Xue xu
Purple Xue stagnation
Puffiness (including ‘bags’ under the eyes)

The area around the eyes may be swollen and puffy due to the presence of accumulated
fluids. In chronic cases it may result in ‘bags’ under the eyes. If the condition is
acute, this will usually be due to an invasion of Wind-Cold or Wind-Heat. This xie
qi can disturb the Lung’s ability to spread and distribute the thin fluids, so these then
accumulate in the Lung. At the same time, xie qi will block the Lung in its function
of sending qi downwards. Lung qi can then become rebellious and rise upwards. The
rebellious qi will carry the accumulated fluids upwards with it, resulting in puffiness
in the face, especially in the area around the eyes where the flesh is very thin.
If the puffiness is a chronic condition, it will probably be a manifestation of
Spleen or Kidney yang xu. Spleen and Kidney yang are responsible for transporting
and transforming fluids. If there is yang xu in either of these organs, there will be an
accumulation of fluids. The result will then be bags below the eyes. As it is a xu
condition, the bags will be more noticeable and pronounced when the person is
tired or has overstrained themselves.
Visual diagnosis of the forehead, the root of the

nose and the area between the eyebrows
Observation of the forehead and the area above the bridge of the nose between
the eyebrows is particularly useful in paediatric diagnosis, but these areas can also
provide relevant information when diagnosing adults.
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I will start by discussing the relevance of changes in these areas in children. The
area between the eyebrows (above the root of the nose) has particular diagnostic
significance in children who are below the age of four. If the root of the nose is
greenish, there will often be digestive problems. A dark green colour can sometimes
be seen when there is an excessive accumulation syndrome and a light green colour
if the accumulation syndrome is due to a xu condition.
Green macules in this area are sometimes seen when there is diarrhoea. Blue
veins in the region can be seen when there is abdominal pain.
The forehead of small children should also be observed. If there is a bluish colour
here, it can indicate that the mother has been exposed to a strong shock during
pregnancy that may have affected the foetus’s Heart qi. Post-natal shock and Cold
will also be be capable of producing a blue colour in this area.
In adults we should observe the colour of the forehead and the bridge of the nose,
as well as noting the amount and distribution of wrinkles or lines in the forehead
and between the eyebrows.
If the skin of the forehead is red and dry, there can be Heat in the Urinary
Bladder. Acne in this area, particularly if the spots are large, red and pus-filled, can
be seen when there is Heat and Damp-Heat in the Stomach and Intestines. The skin
of the forehead will often also be oily when there is Damp-Heat. Small red spots on
the forehead can be indicative of Stomach Fire.
If there is a single deep, horizontal line on the forehead, it can indicate a chronic
Small Intestine imbalance. Multiple horizontal wrinkles or lines in this area can be
seen when there is Spleen qi xu.
A single vertical furrow between the eyebrows can be seen when there are chronic
Stomach imbalances, whereas two vertical lines or wrinkles between the eyebrows
are indicative of Liver qi stagnation.
Liver xue stagnation can result in the bridge of the nose being dark and yellowish,
whereas Liver xue xu and Lung qi xu can result in this area being paler than normal.
Observation of the forehead and root of the nose

Single deep, horizontal furrow or wrinkle on the forehead Chronic Small Intestine imbalance
Multiple horizontal furrows or wrinkles on the forehead Spleen qi xu
Single vertical furrow or wrinkle between the eyebrows Chronic Stomach imbalance
Two vertical furrows or wrinkles between the eyebrows Liver qi stagnation
Dry, red forehead Heat in the Urinary Bladder
Large, red, pus-filled spots on the forehead Damp-Heat in the Stomach and
Intestines
Small red spots on the forehead Stomach Fire
Oily skin on the forehead Damp-Heat
Dark and yellowish bridge of the nose Liver xue stagnation
Pale bridge of the nose Liver xue xu or Lung qi xu
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Dark green between the eyebrows in small children Shi accumulation syndrome
Light green between the eyebrows in small children Xu accumulation syndrome
Green macules between the eyebrows in small children Diarrhoea
Blue vein between the eyebrows in small children Abdominal pain
Dark green between the eyebrows Accumulation syndrome
Light green between the eyebrows in small children Xu accumulation syndrome
Visual diagnosis of the nose

The nose is under the influence of the Lung and has a channel connection with the
Large Intestine, du mai, Stomach and Urinary Bladder channels. Secretions from
the nose are differentiated in the section ‘Observation of secretions, excretions
and exudations’ (page 113). The colours on the nose have a diagnostic relevance,
in relation to not only the Lung, but also the Stomach, Spleen, Liver, Heart and
Gall Bladder.
A pale nose tip will be a manifestation of Stomach and Spleen qi xu. If the tip is
pale and swollen, there may be an accumulation of Phlegm-Fluids.
If the bridge of the nose is pale, this will be a sign of Liver xue xu or Lung qi xu.
A yellowish nose can be seen when there is Damp and Damp-Heat. When there
is Damp-Heat the yellow colour be more intense.
Liver xue stagnation can result in the bridge of the nose being dark and yellowish.
A red nose can be seen when there is Heat. If the upper part of the nose is red,
the Heat is in the Lung. The middle part of the nose can be red when there is Heat
in the Liver and the tip can be red if there is Heat in the Spleen or xu Heat. A red
nose can also be seen when there is Wind-Heat.
If the nose is not red but reddish-purple in colour, this will be a sign that the
Heat has stagnated xue.
Liver xue stagnation can result in the nose having a green/blue tinge.
Both Phlegm and Cold can create stagnation where the tip of the nose becomes
bluish in colour when these are present.
Dark or an almost black nose can be seen when there is extreme Heat, xue
stagnation or Kidney xu conditions.
When there is Lung Heat, the nostrils may ‘flap’ as the Lung tries to create a
greater circulation of air around its sense organ and thereby dissipate the Heat.
Bleeding from the nose may occur when Spleen qi is weak and cannot hold xue
inside the blood vessels or when Heat agitates xue and causes the walls of the blood
vessels to burst due to the pressure.
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Observation of the nose

Pale nose tip Spleen qi xu
Pale and swollen nose tip Phlegm
Pale bridge of the nose Liver xue xu or Lung qi xu
Red nose Heat
Reddish-purple nose Stagnant xue due to Heat
Green/blue nose Liver xue stagnation
Blue nose tip Phlegm or Cold
Flaring nostrils Lung Heat
Nose bleeds Spleen qi xu or Heat
Visual diagnosis of the ears

In the same way that the eyes are an aspect of the Liver but are influenced by
many other organs in the body, the ears are an aspect of the Kidneys. The Kidneys,
especially Kidney jing, have a direct influence on the ears, but several other organs
can also influence the ears via their channel connections. Each of the yang channels,
for example, connects to the ears, either via the main channel or via their internal
and sinew channels. The ears can be invaded by exogenous xie qi or disrupted by
internally generated xie qi.
The shape of the ears

The ears are created from and nourished by Kidney jing. The shape, size and texture
of the ear can therefore relay information to us about the person’s constitution.
A small ear can be a sign of jing xu. If the ear appears shrunken, it can be a sign
of jinye xu or yin xu.
If the ears are inflamed or swollen, this may well be a sign of Damp-Heat or
Heat forcing body fluid up to the ears.
Pain in the ears can be a sign of Heat in the Liver and Gall Bladder or an invasion
of exogenous xie qi. It can also be a sign of an imbalance in the body or body part
that corresponds to a specific area of the ear.
Discharges from the ear

An increased production of wax in the ear can be a sign of Damp or Damp-Heat,
in which case the increased exudation will be thick and sticky. More watery wax can
indicate Spleen or Kidney yang xu, because jinye is not being transported optimally
and collects in the ears.
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Inflammation of the ear may arise when there is either an invasion of Wind-Heat
or Damp-Heat in the Liver and Gall Bladder. Damp-Heat in the Liver and Gall
Bladder can be both chronic and acute in nature. Wind-Heat will always be acute.
In both cases, the discharge will be yellowish and sticky.
If the discharge from the ear is more watery and clear, it will be due to Spleen qi
xu creating Dampness, which has then accumulated in the ear.
Kidney yin xu can also manifest with a thin, watery secretion from the ear.
As with other excretions, information about this will probably be gained by
interviewing the client, rather than direct observation, because the client will
probably have cleaned their ears due to these secretions.
Observation of the ears

Small ears Jing xu
Shrunken ears Jing xu or yin xu
Pain in the ear Liver and/or Gall Bladder Heat
An imbalance in the organ or part of the body that corresponds to
that zone in the ear
Inflammation of the ear Invasion of Wind-Heat, Liver/Gall Bladder Damp-Heat
Yellowish sticky earwax Phlegm, Damp-Heat
Thin, watery earwax Spleen qi xu
Visual diagnosis of the lips

In general, the lips are an aspect of the Stomach and the Spleen, but they will also
give an indication of the condition of xue in general, and they can indicate the
presence of Heat and Cold in the body. Du mai, ren mai, chong mai, and the Large
Intestine, Liver, Stomach and Kidney channels all course around or connect to the
lips. This means that the state of these channels can also be seen in this area.
Xue is almost directly visible in parts of the body such as the lips, where the skin
is very thin and delicate. Xue xu can manifest with lips that are pale. This is because
there will be too little xue to give the lips their characteristic rosy, red colour. The
lips in these situations will also often be dry due to the lips not being moistened
and nourished by xue. A tendency to xue stagnation can be seen when the lips are
more purple in colour. This is because xue is moving slowly and is not replenished
with fresh xue. This is similar to Western medicine, where the lips will be darker in
colour when there is poor blood circulation and the blood lacks oxygenation and is
saturated with carbon dioxide. The purple lip colour can be either reddish or bluish,
depending on whether it is a condition of Cold or Heat, which is the cause of the
xue stagnating.
Cold will result in the lips being more blue in colour. This is due to Cold
stagnating the movement of the xue, as well as the yin nature of Cold. The yin
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dynamic of Cold will cause xue to contract inwards to the centre of the body.
This will result in a reduced flow of xue in the superficial network of vessels found in
the lips. This, again, corresponds to the Western medicine physiological explanation
of how cold affects the body. When the body temperature is lowered or the body
is cooled down, there is a reduced movement of the blood in the superficial blood
vessels. This is the body’s attempt to reduce the dissipation of heat to the external
environment, thereby helping to keep the vital internal organs warm.
Very red and full lips will indicate a condition of Heat. This is due to Heat
increasing the circulation of xue and sending xue outwards and upwards to the surface
to cool it down (again, this is an expression of the intrinsic nature of yin and yang,
where Heat is yang and thereby has an upward and outward, expansive dynamic).
A temporary state of Heat can be seen during sexual arousal. When a person
experiences desire or arousal, mingmen blazes up. This generates physiological heat
in the body and can be seen in places such as the lips and nails. For centuries women
have imitated this signal by painting the lips, cheeks and nails red. If a woman
is wearing lipstick during the consultation, it will, of course, hamper the visual
diagnosis of the lips.
The lips can have a yellowish hue when there is Damp present in the body.
Dry lips will logically indicate that there is a state of Dryness. This can be a
local condition, in which case it will not have particular diagnostic significance or
it can be systemic Dryness. When the lips are dry, the colour of the lips will help
differentiate the cause of the dryness. Red and dry lips are a sign of Heat, either yin
xu Heat or shi Heat, the lips being dry as a result of the Heat damaging yin fluids.
Pale lips are a sign of xue xu, the lips being dry because yin xue is not moistening
them. If the lips are very dry, the surface of the skin can crack. Using lip balm will,
of course, veil the dryness of the lips, but the fact that a person needs to use lip balm
can in itself be a diagnostic sign of Dryness.
Very moist lips indicate that the transportation of fluids is disturbed as in an
invasion of Wind-Cold or when there is yang xu.
Weeping sores, such as those seen in herpes simplex, can be a sign of Damp-
Heat in the Liver and Gall Bladder, when Heat is the dominant pathogen. This is
because the Heat will rise up along the Liver channel to the mouth. If Dampness
was the dominant aspect of xie qi, it would be more likely that the symptoms would
have manifested around the genitals. This is because the yin nature of Dampness
means that it tends to sink downwards. The Damp-Heat could also have its source
in the Stomach and Large Intestine channels or it could be due to an invasion of
Toxic‑Heat. Yin xu Heat may in some cases also result in sores around the mouth.
Fine wrinkles around the lips are a sign of yin and xue xu. This is typically seen
in post-menopausal women. This is due to ren mai and chong mai drying out and no
longer overflowing with xue and yin. Ren mai and chong mai both circle around the
mouth, moistening and nourishing the skin here.
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Observation of the lips

Pale Xue xu, yang xu
Very red Heat (both xu and shi)
Pale blue Yang xu, Cold, xue stagnation
Bluish Cold (both xu and shi)
Yellowish Dampness
Dry Heat (both xu and shi)
Cracked Heat (both xu and shi)
Weeping sore Damp-Heat in the Liver, Invasion of Wind-Heat or Toxic-Heat
Stomach Fire, yin xu Heat
Wrinkles around the lips Ren mai and chong mai are xue xu and yin xu
Visual diagnosis of the mouth

Sores around the mouth have been discussed above. Other signs that can have a
diagnostic relevance are distortion of the mouth and saliva from the mouth.
If the mouth is skewed without there being a history of physical trauma in
the region, the distorted shape may be due to an invasion of Wind-Cold blocking
the movement of qi and xue in the local area or Wind-Phlegm creating a chaotic
movement of qi and blocking qi and xue in the area.
If there is a history of physical trauma to the area, the distortion will be due to
local stagnation of qi and xue.
If the person drools from the corners of their mouth, this can be due to Spleen
and/or Lung qi xu. The qi xu results in jinye accumulating in the mouth and an over-
production of saliva.
Internal Wind can cause paralysis of the muscles around the mouth. This means
that the lips cannot hold the saliva in the mouth. In these situations, the saliva will
usually only dribble from one side of the mouth. An invasion of Wind-Cold can
also block the movement of qi in the area, resulting in a unilateral paralysis and
subsequent dribbling from this side of the mouth.
Heat in the Stomach can drive fluids from the Stomach up to the mouth, so that
there is an over-production of saliva. In small children, the pattern of Stomach Heat
can be caused by the accumulation of parasites in the digestive system.
Observation of the mouth

Distortion of the mouth Wind-Cold, Wind-Phlegm, xue stagnation
Dribbling from the mouth Wind-Cold, internal Wind, Spleen and/or Lung qi xu, Stomach
Heat, parasites
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Visual diagnosis of the gums

Like the lips and the tongue, the state of the gums can be used to diagnose conditions
of Heat and xue xu. Furthermore, the gums are under the direct influence of the Spleen
and Stomach. This means that imbalances in these two organs can manifest directly
in the gums. This is also logical when viewed from a Western medicine perspective:
the oral cavity is part of the digestive tract and has evolved from the same tissue as the
stomach in the embryological stage. In practice, this means that a state of Stomach
Fire can manifest with very red, bleeding gums. Bleeding gums can also arise from a xu
condition. Stomach yin xu Heat can also manifest with bleeding gums, as can Spleen
qi xu. In both yin xu and shi Heat, the haemorrhaging will occur because xue has
become agitated by the Heat, rupturing the walls of the vessels. When there is Spleen
qi xu, the Spleen may be unable to hold xue within the blood vessels. There can, of
course, be situations where both of these aspects are present simultaneously. It could
be that the xue is agitated by the Heat and the Spleen is too weak to keep the agitated
xue inside of the blood vessels. The primary diagnostic difference in bleeding gums is
the colour of the gums. In conditions of Heat, the gums will be red. If there is Spleen
qi xu, the gums will be pale in colour. The gums can also be pale if there is xue xu, yang
xu or Cold resulting in a lack of xue in this area.
When there is qi and xue xu, the gums can begin to recede, exposing the roots
of the teeth.
Heat, on the other hand, can damage the tissue, resulting in ulcers in the gums.
Observation of the gums

Pale gums Spleen qi xu
Can also be xue xu, yang xu or Cold
Very red gums Heat (both xu and shi)
Weeping ulcers Damp-Heat, Stomach Fire
Receding gums Qi and xue xu
Visual diagnosis of the tongue

Analysis of the tongue and pulse are some of the most important diagnostic tools
we have at our disposal. The analysis of these two aspects of the body will often be
used to determine a diagnosis, especially when doubt has arisen due to the symptom
picture being contradictory and confusing.
The tongue can provide us with a great deal of information. It provides an
insight into the state of an individual’s qi and xue and the state of the various zangfu
organs, and it is an important tool for differentiating patterns in relation to the
Eight Principles.
Most people find tongue diagnosis easier to learn than pulse diagnosis. This is
because tongue diagnosis is less subjective; with the pulse it is easier to feel doubt.
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You can be uncertain that what you are feeling under the tips of your fingers, and
define as Wiry for example, is the same sensation that another person feels when
they say that a pulse feels like a guitar string under the finger. The tongue is more
objective. It is something you can see with your eyes. A pale tongue with a thick
white coating is a pale tongue with a thick white coating. It is something that you
can compare with a photograph in an atlas of tongue photographs. Pulse diagnosis
requires repeated hands-on training together with an experienced practitioner,
whereas tongue diagnosis can be learned by studying photographs of tongues, with
an explanation of which signs are significant on each tongue.
There is also a greater consensus in textbooks and amongst practitioners about
which organs the various areas of the tongue relate to in the body and the significance
of the changes in these areas. The pulse positions and definitions are much more
open to debate and interpretation between the various systems.
The great strength of the pulse is that it is very precise, but it is also easily
influenced and affected by many factors, which may only have limited diagnostic
relevance. If you run up the stairs, if you are momentarily very irritated or if you
have not slept all night, the pulse qualities will be radically different than if you had
been sitting calmly for half an hour and had had a good night’s sleep. The tongue
though, for all intents and purposes, would remain the same in these situations.
The tongue gives us a good insight into the general condition of the patient. This
is especially true of the tongue body itself. Compared with the pulse, the tongue is
slower to manifest changes. However, the pulse’s ability to change immediately
is also an advantage. For example, you can perceive immediate changes in the pulse
when the body is invaded by Wind-Cold, but changes in the tongue are difficult
to detect in this situation. The pulse can also be used to control and adjust the
needles that have been inserted into the body; again, something that is not possible
with the tongue.
For its part, the tongue is excellent at showing the overall condition of the body
and the imbalances that have affected the body over a longer period of time.
There are also internal variations with regards to how quickly the different aspects
of the tongue can alter characteristics. The colour of the tongue body will not change
as fast as the coating, which can change by the hour during an invasion of the body
by exogenous xie qi. The tongue body’s shape changes more slowly than its colour.
The coating will reflect which influences the body has been exposed to during the
previous hours and days.
There are several reasons that the tongue is such an effective diagnostic tool. To
start with, the tongue is a bodily structure that is simultaneously on both the inside
and the outside of the body. Visually, it is something that can be observed from the
exterior, but it is also a part of the digestive tract and thereby a part of the interior.
The tongue surface consists of a different cell structure than the normal skin. Both
of these factors make it possible to see clearly the quality of xue through the surface
of the tongue. It is possible to observe fluids on and in the tongue body, and you can
see clearly the influence of factors such as Heat and Cold.
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Changes in the pulse and the tongue

Pulse Can change immediately Can indicate what is affecting the body here and now.
It can, of course, also supply information about long-
term influences and changes, because these are the
foundation for what is happening right now
Tongue Can change over the course Indicates which aetiological factors and imbalances
shape of weeks and months have affected the body over a longer period of time
Tongue May change during the Indicates which imbalances and aetiological factors
colour course of the day and from have affected the body in recent days. Again, as with
day to day the pulse, chronic imbalances will also be seen, as they
are part of the current situation
Tongue Can change by the hour Can indicate whether the aetiological factors and
coating imbalances are chronic or acute
The tongue is directly under the influence of the Heart. The tongue is supplied
with xue and qi via the Heart luo mai. Shen, which has its residence in Heart xue, is
conscious of everything that is happening and in all changes that take place in the
body. The shen will therefore influence the tongue via Heart xue. Apart from the Heart
luo mai vessel, most channels have a branch that connects to the tongue. The Kidney
channel terminates in the root of the tongue. The Spleen channel has an internal
branch that connects with the tongue. The Liver, Stomach, Urinary Bladder and
san jiao all have divergent channel connections with the tongue. The only channels
that do not directly connect to the tongue themselves are the Lung, Large Intestine,
Small Intestine and Gall Bladder channels. They connect to the tongue through
either their partner channel or deep, internal channel connections. This means that
changes in zangfu organs and their channels can be seen in the tongue.
The tongue coating is created from the impure residue that is sent upwards by
the Spleen along with gu qi after transformation processes have taken place in the
Stomach. The tongue therefore clearly shows the condition of the Stomach qi.
Finally, there are various micro-systems on the exterior surface of the body, where
one can both treat and diagnose imbalances in the body. These are places where the
whole body is reflected in a small, distinct area. This is clearly seen, for example, in
the ear. These micro-systems exist because everything in the universe has an energetic
resonance; things will resonate and influence other objects that have the same
energetic vibration. This is also true of the body. Specific areas within the body can
therefore be affected by changes elsewhere in the body. This means, for example, that
when the Liver has been energetically or physically influenced, it can be observed
and palpated in many parts of the body that resonate with the Liver, including
observable changes on the side of the tongue.
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The topography of the tongue

The tongue, as with many other parts of the body, reflects the condition of the
various internal organs. This is seen in both the tongue’s general appearance and
changes in specific areas of the tongue.
There are three basic models that depict what the various areas of the tongue
represent. The models are not intrinsically contradictory but support and supplement
each other.
In the first model, the tongue is divided into three zones. Each zone represents
one of the three jiao. The upper jiao can be seen in the front third of the tongue, the
posterior third of the tongue is the lower jiao and in between them is the middle jiao.
Lower jiao
Middle jiao
Upper jiao
Figure 1.2 Positions of the three jiao on the tongue
In the second model, the front and the sides of the tongue are the areas that will
manifest changes if there is an invasion of xie qi in the exterior. The areas that are
inside of and behind these areas will reflect the body’s interior. These areas will
manifest changes if exogenous xie qi penetrates into the interior.
In the third model, the imbalances in the various zangfu organs manifest in
specific areas of the tongue. It is important to remember that this model reflects an
organ’s physical location in the body and not its energetic or functional location.
This means that the Liver, which physiologically belongs in the lower jiao, is to be
found in the middle jiao area of the tongue (something that is also seen in its pulse
position). This is in accordance with its anatomical location in the body. Some sources
place the Liver on the left side of the tongue and the Gall Bladder on the right side;
other sources assign both sides of the tongue to the Liver and Gall Bladder jointly. I
personally utilise the latter in practice, as imbalances in the Gall Bladder channel are
usually caused by Liver imbalances, and therefore both organs are involved and will
be reflected on the tongue. Likewise, the very centre of the tongue is often assigned
to the Stomach and the area around it to the Spleen, but the whole central area can
also be seen as being representative of the Stomach and Spleen.
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Xie qi in the
interior
Xie qi in the
exterior
Figure 1.3 Areas of the tongue that reflect how deep an invasion
of exogenous xie qi has penetrated into the body
Similarly, some sources divide the root of the tongue into four zones – Kidneys,
Urinary Bladder, Small Intestine and Large Intestine – whilst other sources define
the whole area as corresponding to all four organs at the same time. Again, I mostly
utilise the latter interpretation. In clinical practice you must compare the tongue
with the rest of the symptoms and signs. This will help to define which of these
organs is manifesting on the root of the tongue. The Kidneys only have xu patterns of
imbalance; conversely, the other three organs on the root tend towards shi patterns
of imbalance. This means that if the root of the tongue, for example, has a greasy,
yellow coating with raised papillae, it indicates that there is Damp-Heat present in
the lower jiao. The Kidneys do not have a pattern of Damp-Heat, therefore it must
be one of the other three organs that are manifesting Damp-Heat. If the person
has a burning sensation when urinating, this will confirm that it is the Urinary
Bladder and not the Intestines that is affected by Damp-Heat. On the other hand,
if the person has diarrhoea, the Damp-Heat will not be in the Urinary Bladder but
in the Intestines. If the root of the tongue is peeled and lacks coating, this indicates
a yin xu condition. This will therefore be more indicative of a link to the Kidneys,
rather than the Intestines or Urinary Bladder.
One must always remember that it is not only the zangfu organs, but also
the three jiao that can be seen on the tongue. For example, a general condition
of the Damp-Heat in the lower jiao could manifest on that area of the tongue.
The tip of the tongue reflects the Heart and the area behind the tip reflects the
the Lung. The centre of the tongue manifests the Stomach and Spleen. The sides
of the tongue reflects the condition of the Liver and Gall Bladder and the root the
lower jiao organs – Kidney, Urinary Bladder and the Intestines.
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Large Intestine
Small Intestine
Kidney Urinary Bladder
Liver Liver
Gall Bladder Stomach Spleen Gall Bladder
Lung
Heart
Figure 1.4 Areas of the tongue that reflect

the condition of the various zangfu organs
Tongue diagnosis according to the Eight Principles

Changes in the tongue can give a quick overview of diagnosis according to the Eight
Principles.
The tongue and the Eight Principles

Significance Observation
Exterior No changes in the body of the tongue
The coating can manifest change
Interior The structure, form and colour of the tongue can have changed
The coating will be affected in some way
Cold Pale or bluish tongue body, white coating
Heat Red tongue body, yellow coating or no coating
Dry tongue
Xu Qi xu – pale or swollen tongue body
Yang xu – pale or bluish tongue body
Xue xu – pale, thin tongue body and/or dry surface of the tongue
Yin xu – red tongue body, cracked, dry, lacks coating
Shi Thick coating
Optimal conditions for observing the tongue

There are various factors to take into consideration when observing the tongue that
can influence its appearance.
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• Consumption of various food and beverages can colour the coating on the
tongue, leading to a false impression of how the coating looks. The following
are typical examples of things that will affect the colour of the tongue:
coffee, cigarettes, wine, liquorice, certain sweets, beetroot and Chinese
herbal medicine, as well as spices such as turmeric, paprika, saffron, etc.
It is therefore a good idea to ask the person whether they have ingested
anything that could have affected the tongue colour, especially if the colour
of the tongue is different to what you were expecting to see or when the
colour is in contrast to the rest of the diagnostic picture.
• Many kinds of Western pharmaceutical medicine can affect the tongue.
Whilst changes created by things that dye the tongue have no diagnostic
relevance, as they will not have affected the physiology of the body, the
changes created by medicines are relevant to the diagnosis. This is because
medicine by its very nature affects the body’s physiology, which creates a
change in the tongue’s appearance; therefore these changes in the tongue’s
appearance are diagnostically relevant. Antibiotics, for example, have a very
cold energy and create Dampness in the body. When a person has been
treated with antibiotics, they will often have a thick, white or a geographically
peeled tongue coating. This is not a false sign and something that should be
ignored when diagnosing the tongue; on the contrary, it tells us about the
current situation, which will have relevance in the treatment of the patient.
Likewise, some asthma sprays are hot and spreading in their dynamic. The
long-term use of these sprays can result in a tongue whose front third is
reddish and slightly peeled. Even though it is the medicine that is the cause of
this change in the tongue’s appearance, it is an indication that the medicine
has injured the patient’s Lung yin.
• It is increasingly common for people to brush their tongues. Removing the
coating on the tongue makes the diagnosis more difficult and the conclusions
more fraught with uncertainty. You should request that the patient does not
brush their tongue in the days prior to a consultation, so that you can get
a truer picture of their condition. It can sometimes be a diagnostic sign in
itself that the person brushes their tongue. Dampness and Phlegm will often
manifest with a thick, sticky tongue coating. This can result in an unpleasant
sticky sensation in the mouth and the person may well brush their tongue to
rid themselves of this unpleasant sensation.
• Lighting is important. The tongue should be well illuminated during
inspection, preferably being viewed in natural light. Direct sunlight is
optimal, but unfortunately most of us do not have clinics with panorama
windows, and we do not live in the south of France but in countries with
limited sunshine. Furthermore, many patients book appointments after
work when it is dark. We must therefore view the tongue using sources of
light other than sunlight. Halogen lighting is one of the best alternatives,
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but it is far from perfect. Energy-saving light bulbs and fluorescent lighting
are, on the other hand, some of the worst alternatives, as they seriously affect
the appearance of the colours. I normally observe the tongue in either the
daylight that is available or illuminated by an ordinary light bulb and I then
inspect the tongue using a torch with a halogen bulb. The advantage of using
the torch is that I can focus the beam of light on specific areas of the tongue
and on the root of the tongue, which is otherwise difficult to illuminate. It
is a good idea to train yourself to look at various tongues, first in ordinary
daylight and then with the light source that you will be using in your
consulting room. This will give you an idea of how the tongue’s colouration
is affected by this particular light source.
• The tongue should be relaxed during inspection. It is better to get the
patient to show you their tongue several times for a short duration (about
15 seconds each time) than to make them sit with their tongue hanging out
for five minutes whilst you analyse everything you can see and consider the
implications of any changes – it is both unpleasant and strenuous for
the patient. It will also affect the colour and moistness of the tongue, thereby
giving a false impression.
When analysing the tongue, it is important to remember that all aspects of tongue
diagnosis are indispensable and that you should not see any aspect as being separate
from the whole. This is because the various pieces of information must be seen in a
context and as a part of a whole picture. This is particularly important, as most signs
can have multiple interpretations depending on what other signs are present. A pale
tongue body, for example, can be a sign that there is yang xu, shi Cold, qi xu or xue
xu. Knowing that the tongue is pale therefore does not give enough information for
us to be able to treat the patient. We must compare the tongue body’s colour with
other aspects of the tongue, especially the tongue body shape and the thickness,
colour and distribution of the coating. In this example, the pattern of imbalance will
be shi Cold if the pale tongue has a thick, white tongue coating. If there is xue xu,
the tongue will not only be pale, but also thin and dry. Yang xu will manifest with
a tongue that is pale, swollen and wet, whilst if there is qi xu in a specific zang organ,
then the shape of that area of the tongue may be affected, as well as being pale.
All the information and signs that can be seen on the tongue can initially seem
confusing and overwhelming. This will lessen if you proceed logically in your
inspection and analysis. It is important that you are systematic, so that you are
certain that you have observed all the relevant signs. I recommend having a checklist
in the intake journal to ensure that you have observed and noted all relevant aspects
of the tongue.
Remember to record the tongue body’s colour, shape, size and structure, as well
as variations between the various areas of the tongue body: the tongue coating’s
colour, thickness, distribution, moisture and quality; the movement and flexibility
of the tongue; the tongue’s vitality. Note each aspect separately and then compare
the pieces of information with each other.
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Something that is very important to remember is that the tongue reflects the
body as a whole and can reflect several patterns of imbalance simultaneously. This
means that even if there is a certain pattern of imbalance, if the tongue is manifesting
another pattern of imbalance that veils these signs, it may not be very obvious. For
example, the classic xue xu tongue should be thin, pale and dry, but if the condition
of xue xu is due to Spleen qi xu, the tongue may well be pale, swollen and wet, thus
negating the signs of dryness and thin tongue body.
The amount of information you need to take into account when you diagnose
the tongue can seem overwhelming. Personally, I think that instead of laboriously
learning by heart all the various colours, shapes, coatings, etc. and what each of these
signs indicate, it is easier to try and think about how these changes will have arisen,
i.e. what dynamic processes create these changes. For example, if the tongue is pale,
instead of having to remember that a pale tongue is a sign of qi xu, xue xu, yang xu
and shi Cold, you can think to yourself: Why does the tongue look pale? What could
the dynamic be behind this change? The tongue can be pale because there is too little
xue in the tissue of the tongue. This lack of xue in the tissue can be because there is
too little xue in the body in general, i.e. a pattern of xue xu, or because something
is either preventing the xue from reaching the tongue – shi Cold – or xue is not
being lifted up to the tongue – qi xu or yang xu.
Shen
The first impression we get from the tongue is whether there is shen. Shen in this
context means vitality and refers to the general appearance of the tongue. It is the
same kind of shen that we talk about as being visible when the eyes or face have shen.
A tongue with shen radiates vitality, flexibility and is not limp or stiff. The tongue
should radiate the same energy that a live fish has, not a fish that has been lying
around for a couple of days on a fishmonger’s slab.
Shen in this context is mainly used for prognosis. A tongue with shen means that
although there may be many signs of a serious imbalance in the body, the patient’s
zheng qi is still strong and xie qi is not deeply rooted. This means that the imbalance
can be rectified. The absence of shen in these situations, though, is serious and can
indicate that the condition is deep rooted and therefore more difficult to rectify.
Tongue colour
The tongue colour refers to the colour of the tongue body itself and not the coating.
If the coating is so thick that you cannot see the tongue body, the colours on the
underside of the tongue may give an indication of the colour of the tongue’s surface.
The colour of the tongue can be used to diagnose conditions of Heat, Cold, yin xu,
yang xu, qi xu and xue xu, as well as the state of the zangfu organs. The colour of the
tongue can give an idea of how deep xie qi has penetrated into the body. The colour
should always be seen in relation to the shape of the tongue. These two aspects
cannot be seen separately from each other and they are the single most important
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aspect of tongue diagnosis. In cases where you are unsure of your tongue diagnosis
because of conflicting information, it is the tongue’s colour that should determine
the diagnosis, because it is the most important aspect. This is because the colour
of the tongue body reflects the long-term influences and the underlying patterns of
imbalance.
Five pathological colours have traditionally been differentiated on the tongue:
pale, red, dark red, purple and blue.
The overall colour of the tongue should be noted, as well as any colour changes in
specific areas. The colour of the tongue as a whole will reflect the general condition
of the body, and changes of colour in the specific areas of the tongue will relate to
imbalances in these areas of the body, especially the zangfu organs that these areas
pertain to.
Pale tongue
A tongue will be pale when there is not enough xue circulating in the it. This may be
due to there being too little xue in the body in general – xue xu (and possibly qi xu),
there being too little qi or yang to transport xue up to the tongue or there being
something (Cold for example) that is blocking xue from reaching the tongue. It is
necessary to compare the colour of the tongue with the shape of the tongue body,
as well as the coating and the moistness of the tongue, in order to determine which
pattern is involved. Xue xu will make the tongue not just pale, but also thin and
dry. There is a rare situation in which yang xu can also result in a pale and dry
tongue. This is when the yang is so weak that it is unable to transport fluids and xue
up to the tongue and therefore the tongue is dry.
A yang xu tongue will not only be pale, but it will also be swollen and wet, as
will a qi xu tongue. This means that you will have to compare the tongue with the
patient’s pulse and ask the patient relevant questions that can help to differentiate
these patterns, such as whether they have an aversion to cold.
If there is shi Cold, the tongue can be pale with a thick, white and wet coating.
It is very common for the side of the tongue to be paler than the rest of the
tongue. This is a manifestation of Liver xue xu. The sides of the tongue can also have
a pale orange hue when there is Liver xue xu.
Red tongue
The presence of Heat can turn the tongue red. This is because the yang nature of
Heat drives xue upwards to the surface of the body. In Western medicine physiology,
the body opens and increases the flow of xue in the exterior aspects of the body
when the temperature rises, enabling blood to dissipate some of the heat to the
surroundings. This means that the tongue will be more red in colour. The opposite
is the case when the body is too cold (yang xu Cold and yin shi Cold in Chinese
medicine). In these situations, the tongue will be pale in colour due to the reduced
amount of xue in the superficial blood vessels.
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The whole of the tongue may be red, or it may only be specific areas of the
tongue that are red. If an isolated area of the tongue is redder than its surroundings,
it will indicate the presence of Heat in the organ that manifests in this area of
the tongue.
The presence or lack of coating is diagnostically very important when diagnosing
a red tongue. The presence or lack of coating will indicate whether to diagnose shi
Heat or yin xu Heat: in shi Heat there will be a yellowish coating, whilst there will
be a lack of coating on the tongue when there is yin xu Heat.
When there is Heat present, the tongue will usually be dry. There is, however,
a situation where the tongue can be red and wet. This can occur if there is an acute
condition of extreme Heat. In this case, the extreme Heat drives fluids in the body
upwards and outwards. This will make the tongue temporarily wet. The person will
probably also sweat profusely in this situation for the same reason.
Another scenario that can manifest with a red and wet tongue is the condition of
Damp-Heat. Here, there is the presence of a yin and a yang pathogen simultaneously.
It is important to remember that yin xu can exist without resulting in Heat, in
which case there will be a normal-coloured tongue that is dry and lacking in coating.
Red spots
Red spots and speckles always signify the presence of Heat. The size and height of
the spots reflect the intensity of the Heat and how much stagnation the Heat has
generated. The larger and more raised the spots, the more Heat there is present.
Sometimes you can see that the papillae on the tongue are raised without
being red. This is also Heat, but the Heat is not as intense as when there are red
spots although there is sufficient Heat to raise the papillae up from the surface of
the tongue.
The distribution of the spots and speckles on the tongue’s surface will indicate
which organs are affected by Heat. Small speckles are mainly seen on the sides and
tip of the tongue. Larger spots and raised papillae are usually seen on the rear of
the tongue.
Purple
When xue stagnates, the tongue will become purple in colour. This reflects poor
circulation, which in Western medicine will be a sign that the blood is not being
optimally oxygenated. There may be a reddish-purple or bluish-purple colour. If
the tongue is reddish-purple then it is Heat that has stagnated xue, resulting in xue
becoming thick and sticky. Xue stagnation can in itself also generate Heat.
Cold can also stagnate xue by causing the vessels to contract, making it more
difficult for xue to circulate through them. At the same time, Cold will block the
yang qi that propels xue through the vessels. The tongue will be bluish-purple in
colour when the stagnation is due to Cold.
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The tongue can also have a slight mauve tinge, which the eye must be trained to
perceive. This indicates Liver qi stagnation resulting in xue not circulating optimally.
There may also be purple spots in specific areas of the tongue. This will indicate
that there is xue stagnation in the relevant area of the body. The sides of the tongue
can be purple when there is Liver xue stagnation
Veins on the underside of the tongue

It is also important to observe veins on the underside of the tongue. These are often
dark and purplish if there is xue stagnation. The veins in this case will usually also
be swollen or knotted.
If the veins are pale and flat, it can indicate xue xu or qi xu. If the veins are milky
in appearance, this can indicate the presence of Dampness and Phlegm.
The sub-lingual veins may also be longer than normal, which is a sign of Heat.
It is not only the two main sub-lingual veins that can change colour and shape.
Small veins on the lower surface of the tongue changing colour and shape is a sign
of xue stagnation. Similarly, small, purple spots appearing on the underside of the
tongue is a sign of xue stagnation.
Tongue body colour

Pink Normal
Pale and wet Yang xu Cold or shi Cold patterns
Qi xu
Pale and dry Xue xu (in some cases yang xu)
Pale sides Liver xue xu
Pale-orange sides Liver xue xu
Red Shi or xu Heat, depending on the coating
The entire tongue can be red or only the area that relates to a
specific area of the body or a specific organ
Red tip Heat in the Heart
Red sides Liver Heat
Red central area Stomach Heat
Red spots Heat, xue Heat and/or xue stagnation, depending on size
The location of the spots gives an indication of where the Heat
is in the body
Red and wet Short-term Heat or Damp-Heat (in rare but very serious
situations, this is a sign of true Cold/false Heat)
Red, swollen Xie Heat in the interior
Heart Fire
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Purple or purple spots Xue stagnation

The whole tongue or just specific areas that relate to the organs
involved, can be purple
The purple colour will be either bluish purple (Cold stagnating
xue) or reddish purple (Heat stagnating xue or the stagnant xue
generating Heat)
Purple veins on the underside Xue stagnation
of the tongue
Pale veins on the underside of Xue xu or qi xu
the tongue
Milky veins on the underside Damp-Phlegm
of the tongue
Extended veins on the Heat
underside of the tongue
Purple spots on the underside Xue stagnation
of the tongue
Tongue body shape

The shape of the tongue includes the tongue’s size, physical shape, whether there are
cracks on the surface and the length and mobility of the tongue.
The tongue’s shape will mainly reflect whether there is a xu or shi condition.
The tongue shape will give an impression of the condition of qi and xue, as well as
whether Wind and Dampness are present.
The shape of the tongue will also reflect the severity and duration of the
imbalance.
A pale, wet tongue that has arisen due to yang xu is less serious and indicates
a shorter duration than if the tongue is pale, wet and swollen. The swelling of the
tongue indicates that the yang is chronically weak and therefore not performing its
function of transforming and transporting fluids in the body. Similarly, yin xu that
manifests with a tongue that is red and without coating is not as serious and chronic
as yin xu that manifests with a tongue that is red, thin, lacking in coating and with
cracks in the surface of the tongue. The latter shows that the yin xu is so deep rooted
and chronic that it is starting to damage the body’s tissues.
Even though the shape of the tongue is highly significant, it is still the tongue
colour that is the single most important aspect in tongue diagnosis.
Thin tongue body

A ‘thin tongue’ refers to the thickness and not the breadth of the tongue. A tongue
becomes thin when there is too little fluid and too little xue to ‘fill’ the tongue, i.e.
there is too little yin in the tongue. This will be due to there being too little yin and/
or xue in general or there being something that has damaged these yin aspects, which
will be some form of Heat. The colour of the tongue will be the determining factor.
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A red tongue indicates that there is Heat damaging the yin aspects and a pale tongue
that there is too little xue.
A thin tongue is not seen as often as might be expected. Many clients are xue
xu and yin xu, but because they also have Dampness and Phlegm, this results in
their tongues being swollen. This means that a tongue that would otherwise have
been thin due to xue xu or yin xu can be swollen due to the presence of Dampness
and Phlegm.
Swollen tongue body

It is necessary to distinguish between a tongue that is completely swollen and a
tongue where only certain areas are swollen.
A swollen tongue will be the result of too much fluid accumulating in the
tongue, i.e. Dampness, Phlegm or accumulation of fluids, which is the opposite
of the previous situation where the tongue was too thin due to a lack of fluids. The
accumulation of Dampness, Phlegm or fluids in the body is in itself a shi condition.
Shi conditions will often, though not always, have their root in a xu condition. Heat,
for example, can force fluids upwards to the tongue or condense them so that they
transform into Phlegm.
As with the colour of the tongue, the swelling can encompass the entire tongue
body or just be limited to a certain area that corresponds to specific organs or areas
of the body.
Partially swollen tongue body

Whilst an entirely swollen tongue will be due to a shi condition of Dampness,
Phlegm or accumulated fluids, a partially swollen tongue can be a sign of a xu or a
shi condition. Qi xu, qi stagnation and Heat can all result in the swelling of certain
areas of the tongue. The areas of the tongue that most often swell up are the tip, the
central area and the edges of the tongue.
If the sides are swollen, it is important to differentiate between whether it is
the whole side of the tongue that is swollen (a Liver imbalance) or just the sides
in the central area of the tongue (Spleen qi xu). If the swollen sides are also red, this
indicates Liver Heat. If they are normal in colour, there will be Liver qi stagnation.
The reason that Spleen qi xu can result in swelling of the sides of the tongue,
which is an area normally associated with the Liver and Gall Bladder area, is that
when the Spleen area in the middle of the tongue swells, this forces the side of the
tongue outwards in this area. Spleen qi xu swelling will usually result in there being
teeth marks on the side of the tongue.
If there is Phlegm-Dampness or qi xu in the Lung, there will be swelling of either
the whole of the front third of the tongue or just the sides of this area.
The tip of the tongue can swell when there are Heart imbalances. This will
typically be seen if the mental-emotional aspect of the Heart, the shen, is not in
balance; the tip will usually also be red in these situations.
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Sunken areas
Some areas of the tongue can appear to have sunk downwards. This indicates a
condition of qi xu in the organ that is reflected in this area of the tongue. The
depression in the tongue’s surface can sometimes only be seen immediately after
the person has presented their tongue, and then the area ‘fills’ up and the depression
is no longer visible. It is sometimes necessary to get the patient to extend their
tongue a couple of times to be sure that you have observed the depression correctly.
On the other hand, an area of the tongue may only ‘collapse’ after the tongue has
been extended for a while. In both cases, this will most typically be seen in the area
corresponding to the Lung or the Spleen and Stomach, and is indicative of qi xu in
these organs. If the root of the tongue is sunken, this can be a sign of Kidney jing xu.
Uncontrolled movement and stiffness

There should be flexibility and movement in the tongue. If the tongue movements
are involuntary, this may be interior Wind causing qi to move chaotically or the
Spleen failing to control the muscles. When the Spleen does not control the muscles
in the tongue, the tongue can quiver. Sometimes the tongue will begin to quiver
after the person has had their tongue extended for a few seconds. It is as if the Spleen
is no longer capable of keeping the tongue still.
In the same way that a light wind will cause a flag to wave from side to side, high
winds will make the cloth of the flag hard and stiff. The same applies to the tongue.
Interior Wind can make the tongue sway from side to side or result in a tongue that
is rigid and inflexible.
If the tongue deviates to one side, this can be due to the channels on one side of
the body being shi (Wind or Phlegm) or the channels on the other side of the body
being xu.
A flaccid tongue, especially if it is swollen, indicates qi xu or Phlegm.
Flaccidity
If the tongue seems limp and lifeless, this may be due to a lack of fluids or xue,
causing the tongue to wilt. There may therefore be qi xu or xue xu. Alternatively,
Heat may have damaged the fluids. The colour of the tongue will determine whether
it is xue xu and/or a qi xu condition, on the one hand, or yin xu or Heat, on the
other. In the first two cases the tongue will be pale, and in the latter two cases
the tongue will be red.
Length
The yang nature of Heat is expansive. This can cause the tongue to become longer.
At the same time, Heat damages fluids and this can therefore cause the tongue
to shrink, resulting in a short tongue.
Cold has a yin dynamic that makes things contract. Cold can therefore also
result in a tongue that is shorter than normal.
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The difference between a tongue that is short due to Cold and one that is
short due to Heat will be seen in the colour of the tongue. Heat will result in a short
tongue that is red, whereas Cold will manifest with a pale and short tongue.
Cracks
Cracks are often, but not exclusively, a manifestation of yin xu. Body fluids nourish
and moisten the tongue, in the same way that rain moistens the soil. If there is too
little rain, the surface of the earth cracks, and if there is too little body fluid, the
tongue surface cracks.
The shape and distribution of the cracks will depend on the type of yin xu
involved. The depth and size of the cracks will say something about how serious the
situation is and how long it has existed. Deep, long and multiple cracks signify a
more deep-seated imbalance than single, short, shallow cracks.
A very swollen tongue may look as if it is cracked, but this is because the tongue
is ‘wrinkled’ and ‘creased’. The patient can be asked to pull the sides of the tongue
outwards. If the cracks disappear, the tongue is just swollen and not cracked. By
pulling on the side of the tongue you can also get an idea of the depth and thus the
severity of the cracks.
A short crack in the middle of the tongue indicates a xu condition in the
Stomach or Spleen. If the crack and the area around it is red and lacks coating, this
is a sign of Stomach yin xu. If the area is normal or pale coloured and has coating, it
will not be yin xu, but Spleen and Stomach qi xu. If the crack is deeper or wider with
a sticky, yellowish coating (it may look as if the crack is furry), it is a sign of Stomach
Fire or Phlegm-Heat in the Stomach.
If there are more irregular or transverse cracks in the central area of the tongue,
it will be a manifestation of Stomach yin xu. If the cracks are more extensive and
cover the entire tongue, this indicates Stomach and Kidney yin xu. Likewise, a
longitudinal crack along the middle of the tongue with several transverse cracks
extending out from it, reflects Stomach and Kidney yin xu.
A crack that runs all the way down the centre of the tongue and out to the tip
shows that there is a constitutional weakness and the person can have a tendency to
develop Heart imbalances.
Two diagonal cracks on the front third of the tongue behind the tip is a sign of
Lung yin xu. The cracks may be the remnants of an old condition, such as a severe
respiratory disease in early childhood that damaged the Lung at the time.
Short transverse cracks on the sides of the tongue are a sign of Spleen qi and
yin xu.
Veins on the underside of the tongue

If the veins on the underside are swollen or knotted, it indicates that there is xue
stagnation.
If the veins are very flat and pale, there may well be xue xu or qi xu.
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Tongue body shape

Neither swollen nor thin, the Normal
same shape all over, flexible but
static
No cracks
Thin Yin xu, xue xu or lack of fluids (Dryness)
Pale, large, swollen, tooth Qi and yang xu
marked Damp-Phlegm
Normal coloured, swollen Dampness or Phlegm
Red, swollen Stomach and Heart Heat, Damp-Heat
Purple, swollen Poisoning
Partly swollen Depends on the colour and the area:
Sides – Liver/Gall Bladder Fire if the sides are red or Liver qi
stagnation if the sides are normal coloured
Middle of the sides or teeth marks – Spleen qi xu
Tip – Heart, usually Phlegm or Heat
Front third – Lung usually Phlegm, but can also be qi xu
Sunken areas Depends on the area:
Middle – Stomach and/or Spleen qi xu
Front – Lung qi xu
At the rear – Kidney jing xu
Quivering Wind or Spleen qi xu
Stiff Interior Wind
If the tongue is red, this is due to extreme Heat
Flaccid and pale Spleen and Heart qi and xue xu
Flaccid and red Heat
Flaccid, red and dry Kidney yin xu
Long Heart Fire
Short If the tongue is red – Heat
If the tongue is pale – Cold
Swollen veins on the underside Qi and/or xue stagnation
of the tongue
Very flat and pale veins on the Qi xu or xue xu
underside of the tongue
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Cracks A short crack in the centre, the area is pale and with coating –
Stomach or Spleen qi xu
A short crack in the centre, the area is red and lacks coating –
Stomach yin xu
The crack in the middle is deeper or wider with a sticky,
yellowish coating – Stomach Fire or Phlegm-Heat in the
Stomach
Irregular or transverse cracks in the central part of the tongue –
Stomach yin xu or Stomach and Kidney yin xu
Long crack along the central area with several transverse cracks
spreading outwards – Stomach and Kidney yin xu
Crack all the way down the middle of the tongue and out to
the tip – constitutional weakness with a tendency to Heart
imbalances
Two diagonal cracks behind the tongue tip – Lung yin xu
Short transverse cracks on the sides of the tongue – Spleen qi
and yin xu
Tongue coating
The tongue coating is a natural consequence of transformation of the ingested food
and liquids in the Stomach. It is some of the ‘dirty’ residue rising upwards along with
the pure qi that has been separated from the impure dross.
The tongue coating should be thin enough to enable the tongue itself to be
seen through the coating. The tongue should look like a wheat field in the spring
when the wheat has sprouted and is just beginning to push its way up through the
soil. The soil can still be clearly seen, but the field has a green hue and when you look
closer you can distinguish the individual wheat sprouts. Similarly, you should be
able to see the body of the tongue through the coating and the coating should look
like small individual dots on the tongue.
The coating will be thickest in the middle and at the rear. This is because these
areas of the tongue correspond to the Stomach and Intestine, which are the organs
that receive and transport the impure residue that is left behind after the
transformation of the pure qi. This is reflected in these areas having a thicker and
dirtier coating than the rest of the tongue. An alternative explanation for why the
coating is naturally thicker on the rear of the tongue is that some of the impure
residue from the transformation process rises from the Stomach and ascends towards
the mouth. This impure residue settles on the back of the tongue, as it is this part
of the tongue that it hits first. This is likened to when steam rises upwards from a
kettle and condenses on the bottom of a windowpane, but the upper part of the glass
is still transparent and dry.
The coating on the tongue does not usually extend to or cover the sides or the tip.
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The tongue coating primarily reflects whether a condition is shi or xu in nature,

whether the condition is Hot or Cold, and the condition of the fu organs. The
coating is not necessarily directly associated with the tongue colour and shape and
therefore can be viewed separately in certain situations.
The tongue coating can be used to rapidly differentiate the Eight Principles.
The tongue coating in relation to the Eight Principles

Significance Observation
Interior/exterior The distribution of the coating on the tongue will reflect whether
xie qi is in the interior or the exterior
Hot/Cold Heat Yellow and dry coating
Cold White and wet coating
Shi/xu Shi Thick coating
Xu Yin xu – very thin or peeled coating
Qi xu – coating lacks root
Yin/yang Yin xu Very thin or peeled coating
Yin shi Thick, white and moist coating
Yang xu White and wet coating
Yang shi Thick, yellow, dry coating
Observation of the tongue coating is particularly relevant in acute conditions.

This is because the coating is the aspect of the tongue that is quickest to change; it
can change by the hour. In an acute invasion of xie qi, it is sometimes possible to
observe changes in the coating in the front third of the tongue, especially the outer
edge of this area. If xie qi penetrates deeper into the body, the coating will change
by becoming thicker in the central areas of the tongue and possibly also changing
colour and consistency.
It is not only exogenous invasions that can produce rapid changes in the tongue
coating. Food stagnation will also manifest with changes in the tongue coating
relatively quickly.
A general rule of thumb is: the thicker the coating, the stronger the xie qi.
If an organ is yin xu the tongue may manifest with a lack of coating in the area
of the tongue that corresponds to that organ.
A healthy coating should have root, be evenly distributed and be slightly moist.
Having root means that the coating should appear to be growing out of the tongue
and not just lying on top of the tongue. If we go back to the metaphor of a wheat
field, the wheat should appear to be growing up through the soil and not lying
uprooted on the top of the earth like mown grass.
When a coating lacks root it can be easily scraped off. This is because the
Stomach, Spleen and Kidney are not functioning as they should and a new,
healthy coating is not being formed to replenish the existing coating from below.
The old coating eventually loses its connection to its root and starts to fall off.
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A rootless coating is always indicative of a xu condition. There may be a rootless

coating in the early morning upon waking. This is because the Stomach and Spleen
are inactive at night and have therefore not created a new coating on the tongue
whilst the person slept.
The coating also gives an impression of the development of a pathological
condition. The coating suddenly disappearing in a disease is a negative sign, even
if the coating was excessively thick. Intuitively, a thick coating disappearing might
seem to be a positive development, but it is only positive if the change is gradual and
not sudden. If the change is sudden, it is probably due to yin or qi being damaged
by the xie qi.
A coating that suddenly becomes thick is usually seen when Dampness blocks
the middle jiao.
When exogenous xie qi invades the body, the changes in the coating will usually
only be seen in the front third of the tongue and the sides of this area. If the coating
begins to thicken further towards the centre of the tongue and if the coating changes
colour from white to yellow and starts to dry out, this indicates that xie qi has started
to penetrate the interior and begun to generate Heat. This process can often be
quite rapid.
In interior pathological conditions, the distribution of the coating will indicate
where the imbalance is in the body and which organs are most likely to be affected.
The colour and texture of the coating will give an indication of what type of
imbalance is probable.
One should therefore observe whether the coating is thicker or thinner in certain
areas of the tongue and whether there is a difference in the condition of the coating
in these areas.
Colour of the coating

The coating is naturally a pale, white colour. It will also be white if there is pathogenic
Cold present, but the coating will be thicker and moister.
When there is Heat, the coating turns yellow. The more Heat there is, the darker
the coating becomes. The coating will usually be drier, unless there is Damp-Heat or
Phlegm-Heat, in which case the coating can be sticky, greasy or oily.
In some situations, the coating is black or almost black. This may be a sign of
extreme Heat or of Damp-Cold, depending on how moist the coating is and what
colour the tongue body has. When there is extreme Heat, the Heat will have damaged
fluids in the body; therefore the black coating will also be dry. If the black coating
is a manifestation of Damp-Cold, the coating will instead be wet, because Cold can
block the transportation and transformation of fluids, which then accumulate on
the surface of the tongue.
There may well be differences in the colour of the coating from one area of the
tongue to another. This can be a reflection of Heat in a certain area of the body or
in an organ. Typically, the coating at the rear of the tongue is more yellow than at
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the front of the tongue. This is because Damp-Heat tends to accumulate in the
lower jiao.
Heat in the Stomach will turn the coating yellow in the centre of the tongue or
in a crack in the centre of the tongue.
If the coating on the sides of the tongue is yellow, it is important to observe
how the colour is on the rest of the tongue. If there is a yellow coating on the sides
and the rest of the tongue coating is white, this indicates that there is an invasion of
Wind-Heat or Heat in the Intestines. If the rest of the coating is also yellow but the
sides are even more yellowish, this usually indicates that there is Heat in the Liver
and Gall Bladder. Finally, if one side of the tongue has a yellow coating and the other
side is white, this can be a sign that exogenous xie qi is locked in the shaoyang aspect
or that there is Heat in the Liver and Gall Bladder.
Moistness
Moistness refers to both the general moistness of the tongue and the moistness of
the tongue’s coating. Both the tongue and the coating should be slightly moist but
not wet.
Pathogenic Heat will dry and damage fluids and xue.
Yin xu is characterised by a lack of fluids, therefore the tongue will also be dry.
Fluids and xue are closely linked to each other and xue helps to moisten the body.
A dry tongue can therefore also be seen when there is xue xu.
Yang xu and Cold can mean that body fluids are not transformed and transported
optimally and these will therefore accumulate on the tongue, causing the tongue
coating to become wet.
Greasy and sticky coatings

Greasy coatings arise when qi does not transform fluids, causing Dampness and
Phlegm to arise.
Greasy and sticky coatings are very similar in appearance and cause. Maciocia
describes the papillae on the tongue in a greasy coating as looking like the bristles on
a toothbrush that are covered in butter. You can still see each individual bristle, but
they are thicker and have a greasy coating. In a sticky coating, the individual papillae
are no longer distinguishable from each other and the coating will look more oily
(Maciocia 2004, p.224).
A greasy or sticky coating always indicates the presence of Dampness or Phlegm.
Mouldy coating
A mouldy coating, is also called a ‘tofu coating’ in Chinese, because it seems as if
there are small pieces of tofu on the tongue. In English this could translate as a
cottage cheese coating, because it will look as if the person has just eaten cottage
cheese. The mouldy coating is seen when there is Stomach Fire or Toxic-Fire in
the throat.
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Tongue coating
Thin, white, rooted, normal moistness Normal
Rootless coating Stomach qi xu or yin xu
White, thin, slippery Damp-Cold disrupting wei qi
White, thick, slippery Internal Damp-Cold, food stagnation of short
duration
Thick, white Food stagnation, shi Cold
Dry, white Cold that is in the process of transforming into Heat
Fluids are being injured
Greasy, white Internal Dampness or external Cold or Dampness
Spleen yang xu
Dry, yellow Internal Heat is starting to damage yin
Thin, yellow Wind-Heat
Thick, yellow Food stagnation turning into Heat, shi Heat
Greasy, yellow Internal Damp-Heat or Phlegm-Heat
Yellow stripes on the sides of the tongue Exterior pathogen invading inwards
and the rest of the coating is white Heat in the Stomach and Intestines
Dark yellow stripes on the sides of the Heat in the Liver and Gall Bladder
tongue and the rest of the coating is yellow
Yellow on one side and white on the other Heat in Liver and Gall Bladder
Shaoyang syndrome
Damp, grey-black/brown Cold-Damp
Dry, grey-black/brown Extreme Heat
Mouldy Stomach Fire, Toxic-Fire
No coating Yin xu
Dry tongue Heat, xue xu or yin xu
Wet tongue Yang xu or Cold
Visual diagnosis of the hair

This section deals mainly with observation of the head hair. Pubic and body hair will
be discussed in the following section.
Head hair
Diagnosis of the hair on the head encompasses the volume of the hair, whether the
hair is dry or greasy, the colour of the hair and the quality of the scalp.
In a healthy state, there should be an even distribution of hair, covering the
entire scalp. The hair should be neither too dry nor too oily. It should have a sheen
and be soft. Similarly, the scalp should be smooth and without dandruff.
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A healthy head of hair that has lustre, shine and volume indicates that the person
has sufficient jing and xue to nourish the hair.
The hair can also give an indication of the state of a person’s shen. A person
whose shen is disturbed can often have a slightly odd or eccentric appearance, the
person’s shen lacking the ability to conform to what is normal. This may manifest in
the fact that their hair is either chaotic or looks slightly odd. This is sometimes seen,
for example, in people who are mentally ill. An unusual hairstyle can, of course, be
a conscious intention, especially in younger people. In this case, the appearance of
the hair loses its diagnostic significance.
Hair loss
It is not only jing that has a direct impact on the head hair. The hair is created by jing
in the same way that grass seed creates the grass on a lawn: seed alone is not enough,
as the grass must be nourished and watered. The hair on the head is nourished and
moistened by jinye and xue. This means that the quality and amount of head hair
can be affected negatively if either or both of these are xu. The fact that jing xu is
not the only cause of hair loss is seen in post-partum women who are xue xu. If the
hair loss was only due to the loss of jing through pregnancy and birth, the condition
would be more permanent and not improve with the improvement of their xue.
Furthermore, Fire and Damp-Heat can scorch the roots of the hair, resulting in hair
loss. Xue stagnation can prevent fresh, nourishing xue from reaching areas of the
scalp, resulting in the roots of the hair not being nourished.
Dryness
If the body is in balance, the hair on the head has a healthy shine and is soft. This
indicates that it is well nourished by xue and yin.
Dry hair will therefore be seen, when there is a condition of yin xu or xue xu. Shi
Heat conditions such as Fire can also injure yin or xue, resulting in dry hair.
Greasy hair is usually an indication of Damp-Heat or Phlegm-Dampness.
It is, of course, important to take into account the use of various hair products
that can give the hair an oily or greasy appearance, as well as hair treatments such as
bleaching and perming that can desiccate the hair. In these situations, the dryness or
greasiness is caused by factors that do not have a diagnostic significance.
Colour
If the hair turns grey or white, this is usually a sign that jing is weakened and is no
longer strong enough to produce normal-coloured hair. This is a natural part of the
ageing process, manifesting the decline of jing.
If the person loses their hair colour prematurely, this may well be a sign of jing
xu. It can also be the result of a powerful shock injuring the Kidney and Heart or
from Liver and/or Heart Fire damaging the hair. Some people lose their hair at an
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early age without this having diagnostic relevance. In these cases, the people will be
otherwise healthy and strong, without any further signs of jing xu.
The scalp
The scalp is affected by the same factors as the rest of the skin. The scalp is nourished
and moistened by xue and jinye. The most typical manifestation of an imbalance that
can be seen in the scalp is dandruff. Dandruff can be dry, in which case it is usually
due to xue xu or yin xu not nourishing the scalp. The dandruff can also be oily in
appearance, in which case the cause will probably be the presence of Damp-Heat or
Phlegm-Dampness. Damp-Heat will usually also result in the scalp being itchy at
the same time.
Observation of the head hair

Hair loss Jing xu, xue xu, Fire, Damp-Heat or xue stagnation
Greasy hair Damp-Heat, Damp-Phlegm
Dry hair Yin xu, jinye xu, xue xu, Fire or shi Heat
Grey or white hair Jing xu
Dandruff Yin xu, jinye xu, xue xu or Damp-Heat
Chaotic or odd hairstyle Shen disturbance
Visual diagnosis of the body hair

The body hair is under the influence of the Lung and wei qi, but it is also nourished
by xue. If there is a lack of body hair, it may indicate that there is Lung qi xu or xue
xu. If the body hair is fragile, breaks easily or falls out, this is usually a sign of qi xu
and/or xue xu resulting in the hair not being nourished.
Body hair is used to control and regulate the body temperature, especially when
the person is exposed to cold. This is one of the functions carried out by wei qi.
When the body is exposed to Wind-Cold, wei qi raises the body hair and closes the
pores of the skin to keep the invading xie qi out.
The pubic hair should appear at the start of adolescence. This is a manifestation
of the transition from the second to the third jing cycle. A lack of pubic hair can
therefore be a sign of jing xu. It is important, however, to remember that as with the
hair on the head, a lack of pubic hair can also be a sign of xue xu if the roots of
the hair are not receiving sufficient nourishment.
An excessive growth of pubic hair, for example down the thighs or upwards towards
the navel, can be seen when chong mai is disrupted by Phlegm or xue stagnation.
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Observation of the body hair

Lack of body hair Lung qi xu or xue xu
Fragile body hair that breaks easily Qi xu or xue xu
Lack of pubic hair Yin xu or xue xu
Excessive growth of pubic hair Phlegm or xue stagnation in chong mai
Visual diagnosis of the throat

The pharynx
Observation of the pharynx is mainly relevant when there are invasions of exogenous
xie qi. Invasions of Wind-Heat can manifest with redness and swelling in this area. If
the Heat is so intense that it has created Toxic-Fire, there can also be ulceration and
white exudate in the throat.
The throat can also become red and swollen when there is Stomach Fire that
flames upwards, scorching the throat.
Swollen tonsils that are pale are an indication of Phlegm, Phlegm-Dampness or
a retained pathogen.
If the tonsils are swollen and the throat is red, there will be an invasion of
Wind‑Heat.
The outside of the throat

The two most common diagnostic signs that can be observed on the outside of the
throat are a swollen thyroid gland and redness of the skin on the throat and neck.
A swollen thyroid gland can be a sign of Phlegm. The Phlegm can be an
independent pattern or it can be seen in combination with the following patterns:
Liver qi stagnation, xue stagnation, Liver Fire, Heart yin xu or Liver yin xu.
Red skin on the neck is a sign of Heat. It will usually be seen when Heat ascends
from the Lung or the Heart.
Observation of the throat

Red pharynx Wind-Heat, Stomach Fire
Very red throat with ulcers or exudation Toxic-Fire
Swollen tonsils Invasion of Wind-Heat, Phlegm-Dampness or
retained pathogen
Red skin on the outside of the neck Heart or Lung Heat
Swollen thyroid gland Phlegm
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Visual diagnosis of the chest and the back

Observation of the thorax
The thorax is especially influenced by zong qi and the Lung and also the Heart.
Ren mai, chong mai, Liver and Gall Bladder channels all also influence the area.
Stagnation or accumulation of qi, xue or Phlegm in the area will create distension of
the chest. This can give the appearance of being barrel-chested.
A lack of zong qi can cause the chest area to be hollow or sunken. Jing xu can also
manifest with a sunken chest.
Observation of the chest

Distended Qi, xue, or Phlegm stagnation
Hollow and sunken Zong qi xu, jing xu
Visual diagnosis of the back

The Kidneys have a determining influence on the lumbar area, but the back is also
affected by the channels that traverse the spinal column and the muscles alongside
the spine. Furthermore, the muscles in general are affected by the Liver and the
Spleen, so Liver qi stagnation, Spleen qi xu and Dampness and Damp-Heat can all
affect the muscles of the back.
Abnormal curving of the spine

An abnormal curvature of the spine, such as scoliosis, lordosis or kyphosis, can be
a manifestation of jing xu that has resulted in improper development of the body’s
structure, or it can be due to du mai imbalances. If there is only a slight distortion,
this may be caused by muscle tension. The muscle tension may arise from Liver qi
stagnation, xue stagnation, an invasion of exogenous Cold or Spleen qi xu.
Muscle tone
If the muscles along the spine appear to be tense and tight, it will be a sign of
stagnation of qi in the area. The stagnation may be due to a local blockage of qi from
an invasion of Cold or xue stagnation. It is often the consequence of a more general
Liver qi stagnation that has caused the muscles to tense up.
A shi condition in one or more of the zangfu organs can manifest with the area
around their back-shu point becoming tense and tight.
The muscles along the spine and in the back can be weak, lacking in tone or
slightly sunken. This can be unilateral or bilateral. Weak muscle tone will indicate
qi and xue xu. If the weakness of muscle tone is more local, this may be due to a
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disturbance of qi in the Urinary Bladder channel or it may be a sign of a xu condition

in the organ, whose back-shu point lies adjacent to the area.
Observation of the back

Abnormal curvature of the Jing xu, du mai imbalances, Liver qi stagnation, xue stagnation, an
spine invasion of exogenous Cold or Spleen qi xu
Tight and distended Qi stagnation
muscles If the tightness and distension is localised to specific back-shu points,
there can be a shi condition in these organs
Weak, soft and sunken Qi xu
muscles If the weakness and hollowness of the muscles is localised to specific
back-shu points, there can be a xu condition in these organs
Visual diagnosis of the limbs

Visual diagnosis of the limbs includes observation of the size and quality of the
muscles, whether there is oedema, observation of the skin and blood vessels and
whether there are spasms, tremors or muscle cramps. Observation of the limbs has
relevance in both acute and chronic patterns.
Stomach and Spleen qi is reflected in both the quality and mass of the muscles in
the arms and legs. If there is Stomach and Spleen qi xu, there will be an inadequate
production of qi and xue. This will mean that the muscles lack nourishment. A
sign of Stomach and Spleen qi xu and xue xu can therefore be muscle atrophy or
underdeveloped muscles. This can, of course, also be a sign of jing xu, especially in
children, as well as Kidney and Liver yin and xue xu in older people.
Muscles that are flaccid and weak, but without a loss of mass, can be seen in
acute conditions when Heat injures jinye.
Chronic conditions of weak and soft muscles are seen when Stomach and Spleen
qi xu results in xue and ying qi not nourishing the muscles. Kidney and Liver yin
xu can also result in muscles not receiving adequate nourishment. Dampness and
Phlegm can block qi and xue from nourishing the muscles.
Very stiff and inflexible arms and legs usually indicate an invasion of exogenous
Wind in acute cases or internally generated Wind in chronic cases.
The arms and legs can be rigid and stiff because joints are inflexible. This
inflexibility can be due to Phlegm resulting in changes and deformity of the joint. It
can also be due to xue stagnation or oedema on the muscles around the joint.
Oedema around the joint arises when there is Damp bi or when there is Spleen and
Kidney yang xu.
Liver and Kidney yin xu can result in the joint being too dry and becoming stiff.
Liver xue xu can mean that the tendons and sinews lack nourishment and thus
become stiff.
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Tremors, spasms and cramping of the muscles in the limbs will always be caused
by Wind. There are, though, differences in how the Wind has arisen. It can be due to
invasions of exogenous xie qi penetrating deeper into the body and generating Heat,
resulting in the arousal of internal Wind. This is seen, for example, when there are
febrile convulsions. Internal Wind can also arise when there is ascending Liver yang,
Liver yin xu and Liver xue xu.
Acute oedema of the hands may occur during an invasion of Wind-Cold that
interferes with the Lung’s ability to spread jinye. If the oedema is chronic, and
especially if it is pitting, it will probably be due to Kidney and/or Spleen yang xu.
Oedema that is not pitting is more typical of qi stagnation.
Xue stagnation can manifest with small, but visible, purple thread veins or ‘spider
naevi’. This is typically observed on the ankle area in geriatric patients.
Varicose veins are a sign of Spleen qi xu that is failing to maintain the structure
of the blood vessels and/or xue stagnation.
Observation of the limbs

Muscle atrophy or underdeveloped Stomach and Spleen qi xu, qi and xue xu, jing xu
muscles
Muscle weakness or laxity Stomach and Spleen qi xu, Heat, Damp-Heat, Liver and
Kidney yin xu
Rigid and inflexible arms and leg Xue stagnation, qi stagnation, Dampness, Phlegm, Wind,
muscles Kidney and Liver yin xu, Liver xue xu
Paralysis of the arms or legs Wind (internal and external), Phlegm, Dampness, xue
stagnation or Liver and Kidney yin xu
Tremors, spasms and muscle cramps Wind (internal and external)
Oedema Invasion of Wind-Cold, Kidney and/or Spleen yang xu or
qi stagnation
Spider naevi Xue stagnation
Varicose veins Spleen qi xu, xue stagnation
Visual diagnosis of the joints

Visual observation of joints is imperative in the diagnosis of joint pain, including in
bi syndrome.
Visual diagnosis can elicit useful information that can indicate the presence of
Heat, Dampness, Phlegm or xue stagnation.
If there is Heat in the area, the skin will often be red and the area can be swollen
due to the underlying stagnation of qi and thereby jinye that is creating the Heat.
The skin will also feel warm on palpation.
If there is an accumulation of Dampness or jinye in the joint and surrounding
tissue, the area will be swollen and spongy.
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If the bi syndrome becomes chronic, the stagnation of jinye and Heat can result
in the formation of Phlegm in the joint. This will result in the joint becoming
deformed and gnarled. This will clearly be visible with the naked eye.
Xue stagnation in the joint can prevent the flow of fresh xue to skin above the
joint. This means the skin will lack nourishment and moisture and can therefore be
dry and flaky.
Observation of the joints

Redness and swelling Heat
Swelling Dampness, accumulation of jinye
Deformity Phlegm stagnation
Dry flaky skin Xue stagnation
Visual diagnosis of the hands

Visual diagnosis of the hands includes the observation of colour, shape and moistness
of the hands and fingers, as well as the observation of the fingernails.
Colour
The normal colour of the hands in white Europeans should be pinkish red, indicating
that the hands are being supplied with sufficient xue and yang qi. Account should be
taken of the colouration of the skin in other ethnic groups.
If there is Heat, the hands can be more red in colour. If the Heat is shi in
nature, this will be seen on both sides of the hand. If the Heat is xu, it will only be
the palm that is red.
Pale hands are a sign of yang xu and xue xu.
Shape of the fingers

Thickened or swollen fingers can be caused by Phlegm or Dampness. They may also
be due to oedema, but this will usually be periodic and sporadic.
Phlegm-Dampness can often manifest with ‘chubby’ fingers. Other causes of
swollen fingers can be Cold or Damp bi. If there is Cold or Damp bi, there will also
be pain in the fingers that is affected negatively by cold weather.
Fingers that are spoon-shaped (thicker at the tips) are usually an indication of
a chronic Lung imbalance. It may be Phlegm-Cold, Phlegm-Heat or Lung and
Kidney yin xu.
Very thin fingers may indicate Stomach and Spleen qi xu. The fingers will be thin
because the muscles are malnourished and withered.
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The joints in the fingers can change shape or become swollen or gnarled when
there is a chronic bi syndrome if the stagnation has led to the formation of Phlegm
in the joint.
Moistness
The skin in the hands, especially the palms, can become dry and even cracked.
The dryness can be due to either Heat injuring jinye or a lack of nourishment and
moisture due to xue xu and/or yin xu. If the dryness is due to Heat, the skin will be
red. If the dryness is due to xue xu, the skin will be pale in colour.
Palms that are moist and sweaty can be seen when there is Heart yin xu, Heart qi
xu or Heart Fire. In some cases this can be due to Lung qi xu or Lung Heat. Both of
these organs’ channels connect to the hands, and both organs have a direct influence
on sweating. Sweaty palms after the insertion of acupuncture needles may be due
to the person being nervous (a Heart imbalance) or to the needles causing the Lung
and the Heart to lose their control of the pores temporarily, resulting in spontaneous
perspiration along the course of the channel.
Account should be taken of the use of hand creams and other lubricants and
moisturisers. It can be a good idea to ask whether the patient uses a hand cream and if
so ask why. The need to use a moisturising cream can in itself be a diagnostic sign.
Tremors
Shaking of the hands can be a consequence of internally generated Wind. Internal
Wind can arise from Liver imbalances – both xu and shi imbalances.
Veins
Veins on the hands and forearms that are very prominent, both in adults and
children, are usually an indication of Heat.
In small children, observation of the vein on the side of the index finger is an
important part of the diagnosis. The diagnostic significance of this vein is explained
in the appendix to this section, where the visual diagnosis of children is discussed.
This diagnostic sign does not have relevance when diagnosing adults.
Fingernails
Fingernails are viewed as being a tendon in Chinese medicine and therefore as being
nourished by Liver xue.
The Liver, especially its xue aspect, has a determining influence on the condition
of the nails. Attention should be paid to the nails’ shape and quality, including their
colour and strength.
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There is a whole nail diagnosis system in which the various organs and areas of
the body are reflected in the fingernails. For further information on this system see
Chinese Medical Palmistry (Xiao and Liscum 1995) or Diagnosis in Chinese Medicine
(Maciocia 2004).
The colour of the nail

The colours described in the table below are, with the exception of white spots, the
colour of the nail bed that is seen through the surface of the nail.
The colour of the nail bed

Red Heat
White Xue xu, qi xu or yang xu
Yellow Damp-Heat
Dark Xue stagnation, Kidney yin or yang xu
Green nails in young children Spleen qi xu and internally generated Wind
Blue Xue xu
White spots Qi xu
Fingernail shape
Nails that are ridged or have small indentations are a manifestation of Liver xue xu
and sometimes of Liver yin xu. The ridging and unevenness will be due to the nails
lacking nourishment. These nails will often appear to be dry.
Nails that are thicker than normal are due to Dampness, Damp-Heat, Phlegm,
xue stagnation or Liver Fire, depending on the colour.
If the nails itself bends down or upwards, it can indicate that there is qi xu or xue
xu combined with xue stagnation.
Very thin nails that lack strength are a sign of Liver xue xu, Liver yin xu or jing xu.
Nails that flake and break easily may be a sign of Liver xue xu or Liver yin xu. If
they are also thickened and grey, this is a manifestation of Spleen qi xu combined
with Dampness or Damp-Heat.
Nails that are ragged and frayed are also the result of Liver xue xu, Liver yin xu
or Kidney yin xu.
Nails that are very dry are an indication of Liver xue xu or Liver yin xu.
It is important to be aware that the long-term use of nail varnish and nail varnish
removers, as well as the glue used in nail extensions, can weaken the structure of the
nail. They can also dry the nail out.
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The form of the fingernail

Ridged or indented nails Liver xue xu or Liver yin xu
Thick nails Dampness, Damp-Heat, xue stagnation or Liver Fire
Thin, weak nails Liver xue xu or Liver yin xu, jing xu
Broken nails Liver xue xu or Liver yin xu, jing xu
Thick grey but weak nails Spleen qi xu with Dampness or Damp-Heat
Nail that bends upward or downward Qi and xue xu with xue stagnation
Visual diagnosis of the skin

The skin as a whole is under the influence of the Lung. This is because the skin is a
respiratory organ5 and also because the Lung controls wei qi, which circulates under
the skin, and it is wei qi that warms and moistens the skin. There are, however, other
organs and body substances that also have a direct influence on the skin.
Many of the changes that occur in the skin arise due to xue imbalances. This is
because xue nourishes and moistens the skin. The Liver also has great influence on
the skin. This is because the Liver is a reservoir for xue, and Liver qi ensures the free
flow of xue.
The Heart controls xue and the vessels, therefore Heart imbalances can also
manifest in the skin.
The Stomach and Spleen create xue. This means that xue xu imbalances manifesting
in the skin can have their origin in Spleen and Stomach qi xu imbalance. Stomach
and Spleen imbalances can also give rise to Damp-Heat, which can manifest as skin
diseases. Furthermore, Damp-Heat can cause the skin to become greasy or spotty.
The Kidney is the root of yin and yang in the body. Kidney imbalances can affect
the moistness of the skin.
All the channels course under the skin. This means that changes in the skin may
also be caused by imbalances in the channels passing through the area. It is particularly
the small luo-connecting vessels that affect the skin. These luo-connecting vessels
are the most superficial aspect of the channel system and are similar in structure
and function to the capillary network system in Western medicine anatomy.
There are two levels to visual diagnosis of the skin. One level is the general
impression given by the skin. What colour is it? How intense or deep are these
colours? How is the moistness? Is the skin greasy? Is the skin dry and flaky? How is
the skin elasticity?
The second level is the diagnosis of specific skin disorders, such as eczema,
psoriasis, acne and so on. The appearance of the affected skin is of vital importance
in Chinese medicine dermatology.
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Skin colour
When we observe the skin colour, it is often the facial colour that we notice first. This
is because the face is the body area that is most often visible at first glance. This is also
where much of our attention is focused when we are talking to the patient. It’s not
just in the face, though, that we look for variances in skin colour. In bi syndrome,
it is important to see whether there are changes in the skin colour around the joint,
and in the diagnosis of skin diseases, changes in skin colour are a determining
diagnostic sign.
When diagnosing the colours of the face, it is important to pay attention to the
use of make-up. Furthermore, one must, of course, take into account the ethnicity
of the person. A pale colour in a person who originates from North Africa will still
be much darker than the skin tone of a person who originates from Scandinavia;
likewise, a yellow hue will be more diagnostically significant in this person than
someone who is originally from East Asia. Changes in skin colour have the same
diagnostic significance in all ethnic groups, but the starting point for the colour
variations will be different.
The dynamics behind the changes in skin colour also correlate to the Western
medicine physiological model. The skin colour is influenced by the amount and
movement of blood in the superficial blood vessels. When blood does not flow
optimally and stagnates, either in or outside of the vessels, for example when there
is bruising after a physical trauma, the skin becomes purple or bluish-green. This is
because blood is not being oxygenated optimally. When the body is too hot, it tries
to dissipate heat by increasing the circulation of blood in the superficial capillary
network just below the skin. The increased flow in these vessels will cause the skin
to appear to be more red than normal. Conversely, when the body temperature is
reduced, blood is drawn inwards to reduce temperature loss and keep the internal
organs warm. This means that the skin will look more pale. This complements the
Chinese medicine model, where the yang dynamic of Heat and the yin dynamic of
Cold cause xue to be driven upwards to the surface of the body and the skin or to
contract inwards away from the surface.
The following section discusses diagnosis of skin colour in general. Facial
diagnosis is discussed in a separate section. It is important to note not only the
colour of the skin, but also the depth of the colour. The colouration can appear to
be relatively shallow, as if it is almost lying on the surface of the skin, or the colours
can be more deep rooted.
When the colours appear to be more superficial, this may well be a consequence
of an exterior imbalance, whereas interior imbalances tend to result in more
deep‑rooted colour changes. Xu conditions tend to manifest with weaker colours
that are not as concentrated and as intense as those seen in shi conditions.
105
Pale
Pale skin arises when there is too little xue in the superficial vessels located below
the surface of the skin. This can be due to there being qi xu. Qi xu can result in
there being too little xue because there is a poor production of the post-heaven
qi needed to create xue, but also because qi is not strong enough to propel xue
to the exterior aspects of the body. Yang xu will likewise also mean that there is a
reduced dissemination of xue in the exterior aspects of the body. Pale-coloured skin
is differentiated from sallow or wan coloured skin, which is seen in xue xu conditions.
Wan
When there is xue xu, it is not only the quantity but also the quality of xue that is
deficient. This means that the skin does not receive sufficient nourishment. The skin
will therefore not only be pale, but also dry, matt and lifeless.
Phlegm can also result in the skin being sallow and lacking lustre. This is because
Phlegm can block xue so that it cannot nourish the skin.
Yellow
A yellow skin colour can be due to Dampness or, if it is very dry, a chronic qi
and xue xu condition. A more powerful or even shiny yellow colour will be a sign
of Damp‑Heat.
Black
Kidney imbalances, which will always be xu in nature, can result in a black hue
on the skin. This can also be seen when there is xue stagnation. When there is xue
stagnation, the skin will be more matt. This is because the stagnant xue will prevent
the circulation of fresh and nutritious xue reaching the skin.
Purple
Purple skin will be seen locally after a physical trauma and is due to stagnation of
xue in the area.
Blue
When Cold invades the body, it will block the movement of qi and xue due to its
contracting nature. This will result in the skin having a bluish colour, because xue is
less oxygenated.
Green
A greenish tinge of the skin is an indication of qi and xue stagnation. It is most
often seen in the area around the eyes, on the bridge of the nose and on the
abdominal cavity.
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A useful technique for measuring the extent of xue stagnation in the superficial
aspects of the body is to depress the skin with your fingers and observe how long
it takes for the colour to return to where the fingers pressed the skin. The more
stagnation there is, the more time it will take before the white fingerprints disappear
from the skin.
Observation of skin colour

Red skin colour Heat, both xu and shi
Wind-Heat
Pale skin colour Yang xu or qi xu
Sallow and wan Xue xu or Phlegm
Yellow skin colour Damp or Damp-Heat
Black skin colour Kidney xu or xue stagnation
Purple skin colour Xue stagnation
Green skin colour Qi and xue stagnation
Blue skin colour Shi Cold
White fingerprints that remain after palpation Xue stagnation in the skin or muscles
The moistness of the skin

The skin is moistened and nourished by jinye and xue. If xue, yin or jinye are xu, the
skin will not be moistened and will become dry.
If the skin is excessively damp or oily, there is probably Damp, Damp-Heat
or Phlegm conditions. Dampness and Phlegm are forms of xie qi and therefore do
not have nourishing qualities. They will, in fact, prevent the circulation of qi, xue
and jinye. This will mean that the skin can be both oily and undernourished at the
same time.
Yang qi xu can mean that there is not enough qi to keep the pores in the skin
closed. The spreading dynamic of exogenous Wind can also force open the pores.
Both of these situations will result in spontaneous sweating. Heat can also drive
fluids upwards and outwards, causing the person to sweat. People who are anxious
will also sweat spontaneously when they are nervous. This can be experienced before
and during an acupuncture treatment. This is a sign that their shen is unsettled and
the Heart therefore can no longer control sweat.
There may be certain areas of the skin that are not being nourished as they should.
This will result in the skin in these areas becoming dry and flaky. This indicates that
there is a xue stagnation deeper down, blocking fresh, nutritious xue and jinye from
reaching the area, resulting in the skin lacking nourishment.
It is, of course, important to be attentive to the use of moisturisers and creams
that will confuse or obscure the diagnosis.
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Observation of the moistness of the skin

Dry skin Xue xu, jinye xu, yin xu, xue stagnation
Oily or greasy Damp, Damp-Heat or Phlegm
Wet (sweaty) Lung qi xu, Spleen qi xu, yang xu, Heart qi xu, shi Heat, xu Heat, invasion of
Wind
Visual diagnosis of the skin’s elasticity

The skin should be soft, elastic and smooth, which reflects that the Lung and the
Spleen are healthy.
If the skin is thickened or hard, this can be a manifestation of xue stagnation
or Dampness.
Phlegm can cause the skin and connective tissue to become ‘doughy’. The skin
will usually also lack shen. This is due to Phlegm blocking the small spaces in the
tissue (cou li) and preventing the circulation of xue.
Wrinkles or loose skin are an indication that the skin is not nourished optimally.
This will usually be an indication of yin xu or xue xu. Sometimes the wrinkles are
localised to specific locations and can indicate a xu condition in the channel or
channels that traverse the area. An example of this is the fine wrinkles that can be
seen around the mouth in post-menopausal women. This is because ren mai and
chong mai have dried out.
Observation of the elasticity of the skin

Elastic and soft skin Normal skin
Loose or wrinkled skin Xue xu or yin xu
Doughy skin without lustre Phlegm
Thickened skin Xue stagnation or Dampness
Visual diagnosis of veins

Small, purple blood vessels that are visible in or below the surface of the skin, as
well as spider naevi, are an indication of xue stagnation. These vessels can be a sign
of a local stagnation, such as those seen on the lower back when the back pain
is the result of xue stagnation. The vessels may also be indicative of a general xue
stagnation. Many older people with xue stagnation have, for example, many visible,
small purple veins in the area on the inside of the ankles.
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Visual diagnosis of skin lesions

Skin lesions are mainly used in the diagnosis of skin diseases. In dermatology the
diagnosis of the lesions is the primary diagnostic tool and is even more important
than the tongue and the pulse.
Skin lesions are divided into primary and secondary lesions. The primary
lesions are the lesions that arose originally. Secondary lesions occur as a result of the
primary lesion.
Primary lesions
Macules
Macules are flat. They are neither raised nor sunken and they cannot be felt when
palpating the area with a finger. They can only be observed visually. Macules can
have various sizes6 and colours, depending on the cause.
• Red macules will always be a sign of Heat. The redder they are, the more Heat
there is. Red macules are often seen in febrile diseases. In these situations,
their appearance will be a serious sign. When they are observed, it is an
indication that xie qi has penetrated to the xue or ying level in ‘Diagnosis
according to the Four Levels’ (see page 669). Red macules can also be seen in
chronic skin diseases, but this is still a sign of Heat.
• White macules can arise when the skin is not nourished by qi and xue. This
lack of nourishment can be due to qi xu, xue xu or a stagnation of qi.
• Brown macules arise when the skin is not nourished by qi and xue. This lack
of nourishment can be due to qi xu, xue xu or a stagnation of qi.
• Purple or black macules are due to xue Heat creating xue stagnation. The
difference between the purple and black macules is the intensity of the Heat,
black being the most extreme of the two.
In general, the presence of macules indicates that the Heat is at a deeper level than
in the presence of papules does.
Papules
Papules are elevated lesions that can be felt when running your fingers over the
skin. They may be pointed or flat on top. Papules are less than five millimetres in
diameter. If they are larger than five millimetres, slightly raised and flat, they are
defined as being a plaque, but the diagnosis will be the same as the diagnosis of a
papule. If they are larger than five millimetres and elevated, they are called a nodule
(see below).
A papule is often red and is always a sign of Heat.
If the papule is the same colour as the rest of the skin, it will be a virus-
induced wart.
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• Red papules. If the papules are hard and itchy, they will be due to an
invasion of Wind-Heat. If, at the same time, there are red macules, bleeding
or scabbing, this will be due to xue Heat. If there is exudation, the cause will
be Damp-Heat.
• Purple papules are due to xue stagnation generating Heat or the xue
stagnation itself.
Weals
When larger areas of the skin swell up temporarily, these are called weals. The
swellings are caused by localised oedema.
• White weals are due to Wind, Wind-Cold, or yang xu.
• Red weals can arise from Wind-Heat or yin xu. Red weals that arise after
scratching are a sign that xue Heat is generating Wind.
Nodules
A nodule is raised and larger than five millimetres in diameter. There will always be
an underlying stagnation, either of qi and xue or Dampness and Phlegm.
Vesicles
Vesicles, like papules, are elevated and less than five millimetres in diameter. The
difference between the two is that vesicles contain clear fluids (which can become
murky over time). Vesicles may be due to Damp-Heat or Toxic-Fire. The more Heat
there is, the redder the vesicle is around the edge.
Bulla
If a vesicle is greater than five millimetres it is called a bulla. The diagnostic
significance is the same as for vesicles. The more Heat there is, the redder the bulla
is around the edge.
Pustules
Pustules are elevated and contain pus. They will always indicate the presence
of Toxic-Fire. There is a difference in the presentation if Toxic-Fire is internally
generated or caused by an invasion of xie qi. If the pustule has a thin wall and a red
border, it will be due to exogenous Wind-Heat. If the wall of the pustule is thicker,
the Heat will have been internally generated.
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Secondary lesions
Dandruff
Flaky patches of skin are almost always a sign that there is some form of Wind.
Differentiation is made between dry and greasy flakes.
• Dry and white flakes are seen in extreme Heat or when xue xu generates Wind.
• Oily and yellowish flakes are seen when there is Wind, Damp-Heat or
Toxic‑Fire.
Erosion
Erosion arises when the outermost layer of the skin is partially disintegrated, but it
does not leave a scar when the skin heals again. This is usually seen as a consequence
of vesicle or blister. It is a sign of Damp-Heat.
Ulcers
With an ulcer, the outermost aspect of the skin is eroded and there is scarring after
the skin has healed. Ulcers are seen when there is Damp-Heat and Toxic-Fire.
Crusts
Crusting can be seen when there has been a bloody or watery exudate from a lesion.
Crusts are a sign of Damp-Heat, xue Heat or Toxic-Fire.
Excoriation
These are scratch marks or superficial lacerations in the skin that are caused by the
person scratching themselves. Excoriation is seen when there is Wind or xue Heat.
Cracking
Cracks in the skin are seen when there is Dryness. Dryness can be caused by Cold,
xue Dryness or Heat.
Lichenification
Lichenification is thickening of the skin, possibly with visible wrinkles in the
thickened skin. It can be seen when there is xue xu or xue stagnation.
Thin skin
The skin can be thin and almost transparent, enabling the blood vessels to be visible
through skin. The skin is fragile and there will be easy bruising. This is a sign of qi
xu, xue xu or yin xu.
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Pigmentation
If the skin becomes darker or lighter, it is a sign that there is xue stagnation or
malnutrition of the skin. Malnutrition occurs as a consequence of xue xu or
Kidney xu.
Visual diagnosis of acupuncture points and channels

Observation of the channels
Imbalances in the channels can result in changes in the skin or muscles around the
channel.
Changes in the skin’s colouration and skin lesions are particularly important.
Observation of changes in the skin along a channel will give an indication of which
channel is out of balance and what type of imbalance it is. This is particularly helpful
when utilising ‘Diagnosis According to the 12 Regular Channels’ and ‘Diagnosis
According to the Eight Extraordinary Vessels’ (see Sections 10 and 11).
• Stagnation of qi in the channel can result in the skin above the channel
becoming greenish in colour.
• Heat in the channel can turn the skin above the channel red.
• Cold in the channel can manifest with bluish skin above the channel.
• Dampness in the channel can be observed when there is yellow skin along
the path of the channel.
• Purple skin or the presence of small purple veins along the path of the
channel is seen when there is xue stagnation in the channel.
• Pale skin along the path of the channel will be observed when there is qi xu
and yang xu in the channel.
There may also be skin lesions along the path of the channel.
• Red macules indicate the presence of Heat in the channel.
• Green macules indicate a stagnation in the channel.
• Bluish macules are seen when there is pain and xue stagnation in the channel.
• Xue stagnation in the channel can also manifest with purple macules.
• Papules along the path of the channel indicate the presence of Heat in the
channel.
• Vesicles along the path of the channel indicate the presence of Dampness or
Damp-Heat.
• Pustules along the path of the channel indicate the presence of Toxic-Fire.
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Observation of yuan-source points

Changes can be observed in the skin and the flesh above and around the yuan-source
points when there is an imbalance in the associated organ. Typical changes around
the point include the area being sunken or swollen. There can also be changes in skin
colour or visible veins.
Visual diagnosis according to

micro‑systems such as ear acupuncture
There are a vast number of various so-called micro-systems around the body. The most
famous are ear acupuncture, the reflexology zones on the feet, abdominal acupuncture
and ECIWO (Embryo Contains Information of the Whole Organism).7 It is beyond
the scope of this book to include a detailed explanation of the many and varied
micro‑systems. A common feature of many of these systems is that the points or zones
that relate to specific areas of the body or organs become reactive when there is an
imbalance or physiological change in this part of the body. This means that you will
often be able to observe skin changes in these points or zones when the corresponding
area or the organ is out of balance.
Observation of secretions, excretions and exudations

Excretions, secretions and exudations in this context will be discharges from the
bodily openings that can be observed with the naked eye. It was previously a part of
a doctor’s diagnostic approach in Western medicine hospitals to observe the patient’s
stool and to see, smell and sometimes taste the urine. This elicited useful information
for the doctor. Nowadays, microscopic and biochemical analysis of excretions from
the body is utilised instead. Nevertheless, the physical appearance of an excretion
will reveal important diagnostic information about a person. The excretions that will
typically be seen in the clinic do not include excretions from the lower orifices. In
fact, the observation of excretions from the body in general will be limited. This is
because the exudations from the body will usually have been removed by the patient
prior to visiting the clinic. The physical appearance of these exudations is therefore
something we usually have to ask about.
The diagnostic guidelines are the same for all types of discharge from body
openings. Generally speaking, discharges that are clear and watery are caused by
Cold, qi xu or yang xu.
When discharges become thicker, sticky or yellowish, this is an indication that
there is Heat that is condensing the fluids. Extreme Heat can result in the presence
of blood in the excretion.
If the excretion is not just yellow but is also decidedly greenish, then there is
Toxic-Fire.
Dampness makes excretions turbid and cloudy.
In addition to the general guidelines presented above, there are some more
specific observations that are relevant to the specific orifices.
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Exudations from the ears

Excessive earwax is a sign of Phlegm or Dampness.
Yellowish or greenish exudation is a sign of Toxic-Fire or Damp-Heat in the
shaoyang channels.
Exudations from the eyes

A person with Phlegm will tend to have blobs of slime in the eyes, not only in the
morning but also during the day.
Eyes that water can be a sign of an invasion of exogenous Wind and also of the
internal Liver imbalances.
Secretions and exudations from the mouth

Saliva dribbling from the corners of the mouth can be a sign of Spleen qi xu and
Dampness, but can also occur when the muscles around the mouth are blocked by
Wind-Phlegm or when the channels in the local area are blocked by Wind-Cold.
Exudations from the nose

Watery mucus in the nose or a runny nose will be seen when there is Wind-Cold
and Damp-Phlegm.
Yellowish and thickened mucus in the nose is due to Wind-Heat, Phlegm-Heat
or Toxic-Fire if the mucus is decidedly greenish.
Spontaneous bleeding from the nose can be a sign of Heat and also of Spleen qi
xu if the Spleen is not able to keep xue inside the vessels.
Secretions and exudations

Sweat also falls within the category of ‘excretions’. If we observe that the patient
sweats a lot, without the weather being particularly hot or humid, this will in itself
be a diagnostic sign. If the person has just cycled or has been running, the heat that
this activity has generated will have driven fluids upwards and outwards from the
interior of the body to the surface as sweat. This is a natural consequence of physical
activity. If the person has perspired due to less strenuous activity, such as walking up
the stairs, or they just sweat spontaneously, it will be a sign of qi xu, yang xu, Heat
or Damp-Heat.
There are two mechanisms in qi xu and yang xu that can make a person sweat
during light exercise. The first mechanism is that even the heat that the light physical
activity generates will be enough to make the person sweat. This is because the
dynamic nature of heat will always force fluids up to the surface of the skin. Because
there is a lack of qi, particularly yang qi, the pores will not be able to restrain the
sweat. The physical activity itself will simultaneously consume yang and qi, resulting
in there being less yang qi to control the pores.
114
Both xu and shi Heat drive fluids upwards and outwards resulting in increased
pressure against the pores. If there is Damp-Heat, the sweat will usually be more
sticky and yellowish.
Sweat is an important diagnostic sign in invasions of exogenous xie qi. The
differentiation of the sweating can be used to locate which level or stage xie qi has
penetrated to. When there is an invasion of Wind-Cold in the taiyang aspect, there will
not be any sweating unless the person is wei qi xu. This is because the exogenous Cold
is blocking the pores and preventing them from opening. When exogenous xie qi
penetrates to the yangming aspect or qi level, there will be profuse sweating without
any relief of the symptoms. This is because the extreme Heat is driving the fluids
upwards and outwards. If sweating ceases during the day and is only seen at night,
this will be because the invasion of xie qi has entered the ying level or shaoyin or
jueyin aspects. It reflects that yin has been damaged by the xie Heat.
Yellowish, oily sweat beads can be seen on the forehead when yang collapses.
Vaginal discharge
A watery or whitish discharge from the vagina is due to Cold or Spleen and Kidney
yang xu. The blockage by Cold or the lack of yang qi results in fluids not being
transported away from the area, whilst the lower orifices lose the ability to hold
the fluids in the body, either because there is a lack of yang qi or because yang qi is
blocked by the Cold.
Yellowish and sticky discharge from the vagina is seen when there is Damp‑Heat.
The Heat condenses the fluids, turning them yellow.
Greenish discharge is seen when there is Toxic-Fire.
Urine
Dark and scanty urine is seen when Heat condenses the urine.
Yang xu Cold will give rise to copious amounts of clear urine. This is because
a deficiency of yang qi means that fluids are poorly transformed and transported.
These fluids then seep down to the Urinary Bladder in the lower jiao.
Dampness causes the urine to become cloudy or murky.
If analysis of the urine reveals the presence of blood in the urine, the cause can
be Heat, xue stagnation or Spleen qi xu.
Stools
Watery stools that contain undigested food are seen when there is Kidney and Spleen
yang xu. This is due to the inability of yang to transform the ingested food.
Sticky stools are a sign of Damp-Heat. The Heat condenses the fluid aspect of
the stool so they become sticky.
Blood in the stool can be caused by Heat, xue stagnation or Spleen qi xu, which
can all result in the walls of the blood vessels rupturing.
115
If the stool is very dry, there will be either Heat, yin xu or xue xu. The Heat
injuring fluids or yin xu and xue xu result in a lack of fluids.
Stools that are small, hard and pebble-like, similar to goat droppings, are due to
Liver qi stagnation, especially if the stagnation has generated Heat.
Long and thin stools, can be seen when there is Spleen qi xu. If the stools contain
mucus, this is usually a sign of Phlegm-Dampness.
Observation of excretions and discharges

Watery and clear excretions Cold, qi or yang xu
Yellow, sticky or thick discharges and excretions Heat, Damp-Heat
Greenish discharges Toxic-Fire
Cloudy and murky discharges Dampness
Bloody discharges Heat (but can also be Spleen qi xu or xue
stagnation)
Copious earwax Phlegm or Dampness
Eyes that water Invasion of Wind, Liver imbalances
Saliva dribbling from the mouth Spleen qi xu, Dampness, Wind-Phlegm,
Wind‑Cold
Clear, watery mucus in the nose Wind-Cold, Damp-Phlegm
Nose or sinuses that are blocked with yellow or Wind-Heat, Phlegm-Heat, Toxic-Fire
green mucus
Spontaneous sweating or sweating on light Qi and yang xu, Heat or Damp-Heat
activity
Yellow or sticky sweat Heat, Damp-Heat
Watery or whitish vaginal discharge Cold or Spleen and Kidney yang xu
Yellow, sticky vaginal discharge Damp-Heat
Greenish vaginal discharge Toxic-Fire
Dark urine Heat
Clear urine Yang xu
Cloudy or murky urine Dampness
Blood in the urine Heat, xue stagnation or Spleen qi xu
Watery stools containing undigested food Spleen and Kidney yang xu
remnants
Sticky stools Damp-Heat
Blood in the stools Spleen qi xu, xue stagnation or Heat
Dry stools Heat, yin xu or xue xu
Pebble-like stools Liver qi stagnation
Long, thin stools Spleen qi xu
Stools that contain slime and mucus Phlegm-Dampness
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Appendix to Section 1
VISUAL DIAGNOSIS OF CHILDREN
Observation is a significant aspect of Chinese medicine paediatric diagnosis, particularly

when diagnosing babies and small children. Diagnostic information can be obtained by
asking the parents and the child, but an essential part of diagnosis is also carried out
by observing the child. The most important aspect of paediatric diagnosis is to assess
whether it is a shi or xu condition and whether there is Heat present. The differentiation
of these conditions is highly dependent on visual diagnosis.
Observation of the child

Radiance
One of the first things to observe is whether there is shen. Shen is seen in the radiance
that there is in the skin of the face, especially in the child’s eyes. Ideally, there should be
a soft glow in the skin of the face, and the eyes should be bright and clear. This will show
that zheng qi is strong and that xie qi, if it is present, has not penetrated very deeply.
If the eyes are dull and without lustre, and the skin of the face lacks radiance, this
is a sign that zheng qi is weakened and xie qi is strong or that there is a significant xu
condition.
If there is shen, there will also be good eye contact. The child should appear alert
and take an interest in their surroundings. Something that can blur the picture is that
children are often nervous when meeting a stranger, especially if that stranger is an
acupuncturist. This is not such a problem with babies, but the parents’ nervousness and
fear that the needles will hurt the baby can affect the baby and make it nervous. This will
affect the radiance from the eyes.
Movement
Children’s movements are faster and more restless than adults. This is because children
are relatively more yang and do not have as much yin in their body yet. Constitutionally,
they tend to have an excess of yang and have too much Heat. Their yin is not strong
and has difficulty controlling yang Heat. This is seen especially in the evening when
the child is tired. Children will often have difficulty rooting their yang, and the more
tired they are, the more their yang is active. An overtired child can become hyperactive
in the evening. If the child is like this during the day, and is very restless, fidgety and has
difficulty sitting still during the consultation, this is an indication of Heat. Heat will also
result in rapid movements. A child with Heat will kick off their bedclothes when they
sleep as they try to dissipate some of their Heat.
If the child seems very quiet and there is a lack of movement, this is a sign of a xu
condition or Cold. In xu conditions the child will seem limp, whereas Cold will mean
that they sit or lie huddled up. When they sleep, they may well lie curled up with a
duvet pulled up over them to retain body heat. As stated earlier, this quietness and lack
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of movement can also be due to the child being shy. In an adult, this shyness would itself
have diagnostic significance, but it is to be expected in small children, as their Heart qi
is not stable.
Muscle spasms and cramps will rarely be seen in the clinic, but if they are, it will be
a sign of Liver Wind.
Muscle tone
The muscles and posture should not be too lax, but at the same time they should not
appear to be rigid. Flaccidity will be seen in a xu condition and muscle tenseness in a
shi condition.
Sudden tenseness and cramping of the muscles, with rigid neck muscles, means
there is internally generated Wind. A milder form of internally generated Wind is seen
when there are spasms, convulsions, tics and muscle trembling.
The skin should be supple, elastic and not too loose.
Observation of children’s movements and muscle tone

Restless or fast movements Heat
Sitting or lying huddled up Cold
Tense muscles Shi condition
Lax muscles Xu condition
Muscle spasms, convulsions, tics and muscle tremors Liver Wind
Stiff muscles Liver Wind
Observation of skin colours

The diagnostic significance of the colours in the skin in general, and especially in the
face, is the same as it is for adults. In xu conditions, the colours will be paler, and they
will be more intense in a shi condition.
Red colours are seen when there is Heat. A white or pale face is seen when there is
qi xu and yang xu.
Cold and shock are capable of producing a blue colour. If the mother has been
exposed to a strong shock during pregnancy, it may affect the foetus’s Heart qi. This can
be observed as a bluish colour on the forehead.
Pain and the internal Wind can manifest with a green hue to the face.
A yellowish hue in the facial complexion is a sign of Stomach and Spleen imbalances.
A blue or blue/green (qing) colour on the bridge of the nose between the eyebrows
is a sign of Liver Wind and can be seen when there are muscle cramps.
Observation of facial skin tones in children

Red Heat
Blue Cold or shock
White or pale Yang or qi xu
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Appendix to Section 1: Visual Diagnosis of Children
Yellow Spleen and Stomach imbalances

Green Pain or Wind
Paleness Xu conditions
Strong, intense colours Shi conditions
Visual diagnosis of the index finger vein

Something that is unique in the diagnosis of children under three years is the observation
of the vein along the Large Intestine channel on the index finger.
The radial aspect of the finger should be rubbed lightly and then observed to see the
length, colour, depth and distinctness of the vein.
The index finger is divided into three zones. The borders of these zones are the three
creases in the joints of the finger. These creases are called ‘gates’. The proximal finger
joint, i.e. the metacarpo-phalangeal joint, is called the Wind Gate, the middle joint of
the finger is called the qi Gate and the distal joint of the finger is called the Life Gate.
If the vein is only visible just beyond the Wind Gate, the disease is mild and xie qi
has not penetrated deeper than the exterior aspects of the body and is located in the
small luo vessels. If xie qi has penetrated deeper down to the channels, the vein will
also be visible beyond the qi Gate. A visible vein beyond the Life Gate is a serious sign
indicating that xie qi is virulent, has penetrated into the interior and has reached the
zangfu organs. It is even more serious if the vein reaches all the way to the nail bed of
the index finger.
A thin and pale vein will be seen if it is a xu condition, whilst a thicker and more
deeply coloured vein will be seen in shi conditions, in particular when there is a stagnation
in the Intestines.
Veins that disappear when massaged with your fingers are seen in xu conditions. If
the vein does not disappear, even with strong massage, it is a shi condition.
If the vein is very superficial and clearly visible just under the skin, then xie qi is in
the exterior. Conversely, if the vein appears to be deeper lying and is almost hidden, the
xie qi is in the interior. The colours here will also be more intense.
Vein colour
Ideally, the vein should have a reddish, yellow colour. The vein will become bright red
when there is an invasion of exogenous xie qi in the exterior.
If the vein is a purple/red, this is a sign of Heat, whilst a green/blue-coloured vein
can be seen when there is internally generated Wind, pain or food stagnation. If the
vein is more black/purple, this is more serious and that indicates Phlegm and stagnation
Heat are blocking the vessels.
If the vein is thick and seems to pulsate, this is a shi condition, which is seen when
there is food stagnation, Phlegm and qi stagnation.
Visual diagnosis of the eyes in children

The eyes can become red when there are invasions of Wind-Heat and when internally
generated Heat ascends upwards to the head.
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Yellow sclera can be seen when there is Dampness, particularly Damp-Heat.

Liver Wind can manifest with the sclera having a greenish blue tinge.
Red and fissured skin along the canthus is a sign of Damp-Heat or accumulation
syndrome (food stagnating in the Stomach and Intestines).
Inflammation of the eyes with pus indicates the presence of Toxic-Fire. Toxic-Fire
can arise from shi Heat conditions, in either the channels or their associated organs,
ascending to the eyes. It can also arise from invasions of Wind-Heat.
Visual diagnosis of the ears in children

One of the most important diagnostic signs that relate to the ears in children is the size
of the ears.
The ears are created from Kidney jing. This means that small, crumpled ears can be
a sign of jing xu.
Red ears can be a sign of Heat in the Liver. Red ears are also seen when there are
invasions of Wind-Heat or Toxic-Fire in the ears.
If there is yellowish/greenish discharge leaking out of the ears, Toxic-Fire is present.
Visual diagnosis of the tongue in children

Tongue diagnosis is basically the same in children as in adults. It can, however, be
difficult to get to see the tongue in very young children. It can require patience and
coaxing, but even then it is not always possible. For this reason, I often rely on observing
the colouration, moistness and sometimes the size of the lips to provide me with some
of the information that the tongue normally elicits. The relevance of the diagnostic signs
on the tongue are no different from those in adults.
Visual diagnosis of the lips in children

The lips are under the influence of the Spleen and Stomach, but are nourished by xue.
Red lips can therefore indicate both xue Heat or Stomach Heat.
Pale lips can be a sign of Spleen qi xu or xue xu.
The lips can become dry when yin has been injured. This will be seen after or during
a febrile disease.
The Liver channel is one of the channels that encircles the lips. Liver Wind, Cold
in the Liver channel or abdominal pain due to Liver qi stagnation can manifest with a
greenish colour around the mouth.
Visual diagnosis of the throat in children

Changes in the throat are mainly seen when there are invasions of xie qi or Phlegm or
when there are Lung, Stomach and Intestinal imbalances.
A red and sore throat, where the condition is of short duration, will be seen in
invasions of Wind-Heat.
If the redness and soreness are chronic, the Heat is more likely to come from the
Lung, Stomach or Intestines.
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If the throat is swollen and red and there is ulceration, this indicates the presence of
Toxic-Fire. This is usually seen after or during an invasion of Wind-Heat. If the tonsils
are swollen and red, the Wind-Heat has generated Toxic-Fire. The Fire can also have its
origin in the Stomach or the Intestines, especially if the condition is chronic.
If whitish or yellowish exudation is observed in the throat or on the tonsils, it is a
further confirmation of Toxic-Fire.
If the tonsils are swollen but have a normal colour, this indicates Phlegm and qi xu.
This can be seen when xie qi is retained in the body and has not been expelled or
drained out of the body.
Visual diagnosis of the gums in children

The oral cavity is under the influence of the Stomach and Spleen. This means that
pathological changes in the gums are usually due to Stomach imbalances.
If the gums are red and swollen, this can be a sign of Heat in the Stomach, food
stagnation or parasites in the Intestines.
The gums can be red and swollen when a child is teething. This can be treated as
Heat in the Stomach with good effect.
Visual diagnosis of the nose in children

The nose is under the direct influence of the Lung and is connected to the Large Intestine
channel. This means that imbalances in the Lung will often manifest in the nose. Nasal
discharges have particular diagnostic relevance.
Phlegm and Damp-Phlegm will often manifest with increased mucus in the nose.
A nose that is running with clear and watery mucus will be seen when there are
invasions of Wind-Cold and when there is Lung qi xu.
If the mucus is whitish or yellowish, it is a sign of Wind-Heat.
If the nose is blocked with thick, sticky mucus, it will be Damp-Phlegm or
Phlegm‑Heat.
If the mucus is yellowish or greenish, it indicates the presence of Heat.
If there is a lot of Heat present in the Lung, the nostrils can ‘flare’.
Visual diagnosis of the root of the nose in children

The root of the nose (the area between the eyebrows) can be used in the diagnosis of
children who are below the age of four years old.
If the root of the nose is greenish, there will often be digestive problems.
A dark green colour can sometimes be seen when there is accumulation syndrome
that is an excess condition and a light green colour can be seen if accumulation
syndrome is due to a xu condition.
Green macules in this area are sometimes seen when there is diarrhoea.
Blue veins in the region can be seen when there is abdominal pain.
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Visual diagnosis of the eyes, ears, nose, throat, lips and gums in children
Red sclera Wind-Heat or internally generated Heat
Blue/green sclera Liver Wind
Yellow sclera Damp, Damp-Heat
Red and cracked skin around the canthus Damp-Heat, accumulation syndrome
Small, crumpled ears Jing xu
Red ears Liver Fire, invasions of Wind-Heat or Toxic-Fire
Yellow or green discharge from the ears Toxic-Fire
Red lips Xue Heat, Stomach Heat
Pale Lips Spleen qi xu, xue xu
Dry lips Yin is injured
Green colour around the mouth Liver Wind, pain, Liver qi stagnation affecting the
abdomen or Cold
Red throat Wind-Heat, Toxic-Fire, Lung Heat, Stomach Heat or
Intestinal Heat
Red, swollen throat Wind-Heat, Toxic-Fire, Stomach Fire
Swollen tonsils Phlegm
Red and swollen tonsils Toxic-Fire, Heat in the Stomach or Intestines
Red, swollen tonsil with exudate Toxic-Fire
Red gums Stomach Heat, accumulation syndrome or parasites
Runny nose with clear, watery mucus Wind-Cold
Runny nose with yellow, sticky mucus Wind-Heat
Blocked nose Damp-Phlegm, Phlegm-Heat
Flapping or flaring nostrils Lung Heat
Dark green between the eyebrows Accumulation syndrome
Light green between the eyebrows Xu accumulation syndrome
Green macules between the eyebrows Diarrhoea
Blue vein between the eyebrows Abdominal pain
Visual diagnosis of the sleeping position in children

This is usually something that we must ask about.
A child who sleeps curled up and packs themselves into the duvet has a Cold
condition.
A child with Heat will toss and turn, kicking off the bedding, and will often sleep
with the arms and legs splayed to the sides.
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Visual diagnosis of the faeces and urine in children

The stools and urine are usually not observed in a clinical context. We are therefore again
reliant on the parents’ observations. The diagnostic significance of these signs is the same
as for adults and is described on page 115.
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Section 2

LISTENING AND SMELLING
Introduction
The diagnostic pillar ‘To Listen and to Smell’ may seem to be a strange combination,
because these are two separate senses that do not seem to be related. In Chinese, the
same character, wen zhen, represents both of these words. Both of these senses are
often used whilst carrying out other parts of the diagnosis. The diagnostic signs in
this pillar can often be very subtle and hard to detect unless you are very attentive.
We can gather olfactory information whilst we are in close physical contact with the
client, for example whilst we are palpating them or when we are inserting needles.
Sometimes, the subtle odours that a client emits are more pronounced when
the needles are being removed. We will also have ample opportunity to listen to the
patient’s voice and breathing whilst they are relating their symptoms and medical
history to us. We constantly utilise the first aspect of the pillar to listen, all the
time, without necessarily thinking about it and without having structured it into
a system. Even before we have met a client, when we have only talked to them on
the phone, we have often formed an impression of who they are just by hearing
their voice. The great strength of Chinese medicine is that it has systematised and
categorised the impressions we get from a person in a diagnostic context.
Unfortunately, some practitioners prioritise listening and smelling less, for
various reasons. This is a pity, because by listening to the client, you can gain vital
information. It is important to listen to the various sounds emanating from the
abdomen and chest, as well as to the sound of the patient’s voice. Here it is important
to be observant of not only the classical sound qualities in the voice that are described
in Chinese medicine textbooks, such as laughing, crying, shouting etc., but also of
how they are talking, the words they use, how they express themselves, how they
converse and, very significantly, how easy it is to engage them in a conversation and
how communicative they are.
Furthermore, many of the signs described in this section and the previous
section on visual diagnosis, are not necessarily things that you will see or hear that
often. What is important is to be sufficiently vigilant to spot the signs when they
are there. Physiological harmony is characterised by an absence of pathological
symptoms and signs. It is when things digress from the norm, from what is expected,
that we prick up our ears and open our eyes. When we see or hear these signs, we
must ask ourselves: What does this mean? How do I interpret this from a Chinese
medicine perspective?
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The Diagnostic Pillar: Listening and Smelling
Olfactory and auditory diagnosis

Relative strengths of olfactory and auditory diagnosis
• Auditory diagnosis is, together with visual observation, the cornerstone of
the intuitive approach to diagnosis. Through these two approaches we can
often determine a substantial part of the diagnosis. We must learn to trust this
ability but at the same time not confuse intuition with guessing.
• Listening to the client means we are not dependent on their subjective
interpretation and presentation of their diagnostic signs.
• Many patterns of imbalance manifest with changes in how the person
communicates and changes in the quality of their voice.
• We can hear the sounds emanating from the client, even when we do not
interview them (for example, in the waiting room, on the phone or whilst we
are needling them).
• Auditory diagnosis is very important in the diagnosis of children.
Relative weaknesses of olfactory and auditory diagnosis

• There is a limited amount of literature that you can use as reference material.
• Olfactory diagnosis is difficult because people frequently wash themselves,
wash their clothes regularly and use creams, deodorants, perfumes, etc.
• Both diagnostic approaches are very subjective and you can be uncertain
about whether what you hear or smell is the same as what is written in the
textbook. This is particularly relevant in olfactory diagnosis.
• Some things, such as the patient’s stools, urine or vaginal discharge, are not
things that we smell ourselves. We are therefore dependent on the patient’s
subjective reporting of these signs.
• Many of the olfactory and auditory signs are very subtle and thereby difficult
to differentiate.
Diagnostic tips
• Ask the client how the various excretions from the body smell and possibly
taste (for example, mucus from the sinuses and nose).
• Things that have a strong smell or taste are usually a sign of pathological
Heat.
• Ask some questions for which the answer is not important. This gives you
the opportunity to listen to how the patient talks instead of having to focus on
what they are saying.
• Ask the patient to put a t-shirt, vest or pillow case that they have been using
in a plastic bag, which they then tie and bring to the clinic. This will make the
odours more prominent.
Auditory diagnosis
There are two main focus areas in auditory diagnosis. When we are together with
a client, we must be diagnostically aware of the sounds emanating involuntarily
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from their body, such as coughs, abdominal rumbles or respiration. At the same
time, we must listen to the sound of their voice. We may well have already heard
the sound of their voice on the telephone and answerphone. We may also have
heard them talking outside our door whilst they were in the waiting room. This
will have started to create an impression of who they are from a Chinese medicine
perspective. A resonant or loud voice will usually indicate that the person has a shi
condition, whereas a weak voice will tell you that their imbalances are probably
more xu in nature. A gravelly voice will indicate Phlegm, whilst a staccato or clipped
voice will point us in the direction of Liver qi stagnation. The patient can continue
to provide us with auditory information before we see them. The way they press the
doorbell, the sound of their steps in the hallway, the strength of their voice while
talking on a mobile phone in the waiting room and their coughs and sniffles, etc.
can all potentially elicit relevant information about the client and their patterns
of imbalance.
When we initiate the verbal interview, we should be simultaneously gleaning
information on two levels. We should be listening not just to their answers to
our questions and their descriptions of their condition, but also to how they are
communicating.
When they sit opposite us during the diagnostic interview and whilst they lay
on the couch, we should pay attention to their breathing. If they have a cough, it
is a great help to be able to hear the sound of them coughing, rather than them
giving you a description of how it sounds. It is, unfortunately, necessary to ask about
several aspects of this diagnostic pillar, rather than actually experiencing them. It
is probably more likely that you are going to have to ask a woman with morning
sickness about how her vomiting is, rather than actually hearing her vomit.
Auditory diagnosis of the person’s voice

The voice is something we will hear during the consultation and we may well have
already heard their voice on the phone or in the waiting room. This may even be the
only auditory sign from the patient that we pick up. The voice will nearly always give
us relevant diagnostic information about the patient, and this can be vital.
The voice is affected directly and indirectly by various organs and vital substances,
the emotions and xie qi, particularly Heat. Listening to the patient’s voice will give
us an impression of more than one aspect of the client’s imbalances.
It is the Heart that enables a person to communicate with others. The Heart
gives a person the ability to express themselves and open up to others. A person
literally tells other people what is in their heart or on their mind. It is therefore said
that speech is controlled by the Heart.
When the Heart is in balance, a person has a desire and a need to communicate
with others. At the same time, the Heart should also be able to close when appropriate
and have a sense of li or propriety. When the Heart is imbalanced, a person can have
a tendency to either over- or under-communicate – to talk too much or too little
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and give out too much, too little or inappropriate information. The Heart has a very
close relationship with the tongue. The tongue is the sense organ that relates to the
Fire Phase and to the Heart organ. Whereas the other sense organs are hollow and
therefore can receive and absorb impressions, the tongue is solid. This is relevant
to the Heart, which needs to be empty and not filled so it can receive and manifest
the dao. Where the other zang organs receive stimulation and impressions via their
sense organs, the Heart can empty itself through the use of the tongue. The tongue
communicates a person’s thoughts, ideas and emotions via speech. The more activity
and movement that there is in the Heart and shen, the more the tongue will be active.
A person with Heart qi xu or Heart qi stagnation will tend to be reserved, and
thus they will talk less and you will have the sensation of having to draw each word
out of them. There is, though, a difference in their taciturnity. A person who is Heart
qi xu will be more shy and timid, whereas a person with Heart qi stagnation will be
more terse and uncommunicative. If there is Heat agitating the Heart, on the other
hand, the person will often have a tendency to over-communicate, i.e. they will
be loquacious.
The speed of the voice is also affected by how much Heat there is in the Heart. A
person with Heart Fire will tend to talk more quickly. This is because Heat accelerates
processes, including speech, but also because Heat will agitate the shen and thereby
increase mental activity. At the same time, Heat in the Heart will often result in a
person ‘opening’ too much and over-communicating. An extreme example of this is
someone who is manic.
The voice should have vitality. This is not dissimilar to the tongue, pulse and
skin, which should all have shen – a quality of vitality. The same is true of the
voice, but it does not have the same connotations. When there are xu conditions or
stagnations in the Heart and the shen is either blocked or malnourished, the voice
will lack a certain quality. This quality isn’t volume and it isn’t necessarily joy, it is
more movement. The voice should vary and change as they talk, especially as the
subject area that they are talking about changes. This reflects the natural movement
of the shen. The voice should not be stuck in a certain gear. Where the pulse with
shen is firm, solid and rhythmic in its beating, the voice should have an even flow
and not be stuttering or confused. It should also have the sound of joy and happiness
in it. If there is no joy – if Heart qi and shen are either blocked or undernourished –
there will be a flatness and maybe even a tone of sadness in the voice. On the other
hand, if there is too much Heat in the Heart, there can be too much of the quality
of joy and happiness. The voice can be unnaturally glad. This is the ‘life and soul of
the party’ voice. Here, the voice will often be voluble and accompanied by too much
laughter. Also, there will frequently be too many and inappropriate jokes. All this
indicates too much Heat in the Heart. The Heart yin xu Heat voice won’t, of course,
be voluble, and the laughter accompanying the voice is more a nervous laughter,
often at the end of the sentence like an inappropriate punctuation mark.
It is not only the Heart and Heat that affect the voice, zong qi is also used to
create the voice. This means that the Lung will give the voice resonance and force.
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It is said that the Lung controls the voice. A person with Lung qi xu will have a weak
or quiet voice.
The Liver ensures that the flow of qi is free and uninhibited throughout the
body. This means that even though zong qi gives the voice its strength, it is Liver qi
that ensures that the voice flows freely and evenly. When there is Liver qi stagnation
the voice can have a hardness and become staccato, sounding a bit like a machine
gun firing.
The vocal cords, which create the sound of the voice, depend on being moistened
and nourished. This moisture and nourishment is provided by xue and jinye. This
means that xue xu, yin xu and shi Heat can all affect the sound of the voice. The vocal
cords can also be coated and thereby blocked by Phlegm.
Strength and quality of the voice

The strength of a person’s voice will give us an immediate indication of the quality
of a person’s qi – of whether it is an overall xu or shi condition. A shi condition,
particularly Heat, will make a person’s voice become louder and more resonant.
These are the people whose voices travel through doors and walls into the next room.
This is the voice that is heard on the streets on a Saturday night when people have
consumed large amounts of alcohol. The alcohol creates shi Heat in the Liver, their
voices become loud and they no longer talk quietly and softly with each other;
their voices have volume and resonance. When you speak to these people on the
phone you instinctively move the earpiece further away from the ear, and you lean
backwards slightly when sitting next to them. The opposite is the case with people
whose voice is so quiet and soft that you have to strain your ears and sometimes even
physically move closer to them to hear them. These people will usually have a qi xu
condition. They will lack the zong qi necessary to give the voice volume.
Listening to the strength and volume of the voice is something most people
already do subconsciously. We must consciously observe this and place the impression
in a diagnostic context.
We must also pay attention to the quality of the voice. Whether the voice sounds
dry or gravelly and whether the person sounds hoarse or nasal. Furthermore, the
tone of the voice can also impart important diagnostic information. Besides listening
to the overall tone and strength of the voice, we should observe how the voice is
influenced by what they are talking about. If the quality of their voice changes when
talking about a particular subject, situation or person, this may be an aetiological
factor that is relevant to their imbalance. If a person’s voice, for example, becomes
harder and more staccato when they talk about their job, it could indicate that their
job or work environment is detrimentally affecting their Liver qi. Conversely, if this
person talks about something else and their voice becomes gentler and more mellow,
this may be something that can help to alleviate their imbalance.
It is particularly important to notice how much and how fast they speak. The
more Heat there is, the more verbose they are and the quicker they talk.
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Normal voice
The normal voice is neither too loud nor too soft and should sound harmonious.
‘Harmonious’ here means that the tone of the voice naturally goes up and down and
the tone is appropriate to what is being talked about. A discordant voice, for example,
could be when a person has joy in their voice when they talk about something worrying
or sounding sad or unenthusiastic when they talk about a happy event. On the other
hand, the voice will be harmonious if there is joy in the voice when they are happy.
The volume and depth of the voice will, of course, depend on the person’s
gender, age and build. I don’t expect a loud, resonant voice in an 80-year-old woman
or three-year-old child, in the same way that I don’t expect a timid, weak voice in a
30-year-old builder. If the voice is incongruous, we must immediately ask ourselves
why. What is the possible or probable cause of this difference between what I expect
and what I hear?
The Five Phases in the voice

Each of the Five Phases imparts a specific quality in the voice. All five qualities
should be present. There should be neither too much nor too little of these qualities.
These qualities should also vary and be appropriate to the situation. For example,
it is natural that the voice is harder, louder and angrier if a person is exposed to
an injustice. A lack of anger in the voice in this situation is as much a sign of an
imbalance as there being too much of this quality in other situations. If the voice is
dominated by or lacking a certain quality, this indicates an imbalance in the relevant
phase or its related organ.
Five Element acupuncture utilises the quality of the voice when determining
which constitutional type a person is. Furthermore, in Five Element acupuncture, it
is a more serious sign when a person’s voice has a vocal quality from a different phase
than their constitutional type. It is less serious if they manifest with a powerful vocal
quality from their own phase.
As stated above, it is a sign of imbalance when there is too much and too little of
any of the vocal qualities that relate to the Five Phases and their associated organs.
When we are talking to the client we must therefore listen to whether a certain vocal
quality is lacking or dominant in their voice.
Fire – joy and laughter

Fire gives the voice a quality of joy and happiness. It’s the voice you hear when
someone tells you about a happy event. The voice will have vitality. The Heart is
nourished by and manifests with joy. In Heart xu imbalances or Heart stagnation
conditions, the voice will often lack this quality. There will be a flatness and sadness
to their voice. Too much joy and laughter in the voice is usually an indication of
some form of Heat in the Heart. Heart yin xu Heat will affect the voice, so there
will be nervous laughter. This nervous laugh will often end the sentences, almost
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like an inappropriate punctuation mark. Heart Fire will be more of the ‘life and soul
of the party’ voice. This person is exaggeratedly jovial. There can often be an actual
laugh, rather than a nervous giggle, in the middle of sentences. The voice must be
appropriate to what they’re talking about. A person whose voice is cheerful and
lively, or who laughs while talking about something sad, will undoubtedly indicate
a Heart imbalance; the question is which one. It could easily be nervousness or
embarrassment (which in themselves are manifestations of Heart imbalances).
Similarly, a Heart imbalance could be manifested by a person who talks about a
happy event but has a noticeably sad and flat voice.
Earth – singing
The Earth Phase manifests with a singing voice. This is a voice that is varied in its
tone. The tone fluctuates up and down. It is the voice that you would use when
reading a story out loud. A voice that has either too much or too little of this quality
indicates a Spleen or Earth Phase imbalance.
Metal – crying
The emotion of the Metal Phase is sorrow. Grief can also be heard in a person’s voice
when there are Lung or Metal Phase imbalances. There may be a slight choking
of the words. The voice will sound as if the person is on the verge of tears. An
extreme version of this voice is when a child is telling you something just after they
have been crying. In Lung imbalances the voice may be lacking in strength and the
sentences can have a tendency to ebb out before they are completely finished. This is
because zong qi is often weak in many Lung imbalances and there will not be enough
strength to complete the sentence.
Water – complaining and moaning

This voice is heard when the Kidneys or the Water Phase are out of balance. It is
a very flat voice, lacking in tonal variation. The voice also sounds like it is about
to break into tears. It is the opposite of the Fire Phase voice, which is full of joy
and laughter.
Wood – shouting
The voice of the Wood Phase is a hard voice. When the Liver and the Wood Phase are
in balance, the voice is neither too hard nor too soft. The voice should be resonant
without shouting. If there is imbalance, the person’s voice can acquire a very hard
tone. It will have a shouting quality. The voice will sound sharp and have force and
direction. It is a voice that has no problem being heard and is not hesitant. It is the
tone that is heard when someone is angry.
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If a person’s Liver qi stagnates, the words will be clipped and the voice will
become staccato.
These Five Phase qualities can be seen as balancing qualities when you place the
Five Phases in the Cosmological Five Phase sequence – North, South, East, West
with Earth located in the centre. The Water Phase’s flatness is the yin/yang antithesis
of the Fire Phase’s joyful voice. They are opposites and they therefore balance each
other. Too much of one will mean that there is, as a consequence, too little of
the other. The more happiness there is in the voice, the less flatness there will be and
vice versa. This is fundamental yin/yang principles and dynamics. The more yin there
is, the less yang. They are opposites that consume each other. If we look at the other
axis, the Metal Phase voice has a tendency to be strangled by sorrow, and both the
words and sentences have a tendency to ebb out before they are finished. There is less
definition, especially at the ends of words and sentences. This is the opposite of the
Wood Phase voice, which is hard and clear cut and the words don’t drag out before
ebbing away but are instead sharply clipped and well defined. Where the Metal
Phase voice lacks strength due to zong qi being affected, the Wood Phase voice is
expansive. It can travel through walls and doors when it is in excess. It is difficult to
be aggressive and sorrowful at the same time; you have to alternate between the two.
This then leaves the Earth Phase. Here, the voice is described as singing – a voice
where the tone is variable and going up and down. This makes sense, as the Earth is
the centre – the axle that everything revolves around and passes through. The other
phases’ voice qualities are constantly moving backwards and forwards, up and down
through the Earth centre giving the voice a singing quality.
Five Phase vocal qualities

Phase Significance
Fire Laughter, joy
Earth Singing
Metal Crying
Water Complaining and moaning
Wood Shouting
Emotions and the voice

The five emotions are similar to, but not exactly the same as, the five vocal qualities.
Sometimes there are certain emotions that are prevalent, not only in the vocal
quality, but also in the conversation itself. This can be heard in the answers and
explanations that the patient gives and in the questions they ask. Some patients
with Kidney or Water imbalances, for example, will be excessively fearful. You can
hear in the way that they describe their life and their symptoms how there is an
undertone of fear and anxiety. There are many things that they are scared of, not
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just the disorder they suffer from. They will often wonder whether: the treatment
is safe or dangerous; you think that their condition is life threatening, even though
the doctor has told them it isn’t and that there is nothing to worry about; there is
a danger of the needles puncturing an organ; the needles are sterile. They will also
be scared that you have forgotten to take all the needles out again. You will hear,
repeatedly, how fear dominates their life. A person with Liver or Wood imbalances
may, on the other hand, tell you about all of the frustrations and problems that
they have in their life and all the dissatisfaction and frustration that they have had
when visiting other therapists. It is not that emotions themselves are imbalances but
they should be appropriate to the situation and, importantly, neither too dominant
nor too weak. This means that we must be listening to how and what they are
communicating. Do they, for example, constantly apologise, even though it is not
necessary – sorry for coming early, sorry for having chewing gum in their mouth,
sorry for not taking their clothes off quickly enough, sorry for the state of their
clothes? Do they constantly or excessively compliment and praise you and others?
Do they express excessive gratitude? As with so many things, there is no hard-and‑fast
definition of any of these things, it depends on the underlying emotion, the tone of
the voice and the emotional motivation. If we look at apologising, for example, it
can be an expression of constant worrying, it can be fear, it can be lack of self-worth
and it can be a combination of all three. We therefore have to see this in the context
of the other symptoms and signs.
The emotion in the voice should also be appropriate to the subject being talked
about. We listen subconsciously to the tone of the voice as much, if not more than,
what is being said. The same sentence can have a multitude of meanings, depending
on the tone of the voice and where the stress in the sentence is placed. It is also
important that the tone of the voice changes in relation to what they are talking about.
Sometimes an imbalance that can be heard in the voice only becomes obvious
when they talk about a subject that generates a certain emotion, such as anger, fear
or sorrow.
Five Phase emotional qualities

Fear and anxiety Kidney xu or Water imbalances
Worry and speculation Spleen qi xu, Dampness or Earth imbalances
Sorrow and grief Lung or Metal imbalances
Anger and frustration Liver or Wood imbalances
Excessive merriment or sadness Heart or Fire imbalances
How easy is it to engage the patient in conversation?

When we are sitting in front of a patient, we are listening to what they are saying
and the quality and volume of their voice. We must, though, also have a focus on
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the conversation itself – not only how quickly and how structured their conversation
is, which will be discussed below, but also how effortless the conversation is between
you and them. How easy is it to create contact with them? Are they open and
communicative? If not, in what way are they not? Is it shyness, which will usually
indicate a Heart xu condition, or is it because they are closed, uncommunicative and
difficult to engage? As always, things must be seen in a context of the other signs
and body language. These will be significantly different between a person who is
difficult to engage because they are shy and reticent and a person who is stubborn
and dour due to stagnation of their Heart and Liver qi.
If the Heart is harmonious, the person will be easy to engage and they will
open themselves but with a degree of restraint. The Heart not only has the ability
to open up and communicate with others, it is also responsible for ‘closing’ and not
communicating when this is appropriate. A person who has Heat in their Heart can
be over-communicative. They can initially be very easy to engage, quickly opening
up and creating a connection, but if there is a lot of Heat, they can have a tendency
to be too communicative, too open and lose the sense of li or propriety that is an
aspect of shen. These people will not only start talking to anyone and everyone, they
will also ‘open up’ too much, even when it is not appropriate or relevant. This is the
person who, whilst sitting in the waiting room, tells the person sitting next to them
all sorts of personal details about their life, family, neighbours, illness and journey
into the clinic. The Heat opens the Heart so much that it is unable to close when
appropriate and is therefore open and communicating all the time.
These people are very easy to engage, but in this case it is an expression of
imbalance rather than harmony. As with everything in Chinese medicine, both too
little and too much of something is a sign of imbalance and a lack of harmony.
What is too much and too little will, as always, be dependent on the situation, and
a person should be able to adjust to the various situations and contexts.
How easy is it to engage the client?

Easy to engage in conversation and communicate with Normal or Heat in the Heart
Shy, reserved and reticent Heart qi xu
Closed, uncommunicative and terse Liver and Heart qi stagnation
Opens excessively, no boundaries Heart Fire, Phlegm-Fire
Flow and structure of their speech

The flow of the voice will reflect the condition of the patient’s shen. This is obvious
when we experience fright, start to stutter and become ‘tongue-tied’. This is one
of several manifestations indicating that Heart qi has been spread and has become
unstable due to the fright. We will probably also be sweating in the armpit and in the
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palms of our hands, and our heart will be thumping, beating rapidly and possibly
slightly irregularly.
When the Heart and the shen are affected, the flow of the voice can also be
affected in other ways. These changes in the speech pattern reflect what it is that
is affecting shen. If shen is agitated by Heat, the structure of their speech and their
replies to your questions can become disrupted. The mind can start rushing –
moving faster than the words can keep pace with – so the conversation loses some
of its structure. Heat, by agitating shen, will result in the person not always finishing
describing or explaining what they were talking about before they start veering off
in other directions because new thoughts have overtaken the ones that they were
elaborating on.
When Phlegm is blocking shen, there will also be a disruption in the structure
of the conversation. The speed of the voice can be slower due to Phlegm slowing the
ability to formulate what is in their mind, but at the same time the blockage of shen
will also mean that the person has difficulty thinking clearly. They will be more easily
confused and they may even lose the thread of their thoughts when talking. The flow
of the conversation can pause whilst they mentally search for a word or something
that they were going to say but somehow just can’t recall. Their conversation can
also change tack almost without them being aware of it themselves. If there is a lot
of blockage, their responses can also be inappropriate and confused. This is because
shen ensures that our reactions and responses are appropriate to the stimulation we
have received. When Phlegm is blocking the Heart’s orifices, the patient may also
have difficulty clearly understanding what you are asking them and therefore have
difficulty answering precisely. This is something most of us can recognise, either
from when we have a heavy head cold where it feels as if your head is full of cotton
wool or when we have a hangover. For people with a lot of Damp‑Phlegm, this is a
chronic sensation that they may not even be conscious of any more, as it has become
normal. It will often be worst in the morning when the person has been lying flat all
night and this yin xie qi has seeped down to the head and the Heart, thereby blocking
the ‘orifices of the Heart’. It will also be aggravated when the person consumes
Phlegm- and Damp-producing foods.
In general, a person with Phlegm blocking the shen will tend to meander verbally
back and forth, going round in circles, jumping from subject to subject, losing
their thread or completely wandering off the path in irrelevant and inappropriate
directions. This is different from the person with Heat agitating the shen. The
structure of their conversation can be disrupted by an over-eagerness and a surfeit
of ideas and things they want to tell you. They lose their thread because they keep
changing subject before the last subject area is finished. A person with Heat in the
Heart will lack the necessary composure to maintain the structure of a conversation.
If shen is undernourished, as it is, for example, when there is Heart xue xu, the
structure of the conversation can be affected by forgetfulness. They will also have
difficulty finding words or remembering what they were talking about, but this is
more due to absentmindedness than confusion or over-exuberance.
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When there is yang xu and qi xu, the conversation will retain its structure, but the
speed of delivery and the volume can be affected. The conversation is less animated.
It may seem as if it is an effort to talk. People who are yang xu, in particular, will
tend to speak slower and more lethargically. The other person in the conversation
sometimes wants to finish the sentences for them, because they get impatient. This
is something we must try to be consciously aware of. Whilst interviewing the client,
we have to constantly ask ourselves: How does their voice and the way they talk affect
me? How am I reacting to them? Do I feel stressed, annoyed or bored? If so, why?
Am I dominating or are they dominating the conversation? It is very important to be
aware of your own patterns of imbalance – we can feel that they are dominating the
conversation because they are preventing us from doing so when we normally would,
or they can dominate the conversation because we are too passive and taciturn. We
may be tired and qi xu. If we are annoyed by them, is it because they talk too much
or too little or is it their subject matter or their aggressiveness? There are definitely
some patients in whom you quickly pick up on a latent aggressiveness. You can
feel them almost looking for something to pick a fight over. It is not against you
personally, and it isn’t something that they are conscious of, but in situations outside
of the clinic – such as at home or at work – it probably is a problem; a problem
they may not be aware of. They are often people who have a lot of conflict in their
relationships. This is a problem because it is often caused by Liver qi stagnation,
and the conflicts their persona provokes will in themselves become causes of Liver
qi stagnation.
It is, as stated, important to be aware of your own patterns of imbalance. These
will affect how you react to other people. If you have Heat, you will more easily
become impatient with someone who speaks slowly and laboriously but possibly
enjoy the snappiness of talking to someone who also has Heat. The opposite can also
be the case. If you are yourself verbose and loquacious, it can be frustrating when
someone else dominates the conversation. If you have Heart qi xu or Heart and Liver
xue xu, you may well find many people intimidating and find that you quickly feel
overwhelmed by others when you are talking to them. Likewise, if you are yang xu,
you may well think of people who talk slowly and methodically as being an example
of how everyone should speak.
Our imbalances can often mean that we either over-diagnose our own patterns
of imbalance – we easily recognise these signs and symptoms because we know what
they are – or under-diagnose these patterns of imbalance – we are blind to them
because we subconsciously or consciously think that these signs and symptoms
are normal.
Structure and flow of the conversation

Loquacious and verbose Heart Fire, Phlegm Fire
Taciturn, silent Heart qi stagnation, Phlegm, Heart qi xu, zong qi xu
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Talks quickly Heat
Talks slowly Yang xu, Phlegm-Dampness
Confusion, delirium Phlegm, Heat in the Pericardium
Incoherent speech Phlegm blocking the Heart’s orifices
Difficulty finding words or Heart xue xu, Phlegm
maintaining their thread
Talking to themselves Phlegm blocking the Heart’s orifices
Laughing excessively or inappropriately Heart imbalances
Stuttering Heart xue xu, Heart Fire
Talking in their sleep Shi Heat, Heart xue xu
Sudden shouting Liver qi stagnation, Liver Fire, Heart Fire
Quality of the voice

Apart from observing the emotional qualities, the volume and the flow of the
conversation, we should also note other qualities in the voice. These will again reflect
patterns of imbalance that have affected the voice and made it deviate from the
norm. We should, as always, be thinking: What should I expect to be hearing and
how does what I am actually hearing differ from this? What is the pathomechanism
that could create this aberration?
Gravelly voice
Phlegm, especially Phlegm-Heat in the Lung, will manifest with a gravelly voice.
This is the typical barfly and heavy smoker’s voice. If it is extreme, there will also
be a rattling sound in the throat and a sticky cough. Cigarettes are drying and
heating. They will damage Lung yin and generate Lung Phlegm-Heat. Alcohol will
create Phlegm and Heat that can rise up to the Lung and the throat, affecting the
vocal cords.
Hoarse or husky voice

Invasions of Wind-Heat, as well as chronic Heat and yin xu conditions, will mean
that the throat and the vocal cords lack moisture and lubrication. Again, alcohol and
tobacco are often contributing or causative factors.
Dry voice
A person with yin xu or xue xu will lack yin and xue’s moistening qualities. This can
be heard in the voice, even though it is a very subtle quality (or lack thereof ). Often,
elderly patients’ voices have this quality.
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Nasal voice
The voice should be clear and ring like a bell. If the bell is smothered, as when
the sinuses are filled with varying amounts and consistencies of Phlegm, the voice
becomes more or less nasal. This can be both acute and chronic, depending on the
underlying imbalance.
Staccato voice
Some people have a staccato voice. Their voice sounds like a machine gun when
they talk. They do not necessarily talk quickly, but their words are clipped and the
voice is hard, sometimes even aggressive. This relates to the Liver qi and its function
of helping the qi and thereby the voice to flow freely and unhindered. Liver qi
stagnation will also result in a tendency to be irritable, which one will often hear in
the voice.
Aggressive voice
Again, Liver imbalances can give an aggressiveness or anger to the voice. It may be a
general tone or only heard when patients talk about certain subjects.
Slurred voice
Phlegm can slur the voice. This is heard when people are drunk and the intense Heat
and Dampness of the alcohol results in Phlegm. It can, though, be a more chronic
condition. An extreme example is after a stroke where Wind-Phlegm has resulted
in Phlegm blocking the orifices and the person has difficulty speaking, their voice
being heavily slurred.
Very soft voice

Liver xu imbalances can manifest with a voice that lacks resonance and the hard
qualities that the Liver gives to the voice. The voice will be too soft and will
lack authority.
Sleep talking, talking to themselves and delirious speech

There are also some situations where various forms of xie qi have affected the speech,
but we are unlikely to experience these in the clinic. Shi Heat can agitate the shen
at night when it should be calmly resting in the Heart. This can result in the person
talking in their sleep. Shen can also become active when it is not rooted by Heart xue,
i.e. Heart xue xu. In this case, the voice will be more quiet and tranquil.
In some febrile diseases where Heat has invaded the Pericardium, the Heat can
agitate the shen so much that the person’s speech is delirious and incomprehensible.
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Another sign in the voice that usually isn’t heard in the clinic is people talking to
themselves when Phlegm has blocked the orifices of the Heart and they are locked
in their own world. This can be observed in people who are mentally ill and hold
conversations with themselves, the content of which can sometimes be meaningless
to outsiders.
Sudden shouting is seen in some types of Tourette’s syndrome. This is usually a
sign of Heat in the Liver and Heart.
The sound of the person’s voice

Loud, resonant voice Shi condition
Quiet, soft voice Xu condition
Hoarse voice Invasion of Wind-Heat or Wind-Dryness, Liver or Lung qi stagnation,
Phlegm, Heat, xue stagnation, Kidney yin xu or Lung yin xu
Staccato voice Liver qi stagnation
Aggressive voice Liver shi condition
Shouting voice Liver shi condition
Dry voice Yin xu
Gravelly voice Phlegm
Slurred voice Phlegm
Nasal voice Phlegm, Dampness
Auditory diagnosis of other sounds coming

from the mouth, nose and chest
As well as all these verbal impressions, we also have the classical diagnosis of sounds.
We can ask the client about these, but they should also be things that we keep our
ears open for when we are interviewing the client. We should, for example, listen
to the patient’s breathing, both whilst interviewing them and whilst they are lying
on the couch.
Yawning and sighing

When there is Liver qi stagnation, the body will instinctively try to set qi in motion
again. One of the ways of doing this is to sigh or yawn. When we sigh or yawn, we
inhale a larger amount of air. This increases zong qi, which then helps to force the
blocked qi into circulating again. The patient may well be unaware that they sigh
frequently, especially as the sighs can be quite subtle. This means that they might well
answer negatively, when you ask about sighing. These more subtle sighs can often
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be heard when the patient talks about a particular subject area or about things that
frustrate or annoy them. This is important in that it not only can help to reveal a
pattern of imbalance, probably Liver qi stagnation, but also, importantly, it can help to
reveal the aetiology, i.e. one of the contributing causes of the client’s Liver qi stagnation.
Yawning can be a way of moving stagnant qi and a way of increasing qi. When
a person is qi xu, from, for example, a lack of sleep, the body will try to compensate
by increasing the production of qi. The quickest way to do this is to increase the
production of zong qi by inhaling a larger amount of air.
Moaning, complaining, gasping, screaming and crying

These sounds are often heard as a response to pain. This may be a pain on movement
or palpation or a constant pain. It indicates that there is a stagnation of qi and/or
xue with accompanying pain.8 The strength of the sound will often reflect the degree
of stagnation.
Snoring
You will not hear snoring during the consultation, but you may hear it when the
patient is lying on the couch. Otherwise, snoring is something you will have to ask
the patient about. Snoring occurs most frequently when there is Phlegm blocking the
nasal passages. The strength of the sound will tell you whether it is an exclusively shi
or a xu/shi condition.
Respiration
Listening to the respiration can elicit vital information, especially about the condition
of the Lung. The breathing should be calm, relaxed and deep.
Weak and shallow breathing shows that the Lung is not descending and spreading
qi optimally. The weakness of the breath indicates that it is a xu condition.
The breathing can be laboured and shallow if Lung qi is blocked by xie qi,
Phlegm or qi stagnation.
The Kidneys grasp the qi that the Lung sends downwards to the lower jiao.
This means that Kidney qi xu can also affect the respiration, causing the person to
become breathless.
Heat accelerates physiological processes. This can cause the person to breathe
more rapidly.
The presence of Phlegm can be heard when there are sounds accompanying the
respiration. This could be a wheezing or rattling sound when the person breathes.
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Sounds from the person’s mouth, nose or chest

Calm, relaxed and deep breathing Normal
Weak and shallow breathing or breathlessness Lung xu conditions, Kidney qi xu
Laboured and shallow breathing or breathlessness Xie qi blocking Lung qi, qi stagnation,
Phlegm
Rapid breathing Heat
Wheezing Phlegm
Rattling sound during breathing Phlegm
Snoring Phlegm
Moaning, complaining, gasping, screaming and crying Stagnation of qi and/or xue
Sighing and yawning Liver qi stagnation
Coughs, sneezes and sniffles

You may hear coughing during the consultation or whilst the patient is waiting
outside the treatment room, and this is often something you ask about (see page 226).
If you do not hear the cough during the consultation, you can ask them to cough in
order to gain an impression of it, although it is best if you can hear an involuntary
cough, as this will give a more accurate impression.
Fundamentally, a cough is nothing other than rebellious Lung qi. The stronger
and more explosive the sound of the cough, the more qi there is rebelling. An
explosive and loud cough will therefore be a sign of a shi condition.
Heat in the Lung will manifest with a barking cough. The Heat will make the
sputum in the Lung stickier and more difficult to expectorate. This means that
the person will often cough vigorously several times until the sputum disengages.
The sputum will be looser and more watery if there is Phlegm-Dampness or an
invasion of Wind-Cold. The cough will sound wetter and it will require less effort
to expectorate the sputum.
If the person is Lung yin xu, the cough will be very dry. If there is sputum, it will
be rubbery and dry. It will require a greater effort to expel the sputum. The cough
will not be as loud as when there is Phlegm-Heat and Lung Heat but will instead be
a dry, ‘ticklish’ cough. You can almost hear how it tickles the throat and the Lung.
An invasion of Wind-Cold disrupting the Lung’s ability to spread jinye or the
presence of Damp-Phlegm in the Lung can lead to the accumulation of thin, watery
mucus in the nose, causing the person to sniff repeatedly.
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The sound of the cough and sniffles

Loud cough with the sound of loose sputum Wind-Cold, Damp-Phlegm
Loud cough with sputum that is difficult to expectorate Lung Heat, Phlegm-Heat
Barking cough Lung Heat, Phlegm-Heat
Loud and explosive cough Shi condition
Dry or ticklish cough Lung yin xu
Weak cough Xu condition
Sniffles Wind-Cold or Damp-Phlegm
Diagnosis of sounds from the abdominal cavity

Borborygmi and other sounds
Sounds emanating from the abdominal cavity can sometimes be heard whilst talking
to the client. More often though, they will be heard whilst the client is lying on the
couch. This is mainly due to the change in posture as gases and liquids move from
where they were to a new position in the gastrointestinal tract. The sounds can be
anything from a rumble to the sound of liquid sloshing around. Rumbling sounds
will usually be heard when there is Spleen qi xu and qi stagnation in the Intestines.
A sloshing sound of fluid in the Intestines will be heard when there is yang xu or shi
Cold in the Small Intestine or Large Intestine.
Hiccup
Hiccupping occurs when Stomach qi becomes rebellious and starts to ascend.
This may indicate that there is a shi condition such as Stomach Heat, Stomach
Cold or Liver qi invading the Stomach, in which case the sound of hiccups will be
loud. The Stomach can also be too weak to send its qi downwards, i.e. Stomach qi
xu or Stomach yin xu. In these cases, the sound of the hiccup will be weaker and
more subdued.
Vomiting
It is unlikely that we will experience the sound of vomiting in the clinic and this
will therefore be information that we are reliant on the client reporting to us.
Vomiting that is loud and explosive is heard in shi conditions, particularly when
there is Heat, the qi being forcibly propelled upwards and out of the body. In xu
conditions there is not enough qi to transform the food and liquid consumed nor
to send them downwards into the Small Intestine. The accumulation of food and
liquid will eventually force qi upwards, but the sound and the force of the vomiting
will not be strong.
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Flatulence and belching

Flatulence is usually a sign of stagnation of qi in the Intestines, food stagnation or
Damp-Heat in the Intestines. The louder the flatulence, the more shi the imbalance is.
Like vomiting, belching is a sign of rebellious Stomach qi. Again, it can be due
to both shi and xu conditions, depending on the volume of the belching – the louder
the eructation, the more shi the condition.
Sounds emanating from the abdominal cavity

Hiccup Rebellious Stomach qi, may be due to Stomach Fire,
Stomach Cold, Stomach yin xu, Stomach qi xu or Liver qi
invading the Stomach
Rumbling sounds from the Intestines Spleen qi xu, qi stagnation
Borborygmi Fluid accumulation due to shi Cold or yang xu
Diagnosis of the sounds of the person in the clinic

Auditory diagnosis is not limited to the sounds emanating from the client’s body,
such as their voice, cough and respiration. All the sounds they create can have a
diagnostic relevance. Imbalances affect the body’s physiology – the way the body
moves and reacts and the way the person interacts with their environment. This
means that different patterns of imbalance can, in certain circumstances, manifest as
audible sounds created by the person.
One of the first things we hear is the client ringing the doorbell. Often there is
nothing to note, and at best it is a very tenuous sign, but when there is something
to note, it can say a lot about certain people. The most obvious example of this is
someone who has Heat in their Liver. The person is often extremely goal oriented
and impatient. They tend to press the doorbell repeatedly and for a long time. More
importantly, they will often not wait very long before re-ringing the bell if you do
not buzz them in immediately. A person with Liver and Heart xue xu is more likely
to wait longer before ringing again, as they do not want to be a bother to you.
The time it takes for them to come from the street door to the clinic door can
also have relevance if you have stairs. Someone who is qi xu or yang xu will usually
take longer than someone who has shi Heat. This is, of course, a very small sign, and
there may be other explanations, for example if the person is talking on their phone.
If you have a door that they knock on, the sound of their knocks will be more
revealing than an electric bell. Sometimes the knock can give an impression of the
person. Again, this is an extremely tenuous sign that must be seen in the context of
all the other signs and symptoms. A person who is shi will tend to knock harder and
more times than a person with a xu condition. A shy person, for example a person
with Heart and Gall Bladder qi xu, will tend to be more hesitant and will not knock
so many times, if they knock on the door at all. As a rule, they will wait until you
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come out to them. A person with Heat in the Liver is more likely to knock on the
door even though they have arrived ahead of schedule. In extreme cases, they will
not even wait for you to open the door before entering the room.
A more dependable auditory sign is the sound of their steps in the hallway or
waiting area. Quick steps can indicate Heat and heavy steps a shi condition. The
sound of shuffling or dragging feet can indicate yang xu, qi xu or Damp-Phlegm
conditions. Other factors, though, such as the person being late or heavy winter
boots, must also be taken into account.
Other audible signs from the waiting area could be the sound of them repeatedly
getting up and sitting down again or walking backwards and forwards. This could
again indicate Heat agitating the shen, creating restlessness and impatience. It
could, though, also be due to pain and discomfort or nervousness. We must, as
ever, place these small impressions into a bigger picture before we can allot any
significance to them.
Another sound that can have relevance in some patients is the need to rush to
the toilet to urinate immediately on arrival. This, of course, does not have to mean
anything, but some clients urinate both on arrival before lying on the couch and
immediately after the treatment. This will tell you that they have frequent urination
without you having to ask them.
We can also hear the sound of the patient’s voice whilst they are sitting in the
waiting area if they are talking on the phone or speaking to their family members
or other clients. Is the voice so loud and resonant that we can hear it through our
door? Is the voice so soft and quiet that we cannot really hear it, even though there
is only a curtain and a short distance between us and them? Are they a person
who immediately starts talking to complete strangers in the waiting area? Do they
constantly make jokes and try to be funny? Do they start revealing very personal
information to people they don’t know?
The diagnostic significance of the voice itself was discussed earlier. What we hear
can also reveal something of their relationships with other people. We may hear a lot
of bickering or arguing, for example, something that could be an aetiological factor
or something that we should at least consider when feeling their pulse, as this will
have affected the pulse quality.
Olfactory diagnosis
The second aspect of the diagnostic pillar ‘Listening and Smelling’ is the impressions
we receive from the client via the nose. Unfortunately, these impressions are more
difficult to use in modern times in the developed world. This is because many people
bathe daily and wash their clothes frequently, as well as using deodorants, creams,
perfumes, etc. This means that we often cannot smell their natural odour, because
they have washed it off their body and out of their clothes and masked it with
various fragrances. A trick can be to get the patient to put a t-shirt, vest or pillow
case that they have been using in a plastic bag, which they then tie and then bring
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into the clinic, making the odours more prominent. In general, the odours that
have a diagnostic significance can be difficult to smell. It is usually only when there
is a very dominant smell that it is noticeable. If we do pick up a certain odour, it
usually has diagnostic significance. In these situations, it is often a very important
diagnostic sign.
There are two aspects to olfactory diagnosis. First, the person’s body odour, which
can provide information that can help to determine a person’s constitutional type
or their imbalance in Five Element acupuncture diagnosis. Second, the diagnostic
significance of the various discharges and excretions from the body.
Olfactory diagnosis of the body odour

Olfactory diagnosis plays a central role in the Five Element acupuncture system,
founded by J. R. Worsley. Worsley and the schools inspired by him place great
emphasis on training their students to be able to distinguish between the odours
that resonate with the Five Phases. It is considered a serious sign of imbalance if a
person does not manifest the odour that is characteristic for their own constitutional
types but instead has the smell of one of the other phase’s odours.
The following descriptions of the odours are mainly based on Five Element
Constitutional Acupuncture by John Hicks, Angela Hicks and Peter Mole (2004)
and J. R. Worsley’s book Traditional Acupuncture Volume II – Traditional Diagnosis
(Worsley 1990).
• Water Phase – Rotten and putrid: The Chinese character fu can be translated
into English as ‘putrid’. The character is built up of two components. The
first has the meaning of a building or shed and the second component means
to dry meat that is tied together. This gives the character a sense of the odour
you would expect to smell in a shed that is used to dry meat. The difference
between this odour and the odour of the Metal Phase is that the fu odour is
more tart and caustic.
• Wood Phase – Rancid: Sao, as this smell is called in Chinese, is the smell
that animals or urine can have. This is rancid, as in rancid butter or rancid
fats, but even sharper. Hicks et al. describe this smell as newly mown grass
but without that smell being pleasant (2004, p.57).
• Fire Phase – Burnt: This odour is called zhuo in Chinese. The smell can
be described as being similar to toast that has been burnt, clothes that have
just come out of a tumble dryer, a shirt that has been burnt with an iron
or vegetables burning dry in a saucepan. In the same way that the smell
varies depending on what it is that is burning, the burnt smell can vary from
person to person. The aroma may be noticed when a person has a high fever.
• Earth Phase – Sweet and aromatic: The Chinese word xiang means
aromatic. It is a word that is used in the name of many aromatic herbs
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for example. This can be misleading, as the odour referred to here has a
heavy, sticky, almost nauseating aroma.
• Metal Phase – Rotten: Rotten is lan in Chinese. This is the rotten odour
that is smelt when meat, fish or vegetables rot. This odour can be smelt in
old dustbins or garbage trucks.
Odour
Phase Significance
Water Putrid
Wood Rancid
Fire Burnt
Earth Sweet and aromatic
Metal Rotten
Some imbalances can have specific smells that can be difficult to describe but are
immediately recognisable when you notice them on another patient with the same
pattern of imbalance. Phlegm patients, for example, often have a very heavy, sticky
odour. It smells a bit like a wet leather jacket, but it lingers in the room long after the
person has left. Sometimes you can go into the treatment room an hour after they
have gone and the smell still lingers in the air.
Olfactory diagnosis of the body’s excretions

We are usually dependent on the patient’s reporting of how the various discharges
and excretions from the body smell. Very few clients bring an example of their stools,
urine or vaginal discharge for inspection in the clinic. We can, though, still smell
things like their sweat and their breath during the consultation.
A general rule of thumb is that strong-smelling excretions and discharges are
a sign of Heat. If there is no significant odour to the discharge, this will not be
pathological unless there is a change in the volume, consistency or frequency of
the discharge. These aspects are dealt with in Sections 1 and 4 on visual diagnosis
and interviewing.
Olfactory diagnosis of the urine and stools

Urine and stools that have a strong odour will most often be a sign of shi Heat,
usually Damp-Heat.
If the stool or urine does not smell, the lack of smell will only be relevant if there
are other disturbances in the frequency and consistency of the stool or the volume
and frequency of the urine, in which case the lack of odour can contribute to a
diagnosis of shi Cold or yang xu Cold.
Stools that smells like sewage will be a symptom of food stagnation.
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Olfactory diagnosis of sweat

A strong body odour from sweating is a manifestation of Damp-Heat. As explained
in the introduction, this will probably be something that you have to ask the patient
about because the strong body odour means they will have used deodorants and
antiperspirants. Sometimes, though, you can still smell the sweat because the odour
is very strong or your nose is close to their body whilst treating them with needles.
Olfactory diagnosis of the breath

A person’s breath can sometimes be smelt whilst conducting visual diagnosis of the
tongue or needling points in the face; otherwise it will be something you have to
ask about.
Malodorous breath can result from imbalances in the Stomach, Spleen and Large
Intestine. Heat from Stomach Fire or food stagnation can rise up to the mouth and
be smelt on the breath. Heat in the Stomach and Large Intestine channels can result
in paradentosis, rotten teeth, etc., which can give bad breath.
Olfactory diagnosis of nasal and pulmonary mucus

This will more likely be something the client can taste, but sometimes it is so
powerful that the therapist also can smell it. If sputum in the Lung is infected, it
may smell slightly of fish. This will be experienced when there is Toxic-Fire in the
Lung. Strongly smelling mucus in the nose will be a sign of Lung Heat.
Olfactory diagnosis of menstrual blood and vaginal discharge

Menstrual blood and vaginal discharge that have a strong, pungent odour is a sign
of Damp-Heat. If the vaginal discharge has a fishy odour, it is a sign of Damp-Cold.
Olfactory diagnosis of flatulence

An increased amount of intestinal gas that smells strongly is a sign of Damp-Heat or,
in extreme cases, Toxic-Fire in the Large Intestine. An increased amount of intestinal
gas that does not smell is a sign of Spleen qi xu.
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The smell of excretions and discharges

Strong-smelling urine Shi Heat, Damp-Heat
The urine does not smell, but there is increased Shi and xu cold
volume and frequency of urination
Strong-smelling stools Shi Heat, Damp-Heat
The stool smells of sewage Food stagnation
Strong-smelling sweat Damp-Heat
Bad breath Stomach Fire, Heat in the Stomach or
Large Intestine channel
Nasal mucus that smells or tastes strongly Lung Phlegm-Heat
Pulmonary sputum that smells strongly or has a Lung Phlegm-Heat or Toxic-Fire in Lung
significant flavour
Strong-smelling menstrual blood Damp-Heat
Strong-smelling vaginal discharge Damp-Heat
Vaginal discharge that smells of fish Damp-Cold
Strong-smelling flatulence Damp-Heat
Flatulence without odour Spleen qi xu
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Section 3

PALPATION
Introduction
The diagnostic pillar ‘palpation’ includes all the information that can be acquired
by palpating the patient. In addition to feeling the pulse, this also includes the
palpation of the channels, acupuncture points, skin and various areas of the body.
Some aspects of this diagnostic pillar can seem daunting and difficult to learn.
This can be the case with pulse diagnosis and its 28 qualities, 12 positions and three
depths. At the same time, we need to train our abilities that we are not accustomed
to using intellectually. We are well trained in translating verbal information into
intellectual knowledge so the interviewing approach to diagnosis feels more reliable
and trustworthy. Visual diagnosis also appears to be more accessible, because we can
look at pictures in a manual and compare them with what we can see in front of
us. However, we are not used to using our fingertips to provide information that we
can utilise intellectually. Furthermore, it is more difficult to compare and contrast
what we feel with our fingers with the descriptions presented in a textbook. What
we experience will be a subjective assessment, and we can be in doubt about whether
what we are feeling is the same as what’s described in the book or whether it is, in
reality, something else. Nevertheless, palpation is a vital and indispensable part of the
diagnostic process and should not be neglected. Diagnosis is like a roof supported
by four separate diagnostic pillars. If one of the pillars is missing or incomplete, the
diagnosis will be unstable and unreliable.
Pulse diagnosis is particularly important in the differentiation of the Eight
Principles, in zangfu diagnosis, qi and xue diagnoses and diagnosis according to xie
qi. You will not be able to make a reliable diagnosis without having first palpated
the pulse.
One of the great advantages of palpation is that it can be used to monitor and
adjust treatments. There should be qualitative changes in the pulse, the abdomen or
the skin and muscles in general after the needles have been inserted and stimulated.
By feeling the pulse or the abdomen, one can see if the treatment has had an
affect. Because the pulse can change instantly, it can reveal the state of a person’s qi
right now.
The pulse will also be able to give an indication of changes in the body’s qi and
vital substances, and it can reveal the presence of xie qi before actual symptoms have
started to manifest.
The diagnostic techniques in this pillar require participation in practical training
with an experienced teacher. Hands-on training will help to refine and clarify the
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The Diagnostic Pillar: Palpation
details of these diagnostic methods and techniques. That said, a lot can be achieved
by following the descriptions of these methods presented in various textbooks,
especially if you use a logical and systematic approach, consciously ensuring that
you have examined all the relevant aspects and compared the findings with those
that are presented in the textbooks.
One way to become familiar with the various pulse categories when you are not
with a teacher who can monitor your approach and conclusions is to systematically
feel the pulse of each and every patient you come into contact with. When you have
a patient with a very clear and definite diagnosis (using the other three diagnostic
pillars), you should ask yourself: What should I be experiencing right now? You
should then compare this with the sensations that you are experiencing in your
fingertips. For example, if you have a patient with an obvious pattern of Liver qi
stagnation, you would expect the pulse to have a Wiry quality in the left guan or
middle position. You can then compare what you are feeling beneath your fingertips
with the description in the textbook and see if you can recognise the qualities
described in the book. By constantly repeating this procedure, you will eventually
learn with certainty how, for example, a Wiry pulse feels. The more you practise, the
faster you learn to diagnose with your fingers.
Palpation
Relative strengths of palpation
• It is indispensable when diagnosing muscular and skeletal problems.
• We are not dependent on the patient’s interpretation and presentation of their
diagnostic signs.
Relative weaknesses of palpation

• It is a subjective diagnosis. It can be difficult in the beginning to determine
whether you are actually feeling what you are supposed to be feeling.
Diagnostic tips
• Always remember to palpate muscles and joints when a person has physical
pain and impaired movement.
• Everything that feels hot is a sign of Heat, at least in the local area.
• Consciously investigate the skin temperature whilst palpating and whilst you
are locating acupuncture points.
• Consciously investigate the skin moistness whilst palpating and whilst you are
locating acupuncture points.
• Consciously investigate the skin elasticity whilst palpating and whilst you are
• Consciously investigate the muscle tone whilst palpating and whilst you are
• A rapid pulse is always a sign of Heat.
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Pulse diagnosis
Introduction
Pulse diagnosis is regarded by some as a precise but at the same time esoteric
diagnosis tool. Some acupuncturists have shied away from it because they have
not had teachers and textbooks that have presented it as an accessible tool that is
indispensable in practice. Despite its reputation, pulse diagnosis is not difficult to
learn and, even with very little practice, it can provide vital diagnostic information
to the novice. With practice and hands-on instruction the novice can soon develop
their skills and gain a deeper insight into their patient’s physiological condition.
At first, seeing a list of 28 pulse descriptions with 12 separate pulse positions
can be daunting and confusing. Furthermore, people are astounded when they hear
stories of Chinese doctors who can relay to the patient their entire medical history
just by feeling their pulse. This gives pulse diagnosis a veil of mysterious complexity
and unattainability. It is important not to be deterred. There are many different
levels of competence in pulse diagnosis. An expert in pulse diagnosis may get a lot of
incredibly detailed information from the pulse, but you can learn in ten minutes to
take the pulse to a degree where you will always be able to gain a quick and accurate
overview of the client imbalances. You can gain vital information just by quickly
feeling the pulse. It does not take long to feel whether a pulse is weak or replete, fast
or slow, deep or superficial. These six characteristics of the pulse are relatively easily
perceived. It’s something anyone can do. The differentiation of these six parameters
will help to define at least six out of the Eight Principles (xu/shi, Heat/Cold,
interior/exterior). This can be essential, as we often need to determine whether a
diagnosis is one or the other of these – whether it’s a shi or xu condition for example.
Most patients we see present with complex conditions consisting of several
conflicting patterns of imbalance at the same time. This creates the need for a bird’s-eye
perspective. Pulse diagnosis can be used both to refine and to simplify a diagnosis. We
can use it to get a deeper insight and thereby a more accurate diagnosis. An example of
this could be a client who suffers from fatigue and shortness of breath. Their pulse is
weak, so we know that it is a xu condition. By feeling whether the pulse is weakest in
the front or the rear position on the right wrist, we can determine if there is Lung qi xu
or Kidney qi xu. But we can also move in the opposite direction and use the pulse to
take a step back and clarify a situation. If the symptom picture is complex and messy
with conflicting symptoms, you can quickly feel the pulse to answer questions like: Is
there Heat or Cold? Is it a shi or xu condition? Is it yin or yang?
Pulse diagnosis has the strength to be utilised on its own. Where other changes
in the body’s physiology need to be compared with other symptoms and signs, or to
be corroborated by asking supplementary questions, the pulse can be used alone. A
deep and weak pulse in the rear or chi position is a sign of a Kidney xu condition; a
rapid pulse is a sign of Heat. Tongue diagnosis and Hara (abdominal) diagnosis can
in certain instances be used unaccompanied, but not to the same extent as the pulse.
Learning to take the pulse is not dissimilar to learning to play a musical
instrument. It is reasonably easy to learn the most basic aspects, especially with a
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good teacher, but it takes years of practice to attain a high level of skill. As with
learning a musical instrument, some people have natural talents and rapidly achieve
a high level of proficiency, the rest of us have to work harder to achieve these skills.
Everyone, though, whether they are natural prodigies or have more mediocre talents,
will need to practise to become more adept. The only way to do this is to place your
fingers on the radial artery of the wrist a great many times.
As well as constant practice, you must also study and commit to memory the
diagnostic interpretations of the various pulse qualities, for example that a Full,9
i.e. replete, pulse signifies that it is a shi condition.
History
Pulse diagnosis has been discussed in Chinese medical texts ever since Huang Di
Nei Jing – Su Wen (The Yellow Emperor’s Classic – Simple Questions). The book
describes how the pulse is felt at nine locations on the body. The positions are
directly related not only to the specific channels, but also to the five zang10 organs
and to specific areas of the body.
In the Nan Jing (The Classic of Difficulties), we can recognise the pulse
diagnosis that we use today, with three positions on each wrist and three depths. The
three positions reflect the three jiao, and specific organs are attributed to the different
positions. There have been varying definitions over the following centuries of what
the different positions relate to, but there has always been a general consensus on
their relationship to the three jiao.
Physiology
The pulse that we feel under our fingertips is xue that is being circulated by qi. Xue
can be more easily felt than qi, because it is more yin, i.e. more physical. Qi and xue
have a close relationship: qi is the commander of xue and xue is the mother of qi.
This means that we can perceive qi via xue.
We can perceive changes in how the artery feels when there is a qi imbalance.
This is because changes in qi will affect the way xue moves through the vessels.
Furthermore, xue is created from gu qi and yuan qi, driven by zong qi and guided by
Heart qi, whilst the Liver ensures that qi flows freely and unhindered throughout
the body. This means that imbalances in the Stomach, Spleen, Kidney, Lung, Liver,
Heart and san jiao will be felt directly in the pulse quality and strength.
The structure of the pulse

Something that can initially create confusion and frustration is the diagnostic
relevance attributed to the depths and positions of the pulse positions in the various
pulse diagnosis texts.
The pulse was originally palpated in nine different locations on the body. The
nine sites were specifically related to the various zang organs and to the three jiao
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in general. The pulse was felt in three locations in the head and neck, three places
on the torso and three places on the legs. These three areas of the body in themselves
related to the continuum of Heaven, Man and Earth. The same was therefore also
true of each of these three pulse positions in these areas of the body. When the
pulse was later felt only on the radial artery, this division into nine positions on
each wrist was maintained as: three positions in the superficial level, three positions
deeper down and three positions in the level between the superficial and deep levels.
The pulse can be comprehended as a two-dimensional structure. On the
horizontal plane there are three positions along the length of the artery – cun, guan
and chi. The vertical plane has three depths – deep, middle and superficial. In reality,
it is a three-dimensional structure because the width of the pulse has also significance.
Furthermore, some pulse diagnosis systems operate with positions lateral to the cun,
guan and chi positions.11
Some people have a very rigid definition of the pulse positions and their relation
to the organs or channels. In this approach, the deep level of the pulse relates to
the zang organs or channels and the superficial level to the fu organs or channels.
Personally, I prefer a more dynamic approach to the pulse, with changes in the pulse
being seen in the context of changes in the body’s qi and how these changes will have
affected the pulse.
In most situations I view the organ pairs as an organic whole, the different levels
reflecting both organs simultaneously. An example of this is when there is ascendant
Liver yang, the pulse will manifest with a Full, Wiry and Superficial pulse in the left-
hand side guan position, whereas Stomach qi xu will often manifest with a relatively
deeper, Weak pulse in the right guan position. This is because yang rises upwards and
outwards and therefore the pulse in the left guan position becomes tenser and more
superficial than it otherwise would be. Qi xu, on the other hand, will mean that the
pulse is weaker and there is not enough qi to lift the pulse up to the superficial level.
The three levels

There are three levels or depths in the pulse. The superficial level is felt with a very
light touch, being located just below the skin. The deep level is felt with the exertion
of greater pressure by the fingers. It is not so deep, though, that you are pressing into
the muscle below. The middle level is located between the superficial and deep level.
The different levels represent different aspects of the body. It may seem paradoxical
that the same level can reflect several aspects simultaneously. What is important to
bear in mind is that the different levels reflect where qi is, or is not, in the body. A
pulse that is only felt in the deep level, for example, will indicate that there is yang
xu – that there is not enough yang to be able to raise the pulse up to the superficial
level. At the same time, a pulse that is only present in the deep level can also indicate
that there is a stagnation of shi Cold in the interior, the Cold blocking yang qi
and thereby preventing yang from lifting the pulse upwards. There will, though, be
significant differences in the qualities of these two pulses, even though they are both
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felt only in the deepest level. In this instance, the yang xu pulse will be not only deep,
but also lacking in strength, whereas the pulse when there is a stagnation of Cold in
the interior will feel tight and hard. There will also, importantly, be differences in the
other symptoms and signs that the patient is presenting with.
The superficial level of the pulse represents both qi and yang, as well as the yang
organs and channels. At the same time, the superficial level can also indicate whether
an imbalance is located in the exterior (which is the yang aspect of the body) from an
Eight Principles perspective.
There are only contradictions when you do not see the pulse in a greater context.
If there is a Tight, Superficial pulse and the person freezes and has an aversion to Cold,
a stiff neck and sore muscles, the Superficial pulse will indicate that the imbalance
is located in the exterior. This does not contradict the other aspect of the Superficial
pulse, which is that the Superficial pulse represents qi and yang. When there is an
invasion in the exterior, it is the yang wei qi that is activated and the struggle takes
place in the outermost aspect of the body, just below the skin. Conversely, a pulse
that is only present in the superficial level, but feels thin and weak, could be a
sign that there is yin xu and xue xu. In this case the yin and xue are no longer capable
of anchoring qi, which therefore drifts up to the surface.
According to Ming dynasty doctor and author Li Shi Zhen, the condition of the
various zang organs can be felt in the different levels. This model sees the three levels
as a reflection of the three jiao. Again, this analysis does not in reality contradict the
other perceptions of levels, but is in fact complementary. The superficial level relates
to the Heart and the Lung. The Lung governs qi and wei qi. This means the exterior
imbalances will directly and indirectly affect the Lung through its relation to wei qi.
The Lung and the Heart have a close relationship, with zong qi driving xue from the
Heart through the vessels.
The middle level reflects the quality of xue. Because xue is produced by the
Stomach and Spleen and because the Stomach and Spleen are both in the middle
jiao, their status also affects the pulse of the middle level.
The deepest level reflects yin, i.e. the yin organs and yin qi. When an imbalance
is in the interior, it will be felt in the deepest level of the pulse. Furthermore, yin
imbalances from an Eight Principle perspective will create changes here. When there
is yang xu, the upward momentum of yang will be too weak to push the pulse up to
the superficial level.
Kidney and Liver yin are the deepest level of yin in the body. This means that
weaknesses of Kidney and Liver yin will be felt, not just in their respective organ
positions, but also in the deepest level of the pulse in general.
Level Type of qi Level Organs according to

Li Shi Zhen
Superficial Qi and yang (as well as yang organs) Exterior Yang (Lung and Heart)
Middle Xue Stomach and Spleen Stomach and Spleen
Deep Yin (as well as yin organs) Interior Yin (Liver and Kidney)
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The three positions

The pulse is felt in three positions on each wrist. The distances between the positions
depend on the size of the patient’s body, so one must align the fingers in a way that
is relative to the patient’s anatomy. In small children it may be necessary to use only
one or two fingers to feel the pulse. The three positions are named cun, guan and chi
in Chinese, which translate as ‘inch’, ‘gate’ and ‘foot’ respectively. Their names are
derived from their locations: inch and foot being units of measurement and a gate
connecting these two positions.
The middle or guan position is located on the radial artery medial adjacent to
the styloid process. The front or cun position will be nine fen (9/10 of a cun) distal
to the guan position, proximal to the crease in the wrist at the base of the thenar
eminence. The rear or chi position is 1 cun proximal to the guan position. This means
that if you place the middle finger on the artery next to the Lu 8 and the index finger
on the cun position proximal to the wrist, the ring finger will be placed proximally in
almost the same distance from the guan position (it will be 1/10 of a cun further away).
Chinese name English names

Cun Inch
Guan Bar or gate
Chi Foot
It is important not to have a rigid idea of a pulse position’s significance. The pulse
reflects changes throughout the body in the organs, the channels and qi and xue.
This means that changes occurring in the same pulse position will have different
connotations when seen in different contexts. Like so much of Chinese medicine, it
is the context that is the defining factor, for example other symptoms and signs that
are present and the prehistory leading up to the situation. When one understands
the pulse positions as being a reflection of the three jiao, instead of being a template
of the organs’ and channels’ locations, it’s easier to reconcile the different models.
If the pulse is, for example, Superficial and Tight in the right cun position and the
patient has a shoulder pain, the pulse will be reflecting a disturbance of the Large
Intestine channel and therefore treatment of the Large Intestine channel would be
relevant. If the pulse has the same quality and the person has been exposed to Wind
and Cold, they have an aversion to cold and feel tired and have sore muscles, the
pulse will tell you that there is an invasion of Wind-Cold blocking wei qi, which is a
yang aspect of the Lung. The same pulse could also be seen when there is toothache,
headache, tightness of the chest or something else.
Initially, it can be difficult and confusing to remember all the different divisions of
the pulse. Some people start by just learning one of the pulse models. It is important,
though, to remember that there are other models. If the pulse is not consistent with
what one expects to feel, it may well be because the pulse is reflecting another aspect
of the body’s physiology.
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The three horizontal pulse positions can also be seen as a reflection of yin,
yang and xue in the same way as the three levels, where changes in yang and yin
will affect the cun and chi positions respectively and changes in xue will affect the
guan positions.
Pulse position Type of qi Jiao

Cun Qi (yang) Upper
Guan Xue Middle
Chi Yin Lower
The following are four of the best known representations of pulse positions from
different historical textbooks.
Nan Jing (The Classic of Difficulties) ca. 100 ce

The pulse positions are defined by the channel pairs in relation to the Five Phase
sheng cycle.
Level Left Right

Cun Superficial Hand taiyang (Small Intestine) Hand yangming (Large Intestine)
Deep Hand shaoyin (Heart) Hand taiyin (Lung)
Guan Superficial Foot shaoyang (Gall Bladder) Foot yangming (Stomach)
Deep Foot jueyin (Liver) Foot taiyin (Spleen)
Chi Superficial Foot taiyang (Urinary Bladder) Hand shaoyang (san jiao)
Deep Foot shaoyin (Kidney) Hand jueyin (Pericardium)
Mai Jing (The Pulse Classic) – Wang Shu He, 280 ce

The pulse positions are also distributed in relation to the Five Phases. In this model
the organs rather than the channels are evaluated. This is because this book focuses
more on interpreting the pulse in relation to treating the patient with herbs rather
than needles, so the internal organs are more relevant than the channels.
Level Left Right

Cun Superficial Small Intestine Large Intestine
Deep Heart Lung
Guan Superficial Gall Bladder Stomach
Deep Liver Spleen
Chi Superficial Urinary Bladder San jiao
Deep Kidney Pericardium
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Bin Hu Mai Xue (The Study of the Pulse by the Bin

Hu Lake Master) – Li Shi Zhen, 1564 ce
In this model there is no distinction between the superficial and deep levels and it is
mainly the zang organs that are being diagnosed.
Left Right
Cun Heart Lung
Guan Liver Stomach/Spleen
Chi Kidney Kidney
Jing Yue Quan Shu (Jing Yue Complete

Book) – Zhang Jie-Bin 1624 ce
Here it is not necessarily the zang organ that is deepest or the fu organ that is most
superficial.
This is the model that is mainly utilised in TCM-style Chinese medicine, i.e. the
model utilised in mainland China today and also in much of the Western world.
Left Right
Cun Heart and chest Lung and chest
Guan Liver and Gall Bladder Stomach and Spleen
Chi Kidney, Urinary Bladder and Small Intestine Kidney and Large Intestine
The right chi position is perceived as representing Kidney yang, whereas the left chi
position is seen as reflecting the condition of Kidney yin.
Although all these different models can appear to be confusing and contradictory,
there is logic in the different systems. Common to them all is the fact that three
pulse positions represent the upper, middle and lower aspects of the body. There is
generally consensus with regards to most of the organs’ and channels’ positions. As
written earlier, some people initially choose only to utilise one model, for example
the model used in modern China, and learn these positions by heart, whilst keeping
in mind that there are other models that could also be relevant.
How to take the pulse

There are various factors to take into consideration and preparations to be made
before you take the pulse.
The client should sit or lie in a comfortable position. The therapist should also
sit or stand in a position that is relaxed. This is because diagnosing the pulse can
take a long time and if the patient is tense and uncomfortable this will affect the
pulse. If you are not positioned comfortably with a relaxed arm, this will affect
your concentration.
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The patient’s wrist should be level with or lower than their heart.
Place the middle finger on the radial artery next to Lu 8, the front finger proximal
to the crease in the wrist at the base of the thenar eminence and the rear finger at
a similar distance proximal to Lu 8. The distance between the positions depends
upon the person’s build. In children, it may be necessary to use only two fingers and
afterwards palpate the different positions separately with one finger.
It is important to align the length of the three fingers. The middle finger is
longer than the ring and index fingers and therefore it must be slightly bent. If the
middle finger is not bent it will press harder against artery than the other two fingers,
and this will give a false impression of the guan position’s strength.
Start by noting the impression received from all three positions as a whole. This
will give you a general idea of the pulse’s overall quality. It can be a good idea to write
down the first impression you get from the pulse, as this is often the truest. Take
note of whether the pulse corresponds to the expectations that you have with regards
to the person’s body type, gender, age and so on.
Afterwards, you can lift two fingers so that only one position is being felt. Focus
on the sensation below the tip of the finger and not the side of the finger. It is
important to be aware that a strong pulse in a neighbouring position can pulsate
on the side of the finger and give the impression of a pulse position below the
fingertip that is stronger than it really is.
Roll the fingers back and forth and from side to side. This is to measure the
breadth and width of the pulse and to feel qualities such as slipperiness and wiriness.
Press your fingers downwards and gently release the pressure again to get an
impression of the depth. It is important to be conscious of the sensation in the
fingertips, while both pressing and releasing the pressure. It is often whilst releasing
the pressure that you get the clearest impression of the Superficial pulse and the
Wiry pulse. In general, the clearest impression of depth is obtained by repeatedly
pressing and releasing the finger pressure.
Let your fingers rest gently on the pulse, so you can feel the speed and rhythm
of the pulse.
Count the beats.
Allow ample time to feel the pulse. Repeat the above procedures more than once.
The pulse can be volatile and some of the qualities can change whilst you are feeling
the pulse. This in itself can be a diagnostic sign.
Note the various qualities you have felt and the differences between the various
positions and depths.
The following should be noted:
• whether the pulse has shen, Stomach and root
• the depth of the pulse
• the width of the pulse
• the strength of the pulse
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• the rate of the pulse

• the rhythm of the pulse
• other qualities
• the cun, guan and chi positions.
It is a good idea to have these parameters printed in the journal or intake sheet, so
you do not forget to take note of all of the qualities.
Take into account different factors that may have an effect on the pulse: the
person’s physical build, gender, age and profession, whether the person is tired, has
just eaten, is stressed and in a rush, has just drunk coffee, etc.
The normal or healthy pulse

A healthy pulse is called ping mai in Chinese. For a pulse to be healthy, it must
have certain qualities. It must have shen, Stomach and root. A pulse that lacks these
qualities is called a sick pulse or bing mai.
Having shen means that the pulse has vitality, is soft and yet has strength and is
regular in its beating. The pulse gets the shen quality from the Heart. This is similar
to the quality that should be seen in the tongue and the eyes. If a pulse has shen, the
Heart is harmonious and the prognosis is good.
Having Stomach means that the pulse is relatively slow (60–66 beats per minute),
is calm and is soft. The Stomach quality comes from the Stomach and Spleen’s
transformation of body fluids during digestion. This is similar to the tongue, where
the coating on the tongue is generated by the transformation processes in the middle
jiao. Just as the tongue should have a thin coating indicating health, the pulse should
have a smoothness and softness. Too much of these qualities on the tongue and in
the pulse indicate Dampness, reflecting that there is too much impure qi being sent
upwards with the pure qi.
Having root means that the pulse can be felt at the deepest level and in the chi
positions. It is the Kidneys that give the pulse ‘root’. If the pulse has root, it indicates
that the Kidneys are strong and can anchor qi.
These three qualities represent the three treasures: shen, qi and jing. All three
qualities must be present and in adequate amounts for the body to be harmonious.
Even though the pulse can have many different qualities and even if the person is ill,
a ping mai or healthy pulse, will indicate a good prognosis.
Disturbing factors and natural differences

There are several factors that must be taken into account when diagnosing the pulse.
This is because these factors can alter the quality of the pulse. Some factors are
natural differences caused by, for example, the changes in the seasons or the person’s
gender or age. Other things can be artificial factors, such as medicine or coffee.
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The best time of day to take the pulse is early in the morning, just after the
person has woken up and before they have become physically and mentally active.
At this time the pulse will give the truest impression of the person. This is obviously
unrealistic in a normal clinic and only something you would be able to do if you
worked with in-patients.
If a person has just walked briskly, cycled or run up the stairs or is stressed, heat
will have been generated in the body and the pulse rate will be faster and stronger
than normal. The pulse is not giving a false impression of the body’s physiology; on
the contrary, it is giving a very accurate impression of the body’s condition right
now. The pulse is showing that there is a state of shi Heat caused by the physical
activity. Their face will probably also be slightly redder and their skin warmer than
normal. It is therefore important that the client is calm and relaxed when taking the
pulse. I usually delay taking the pulse until the end of interviewing of the client.
This is because I want the patient to be as relaxed as possible after their arrival at the
clinic and because new patients may be nervous if it is the first time that they have
been treated with acupuncture or Chinese herbs and this could affect the pulse. By
waiting, one can hope that they will relax as they gain confidence in the therapist
and become comfortable with the situation.
The position of the patient’s arm is important. If the arm is raised above the
heart itself, gravity will cause the blood to flow downwards and away from the wrist.
This will make the pulse felt weaker than it really is.
Pay close attention to whereabouts on the fingertip you are feeling the pulse. If
a pulse position is weak and thin, and the position next to it is strong and replete,
you can risk misinterpreting the sensation in the fingertip. This is similar to the way
that a loud radio can drown out the sounds coming out of a radio closer by that is
turned down low.
Remember to ask the patient if they are taking medication for blood pressure,
heart medications, blood thinners, anti-depressives, etc., because these will corrupt
the pulse image.
Factors that can interfere with the pulse diagnosis

Factor Effect
The person is stressed, just ran, cycled or Generates heat and makes the pulse rate
walked quickly increase in speed and strength
Stress Can stagnate Liver qi and produce a Wiry pulse
Stress can also generate Heat
Nervousness Unsettles the shen and spreads Heart qi
Medication Blurs and complicates the pulse image
The arm is higher than the heart The pulse will be weaker
Several other factors must also be taken into account. These factors are natural
differences or changes that are normal and to be expected. It is only when the person’s
pulse differs from what we expect to feel that it is defined as being pathological.
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The pulse, like many other things, manifests the fluctuation of yin and yang
throughout the year. Summer is the most yang time of year, so the pulse should be
more yang in nature. It will be more superficial and overflowing. The yang heat of
summer can increase the pulse rate so it is faster. Winter is the most yin time of the
year when everything is drawn inwards and becomes quieter. The pulse in winter
should therefore be deeper. Spring is young yang; it is the Wood phase. This can be
felt in the pulse, which should gain a slight Wiry quality in the spring. In the autumn
the pulse should become softer, because yang is decreasing and yin is increasing. This
means that if a pulse is Superficial and Flooding in the winter, it is a more serious
sign than if this sensation is felt in the pulse in the summer.
Men generally have stronger and more replete pulses, whilst women’s are
generally weaker. Because men are yang in nature and the left side of the body is
perceived of as being yang,12 their left pulse should be stronger than their right pulse,
and their cun pulse should be stronger than their chi pulse. Conversely, because
women are yin, their right pulse and their chi positions should be strongest. This
means a deficient pulse in the left cun position is diagnostically more significant in
a man than in a woman.
People whose occupation involves hard physical work should have a stronger
pulse than someone who works in an office. Therefore, it will be a more serious sign
if a man who works as a builder has a deficient pulse than it would in a woman who
works as a secretary.
People who regularly play a lot of sport, physically train or work out will often
have a slower pulse. Children have faster pulses and the pulse rate decreases with
age. It will therefore be a more significant sign of Heat when a 50-year-old marathon
runner has a pulse rate of 80 beats per minute than if it is a ten-year-old child.
However, it is not necessarily a healthy sign if a person who is very physically active
with a hard training programme has a slow resting pulse. The physical exertion of
training and sport can damage their yang qi, which is why their pulse rate is slow.
The person’s body build will also have an influence. An obese person’s pulse will
be deeper than a thin person’s, whose pulse will be more superficial.
In the week before menstruation the pulse has more of the Slippery quality and
in the week after menstruation the pulse is weaker, because the woman is relatively
xue xu at this time.
The pulse is more Slippery during pregnancy. If the pulse becomes Choppy during
the pregnancy, this is a negative sign and may indicate the threat of a miscarriage.
If the person is tired or has not slept properly, the pulse will be weaker.
If the person has just eaten, the pulse can be affected in two ways. The pulse may
be fuller and Slippery in the right guan position, because there is an accumulation of
food and qi in the Stomach. Or it may be weaker in this position, because Spleen qi
is burdened by having to transform the meal.
The qi-producing organs’ pulses are felt on the right wrist. The left-hand pulse
includes the organs that are the root of xue and that store and govern xue. This means
that the right-hand pulse will reflect the condition of qi and the left the state of xue.
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Natural variations in pulse

Factor Variation
The seasons Spring – more Wiry
Summer – more Superficial and Flooding
Autumn – softer
Winter – deeper
Gender Men – stronger pulse than women’s, stronger in the left
and cun positions
Women – weaker pluse than men’s, stronger in the right
positions and in the chi positions
The person’s profession Physical work – stronger pulse
Sedentary work – weaker pulse
Individuals who physically train a lot Slower pulse
Age and speed Age Beats per minute
1–4 90+
4–10 84
10–16 78/80
16–35 76
35–50 72/70
50+ 68
Body build Heavy set or obese – the pulse is generally deeper
Thin body – the pulse is generally more superficial
Menstruation The week up to menstruation – the pulse is more Slippery
The week after menstruation – the pulse is weaker
Pregnancy The pulse becomes more Slippery during the pregnancy
Fatigue or lack of sleep The pulse will be weaker
The person has just eaten The pulse can be stronger and Slippery or weaker
Diagnostic parameters
When you see the list of all the 28 different pulse qualities, it can seem overwhelming
and complicated. This does not need to be the case if you utilise the correct
methodology and are systematic and logical in your approach.
When you feel the pulse, you must ask yourself the following questions.
• Is the pulse superficial or deep?
• Is the pulse wide or narrow?
• Is the pulse deficient or replete?
• Is the pulse fast or slow?
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• Is the pulse rhythmic?

• What other qualities are there?
Each of the questions is fairly simple, and the points are easy to differentiate
individually, which is what you have to do. You must consciously investigate and
answer each of these questions one by one, noting down the answers on a piece of
paper. When you have the answers to these questions, you can, from the following
descriptions, see which type of pulse the patient has. This is because the majority of
the 28 pulse images are just different combinations of the parameters listed above.
It is easier to remember the pulse images if you divide them into categories.
Seven of the pulses are superficial, four are deep and three are irregular. As a result,
just determining that the pulse is superficial, for example, limits the possibilities
to only seven definitions. Many pulse images can be divided into pairs, either as
opposites of each other or as developments of each other. A hidden pulse, for example,
has the same qualities as a weak pulse; it’s just more extreme. This approach means
that the 28 images quickly become much less overwhelming and more applicable
in practice.
You can choose to learn the list by heart, meaning that you would be able to
identify a pulse automatically when you feel it in a client.
If you cannot learn the 28 qualities by heart, you can make a copy of the table
with the 28 pulse images, which you can keep close at hand. You can then compare
the answers to the questions written above with the descriptions of the various
pulse images.
Pulse qualities
It is important to remember that the various parameters can be combined with other
qualities such as speed and strength. For example, a pulse can be both Deep and
Rapid, or it could be Superficial and Tight.
The pulse depth

Learning to judge the depth of a pulse is best achieved through hands-on training
with a teacher, because the differences in the depths is quite subtle. That said,
learning to feel the depth of a pulse is something that can be learnt quite quickly.
The pulse should be palpable in the area just below the skin and you should be
able to feel the pulse continuously while increasing the pressure and pushing deeper
with the fingers. About two thirds of the way down to the bone, the sensation from
the pulse will cease. The pulse should, therefore, not be felt all the way down to the
bone. You should press the fingers slowly downwards and then release the pressure
again slowly several times. This is because we often do not notice certain qualities as
the pressure increases, but these qualities become evident on releasing the pressure,
as the fingers return to the surface again.
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Account must be taken of a person’s body size. A thin person’s pulse will generally
feel more superficial than a corpulent person’s. The corpulent person’s pulse will feel
deeper than that of a person who is thin and slender.
A healthy pulse can be felt equally clearly in all three levels. It will, though, be
slightly deeper in the chi positions and slightly more superficial in the cun positions.
A Superficial pulse will be palpable with very little pressure. If the pulse is very
superficial, it will be felt with no pressure at all. The Superficial pulse will either
disappear completely when you push deeper or its strength will diminish as you
press downwards.
The Superficial pulse is sometimes described as feeling like a piece of wood
floating in water. When you push it down it disappears, but when you release the
pressure, the wood floats back up again. This means that if you push your fingers
down to the deepest level of the pulse and then release the pressure again, so that
the fingers return to the superficial level, the sensation from the pulse increases as
your fingers release the pressure.
The pulse is often only superficial in the cun position. The more positions the
pulse is superficial in, the more serious or dominant the imbalance is.
The Deep pulse is either only palpable with pressure or its strength decreases as
the pressure is released and the fingers return to the surface of the skin – the Deep
pulse is felt most clearly in the middle and deepest levels and is weakest or is not
present in the superficial level.
It is important to combine the pulse’s depth with other factors such as speed
and strength.
The pulse rate

Chinese doctors traditionally measured the speed of the pulse by counting the
number of pulses in relation to their own respiration. This was before the invention
of watches with a second hand. A simpler and more reliable method of counting the
number of beats per minute is to count the number of beats in a period of 15 seconds
and multiply this number by four. It is a good idea to repeat this measurement a
couple of times, as the rate can vary. If there is a variation, this will in itself have
diagnostic significance.
It is important to note that the speed of the pulse diminishes with age. The
average speed of the pulse in various age groups is as follows.
Age Beats per minute

1–4 90+
4–10 84
10–16 80
16–35 76
35–50 70
50+ 68
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A Rapid pulse is defined as a pulse where the beats per minute exceeds the pulse
rate that you would expect for someone of that age. This means that a pulse rate of
84 beats per minute is normal for a child under the age of 10, but fast for a woman
of 60. The faster the pulse, the more Heat there is. If the pulse is slower than the
average, it can indicate Cold or a lack of yang.
People who work out and train hard physically usually have a slow pulse. This
is considered by many people to be normal, so if these individuals have a normal
speed pulse, it is in reality a Rapid pulse. Others, myself included, disagree with this
point of view. The slow pulse rate in people who train and play a lot of sport or work
out may well reflect that they have damaged their yang through excessive physical
exertion and that their languid pulse is in fact a true reflection of their physiology.
The strength of the pulse will determine whether it is a shi or xu condition.
Situations in which the pulse is not fast,

even though there is Heat present
• The person trains hard or is very physically active
• The person takes medicine
• Old age
• Damp-Heat
• Damp-Phlegm
• Mixed patterns where there is both Heat and Cold simultaneously or where
there is also qi xu or yang xu
• The person has both Kidney yin xu and Kidney yang xu
• True Cold, false Heat
The pulse strength

In order to determine whether a pulse is Weak or Full, you must judge how much
strength the pulse has. The strength of the pulse is determined by how much it
pounds against the fingers.
A pulse without strength will only be felt faintly beneath the fingers and will
disappear with pressure. There are several types of pulse that lack strength, such as
an ‘Empty’ pulse, a ‘Weak’ pulse and a ‘Faint’ pulse. You therefore have to be careful
when you use these terms, because they define specific pulse images, each with its
own diagnostic significance. This is why I have capitalised the names of specific pulse
qualities. If a pulse feels weak and is not very palpable, it is better to say that the
pulse lacks power or strength.
It is important to distinguish between the size of the pulse, i.e. the width and
depth, and how replete it is. A pulse can quite easily be large without being replete.
Conversely, you could feel a pulse that is superficial and thin, yet has strength.
This pulse will only be felt strongly in the superficial level and will feel weaker or
non‑existent when you push downwards with the fingers.
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A pulse with strength can feel hard, full, tense and long. It strikes back against
the finger and does not yield when pressed. It lacks softness and pliancy. It is
important to be aware of where in the fingertip the sensation is felt. It should be
felt just below the fingertip. If a pulse position is Weak, while the position next to it
is Full, the strong pulse position can drown out the weaker one. The pressure from
the Full position will be felt on the side of the fingertip, which can therefore give the
impression that the pulse position that is Weak also feels as if it is Full.
A pulse that has too much strength or is Full generally indicates a shi condition.
This reflects that there is too much qi present. If a Full pulse is felt in a client who
has an acute illness, this is a good sign – the strength of the pulse indicating that the
person has strong zheng qi, which is combating the xie qi.
The width of the pulse

Divergences in the width of the pulse result in the pulse being described as being
either wide or thin. The width of the pulse can be determined by slowly rolling the
fingertips laterally back and forth around the artery. A wide pulse feels broader than
a thin pulse.
The pulse’s width is independent of its strength and depth.
The length of the pulse

The pulse’s length is determined by rolling the tips of the fingers backwards and
forwards along the length of the artery. The length of the pulse is defined by how far
up the arm the pulse is felt or, in the case of a Short pulse, how little it fills out the
three pulse positions.
A Long pulse can be felt further up the arm towards the elbow beyond the
chi position. The Long pulse can be a sign of Heat or rebellious Liver qi (Liver qi
stagnation or ascending Liver yang). If the pulse is normal in its rate and strength,
this is a normal pulse and it will not be given any diagnostic significance.
A Short pulse will not fill out all three pulse positions, i.e. it is not as long as a
normal pulse, or it will feel as if the pulse cannot be felt fully in each of the individual
pulse positions, i.e. the pulse positions themselves seem shorter than normal.
The rhythm and regularity of the pulse

The pulse should be rhythmic in its beating. It should not skip any beats and the
speed, strength and other qualities should remain constant whilst you feel it. Some
pulses are rhythmic in their beating but irregular in terms of strength and speed.
Other pulses skip beats. When a pulse skips beats, it is important to determine
whether it is the same beat that it skips, for example every fifth beat, or whether the
breaks in the rhythm are random. The speed of the pulse has diagnostic significance
in an irregular pulse.
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Other qualities of the pulse

The other qualities will be discussed under the individual pulse categories.
Diagnostic pulse images

The easiest way to learn the various pulse images is to learn them as groups.
• Seven superficial pulses: Superficial, Drumskin, Hollow, Empty, Flooding,
Soggy and Scattered.
• Four deep pulses: Deep, Weak, Hidden and Confined.
• Three irregular pulses: Knotted, Intermittent and Skipping.
• Other pulse images: Long, Short, Wiry, Tight, Choppy, Slippery, Stirring,
Rapid, Very Rapid, Slow, Full, Large, Fine and Faint.
I have included the Chinese names of the pulse images because they are often
translated differently from book to book. The Chinese name can be used as a
reference point when reading other books.
Superficial pulse
There are several types of pulse that are classified as being superficial. It is important
to note which other qualities the pulse has to distinguish the different pulses from
each other. Many of the pulses are very similar to each other and their diagnostic
significance is often also very similar. The main differentiating factor amongst the
superficial pulses is their strength. It is important, therefore, to ask yourself whether
the pulse feels strong or deficient.
A Superficial pulse will be a consequence of the presence of xie qi in the exterior
or an interior xu condition. In an internal xu condition, the pulse will feel weaker or
absent when you press down to the deep level. When there is an invasion of exogenous
xie qi, the pulse will generally be powerful, but even more so in the superficial level.
It is also important to note whether the pulse is Rapid or Slow, in order to determine
if there is Heat or Cold.
The seven superficial pulses are: Superficial, Drumskin, Hollow, Empty,
Flooding, Soggy and Scattered.
Superficial pulse (Fu mai)

The Superficial pulse is a pulse that is superficial and is not felt in the deep and/
or middle levels or the strength of the pulse decreases when you press your fingers
downwards and increases again when the pressure is released again.
The Superficial pulse reflects that there is more qi and yang in the exterior
aspects of the body. There will be a relative excess of qi and yang in the exterior aspects,
either because there is a lack of yin to anchor yang or because xue is very weak
and cannot hold qi down. In these cases, the pulse will be both superficial and
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without strength. Yang and qi may also be relatively strong in the exterior, because
there is an invasion of exogenous xie qi. In this case, the pulse will be more replete,
because there is a struggle between wei qi and xie qi. An exception, though, is if there
is an invasion of exogenous xie qi whilst there is wei qi xu. In this situation, the pulse
will be superficial and without strength. If there is Heat present, the pulse will be
Rapid. The presence of shi Cold will result in a pulse that is Tight.
Extreme yang xu can also manifest with a Superficial pulse. This is a very serious
sign and signifies that yin and yang are in the process of separating and the remaining
yang is now drifting upwards.
Superficial pulse
Patterns of imbalance: Xie qi in the exterior, yin xu, xue xu, severe qi xu (in extreme
cases yang xu).
Typical combinations
Superficial and Tight Wind-Cold
Superficial and Rapid Wind-Heat
Superficial and Slow Invasion of exogenous Wind
Superficial and without strength Wei qi xu
Superficial and empty in the middle and/or deepest level Interior xu condition
Drumskin (ge mai)

Ge mai is often translated as a ‘drumskin’, ‘leather’, ‘tympanic’ or ‘hard’ pulse. This
type of superficial pulse is wider than a normal pulse and it feels hard. It will provide
the fingertips with resistance when you press downwards, but when you reach the
middle level the resistance disappears. The width of the pulse will be felt when rolling
the fingers laterally back and forth. The Drumskin pulse will be felt more laterally
than the Empty and Soggy pulses. It is called a Drumskin pulse, because the pulse feels
hard and wide in the same way that a drum skin does. It will also feel empty beneath
the hard surface like a drum skin. The Drumskin pulse is not something that you will
ordinarily encounter in a normal practice; it arises when there is a significant loss of
blood. In Chinese medicine, the heavy blood loss will result in an extreme xue xu and/
or yin xu. This will result in an abundance of yang qi ascending up to the surface. Yang
is expansive in its dynamic; the pulse will therefore be superficial, hard and wide, but
because there is an extreme deficiency of yin and xue, it will feel empty further down.
Extreme jing xu can also manifest with this type of pulse.
Drumskin pulse
Patterns of imbalance: Xue xu, yin xu.
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Empty pulse (xu mai)

This pulse is also translated as ‘vacuous’ and ‘deficient’. Similar to the Drumskin
pulse, the Empty pulse is superficial and wide, but the difference between the two
is that the Empty pulse is not hard and the pulse is without force. The Empty
pulse’s weakness is reflective of a xu condition. If the pulse is also Rapid, it will be a
manifestation of yin xu Heat. This pulse can also be seen when there is jing xu or qi
xu or if a person has been invaded by exogenous Summer Heat that has injured jinye
and yin. If there is an invasion of Summer-Heat, the pulse will be Rapid.
Empty pulse
Patterns of imbalance: Yin xu, xue xu, qi xu and jing xu.
Empty and Rapid pulse Yin xu Heat or Summer-Heat
Hollow pulse (kou mai)

This pulse is often translated as a ‘scallion stalk’ pulse. This pulse, like the Empty
pulse, is superficial and without strength. The difference between the two is that
when you push down to the middle level, the Hollow pulse disappears completely.
There is disagreement in the texts about what happens if you push further down to
the deep level. Some books write that you will feel the pulse again at the deepest
level, others that you will not. Some also state that the edges of the pulse can be felt
clearly when you roll your fingers back and forth across the pulse.
The reason that the pulse is called a ‘scallion stalk’ is that it feels like the stem of
a spring onion. If you put your fingertips on a scallion stalk, it will feel round and
wide but also frail and without strength. There is nothing in the centre of it and a
void will be felt when you press harder on the scallion stalk.
The middle level of the pulse reflects the condition of xue and the Stomach and
Spleen. An emptiness in this middle level will therefore be interpreted as more a
severe xu condition than if there was an ‘Empty’ pulse that was not empty in the
middle level.
Hollow pulse
Hollow and Rapid pulse Yin xu Heat or Summer-Heat
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Scattered pulse (san mai)

This pulse is superficial, wide and without strength and disappears on pressure. The
difference between this and a Hollow pulse is that the Hollow pulse has clearly
defined boundaries when the fingers are rolled back and forth. This is not the case
with the Scattered pulse. The edges of the vessel are not defined, making them
difficult to perceive. The pulse is so feeble that it disappears with the slightest touch.
Maciocia describes the sensation as being like a lot of small dots below the fingertip
instead of a wave. (Maciocia 2004, p.484)
The Scattered pulse arises in the same situations as the Drumskin pulse. The
difference between them is that in the Scattered pulse the loss of qi means that
the walls of the vessel lack qi and this can be felt by the lack of clear definition. The
diagnostic significance of the two pulses is therefore almost identical, but with
the difference that in a ‘Scattered’ pulse the loss of qi is greater.
Scattered pulse
Soggy pulse (ru mai)

Some sources term this pulse ‘soft’. This pulse image is described in Huang Di Nei
Jing – Su Wen as being like a piece of silk thread lying on the surface of water. This
description is very apt. The pulse will be felt superficially; it is without strength
and feels narrow when rolling the tips of the fingers back and forth. The pulse will
disappear when you press your fingertips downwards. The Soggy pulse can be felt
when there is qi xu and xue xu and when there is Dampness. The Dampness will
‘smother’ the pulse as if it is wrapped in cotton wool. The qi xu and xue xu will mean
that the pulse does not have the strength to be ‘heard’ through the Dampness.
Soggy pulse
Patterns of imbalance: Dampness, qi xu and xue xu.
Soggy and Rapid Damp-Heat
Soggy and Slow Damp-Cold
Flooding pulse (hong mai)

This pulse is also translated as ‘overflowing’ and ‘surging’. This pulse is felt when
there is extreme Heat. The pulse’s name alludes to the sensation it creates. It is large,
replete, wide and superficial. It is like a flood wave that overflows or a tidal wave.
The pulse rises powerfully from the deep level and hits the fingers with force in the
superficial level.
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The Flooding pulse will often be experienced when exogenous xie qi has
penetrated down to the qi level or the yangming aspect. At this point there will
usually be a fierce struggle between zheng qi and xie qi. This struggle will manifest
with a very replete pulse. At the same time, the exuberant Heat that the struggle
generates will increase the speed of the pulse so that it is quite fast. The Heat is so
intense that it forces qi and jinye to the surface and this can be felt in the pulse.
The Flooding pulse can start as a deep or normal pulse in the chi position and
increase in strength and width, rising upwards so that when it reaches the cun
position, it is superficial, wide and replete.
Maciocia writes that the Overflowing pulse will sometimes only be felt in one
position (Maciocia 2004, p.487). In this case, this pulse position will feel very strong
and full in the superficial aspect relative to the other pulse positions. This is a sign
that there is Heat in the organ or organs related to this pulse position.
If the pulse is generally weak, but is relatively full and superficial in a single
position, it will be a manifestation of yin xu Heat in this organ or organs.
Flooding pulse
Patterns of imbalance: Shi Heat, yin xu Heat.
Deep pulses
The clinical significance of the deep pulses is that the imbalance is in the interior. The
imbalance can be both xu or shi in nature. The pulse can be deep because it lacks
yang and qi to lift it up to the surface or there may be xie qi, which inhibits qi,
xue and yang from lifting the pulse upwards. The difference between a xu condition
and a stagnation will be felt by the pulse being either without strength or being
forceful, respectively.
The four deep pulses are: Deep, Weak, Hidden and Confined.
Deep pulse (chen mai)

The Deep pulse will be felt when you have pressed down from the superficial level
(and will only be felt in the middle and/or the deepest levels) or when the strength of
the pulse increases as you press down and decreases again upon releasing the pressure
of your fingers.
That the pulse is Deep is not enough information in itself and it must be coupled
with other qualities before it can be used diagnostically.
If the pulse lacks strength, it will be because there is not enough qi or yang to
‘raise’ the pulse upwards.
If it is forceful, it is because qi and yang are blocked by Cold, food stagnation, qi
stagnation, xue stagnation or a stagnation of fluids. The speed of the pulse will also
determine whether it is a Hot or Cold condition.
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Deep pulse
Patterns of imbalance: The imbalance is in the interior, yang xu, qi xu, qi stagnation
food stagnation, Phlegm, Dampness, xue stagnation, Cold.
Deep and Slow Internal Cold
Deep and Rapid Internal Heat
Deep and forceful Internal shi condition
Deep and without strength Internal xu condition
Deep and Tight Internal stagnation
Deep and Slippery Phlegm
Deep and Fine Dampness or qi and xue xu
Weak pulse (ruo mai)

The Weak pulse is felt only in the deepest level or the pulse feels weak in depth and
decreases even more when pressure is released by the fingers. The Weak pulse lacks
force and when the tips of the finger are rolled back and forth it feels narrow. This is
because there is either not enough yuan qi and xue to fill the vessel or because yang
is so weak that it cannot push outward and upwards.
Weak pulse
Patterns of imbalance: Qi xu, xue xu and yang xu.
Weak and Slow Yang xu Cold
Weak and Choppy Xue and qi xu
Hidden pulse (fu mai)

The Hidden pulse is a more extreme version of the Deep pulse. The Hidden or ‘deep-
lying’ pulse will only be felt near the bone and only when the fingers are pressed down
firmly, so it is much deeper than the Deep pulse. You have to press very deeply and
be very attentive to your fingertips before you can feel it. It is, again, important to
differentiate between a feeble and a forceful pulse. The diagnostic significance of the
Hidden pulse is the same as for the Deep pulse but more extreme and more serious.
Hidden pulse
Patterns of imbalance: Stagnation or extreme yang xu.
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Hidden and without strength Severe yang xu or qi xu
Hidden and forceful Severe stagnation in the interior
Hidden and Rapid Internal Heat
Hidden and Slow Internal Cold
Confined pulse (lao mai)

The Confined pulse, which is also sometimes called a ‘firm’ pulse, is a deep, long,
forceful and hard pulse. It provides resistance when you press down on it and it
lacks softness. The difference between this pulse and the Full pulse is that the Full
pulse is felt clearly in all three levels, whereas the Confined pulse is only felt in the
deepest level. When you feel a pulse that is deep and hard, it will be because there
is something that is stagnating qi and xue in the vessel. This could be Cold, food
stagnation, qi stagnation, Dampness, Phlegm or xue stagnation.
Confined pulse
Patterns of imbalance: Cold, qi stagnation, xue stagnation or food stagnation.
Confined and Slow Internal shi Cold
Confined and Choppy Xue stagnation
Irregular pulses
The three irregular pulses are the Knotted, Intermittent and Skipping. All three
of these pulses miss beats. The difference between the three lies in their overall speed
and whether they are irregular or regular in which beats they skip. When the pulse is
very irregular, it can be difficult to assess how rapid the pulse really is. This is because
if the pulse skips a lot of beats, it is difficult to estimate how many beats per minute
there otherwise would have been.
An irregular pulse is always indicative of a Heart imbalance, both in the Western
medicine and Chinese medicine sense.
Knotted pulse (jie mai)

This is sometimes also translated as a ‘bound’ pulse. The Knotted pulse is slow and
irregular in its rhythm. It randomly misses beats. The reason for it missing beats
and its slowness is because there is something (Phlegm, Cold, xue stagnation or
food stagnation for example) inhibiting the Heart from circulating xue through the
channel and vessels, or because Heart qi or Heart yang are too weak to perform
their functions.
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In the former, the pulse will also be forceful, whereas it will lack strength in a
xu condition.
Knotted pulse
Patterns of imbalance: Qi stagnation, xue stagnation, Phlegm stagnation, food
stagnation, Heart qi xu or Heart yang xu.
Knotted and forceful Qi stagnation, xue stagnation, Phlegm or food stagnation
Knotted and without strength Heart qi xu or Heart yang xu
Intermittent pulse (dai mai)

Unlike the Knotted pulse, the Intermittent or ‘regularly interrupted’ pulse is regular
in terms of which beats it skips. After it has skipped a beat, it will feel like the pulse
waits momentarily before it starts beating again. This is because qi is so weak that it
is unable to keep xue in motion and the body must gain strength before it can move
xue again. It may be necessary to feel the pulse for a long time before it skips a beat
– perhaps as many as 50 beats. The Intermittent pulse arises in xu conditions of the
Heart and in one or more of the other zang organs.
Intermittent pulse
Patterns of imbalance: Zang organ xu.
Skipping pulse (cu mai)

The Skipping pulse is also termed ‘hasty’ in some books. This pulse is rapid and
irregular. It randomly skips beats. The Skipping pulse can arise when internal Heat
over-activates the Heart. It is as if the Heart beats so fast that the pulse cannot
keep pace. Yang qi has become more powerful than yin can control and harmonise.
This means that qi separates from xue and ‘races’ ahead. The Heat can also create
stagnations of xue or Phlegm, which then block the flow of xue in the vessels.
The Heat is usually shi in nature and will be due to factors such as xie qi,
stagnations of qi, xue, Phlegm or food, or Heat from other organs. This pulse image
can also arise in extreme and severe conditions where yin and yang are beginning to
separate from each other. In this case, the pulse will be very frail.
Skipping pulse
Patterns of imbalance: Heat.
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Skipping and forceful Shi Heat
Skipping and without strength Extreme yin xu
Other pulse qualities

Wiry pulse (xian mai)
This pulse is also translated as ‘bow string’ or ‘taut’. This is a very common pulse
quality, and when you have felt it a few times, you are never in doubt about it
again. It is thin and hard and pushes into the fingers like a guitar string. This will
be especially noticeable when you release the pressure and let your fingers move
upwards from the deep level to the surface – it is as if the pulse is in a hurry to get
back to the surface after it has been pressed down.
The Wiry pulse will most often be seen when there is a Liver imbalance, usually
Liver qi stagnation or ascending Liver yang, and also when there is Liver Wind
or Liver Fire.
The Wiry pulse can also arise when there is pain or xue stagnation and in
Phlegm conditions.
Wiry pulse
Patterns of imbalance: Liver imbalances xue stagnation, Phlegm, pain.
Wiry and Rapid Qi or Phlegm stagnation that generate Heat
Wiry and Slow Cold stagnation in the Liver channel
Wiry and Slippery Phlegm
Tight pulse (jin mai)

This is also a ‘hard’ pulse like the Wiry pulse, but here the pulse is wider and less
springy. It feels like a rope that has been twisted and tightened, such as a tightrope.
The Tight pulse is seen when there is Cold. The Cold can be both in the exterior and
in the interior. The depth of the pulse will be decisive.
The Tight pulse can also be experienced when there is pain.
Tight pulse
Patterns of imbalance: Cold, pain.
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Tight and Slow Cold
Tight and Superficial Invasion of Wind-Cold
Tight and Deep Internal shi Cold
Tight and Slippery Cold and Phlegm stagnation
Slippery pulse (hua mai)

The Slippery pulse feels very smooth, like ‘glass beads rolling in a bowl’ or the
sensation that is felt when you squeeze an almond that has been boiled and the skin
slips off. It has also been described as water droplets on a duck’s back. Like the Wiry
pulse, this pulse will be easily recognised once you have felt it a few times.
Women who are in the later stages of pregnancy should have a Slippery pulse, so
this may present an opportunity to experience this pulse in practice.
A normal pulse or ping mai should feel slightly slippery. This is due to the
movement of xue through channels and vessels giving the pulse this quality. It is
part of the pulse’s ‘Stomach’ quality. It indicates that there is sufficient xue, qi and
jinye and that xue is flowing freely through the vessel system. The pulse should have
an aspect of the slippery quality in the same way that the tongue should have a thin
coating. A small amount is a healthy sign, but too much coating on the tongue or
slipperiness in the pulse is a pathological sign.
Heat can agitate xue. This will cause xue to flow faster through the vessels. The
increased movement of xue will give the pulse a more slippery quality. In this case,
the pulse will be Slippery and Rapid.
The Slippery pulse is often an indication that there is Dampness and Phlegm
in the body. Dampness and Phlegm will mean that there is extra lubrication in the
vessels, so xue flows more smoothly than usual.
Food stagnation can also lead to the creation of Dampness, Phlegm and Heat,
thereby making the pulse Slippery.
Slippery pulse
Patterns of imbalance: Phlegm, Dampness, food stagnation, Heat, pregnancy.
Slippery and Superficial Wind-Damp or Wind-Phlegm
Slippery and Deep Food stagnation, Phlegm or Dampness in the interior
Slippery and Rapid Phlegm-Heat or Damp-Heat
Slippery and Slow Damp-Cold or Phlegm-Cold
Slippery and Large Phlegm-Heat
Slippery and without strength Dampness or Phlegm due to qi xu
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Choppy pulse (se mai)

This pulse is often also translated as a ‘rough’ or ‘hesitant’ pulse. A Choppy pulse can
be experienced in various ways. The pulse can feel coarse and rough like sandpaper
beneath your fingers. The pulse feels a bit ‘dry’. Another quality the pulse can have
is that the strength and rhythm may vary whilst you are feeling it. It is therefore
also called a 3/5 pulse in Chinese, because sometimes there are three beats to each
breath and sometimes there are five beats for each breath. Even though the rhythm
can vary, the pulse does not skip any beats, it just accelerates and decreases in speed
and/or strength.
One of the classical images used to describe this pulse is that it feels like a knife
being scraped along a piece of bamboo. This conjures up two images. First, there is
a roughness in the fingers as the knife scrapes along the bamboo. Second, the knots
in the bamboo are unevenly distributed and are different sizes. This means that
there will be an unevenness in the frequency and the size of the bumps as the knife
passes over them. Another classical image that demonstrates how the Choppy pulse
feels is fine rain falling in sand. This again conjures up a slightly abrasive sensation
in the mind. In comparison, the normal pulse feels like rain running off a smooth
jade stone.
The reason why this pulse has these rough and choppy qualities is that qi and
xue are not flowing freely. The pulse has therefore lost some of its smoothness. The
Choppy pulse will almost always arise due to there being too little xue in the vessels,
meaning that xue cannot flow unhindered and smoothly through the vessels. This is
like a stream that is starting to dry out. The pulse will be relatively weak. If the pulse
is replete and Choppy, it is because there is a shi pattern of xue stagnation, and the
stagnant xue is preventing xue from flowing freely through the vessels.
Apart from xue stagnation and xue xu, the Choppy pulse can also be seen when
there is jinye xu and jing xu.
Where the Slippery pulse is normal and signifies positive qualities in pregnancy,
the Choppy pulse is a very negative sign if it suddenly appears in a pregnancy, as it
may indicate a possible miscarriage.
Choppy pulse
Patterns of imbalance: Xue xu, xue stagnation, jinye xu, jing xu.
Choppy and Wiry Qi and xue xu
Choppy and replete Xue stagnation
Choppy and Weak Qi and xue xu
Choppy and Soggy Qi and xue xu with Dampness
Choppy and Deep Qi and xue xu
Choppy and Knotted Xue stagnation due to shi or xu Cold
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Stirring pulse (dong mai)

This pulse is also called a ‘moving’ or ‘shaking’ pulse. The Stirring pulse will be seen
when a person is in shock or acute pain. It is as if the pulse does not travel in a wave
but remains in the individual positions and vibrates. The pulse is described as being
like a bean that spins around on its own axle. The pulse is fast, smooth and strong.
Pain results in the pulse contracting and becoming Wiry; shock causes qi to become
chaotic. Qi and xue separate from each other and qi races ahead without xue being
able to follow.
Stirring pulse
Patterns of imbalance: Shock, acute pain.
Slow pulse (chi mai)

As described earlier, what is defined as a Slow pulse will be different from person
to person. A rule of thumb is that a pulse that is slower than 64 beats per minute is
a Slow pulse. The Slow pulse arises when there is Cold. Xu Cold can be seen when
there is yang xu, in which case the pulse will be Weak and Slow. Shi Cold blocks yang
and inhibits xue in its movement by contracting the vessels together. When there is
shi Cold, the pulse will feel Tight or Confined. The depth of the pulse will give an
indication of which aspect of the body the Cold is located in.
Slow pulse
Patterns of imbalance: Cold.
Slow and Weak Yang xu
Slow and Full, Tight or Shi Cold
Confined
Slow and Superficial Invasion of exogenous Cold
Slow and Deep Internal Cold
Slow and Slippery Slim or Damp-Cold
Rapid pulse (shu mai)

The Rapid pulse is usually a pulse where there are more than 80 beats per minute.
What defines a rapid pulse will depend on the person’s age. The Rapid pulse is
always a sign of Heat. Heat agitates the Heart accelerating its circulation of xue. The
strength of the pulse will determine if it is yin xu Heat or shi Heat; the depth of
the pulse will determine in which aspect of the body the Heat is located.
Even though a fast pulse always indicates the presence of Heat, the opposite is
not always the case. There are several situations in which the pulse is not rapid even
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though there is Heat. In some of these situations the lack of speed in the pulse has
diagnostic relevance; in others it does not.
Some of the reasons that the pulse is not rapid, despite the presence of Heat are:
• the person plays a lot of sport or is very physically active
• the person takes medication
• old age
• Damp-Heat
• Phlegm
• the Heat is chronic and has weakened qi
• mixed patterns where there is both Heat and Cold
• concurrent Kidney yin xu and Kidney yang xu
• true Cold, false Heat.
There are also situations where the pulse is Rapid, even though the person does not
have a Heat imbalance. This will usually be due to the temporary presence of Heat
in the body, for example, because the person has just run up the stairs, which will
have generated warmth in the body. The person’s face will be red, they will sweat
and their pulse will be faster than normal. These are all Heat signs, indicating that
the person has Heat in the body right now. This is, however, a temporary condition
with no diagnostic relevance.
Other conditions that can cause the pulse to temporarily accelerate are:
• mental stress
• irritability and anger
• shock
• overexertion in a patient who is qi and xue xu
• nervousness.
Rapid pulse
Rapid and without strength Yin xu Heat
Rapid and forceful Shi Heat
Rapid and Superficial Invasion of exogenous Heat
Rapid and Deep Internal Heat
Rapid and Slippery Phlegm-Heat or Damp-Heat
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Very Rapid pulse (ji mai)

This pulse is the same as a Rapid pulse but even faster. The dynamics of the pulse are
the same. The Heat is so powerful here that yin is being injured.
Very Rapid pulse

Patterns of imbalance: Extreme Heat.
Very Rapid and without strength Yin xu Heat
Very Rapid and replete Shi Heat
Very Rapid and Superficial Invasion of exogenous Heat
Very Rapid and Deep Internal Heat
Very Rapid and Slippery Phlegm-Heat or Damp-Heat
Short pulse (duan mai)

The Short pulse does not occupy all the positions. It will often be in the cun position
that the pulse is not fully present. The pulse reflects that yang qi cannot ascend all
the way up to the upper jiao. This may be because there is something blocking it,
probably food stagnation, or because there is a severe qi xu.
Short pulse
Patterns of imbalance: qi stagnation, food stagnation, qi xu.
Short and without strength Qi xu
Short and forceful Stagnation
Short, forceful and Rapid Stagnation condition that is generating Heat
Short and Slippery Phlegm stagnation
Long pulse (chang mai)

The Long pulse can be felt further up the arm proximal to the chi position. Most
people have a Long pulse and therefore the Long pulse is a ping mai (healthy pulse)
unless there are other qualities present. If there are other qualities present, the Long
pulse will usually indicate that there is Heat or rebellious Liver qi. A long pulse can
also be defined as a pulse that extends further than an individual position itself, i.e.
a pulse that is felt when rolling the individual fingertip distally and proximally along
the pulse.
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Long pulse
Patterns of imbalance: Heat, rebellious Liver qi.
Long and Rapid Heat
Long and Wiry Rebellious Liver qi
Large pulse (da mai)

The Large pulse is a pulse that is broad and replete. It is rarely used as a separate pulse
image, but is usually used as an aspect of other pulse images. The expansive dynamic
of Heat is the mechanism behind this pulse image.
Large pulse
Fine pulse (xi mai)

The Fine pulse is also translated as ‘thin’ and ‘thready’. The Fine pulse is thin, weak
and soft. It will feel like a piece of silk thread, but, unlike the Soggy pulse, the Fine
pulse is not superficial. The Fine pulse arises when there is too little xue, yin or qi to
fill the vessel or when Damp ‘smothers’ the vessels.
Fine pulse
Patterns of imbalance: Xue xu, yin xu, qi xu, Damp.
Fine and Rapid Yin xu Heat
Fine and Slow Qi and xue xu plus Cold
Fine and Choppy Xue xu
Fine and Slippery Dampness
Faint pulse (wei mai)

The Weak pulse is also called a ‘minute’ pulse.
The Weak pulse is a more extreme version of the Fine pulse, as it is even thinner,
weaker and softer. The pulse can be difficult to palpate because it is so weak and
thin. The diagnostic significance and the dynamics are the same as those for the Fine
pulse. The Faint pulse is seen when there is extreme qi xu, xue xu and yin xu. It will
always be a chronic condition.
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Faint pulse
Patterns of imbalance: Extreme qi xu, extreme yin xu, extreme xue xu.
Faint and Rapid Extreme yin xu Heat
Faint and Slow Extreme qi and xue xu plus Cold
Faint and Choppy Extreme xue xu
Full pulse (shi mai)

The Full pulse is also known as an ‘excessive’ or ‘replete’ pulse. The Full pulse feels
strong, long and hard to the touch. It is felt on all three levels. The Full pulse will
arise from shi patterns of imbalance. This is because when there is xie qi present,
there will be more qi present in the body than normal. This results in the pulse
feeling ‘fuller’.
The speed of the pulse will determine if there is shi Heat or shi Cold.
Full pulse
Patterns of imbalance: Shi conditions.
Full and Slow Shi Cold
Full and Rapid Shi Heat
Full and Tight Shi Cold
Full and Slippery Phlegm
Overview of the 28 pulse qualities

English Pinyin Significance Quality
name name
Superficial Fu mai Xie qi in the exterior, yin xu, xue Superficial, lacks strength in depth
xu, severe qi xu (in extreme cases
yang xu)
Drumskin Ge mai Xue/yin loss, extreme jing xu Superficial, wide, hard
Flooding Hong Heat Superficial in cun position, but
mai not in the chi position
Forceful, superficial, wide
Empty Xu mai Xue xu, yin xu, qi xu, jing xu and Superficial, without strength
Summer-Heat
Hollow Kou mai Xue xu, yin xu Superficial, wide, without
strength, empty in the middle
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English Pinyin Significance Quality

name name
Scattered San mai Xue, yin or qi loss Superficial, wide, without
strength, no edges, empty upon
pressure
Soggy Ru mai Qi xu, xue xu, Dampness Superficial, thin without force
Deep Chen Yang xu, qi xu, xie qi in the Deep
mai interior or stagnation
Weak Ruo mai Yang xu, xue xu, yuan qi xu Deep, thin, no strength
Hidden Fu mai Stagnation or extreme yang xu Very deep
Confined Lao mai Stagnation of Cold, food, qi, xue Deep, wide, long, hard
or Dampness
Knotted Jie mai Qi stagnation, Phlegm, xue Slow, irregular
stagnation, food stagnation, shi
Cold, yang xu, Heart qi xu, yuan
qi xu, jing xu
Intermittent Dai mai Organ qi xu Regular disturbance in the rhythm
Skipping Cu mai Shi Heat or yin and yang are Rapid, irregular
separating
Wiry Xian mai Liver imbalances, pain, Phlegm Thin, hard, feels like a guitar
string
Tight Jin mai Cold, pain Wide, hard
Slippery Hua mai Dampness, Phlegm, food Feels slippery, like small beads in
stagnation, Heat, pregnancy oil
Choppy Se mai Xue xu, xue stagnation Variable strength and speed or
rough feeling
Stirring Dong Shock, pain Slippery, rapid, forceful, vibrating
mai
Slow Chi mai Cold Less than 60 beats per minute
Rapid Shu mai Heat More than 80 beats per minute
Very Rapid Ji mai Extreme heat More than 110 beats per minute
Short Duan Extreme qi or xue xu, food Does not completely occupy all
mai stagnation the positions
Long Chang Heat or rebellious Liver qi (can Longer than normal
mai also be normal, if there are no
other pathological changes in the
pulse)
Large Da mai Heat Wide, overflows its boundaries, is
forceful
Fine Xi mai Yin xu, xue xu, Dampness with Soft, weak, thin
qi xu
Faint Wei mai Extreme xue xu, qi xu or yin xu Very weak, very thin
Full Shi mai Shi condition in which there is Wide, forceful in all levels
xie qi at the same time as strong
zheng qi
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Palpation of the abdomen, including Hara diagnosis

Palpation of the abdomen includes observing the general sensation and warmth of
the abdominal region. Palpation of the abdomen also encompasses palpation of the
channels, mu-collecting points and the so-called Hara diagnosis. In Hara diagnosis
the abdominal area is divided into various zones that relate to the internal organs.
Changes in these zones will indicate that there is an imbalance in the organ.
Palpation of the abdomen

Varying amounts of pressure should be applied whilst palpating the abdomen. Start
by gently placing the hand lightly on the skin and slowly draw your fingers over the
skin. This allows you to get a sense of the temperature, smoothness and moistness
of the skin. Next, slowly apply pressure to the different areas of the abdomen with
the fingers. Start with a light, superficial touch to get a sense of the elasticity of the
skin and resistance in the superficial tissue. Then, gently press deeper to gauge
the resistance further down. Take note of how hard and elastic the area feels and
whether there are any lumps. The abdomen should be relatively soft and elastic in the
surface aspect, but there should be an increasing resistance the deeper one presses.
Whilst palpating, be aware of any noises from the patient. The noises can be the
patient’s verbal responses, indicating discomfort, pain or pleasure, or involuntary
sounds from the body, such as sloshing or bubbling sounds in the intestines.
A woman’s abdomen should generally be softer than a man’s. This means that
if you feel a very soft and flaccid abdomen in a man, it has greater diagnostic
significance than if you feel the same quality in a woman. Conversely, a very tense
and hard abdomen is a more negative sign in a woman than it is in a man.
Temperature
It is important that the entire abdomen has a uniform temperature. Hotter skin
in one area will indicate the presence of Heat, whereas cold skin will tell you that
there is Cold or yang xu present. It is, of course, important to take clothing into
account. If the person has just come in from outside and is wearing clothes that only
partly cover the abdomen or are very thin, this area of the abdomen will probably
feel colder. In children, palpable heat in the abdomen will usually be an indication
of food stagnation, the Heat from the food stagnation emanating through the
abdominal skin.
Tension and hardness

When the abdomen feels hard and tense, it indicates that there is a shi condition.
Qi stagnation will manifest with abdominal distension. The abdomen may be
visibly bloated or the area may just feel hard and tense but also elastic. It will feel a
bit like a trampoline. The patient will usually experience discomfort being palpated.
This is because the pressure from the fingers increases the amount of qi in an area
that already has an excess of qi.
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If there is food or xue stagnation the abdomen will also feel hard and tense, but
there will not be the same elasticity in the abdomen as when there is qi stagnation.
A sharp pain on palpation is a further indicator of xue stagnation. Food stagna-
tion can elicit a distended sensation in the abdomen. Dampness can also give a
similar sensation.
The area below the costal region can become tense and hard when there are Liver
and Gall Bladder imbalances or when there is xie qi locked in the shaoyang aspect.
Tightness in the epigastric area, inferior to the sternum, will indicate a stagnation
in either the Stomach or the Heart.
Tension in the central area of the lower portion of the abdomen above the pubic
bone is felt when there is a shi condition of the Urinary Bladder or the Small Intestine.
If the areas lateral and inferior to the umbilicus are tight, this indicates a
chong mai stagnation or a stagnation in the Intestines. Stagnation of qi or xue in
the chong mai can also manifest with tightness around the umbilicus. If this area is
flaccid and loose, it can indicate that there is a xu condition in the Kidneys, ren mai
or chong mai.
An abdomen that has an overall flaccid and soft sensation is felt when there is a
xu condition. Spleen and Stomach qi xu will manifest with softness in the upper part
of the abdomen whilst Spleen and Kidney qi xu can manifest with a lack of tension
in the lower part of the abdomen.
Palpation of the abdominal flesh is indispensable in paediatric diagnosis.
Pain
When there are shi patterns of imbalance, pain and discomfort can be experienced
by the patient during palpation. A sharp, severe pain is a more serious diagnostic sign
than a deep tenderness or soreness. If there is a pain or discomfort that is alleviated
by pressure, or if the palpation feels pleasurable, the imbalance will be xu in nature.
On the other hand, a pain that is aggravated by palpation indicates a shi condition.
Lumps
If lumps are felt during palpation, it will be a manifestation of a shi imbalance.
This is because the physical masses arise when there is an accumulation of qi, xue
and/or Phlegm.
Differentiation is made between lumps that are localised and do not move and
lumps that can change position when you press them.
Physical accumulations that are not fixed will be palpable sometimes and not
at other times. Qi stagnation can create temporary accumulations, because qi is
more volatile than xue and Phlegm. This means that accumulations that arise from a
stagnation of qi will move around the area and will sometimes vanish. Xue stagnation
and Phlegm stagnation lumps will be fixed in location and will not be movable.
Xue stagnation accumulations will feel harder than Phlegm accumulations and
will have more defined edges. Xue stagnation lumps are also characterised by being
more painful.
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Damp-Heat can also create lumps in the lower jiao. These will be very sore and
painful on palpation.
Physical accumulations can also be palpated in the area of the intestines. These
may be stools in the intestines, which do not have diagnostic significance.
Physical accumulations can also be used prognostically. If the lump is reduced in
size after the treatment, this is sign of progress and a good prognosis.
Patients with physical accumulations should always be referred for further
examination by a Western medical doctor.
Sounds
Water retention due to Cold or yang xu can result in sloshing sounds as if there is
liquid that is swishing around the Intestines or the Stomach.
Palpation of the abdomen

Warm skin Heat conditions, food stagnation in young children
Cold skin Yang xu or an invasion of Cold
Hard and tense abdomen Qi stagnation, food stagnation, xue stagnation or Dampness
Soft and flaccid abdomen Spleen and Stomach qi xu (upper abdomen) or Spleen and
Kidney qi xu (lower abdomen)
Pain and tenderness Cold, Heat, xue stagnation, Damp-Heat, qi stagnation, food
stagnation or Dampness
Lumps Xue stagnation, qi stagnation, Damp-Heat or Phlegm
Sloshing sounds in the abdomen Accumulation of fluids in the Intestines due to Cold or yang xu
Tension in the hypochondriac Liver and Gall Bladder imbalances, xie qi in the shaoyang
region aspect
Tension in the epigastric region Stomach and Heart stagnation
Tension around the umbilicus Chong mai stagnation
Tension in the lower region of Chong mai stagnation, shi imbalance in the Urinary Bladder,
the abdomen Small Intestine or Large Intestine
Flaccid upper abdomen Stomach and Spleen qi xu
Flaccid lower abdomen Kidney and Spleen qi xu
Flaccid around the umbilicus Kidney qi xu, ren mai xu imbalances or chong mai xu
imbalances
Hara diagnosis
Hara diagnosis is a diagnostic technique utilised in some forms of Japanese
acupuncture and shiatsu. Hara diagnosis differs from conventional abdominal
palpation in that the abdomen is divided into different areas that relate to specific
internal organs based on the descriptions from the Nan Jing. This is especially useful
when utilising a Five Phase diagnosis. By palpating the abdomen, one can determine
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whether an organ is out of balance. When an organ is out of balance, there will be
palpable changes in the area upon palpation. There are several different diagnostic
models and accompanying techniques. The following approach is mainly based upon
the writings of Kiiko Matsumoto and Stephen Birch in their book Five Elements and
Ten Stems (Matsumoto and Birch 1983).
Start by holding the hand just above the abdomen without touching the skin.
Let the hand pass slowly through the air above the various zones. Notice whether
you can sense any variations in the perceived temperature or if there are changes in
the sensation experienced in the palm of your hand. Some people sense or describe
feeling a slight breeze on the hand. This is not as mysterious as it sounds: it’s just a
refined sense of qi. You do not have to feel anything. If you feel something, it is
a sign of an imbalance, whereas the absence of a sensation may just be a sign that
there is harmony and balance. Next, palpate the abdomen to ascertain whether there
are areas that are tense and hard or soft and flaccid. Differences in the temperature
in the various areas should be compared with the rest of the abdomen and between
the abdomen and the rest of the body. Tenseness, tightness and resistance in an area
is an indication that there is a shi condition. An area that feels flaccid, soft and weak
will conversely be experienced when there are xu conditions. Areas that feel hot or
cold will also indicate shi and xu conditions. Strong pulsing sensations can also be
felt in shi conditions.
In addition to physically palpating the abdomen, visual observation should also
be conducted to see if there are any changes in the skin, such as colour changes,
visible blood vessels and increased moistness or dryness.
Diagnosis and treatment will typically merge into each other. When an aberration
is felt in a specific area, this will dictate which needles are inserted. Once the needle
has been inserted, the area is palpated again to see if the needle has engendered
qualitative changes in the area. If there is no change in the area, the therapist will
either adjust the manipulation of the needle or insert another needle. The area is then
palpated again and the process is repeated until there is a perceptible improvement
in the abdomen. It is important that the practitioner releases the physical pressure
on the site each time before palpating again, thereby allowing a change to take place.
Diagnostic areas
The diagnostic areas described below are based on the areas outlined in the Nan Jing.
It is important to take into account the various channels that traverse the abdomen.
Palpable changes in the abdomen can also reflect imbalances in the channels
themselves. Furthermore, imbalances such as qi stagnation and xue stagnation in the
Stomach and the Intestines can also be felt when palpating the abdomen. It is also
important to note that the following is just one interpretation of the abdominal
areas and there are also other diagnostic interpretations of the abdominal zones.
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Lung area
The Lung area is located between the acupuncture points St 25 and St 27 on the
right hand side of the umbilicus (the patient’s right-hand side).
Spleen area
The Spleen area circumscribes the umbilicus in a circle that is one cun in diameter
and in a line from Sp 14 to Sp 15.
Liver area
The area below the patient’s right costal region relates to the Liver. Furthermore,
palpable lumps in the area to the left of and below the patient’s navel in a line
running St 25 to St 27 can be seen when there is Liver xue stagnation.
Heart area
The Heart area is located in the area around Ren 14 and Ren 15.
Kidney area
The Kidney area extends from Ren 4 to Ren 6 between the two Stomach channels.
Palpation of the Ren channel

Whilst palpating the abdomen, the various channels that traverse through the area
should be palpated. Special attention should be paid to palpating along ren mai,
especially the points Ren 6, Ren 12 and Ren 15. Ideally, there should not be any
feelings of heat, cold, lumps, hardness or weakness, but there should be qualitative
differences in how the three areas feel. Ren 6 should feel tighter and more elastic
than Ren 12, and Ren 12 should feel tighter and more elastic than Ren 15, i.e. there
should be an increasing resilience from Ren 15 to Ren 6. Aberrations in the form
of increased tightness, softness, cold or heat in these areas will be an indication of
imbalance in the respective jiao.
Palpation of the thorax

The thorax is mainly influenced by zong qi and the organs that are in the area – the
Lung, Pericardium and Heart. The Liver will also have an influence on the area, as
will the channels that traverse the area. The patient should be asked whether they
experience pain, tenderness, discomfort or relief whilst being palpated
Tenderness in the area around Ren 17 can be experienced when there are
stagnations in the Heart. Lung shi conditions can manifest with pain and tenderness
in the entire area around the sternum and the ribs will often be sore. If there are xu
conditions in the Heart or Lung, palpation will relieve the soreness and tenderness.
Liver and Gall Bladder imbalances can manifest pain, tenderness and tension
below the ribs and on the side of the chest.
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Palpation of the thorax

Pain and tenderness around Ren 17 Heart shi conditions
Pain and tenderness in the central area of the chest Lung shi conditions
Pain and tenderness on the sides of the thorax Liver and Gall Bladder imbalances
Tension in the hypochondriac region Liver and Gall Bladder imbalances
Shaoyang stage imbalances
Palpation of the skin

Palpation of the skin includes the inspection of the skin’s temperature, humidity
and elasticity, as well as palpating the tissue below the skin.
Palpation of the skin is especially important in the diagnosis of bi syndrome and
in dermatological disorders.
Skin temperature
Gauging the temperature of the skin can give an indication of whether there is
pathological Heat or Cold in the body. Investigation of the skin temperature is vital
when diagnosing invasions of xie qi, particularly when there are bi syndromes.
Hot skin
If the skin feels hot when you place your hand on it, this will be a sign that there is
Heat. The Heat can be both xu and shi in nature.
If it is only a limited area of skin that feels hot, for example the elbow, this will
indicate that there is a localised condition of Heat, which is likely to be due to a
stagnation in the area. Localised accumulations of Heat can also be seen when there
is Toxic-Fire.
Cold skin
Cold skin can be experienced when there is both shi Cold and yang xu. Again, it can
be the skin in general that feels cold or a limited area. Localised areas of Cold arise
from invasions of exogenous Cold.
Skin temperature
Hot Shi heat or yin xu Heat
Cold Shi Cold or yang xu
Note: If the person is wearing a lot of clothes or has just run or cycled, their skin will
feel hotter. Likewise, exposed areas of skin will feel colder than areas that are covered.
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Humidity
Dry skin
The skin is moistened and nourished by jinye and xue. Skin can feel dry due to a lack
of moisture if xue, yin or jinye are xu, injured by Heat or prevented from flowing to
the area. The latter is important, as both Phlegm and xue stagnation can inhibit the
circulation of yin, xue and jinye.
Sticky or oily skin

The skin can feel oily, sticky, greasy or moist when there is Damp-Heat or Phlegm.
Moist skin
Yang xu, qi xu or invasions of exogenous Wind can result in the pores in the skin
not closing and sweat seeping out. Heat can also drive fluids upwards and outwards,
causing the person to sweat. In all these cases, the skin will feel wet.
People who are very anxious will often sweat spontaneously when they are
nervous. This can be experienced before and during an acupuncture treatment.
Rough or flaky skin

Certain areas of the skin can become dry or flaky when they are not nourished by
xue or jinye. If the skin in general is dry and flaking this indicates xue xu or yin xu.
Localised areas of dry, flaking skin can also arise due to xue stagnation blocking the
flow of xue and jinye to the area.
It is, of course, important to take into account the use of creams and moisturisers,
which can confuse or veil the diagnosis.
Humidity of the skin

Dry Xue xu, jinye xu, yin xu, xue stagnation
Greasy or sticky Dampness, Damp-Heat or Phlegm
Moist (sweaty) Invasion of Wind, Lung qi xu, Spleen qi xu, yang xu, Heart qi xu, shi Heat,
xu Heat
Rough or flaking Xue xu, xue stagnation
Note: The use of creams and moisturisers will obscure the diagnosis.
Suppleness of the skin

The skin should be soft, elastic and smooth. This reflects that the Lung and Spleen
are harmonious. It shows that there is sufficient xue and jinye to nourish and moisten
the skin. The flesh below the skin should also feel firm but not hard. This indicates
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that qi and xue are nourishing the tissue and that fluids are being transported away
from the tissue again.
Stagnations of Phlegm and/or xue will block the flow of fresh, nutritious xue and
jinye. This will result in the skin feeling hard and thickened.
Loose skin is an indication that the skin is not being nourished, usually an
indication of yin xu or xue xu.
The connective tissue and the muscles beneath the skin can feel hard and tense
when there is a stagnation.
If the Lung, Kidneys or Spleen do not perform their task of spreading,
transporting and transforming the fluids, either because there is an invasion of xie
qi blocking their functioning or because they are qi xu, an accumulation of fluids in
the tissue can arise.
Palpation of the hands and feet

The first handshake can give an indication of which patterns of imbalance may be
present. The strength of the handshake, the temperature and the humidity of the
hand will all reveal information that can be utilised in the diagnosis.
A person who is extremely qi xu will often have a limp handshake. This is not a
hard and fast rule, especially as some people deliberately try to send signals to other
people via their handshake, for example that they are strong (crushing handshake)
or that they are trustworthy (firm handshake).
A person who is nervous will often sweat in the palms of their hands. This
is because the Heart controls sweating. The other area where people sweat when
they are nervous is under the arms. Both these places are located at the ends of the
Heart channel. A person with Heart qi xu will often be slightly more nervous than
others, which can manifest with sweaty palms. Shi Heat, especially Damp-Heat,
can also manifest with sweaty palms. When there is Damp-Heat, the palm will
usually also feel hotter. Invasions of xie qi can also make a person sweat, but the
sweat in these cases will not be localised on the hand.
Hands and feet that feel hot are a sign of Heat. If the hands feel warm or hot,
it is important to ascertain whether it is the whole hand or only the palm that feels
hot. The whole hand will feel hot if the Heat is shi in nature, whereas yin xu Heat
manifests with only the palms feeling hot.
Damp-Heat can manifest with hot and sweaty feet.
Cold hands and feet can be experienced when there is yang xu and xue xu, as
well as Liver qi stagnation. If there is yang xu, usually the hands and arms are cold.
The further away from the torso, the colder the sensation will be. This is because
yang warmth is too weak to expand and extend away from the centre, but also
because warmth is retained in the interior so the internal organs can utilise the
transforming power of yang.
Xue and qi travel together. This means that if there is xue xu, there can be a lack
of warming qi in the extremities with cold hands and feet as a consequence.
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A very common cause of cold hands and feet is when there is Liver qi stagnation.
The body itself will feel warm enough, but because qi is stagnated, the warmth
remains trapped in the torso and is not distributed to the extremities. Because their
hands and feet are cold, these people will often report that they have an aversion
to cold when asked about their perception of temperature, leading to an incorrect
diagnosis of Cold. Often it is not only the hands and feet that are cold, but all the
extremities such as the tip of the nose and the buttocks.
Phlegm can block qi and in some situations manifest with cold extremities.
Palpation of the hands and feet

Weak and limp handshake Qi xu
Sweaty palms Heart qi xu, invasion of xie qi, Heat
Sweaty feet Damp-Heat
The entire hand is hot Shi Heat
Only the palm is hot Xu Heat
Cold hands and feet Yang xu, xue xu, Liver qi stagnation or Phlegm
Palpation of acupuncture points,

channels and micro-systems
Palpation of acupuncture points
Palpating acupuncture points is an important, but unfortunately sometimes
overlooked, area of diagnosis. Specific groups of points, for example mu-collecting
and back-shu points, can be palpated to diagnose imbalances in their associated
zangfu organs. Palpation of channel and a-shi points is especially relevant in
relation to channel diagnosis. Palpation of acupuncture points is also useful when
determining which points to use therapeutically and to judge the depth of insertion.
When palpating points, it is best to run your finger lightly over the skin where
the point is to sense the point and its location. Next, press gently downwards
into the point, paying attention to the sensations in the fingertip and at the same
time registering any responses in the patient’s reactions.
Tightness, stiffness, weakness, flaccidity, sponginess, granulations, lumps, skin
changes, heat or cold can all be experienced when palpating in and around an
acupuncture point. The area at the point can be raised or sunken. It is also possible to
observe ruptured capillaries and spider naevi in the area. The patient can experience
pain, discomfort, soreness, tingling or relief whilst the point is palpated.
Palpation of channel points and a-shi points

Channel points can be palpated both as part of the diagnostic process itself and
of the point selection process. Palpation of the point can also give an indication
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of how deeply qi is located in the point and thereby determine the depth of the
needle insertion.
Points that are sore, tight and tender can indicate that there is a stagnation
of qi in the channel in this area. Tenderness and soreness arise because of the
accumulation of qi. Pressure on the point will increase the amount of qi in the area,
causing the point to feel painful on palpation. Furthermore, sensations of cold, heat
and sponginess in and around the point can respectively indicate the presence of
Cold, Heat or Dampness. The points will often lie on the channel itself, but they can
also lie outside of the channels. These points are called a-shi points.
Tingling sensations are felt when stagnated qi is activated by the pressure from
the finger.
If the patient experiences a pleasant sensation or relief upon point palpation or if
the area in and around the point feels flaccid and soft, this indicates a xu condition.
This is because there is too little qi present in the point, resulting in a lack of tension
in the area. Pressing the point will increase the amount of qi in the point so it will
feel pleasurable.
Palpation of acupuncture points can be a significant aid to determining which
points to utilise in a treatment. It is not uncommon, when formulating a treatment
protocol, to have a choice of several acupuncture points that have similar actions.
By palpating the various acupuncture points, you get a sense of which points are the
most reactive or dynamic and can then select these points.
By pressing slowly and gently into a point, one can sense how deep you have to
press before there will be a response from the patient or a feeling of qi in the finger.
The depth in which one experiences the response is the depth that qi is located, and
this is the correct depth for needle insertion (whilst of course paying regard to the
underlying anatomy).
Palpation of acupuncture points

Sore, painful and tight Shi conditions
Soft and flaccid Xu conditions
The sensation in the point feels worse with pressure Shi conditions
The sensation in the point feels better with the pressure Xu conditions
Heat Heat
Cold Cold
Sponginess Dampness
Two categories of points that are very important, both therapeutically and
diagnostically, are mu-collecting and back-shu points. They are important because
the points in both of these categories are directly in contact with their associated
organs. This means that these points may well be reactive when there are imbalances
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in these organs. The diagnostic significance of sensations felt in these points is the
same as those described above.
Palpation of the channels

Palpation of the channels is indispensable in the diagnosis of bi syndromes and channel
disorders. The information from channel palpation can also provide significant and
relevant information in the diagnosis of internal imbalances, such as zangfu imbalances.
This is because the organs and channels are directly connected to each other and the
channels are, in reality, a manifestation of the organ itself. Unfortunately, channel
diagnosis has been less emphasised in TCM acupuncture training in China and here
in the West. I will give a very brief overview of channel diagnosis below. For a deeper
elaboration of the techniques and diagnostic interpretations of channel diagnosis, the
reader is referred to Professor Wang Ju-Yi and Jason D. Robertson’s excellent book
Applied Channel Theory in Chinese Medicine (Wang and Robertson 2008).
All 12 channels should be palpated from the tips of the fingers and toes to the
elbows and knees respectively. The side of the thumb is slid along the path of
the channel three or four times, first superficially and then deeper each time. The aim
is to find changes not in the texture of specific acupuncture points but in the tissue
in and around the channels themselves. This is because imbalances in the internal
organs and in the channel as a whole can manifest with changes along the path of
the channel. Changes in the tissue can be the presence of nodules, graininess in the
tissue, sponginess, tightness and hardness, and softness and weakness. There can also
be changes in the temperature of the skin along the channel.
The size, depth and hardness of any changes along the path of the channel are
also important diagnostic factors.
Tightness, hardness and tension are usually indicative of a shi condition in the
channel or its associated organ. The more superficial the hardness, the more acute
the condition is likely to be.
Softness and weakness in the tissue along the path of the channel is a sign of a
xu condition in the channel or its associated organ. If there is a xu condition, the
palpation will feel more pleasant for the patient than if there is a shi condition.
Deep hardness and tightness will often be seen when there are interior and
chronic imbalances.
Cold and xue stagnation can manifest with nodules that are hard and immobile
with clearly defined edges, whereas Phlegm and Dampness nodules will tend to be
smoother and slippery with less clearly defined edges. Phlegm and Damp nodules
will be easily moved when palpated.
Longer, stick-like nodules can also be felt along the path of the channel. If the
stick-like nodules are very bumpy and lie along the channel, this is a sign that it is
a chronic condition that can be difficult to treat. Stick-like nodules that can be felt
across the path of the channel are more typically acute or are due to stagnations of
qi and are thereby easier to treat.
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If the patient reports sensations of numbness whilst an area is being palpated,

this can be due to Phlegm blocking the channel.
Palpation of the channels

Tenderness, tightness and tension along the Shi condition in the channel or its associated
channel organ
Softness and weakness along the channel Xu condition in the channel or its associated
organ
The sensation in the channel feels worse with Shi condition in the channel or its associated
pressure organ
The sensation in the channel feels better with Xu condition in the channel or its associated
pressure organ
The channel feels warm Heat in the channel or its associated organ
The channel feels cold Cold in the channel or its associated organ
Superficial hardness or nodules just below the Acute conditions
surface of the skin
Deep hardness, graininess or nodules Chronic conditions
Hard, clearly defined nodules Cold or xue stagnation
Hard, defined nodules that are slippery and Phlegm, Dampness
smooth
Hard, bumpy, longitudinal ‘stick-like’ lines Chronic condition
Hard, transverse ‘stick-like’ lines Acute condition, stagnation of qi
Numbness Phlegm
Palpation of micro-systems, including ear acupuncture

There is a vast number of different so-called micro-systems around the body, the
most famous being ear acupuncture. It is beyond the scope of this book to give
a detailed description of these various zones in the body. The reader is therefore
referred to relevant literature, for example Terry Oleson’s Auriculotherapy Manual
(Oleson 2014). Common to most of these systems is that the points and the areas
that relate to different areas of the body and the organs are reactive when there is an
imbalance or a change in these areas of the body. This means that palpation of these
points or zones can help to identify where in the body an imbalance is and what its
character is.
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Section 4

INTERVIEWING
Introduction
This diagnostic pillar ostensibly appears to be more accessible than the other three
diagnostic approaches. This is because interviewing the client is not dependent on the
subjective perception and interpretation of the signals that are being received through
the fingertips, nose and ears. You do not, for example, have to judge how much a
certain hue in the complexion is an aberration from what you ought to be seeing
right now in the complexion. In general, we are better at intellectually interpreting
verbal responses than we are at intellectually interpreting visual, olfactory, auditory
or palpable signals. Nevertheless, this pillar contains the most pitfalls. This is because
the same verbal response can have multiple diagnostic interpretations. The person’s
responses can also be misleading, since the client may not understand the question
in the same way as you do. They may not remember correctly what you are asking
them about or they may not even be consciously aware of what you have asked them
about. They may, for example, believe that they do not sweat at night, but if you
asked their wife, she would say that they do indeed sweat at night. They may also
be imprecise in their answers. For example, a woman may not place any significance
in her menstrual cycle being 26 days long or 30 days long. This for her is a regular
cycle, because her menstruation arrives once a month. Even though her cycle can
vary in length by up to four days, it is still regular in her eyes, because it comes once
a month. Even if you ask her to elaborate with a supplementary question about the
number of days in the cycle, she might reply that it is 28 days long, because for her
there is no significant difference between a 26-, 28- or 30-day cycle, but for us as a
diagnostician, there is. Even if you get precise and detailed answers, they will still not
be definitive in relation to the diagnosis. They will just be pieces of a jigsaw puzzle,
because in Chinese medicine everything must always be seen in a context. Night
sweats can, for example, be a manifestation of yin xu and Damp-Heat. You will need
to compare each answer you get with all the other symptoms and signs, as well as
comparing the individual answers with the answers to all the other questions. This
is a major difference between Chinese medicine and Western medicine. In Western
medicine, A is often equal to B. In Chinese medicine, A will only be equal to B if D,
G and R are present, whereas A will be equal to C, if D, F, J and W are present. It is
therefore important that the questions you ask are very precise and comprehensive.
For example, when you ask someone how their stools are and they say that they are
regular, you need to find out what they really mean by this? Daily? Three times a
day? Once a week? Furthermore, if they have constipation, it is important to know
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what the stools are like – whether they are dry, pebble-like or long and thin like a
pencil, whether there is pain and whether they are exhausted or relieved after they
have passed the stools. Each answer you get will usually result in having to ask a
further elaborative question, and each response to these questions must be seen
in the context of the other answers and in the context of all the other signs and
symptoms that you have observed.
Interviewing techniques
When we listen to the patient, we should not only listen to what they are saying,
but also to the sound of their voice and its tone, speed and strength. We should also
observe their body language, posture and eyes, the speed and strength of their body
movements and so on. These things are not an aspect of this diagnostic pillar, but
interviewing the client gives us ample opportunity to observe the person. It does,
though, require a degree of ‘multi-tasking’ to focus intellectually on the conversation
and the information that is being given, whilst trying to observe visually and listen
to the more subtle diagnostic signs emanating from the client.
As written above, interviewing the client is perhaps the most accessible of the
four diagnostic approaches, but it can also be the most difficult, because it is not
always easy to get the information you need from the client. This may be because
the client is not particularly aware of their bodily functions. They may consciously
or subconsciously not want to answer all the questions that we ask. The opposite
is often also the case: the patient tells you too much. These patients can start to
take control of the conversation or they relay to you too many details and a surfeit
of information that has no relevance to what you are asking them about. This is a
problem because you only have a limited amount of time set aside for each patient
and because it can be very exhausting as a therapist to spend so much energy staying
focused and trying to steer the conversation back to the topic. Patients with Heat
in the Heart are especially problematic in this way. Heat in the Heart means that
they are over-communicative. Their shen can have difficulty distinguishing between
what is relevant and irrelevant, and it cannot control how much they open up to
others. What they say may have relevance for the diagnosis, but often they begin
to talk about something other than what you asked them about. It is, of course, an
important diagnostic sign in itself that they are talking and telling you so much. It
is, perhaps, only this and a red tip on the tongue that tell you that they have some
form of Heat in the Heart. Once you have established this, it is important that you
gain control of the interview again. It is important to learn how to cut people off
in a polite and courteous manner. This can be difficult because they might feel that
what they are telling us is relevant to their situation or that they are paying you
to listen to them. It may also be that what they are telling us has a great deal of
relevance to their imbalances, but that we do not possess the relevant therapeutic
skills to help them as a counsellor. This could, for example, be a woman who says
that she has been subjected to incest or rape. This will be an extremely important
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The Diagnostic Pillar: Interviewing
aetiological factor, but after we have listened and sensed how it affects and has
affected her, it’s not our job as an acupuncturist or herbalist to provide her with
psychological counselling. We are not qualified to do this. We can offer empathy and
we can give her the space to talk about it, but we must also be conscious of where
our therapeutic tools and skills start and stop. In these situations, we must refer
the client to others who possess these skills. We can, importantly, help her on the
energetic level, and people who have undergone several years of counselling often
experience a therapeutic breakthrough as a result of acupuncture. This, though, is
through the actions of the needles and herbs and the space we create, not through
our abilities as amateur psychotherapists.
Respect, sensitivity and being non-judgemental are keywords when interviewing
clients. The patient must always feel that you have respect for them, that they can
trust you and that you do not judge them. The latter is something most clients are
excellent at doing themselves and they do not need any additional help! It is a great
leap for some people to contact an acupuncturist or herbalist, as this is something
that they may perceive of as being ‘alternative’ or even ‘mystic’. It is important that
they understand why we ask so many questions that can seem irrelevant and even
strange. They may well have thought that it was enough to say that they suffer from
migraines – that you would then stick some needles in the headache point and that
would be all. It is therefore a good idea to explain how in Chinese medicine we are
constantly looking for patterns and relationships, rather than isolated symptoms.
You should explain to them how ostensibly disparate symptoms and signs can
relate to a specific organ’s functioning. For example, that the soreness in their knees
and their tinnitus can relate to the Kidneys and that these signs therefore have
relevance in the treatment of their night sweats – something that they have been
told is hormonal. It is also important to inform the client of the difference between
the Western medicine and Chinese medicine concepts of the internal organs. For
example, when we say that there is an imbalance that relates to their Liver or Heart,
this does not mean that they have cirrhosis or that they are about to have a cardiac
arrest. We must explain to them that organs in Chinese medicine are more about
functional relationships than physical structures.
Tact and respect are needed when you are enquiring into areas that may be
sensitive or private. Some people may find it embarrassing to talk about certain aspects
of the body. For example, a 15-year-old girl may not be completely comfortable
talking to a 50-year-old man about her vaginal discharge. For others, it could be
certain emotional aspects that they are sensitive about. It is therefore important that
we win the client’s trust in us as therapists and help them to understand why our
questions are relevant.
It’s also a good idea to rephrase questions so the person can relate to them or
comprehend them. It is important to remember that the patient is not trained in
Chinese medicine. It is, for example, unlikely that they will know what ‘plumstone
qi’ is. This can, of course, easily be rephrased to asking them whether they have
a sensation that there is a lump in the throat, as if there is something that they
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cannot swallow. Other questions that are ostensibly straightforward should

sometimes be reformulated, such as asking them whether they have a sensation of
heat in the evening. The difference in temperature may be too subtle for them to
register it as a sensation of heat or fever, but if you ask them whether they remove
their jersey or are less sensitive to cold in the evening, they may answer yes.
There are various strategies that can be employed when interviewing the client.
It is definitely important to gather as much information as possible that is relevant to
the diagnosis. However, Bob Flaws believes that you should be systematic and only
ask questions that are relevant to the imbalance patterns that may be manifesting in
the specific disorder that the patient has sought help for. His view is that you should
only investigate the patterns of imbalance that are relevant in the treatment of this
disorder. His strategy is to look for confirmation or rejection of the patterns of
imbalance that manifest in this disorder. Once you have received enough information
to confirm or reject a pattern, you do not have to investigate further. He believes it
is a sign of sloppiness when you ask haphazard questions and lack focus.
The second strategy is to investigate all the available avenues. In this way, it is
possible to identify patterns of imbalance that may not initially seem relevant but
are subsequently found to be significant in relation to the disorder that the patient
presents with. The information obtained can also reveal symptoms and imbalances
that the patient has not sought treatment for but that may well be more important
to address in the treatment. They may, for example, have sought treatment for
allergic rhinitis, but through the diagnostic investigation you discover that they
suffer from insomnia, stress, palpations and cardiac pain. In these situations, you
must make the patient aware that Chinese medicine can treat these disorders or the
imbalance. They may well decide that they still only want treatment of their rhinitis,
but now they can make a conscious choice.
The two approaches are, of course, not mutually exclusive. In both scenarios it
is important to follow a thread when interviewing a person and not just ask them
random questions. You should thoroughly investigate a certain topic before moving
on to another area of questioning. My personal opinion is that the more information
that you can gather from a patient and the more detailed a picture you can paint, the
more accurate the diagnosis will be. In both strategies, it is important that you do
not just leap to the next question when a patient has given you an answer. You must
ask yourself whether their response generates a new question or whether the answer
needs elaboration or more specific details. For example, if when asking about their
bowel movements, they respond that they have loose stools, you need to find out:
what the consistency of the stools are; whether the stools are watery containing
undigested food particles; whether the stools are sticky; whether the stools have
a strong odour; whether there is a burning sensation in the anus during or after
defecation; whether there is pain or if they feel bloated in the abdomen before they
have bowel movements; whether the stools and their movements are influenced by
certain foods or stress and so on
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Interrogating the client is an integral part of the consultation and treatment. We

must, though, be conscious from the outset and during the interview of precisely
what information we are trying to gain. We must also be aware of how much time
we have available to achieve these goals. If we have set aside an hour to diagnose
and treat the client, we cannot sit talking to the client for three-quarters of an hour,
as apart from treating the client, we must also receive payment and book a new
appointment and they must dress and undress. This means that we, not the client,
must be the one who controls the structure and direction of the interview.
The 10 questions
There are some classic questions or areas of verbal investigation. Classically, between
8 and 10 questions or areas of interrogation have been described. The list below is
slightly longer, as I have expanded some of the areas of interrogation. Most of the
10 questions are also more categories of questions, rather than individual questions.
The areas that I investigate when interviewing a client are:
• general questions, including: age, occupation, family situation, medical
history and medication
• specific questions relating to the disorder or symptom that they are seeking
treatment for, including the history and specific details of the disorder
• questions relating to body temperature and their relationship to heat and cold
• energy levels
• sweating
• thirst, appetite, taste, nausea and vomiting
• defecation and urination
• questions relating to the Heart
• questions relating to the Lung
• dizziness
• questions relating to the skin and hair
• questions relating to the ears, eyes, vision and hearing
• sleep
• pain, including headaches
• questions that are specific to women, for example questions about
menstruation and childbirth
• questions that are specific to men
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• emotions
• lifestyle and diet.
This list is not comprehensive and there are other areas that can be investigated
verbally, but these are some of the most traditional focus areas.
The order of questions is not important. The questions will often be determined
by the responses and in relation to the disorder that the patient has sought treatment
for. What is important is to ensure that all relevant issues are investigated during the
consultation. A well-designed journal is of great help here.
General questions
Age/gender
Knowing the age and gender of a person already gives us an idea of what imbalances
are probable and thereby which signs and symptoms we should look for. This is
because there are specific physiological factors that affect the respective genders and
people of different ages. There are also certain lifestyle and emotional influences
that are more relevant to specific genders and age groups. These are, of course,
only probabilities and are definitely not certainties. This is because even though a
person’s age and gender will predispose them to certain imbalances, there are a great
many other factors that will also have had an influence that may have resulted in
completely different imbalances.
Women lose blood when they menstruate and when they give birth. This means
that they have a tendency to develop not just xue xu, but also Spleen qi xu, because
the Spleen will have to generate gu qi constantly to help replenish the xue that has
been lost. This constant demand on their Spleen will also lead to their mingmen
becoming weaker, especially when they are 35 and enter the fifth jing cycle, where
there is a natural decline in strength of the mingmen. This will manifest with an
increased tendency to Dampness and Phlegm. This is the reason many women’s
bodies become more pear-shaped at this age. When a woman is 49 years old, her yin
and xue will be so depleted that she will enter menopause. This means that patterns
of xue xu and yin xu Heat are more probable from this age onwards in women. As
stated, it is very important to be observant of other possible patterns. Women’s
tendency to xue xu means that women may also manifest with Liver qi stagnation.
This is because xue helps to moisten the Liver and make it flexible. Furthermore,
women’s position in society and the expectations placed on modern women, in terms
of having a career whilst being a good mother, looking after the home, trying to look
good and having an active social life, can all help to create a sense of frustration that
will stagnate her Liver qi.
Young men tend more towards shi Heat, especially in the Liver and Stomach,
because young men are more yang in general, but also due to their lifestyle, where
a higher intake of alcohol is more likely than in women and older men. As written,
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these examples are only broad generalisations and many people do not necessarily fit
into these descriptions.
Teenagers tend to develop shi Heat. The reason for this is that their mingmen
flares up during this period. This creates Heat in various organs. Heat in the Stomach
can manifest in their appetites – most people have experienced a 16-year‑old boy’s
insatiable appetite – and in their skin, where the Heat in the Stomach and Damp‑Heat
will mean that they are prone to acne. The increased heat from mingmen will also
affect their mood. This is because the Heat will agitate the Liver and Heart making
them more hot-tempered and moody. Their libido is also relatively high, due to the
increased Heat from the mingmen.
Babies and small infants tend to develop food stagnation. This is because their
Stomach and Spleen are not fully developed yet. The Stomach and Spleen are first
fully developed from about the age of seven. This means that babies find it difficult
to transform and process the food that they consume. One must therefore be careful
of what they are given to eat; how much they are fed at a time and how often they
are fed. This also, of course, applies to older children, but it is especially relevant for
infants. Many disorders that affect babies and toddlers will relate to their tendency
to develop what is known as accumulation disorder and the patterns of imbalance
that this can engender.
Because children’s yin is not strong, they tend to generate pathological Heat,
especially when they get ill. When they are affected by xie qi, they will quickly
develop a high fever, because their yin is not capable of controlling the Heat. This
is also seen in the evening when they are tired. When their yin cannot control yang
in the evening, they become overexcited and restless, and their cheeks become red
and flushed.
The older people get, the more they become both yin xu and yang xu. This is
because their Kidney jing becomes continuously weaker and the Kidneys are the
root of all yin and yang in the body. However, this is not the whole story. It is
because Kidney yin xu and yang xu will undermine other organs and these organs’
production of the vital substances, resulting in a tendency to qi xu and xue xu. At
the same time, there is also an increasing tendency to develop stagnations of qi, xue
and Phlegm the older one gets. This can be clearly seen in the body movements of
older people. There is not only a lack of strength, but also a lot of stiffness in their
movements. Their skin will often manifest signs of xue stagnation, with many spider
naevi, visible purple blood vessels and ‘liver spots’.
Some Chinese medicine doctors also believe that there is an increasing
accumulation of xie Heat retained inside the body as people get older. This is because
each time there has been a pathological invasion of xie qi, there will remain a residue
of the xie qi in the body. These residues of xie qi will accumulate, creating Heat and
stagnating the vital substances. This is one of the theories behind the development
of age-related cancer.
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Employment
Some jobs or occupations will predispose people to particular imbalances. People
who work in environments where there is a pronounced or constant climatic
influence can be invaded or weakened by these exogenous influences. This could,
for example, be a person who works on a trawler or in a cold storage unit. All day
long they will be exposed to dampness and cold. Steel mill workers are, on the
other hand, constantly exposed to heat, whilst laundry workers and kitchen staff are
often affected by dampness and heat. Clerical staff can also be affected by climate.
This could, for example, be due to dryness, resulting from a poor indoor climate in
concrete buildings, even though Dryness is not usually a form of exogenous xie qi
that is often seen in Western and Northern Europe. They could also sit in a draught.
Repetitive or excessive strain and poor posture can also be an aspect of some
people’s jobs and this can damage the muscles and channels and weaken certain
organs. Lifting heavy objects weakens Kidney yang. Standing for long periods of
time also weakens the Kidneys, whereas sitting excessively can weaken Spleen qi, as
well as stagnating Liver qi and qi in the Intestines. Lung qi is weakened by sitting
with the shoulders slumped forwards.
One must also listen to the person’s voice and observe their eyes whilst they talk
about their employment. Do they sound happy or frustrated and sad? How do they
talk about their work? Does it sound as if there are conflicts and friction? Does it
sound as if their work gives them inspiration and joy? Their work can be a part of
their aetiology, but it can also be something that contributes positively to their lives.
Habitation
The standard of housing used to be a major aetiological factor here in Northern Europe,
and it still is in many other parts of the world. This is because the home is a place we
spend a lot of time. To live in an abode that is cold, damp or draughty would have been
a major aetiological factor in the past. The standard of living has generally increased
over the last 50 years, but the person’s housing can still be a relevant factor. Some
people still live in damp and cold buildings, while others who live in modern concrete
constructions can have the opposite problem, i.e. that the indoor air is too dry. Others
are affected by there being fungus, for example dry rot, in the building where they live
or work. This fungus will often give the person the same symptoms and signs that are
seen in Dampness. It is important to find out whether a person’s symptoms improve
when they are not at home or at work in this building.
Family situation
Enquiring about the person’s family situation – whether they are married or have a
partner, whether they have children and whether they have a social network around
them – can tell us several things. It will give us an idea of how much support they
have, but also the way that they talk about these things can give an indication of
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whether there is Heart qi xu or Liver qi stagnation. If they sound lonely and sad, this
can indicate that there is Heart qi xu, because social contact, love and joy all help
to nourish Heart qi. Being stuck in situations where there is frustration, irritation
and dissatisfaction will create Liver qi stagnation. It requires respect and tact to ask
about these issues, and, as described earlier, we must be conscious of our limitations
as a therapist.
Medical history
This refers not to the current symptoms that the person has sought treatment for,
but the diseases and disorders they have previously suffered from, the surgery they
have had and the medication they have taken throughout their life. The diseases,
surgeries and disorders that they have had will inform you about possible historical
and current imbalance patterns. These patterns can also be instrumental in the
development of their current patterns of imbalance. A severe febrile illness can
have damaged their yin or created Phlegm. An operation will usually result in xue
stagnation in the form of scar tissue. Medication, especially prolonged or repeated use
of the medicine, is often a relevant aetiological factor. Antibiotics, for example, may
have weakened their Spleen yang and created Dampness, whilst painkillers may have
created Stomach Fire and damaged their yin. For more details about the energetic
effects of Western medications, the reader is referred to Dr Stephen Gascoigne’s The
Clinical Medicine Guide (Gascoigne 2001).
It can also be relevant to ask about hereditary diseases. Some diseases and
disorders are inherent in some families. Imbalances and diseases can be passed on in
several ways. A person’s constitution is dependent on the jing that they have inherited
from their parents. This means that weaknesses can be passed on to the children in
the same way that diseases are genetically inherited in Western medicine. A foetus is
created and nourished for nine months by its mother’s qi, xue and jing. It is physically
and energetically a part of her body. This means that as the foster develops it may be
significantly and fundamentally influenced by her patterns of imbalance. Another
factor is that by growing up in the same climatic and psychological environment, as
well as eating the same diet for years, a person will often develop some of the same
imbalances as their parents and siblings. Finally, a small child resonates energetically
with its mother and is not yet completely separated from her qi. This means that her
patterns of imbalance can affect the child’s qi and thereby produce the same patterns
of imbalance.
Current medication
Enquiry should be made about a patient’s current medication use, including which
medicine they are taking, what they are taking it for, how long they have been taking
it and in what dosages. This should include not only prescription medicine, but
also over-the-counter medicines and herbal remedies. It is important to ask about
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everything a person takes. Amazingly, there are many patients who do not think
of their sleeping pill as being medicine, even though it is prescribed by a doctor,
nor the painkillers that they take because you can buy them from the supermarket.
Nevertheless, these medicines will have a greater or lesser effect on their physiology.
They can blur the relevant signs, such as insomnia for example, but they may well
also be part of the aetiology of the patient’s current imbalances. Herbal medicine and
dietary supplements also have a physiological effect on the body, so it is important
to ask about the patient’s use of these. It is a good idea to familiarise yourself with
the Chinese medicine dynamics of the most common medications, both those used
in Western medicine and commonly used supplements. It is beyond the scope of
this book’s competence to go into detail about the energetic effects of the many
and varied medications that people take. Reference is therefore made to relevant
literature, such as Stephen Gascoigne’s The Prescribed Drug Guide (Gascoigne 2003).
Disease history
We must ascertain how and when a disorder arose to get an idea about its aetiology,
which will help us to reveal which patterns of imbalance can have initiated the
disorder and which imbalances can have arisen as a consequence of it.
We must ask the patient how long they’ve had the symptoms and whether the
symptoms appeared suddenly or slowly over a period of time.
A disease or symptom that develops slowly and gradually usually occurs due to
a xu condition. An exception to this is xue xu. Xue xu can arise when there is heavy
bleeding, such as there is in childbirth for example. A shi condition, on the other
hand, will often result in symptoms that appear suddenly or over a shorter period of
time. This therefore means that acute conditions are usually shi in nature.
Chronic disorders will almost always be pure xu conditions or, more commonly,
combined xu and shi conditions. A condition that starts as a xu condition can easily
develop a shi aspect. For example, Liver yin xu can also begin to manifest with
ascending Liver yang, whilst Spleen qi xu will often result in Dampness, to name just
two very common examples. Conversely, a shi condition can easily develop into a xu
and xu/shi condition. Extreme Heat, such as in a febrile illness, can injure yin; xue
stagnation can result in heavy menstrual bleeding, which then leads to xue xu, etc.
Enquiring about how the symptoms themselves have developed and how they
have changed will also give you an idea of the nature of the disorder. Symptoms that
rapidly change are usually more yang shi in nature, whereas yin xu symptoms tend
to develop more slowly.
Enquiry should also be made into the circumstances surrounding the onset of
symptoms. How was their life at that time, and were there any changes in their
life in this period? Had they started taking a new medication? Did they have a
febrile illness? Were there any significant climatic influences? Was there crisis in their
relationship or a change of employment or had they made dietary or other changes
in this period? The answers to these questions will give an idea of the aetiology of
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the disorder. If we know what the aetiology is, we will then have a good idea of the
imbalances that may be present.
The patient’s medical history is also relevant. What disorders have they suffered
from over the years? Knowing this will give an indication of whether there is a
particular pattern and whether the current situation could be a part of this pattern.
A severe febrile illness could have weakened their yin or qi or it could have generated
Phlegm. A gastrointestinal ailment that they picked up in India 10 years ago could
help to explain the presence of Damp-Heat in the lower jiao and Spleen qi xu.
It is vital that the patient is asked about what makes their symptoms better
or worse and when the symptoms occur. This requires the memorising of which
aetiological factors can create which patterns of imbalance. The following examples
are presented to give an idea of this way of thinking and are far from comprehensive.
To learn more about which aetiological factors lead to the creation of the various
patterns of imbalance, please see the sections on diagnosing patterns of imbalance in
the second part of this book.
• A condition that is adversely affected by dietary factors is usually a Stomach/
Spleen imbalance, but it could also indicate the presence of Phlegm,
Damp‑Heat, Heat, Cold, yang xu or yin xu.
• If the disorder is affected by climatic influences, then one or more of the six
forms of exogenous xie qi will be involved. It can, though, also indicate a Lung
disorder, wei qi xu or the presence of internally generated Damp-Phlegm.
• If the symptoms are provoked by activity, then it is probably often a xu
condition, whilst a shi condition usually improves with activity. This,
though, is just a rough rule of thumb. A xu condition can, for example,
result in a stagnation, in which case the patient may well feel amelioration
immediately after activity, but the symptoms or their general condition will
usually feel worse later on in the day or the day after. The reason for this is
that the physical activity will help to circulate qi, but will at the same time
consume their qi and xue, so the condition will deteriorate in the long term.
Conversely, xue stagnation can manifest with a strong, sharp pain when a
joint is activated or extended beyond a limited range of movement, but will
be less painful when the joint is at rest.
• Stress can create stagnation of Liver qi, generate Heat in the body and
injure yin. This means that symptoms that are exacerbated by stress can be
manifestations of these patterns.
• Emotional influences that provoke or exacerbate a disorder will indicate an
imbalance in the organ that relates to these emotions.
• Certain symptoms arise at specific times during the day. Symptoms that
come later in the day or in the evening can be a sign of a xu condition. If
they come in the evening or at night, it will often be yin xu. Symptoms that
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are related to certain hours of the day can also be interpreted through the
Chinese horary clock and whether an organ or channel is at its peak or ebb
during this period. Xue stagnation symptoms are often worse or manifest at
night, when xue is not being circulated by physical movement and activity.
This is typically seen in joint pain and traumatic injuries.
• Symptoms that are worse in the premenstrual period are often related to
Liver qi stagnation and symptoms that are worse immediately after the
menstrual bleeding are more typically seen when there is yin xu or xue xu.
It is also important to determine whether there are other symptoms that arose
concurrently with the symptoms or the disorder, as the more symptoms that relate to
a certain organ, the more likely it is that this organ is directly or indirectly involved
in the present imbalance.
Disease history
Symptoms Significance
Symptoms that have arisen gradually Usually a xu or a xu/shi condition
Symptoms that have arisen suddenly Generally a shi condition, but can also be
a xu condition
The symptoms that have changed rapidly Usually a yang or shi condition
The symptoms have changed slowly and gradually Usually a yin xu or a xu/shi condition
Temperature
This area of enquiry is used to determine how deep xie qi has penetrated into the
body and whether the imbalance is Hot or Cold in nature, as well as to identify
yin and yang imbalances. It is important to point out that in Chinese medicine the
presence of Heat in the body is determined by the patient’s subjective perception
of their body temperature or by the practitioner’s physical palpation of their skin
and their observation of skin colour changes. This means that even if a thermometer
reading says that they do not have an increased body temperature, if they themselves
feel that they are warm or have a fever, or if the practitioner can feel that their
skin is hot or see that the face it is red, then there is Heat, even though it cannot
be measured physically by the thermometer. On the other hand, if they do have a
measurable rise in body temperature, this is always a sign of Heat.
If a person feels cold or has an aversion to cold, it is important to ask them if
they can get warm again by putting on more clothes or wrapping themselves in a
blanket. If the increase in clothing or bedding makes them feel warmer, this is yang
xu Cold. If they are yang xu, they will have difficulty maintaining the warmth of the
body, but by packing the body into warm clothing they reduce the heat loss and
no longer feel cold. If they have an invasion of exogenous xie qi, which blocks the
circulation of wei qi, they will not be able to get warm again, even though they put
more clothes on or lie beneath a duvet or blankets. This is because wei qi, as well as
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protecting the body and controlling the sweat pores, warms the muscles just below
the skin. When xie qi invades the exterior, the warming wei qi is blocked and cannot
circulate. This means that it does not help to increase the amount of clothing or
bedding that is insulating the body. The xie qi must first be expelled so wei qi can
circulate before the person will feel warm again.
When xie qi is in the exterior, as well as feeling cold and chilly, the person will
often have a slight fever or feel feverish. This is because the exogenous xie qi will not
only prevent the circulation of the warming wei qi, it will also give rise to a conflict
with, and a stagnation of, wei qi, resulting in the generation of Heat. The difference
between Wind-Cold and Wind-Heat is that in Wind-Cold there is a greater aversion
to cold and little or no fever sensations, whereas in Wind-Heat the fever sensation is
more predominant and the aversion to cold less noticeable.
When exogenous xie qi has penetrated the yangming aspect, it will generate a great
amount of Heat. This is because there is a violent struggle between the body’s zheng
qi and the invading xie qi. One of the most important diagnostic differentiations
between xie qi that is in the exterior and xie qi that has penetrated to the interior
is the strength of the Heat and whether there is an aversion to cold. When xie qi is in
the interior, it no longer blocks the circulation of wei qi. This means that the person
no longer experiences chills and muscle soreness. The fever, on the other hand, will
be much more virulent.
If the person experiences alternating fever and chills or an alternating sensation
of heat and an aversion to cold, this will indicate that xie qi is located in the shaoyang
aspect. Xie qi can become lodged in this hinge between the interior and the exterior.
This results in symptoms that alternate between these two stages.
Internal Heat conditions can give rise to an aversion to heat, but it is not
certain that the person is aware of it. Often, if you ask them how they feel they will
say that they do not have an aversion to heat or feel hot, but you can often observe
that they are more lightly clad than others.
A major difference between xu and shi Heat is that when there is shi Heat, there
is a sensation of heat throughout the day. When there is yin xu Heat, the person will
only feel warm in the evening and at night. Again, it is not certain that the person
is aware of this. They do not think about whether their duvet is thinner than other
people’s or that they feel warm at night. Furthermore, a person with yin xu might
not answer yes to feeling hot in the evening, because they are sensitive to cold during
the day because they are also yang xu. In the evening and at night they just feel less
cold and perhaps remove the jersey that they have worn all day.
Another difference between xu and shi Heat is that when there is shi Heat,
the whole body feels warm. When there is yin xu heat, the person can experience
what the Chinese call ‘five palm Heat’. In ‘five palm Heat’, it is only the palms of
the hand, the soles of the feet and the centre of the chest that feel hot. My own
experience is that many European patients rarely report a sensation of heat in the
chest in these situations. There are also many yin xu patients who only feel the heat
in the palms of the hand. It is important when differentiating between xu and shi
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Heat to ascertain whether it is the palm of the hand (yin xu Heat) or both sides of
the hand (shi Heat) that feel hot.
A person who is qi xu can have difficulty controlling their temperature. Therefore,
they may well experience an increase in temperature on exertion.
Cold hands and feet can be a sign of many different patterns of imbalance.
One of the most common causes is Liver qi stagnation. When there is Liver qi
stagnation there is sufficient heat in the body but the warmth cannot circulate out
to the extremities. The difference between Liver qi stagnation and yang xu is that
when there is Liver qi stagnation it is only the hands and feet (and sometimes only
the hands) that are cold. When there is yang xu, it is the entire arm and leg that
feel cold. The arm or leg will also feel increasingly cold, the further you get from
the torso. Xue xu and qi xu can also manifest with cold hands and feet, because the
warmth does not get transported from the torso.
When a person has cold hands and feet, they might say that they feel cold or have
an aversion to cold. This can create confusion when there is, in reality, a diagnosis
of Heat. One would expect that a person who has Heat would feel hot, have an
aversion to heat or at least not say that they are cold or dislike cold. If they have
Liver qi stagnation, which may well be the underlying cause of their Heat, their cold
hands and feet mean that they have an aversion to cold and feel cold, whilst in reality
the body itself is warm.
Temperature
Aversion to cold Shi Cold or yang xu
If there is an invasion of exogenous Cold, the person will freeze,
no matter how much clothing and blankets they wrap themselves
up in
In yang xu Cold, the person can keep warm by wrapping
themselves up in warm clothes or bedding
Aversion to heat Heat
Simultaneous chills and Invasion of Wind-Heat or Wind-Cold
fever If there is Wind-Heat, the fever will be dominant; if there is Wind-
Cold, the chills will be dominant
Prolonged or intense fever Internal shi Heat
Fever that arises in the Yin xu Heat
afternoon or evening
A feeling of heat that arises Qi xu
on slight physical exertion
Alternating fever and chills Xie qi located in the shaoyang aspect
‘Five palm Heat’ (hot Yin xu Heat
sensation in the palms, soles
of the feet and chest)
Cold hands and feet Liver qi stagnation, yang xu, qi xu, xue xu
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Energy levels
It is important to remember that fatigue can be not only a xu condition, but also a shi
condition. There are, however, fundamental differences in the underlying dynamics
of the two types of fatigue. There are also significant differences in when and how
the fatigue manifests.
In a xu state of fatigue, there is a genuine deficiency of energy in the body, which
makes the person feel tired. The fatigue will last all day, become more apparent as the
day goes on and will usually be worst in the late afternoon and evening. The fatigue
will also be worse after physical and mental activity or exertion, because the physical
and mental activity will consume the person’s qi and make their deficiency greater.
It is, however, important to be aware that the person might feel refreshed and more
energetic immediately after physical activity. This is because the physical activity
has created movement, thereby circulating and activating their qi. The fatigue will,
though, resurface and be greater later on that day or the day after, as they have drawn
on their reserves.
When there is fatigue, it is also important to determine whether the fatigue is
due to an actual xu condition or whether the person has unrealistic expectations
with regards to how much energy a person should have. It is not uncommon for
a person to complain that they feel tired or exhausted, but when questioned you
discover that they are constantly physically and mentally active from early morning
to late evening, and they sleep too little. These patients are qi xu, but their qi xu is
the consequence of unrealistic expectations of how much qi the body is capable of
producing, rather than an imbalance in one or more of the qi-producing organs.
When there is a shi condition manifesting with tiredness, it is not because there is
insufficient qi. The tiredness arises because there is something that is blocking the qi,
so it cannot circulate around the body, resulting in the person experiencing fatigue.
In these cases, the fatigue will be worst in the morning. This is because the person
has been physically inactive all night and their qi has therefore not been circulated by
the body’s natural movement. This means that they feel tired and find it difficult to
get going in the morning. Once they have been up and about for a while, the body’s
natural movements help to circulate qi and the tiredness is reduced. Fatigue due to
shi conditions will also be relieved by physical activity such as running, biking, yoga,
chopping wood and so on. They will, on the other hand, feel more lethargic and
fatigued if there is a lack of physical movement.
There are differences not only in the overall underlying mechanisms of xu and
shi tiredness, but also in the mechanisms within the two groups themselves. These
differences mean that there are some characteristic signs that can be asked about
when differentiating the various imbalances.
Qi xu fatigue
Qi xu fatigue arises when not enough qi is produced to carry out the various processes
in the body.
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The person may well feel tired already when they wake up in the morning, either
because there is not enough qi or because their qi xu means that qi and xue have a
tendency to stagnate due to a lack of propulsion. This condition is then exacerbated
when the person has been inactive all night and the circulation of qi has not been
assisted by the body’s physical movement. The vital difference here between them
and a person who has a pure stagnation condition, is that the fatigue worsens as the
day goes on and is aggravated by activity and exertion.
A person with Spleen qi xu will often feel tired after meals, especially after eating
a lot or eating rich food. This is because large or rich meals place a greater burden
on the Spleen qi when the Spleen transforms the ingested food into gu qi. The
weakening of Spleen qi will also often give rise to the emergence of Dampness,
which blocks the pure yang qi from ascending upwards, whilst blocking the shen so
the person becomes drowsy and lethargic.
Yang xu fatigue
One of the tasks that yang performs is to activate the body. When there is yang xu,
a person will experience both physical and mental lethargy and fatigue. They will
lack a fundamental sense of enthusiasm and motivation. The difference between qi
xu fatigue and yang xu fatigue will be apparent in the other signs and symptoms.
Yang xu conditions will simultaneously manifest with signs such as an aversion to
cold, cold limbs and so on. Yang xu fatigue is sometimes more apparent in winter,
the most yin period of the year. The person may also suffer from winter depressions.
A man with Kidney yang xu will feel more fatigued after he has had sex or
ejaculated, because he loses both Kidney jing and Kidney yang on ejaculation. This
is also the reason that many men fall asleep immediately after sex.
Xue xu fatigue
To be completely correct, neither xue xu nor yin xu directly result in tiredness. This
is because they are more physical substances that nourish but do not activate the
body. Nevertheless, most books state that tiredness is a symptom of both xue xu and
yin xu. Fatigue arises in these conditions because xue and yin nourish the organs that
produce qi and because yin is the fundamental substance that is transformed into
yang. Furthermore, the brain is nourished by xue. This means that whilst too much
mental activity depletes xue, a lack of xue will also result in a person feeling mentally
tired and exhausted.
Both xue xu and yin xu fatigue can be exacerbated when the person has difficulty
falling asleep or sleeps poorly at night, which is a typical consequence of yin xu and
xue xu.
The difference between xue xu fatigue and qi xu fatigue will be seen in the
accompanying symptoms and signs, such as dry skin, poor vision, scanty menstrual
bleeding and so on when there is xue xu.
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Yin xu fatigue
A person with yin xu fatigue will not always be conscious of their tiredness. This is
because they are often restless. Their fatigue can be exacerbated when they do not
go to bed at the proper time and when they sleep poorly. They will often feel tired
during the day, but in the evening when yin should control yang, their yang starts
to ascend because it is not anchored, resulting in their shen becoming more active.
This means that they feel more awake and start to become more active. This is
unfortunate, because by being active in the evening and at night, they will further
consume their yin, worsening the condition. The inability to anchor their shen also
means that they have difficulty in sleeping. This just exacerbates their fatigue the
next day. People with yin xu can sometimes find that their fatigue feels worse or
arises after they have started to receive acupuncture. This is because acupuncture
controls the restless empty energy that they have and they then begin to become
aware of their underlying fatigue. This is not dissimilar to small children who are
overtired in the evening: the later it gets, the more restless and agitated they become.
They do not feel tired but are, in fact, exhausted.
Qi stagnation fatigue
A person with qi stagnation fatigue will often feel tired in the morning and when they
are physically inactive. They do not feel tired later in the day or when they have been
physically active. This is the reason that many people with Liver qi stagnation play
a lot of sport or exercise physically. Training excessively can, in fact, be a diagnostic
sign of Liver qi stagnation. It can be a form of self-medication. A person with Liver
qi stagnation will often experience fatigue when faced with the tasks or situations
that they have an aversion to. They will also feel tired during stressful periods.
A person with Liver qi stagnation will not just be tired in the morning, but often
will also be grumpy and bad tempered, because their Liver qi is stagnated. This is a
significant difference from a person with a Damp-Phlegm stagnation, who will be
mentally absent and hazy in the morning.
Heart qi stagnation can also cause tiredness but it will be more on the mental-
emotional level. They will lack joy and vitality and they will often feel depressed.
Dampness or Phlegm stagnation fatigue

People with Phlegm or Dampness will often feel tired and lethargic in the morning.
Dampness and Phlegm will accumulate around the body when it is not transformed
and transported. When the person lies horizontally at night, yin substances such as
Phlegm-Dampness will seep down to the head, blurring the brain. Furthermore, the
lack of physical movement in the body will also add to the stagnation of Dampness
and Phlegm at night. A person with Phlegm-Dampness will also have an increased
desire to sleep. They will have trouble waking up in the morning and feel heavy and
tired, both mentally and physically. They will have difficulty being mentally present
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at the start of the day, because their shen is blocked. A person with Phlegm must be
careful not to sleep too much during the day. Sleeping will not usually ameliorate
their fatigue and lethargy but will usually make it worse.
Humid weather and low pressure can cause a person with Phlegm-Dampness
to feel more tired. This is because the external dampness will aggravate the inner
condition of Dampness and thereby block the circulation of qi in the body.
Fatigue
Fatigue that is worse after activity or increases during the day Qi xu, yang xu, xue xu
Fatigue that is the worst in the daytime but gets better in the evening Yin xu
Fatigue that is worst in the morning and the person is irritable in the Liver qi stagnation
morning
Fatigue is worst in the morning and the person is mentally lethargic and Dampness or Phlegm
not present in the morning
Fatigue that is worse after exertion Xu conditions
Fatigue that is better with activity Stagnation conditions
Feeling tired and lethargic when not physically active Liver qi stagnation
Fatigue that is worse or occurs after sex Kidney xu conditions
Fatigue when there is low pressure or high atmospheric humidity Dampness and Phlegm
Fatigue arising when frustrated or faced with challenges Liver qi stagnation
Fatigue after meals, especially after eating rich food Spleen qi xu
Sweating
Enquiring about perspiration is especially important in relation to a diagnosis
according to the Six Stages and the Four Levels, but it also elicits important
information for the differentiation of xu patterns. Sweating imbalances can be
divided into three overall groups: Heart imbalances; xu conditions such as qi xu, yin
xu and yang xu; and invasions of xie qi.
Sweat is the body fluid associated with the Heart and the Fire Phase, but many
other organs’ physiological relationships must also be taken into account when
analysing abnormal patterns of sweating.
The pores in the skin are controlled by wei qi, which is the most yang aspect of
zhen qi. Wei qi is controlled by Lung qi and created by Spleen qi and Kidney qi.
This means that a xu condition in one or more of these organs, as well as an overall
yang xu condition, can result in the pores not being controlled optimally. When
there is physical activity in the body, heat is generated and this will drive the body
fluids upwards and outwards. If wei qi or yang qi are weak, the pores will not be able
to hold back the sweat and there will be spontaneous perspiration or sweating on
light activity.
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Sweat is created when heat evaporates jin. Jin is, amongst other things, a
component of xue and xue is governed by the Heart. This means that imbalances
in the Heart can lead to abnormal sweating. This can be seen in more chronic
imbalances, such as Heart yang xu or Heart xue xu, Heart Fire and so on. It is
also seen in more transient disturbances of shen, such as nervousness, which often
results in spontaneous sweating. Spontaneous sweating due to Heart imbalances
will often be observed in areas of the body that are controlled by the Heart channel,
particularly the beginning and end of the channel i.e. the palms of the hands and
the armpits.
Invasions of xie qi can interfere with sweating. Due to its yang nature, Wind
can spread and disperse wei qi, opening the sweat pores and thereby allowing itself
and other forms of xie qi such as Cold to enter through the skin. Cold will, due to
its astringent yin nature, contract the pores, closing them shut so that the person
cannot sweat (and thereby expel the xie qi). One of the main signs that there is an
invasion of xie qi in the taiyang aspect is that there is soreness and stiffness in the skin
and muscles. This is because wei qi has been blocked by exogenous Wind-Cold, the
stagnation resulting in pain and discomfort, but also, importantly, a lack of sweating
because the pores in the skin are contracted and closed shut. If the person is very
wei qi xu, on the other hand, they will sweat but the sweating will not relieve the
symptoms. This is because their wei qi is not strong enough to control the pores, so
the person sweats spontaneously. Because the wei qi is so weak, it cannot expel the
exogenous xie qi upwards and outwards.
If Wind-Heat has invaded the body, the yang nature of the Heat will force fluids
and thereby sweat upwards and outwards. The pressure of the sweat will force the
pores to open, resulting in sweating. Once again, because the exogenous xie qi has
not been expelled, the sweating does not relieve the symptoms. The difference here,
though, between an invasion of Cold when there is wei qi xu and an invasion of
Wind-Heat is that there will be signs of Heat in the latter scenario. The pulse is often
a good indicator when differentiating between the various types of invasion. An
invasion of Wind-Cold will usually manifest with a Tight pulse, whereas the pulse
will be Empty if there is wei qi xu. Invasions of Wind-Heat should be accompanied
by a Rapid pulse. In all three situations, the pulse will be Superficial, because the
imbalance is in the exterior aspect of the body.
If exogenous xie qi penetrates down to the qi or yangming aspect, the violent
struggle between zheng qi and xie qi will generate a significant amount of Heat.
The extreme Heat will force fluids up to the surface of the body, resulting in
profuse sweating. Because xie qi has now penetrated deeper into the body, the profuse
sweating does not relieve the symptoms. The difference between Wind-Heat and qi
level or yangming Heat is that the pulse and the sweating will be much stronger
when xie qi has penetrated to the interior.
If xie qi becomes locked in the shaoyang aspect, the person will alternate between
periods where they spontaneously sweat and have a fever or feel hot and periods
when they freeze and have chills. Importantly, there will be no sweating and fever
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sensations whilst they have chills, which is otherwise characteristic of invasions of

exogenous xie qi in the taiyang aspect.
Yang xu and qi xu are not the only xu conditions that can cause sweating
disturbances. A classic symptom of yin xu Heat is night sweats. This is because yin
should be able to anchor yang and thereby control Heat. If yin is weak, it will not
be able to control the Heat at night, which is the period in which yin should be
dominant. The Heat will force fluids upwards and outwards during the night. The
problem is compounded by the fact that wei qi, which controls the pores, does not
circulate in the exterior at night but is in the interior. The pores are therefore not able
to hold the sweat in the body. Night sweats due to yin xu can be a chronic condition
or they can be acute when exogenous xie qi has penetrated down to the ying level in
a diagnosis according to the Four Levels.
It is, however, important to note that night sweats are not always a manifestation
of yin xu Heat; Damp-Heat can also result in night sweats. Damp-Heat sweat tends
to be more yellowish. You can ask the patient whether the sweat stains their sheets or
nightclothes a yellowish colour. Damp-Heat night sweats are also more predominant
on the head than the torso and limbs, because Damp can block the pores of the skin
in the body so the Heat funnels the sweat up to the head. Yellowish and sticky sweat
is, in general, a sign of Damp-Heat, as is odorous sweat.
Sweat
Sweating during an invasion of exogenous xie qi, which Wind-Cold with concurrent wei qi xu
does not relieve the symptoms Wind-Heat
Lack of sweating during the invasion of exogenous xie qi Wind-Cold
Spontaneous sweating Yang xu or qi xu
Night sweats Yin xu, ying-level Heat, Damp-Heat
Constant or profuse sweating Yangming stage or qi level Heat
Shi Heat
Alternating sweating and chills (not simultaneously) Shaoyang stage
‘Five palms sweating’ (sweating from the palms of the Yin xu
hands, soles of the feet and the chest)
Yellowish or sticky sweat Damp-Heat
Odorous sweat Damp-Heat
Nervous sweating, especially in the palms of the hands Heart qi xu
and the armpits
Thirst, appetite and taste

Enquiring about a person’s eating habits, thirst, taste preferences and appetite can
tell us a lot about the condition of the internal organs and factors such as Heat,
Cold, yin and yang. It will also help to identify possible aetiological factors among
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the substances that the person ingests. For example, a person whose diet consists
primarily of salads, cheese and yoghurt will have a tendency to develop Spleen
yang xu and Dampness, whilst a person who regularly drinks alcohol can have a
tendency to develop Heat in the Liver and Stomach. The following sections will
address a person’s attraction to certain foods or drinks, their appetite, thirst and
so on as a manifestation of possible patterns of imbalance, rather than possible
aetiological factors.
Thirst
If there is Heat present in the body, it will both injure and expel body fluids. These
fluids must then be replenished. This means that a person with Heat will experience
thirst. One of the differences between shi and xu Heat is how powerful the thirst is.
Shi Heat, being more substantial, results in a thirst that is stronger. A person with shi
Heat will want to drink large amounts of cold fluids. They will also drink in large
gulps, rather than sipping small mouthfuls, which is more typical of a person who is
yin xu. When there is yin xu, the tissues in the body lack moisture. The person will
often have a dry mouth and throat, especially at night. They will therefore not need
to drink as often as a person with shi Heat. They do not have the same need either
for cold drinks to cool the body down, and they do not need to drink as much at a
time. A person with shi Heat will often have a large glass or a bottle of water nearby,
which they quickly empty. A person who is yin xu is more likely to have a glass of
water standing beside the bed, from which they only drink a couple of mouthfuls.
A person with Damp-Heat will be thirsty due to the presence of Heat, but the
Dampness will mean that they still do not feel like drinking or that they forget to
drink.
When there is shi Cold and yang xu Cold, the lack of transport and transformation
of fluids in the body will mean that a person will have less need to consume fluids.
They will, therefore, often have a lack of thirst. The presence of Cold or the lack of
yang will result in a preference for hot beverages to help to warm the body up.
Thirst
Great thirst with desire for cold drinks, drinks in large gulps Internal shi Heat patterns
Thirst or dryness of the mouth and throat, sips the water Yin xu Heat
Lack of thirst or preference for hot drinks Cold patterns, yang xu
Thirst with no desire to drink Damp-Heat
Appetite, nausea and vomiting

The appetite should theoretically be a good indicator of the state of a person’s Spleen
qi, poor appetite being a key sign of Spleen qi xu in Chinese textbooks. Many of the
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clients we see in the clinic who are Spleen qi xu often say, however, that they have a
healthy appetite. The reason for this is that people eat and drink for many reasons,
most of which are not directly related to their nutritional needs. Eating food is closely
connected to factors such as pleasure, comfort, bodily control, habits, boredom,
upbringing, culture, procrastination and so on. This means that the answers given in
relation to appetite and diet must also be seen in this context.
As stated, the Spleen and the Stomach have a determining influence on appetite.
If there is Spleen and Stomach qi xu, the person will have difficulty transforming
the food that is ingested and the qi ji (qi mechanism) in the middle jiao will start to
stall. It will manifest with a reduced appetite or being easily sated. Despite this fact,
it is more common that patients who are Spleen qi xu will say that they have a good
appetite, as will patients with Dampness blocking the qi ji in the middle jiao. This
is because people eat for many reasons other than hunger. If the patient consciously
observes the sensation in their stomach, they will often discover that the sensation
of hunger is located in the mouth or somewhere other than the physical stomach.
You can ask the patient how their appetite is in the mornings. Many people with
Spleen qi xu, especially those with Dampness or Phlegm, will have no appetite in the
mornings. They will often skip breakfast and only eat later in the morning, maybe
after they have arrived at their job. This is because the Stomach and Spleen’s qi ji is
inactive whilst they are sleeping. When they arise it will take a while for the Spleen
and Stomach qi to start circulating if they are Spleen and Stomach qi xu, especially
if Dampness blocks the movement of the qi.
Many people also express that they have a large appetite. This, again, is something
that you have to be cautious about when drawing conclusions. A patient saying they
have a large appetite is not always an indication of Stomach Fire. Many people,
especially women, say their appetite is large, because they think that they eat too
much but in reality their appetite is normal. The problem is that they think that they
should be thinner than they are. Some people think that they have a large appetite
because they are constantly nibbling at food and eating all day long. The question
is whether they are constantly eating because they are actually physically hungry,
as in Stomach Fire, or whether they eat because they are bored, mentally restless
or to drown their feelings. These are more Heart imbalance patterns than they
are Stomach Fire patterns. Stomach Fire will typically manifest with an insatiable
appetite and the person will quickly feel hungry again soon after eating. This is
typically seen in teenage boys, who immediately after having eaten a large meal
will go into the kitchen to get a bowl of cornflakes or a sandwich. This is because
their mingmen has flared up, creating Heat in the Stomach. Stomach Fire quickly
burns up the food that has been consumed. The yang Heat also creates a need for
something solid and yin to create a balance in the Stomach, especially something
that is Cold in its dynamic.
Heart imbalances can also affect the appetite. Heart qi xu and Heart qi stagnation
can lead to a person either comfort eating or losing their appetite entirely, such as
when people are heartbroken or depressed.
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Heat Patterns can manifest with an attraction to cold foods. This will be both
food that is cold in temperature and food that is energetically cold. This is because
the body needs to cool down when there is Heat. Consuming foods that are
energetically hot will often have a negative effect on their symptoms. Conversely,
people with Cold patterns will either prefer to eat warm meals or they will feel that
it is unpleasant to eat food that is energetically cold or has a cold temperature.
Individuals with internal Heat and a stagnation of qi or xue will often be attracted
to spicy food, which is often energetically hot. This is despite the fact that they
should, theoretically, prefer cold food. This is because the hot and spicy food will
help to alleviate and disperse the stagnation. Although the hot, spicy substances
will ameliorate their symptoms in the short term, they will often have a negative
effect in the long run, creating further Heat.
Food stagnation can manifest with an aversion to eating. This is because there is
a physical accumulation in the digestive system that blocks the qi ji. Food stagnation
can also generate Heat in the Stomach. This can mean that the person soon feels
hungry again, even though the Stomach is still full.
Food stagnation can also cause the Stomach qi to become rebellious and manifest
with acid reflux or burping, which can also be seen when there is Stomach Fire.
This is because Heat has an ascendant energy, thereby sending Stomach qi upwards.
Stomach Fire can also manifest with a stinging or burning sensation in the Stomach.
Nausea
Nausea can encompass anything from a lack of appetite to a feeling of wanting to
vomit. Nausea is again a sign that the qi ji in the middle jiao is impaired. The reasons
can be varied, and differentiation of the relevant patterns will often be based on
when the nausea is worst. Nausea immediately after eating is mainly a manifestation
of Spleen qi xu and food stagnation. The nausea arises due to the Spleen not being
able to transform the food that has been consumed, which then accumulates in the
Stomach and blocks the Stomach’s qi ji.
If the nausea manifests in the premenstrual phase or arises when the person is
stressed or emotionally affected, the nausea will be due to Liver qi stagnation, where
the stagnated Liver qi invades the Stomach and Spleen, disturbing the movement
of their qi.
Nausea is also seen in pregnancy and is caused by a disturbance of the chong mai.
This is due to the physiological changes that the foetus initiates in the Uterus. Chong
mai connects the Uterus and the Stomach. This means that disturbances of qi in the
chong mai can disturb the Stomach’s qi ji. This is only one of the causes of vomiting
during pregnancy. Other causes of morning sickness can be Stomach and Spleen
qi xu, Stomach yin xu, Liver qi stagnation, Liver Fire and Stomach Fire. If there is
Stomach and Spleen qi xu, the nausea will be exacerbated when the woman is tired
or if she has not eaten. Often, she can control the nausea by constantly nibbling at
food. If she not only has nausea, but also has vomiting, the vomiting will not be
explosive but more retching. If there is Liver Fire or Stomach Fire, the vomiting
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will be explosive and the vomit will be very sour in taste. Consuming ginger, which
is often recommended to relieve nausea, will often worsen the condition if there is
Fire. This is because it will add to the Heat in the Stomach. Ginger will, on the other
hand, have a beneficial effect if there is Stomach and Spleen qi xu.
Most of these patterns can also be seen when there is vomiting that is not related
to a pregnancy.
Acute vomiting will come from an invasion of exogenous xie qi or food
stagnation. The exogenous xie qi can be Heat, Summer-Dampness, Summer-Heat
or Cold. If there is an invasion of Cold in the Stomach, the vomit will be watery
and contain undigested food. This is because the Cold has blocked or extinguished
Spleen yang, which is the digestive fire. The person will often have a cold sensation
in the Stomach and the skin in the epigastric region can feel cold on palpation.
Heat will cause the vomit to be sour or bitter in taste, and the vomit will be
odorous. This will not be the case in a Cold condition. Summer-Heat and Summer-
Dampness will result in the vomit being yellow and watery.
Observation of the tongue’s coating and colour is important when differentiating
between the above patterns. Heat patterns will manifest with the tongue having a
yellow coating, whereas the Cold patterns will manifest with a white coating.
Damp-Phlegm in the Stomach will result in thin, slimy vomit.
Vomit that contains blood can be seen when there is Stomach Fire or xue
stagnation in the Stomach. Xue stagnation can block the vessels so much that they
eventually rupture. Fire can agitate xue so that it bursts the vessels’ walls.
Appetite, nausea and vomiting

Preference for cold foods Heat patterns
Preference for hot foods Cold patterns
Poor appetite or easily satiated Spleen qi xu
No appetite in the morning Stomach and Spleen qi xu, Damp-Phlegm
Insatiable hunger or becoming hungry Stomach Fire
shortly after having eaten
Aversion to food Food stagnation
Acid reflux Stomach Fire
Nausea after eating Spleen qi xu, food stagnation
Nausea caused by emotional pressure Liver qi stagnation
and stress
Nausea caused by hunger Spleen qi xu
Nausea during the premenstrual Liver qi stagnation
period
Morning sickness Rebellious qi in the chong mai, Stomach and Spleen qi
xu, Liver and Stomach Fire, Liver qi stagnation, Stomach
yin xu
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Acute vomiting Invasion of exogenous xie qi, food stagnation

Chronic vomiting Food stagnation, Damp-Phlegm, Liver qi stagnation,
Stomach Fire, Stomach and Spleen qi xu, Spleen yang xu
Explosive vomiting Shi patterns
Thin, slimy vomit Damp-Phlegm
Sour or bitter vomit Heat in the Stomach, Liver or Gall Bladder
Clear and watery vomit that is Cold in the Stomach or Spleen yang xu
odourless
Blood in the vomit Xue stagnation or Stomach Fire
Burping, with the taste of food that Food stagnation
has been eaten earlier
Taste
Imbalances in the various organs can result in a person being attracted to specific
flavours. This is most typically seen when someone who is Spleen qi xu has a craving
for sweets. The problem is that they often respond to this signal by eating sweets,
cakes or other things that have a high sugar content and have a very concentrated
sweet flavour. This will overload the Spleen and create Dampness, which further
weakens the Spleen. This causes the weakened Spleen to crave more sweet food.
The consequence will be that, because the Spleen is even weaker, the craving for
something sweet will be greater and a vicious cycle begins. The craving for the
other flavours are not as evident in imbalances of the other organs. It is, however,
interesting how many people are attracted to the bitter flavour of coffee!
Certain flavours can be appealing to some people, not because of the organ
that the flavour resonates with but due to the energetic dynamic of the flavour. For
example, the spicy flavour is very dynamic and can help to disperse stagnant qi.
Imbalances in zangfu organs can also manifest with a person experiencing a certain
taste in their mouth. Bitterness is the taste that relates to the Fire phase. If the person
experiences a bitter taste in their mouth (often they will describe it as a bad taste or a
metallic taste), it will not necessarily be a Heart imbalance. The Fire Phase resonates
with Fire and Heat in general. This means that a bitter or metallic taste can be seen
when there is Fire in the Stomach and Liver, as well as the Heart. Liver imbalances can
manifest with a sour taste in the mouth. A sweet, sticky taste or sensation in the mouth
will be a sign of Dampness or Phlegm. The person will sometimes brush their tongue
to get rid of the sticky sensation that often accompanies a very greasy tongue coating
(which in itself can be a sign of Dampness and Phlegm).
It is important to remember that some medicines can result in an unpleasant
taste in the mouth. It is important to assess whether the taste is due to a change in the
body’s physiology, for example a bitter taste has arisen because medicine has created
Heat in the body, or whether the taste itself is from the medicine and therefore has
no diagnostic significance.
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Lacking a sense of taste is mostly a manifestation of Spleen qi xu but can also

result from Phlegm in the Lung that clogs the nose and sinuses or xue stagnation
in the nose after a physical trauma. This is because aromatic flavours are discerned in
the nose.
Taste
Craving for sweets Spleen qi xu
No sense of taste Spleen qi xu, Lung Phlegm or xue stagnation
Sweet, sticky taste in the mouth Damp-Phlegm
Bitter or metallic taste in the mouth Heart, Liver and Stomach Fire
Sour taste or taste of previously ingested food Food stagnation
Stools and urination

Stools
Enquiry about the stool includes the stool’s regularity, consistency and smell and
whether there is pain associated with passing of the stool. Something that ought to
be fairly straightforward and easy to get concrete answers about can sometimes be
surprisingly difficult, because many people are not very conscious about their stools
and can only provide vague answers.
It is also important to define for a patient what regular bowel movements are.
Once a week is, technically, regular and so is six times a day, but both cases are signs
of severe imbalances. Once to twice a day is considered normal, and less or more
often than that is an expression of an imbalance.
The consistency of the stools can deviate from normal by being watery, sticky
or dry.
Constipation
Constipation is when stool movements are less frequent than once daily. Knowing
that a person is constipated is not enough; it is also important to ascertain the
consistency of the stool and whether there is pain associated with passing the stool.
Acute constipation can be due to an invasion of exogenous xie qi. This will
either be a direct invasion of Cold in the Intestines or shi Heat from an invasion
of exogenous xie qi penetrating down to the yangming aspect. If the invading xie qi
is Hot, the stools will dry out and the abdomen will feel tense. If the invading xie
qi is Cold, the stools will not be dry, there will be cramping pain and the abdomen
will feel cold on palpation.
Apart from shi Heat, yin xu and xue xu can cause the stools to be dry due to a
lack of fluids. The difference between xu and shi conditions can be determined by
whether there is pain or bloating, which will occur in a shi condition.
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Liver qi stagnation can also result in the stool not moving freely and smoothly
through the Intestines. Therefore, the stools will typically be pebble-like, similar to
goat droppings. If qi stagnation has generated Heat, the stools will also be dry. Qi
stagnation can cause the movement of the stool to be sluggish, taking a long time
to pass through the Intestines. There may well also be pain, tension and bloating
in the abdomen when there is Qi stagnation. This will be alleviated by the passing of
the stool. It is important to remember that a stagnation of qi in the Intestines is not
always due to Liver qi stagnation.
Liver qi stagnation can also manifest with alternating constipation and normal
or loose stools.
Spleen qi xu can be indicated by stools that are long and thin like a pencil.
The stools will have an otherwise normal consistency. Yang xu constipation will also
manifest with a stool that has a normal consistency, the constipation arising from
a lack of yang movement in the Intestines. The stool will take a long time to pass
through the Intestines, and the person may feel exhausted and sweat after passing the
stool. Lung qi xu can also manifest with exhaustion and sweating after bowel
movements. Again, the person lacks the strength to transport the stool downwards
through the Intestines. The effort of passing the stool will weaken the person’s qi so
much that they will feel exhausted and the Lung will temporarily lose control of the
pores, resulting in spontaneous sweating.
Constipation
Constipation, dry stools, abdominal tension, pain Shi Heat
Constipation, compact stools, abdominal tension, cramping pain Shi Cold
Small lumpy stools, stools that resemble goat droppings Liver qi stagnation
Long loose stools, not hard or dry Spleen qi xu
Dried stool, the abdomen does not feel tense or tight Xue xu, yin xu
Fatigue after defecation Lung qi xu
Sluggish stools Qi stagnation, yang xu
Constipation in a woman who has just given birth Xue xu
Alternating constipation and loose or normal stools Liver qi stagnation
Conditions that are better after defecation Shi conditions
Conditions that are worse after a bowel movement Xu conditions
Loose stools and diarrhoea

It is important to differentiate between an acute and a chronic condition. Acute
diarrhoea will be due to an invasion of exogenous xie qi and will thus be a
shi condition.
In acute conditions, it is important to differentiate between Heat and Cold.
An invasion of Damp-Heat will cause the stool to be explosive, because there is an
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excess of qi present. The stools will also be strong smelling and sticky and there will
be a burning sensation in the rectum due to the presence of Heat. If the Heat is very
strong, it will cause xue to rupture the vessels in the intestinal walls, resulting in
blood in the stools. Damp-Heat can be a chronic as well as an acute condition. The
symptoms will be the same, but the aetiology will be different.
If the stool is very watery, does not smell and contains undigested food particles,
it will be due to an invasion of Cold, which is an acute condition, or Spleen and/or
Kidney yang xu if it is chronic. If it is an acute shi condition, the stools will also be
explosive and the abdomen will feel cold and tense, and there will be a cramping
pain. The tension and pain will be alleviated by passing stools.
Yang xu can manifest with the passing of watery stools early in the morning. The
person will often feel exhausted after defecation.
When there is Spleen qi xu, the ingested food will not be transformed as it
should, so the food will pass more quickly through the Intestines and the person will
have a bowel movement soon after they have eaten. If there is Spleen yang xu, there
will be undigested food in the stool because there has not been a transformation of
the food. The stools will also be watery when there is Spleen yang xu. Neither Spleen
qi xu nor Spleen yang xu will manifest with stools that smell strongly.
Enquiry should be made about which foods affect the stools negatively. Strong
spices, alcohol, fried food, sugar and dairy products will have a negative effect on
the Damp-Heat conditions. Spleen qi xu, Spleen yang xu and Dampness will all be
aggravated by consuming raw vegetables, salad, too much fruit, cold foods, sugar,
sweets, dairy products and the like.
If there is a lot of gas in the Intestines and the person has flatulence, this will be
due to Liver qi stagnation, Spleen qi xu or Damp-Heat. Damp-Heat flatulence will
be odorous.
Diarrhoea
Explosive diarrhoea Shi pattern
Acute condition Shi pattern
Chronic condition Xu pattern
Passing of stools shortly after eating Spleen qi xu
Passing of watery stools early in the morning Kidney and Spleen yang xu
Burning sensation in the rectum and sticky, strong-smelling Damp-Heat
stools
Watery stools containing undigested food particles Yang xu, shi Cold
Cramping pain that is alleviated by the passing of stools Liver qi stagnation
Sticky stools Damp-Heat
Bloody diarrhoea Damp-Heat, Toxic-Fire
Pain or tension that is alleviated by defecation Liver qi stagnation, Damp-
Heat
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Stools containing mucus Damp-Phlegm

Flatulence without odour Liver qi stagnation or Spleen
qi xu
Flatulence which is odorous Damp-Heat
Intestinal discomfort that is alleviated by the passing of stools Shi conditions
The condition is aggravated by consumption of alcohol, fried Damp-Heat
food, dairy products, sugar and dried fruit
The condition is aggravated by consuming salad, raw vegetables, Spleen qi xu, Spleen yang xu,
fruit, cold foods, dairy products, sugar, sweets and dried fruit Dampness
Alternating diarrhoea and constipation/normal stools Liver qi stagnation
Condition improves after the passing of stools Shi conditions
The condition worsens after the passing of stools Xu conditions
Urination
Urinary disturbances relate not only to Kidney and Urinary Bladder imbalances, but
also to various forms of xie qi, such as Dampness and Hot and Cold conditions. It
is important to ask about the frequency of urination, the amount, colour and odour
of the urine and whether there is pain or discomfort upon urination.
If there is Kidney yang xu, the Kidneys will not perform their task of transforming
and transporting fluids optimally. The untransformed fluids will therefore drain
down to the Urinary Bladder due to their yin nature. Kidney yang should also
control the lower orifices and hold the urine in the Urinary Bladder. These factors
result in an increased amount of urine that is clear in colour, and the person will
have difficulty retaining the urine in the body. This can manifest with symptoms
such as frequent urination, urinary incontinence and nocturia.
Kidney yang is used to drive the urine out of the Urinary Bladder. This means
that when there is Kidney yang xu there may be difficulty in voiding the urine or
incomplete emptying of the Urinary Bladder. Incomplete and difficult urination
can also be seen in stagnation conditions such as shi Cold, Damp-Heat, Phlegm and
Liver qi stagnation.
If the urine is dark and/or strong-smelling, this is an indication of Heat. The
Heat may be both xu or shi in nature The Heat will ‘steam’ the urine, so there will
usually be a smaller volume of urine. The Heat may also agitate the urine and force
it out of the Urinary Bladder, so even though there are only small amounts of urine,
there is still frequent urination or an urge to urinate, despite the Urinary Bladder
being almost empty.
The Heat can also cause the vessels in the Urinary Bladder to rupture so that
there is blood in the urine. It is not only Heat that can result in there being blood
in the urine; Spleen qi may be too weak to hold the xue inside the vessels and xue
stagnation can block the vessels so that they finally rupture from the pressure of the
xue that is being blocked from flowing. Heat can also manifest with a burning or
stinging sensation when urinating.
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If there is urinary pain that is ameliorated upon urination, it will be a stagnation

condition. The urination itself is also likely to be difficult. Pain or discomfort after
urination will be a sign of a xu condition.
Dampness tends to makes emissions, exudations and discharges become thicker,
cloudy and less transparent. Therefore, oily or cloudy urine is a sign of Dampness or
Damp-Heat in the lower jiao.
Urination
Dark, yellowish and/or odorous urine Heat
Clear, voluminous urine Cold or yang xu conditions
Frequent, scanty, yellow urine Damp-Heat in the lower jiao
Frequent urination with clear urine Yang xu or Cold in the lower jiao
Urinary difficulty or incomplete Damp-Heat in the Urinary Bladder, yang xu, Cold,
emptying of the Urinary Bladder Phlegm, xue stagnation and Liver qi stagnation
Blood in the urine Shi Heat or Spleen qi xu
Nocturia (urination during the night) Kidney yang xu
Pain or discomfort in urination Stagnation conditions
Pain or discomfort during urination Heat in the Urinary Bladder
Pain or discomfort after urination Xu conditions
Cloudy urine Dampness
Oily urine Dampness
Heart, thorax and Lung

Heart
The main area of enquiry about the Heart is whether there are palpitations, cardiac
pain or pain in the chest.
It is important to note that palpitations in Chinese medicine are not limited to
a rapid heartbeat or a powerful heartbeat. Palpitations in Chinese medicine are all
situations where the person can feel the beating of their heart, because normally you
should not be conscious of your heart beating.
Palpitations where there is also a sense of emotional turmoil or anxiety will be
due to Gall Bladder and Heart qi xu, Heart yin xu, Heart xue xu or shi Heat. Heart
yin and Heart xue, as well as nourishing the physical aspects of the Heart, nourish
and anchor the Heart’s shen aspect, which means that it is not only the physical
aspect of the Heart that becomes imbalanced when these are weak. Heat can agitate
the shen and simultaneously over-activate the physical aspects of the Heart. This will
also give rise to palpitations and emotional turmoil. Gall Bladder and Heart qi xu
results in a person being very nervous and their shen lacks the ability to control their
heartbeat when they are nervous.
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If the palpations are of a more purely physical nature, it is more likely that there
is Heart qi stagnation, Heart qi xu, Heart yang xu or Heart xue stagnation. If Heart
qi or Heart yang are weak, they can no longer control the rhythmic beating of the
Heart. Xue stagnation can block Heart qi and Heart xue, so they can no longer
perform their functions.
Heart xue stagnation will also usually manifest with cardiac or chest pain.
Palpitations
Palpitations with a concurrent sense of Heart yin xu, Heart xue xu, Heat, Gall Bladder
emotional turmoil or anxiety and Heart qi xu
Palpitations with a tight sensation in the chest Heart qi stagnation
Palpitations with stabbing pain in the chest Heart xue stagnation
Thorax
Enquiry should be made about whether there is pain, tightness, heaviness and
agitation in the thoracic region.
Pain in this thorax is often caused by Heart or Lung imbalances, but the Liver
can also be involved.
Cramping, tight pain in the heart that feels as though the heart is being squeezed
in a vice is due to Cold. If the pain is sharp, piercing or stabbing, there will be
Heart xue stagnation. A burning pain is the result of Heat. The Heat can be both xu
and shi.
If the chest feels tight – as if there is a metal rim or a piece of elastic around the
chest, making it difficult to breathe in – this is a sign of qi stagnation. A similar
sensation is that of having a large stone or weight on top of the chest. This will also
inhibit the breathing and the chest will feel ‘blocked’. This sensation results from the
presence of Phlegm blocking the movement of qi in the upper jiao.
Heat in the upper jiao can give rise to a feeling of unease and turmoil in the
chest because the Heat agitates the qi. The sensation may also be experienced when
exogenous xie Heat penetrates deeper and affects the Pericardium.
Patients with acute cardiac and chest pain should immediately be referred to a
Western doctor for further examination.
Thorax
Pain Heart xue stagnation, Heat, Cold
Unrest and turmoil Heat
Heaviness Phlegm
Tightness Qi stagnation
Pain radiating from the heart and down the left arm Heart xue stagnation
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Lung
Enquiry should be made about the respiration, coughing, whether there are
exudations from the nose and whether there is mucus in the chest or in the throat.
Breathing difficulties and coughing always indicate that there is a disturbance of
Lung qi. The disturbance can be due to imbalances in the Lung itself or other factors
affecting the Lung. This is because it is the Lung that controls the breathing by
sending its qi downwards.
Heaviness and tightness in the chest have been described above.
Breathing
When a person becomes breathless, it is because the Lung is not able to send its
qi downwards or because the Kidneys are not able to grasp the qi. Lung qi xu,
possibly combined with the Spleen qi xu, can manifest with the Lung not being
strong enough to descend and spread qi from the chest.
Lung qi can also be blocked in its movement by xie qi. This will typically be
some form of Phlegm, but qi stagnation in the upper jiao may also be involved.
Invasions by exogenous xie qi can also block the Lung qi.
Difficulty breathing can be due to Lung qi xu or Lung yin xu, resulting in the
Lung being too weak to descend and disseminate qi. Kidney qi xu can mean that
the Kidneys are not strong enough to grasp the qi. Phlegm, xue stagnation or qi
stagnation can block the movement of Lung qi. Phlegm will often be the cause of
wheezing or a rattling sound in the chest.
A person who frequently yawns or who has a need to sigh will often be manifesting
Liver qi stagnation. The body yawns or sighs in an attempt to fill the Lung with air
and thereby strengthen zong qi so it can forcibly disperse and circulate the stagnant qi.
Coughing
If the person has a cough, it is important to ask about how loud the cough is, how
long they have had it, if there is sputum, the consistency and colour of the sputum
and when the cough occurs.
A powerful, explosive or barking cough will be seen in a shi condition, usually
Heat and/or Phlegm.
If the cough is acute and has recently arisen, it will probably be due to an invasion
of exogenous xie qi.
Chronic coughs can be xu or shi or a combination of both. Lung qi xu and Lung
yin xu coughs will be weak and will not be loud. Lung yin xu will manifest with a
cough that is dry, ticklish and worse in the evening and at night. There may be dry,
rubbery sputum that is difficult to expectorate. Both Lung qi xu and Lung yin xu
coughs will be worse after the person has used their Lung qi, for example by talking,
triggering a coughing fit. They will also cough more frequently when they are tired.
Exposure to a dry environment can result in a dry cough. The Lung fears dryness,
because dryness will injure Lung yin. Dryness is not normally a climatic influence
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associated with Northern Europe, but it can be seen when there is poor indoor air
quality, such as in buildings made of concrete.
Phlegm pattern coughs are usually worst in the morning. This is because the
Phlegm will have accumulated in the Lung during the night whilst the person is lying
down. There are several types of Phlegm and each will have its own characteristics.
Phlegm-Heat results in a loud, sometimes barking cough with yellowish or greenish
sputum. This mucus can be sticky and difficult to expectorate. This is a typical
‘smoker’s cough’. Damp-Phlegm and Phlegm-Cold will manifest with thin, watery
sputum that is looser. Phlegm-Fluids manifest with sputum that is very watery; there
will be a bubbling, rattling sound in the Lung and the person will have difficulty
lying down because they start to suffocate.
Coughs with profuse sputum that are worse after consumption of certain foods,
such as dairy products, are due to Damp-Phlegm in the Lung. The root of this
Phlegm will often be Spleen qi xu with Dampness. It is said that ‘Phlegm is stored
in the Lung, but produced in the Spleen.’
If there is an element of qi stagnation, the cough or breathing difficulty will
be worst in the morning or when the person is angry, frustrated, stressed or in the
premenstrual phase.
The nose and sinuses

Sneezing is a sign of rebellious Lung qi. The nose is an aspect of the Lung and the
Lung sends qi downwards. If the sneeze is acute, it will usually be due to an invasion
of exogenous xie qi. The exudations from the nose will usually be clear and watery
if there is Wind-Cold. If there is Wind-Heat, the nose will be more blocked and
exudations will be yellowish and thicker. If there is Toxic-Fire the exudations will be
thick and greenish and they will smell and taste foul.
There may be a chronic condition of runny nose with clear transparent and thin
mucus. This is seen in Damp-Phlegm conditions. Phlegm-Heat can result in both
an acute or a chronic blocked nose and sinuses. The mucus will be yellow or white
and it will be thick and sticky. If there is Toxic-Heat, the mucus will be greenish and
thick. Both Liver Fire and Stomach Fire may be involved in Phlegm-Heat conditions
manifesting in the nose and sinuses. Fire conditions can also agitate xue so that it
ruptures the walls of the vessels in the nose, resulting in blood in the mucus.
If there is Lung qi xu, the Lung can easily be invaded by exogenous xie qi. This
can manifest as a chronic condition where the person sneezes after the slightest
contact with the exogenous xie qi.
Coughing, dyspnoea, blocked or runny nose

Loud cough with white or clear sputum Wind-Cold, Damp-Phlegm, Phlegm-Cold
Loud cough with yellow sputum Wind-Heat, Phlegm-Heat
Loud and explosive cough Shi condition
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Barking cough Shi Heat
Dry or ticklish cough Lung yin xu, Dryness
Weak cough Xu conditions
Weak cough with scanty Phlegm, dry, rubbery Lung yin xu
sputum or no sputum
Cough with sticky sputum that is difficult to Shi Heat in the Lung
expectorate
Loose, clear or watery sputum Phlegm-Cold, Damp-Phlegm, Phlegm-Fluids
Cough that is worst in the evening and at night Lung yin xu
Cough that is worst in the morning Phlegm
Cough that is worst when a person speaks or is Lung xu conditions
tired
Cough that is worst after consuming dairy Phlegm
products
Shortness of breath, easily breathless Lung qi xu, Lung yin xu, Kidney xu, Phlegm,
qi stagnation
Difficulty breathing Phlegm, Lung qi xu, stagnation of qi,
xue stagnation in the Lung, invasions of
exogenous xie qi
Wheezing or rattling sounds in the chest Phlegm
Desire to yawn or sigh Qi stagnation
Feeling that there is a heavy stone on top of the Phlegm
chest
Difficulty breathing in deeply because the chest Qi stagnation
feels tight
Sneezing Invasion of exogenous xie qi, Lung qi xu
Runny nose with clear, watery mucus Wind-Cold, Damp-Phlegm
The nose or sinuses are blocked with yellowish or Wind-Heat, Phlegm-Heat, Toxic-Fire
greenish mucus
Blood in the mucus Fire
Dizziness
Dizziness encompasses everything from a slight dizziness when getting up, with dots
in front of the eyes that quickly disappear again, to extreme vertigo, where the room
spins around and there is difficulty maintaining balance.
The main differentiation of dizziness is between xu and shi conditions – whether
there is enough qi, xue or jing to nourish the Brain or something is blocking their
movement up to the Brain.
Enquiry should be made about what triggers the dizziness. If the dizziness comes
when getting up, it is often due to qi xu and or xue xu, because qi and xue are not
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strong enough to ascend as quickly as the person getting up. In some situations, this
can be due to Phlegm blocking the ascent of qi and xue.
Xue xu dizziness is often exacerbated during and after menstruation. This is
because the woman is more xue xu due to bleeding. This type of dizziness is also
common after childbirth. Xu types of dizziness are also worse when the person is
tired after exertion and improve when the person has rested.
If the dizziness comes when the person is stressed, frustrated or irritated, it will
be due to Liver imbalances, such as Liver Wind, Liver Fire or Liver yang rising. Liver
Fire will also manifest with a hot sensation in the head during an attack of dizziness.
If the dizziness is worse after sexual activity, it will be an indication that Kidney
jing is not nourishing the Brain.
A sensation that the room is spinning round indicates Wind-Phlegm. Sensations
of nausea and heavy-headedness will also indicate Phlegm.
Dizziness and vertigo

Dizziness when getting up Qi xu, xue xu or Phlegm
Acute dizziness, especially dizziness when lying down or sitting Wind-Phlegm
Dizziness accompanied by nausea or a heavy sensation in the head Phlegm
Dizziness and blurred vision, which is aggravated by exertion and Qi xu and xue xu
when tired
Dizziness that is worse after sexual activity Kidney jing xu
Dizziness and ringing in the ears Kidney jing xu
Dizziness with loud sound in the ears or headaches Liver yang rising
Vertigo with heaviness in the body or head Phlegm
Skin, hair and nails

Generally speaking, the skin is under the overall influence of the Lung, the hair of
the head is under the influence of the Kidneys and the nails are an aspect of the Liver.
In practice though, there are many other relevant aspects, in particular the condition
of xue, that affect these types of tissue.
The skin
The skin is nourished and moistened by xue and jin. This means that imbalances
manifesting in the skin are more often xue imbalances and patterns of Dampness,
rather than being Lung imbalances. All channels traverse the skin. Changes in
specific areas of the skin can therefore also relate to imbalances in specific channels.
If the skin is dry, it will be because the skin is not nourished and moistened. This
will therefore be a sign of xue xu or yin xu. Oily or greasy skin can be seen when there
is Dampness, Damp-Heat and Phlegm.
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The skin can become dry and flaky when there is xue stagnation in the area
below it. This is sometimes seen in the area of joints that have xue stagnation. Xue
stagnation can block and thereby prevent fresh, nutritious xue from circulating in
the skin in this area.
Damp-Heat and Phlegm can manifest with greasy or oily skin.
Itchy skin will indicate the presence of Wind in the area. It is important to
identify the cause of the Wind. There will often be a combination of both exogenous
and internally generated Wind simultaneously. Internal Wind may arise from
factors such as xue xu or shi Heat. Exogenous Wind can be both Wind-Cold and
Wind‑Heat. Other factors that can be involved in itching are xue stagnation, Dryness
and Dampness. It is important to observe and ask about other qualities of the skin,
such as colour, moistness, texture and so on, to be able to differentiate the aetiology.
The hair
The hair on the head is created from Kidney jing but nourished and moistened
by xue. This means that the quantity and quality of the head hair can be influenced by
both xue and jing. If there is jing xu, there can be baldness, a receding hairline and
thin hair. Xue xu can also result in hair loss, poor hair growth, dry hair or brittle hair.
This is typically seen after childbirth and menstruation.
Phlegm, Damp-Heat and Dampness can make the hair greasy. The scalp can
also be itchy when there is Damp-Heat. Dampness and Phlegm can also block xue
from nourishing the hair so that it starts to fall out. A person can also suffer hair loss
when Heat scorches the roots of the hair. The Heat may be generated internally or
there may be invasions of Wind-Heat. If it is due to Wind-Heat, the hair loss will be
sudden and defined patches will be missing.
The nails
The nails are an aspect of the Liver in the same way that the tendons are. Nails
are nourished by Liver xue. Nails that are weak, break easily or are soft or ridged are
a sign that Liver xue is not nourishing the nails. If the nails are very thick and
yellowish, this can be a sign of Liver xue stagnation or Dampness. Typically, this is
seen in the toenails, because Dampness seeps downwards.
Skin, hair and nails

Dry skin Xue xu, xue stagnation
Greasy skin Damp-Heat, Phlegm
Itchy skin Wind, Dampness, Dryness, xue stagnation
Hair loss and baldness Jing xu, xue xu, Fire, Wind-Heat, Dampness, Phlegm
Dry hair Xue xu
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Greasy hair Damp-Heat, Phlegm

Oily, itchy scalp Damp-Heat
Very thick nails Xue stagnation
Weak, soft nails that break easily Liver xue xu
Ridged fingernails Liver xue xu
The ears and eyes

The ears are an aspect of the Kidneys and the eyes of the Liver, but again, there are
several organs and vital substances that influence them.
The ears
The two organs that have the greatest impact on the ears are the Kidneys and the
Liver. Kidney jing and Kidney yin nourish the ears, whilst the Liver has an influence
on them because Liver yang imbalances can ascend to the ears via the Gall Bladder
channel and disturb their functioning. The ears can also be directly and indirectly
invaded by exogenous xie qi. In particular, Wind-Heat can directly invade the ear,
as well as the san jiao channel. Invasions of exogenous xie qi will cause pain and
the exudation of yellowish discharge from the ear. The invasion can also result in
tinnitus with a loud sound or deafness. Because the condition is due to an acute
invasion of exogenous xie qi, the symptoms will arise suddenly. It will typically be
only one of the ears that is affected.
Kidney jing xu or Kidney yin xu can indicate that the ear lacks nourishment,
meaning that the ear will not perform its functions optimally. Typical symptoms
that may be due to Kidney jing xu or Kidney yin xu are deafness and tinnitus.
Tinnitus due to a xu condition will typically manifest with a constant low tone and
will be exacerbated by fatigue. If the tinnitus is alleviated by sticking fingers into the
ears or pressing on the ears, this is a sign of a Kidney xu condition.
Tinnitus resulting from ascendant Liver yang or Liver Fire will be louder and will
vary in strength. The tinnitus will also be adversely affected by stress and emotional
influences. Liver shi tinnitus can also be exacerbated by sticking the fingers in
the ears. It will often have arisen suddenly, whereas Kidney xu tinnitus will have
developed gradually. These are general guidelines and it is actually most common
that there are aspects of both. This is because Kidney and Liver yin have a common
root, and Liver yin xu can result in ascending Liver yang.
Tinnitus that is worse at night is a sign of yin xu or xue stagnation. It is important
to note that the tinnitus may not actually be louder at night, but because there is less
noise in the room it is more noticeable.
Tinnitus that has arisen after exposure to loud noise will be classified as
xue stagnation.
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Deafness and hearing difficulties will often be due to Kidney yin xu or Kidney
jing xu not nourishing the ear. However, a sudden loss or decrease in hearing will be
due to an invasion of Wind-Heat or ascending Liver yang.
An increased production of earwax is usually due to Liver and Gall Bladder
Damp-Heat. The exudation will be very sticky. Spleen and Kidney yang xu can also
result in an increase in earwax, but it will be thinner and more watery. Phlegm
and Dampness will, in general, result in increased and thicker exudations from the
body’s orifices. This also applies to the ears.
Liver and Gall Bladder Damp-Heat or Toxic-Fire can result in the formation
of increased exudate in the middle ear. There will be pain and possibly yellowish
discharge from the ear. Earache can also be seen in invasions of Wind-Heat, Liver
Fire imbalances and when there is a local stagnation of qi and xue.
Ears that are itchy may be due to invasions of Wind-Heat, Gall Bladder
Damp‑Heat, Liver xue xu generating internal Wind or Kidney yin xu Heat.
The ears
Tinnitus with a loud noise or loud Shi conditions
rushing sound
Tinnitus with a low sound or faint Xu conditions
rushing noise
Tinnitus that has arisen gradually Kidney yin xu, Kidney and Liver yin xu, Kidney jing xu
Tinnitus that has arisen suddenly Liver Fire, ascending Liver yang, invasion of Wind-Heat,
xue stagnation
Poor hearing Kidney xu conditions
Hearing impairment (which occurs Wind-Heat, ascending Liver Wind
suddenly)
Earache Wind-Heat, Liver and Gall Bladder Damp-Heat, xue and qi
stagnation, ascending Liver yang or Liver Fire
Otitis or exudation of yellow Wind-Heat, Liver and Gall Bladder Damp-Heat, Toxic-Fire
discharge from the ears
Itchy ears Wind-Heat, Gall Bladder Damp-Heat, Liver xue xu, which
generates Wind or Kidney yin xu Heat
Increased production of earwax Phlegm, Dampness, Liver and Gall Bladder Damp-Heat,
Kidney and Spleen yang xu
The eyes
Although the eyes are nourished and moistened by Liver xue and Liver yin, there
are many other factors that affect the eyes. Several channels emerge or terminate
in the area of the eyes. The eyes can be disturbed by both exogenous and internally
generated xie qi. Heat in particular can disturb the eyes. The eyes are physically
located in one of the most yang areas of the body and Heat will always rise upwards
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due to its yang nature. This means that if there is internally generated Heat, such as
Stomach or Liver Fire, the Heat can rise upwards resulting in red, stinging or itchy
eyes. Invasions of Wind-Heat can also result in red and stinging eyes. This is typical
of conjunctivitis and hay fever.
Ascending Liver yang and Liver Fire can also force an excess of qi up to the area.
This will cause pain and pressure either behind or in the eyes. The increased amount
of qi can also disturb the vision.
Phlegm can lead to there being a sensation of heaviness in and around the
eyes. It can also block xue and yin from nourishing the eyes. This will result in
visual isturbances.
Liver xue xu will also mean that the eyes lack nourishment. The eyes will feel dry
and the vision will be poorer. The person may have difficulty focusing or there may
be spots in front of the eyes. These symptoms will be exacerbated by fatigue. Liver
xue xu can manifest with a sensitivity to bright light or poor nocturnal vision.
If a person is Liver yin xu, their eyes will also feel dry because they are not
moistened by yin.
Tears are a body fluid that is directly influenced by the Liver, according to
the theories of the Five Phases. This means that Liver imbalances can manifest
with the eyes watering, especially when it is windy. Wind itself also has an adverse
effect on the Liver. As with the other eye disorders, watering eyes can be a xu and
a shi condition. Invasions of Wind-Heat and Wind-Cold can often cause the eyes
to water. This is because the exogenous xie qi will disrupt the Lung and cause the
Lung qi to become rebellious. The rebellious Lung qi will force the fluids that have
accumulated in the Lung to ascend to the eyes.
Itchy eyes can arise when there is not enough yin or xue to nourish the eyes or
when Heat rises upwards or invades from the exterior.
The eyes
Red eyes possibly with swelling and pain Wind-Heat, Toxic-Fire, Liver Fire, Stomach Fire
Dry eyes Kidney and Liver yin xu
Blurred vision, spots or floaters in front of Xue xu
the eyes
Visual disturbances Liver xue xu, Liver yin xu, Liver Fire, ascending
Liver yang, Phlegm
Pressure behind the eyes or feeling of Ascending Liver yang or Liver Fire
pressure inside the eye
Sensitivity to bright light Xue xu
Poor night vision Xue xu
Watering of the eyes, particular when it is Liver imbalances, invasions of Wind-Cold or
windy Wind-Heat
Itchy eyes Liver yin xu, Liver xue xu, Liver Fire, Stomach Fire,
Heart Fire, Wind-Heat
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Sleep
Genuine insomnia is always caused by an imbalance involving a disruption of
the shen.
A good night’s sleep depends on the shen being anchored. This requires that xue
and yin are strong enough to hold it down and that shen is not activated and agitated
by Heat.
It is important to distinguish between genuine insomnia and insomnia that
is caused by other factors such as the person being woken by, for example, pain,
coughing, children, noisy neighbours, bedroom temperature, changing night shifts,
coffee, tea or energy drinks.
Many of the questions that relate to the frequency and character of the insomnia
are guidelines, not hard and fast rules. As always, multiple patterns are often present
simultaneously.
An acute condition of insomnia that has arisen recently will usually be due to
Liver qi stagnation, Liver Fire, food stagnation or shi Heat. Chronic insomnia will
probably be related to yin xu or xue xu, but shi Heat can also be relevant.
Xue xu will usually manifest with a person having difficulty falling asleep. The
person can also have difficulty remaining asleep. They may well feel that they do not
sleep deeply and that they dream a lot. If they wake during the night, their mind
will not be restless or full of thoughts, but they will often just lie awake. They may
even be unsure in the morning if they were awake or not or for how long, because
the mind was not active whilst they were awake.
People who wake after they have fallen asleep and have a restless mind or lucid
thoughts will probably be yin xu and have Heat from Liver qi or food stagnation or
some form of Fire.
Liver qi stagnation or Liver Fire patterns can be characterised by the person
waking between 2 am and 4 am and having difficulty falling asleep again. Usually, a
person who wakes early in the morning and cannot fall asleep again has some form
of Heat or Heart and Gall Bladder qi xu.
Difficulty falling asleep or waking too early can also indicate an imbalance in the
extraordinary channels yin qiao mai and yang qiao mai.
The more Heat that there is, the more restless and unstable the sleep will be.
This is because Heat activates and agitates shen. The Heat can be xu or shi in nature.
The Heat will also agitate the hun so there may be dream-disturbed sleep or many
nightmares. Nightmares are also seen in Heart and Gall Bladder qi xu.
If sleep is affected by stress or the person’s emotional condition, this is usually an
indication that there is Liver qi stagnation or Liver Fire. Stress and too much mental
activity can also worsen a condition of Heart yin xu or Heart xue xu, because the
condition of stress will consume yin and xue whilst also generating Heat. It will be
harder to sleep if they work or play on the computer late in the evening or if they
go to bed too late.
Insomnia caused by food stagnation is closely linked to what they eat, how much
they eat and at what time they eat.
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Insomnia that is a manifestation of Heart and Kidney yin xu can often be

accompanied by palpitations, mental agitation or anxiety. Palpitations can also
be seen when there is Heart Fire.
Insomnia
Acute insomnia Liver qi stagnation, Liver Fire, food stagnation, shi Heat
Difficulty falling asleep (but otherwise Heart xue xu, Heart yin xu, Liver qi stagnation,
sleeps well) disharmony of yin qiao mai and yang qiao mai
Wakes up frequently during the night Yin xu, xue xu, food stagnation, Heat
Restless sleep with many dreams Food stagnation, Heat
Wakes up early without being able to Gall Bladder and Heart qi xu, Liver qi stagnation, Heat,
fall asleep again disharmony of yin qiao mai and yang qiao mai
Nightmares and violent dreams Liver or Heart Heat Fire
Waking up when stressed or under Liver qi stagnation Heat
emotional pressure
Insomnia with palpitations Heart yin xu, Heart xue xu, Heart Fire
Difficulty sleeping after late meals or Food stagnation
eating certain foods
Pain
The category ‘enquiring about about pain’ has traditionally encompassed everything
from headaches and menstrual pain to joint pains and hypochondriac tension. I
have chosen to address some of these areas of pain individually. For example, I will
discuss headaches, chest pain, menstrual pain and abdominal pain as unique areas
of enquiry.
When enquiring about pain, it is important to locate where exactly the pain
is experienced. This is to get an idea of which channels or which organs may be
involved. For example, it is important when diagnosing joint pain to identify which
channel is imbalanced. It is also important to investigate other aspects of the painful
sensation, such as the quality of the pain, what improves or triggers the pain, how
and when it arose, if the joint feels hot, whether there is swelling and so on. This
is because the individual characteristics will help to differentiate one type of pain
from another.
In general, all pain is due to a stagnation of qi: ‘Bu tong ze tong, tong ze bu tong’
(where there is a stagnation, there is pain; where there is free movement, there is no
pain). A stagnation of qi can arise when there is a shi condition and in xu conditions.
In a xu condition, there will not be enough qi or xue to circulate qi, xue or jinye.
The pain seen in a xu condition will be milder. It will typically be described
as being a dull or nagging pain or a tingling sensation. The pain will be relieved
or ameliorated by palpating or putting your hand on the area. This is because the
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physical pressure will increase the amount of qi in an area that is qi xu. Xu types
of pain should, in theory, feel worse after physical activity and improve with rest.
Whilst this statement is true, it is also misleading. In some situations physical activity
may well relieve the pain in a xu condition. This is because the physical activity will
create a circulation of qi, temporarily relieving the stagnation and thereby the pain.
Xu types of pain can be worse in the morning or if the person has been sitting still
for a long time, which is otherwise characteristic of shi pain. Again, this is because
there is too little qi to move the stagnant qi and xue, which stagnate when there is
no physical activity. Xu types of pain are often worse after exertion or return later in
the day when the person is tired. This is seen, for example, in lumbar pain, where the
pain is worse if the person has been standing all day.
Xu pain will usually have arisen gradually. Acute pain, on the other hand, is
almost always a manifestation of a shi condition.
Shi conditions will often be aggravated by inactivity, especially lying or sitting
still for long periods of time, such as when sleeping. Contrary to what is written
in standard TCM textbooks, activity does not necessarily relieve the pain. On the
contrary, if there is a severe stagnation of qi, xue and jinye, such as when there is a
sprain after a physical trauma or an operation, the movement of the joint will be
severely limited and there will be extreme pain if the joint or muscle is moved beyond
this range. Shi pain will typically be aggravated or feel greater if the area is palpated.
This is because the increase in physical pressure will increase the amount of qi in an
area that already has an excess. Something that can therefore seem counter-intuitive
is when people with acute pain, such as a headache, press their fingers against certain
spots, for example the temple, to relieve the tension. If you observe what they are
doing you will often see that they are massaging the spot with very small movements
of their fingers. They are therefore not increasing the amount of qi in the area, but
spreading it with a draining finger technique and thereby relieving the pain. Because
shi pain conditions are aggravated by pressure, the person will often have a dislike of
wearing tight clothes in the relevant area. This is seen, for example, in some women
with menstrual pain having an aversion to wearing tight jeans up to and during the
start of the menstrual bleeding.
The descriptions of some of the individual types of pain can sound very similar.
This is because the mechanisms involved in the generation of the pain can be fairly
similar. Xue stagnation, for example, will manifest with a pain that is stabbing, piercing
and sharp. The pain will be localised to a specific spot and will not move around. Cold
can cause pain that is fairly similar to xue stagnation pain. Instead of being piercing and
sharp, Cold stagnation pain is biting and cramping. The reason that the descriptions of
these types of pain are so similar is that Cold contracts and thereby blocks the vessels,
stagnating xue. When there is Cold stagnation, the area will feel either subjectively
or objectively cold. Cold pain will be alleviated by heat. One should, however, be
careful not to conclude that all pain that is alleviated by heat is Cold pain; it is not.
Heat is yang and thereby creates movement and activity. This means that most types of
stagnation, and therefore pain, will be relieved by warmth.
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Pain from xue stagnation is often worse at night. This is because there is less
movement of qi in the body whilst the person is sleeping, so xue is not circulated as
effectively as during the day when the person is physically active. Furthermore, at
night xue flows back to the Liver where it is stored. This means that there is less xue
circulating in the channels and vessels, so there will be a greater tendency for xue to
stagnate in places where there is already a stagnation.
Pain from qi stagnation will often move from place to place within a specific
area. The person may not be able to localise the focus of the pain to a specific spot
but will feel the pain in an area. Whereas a patient with Cold and xue stagnation will
often point to a specific spot with their finger, a patient with qi stagnation pain is
more likely to show you an area with their whole hand, possibly moving the hand at
the same time. There will often be distension or even bloating in the area. The pain
itself usually comes in waves or is variable in its intensity. It can also be described as
tension or pressure.
Pain caused by Wind will also move from place to place, but in this instance
the pain moves not only within a limited area of the body, but also from one area
to another.
Heat will manifest with a pain that is burning or stinging. Pain caused by
Heat can be relieved by putting something cold, such as ice, on the area. It can
sometimes be relieved by the use of something hot like moxa, because the heat will
help stagnated qi, xue and jinye to circulate.
Dampness will result in a pain that is heavy and dull.
Numbness and tingling sensations

Although numbness and tingling sensations are not actually pain, I have chosen to
discuss them here for clarity. Numbness and tingling sensations occur when tissue
is not nourished by xue. This means that a sensation of numbness or tingling can
arise when there is either a genuine deficiency of xue, i.e. xue xu, or something
that is blocking xue from reaching the area. Phlegm and xue stagnation can
block the channel system so that xue cannot reach certain parts of the body.
Tingling and numbness due to xue xu will usually be bilateral, whereas unilateral
tingling or numbness is more typical of xue or Phlegm stagnation. Xue xu can
manifest with numbness and tingling at night. This is because xue flows back to
the Liver during the night when it is gathered and stored. This means that there is
less xue in the channels and vessels to nourish the tissue. Liver yin xu and Liver xue
xu can also result in cramping in the calf muscles in the evening and at night when
xue flows back to the Liver, resulting in a deficiency of xue in the muscles in the
extremities, meaning they lack nourishment so Wind can develop and manifest as
cramps or restlessness.
Some organs have a special influence over certain areas or parts of the body. Pain
in the lower back or knees can be caused by many factors such as trauma, invasion
of exogenous xie qi and so on, but lumbar and knee pain can also be a reflection of
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a xu condition in the Kidneys. Kidney xu conditions typically manifest with either

weakness, fatigue or stiffness in the lower back and knees. The pain or discomfort is
worst when the person is tired, has stood a lot or has lifted heavy loads.
Hypochondriac tension is a classic symptom of Liver qi stagnation. Another
sign of Liver qi stagnation is when qi stagnates in the throat. This will give a slightly
suffocating sensation. If there is also Phlegm present, it will feel as if something that
cannot be swallowed is stuck in the throat. Western clients will describe it as a lump
in the throat. In China it is called ‘plumstone qi’, because it feels as if a plum stone
is stuck in the throat.
Pain
Pain that is alleviated by pressure or by holding the area Xu conditions
Pain that is aggravated by pressure Shi conditions
Sharp or piercing pain (often localised to a specific area) Xue stagnation
Cramping or biting pain Cold
Burning pain Heat, Damp-Heat
Dull, heavy pain Dampness
Nagging or dull pain Xu conditions
Tension and tightness Qi stagnation
Pain that can ‘come and go’ or comes in waves Qi stagnation
Pain that moves from one area to another Wind
Pain that is localised and does not move Xue stagnation
Pain that is alleviated by cold Heat
Pain that is alleviated by heat Cold (but because heat activates qi,
most types of pain are relieved by heat)
Pain that is alleviated by rest Xu conditions
Pain that is alleviated by movement Shi conditions
Sudden pain Shi conditions
Pain that has developed gradually Xu conditions
Pain that is worse at night Xue stagnation
Tingling or numbness Xue xu, Phlegm stagnation, xue
stagnation
Cramps in the calf muscles in the evening or at night Liver xue xu, Liver yin xu
Soreness, fatigue or stiffness in the lower back and knees Kidney xu conditions
Hypochondriac tension Liver qi stagnation
Sensation of having a lump that cannot be swallowed in Liver qi stagnation and Phlegm
the throat
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Headache
Headache has not traditionally been a separate enquiry area in terms of pain.
Classically, it has been included in ‘enquiry about the head and body’. Because
it is such a common symptom and because there are so many different types of
headaches, I have chosen to devote a separate category to this area of enquiry.
An acute headache in a person who does not normally suffer from headaches is
usually caused by an invasion of exogenous xie qi. Wind-Cold can result in a tight
or tense headache, Wind-Heat in a throbbing headache and Wind-Dampness in a
heavy headache. This is because Cold is yin and has a contracting nature. Invasions
of Cold will often create a stagnation in the taiyang channels in the head. Heat
has a yang expansive nature and will cause qi to ascend and expand outwards. This
will result in a throbbing sensation. Dampness is very yin and gives an oppressive
sensation by blocking and slowing the movement of qi.
By asking about where in the head the pain is, you will be able to ascertain which
channels are disrupted and possibly what the aetiology of the headache may be.
A unilateral headache will usually be due to an excess of qi or a stagnation of
qi in the Gall Bladder channel. Typically, this is seen when there is ascending Liver
yang or Liver Fire. It can also be seen in Liver Wind patterns. A stagnation of qi and
xue due to physical trauma can also manifest with unilateral headaches. Liver shi
imbalances will often manifest with pain in the temples and pressure behind or in
the eyes. A nagging pain behind the eyes is typical when there is Liver xue xu.
A headache in the vertex of the head is usually a manifestation of a Liver imbalance.
This is because there is a branch of the Liver channel that terminates in the acupuncture
point Du 20. However, this type of headache can also be due to qi and xue xu.
Frontal headaches that are located in the forehead are often caused by Stomach
imbalances, which can be both xu and shi in nature. Phlegm and Dampness are also
typical causes.
A headache in the occiput region is often seen when there is an acute invasion
of Wind-Cold. Chronic headaches in this region are sometimes seen when a Kidney
imbalance manifests in the Urinary Bladder channel. Chronic headaches in this
region will typically be due to stagnations of qi and xue resulting from physical
trauma, for example whiplash injuries or due to stagnations of qi related to Liver qi
stagnation.
Physical traumas can result in xue stagnating in the channels on the head. This
will manifest with a headache that is localised in one or more fixed areas. The pain
does not move and is sharp and stabbing. The trauma does not have to be recent –
the xue stagnation can still manifest many years later.
Dull or nagging headaches are usually seen in xu conditions. There will be a
nagging tiredness in the head. This type of headache is worse when the person is
weary and is more likely to occur later in the day or in the evening. In women, it
may manifest during or after the menstrual bleeding. This type of headache arises
because there is not enough qi or xue to nourish the brain. Xu headaches can be
triggered by activity or exertion but can be relieved with rest.
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A throbbing headache occurs when too much qi rises to the head. This will
usually be ascending Liver yang or Liver Fire.
Phlegm-Dampness can influence in a number of ways. It can block the shen, as
well as preventing pure yang qi from rising up to the head. When shen is blocked
by Phlegm-Dampness, the person will have difficulty thinking clearly. It will feel as
if the head is full of cotton wool or that they are in a bell jar. Phlegm-Dampness is
a shi condition, i.e. there is an excess of qi in the head. This means that there can
be a throbbing or thumping sensation in the head. Phlegm-Dampness is yin in
nature and the head can therefore feel very heavy. The person will also feel tired and
exhausted, but the headache will often be aggravated by the person lying down. This
is because Dampness seeps down to the head when the person is lying horizontally.
Headaches due to shi conditions can arise when there have been periods of physical
inactivity, the lack of physical movement resulting in qi stagnation. A headache that
comes from a person sleeping too much is due to qi or Phlegm stagnation.
Damp or humid weather is detrimental when there is Dampness and Phlegm
and it can trigger a heavy or throbbing headache.
Headaches associated with the person’s emotional condition are usually related
to Liver qi imbalances.
Headaches arising after sex are seen in Kidney xu conditions or when there is
ascending Liver yang.
A headache that is provoked by eating can be due to food stagnation, Phlegm-
Dampness or Stomach-Heat. If the headache is relieved by eating, there will be qi xu.
Liver qi can have a tendency to stagnate in the premenstrual period. Headaches
that have a pattern of occurring in this period are therefore probably due to ascending
Liver yang or Liver qi stagnation.
Menstrual bleeding will exacerbate a condition of xue xu. If there is a tendency
for the headache to occur immediately after or during the menstrual bleeding, it can
indicate that there is Liver xue xu.
Headache
Acute Invasion of exogenous xie qi
Unilateral Ascending Liver yang or Liver Fire, it may also be due to Liver Wind
Temporal headache Ascending Liver yang or Liver Fire, it may also be due to Liver Wind
Headache in the top of Liver imbalances, xue or qi xu
the head
Headache behind the eyes Liver xue xu or ascending Liver yang
Frontal headache Stomach imbalances, both xu and shi, Phlegm-Dampness
Headache in the occipital If the headache is acute, it will usually be Wind-Cold
region If the headache is chronic, it can be a Kidney imbalance manifesting
in the Urinary Bladder channel
It can also be due to muscular tension and tightness, resulting from
either local stagnations of qi and xue or due to Liver qi stagnation
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Whole head It may be an invasion of Wind-Cold if the headache is acute,

otherwise it is usually seen in xu patterns of imbalance
Localised in specific spots Xue stagnation
Acute headache Shi condition
Dull, nagging headache Xu condition
Throbbing headache Ascending Liver yang or Liver Fire, Wind-Heat, Phlegm
Heavy headache Phlegm-Dampness
Stabbing or sharp pain Xue stagnation
Arising from a lack of Liver qi stagnation
physical activity
Occurs when the person Xu conditions
is tired or overworked
Arising from weather Phlegm-Dampness
changes and humid
weather
Triggered by stress and Liver imbalances
emotional influences
Triggered by sex Kidney xu or ascending Liver yang
Premenstrual headache Liver imbalances
Headache after Xue xu
menstruation
Enquiry that is specific to women

Menstruation
There are several areas of enquiry that can help to differentiate the diagnosis in
women: the length, regularity, quality and quantity of her menstrual bleeding; pain
associated with the cycle; physical and emotional changes during the cycle; irregular
bleeding during the cycle. Enquiry must also be made into a woman’s gynaecological
history: the age she started to menstruate; whether there have been any births and
pregnancies, and if so how these were; whether there were any complications and
problems; whether there were any symptoms that arose concurrently or immediately
afterwards. Enquiry must also be made into the use of contraception. Many forms
of birth control can cause imbalances in themselves. Furthermore, the use of the
contraceptive pill or the coil will directly affect her menstrual cycle and bleeding,
and this must be taken into account when considering her replies.
If she is menopausal or post-menopausal, she should be questioned about when
her menstruation ceased and whether there were any discomforts associated with it.
Finally, enquiry should be made about discharge from the vagina.
The information obtained about the menstrual cycle, as well as the gynae-
cological history in general, will be relevant not only to the specific diagnosis of
gynaecological imbalances, but also to the diagnosis in general. It is said that women
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are more difficult to treat because there are so many changes in their physiology and
in the balance of yin, yang, qi and xue throughout the menstrual cycle. On the other
hand, women are easier to diagnose, precisely because of these fluctuations during the
menstrual cycle and the menstrual cycle and bleeding will act as a barometer for
the whole body.
Asking about the menarche (the first menstruation) can give some indication of
the woman’s fundamental constitution. If she has never had a menstrual bleeding or if
she had her first menstruation at a late age, it will be a sign of one or more imbalances.
A girl should begin menstruating at the age of 13 (a woman’s jing cycles are seven years
long). The first jing cycle starts in utero, so a child is, in fact, one year old when born.
The menstruation should start at the beginning of the third cycle, i.e. when she is 13).
If menstruation does not start at around this age, it could indicate that she is jing xu or
xue xu, i.e. there is a lack of substance to create bleeding. It can, though, also be a sign
that there is a stagnation preventing the flow of the menstrual blood.
Enquiry into pregnancies and births will give an idea of the state of her jing.
If there have been complications during pregnancies and births, this can indicate
that there may be Kidney xu, Spleen xu, Heat, qi stagnation and so on.
Repeated and frequent abortions, miscarriages and births can weaken a woman’s
jing and xue. On the other hand, a woman who easily becomes pregnant will have
strong jing and xue.
If she has had difficulty becoming pregnant, it can indicate jing xu, xue xu,
Dampness and Phlegm stagnation, qi stagnation, Heat, Cold, Kidney yin xu or Kidney
yang xu. Infertility is due to: a lack of potential – jing xu; a lack of activation of this
potential – yang xu; a lack of nourishment to the fertilised egg or embryo – qi xu or xue
xu; the nourishment being blocked by some form of stagnation – Dampness, Phlegm,
qi stagnation or xue stagnation; Heat that agitates the egg so it does not unite with the
sperm or the fertilised egg does not settle and attach to the wall of the uterus. If the
woman has miscarried several times, it can be a sign that there is Kidney or Spleen qi
xu, but Heat is also a possibility. A very rough rule of thumb is that if she miscarries
in the first trimester, it can indicate Kidney jing xu (this will correspond to a genetic
defect in Western pathology) and if she repeatedly aborts in the final two trimesters, it
is either Kidney qi xu (the Kidneys failing to control the opening and closing the lower
orifices) or Spleen qi xu (the Spleen failing to hold things up and in place).
Enquiry into the menstrual cycle can be difficult. Some women are very precise
and know the regularity of the bleeding, the quality and quantity of the blood and so
on. Other women take little interest in their cycle and sometimes even assume that
you as the therapist know where she is in her cycle better than she does.
The length of the menstrual cycle is affected by many different imbalances.
Spleen qi xu, Kidney qi xu and Heat can makes the cycle shorter. Heat will agitate
xue, so the walls of the vessels rupture, whilst Spleen qi xu will not hold xue inside
the vessels. The Kidney qi xu can result in the Kidney failing to hold the Uterus
closed, so the bleeding comes earlier.
If there is too little xue to create menstrual bleeding or if anything blocks xue
(such as Cold, xue stagnation or qi stagnation) the menstrual bleeding will be delayed.
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Liver qi stagnation can cause the length of the cycle to be irregular.

A woman should menstruate approximately 45 ml of blood during the menstrual
bleeding. Many women have difficulty judging whether they have normal bleeding,
as they only have experience of their own bleeding and using tampon makes it
difficult to gauge the amount of blood discharged. Asking about how often they have
to change their tampon or pad and which type of pad or tampon they use can give
an indication of the heaviness of the bleeding. Many women also have a reasonably
good idea of the amount of blood there is, especially if they have heavy or scanty
bleeding. Heavy menstrual bleeding can be seen when there is either Heat or Spleen
qi xu due to the mechanisms explained above. Xue stagnation can block the vessels
in the Uterus, causing them to rupture. This too will result in heavy bleeding. Scanty
bleeding is due to xue xu, Cold or xue stagnation blocking the flow of xue.
Menstrual bleeding lasting longer than five days, spotting before the menstrual
bleeding and bleeding in the middle of the cycle are all signs of Spleen qi xu resulting
in xue not being held in the vessels. They can also be signs that Heat is agitating xue
and rupturing the vessels or that there is xue stagnation creating a build up of pressure
so that the walls of the vessels burst.
Enquiring about the quality of the menstrual blood is crucial. Again, some women
can have difficulty answering this question, having seen only their own menstrual
blood. Describing the differences between the various colours and qualities can be
useful. Pale, watery or thin blood can be seen when there is xue xu and qi xu. Very
dark, clotted blood is seen when there is xue stagnation. Qi stagnation will manifest
with smaller clots, whilst Cold stagnation can result in very small, grainy clots that
resemble coffee grounds. If there is a Kidney xu condition, the blood may contain
thin ‘threads’ and if there is Damp-Phlegm, the blood will contain mucus.
Bright, red-coloured blood is seen when there is Heat. Heat can also result in the
menstrual blood being sticky. Brown-coloured blood can be seen when there are xue
xu conditions. Xue stagnation causes the blood to be very dark in colour. If there is
a lot of xue stagnation, the blood will be almost black.
The presence of menstrual pain, its quality and when it occurs are important
differential factors when determining which patterns of imbalance are present.
Pain that starts prior to the menstrual bleeding is seen when there is Liver qi
stagnation. Liver qi stagnation pain is generally characterised by coming in waves
and varying in its intensity. The word many women use for this is ‘cramping’. The
pain can be located in front and on both sides of the lower abdomen. It can also
cause soreness or pain in the lower back and may radiate down the inside of the
thigh. This is because Liver qi stagnation will stagnate qi and xue in chong mai.
The pain seen in xue stagnation is a stabbing pain that is sharper and more
piercing than when there is qi stagnation. Furthermore, whilst qi stagnation pain is
felt in a larger area, xue stagnation pain is localised to one spot, usually the same spot
each time. The pain will be worst at the initiation of the menstrual bleeding and the
pain can sometimes be relieved by the discharge of clots.
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Menstrual pain caused by Cold will resemble xue stagnation pain in some ways.
The pain will be biting and fixed. The similarity to xue stagnation pain is that Cold
will stagnate the movement of xue.
Heat can cause stinging, searing or burning pain.
Dampness will cause a sensation of heaviness and dragging downwards, as if the
uterus is falling out of the body.
Breast tension or pain in the premenstrual period is a sign of Liver qi stagnation.
This is because the Liver channel has a branch that travels through the breasts.
Liver qi stagnation will also often mean that a woman is more irritable during this
period. If she tends to be tearful and weepy in the premenstrual period, it is usually
a manifestation of Liver xue xu. Many women experience both of these types of
mood swings. This just reflects that most women’s Liver qi stagnation arises from a
condition of Liver xue xu.
Some women’s menstrual bleeding has a tendency to stop and start, for example
starting with two days of bleeding, then a pause of a day or two, followed by two
or three days of bleeding. This usually indicates that there is a stagnation of qi
and/or xue.
Stagnant Liver qi can invade the Spleen and disrupt its functioning. This can
manifest with symptoms such as alternating diarrhoea and constipation, nausea,
cravings for sweets and oedema in the premenstrual phase.
The menstrual cycle and bleeding

Late menarche Jing xu, xue xu, stagnation
Difficulty conceiving Jing xu, xue xu, Dampness and Phlegm, qi
stagnation, Heat, Cold, Kidney yin xu or
Kidney yang xu
Repeated miscarriages Kidney xu conditions, Spleen qi xu, Heat
Short cycle Heat (both xu and shi), Spleen qi xu, Kidney
qi xu
Long cycle Xue xu, Cold stagnation, xue stagnation,
qi stagnation
Irregular cycle Liver qi stagnation, Spleen or Kidney xu
conditions
Heavy menstrual bleeding Xu or shi Heat, Spleen qi xu, xue stagnation
Scanty menstrual bleeding Xue xu, xue stagnation, Dampness, Phlegm
Prolonged menstrual bleeding or spotting Heat, qi stagnation, xue stagnation, Spleen qi xu
Menstrual bleeding that stops and starts Qi stagnation, xue stagnation
Thick menstrual blood Shi conditions
Thin menstrual blood Xu conditions
Thin, watery blood Xue or qi xu
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Clots in the menstrual blood Stagnation (fresh glistening clots suggest Heat
and dark and dull clots suggest xue stagnation)
Murky menstrual blood (that looks as if it Stagnation due to Cold
contains coffee grounds)
Bright, red-coloured menstrual blood Heat
Black-coloured or very dark menstrual blood Xue stagnation
Brownish-coloured menstrual blood Xu conditions
Sticky menstrual blood Yin xu or Heat
Mucus in the menstrual blood Phlegm
Strong, rotten or foul-smelling menstrual blood Damp-Heat or Fire
Pain before menstruation Qi or xue stagnation
Pain during menstruation Xue Heat, xue stagnation
Pain or discomfort after menstruation Xue xu
Strong, cramping pain just before or during Stagnation conditions
menstruation
Shooting, stabbing or piercing menstrual pain Xue stagnation
Nipping or biting menstrual pain Cold
Heavy or dragging menstrual pain Dampness
Burning or searing menstrual pain Heat
Bleeding occurs suddenly Xue Heat
Delayed bleeding or prolonged bleeding but Xue stagnation
without the bleeding being heavy
Menstruation with a distended sensation, the Dampness, qi or xue stagnation
menstrual bleeding takes a while getting started
Premenstrual breast tension Liver qi stagnation
Irritability and aggressiveness in the Liver qi stagnation
premenstrual phase
Tearful and sensitive in the premenstrual phase Liver xue xu
Alternating diarrhoea and constipation, Liver qi invading the Spleen
nausea, cravings for sweets or oedema in the
premenstrual phase
Vaginal discharge
A light vaginal discharge that is transparent and increases in volume, thickness and
elasticity around ovulation is normal. It is also normal that the discharge increases in
puberty and during pregnancy.
Vaginal discharge is differentiated according to its colour, consistency and smell.
Discharge that is heavier in volume than normal, not odorous and watery,
transparent or white will be a manifestation of Kidney yang xu or Spleen yang
xu. Kidney yang should control the lower orifices, as well as transforming and
transporting the fluids in the body. If Kidney yang fails to do this, Dampness will
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arise and seep down to the lower jiao. Because the Kidneys are not able to control
the lower orifices, the Dampness will leak out of the body. Spleen yang xu can also
result in an increased volume of discharge from the vagina because Spleen yang is
also involved in the transformation and transportation of fluids in the body. Spleen
and Kidney yang xu are often seen together.
If there is shi Cold or Damp-Cold, the discharge will still be whitish, but it will
be thicker in consistency and the discharge will smell slightly of fish.
If there is Heat present, the discharge will not only be thicker and stickier, but
it will also be yellowish and odorous. The more Heat that there is, the thicker and
more odorous the discharge. The colour of the discharge will also be darker. When
there is Toxic-Fire, the colour of the discharge can become greenish.
Vaginal discharge
Yellowish and odorous discharge Damp-Heat
Whitish or transparent discharge Cold, Spleen yang xu, Kidney yang xu
White and red discharge Damp-Heat
Greenish discharge Damp-Heat in the Liver channel or Toxic-Fire
Discharge with a watery consistency Damp-Cold or Kidney xu conditions
Discharge with a thick consistency Damp-Heat
Odorous discharge Heat
Sexuality
While not an outright gynaecological issue, and not an issue that was traditionally
enquired about, a woman’s sexual desire and functionality can reveal important
information. It is not a question I always ask. Some clients, though, do give informa-
tion that is relevant to the rest of the diagnosis. It is important to maintain the
client’s trust and respect and not overstep their boundaries. A woman who has come
with tinnitus may not see the relevance of being asked about the moistness of her
vagina and could feel violated.
Sexual desire
Our sex drive or libido is governed by the flaring up of the mingmen when it is
activated by heat from the Heart. This is cooperation between the Imperial fire
and the Ministerial fire. This is dependent on both the Heart and Kidneys being in
balance.
When we are sexually aroused, there is an increase of heat in the body. This
requires yang. The increase in heat is seen in the cheeks, lips, nails and so on becoming
red, and the skin feels warmer when we are aroused. Heat and yang from the Heart
and mingmen fills the genitals.
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Clear and unimpeded communication between the Kidneys and Heart and a
strong Kidney yang are essential. If Kidney yang is weak, there will be a lack of libido
due to the lack of heat from the mingmen. If Kidney yin is weak, it will not be able
to control the heat in the Heart, and there may be an excessive sex drive. Heat in the
Heart can also arise from other sources.
If the Heart is xu, such as when there is sadness for example, the Heart will not
activate the mingmen. This is typically seen in relationships where a woman believes
she has lost her sex drive. If this relationship ends and she finds a new partner, often
there are no longer problems with her libido.
Liver qi stagnation may also play a role in the lack of libido, because when Liver
qi stagnates there can be a stagnation of qi on all levels.
Lack of self-confidence and low self-esteem may also be factors that affect the
Heart qi.
Orgasm
Liver qi plays a major role in the orgasm and controls the muscles in the genitals.
If there is Liver qi stagnation, a woman may have difficulty achieving orgasm. Her
stagnant Liver qi causes her to have difficulty letting go. It often becomes a vicious
circle. Orgasms are an excellent way to release stagnant qi. Qi accumulates more and
more until the orgasm liberates it. If the woman does not achieve an orgasm, there
is only the accumulation of qi without release. This in itself will stagnate Liver qi. At
the same time, it can be emotionally frustrating not to achieve an orgasm. This will
further stagnate Liver qi.
A lack of yang can also play a role. There needs to be sufficient yang heat to create
sexual arousal and desire in the first place. To create an orgasm, this heat must be
sent down from the Heart. If there is not enough yang or if the Heart is weak there
can be difficulty in achieving orgasm.
A headache that arises immediately after the orgasm can be a sign of ascending
Liver yang, rebellious qi in the chong mai or Heart Fire. This is because the sudden
release of qi will rise up to the head.
Vagina
The Liver channel traverses the area around the genitals and its luo channel runs
to and through the vagina. Stagnant Liver qi can cause the muscles in the vagina to
become so tense that intercourse is painful or not possible, such as when there is
vaginitis and vulvodynia.
If there is Kidney yin xu, the mucous membranes become dry. Many menopausal
women suffer from dry mucous membranes in the vagina. This is because yin and
xue have dried out in the ren mai, which passes through the vagina. This will result in
the mucous membranes of the vagina not being lubricated. Dry mucous membranes
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can also be seen in younger women who are Kidney yin xu or xue xu or where Heat
has damaged jinye.
Discharge from the vagina has been discussed in the section above.
Female sexual function

Lack of libido Kidney yang xu, Heart qi xu, Heart yang xu, Liver qi
stagnation
Excessive sex drive Heat
Lack of orgasms Liver qi stagnation, yang xu, Heart qi xu
Headache immediately after orgasm Ascending Liver yang, rebellious qi in chong mai, Heart Fire
Tense vaginal muscles Liver qi stagnation
Dry vaginal mucous membranes Yin xu, xue xu, Heat
Enquiry that is specific to men

Potency, sexual desire and fertility
Potency and sexual desire is influenced not only by Kidney jing and Kidney yang,
but also by other physiological and pathological factors.
In order to create and maintain an erection, qi and xue must flow out into the
penis. This requires that there is sufficient qi and xue, and that these are not inhibited
in their movement. The man’s shen should be in harmony so that it can focus on his
sexual desire. Heart fire travels down through chong mai to the penis, manifesting with
a sensation of heat in the penis. Finally, Kidney yang sends Kidney jing through the
penis, resulting in an ejaculation.
Kidney yang governs the functional activity involved in an erection. At the same
time, sexual desire or arousal is dependent on Kidney yang. Heart qi xu and Liver
qi stagnation can also manifest with a weak libido due to either a general lack of
passion or a tendency to suppress emotions. A person with Heart qi xu will often be
timid and nervous, which can affect their ability to achieve or maintain an erection.
Liver yin, and thereby to a certain degree Liver xue, shares a common root with
Kidney yin. This means that Kidney yin xu can affect the Liver’s ability to supply the
penis with xue and thereby the ability to create an erection.
Kidney jing influences a person’s reproductive ability. This manifests mainly
in their sperm count and the quality of sperm, but it also influences the volume of
the semen.
The Liver has several functions in relation to an erection. The penis itself is
conceived of as being a tendon in Chinese medicine and thereby under the influence
of the Liver organ, which nourishes and controls the tendons. The Liver channel
traverses the genitals. Furthermore, the Liver ensures that there is enough xue to fill
the penis so that it becomes rigid. Liver qi also ensures that qi and xue flow out into
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the penis. This is evident when periods of stress, frustration or anger affect some
men’s ability to achieve an erection.
The Heart governs xue in general, and during an erection the Heart sends xue
down to the penis. An erection is also dependent on the Heart fire being sent down
through chong mai to the penis. It is therefore important that a person’s shen is
harmonious. A typical example of an unsettled shen affecting the erection is seen
when a man has performance anxiety.
Kidney yin xu and Heart xu conditions can also manifest in a man being able to
achieve but not maintain an erection, with the penis quickly becoming limp.
The Stomach and Spleen ensure that there is a sufficient production of qi and
xue. A qi xu condition in these organs could lead to there not being enough qi
and xue to create an erection or to nourish the penis, which is a tendon, so it becomes
weak and limp.
Damp-Heat can block the movement of qi and xue in the genitals
Uncontrolled ejaculation and low sperm count

Premature ejaculation or uncontrolled ejaculation can arise when there is either not
enough qi and yang to hold the semen back or too much yang in the form of Heat,
which drives the semen outwards. Too much yang can be a shi or xu condition.
Traditionally, sperm quality was not something that could be quantitatively
measured. The only thing that could be observed was the consistency, colour and
quantity of semen. By combining modern analytical techniques and traditional
knowledge, it is now possible to differentiate the relevant imbalance patterns when
diagnosing poor sperm quality. Kidney jing xu, and in some cases xue stagnation,
can manifest with a low sperm count, sperm that are malformed or sperm that have
a short lifespan. Kidney yang xu can manifest with poor sperm motility. Thin and
watery seminal fluid can also be a sign of Kidney yang xu. Seminal fluid that is thick
and sticky is more typical of Dampness, especially Damp-Heat. Damp-Heat can
also make seminal fluid yellowish or too acidic.
The prostate
The prostate is not directly visible and was therefore not traditionally enquired about
during diagnostic questioning. Nevertheless, many older male patients might report
that they have an enlarged prostate, or it may even be the reason that they seek
treatment. An enlarged prostate can become stiff and rigid. In Chinese medicine,
this would indicate some form of stagnation, i.e. qi stagnation, xue stagnation,
Dampness or Phlegm.
The muscles of the Urinary Bladder have to compensate for the prostate’s
narrowing of the urethra. From a Chinese medicine perspective, this means that it
will require more Kidney yang qi to expel the urine from the Urinary Bladder. This,
though, is a time in a man’s life when his Kidney yang qi is in decline.
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From the age of 40 onwards, many men experience various disorders resulting
from the growth in size of the prostate. The prostate grows because there is an
increasing stagnation of xue and Phlegm in the area. Typical symptoms of this
increased growth are: nocturnal urination (nocturia); frequent and urgent, but at
the same time scanty or incomplete, urination; dribbling after urination; cloudy
urine, weak urinary flow and possibly blood in the urine. The fact that various
symptoms associated with a Western medicine diagnosis of an enlarged prostate start
to appear when a man is middle-aged or older harmonises with the Chinese medicine
concept of a progressive weakening of the Kidney yang and a concurrent increase in
the stagnation of Phlegm, Dampness, xue and qi, the older a man becomes.
Genitals
A man may report symptoms that relate directly to his genitalia.
Genital pain can result from Liver qi stagnation, Damp-Heat or xue stagnation.
The Liver channel traverses the genitals, so a stagnation of Liver qi can result in
soreness or pain in the genitals and inguinal area. Xue stagnation in the area will often
arise from physical traumas or surgical operations in the area but can also be due to a
stagnation of qi. Xue stagnation is more likely to manifest as a sharp, localised pain,
rather than tenderness, tension or soreness in a larger area. Damp‑Heat can seep
down to the genitals and block the movement of qi and xue in the area. Damp-Heat
is more likely to manifest with a burning pain or tenderness in the area.
Damp-Heat seeping down to the lower jiao can also manifest with sweaty or
sticky genitals.
Cold genitalia can be seen when there is shi cold or yang xu.
Male imbalances
Lack of libido Kidney yang xu, Heart qi xu, Heart yang xu, Liver qi stagnation
Excessive sex drive Heat
Lack of orgasms Liver qi stagnation, yang xu
Impotence Kidney xu conditions, Heart xu conditions, Liver qi stagnation, qi
and xue xu
Uncontrolled ejaculation Kidney xu conditions, Heat conditions, Heart imbalances
Poor sperm quality Kidney xu conditions, Damp-Heat, xue stagnation
Prostate problems Kidney xu conditions, Phlegm, xue stagnation, Liver qi stagnation,
Damp-Heat, Damp-Cold
Tenderness or pain in the Liver qi stagnation, xue stagnation, Damp-Heat
genitalia or inguinal area
Cold or moist genitals Shi or xu Cold conditions
Sweaty and sticky genitals Damp-Heat
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Enquiry with regard to the emotions and mental state

Chinese medicine defines seven primary emotions that each have their own specific
qi dynamics. These qi dynamics will resonate with, whilst affecting, the various
zangfu organs. This means that the emotions are aetiological factors, as well as being
manifestations of imbalances in specific organs. That Chinese medicine only defines
seven emotions can sound slightly simplistic. These seven emotions should, though,
be perceived of as being primary emotions in the same way that there are only
three primary colours. The various combinations of the three primary colours can
manifest as the infinite myriad of colours that we can see with our eyes. In the same
way, all the emotions we experience contain varying elements and combinations of
these seven primary emotions. The specific qi dynamics of the various emotions are
described in The Fundamentals of Acupuncture (Ching 2016).
Enquiring about a person’s emotional life can give an indication of the state of the
various zangfu organs, as well as possibly revealing relevant aetiology. It is, though,
important to be conscious of a person’s boundaries and to exhibit tact when enquiring
about a person’s emotional universe. Furthermore, we must also be conscious of our
therapeutic limitations. We are practitioners of Chinese medicine and not trained
counsellors. That said, although we ask about the emotions from a diagnostic
perspective, we will often affect the emotions therapeutically by our treatment of the
organs involved. For example, by treating acupuncture points such as Liv 2 and Pe 6,
we harmonise the Liver, drain the Heat from the Liver and Heart and help to get the qi
flowing freely. This will affect the mood of a person with Liver and Heart qi stagnation,
who is irritable, short tempered and impatient. It will often result in them acting and
reacting differently in situations that previously resulted in conflict, which thereby
increased their levels of Liver qi stagnation, thus breaking a vicious circle.
Shi conditions in an organ will often manifest with a certain emotion being
dominant or difficult to control, such as anger when there is Liver Fire. A xu
condition or a stagnation of an organ’s qi can result in a person having difficulty
manifesting certain emotions.
Generally, I tend not to ask directly about the seven emotions, but instead I
enquire about various mental and emotional aspects of a person’s life and in this way
get a sense of how the seven emotions are manifesting.
The emotional aspects that I personally enquire most often about are:
• worry, speculation and obsessive thinking
• anger, irritability, quick temper and impatience
• mood swings
• depression
• anxiety
• the ability to say no and set boundaries and assertiveness.
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Furthermore, I ask about their memory, ability to concentrate, mental restlessness

and brain fog.
A person with Spleen qi xu or Dampness will often express that they have a
tendency to worry a lot or that they speculate about things, pondering and thinking
in circles. They will have difficulty letting go of thoughts again. Due to the weakness
of their Spleen, they will have difficulty digesting information and transforming
this information into knowledge. This will be reflected in the fact that they have to
rerun the information through their head repeatedly in an attempt to extract what
is relevant and useful.
Mood swings are often seen when there is Liver qi stagnation. There is no stability
to the emotions because the Liver is not ensuring that the qi is flowing smoothly.
Heat in the Liver will manifest with irritability and the person can have a
tendency to be temperamental and have a quick temper or be impatient. They will
have a quick temper because anger is the emotion that resonates with Liver.
Severe stagnations of Liver qi can lead to a depressive condition. This is because
Liver qi stagnation can prevent the movement of the hun. This will result in a person
having difficulty seeing a future ahead of them. They cannot conceive of a future or
a situation that is better than the emotional pain that they are feeling at the moment.
When there is Liver qi stagnation, you can sometimes sense that there are pent-up
emotions when the client describes their life.
Phlegm can also lead to depression. Here the shen becomes blocked and
smothered. The person will have difficulty connecting to other people. The person
can also seem torpid and difficult to engage.
Heart qi stagnation and xue stagnation can also result in a person’s shen having
difficultly emanating outwards and connecting to other people. At the same time,
the stagnation of qi in the Heart can manifest with a lack of joy.
Heart xu conditions can also lead to depression or depressive conditions. When
the Heart is harmonious, it manifests joy. If there is Heart qi xu, there will be a lack
of joy and the person will be gloomy and sad. Conversely, if the client says that they
have lacked joy or love in their childhood and in adult life, this can lead to Heart
qi xu.
The Lung is affected by grief and melancholy. This can also be an aspect of a
depressive condition. The person may mention a specific event that their condition
can relate to, but it can also be something that is very far back in the past. Grief and
loss do not, of course, have to manifest as depression. If a client talks of grief or loss,
it may be something that has affected their Lung qi. The Metal Phase gives us the
ability to experience but also let go of grief and loss so we can move on. If the Metal
Phase is not in balance, its qi will not flow and the person will have difficulty letting
go of grief.
I usually ask patients whether they are good at saying no and setting boundaries.
Liver xu conditions and Liver qi stagnation can manifest, to some extent, in a person
having difficultly saying no and setting boundaries. Conversely, by not being able to
set their boundaries, they will often develop a stagnation of Liver qi.
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Mental restlessness, and its extreme form – mania, is a sign of Heat agitating the
shen so the person has difficulty concentrating and being tranquil.
Anxiety may be related to certain situations or objects. It may also be undefined.
Anxiety will weaken Kidney and Heart qi, but in itself is often a manifestation of
Heart and Kidney imbalances.
The memory depends on jing, shen, xue, zhi and yi. A poor memory can therefore
be a reflection of imbalances in the Kidneys, Heart and/or Spleen. Usually it will be
a xu condition, but Phlegm and xue stagnation can also block the shen and thereby
the memory. Shock can also dissipate the shen and lead to amnesia.
Difficulty concentrating is seen when the Heart and the brain are undernourished,
blocked or agitated. This means that Heart qi xu, Heart xue xu and Kidney jing
xu can manifest in poor concentration. The person will often feel ‘empty headed’
and a bit dazed. Heat in the body will always ascend due to its yang nature. Heat
will agitate shen, causing the person to have difficulty concentrating due to mental
restlessness and many thoughts filling the head. Spleen qi xu can also cause a person
to have difficulty concentrating, because the weakening of their yi will result in them
having difficulty focusing their thoughts. Dampness and Phlegm can also mean
that there is difficulty concentrating, because the person feels that their brain is
wrapped in cotton wool. The blockage resulting from Phlegm-Dampness means that
information and impressions have difficulty penetrating into the Heart. If I suspect
that a client has Phlegm-Dampness, I ask them if they have a foggy or blurred
sensation in the head as if there is a blanket smothering their mind or the sensation
of being locked in a bell jar. This is the sensation most of us recognise from when we
have had a heavy cold or have been hung-over.
Mental-emotional signs
Depression Liver qi stagnation, Heart imbalances, Phlegm
Speculation, worry, thinking in circles Spleen qi xu, Dampness
Anxiety Heart and Kidney imbalances
Wrath, anger, quick temper, impatience Heat in the Liver
Difficult saying no and setting boundaries Liver xu patterns and Liver qi stagnation
Mental restlessness Heat
Mood swings Liver qi stagnation
Poor memory Heart xue xu, Kidney jing xu, Spleen qi xu, Phlegm-
Dampness
Difficulty concentrating Heart xue xu, Kidney jing xu, Phlegm-Dampness,
Spleen qi xu, Heart Fire, Phlegm Fire, Heat
Foggy and slurred sensation in the head Phlegm-Dampness
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Lifestyle and diet

Enquiry involves asking not only about physical and emotional signs and symptoms,
but also the person’s medical history. It is also relevant to ask about a person’s lifestyle
and diet, which includes: what they typically eat; how much and how often they
eat; how much they exercise; how much stress they have; how much relaxation
they get; their consumption of stimulants such as coffee, tobacco and alcohol. This
information will inform us about possible aetiological causes. At the same time, it
will give us an idea of what to recommend to the client with regard to supporting
the treatment.
The diet is an incredibly important aetiological factor in many imbalances. It is
therefore important to ask about what people eat in general. I usually get the client
to tell me what they eat during a typical day and afterwards I ask more specifically
about certain dietary factors such as dairy products, sugar, raw vegetables, hot spices,
alcohol and so on that could have a relevance to their diagnosis. The dynamics of
dietary factors is discussed in The Fundamentals of Acupuncture (Ching 2016).
Eating too much at a time, too often or too late in the day, as well as not chewing
the food enough, can lead to food stagnation and weaken the Stomach and Spleen qi.
Exercise is extremely important, and a person who does not get enough physical
movement will tend to develop stagnation conditions. If they have a certain working
position, such as sitting still all day, it will put a strain on specific organs, in this case
the Spleen.
Too much exercise, on the other hand, can weaken a person’s qi and xue. Certain
forms of exercise will have a negative effect on the specific imbalances. Lifting
heavy weights will weaken Kidney yang. Swimming or playing sports in cold, damp
environments will have a negative effect on Cold and Dampness conditions.13
Exercise in which a person sweats profusely is not good for people who are qi xu,
yin xu or xue xu, because qi and fluids are lost through the sweating. Extreme sports
where the person gets an adrenaline rush consumes their jing. The ‘mental rush’ they
experience is jing that has been transformed into shen.
Many people are conscious of the need to get sufficient exercise, but unfortunately
fewer people are aware of the importance of getting enough rest – both physical and
mental rest. We typically live very yang lifestyles and have little yin time in our daily
lives. We need to balance all our yang activity with yin rest and contemplation.
Unfortunately, many people think that they get relaxation and stress relief by
watching television or sitting in front of a computer. Here, they only get physical
rest but are still mentally stimulated. It is good to recommend that people begin
to cultivate meditation, qi gong, tai ji or yoga. If you suspect that they will have
difficulty accepting things that sound so foreign and mysterious, you can propose
instead that they take time daily to really unwind by lying down or sitting completely
still, emptying their head of thoughts and concentrating on their breathing. It is
especially important in the evenings and at night to cultivate calm and tranquillity.
One might be tempted to claim that the invention of electric lighting has in fact
had a fundamentally negative impact on people’s yin. In the past, people only had
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limited opportunities to be active after nightfall, often just staring into the flames of
a fire. Now they can stay physically and, especially, mentally active throughout the
yin period of the night.
Stimulants such as tobacco create Phlegm and Heat in the Lung and injure the
yin. Alcohol creates Heat in the Liver and Stomach, as well as producing Dampness
and Phlegm. Coffee activates Kidney jing, which is transformed into yang qi.
Coffee therefore weakens both Kidney yin and Kidney yang. It overstimulates the
Heart yang and thereby weakens the Heart yin. Illicit substances such as marijuana,
cocaine, amphetamines and so on generally have a draining effect on the Kidney
jing, spreading and thereby weakening Heart qi.
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Part 2
THE DIAGNOSTIC
MODELS
INTRODUCTION TO THE
DIAGNOSTIC MODELS
Chinese medicine has developed various diagnostic models to classify and structure
the information that has been gathered through the use of the four diagnostic pillars.
Using the diagnostic models allows the practitioner to see connections and patterns
in the diverse signs and symptoms that have been collected. In Chinese medicine it
is the overall picture that is the most important, not the individual symptoms and
signs. All signs and symptoms have relevance, but it is the context and the relationship
between them that is the most important, not the individual components.
The diagnostic models can be used as a template that can be placed over the
symptoms, enabling the practitioner to gain an impression of the correlation between
the symptoms and signs.
Several diagnostic systems have arisen throughout the history of Chinese
medicine. The various diagnostic models should not be seen as alternatives to each
other, but as indispensable elements that supplement each other. The same situation,
the same symptoms and the same signs can be analysed and described from several
diagnostic perspectives at the same time. Using more than one diagnostic model at
a time creates a more accurate and precise picture of the person and the imbalances
that they are presenting. If, for example, a person coughs, we can use the model of
zangfu diagnosis. In this diagnostic model, the person will be diagnosed as presenting
with a Lung imbalance. This, in itself, is not a precise enough diagnosis upon which
to base a treatment. It is necessary to know: whether it is a xu or shi condition
(Eight Principles diagnosis); if there is Phlegm present (diagnosis according to xie
qi); if there is Heat or Cold (Eight Principles diagnosis); whether there is qi xu or qi
stagnation (diagnosis according to qi, xue and jinye); whether there is yin xu (Eight
Principles diagnosis); whether the cough is due to an invasion of Wind-Cold or
Wind-Heat (diagnosis according to xie qi, the Six Stages, or the Four Levels) and
so on. Each time you add an aspect of another diagnostic model to the diagnosis,
it does not complicate the picture; on the contrary, the image becomes clearer. By
refining the picture as much as possible, it not only gives a more solid foundation
for treating the disorder most effectively, it also helps to give an impression of how
the condition may have arisen, i.e. what the cause of the disorder is. It is important
to remember that the imbalance patterns we diagnose are not the cause of the
disorder. The causes of the disorder are the factors that gave rise to these patterns of
imbalance. These are the aetiological factors. There is often not just one aetiological
factor but a mixture of several factors. This is especially the case in interior patterns
of imbalance.
The diagnosis tells us how we should treat the patient. The diagnosis determines
the treatment principle. If a person is diagnosed as being Lung qi xu, the treatment
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Introduction to the Diagnostic Models
principle is to strengthen or tonify their Lung qi. When we have a treatment principle
we can construct a treatment strategy. When we should strengthen Lung qi, as in
the above example, we can use herbs or acupuncture points and techniques that
tonify Lung qi. This could, for example, be achieved by needling the acupuncture
points Lu 9 and UB 13 with a tonifying needle technique or prescribing the
herbal prescription Bu Fei Tang. Furthermore, once we are also able to identify
the aetiological factors that have led to creation of a pattern of imbalance, we can
offer the client appropriate advice and this is often where the greatest possibility for
healing is to be found.
The diagnostic models utilised in Chinese medicine are:
1. diagnosis according to the Eight Principles
2. diagnosis according to xie qi
3. diagnosis according to qi, xue and jinye
4. diagnosis according to the zangfu organs
5. diagnosis according to the Six Stages
6. diagnosis according to the Four Levels
7. diagnosis according to san jiao
8. diagnosis according to the channels
9. diagnosis according to the Five Phases.
It is important to remember that the symptoms and signs that are listed in each
pattern of imbalance are the possible symptoms and signs. For example, the signs
and symptoms listed in the diagnosis of Kidney yin xu are: dry mucous membranes,
dry mouth and throat, night sweats, poor memory, nocturnal emissions, premature
ejaculation, infertility, tinnitus, poor hearing, deafness, dry eyes, weak or sore knees,
lumbar soreness or pain, thin body, scanty and dark urine, anxiety, depression,
dizziness, a thin, dry tongue that lacks coating, possibly with cracks in the surface
of the tongue, and an Empty or Fine pulse. It is highly unlikely that we will see
someone with all these symptoms and signs. We will probably only see three or four
of the signs and symptoms that are listed. Kidney yin xu can be diagnosed just by
the person having lumbar soreness, sore knees, tinnitus and a dry, red tongue that
has a cracked surface.
It is important to remember that a person will very rarely manifest only a single
pattern of imbalance. It is normal that a person presents with several patterns of
imbalance simultaneously. A client who seeks treatment will typically manifest
between five and nine imbalances simultaneously.
If we continue with the example of a person who is Kidney yin xu and add two
further patterns – ascending Liver yang and Phlegm – in addition to having some
of the above symptoms, the person could have migraines, a quick temper, a slippery
pulse, poor appetite, vertigo, lethargy and difficulty waking up in the morning.
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Furthermore, several of these symptoms and signs will be worse after consuming
dairy products. This, of course, makes diagnosing clients much harder and more
complicated. The more chronic the disorder, the more complex the mixture of
patterns of imbalance is likely to be.
It is important to remember that when we make a list of the various symptoms
and signs, it is a snapshot, a static image. The body and the organs’ relationships
are dynamic processes where things are constantly influencing and being influenced
by each other. Therefore we must not limit our understanding of an imbalance to
only the possible aetiological factors, but should also understand how other organs
and bodily substances could be involved, how the current situation may develop and
what measures we should take in this case.
The acupuncture points that are discussed under each imbalance should be
viewed as a treatment suggestion. You do not need to use all the points listed and
other acupuncture points could be equally valid if their actions and indications are
relevant. The same is true of the guiding herbal prescriptions.
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Section 5
DIAGNOSIS ACCORDING TO
THE EIGHT PRINCIPLES
Diagnosis according to the Eight Principles is relatively new. It was first described as
a single model in the early Qing dynasty, around the year ce 1680, by Cheng Zhong
Ling. The differentiation of individual principles is, however, seen in books as old as
the Huang Di Nei Jing and Shang Han Lun.
In the Eight Principle diagnosis, the patterns are differentiated in relation to four
opposite pairs. These pairs are: yin and yang; Hot and Cold; interior and exterior; xu
and shi. Each element has specific symptoms and signs that characterise it and these
symptoms and signs are used to differentiate it from its counterpart. If there is Heat,
for example, there may be symptoms and signs such as thirst, dark urine, a red face,
a rapid pulse and a red tongue. If there is Cold, there will be no particular thirst, the
urine will be clear, the face pale, the pulse slow and the tongue pale.
The Eight Principles are ultimately only two principles – yin and yang – where
the other six principles are subcategories or refinements of these two principles.
Diagnoses would be incredibly simple but not very useful if we just differentiated
between yin and yang, so it is necessary to further refine and differentiate the
symptoms and signs. It also means that the six subcategories can be combined
in many different ways. This makes situations more complex, because you can,
for example, combine yin categories such as ‘interior’ with yang qualities such as
‘Heat’, and you can then combine this with xu or shi. The image becomes three
dimensional and more intricate.
As described, the pairs can be combined in varying combinations. Furthermore,
it is not necessary to utilise all four differentiations to create a diagnosis. It is enough,
for example, in an invasion of Wind-Cold to state that it is ‘exterior shi Cold’ or,
if there is xue xu, to state that there is an ‘interior xu’ condition. A diagnosis will
frequently consist of multiple, simultaneous, individual diagnoses. There may also
be contradictions within the same category. It’s not an either/or differentiation, but
can quite easily be a both/and diagnosis. For example, you can have both interior xu
Heat and Exterior shi Cold at the same time (this could be a person who is Kidney
yin xu who has been invaded by exogenous Wind-Cold).
Diagnosis according to the Eight Principles is the basis of all TCM diagnoses.
The difference between this and other diagnostic models is that the Eight Principles
can be and is used every time we make a diagnosis. All differentiation relies on the
distinction between the Eight Principles. Other diagnostic models are relevant in
specific situations and usually involve the Eight Principles in their diagnosis. If,
for example, when making a diagnosis according to qi, xue and jinye, you have
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diagnosed xue xu, it is implicit in this diagnosis that it is an interior xu condition

according to the Eight Principles.
The Eight Principles may appear to be very simplistic but because these principles
are involved in all diagnostic scenarios and because the individual components of the
situation are differentiated separately, there is no situation too complex to be analysed
using the Eight Principles. On the contrary, when something appears to be complex
and confusing, you can always take a step back and assess the entire situation from an
Eight Principles perspective. There are often situations where there are many different
symptoms and signs and it is difficult to gauge which organs are involved and whether
it is qi or xue that has stagnated or whether there is Phlegm and so on. In these situations
you can always ask yourself: What is the overall impression? Is it an interior or exterior
condition? Is it xu or shi? Hot or Cold? and then proceed again.
The Eight Principles form the foundation of all treatment strategies and
acupuncture point selections.
The Eight Principles are also a way of clarifying a diagnosis. For example, if
a patient coughs, we know that it is a Lung imbalance. Because they cough, we
also know that there is rebellious qi. To treat the cough though, it is important to
know whether the imbalance is the result of interiorly generated or exogenous xie
qi, whether it is a xu or a shi condition and whether there is Heat or Cold. All of
these things will help to determine which acupuncture points or herbs are used and
whether the acupuncture points should be tonified or drained.
Using the Eight Principles in practice requires flexibility. One must accept that
there may be contradictions within the same diagnosis. One must learn to understand
the dynamics and the relationship between the individual components. This means that
it is then possible to accept contradictions such Heat and Cold, xu and shi, interior and
exterior, not just in the same patient, but also in the same disorder. It is important to
perceive and comprehend the imbalances as dynamic processes of change. Imbalances
create new situations that in the final end can be the opposite of themselves. The
following example considers Spleen yang xu: the Spleen is in the interior, so this is an
interior imbalance; yang xu is a xu condition; because it is yang that is xu, there will
be a lack of physiological heat. Spleen yang xu is therefore an interior yang xu Cold
condition. Spleen yang xu will often lead to the formation of Damp. Dampness is a
form of xie qi and is therefore something other and more than the body’s zheng qi, so
it is a shi condition. The Dampness is in the interior. This means that Dampness is
therefore defined as being an interior shi condition. Dampness is yin in nature but,
on the other hand, it is neutral in its temperature. Dampness is therefore an interior
yin shi condition but is neither Hot nor Cold. Spleen yang xu resulting in Dampness
is thereby a condition of interior yang xu Cold and interior yin shi at the same time.
Patterns of imbalance are not static but are dynamic and mutable. It is a
fundamental principle of the Universe that yin and yang transform into each other.
Therefore, one pattern can transform to another. Cold can transform to Heat; shi
conditions can injure the body and thereby create a xu condition; exterior imbalances
can become interior, and so on. In the above example, Spleen yang xu could easily
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Diagnosis According to the Eight Principles
have arisen after an Invasion of exterior shi Cold, and the resulting Dampness could
lead to the creation of Damp-Heat.
Even though a diagnosis will usually comprise multiple components, for
example interior yin xu Heat or exterior shi Cold, it is important to understand
the dynamics of each separate aspect of the Eight Principles. For the sake of clarity,
it is therefore necessary in the following sections to discuss each aspect separately.
These individual aspects are, though, inextricably integrated with each other and
the various combinations of these eight components will each have their own
unique manifestations. There are, for example, significant differences, not only in
the symptoms and signs of Cold and Heat, but also in the symptoms and signs that
manifest when there is xu Heat and shi Heat or when there is interior Heat and
exterior Heat, as differences between interior shi Heat and exterior shi Heat, interior
xu Heat and interior shi Heat and so on. It is important to have this in mind when
you read the following sections.
I have tried to be comprehensive in describing the aetiology, symptoms, signs
and treatment of the various patterns, but, for the sake of space and clarity, I have
chosen not to go into too much detail with regards to the various sub-patterns.
Instead, I refer the reader to the relevant sections in the other diagnostic chapters.
Interior and exterior imbalances

The differentiation here is between where in the body the imbalance is located, not
what it is that has created the imbalance. An invasion of Wind-Cold is an exterior
imbalance, not because it is exogenous xie qi that has created the imbalance but
because the imbalance is manifesting in the body’s exterior aspect, more specifically
in the wei qi aspect. This means that even if an imbalance is caused by the presence
of an exterior pathogen, if this exogenous xie qi is located in the interior aspect of
the body, it is by definition an interior pattern.
As well as identifying in which aspect of the body an imbalance is located, interior
and exterior will often give an indication of how serious an imbalance is. Exterior
imbalances are usually less serious than interior imbalances, because it is the zangfu
organs and the vital substances that are affected when there is an interior imbalance.
Exterior imbalances
In exterior imbalances, the symptoms and signs are manifesting in the channels,
between the skin and muscles (wei qi aspect) or in the skin, muscles and tendons.
It is always necessary to incorporate other principles into the diagnosis of exterior
imbalances, such as whether there is Exterior Heat or exterior Cold or whether it is
an exterior xu or an exterior shi condition.
Exterior imbalances are often, but not always, acute. They are usually caused
by invasions of exogenous xie qi. Typical examples of such patterns are invasions of
Wind-Cold or Wind-Heat.
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An example of a chronic exterior imbalance is when xie qi blocks the channels.

This will result in ‘bi syndrome’ or painful blockage syndrome. The Western diagnosis
of arthritis would, for example, fall within this category.
Skin disorders are not necessarily exterior imbalances. Eczema, psoriasis, acne
and so on are often caused by xue imbalances and interior Heat. This means that
they are usually exterior manifestations of interior imbalances.
Exterior patterns will usually have little or no impact on the functioning of the
zangfu organs.
Acute exterior imbalances

An exterior condition will typically be a shi condition. This is because acute exterior
conditions are usually due to the presence of xie qi. There may well be a concurrent
xu condition, for example wei qi xu, in which case it will be a xu/shi condition.14 The
symptoms and signs in an exterior xu condition will be milder than in an exterior
shi condition. In addition to the symptoms and signs of an exterior condition being
dependent on whether it is a xu or shi condition, they will also be different if the
condition is a Hot or a Cold condition.
Exterior patterns will typically be acute and there will usually be tangible
symptoms and signs that indicate that wei qi has been disrupted in its circulation
and functioning. When wei qi is blocked by exogenous xie qi, it will not be able to
warm the skin and muscles, resulting in the person having chills. The blockage of
wei qi will also manifest with pain and tenderness of the skin and muscles. Cold in
the exterior will often disrupt the taiyang channel. This is typically seen with there
being stiffness and pain in the neck and head.
Invasions of Cold will block wei qi from controlling the pores in the skin. This
will manifest with a person either not being able to sweat (shi condition) or sweating
spontaneously without this relieving the symptoms (xu condition). Because wei qi
is compromised, it cannot defend the body against exogenous xie qi. This will be
seen in a person experiencing an aversion to cold, draughts and wind. This aversion
is most pronounced in a xu condition. The conflict between wei qi and xie qi can
generate Heat and therefore there may be a fever. This will be much more significant
when there is exterior Wind-Heat.
An important differentiation in Chinese medicine is between the symptoms and
signs seen in exterior Heat conditions and interior Heat conditions. A key symptom
when differentiating these two patterns is whether there is a concurrent fever and
aversion. In interior Heat, there is no aversion to cold, whilst there is fever. This will
be the case when there is exterior Wind-Heat.
Headaches can be a symptom of an exterior imbalance, but there is a difference
in the headaches seen in various exterior imbalances. Invasions of Heat in the exterior
can manifest with a throbbing headache. This is due to the yang expanding nature
of Heat. Exterior Cold can manifest with a tight and tense headache due to Cold’s
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contracting dynamic. Invasions of Dampness in the exterior (exterior yin shi) can
result in a heavy headache.
An invasion of Heat in the exterior can cause a person to feel thirsty, because the
Heat will injure the body’s fluids.
The pulse in exterior conditions will be Superficial, because there is increased
activity in the superficial aspect of the body. The pulse that is felt when there is
Wind-Heat will be Superficial and Rapid. Wind-Cold will manifest with a pulse
that is Superficial and Tight, whilst a Wind-Dampness pulse will be Superficial and
Slippery. The strength of the pulse will reflect whether it is a xu or shi condition.
In xu conditions, the pulse will lack strength. Because these are acute imbalances,
visible changes in the tongue will rarely be observed. If there are changes, these will
manifest with changes in the coating on the front and at the edges of the tongue.
Differences between exterior Heat and exterior Cold

Exterior Cold Exterior Heat
Immediate symptoms Immediate/delayed/gradual symptoms
Strong aversion to cold No or only a slight aversion to cold
Mild fever or no fever Fever
Tight/tense headaches Throbbing headache
No thirst Thirst
Tight and Superficial pulse Rapid and Superficial pulse
Differences between exterior xu and exterior shi conditions

Xu Shi
Spontaneous perspiration or sweating that does No sweating
not alleviate the symptoms
Extreme aversion to Wind and draughts Aversion to Cold
Milder symptoms Strong symptoms
Empty pulse Full and Superficial pulse
Aetiology
Invasion of exogenous xie qi.
Symptoms and signs

As written above, there will be considerable differences between the individual
patterns depending on whether it is a Heat or Cold, and xu and shi condition.
Some of the common symptoms and signs are as follows:
• Symptoms in the wei qi aspect, skin, muscles, joints or tendons.
• When there is Wind-Heat, there can be a fever or a sensation of fever. If
there is Wind-Cold, there may be only a slight fever or fever sensation.
• Headache.
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• Aversion to Wind.
• Superficial pulse.
Key symptoms
Superficial pulse and aversion to wind and cold.
Treatment principle
Expel xie qi from the exterior, regulate wei qi.
If there is wei qi xu, you must simultaneously tonify wei qi.
Acupuncture points
Choose from: LI 4, Lu 7, GB 20, UB 10, SI 3, UB 62, SJ 5, Du 14, Du 16, UB 12
and UB 13.
• If there is Heat, add: LI 11.
• If there is wei qi xu, add: Lu 9, St 36, Sp 3.
Needle technique
Draining.
Explanation
• LI 4, Lu 7, SJ 5, Du 14, UB 12 and UB 13 activate wei qi and expel Wind.
• GB 20 and Du 16 expels Wind.
• SI 3 and UB 62 together activate wei qi and expel Wind from the taiyang
aspect.
• LI 11 expels Wind-Heat.
• St 36, Lu 9 and Sp 3 tonify wei qi.
Herbal formula
The relevant herbal formula will depend on the exact exterior condition. The
following are examples of such formulas, but there are many other formulas that
could also be used, depending on the symptoms and signs.
• Ma Huang Tang (Expels Wind-Cold)
• Gui Zhi Tang (Expels Wind-Cold and regulates the ying and the wei qi)
• Yin Qiao San (Expels Wind-Heat)
• Chuan Xiong Cha Tiao Tang (Expels Wind-Cold and relieves headaches)
• Xiao Qing Long Tang (Expels Wind-Cold and transforms Phlegm-Fluids)
• Huo Xiang Zheng Qi Tang (Expels Wind-Cold and transforms turbid
Dampness)
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Relevant advice
When there is an acute invasion of exogenous xie qi in the exterior, it is advisable
to consume beverages that are spicy and diaphoretic to open the exterior and expel
xie qi. This could be ginger, garlic, whisky, brandy and chilli, for example, if there
is an invasion of exogenous Wind-Cold, or mint, chrysanthemum, chamomile or
elderflower if there is an invasion of exogenous Wind-Heat. Fasting is also advisable
or only eating soup, such as onion soup. There are two reasons for this. First, when
temporarily fasting qi will not be used to transform food and therefore can be
used to combat the invading xie qi. Second, some sources say that the downward
movement of food and qi in the Stomach can draw the exogenous xie qi inwards
from the surface.
Similarly, the sour flavour should be avoided due to its astringent or centripetal
dynamic. Vitamin C, lemon and other things that are very sour should not be
consumed during an invasion of exogenous xie Cold, as they will draw the xie Cold
inwards whilst closing the pores in the skin, thereby preventing the Cold from being
expelled again. This also means that antibiotics are not recommended at this stage,
as they are cold and drain downward.
Chronic exterior imbalances

Chronic exterior imbalances are typically bi syndromes. Bi syndromes arise from the
simultaneous presence of three separate types of exogenous xie qi in the channels and
collaterals. There may also be disruptions of the channels themselves due to trauma
or repetitive movements that strain the joints, such as computer arm and tennis
elbow. These disorders, with the exception of physical traumas, will often have arisen
gradually, but there may also be episodes of acute flare-ups. These flare-ups will often
be due to climatic influences or physical strain.
Aetiology
Invasion of exogenous Dampness, Heat, Cold and Wind. Repeated stress on the
joint.
Symptoms and signs

• Pain in the joints and/or muscles.
Treatment principle
Expel exogenous xie qi, regulate qi and xue in the channel.
If there is qi xu, tonify qi.
Acupuncture points
Choose from: relevant channel points, local points, distal points, ‘cross channel’
points15 and points to expel exogenous xie qi.
• If there is exogenous Wind, add: UB 12, Du 14, Du 16 and LI 4.
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• If there is exogenous Cold, add: LI 4 and Du 14.

• If there is exogenous Dampness, add: Sp 6, Sp 9 and LI 4.
• If Exogenous Heat, add: Du 14, LI 4 or LI 11.
• If there is xue stagnation, add: Sp 10 and UB 17.
Needle technique
Draining.
Herbal formula
The relevant herbal formula will depend on the exact exterior condition. The
following are examples of such formulas, but there are many other formulas that
could also be used, dependent on the symptoms and signs.
• Qiang Huo Sheng Shi Tang (Expels Wind-Damp-Cold, activates channel qi)
• Du Huo Ji Sheng Tang (Expels Wind-Damp-Cold, activates channel qi and
tonifies qi and xue)
• Chuan Xiong Cha Tiao Tang (Expels Wind-Cold and regulates qi in the head)
• Huo Xiang Zheng Qi Tang (Expels Wind-Damp-Cold and transforms turbid
Dampness)
• Bai Hu Jia Gui Zhi Tang (Expels Wind-Damp-Heat)
Interior imbalances
Interior imbalances are de facto all imbalances that are not exterior.16 Interior
imbalances include all the imbalances where there is a change in the functioning
of the zangfu organs and where the vital substances are affected. There may well
be combined patterns in which there are imbalances in both the interior and the
exterior. An example of this could be a person who is Kidney yang xu (interior xu
Cold) who is also invaded by Wind-Heat (exterior shi Heat).
Imbalances in the interior can arise in one of three ways.
• Exogenous xie qi that has been located in the exterior penetrates downwards
into the interior.
• Exogenous xie qi can directly invade certain fu organs.
• Interior imbalances can also arise due to other factors, such as diet, emotions
and overexertion, affecting the zangfu organs and/or the vital substances.
Invasions of exogenous xie qi will usually be acute, whereas most other interior
imbalances will be chronic in nature.
When an imbalance is in the interior, it will have affected one or more of
the zangfu organs or the vital substances themselves. This means that the body’s
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physiology will be affected and this will be apparent in the signs and symptoms
that are manifesting. When there is an interior imbalance, certain organs and
vital substances will not be carrying out their functions optimally. There will be
observable changes in functions such as urination, defecation, appetite, sleep and
so on. Because the imbalance will have lasted for longer than an exterior imbalance,
and because the body’s physiology is affected, there will not only be changes in the
pulse, but the tongue will also show signs of change.
Differences between interior and exterior imbalances

Interior Exterior
Mainly chronic Mainly acute
May be due to the six forms of climatic xie qi, Usually caused by one or more of the six forms
the seven emotions and the diverse causes of climatic xie qi
Zangfu organs, xue, qi, jinye or jing will be The channels, wei qi, skin, tendons or muscles
disturbed will be affected
Disruption of the body’s internal physiology The body’s internal physiology is not disrupted
Changes in pulse and tongue Generally, only changes in the pulse
The pulse is generally not superficial Superficial pulse
Usually there is no aversion to cold and wind Usually there is an aversion to wind and cold
Aetiology
If exogenous xie qi is not expelled from the exterior, it can penetrate into the interior.
This will occur because the xie qi is very virulent, zheng qi is weakened or the person
has been treated improperly and xie qi has been dragged inwards and downwards.
Initially, xie qi penetrating into the interior will be a shi and a Heat condition. The
symptoms and signs will be powerful due to the struggle between zheng qi and xie qi.
This corresponds to the yangming stage of the Six Stages or the qi level of the Four
Levels. If the xie qi is not eradicated, if there are repeated invasions of exogenous
xie qi or if the body’s zheng qi is xu, the xie qi can penetrate even deeper into the
body and will develop into a xu pattern. This will be similar to the taiyin, shaoyin
and jueyin stages and the ying and xue levels. The patterns here can be Hot or Cold
patterns. See ‘Diagnosis According to the Six Stages’ and ‘Diagnosis According to
the Four Levels’ in Section 9 for a more detailed analysis of the symptoms and signs.
Exogenous xie qi can also directly invade into the interior. These invasions
are almost exclusively into one of the fu organs. This will typically be when Cold
or Dampness invades the Intestines, Stomach, Urinary Bladder or the Uterus, or
when Damp-Heat invades the Intestines or the Urinary Bladder. Direct invasions
of exogenous xie qi into the interior will manifest with acute symptoms, which
will be shi conditions. The reader is referred to Section 8, ‘Diagnosis According
to Zangfu Organ Patterns’, for more details about the relevant symptoms and
treatment principles.
The internal organs and vital substances can be affected by the seven emotions
and the so-called diverse or miscellaneous causes, such as diet, overwork, lifestyle and
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so on. These imbalances will be chronic, but there may still be acute symptoms. This
is typically seen when there are combined xu and shi patterns. An example of this
could be Liver yin xu with ascending Liver yang. Here, the person will often suffer
from acute migraine attacks, even though the underlying patterns are chronic.
Symptoms and signs

There can often be a complex mixture of symptoms and signs resulting from several
organs’ functions being affected and there can also be a combination of xu and shi
patterns. The symptoms and treatment of the individual patterns are described in
‘Diagnosis According to Qi, Xue and Jinye Imbalances’ (Section 7) and ‘Diagnosis
According to Zangfu Organ Patterns’ (Section 8).
Knowing that the imbalance is in the interior is not precise enough. It is necessary,
whenever possible, to locate the imbalance in the interior and find out what its
nature is. There will be significant differences in the symptoms and signs between
the various interior imbalances, depending on which organs and substances are
affected and whether the condition is xu or shi and Hot or Cold. The reader is again
referred to ‘Diagnosis According to Qi, Xue and Jinye Imbalances’ (Section 7) and
‘Diagnosis According to Zangfu Organ Patterns’ (Section 8) for more details about
the relevant symptoms and treatment principles.
Hot and Cold imbalances

In the principal pair of Hot and Cold, the imbalance is differentiated according
to the imbalance’s energetic nature. Heat is yang in nature, it over-activates and
accelerates the body’s processes. Cold is yin and will do the opposite. It will slow
down or weaken processes and, because it has a contracting nature, it will create
blockages of qi, xue and jinye. The precise symptoms will again depend on whether
it is a xu or shi condition and whether it is an interior or exterior condition.
There are often situations in which there is both Heat and Cold present
simultaneously. There may be, for example, Heat and Cold in different organs at the
same time. There may be Heat in the upper part of the body and Cold in the lower
part. There can also be Heat and Cold in different aspects of the body, for example
Wind-Cold in the exterior and Heat in the interior.
Differences between Heat and Cold conditions

Heat Cold
Over-activates and accelerates the body’s Weakens the body and makes processes slower
processes
Expands Contracts and creates stagnations and blockage
Desiccates and concentrates the body’s Disrupts the transformation and transportation of the
fluids body’s fluids
Changes the colour of the skin to red White or bluish skin colour
and exudations to yellow or green
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Causes exudations and discharges to Exudations and discharges do not smell

become odorous, thicker and stickier Clear, watery and more copious discharges from the
body’s orifices
Throbbing, stinging or burning pain Biting or cramping pain
Red tongue Pale tongue
Yellowish tongue coating (shi conditions) Whitish tongue coating
or no tongue coating (xu conditions)
Rapid pulse Slow pulse
Rapid movements Slow and languorous movements (xu conditions), stiff
movements (shi conditions)
Restlessness, agitation Lethargy
Sends qi upward (shi conditions) or does Blocks qi (shi conditions) or does not move qi (xu
not root qi (xu conditions) conditions)
Thirst No thirst
Constipation with dry stool Most frequently loose stools or diarrhoea, but there
can be constipation
The stools will not be dry
Insomnia Possibly hypersomnia if there is xu Cold
Sleeps with limbs stretched outwards Sleeps with the body curled up and with thick bedding
and with increased movement of the Does not move about in the bed whilst sleeping
body whilst sleeping
Sleeps with thin blankets and may have
a tendency to kick the bedding off whilst
sleeping
The skin can feel warm on palpation The skin can feel cold on palpation
Heat
It is necessary to further differentiate between xu and shi Heat, because the treatments
are very different. Furthermore, it is very important to differentiate between interior
and exterior Heat. This is because xie qi can be dragged deeper into the body by
improper treatment. This is particularly important when treating with herbs.
Shi Heat
Shi Heat will often manifest with a sensation of heat in the body or an aversion to
heat. The skin will feel warm and can become red in colour. Anywhere that the skin
has changed colour and become red is a sign that there is Heat present. The Heat
may be localised to this area, as is seen when there is a red, swollen joint due to a
local stagnation of qi, xue and jinye when a joint is sprained. There may be Heat in
an organ and its channel, as is seen when there are red and bleeding gums caused by
Heat in the Stomach channel. The Heat can also be systemic, such as when there is
a general condition of Heat in the body. When there is shi Heat, the face will often
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be red, as will the tongue. This is due to the yang nature of Heat, which means that
it will ascend upwards in the body. When there is Heat in the body, the superficial
vessels become more blood-filled, because the Heat drives xue up to the surface and
therefore the skin appears more red in colour. It is not only the skin that changes
colour when there is Heat – exudations and discharges from the body, such as mucus
in the respiratory passages and nose, discharge from the vagina, urine, fluid from
ulcers and so on will also change colour. When secretions are yellowish or greenish,
it is a sign that there is Heat. Heat concentrates the exudations and this will result in
a change in their consistency. Excretions become thicker and stickier. They will also
begin to smell or taste different.
By driving fluids upwards and outwards, the yang nature of Heat can result in
heavy sweating. Heat can also injure the body’s fluids, in which case there may be a
lack of sweating. By damaging fluids and dehydrating the body, Heat will result in
a person having an excessive thirst, with a desire for cold liquids. Furthermore, by
dehydrating the body, Heat can manifest with constipation.
Because the body feels warm, the person will often wear less clothing than other
people. A patient who turns up wearing just a t-shirt and a jacket in the winter, when
everyone else is walking around with sweaters and coats on, will often have shi Heat.
If there is a pain, the expansive energy of warmth will mean that the sensation
is a throbbing pain. This is typically seen in certain types of headaches and joint
pains. The sensation can also be stinging and burning, for example in the rectum or
in the throat.
Some symptoms are more specific to interior or exterior shi Heat conditions.
They are discussed separately below.
Interior shi Heat

Some people relate the bitter taste to the Heart. In reality, the bitter taste is an aspect
of the Fire Phase, as is Heat. This means that a bitter taste in the mouth can be
experienced in many Heat disorders, for example Liver Fire.
Heat activates and accelerates processes. In a person with Heat, this can be seen
in the movements of their body, and their speech will be faster. Because interior shi
Heat is an excess condition, the person’s voice will be loud.
The nature of Heat is to rise upwards. This means that the Heart will become
agitated when Heat rises upwards to the upper jiao. This can manifest on both the
physical plane, with a faster pulse, and on the mental-emotional level, with the person
being restless, agitated or downright manic. Heat opens and agitates the Heart so
the person will often talk quicker and be more verbose than normal. When shen is
agitated, there can be difficulty sleeping or just restless, dream-disturbed sleep. Shen
and the Heart can also be affected when xue, which is governed by the Heart and is
the residence for shen, is agitated by Heat.
Heat can also result in xue becoming so agitated and over-activated so that it
bursts the walls of vessels and results in bleeding.
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When there is Heat in the interior, the Heat will injure the body’s fluids, resulting
in thirst. The thirst seen in interior shi Heat will be different to the thirst seen when
there is interior xu Heat. Xu Heat arises from a lack of yin and this manifests with a
dryness of the mouth and throat as opposed to an actual thirst. This means that the
person will have a desire to sip small amounts of liquid to moisten the mouth and
throat. Shi Heat will injure fluids, resulting in a pronounced thirst and a desire to
gulp copious amounts of cold fluids.
There will also be specific symptoms and signs that relate to the functions of
specific organs when these organs are affected by Heat. For a detailed description
of these symptoms and their treatment, the reader is referred to ‘Diagnosis According
to Zangfu Organ Patterns’ (Section 7).
Exterior shi Heat

When there is exterior Heat, there will be signs relating to the disturbance of wei
qi or to the muscles and joints, such as in bi syndrome. The only zang organ that
can be affected immediately by an invasion of shi Heat in the exterior is the Lung.
This is because exterior xie Heat will disrupt the functioning of wei qi, which is
controlled by the Lung. When there is exterior shi Heat, there is no disturbance of
other internal organs’ physiology. The pulse will be Superficial and Rapid, because
xie qi is in the exterior and because there is Heat. If there are any changes seen on the
tongue, these will be visible on the tip and/or the sides, which will be red and there
may be a thin yellowish coating in these areas. Exterior Heat symptoms and signs
will be acute. Interior Heat’s symptoms and signs will be more chronic in nature,
but there may be acute episodes. There is often an aversion to wind and cold during
an exogenous invasion of Heat, because wei qi is disturbed. This will not be the
case when there is a condition of Heat in the interior; on the contrary, the person
will often have an aversion to heat. The thirst will not be as strong if there is Heat
in the exterior. This is because Heat is starting to injure the body’s fluids but not to
the same extent as when there is Heat in the interior.
Differences between interior and exterior Heat

Interior Heat Exterior Heat
Most often chronic, but there may be acute episodes Acute
May be due to one or more of the six climatic forms of Due to one or more of the six climatic
xie qi, the seven emotions and diverse causes forms of xie qi
Can be a xu or shi condition Shi condition
Zangfu organs are affected Wei qi, muscles or joints are affected
Disruption of the body’s internal physiology The body’s internal physiology is not
disrupted
The pulse can be Deep or Superficial Superficial pulse
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Interior Heat Exterior Heat

The entire tongue can be red or the tongue can be red The tip and the sides may be red and
in an area that corresponds to a specific organ that is there may be a thin yellowish coating in
affected by Heat these areas
There can be both a yellow coating or a lack of coating,
depending on whether it is a shi or xu condition
No aversion to wind and cold Slight aversion to wind and cold
There may be a strong thirst The thirst is not so pronounced
Rapid body movements Normal body movements
Rapid and verbose speech Normal speech
Shen may be affected Shen not affected
There may be bleeding No bleeding
Treatment principle: Either drain Heat or nourish yin Treatment principle: Expel Wind-Heat
Aetiology
Shi Heat can arise in several ways.
• Excessive intake of foodstuffs, beverages and spices that have a Warm or Hot
energy. Typical examples of these are chilli, garlic, pepper, alcohol, lamb,
fried food such as chips, falafel, crisps and so on. This will be especially
relevant when there is Heat in the Liver, Stomach and Intestines.
• Prolonged emotional imbalances: Stress, frustration and anger will create
Heat in the Heart and Liver.
• Smoking tobacco creates Heat, especially in the Lung.
• Invasions of exogenous xie qi: Heat can directly invade the body. The invasion
can be via the exterior or directly into the interior. Invasions of exogenous
Cold can transform into Heat in the interior. Internally generated xie qi,
such as Dampness, can transform and become Damp-Heat.
Symptoms and signs

• Thirst
• Aversion to heat
• The skin may feel warm when palpated
• The face can be red or ruddy
• Discharges and exudations that have changed colour and become yellowish
or greenish
• Excretions that have become sticky or thicker
• Excretions that smell or taste strongly
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• Pain that is throbbing, stinging or burning

• Excessive sweating or lack of sweating
• Constipation
• Red tongue
• Rapid pulse
Key symptoms
Thirst, aversion to heat, red face, red tongue and rapid pulse.
Treatment principle
Expel or drain Heat.
Acupuncture points
• If there is Heat in the exterior, choose from: Du 14, Du 16, LI 4, LI 11, SJ
5, Lu 11, GB 20 and erjian (Ex-HN 6).
• If there is Heat in the Lung, choose from: Lu 1, Lu 5, Lu 10, Du 14, LI 11,
UB 13 and erjian (Ex-HN 6).
• If there is Heat in Heart, choose from: He 8, Pe 5, Pe 7, Pe 8, Du 14, UB 14,
UB 15, Ren 15 and erjian (Ex-HN 6)
• If there is Heat in Liver, choose from: Liv 2, Liv 14, Du 14, UB 18 and erjian
(Ex-HN 6).
• If there is Heat in the Stomach, choose from: St 43, St 44, St 45, LI 11, Du
14, UB 21, Ren 13 and erjian (Ex-HN 6).
• If there is Heat in Intestines, choose from: St 25, St 37, St 39, St 44 and
erjian (Ex-HN 6).
• If there is Heat in Urinary Bladder, choose from: UB 28, Ren 3, Du 14 and
erjian (Ex-HN 6).
• If there is xue Heat, choose from: Liv 1, Liv 2, Sp 10, Du 14, UB 17 and
erjian (Ex-HN 6).
Needle technique
Draining. Bleeding can be applicable.
Herbal formula
The relevant herbal formula will depend on the exact Heat condition. The following
are examples of such formulas, but there are many other formulas that could also be
used, depending on the organ affected and the specific symptoms and signs.
• Yin Qiao San (Expels Heat and drains Toxic-Fire)
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• Huang Lian Jie Du Tang (Drains Damp-Heat from all three jiao and drains
Toxic-Fire)
• Bai Tou Weng Tang (Drains Damp-Heat from the Intestines and drains
Toxic-Fire)
• Long Dan Xie Gan Tang (Drains Liver Fire and Liver and Gall Bladder
Damp-Heat)
• Ba Zheng Tang (Drains Damp-Heat from the Urinary Bladder)
• Dao Chi San (Drains Fire from the Heart)
• Xie Bai San (Drains Heat from the Lung)
• Qing Wei San (Drains Fire from the Stomach)
Relevant advice
A person with shi Heat should avoid food and drinks that have a hot dynamic.
Typical examples of these are chilli, garlic, pepper, alcohol, lamb, fried food such
as chips, falafel, crisps and so on. They should try to avoid stress. If there is exterior
Heat, you could recommend they drink mint tea or elderflower tea.
Xu Heat
There are significant differences between xu and shi Heat, both in their symptoms
and signs and in how they arise. The treatment principle for these two types of Heat
will also be different. If there is shi Heat, it must be drained or expelled. If there is
xu Heat, yin must be nourished.
Yin has the task of cooling the body. If yin is xu, the body will not be able to
control Heat, which is yang. Even though the nature of Heat is the same, because
the Heat itself is not excessive and because it is not being controlled and balanced
by yin, the symptoms and signs will not be the same as in shi Heat. It is not so much
that there is a difference in the intensity of the symptoms and signs but more how
and when the symptoms occur that is different. This is in contrast to the difference
between xu and shi Cold, where there are significant differences in intensity of the
symptoms themselves.
Difference between shi Heat and xu Heat

Shi Heat Xu Heat
Powerful thirst with desire to drink cold Dry mouth and throat, which results in a desire to sip
drinks in large gulps rather than gulp
Red tongue with a yellow coating Red tongue with little or no coating, possibly with
cracks
Full and Rapid pulse Fine, Rapid and possibly Superficial pulse
Loud voice Weak and possibly nervous voice
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Powerful and quick movements Nervous and restless movements

Restless and dream-disturbed sleep Wakes frequently, difficulty falling asleep
Restlessness, agitation, mania Restlessness and anxiety
Profuse or lack of sweating Night sweats
Sweats throughout the day
Sensation of heat or fever throughout Sensation of heat or feeling feverish in the evening and
the day night, hot flushes
Heat in the whole body Heat in the palms, soles of the feet and centre of the
chest
Constipation with pain in the abdomen Constipation or dry stools without pain in the
abdomen
Bitter taste in the mouth No bitter taste
Heat must be drained downwards or Yin must be nourished, so that Heat can be controlled
expelled through the skin
When there is shi Heat, its yang nature will drive the body fluids upwards and
outwards as sweat. When there is yin xu, Heat will also make the person sweat, but it
will usually only be in the evening and at night. This is because yin is the dominant
energy at night. If yin is weak, it will not be able to control yang Heat in this period.
Furthermore, wei qi, which controls the pores in the skins, circulates in the interior
of the body at night. This means that the pores are not able to hold the sweat that
has arisen from the uncontrolled Heat inside the body at night.
A person who is yin xu will experience sensations of heat or fever mainly in the
evening and at night. The sensation of heat will not be as intense and sustained as
it is when there is shi Heat. When there is shi Heat, the sensation of heat or fever is
sustained throughout the day and the night. Xu Heat usually also comes in waves
as hot flushes, rather than as a sustained sensation. When there is xu Heat, there is
often only a sensation of heat in the palms of the hands, the soles of the feet and the
centre of the chest,17 whereas it is the whole body and particularly the head that feels
hot when there is shi Heat. One of the ways to differentiate xu and shi Heat is to feel
the patient’s hands. If the whole hand feels warm, there is shi Heat. When only the
palm feels hot, it is xu Heat.
The body will be dehydrated when there is xu Heat, but the mechanism is not
quite the same as when there is shi Heat. Xu Heat is not as intense and does not injure
the body fluids to the same extent that shi Heat does. When there is yin xu, the body
fluids are not nourished and replenished by yin. Xu Heat will then further dry out
the body fluids, but the Heat is not as intense as it is when there is shi Heat. This
means that the thirst will not be as intense. Where there was a strong thirst with a
desire to drink cold liquids in large gulps with shi Heat, there will instead be a dry
mouth and throat that results in a person preferring to sip water, especially in the
evening and at night. Often the person will have a glass of water standing beside
the bed that they sip during the night and the glass will not always be emptied. This
is in contrast with a person with shi Heat, who will empty more than one glass.
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As with shi Heat, the dehydration of the body in xu Heat will result in dark and
scanty urine. It can also result in constipation, but there is not the abdominal pain
and discomfort that is seen in shi Heat conditions.
The face and the head will not be as red when there is xu Heat. In shi Heat, the
whole head and face will be red. When there is xu Heat, there will be a malar flush,
with the redness localised on the cheekbones, which is often more pronounced in
the evening and when the person is tired. The is because when there is xu Heat, the
Heat detaches itself because it is not anchored by yin, and then drifts up to the head.
When there is shi Heat, there is an active flaring up of Fire. This means that the
whole head turns red.
Tongue diagnosis is an essential tool in the differentiation of xu and shi Heat. In
both cases the tongue is likely to be red and dry, but when there is xu Heat, there will
be little or no coating on the tongue. The lack of nourishment and yin moisture can
cause the tongue to crack. The pulse will also be weaker when there is xu Heat, but
it can still be Rapid, because the Heat will have accelerated the beating of the Heart.
Because yang is not rooted and anchored, the pulse can have a superficial quality
when there is xu Heat.
Xu heat will also affect the Heart and shen but the impact will not be as great and
the symptoms not as intense as when there is shi Heat. When there is xu Heat, the
person is more nervous and unsettled than manic and agitated. They will often have
a slight anxiety or a feeling that something is wrong without them being able to put
their finger on what it is. If there are palpitations, they will not be as intense as when
there is shi Heat. When there is xu Heat, the palpitations will often be accompanied
by a feeling of nervousness or mild anxiety. Xu Heat often results in insomnia due
to the shen not being anchored by yin. At the same time, the Heat will agitate and
activate shen. Because shen is not anchored and because shen is agitated by Heat, the
person’s movements may well be nervous and fidgeting. Even though a person with
xu Heat will be restless, they will not be as restless and agitated as a person with shi
Heat. The nervousness and anxiety can sometimes be heard in their speech, both
in the voice itself and what they talk about. The voice will not be as loud as it is
when there is shi Heat, but because Heat agitates the Heart, the person can be very
talkative and talk quickly.
Aetiology
Yin is weakened by old age, physical, mental and emotional overexertion (including
stress), disease and illness, shi Heat conditions, too much sex, working at night,
narcotics, energetically hot and spicy food, coffee, blood loss and profuse sweating.
Symptoms and signs

• Malar flush
• Fever or feeling hot in the evening and at night
• Night sweats
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• Sweat or sensations of heat in the palms of the hands, the soles of the feet
and the centre of the chest
• Dry mouth and throat
• Thirst with a desire to sip water
• Nervous, fidgeting movements
• Restlessness
• Slight feeling of anxiety
• Palpitations
• Nervous, rapid speech, talking a lot
• Dark, scanty urine
• Constipation or dry stools
• Red tongue with little or no coating, possibly a cracked tongue surface
• Rapid, Fine and possibly Superficial or Empty pulse
Key symptoms
Night sweats, malar flush, dry mouth, red tongue with little or no coating.
Treatment principle
Nourish yin and control Heat.
Acupuncture points
Choose from: Kid 2, Kid 3, Kid 6, Ren 4, UB 23, UB 52, Sp 6 and He 6.
Needle technique
Tonifying, except Kid 2, which can be treated with an even technique.
Explanation
• Kid 2, Kid 3, Kid 6, Ren 4, UB 23 and UB 52 nourish Kidney yin, which is
the foundation of yin in the whole body.
• Sp 6 nourishes yin.
• He 6 nourishes Heart yin.
Herbal formula
• Zhi Bai Di Huang Tang (Nourishes Kidney yin and controls Heat)
• Tian Wang Bu Xin Dan (Nourishes Kidney and Heart yin, controls Heat and
calms shen)
• Da Bu Yin Wan (Nourishes Kidney yin and controls Heat)
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Relevant advice
A person with xu Heat should avoid food and drinks that have a Hot energy. They
should also avoid stimulants such caffeine drinks, for example coffee, Red Bull and
green, black and white tea. Furthermore, they should avoid having too many spices
in the diet. Stress and overwork will weaken yin. It is important that a person with
yin xu makes sure that they go to bed early and sleep enough. They should avoid
working on the computer too much, especially in the evening. Sweating is best
avoided, as it results in the loss of fluid from the body. This means that they should
preferably not sit in saunas and steam baths. Dynamic activities such as aerobics
or action sports should also be avoided, as they will further consume the person’s
reserves. Meditation, qi gong, tai ji and yoga will, though, be beneficial.
Cold
The difference in when the symptoms and signs of xu Cold and shi Cold manifest,
as well as the treatment itself, is not as pronounced as with Heat. The difference in
symptoms between xu and shi Cold is seen more in the severity of symptoms and
signs, the symptoms’ and signs’ intensity and whether the symptoms are acute or
chronic. There is often an overlap between xu and shi Cold conditions, and one will
frequently result in a person being more vulnerable to the other.
Both shi and xu Cold will result in the body’s yang qi not being able to fulfil its
functions. This will be because yang is either blocked, as it is in a shi Cold condition,
or too weak, as it is in a xu Cold condition. This will compromise the body’s ability
to heat, transform, transport, protect and hold yin fluids inside the body.
Shi Cold
Shi Cold can arise when the body is invaded by exogenous Cold. The Cold can
be located in the exterior, i.e. Wind-Cold, or there may be a direct invasion in the
interior, when Cold invades a fu organ, such as the Stomach, the Intestines,
the Urinary Bladder or the Uterus. There may also be a direct invasion of xie Cold
in the Liver channel and in the taiyin and shaoyin stages of the Six Stages.
Exterior shi Cold

When there is shi Cold, it is necessary to differentiate between interior and exterior
Cold. In exterior Cold, exogenous xie Cold will have invaded the body via the
skin and blocked wei qi. This is reflected in the symptoms and signs. There will
be shivering and an aversion to cold, because wei qi is blocked and cannot warm the
skin and protect the body against the climatic cold. This is, in fact, a key symptom
when differentiating between interior xu Cold and exterior shi Cold. In both cases,
the person feels cold and has difficulty keeping warm. The difference, though, is that
when the warming wei qi is blocked, the person cannot get warm, even though they
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wrap themselves up in blankets and put on extra clothing. There is actually enough
heat in the body but it is prevented from circulating through the muscles and under
the skin. When there is interior xu Cold, there is an actual deficit of heat in the body.
This means that if the person puts on enough clothes or blankets, they can retain the
heat they do have and will feel warm. The blockage of wei qi will result in a general
soreness or aches in the skin, muscles and joints.
When Wind-Cold invades the exterior, it is the taiyang channels that are the first
aspect to be invaded. There will be an acute headache and tension or stiffness in the
shoulders and neck. This is because the circulation of qi in the Urinary Bladder and
Small Intestine channels is blocked. There will also be tenderness and soreness in the
muscles and joints in general, due to the blockage of wei qi.
The blockage of wei qi and the contracting nature of Cold will disrupt the pores
in the skin so that the pores do not open. The person will therefore not be able
to sweat.
An invasion of Wind-Cold will tend to disrupt and block the Lung in its
spreading of jinye. This can manifest as acute oedema in the face and hands. The
blocked fluids will ascend to the eyes and nose along with the rebellious Lung qi
and cause watering eyes, puffy eyes or a runny nose. The fluids can also collect
in the Lung and result in a cough with loose, watery sputum. The Lung qi will
be rebellious, because the Cold has blocked the Lung’s descending and spreading
of qi. When Lung qi is rebellious, there may be coughing, sneezing or dyspnoea.
When there is shi Cold in the exterior, the pulse will reflect this imbalance by being
Superficial and Tight. The tongue will often not have had time to change. If the
tongue has changed, it will have a thin, white and moist coating on the front.
Interior shi Cold

Interior shi Cold is a condition where the exogenous xie qi has invaded the interior
of the body. Fu organs are in direct contact with the environment outside of the
body via the body’s orifices. This makes it possible for climatic xie qi to invade these
organs directly. Furthermore, xie Cold can enter the body through the yin channels
in the legs and thereby invade the organs of the lower jiao.
Cold has a crucial impact on an organ’s physiology and it has an astringent
nature. Cold’s constricting dynamic results in stagnation, blockage and disruption
of qi, xue and jinye. One of the dominant symptoms indicating the presence of
Cold is pain. Where exterior Cold will manifest with pain such as headaches and
muscle aches, interior Cold will manifest with cramping or biting pain. Examples of
this could be menstrual pain, pain in the intestines or abdominal pain. Because the
Cold is located in the interior, the aversion to cold will be different to when there
is an exterior condition; there is not the same blockage of wei qi. The person will
therefore not have the same aversion or fear of cold. The Cold will be more localised
and internal. They will probably feel chilly and will seek heat, especially in the area
of the body where Cold is located, but they will not freeze in the same way as when
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there is Wind-Cold. Their arms and legs can feel cold. Cold extremities are also
seen when there is Liver qi stagnation but then only the hands and feet will be cold.
When there is shi Cold, the whole arm and leg feel cold. The fingers and toes may
become blue due to Cold blocking the movement of xue.
While there is a possibility of a slight fever or sensation of fever in the body
when there is an invasion of Wind-Cold, this is not the case when there is interior
shi Cold. Perspiration will be normal because wei qi is not blocked from controlling
the pores in the skin. The pulse will be Deep because xie qi is in the interior and the
Cold stagnation will make the pulse Tight or Confined. The tongue will be a key
diagnostic factor. When there is interior shi Cold, there will be a thick, white tongue
coating and the coating is often wet.
Interior shi Cold will disrupt and block fluid physiology. There will, therefore,
be an increased volume of urine. The urine will be clear and there will be frequent
urination. Cold can block the flow of qi in the Urinary Bladder and this can cause
the person to have difficulty urinating. The disturbance of the fluid physiology can
also result in the person having a lack of thirst.
Cold does not boil and condense excretions as Heat does; on the contrary,
exudations and discharges from the body will be more copious. These excretions will
be watery, clear and transparent, and they will not be odorous.
Cold can also prevent food from being transformed. If there is Cold in the
Stomach, it can manifest with watery vomit, otherwise there will be watery diarrhoea
with undigested food particles. The blockage by Cold will also manifest with pain in
an organ. The pain and discomfort will be exacerbated by consuming cooling or cold
drinks or food. In some cases, Cold can block the movement of the faeces through
the Intestines. This can lead to constipation and cramping pains in the abdomen.
Palpation of the area of the body, or above the organ, that Cold has invaded will
often reveal a cold sensation in the skin. The person will often also have a subjective
sensation of cold in the area.
Where yang xu Cold will often result in a person having slow and lethargic move-
ments, a person whose qi and xue is blocked by exogenous Cold will have movements
that are stiff and limited due to qi and xue not being able to flow freely. This will
usually be in a particular area of the body, such as the neck, the back or one or more
of the joints in the limbs.
Shi conditions manifest with stronger colours than xu conditions. When there
is shi Cold, the face will be white and shiny. It will not have the same dullness and
lack of radiance that is characteristic of xu conditions. The face is white because Cold
has the opposite dynamic of Heat. Where Heat’s yang nature drives xue upwards and
outwards, resulting in redness of the face, Cold has a yin dynamic and draws xue
to the centre of the body. This is consistent with the Western physiological model,
where when the body is cold, the blood is retained in the middle of the body to
reduce cooling of the blood and keep the vital organs warm.
Cold’s blockage of heat will also manifest with the person sleeping curled up to
retain heat in the body.
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Aetiology
Invasion of exogenous xie qi.
Symptoms and signs

• Aversion to cold
• Cold limbs
• White face
• Clear urine
• Diarrhoea or loose stools (constipation may be seen in some cases)
• Pain
• Stiffness
• No thirst
• Disinclination or discomfort when consuming cold beverages and foods
• Clear transparent excretions
• Oedema
• Slow, Tight or Confined pulse
• A white coating on the tongue
Key symptoms
Aversion to cold, clear urine, pain and stiffness, Tight pulse.
Differences between interior and exterior Cold

Interior Cold Exterior Cold
No headache Acute headaches
Pain in a fu organ Skin, muscle and joint aches
Disruption of a fu organ’s functions No disturbance of the internal organs’ functions
Attracted to warmth Aversion to cold and wind
Normal perspiration Lack of perspiration
Bluish fingers and toes Normal coloured fingers and toes
No fever Possibly a slight fever or fever sensation
Deep pulse Superficial pulse
Pale or bluish tongue with thick, white, The tongue is usually unchanged
moist coating
Treatment principle: Warm the interior Treatment principle: Expel Cold from the exterior
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Treatment principle
If there is interior shi Cold: Expel Cold, warm the interior.
If there is exterior shi Cold: Open to the exterior, expel Wind-Cold.
Acupuncture points
Point selection will depend on which organs or channels have been invaded by Cold.
• If there is Invasion of Wind-Cold (taiyang stage), choose from: SI 3, UB 62,
UB 10, Du 14, Du 16, GB 20, LI 4, Lu 7, UB 12 and UB 13.
• If there is Cold bi syndrome, choose from: LI 4, Du 14 local and distal
channel points, a-shi points.
• If there is Stomach Cold, choose from: Ren 12, Ren 8, St 21, St 34 and
St 36.
• If there is Large Intestine Cold, choose from: St 25, St 37, St 28, Ren 6 and
Ren 8.
• If there is Small Intestine Cold, choose from: St 25, St 39, St 28, Ren 6 and
Ren 8.
• If there is Cold Uterus, choose from: Ren 4, Kid 12, Kid 13, St 30 and
UB 32.
Needle technique
Draining. Moxa is recommended.
Herbal formula
The relevant herbal formula will depend on the exact Cold condition and where it
is located. The following are examples of such formulas, but there are many other
formulas that could also be used depending on the organ or the aspect of the body
that is affected.
• Ma Huang Tang (Expels Wind-Cold from the exterior)
• Chuan Xiong Cha Tiao Tang (Expels Wind and Cold, circulates qi, relieves
pain in the head)
• Duo Huo Ji Sheng Tang (Expels Wind, Cold and Dampness, circulates qi in
the channels, stops pain)
• Li Zhong Tang (Dispels Cold from the middle jiao)
• Huo Xiang Zheng Qi Tang (Expels Wind-Cold and Dampness, regulates qi
in the middle jiao)
• Wen Jing Tang (Expels Cold from the Uterus)
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Relevant advice
A person who has been invaded by exogenous Cold will benefit from drinking hot
ginger tea, a decoction of garlic or hot whisky with spices.
If they have interior Cold, they can use cinnamon in their diet, drink ginger
tea and use warming spices, as well as avoiding food and beverages that are
energetically and physically cold.
Differences between xu and shi Cold

Xu Cold Shi Cold
The symptoms are usually chronic The symptoms are often acute
The person freezes, but if they put on enough The person freezes and cannot get warm, even if
clothes or lie under a quilt, they can keep warm they put on enough clothes and blankets
Dull, pale facial colour Shiny, white facial colour
Milder symptoms Stronger symptoms
Dull pain that is alleviated by pressure Biting or cramping pain that is aggravated by
pressure
If there is diarrhoea or constipation, any If there is diarrhoea or constipation, any
discomfort or pain is not alleviated by the discomfort or pain is alleviated by the passing
passing of stools of stools
Weak, Deep and Slow pulse Full, Tight, Deep, Confined and Slow pulse
Thin, white tongue coating Thick, white tongue coating
Treatment principle: Warm yang Treatment principle: Expel Cold, warm the
interior
Xu Cold
Xu Cold arises when there is insufficient yang to warm the body. The symptom picture
will be characterised by physiological processes that are taking place more slowly or
less effectively. There will be a poor transformation and transportation of the fluids
and the food that has been ingested. This will manifest with symptoms such as
oedema, loose stools or diarrhoea with undigested food particles, borborygmi, lack
of thirst and frequent urination with copious amounts of clear urine.
Qi production will be diminished due to the poor transformation of the ingested
food, air and jing. Fatigue and lethargy will therefore be key symptoms. This lassitude
will be both physical and mental. The person will often have slow, ponderous
movements, possibly dragging their feet and they will have a poor posture, due to
the deficient yang failing to raise the body upwards and counteract gravity.
The person will feel cold and will freeze easily, because they lack the necessary
yang to maintain the body’s warmth. Unlike a person who has exterior shi Cold, a
person who is yang xu Cold will be able to maintain a sensation of warmth in the
body if they wear sufficient clothing. It is, therefore, a diagnostic sign of yang xu
Cold when a person is noticeably more warmly dressed than others. They may, for
example, be wearing a sweater when everyone else is in shirt sleeves. We must always
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be observant of whether a person’s attire is appropriate for their surroundings, as this

is a reliable way of diagnosing Heat and Cold.
The arms and legs of a person who is manifesting yang xu Cold often feel subjectively
cold, as well as feeling cold when palpated. This is because there is not enough yang to
circulate in the extremities. At the same time, there is a lack of heat in general and the
priority of the body is to keep the internal organs warm and utilise yang here.
There will be frequent urination of copious amounts of clear urine, because
fluids are not being transformed and transported and instead are seeping down to
the lower jiao, and because there is not enough yang to hold the urine inside the
Urinary Bladder. The deficiency of yang can also result in food and liquids that
have been ingested not being optimally transformed, resulting in watery diarrhoea
containing undigested food and borborygmi.
A person who is xu Cold will have a preference for hot food and drinks. This is
one of the ways that the body tries to correct the imbalance.
Wei qi is an aspect of yang. When yang is weak, there may be spontaneous
sweating or sweating on light activity. This is because wei qi will not be able to keep
the pores in the skin closed. Likewise, there could be a tendency towards frequent
invasions of exogenous xie qi, especially Wind-Cold.
Aetiology
Xu Cold arises when yang has been weakened. Yang is weakened by repeated invasions
of Cold, excessive consumption of food and drinks that have a cold dynamic or are
physically cold, medicine that has a cold dynamic such as antibiotics, too much sex,
old age, chronic illnesses and physical exertion, such as too much sport.
Symptoms and signs

• Matt, white complexion
• Cold limbs
• Slow, lethargic movements
• Poor posture
• Physical and mental fatigue
• Frequent urination with copious amounts of clear urine
• Loose stools or diarrhoea with undigested food in the stools
• No thirst
• Oedema
• Preference for hot food and drinks
• Freezes easily
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• Wears warmer clothes than necessary

• Slow, Deep and Weak pulse
• Pale, swollen and wet tongue
Key symptoms
Aversion to cold, frequent urination, fatigue, Deep and Weak pulse.
Treatment principle
Warm and tonify yang.
Acupuncture points
Choose from: Du 4, Kid 3, Kid 7, UB 23, Ren 4, Ren 6 and Ren 8.
Needle technique
Tonifying. Moxa is recommended.
Explanation
• UB 23, Du 4, Ren 4, Kid 3 and Kid 7 tonify and warm Kidney yang.
• Ren 6 and Ren 8 tonify and warms yang.
Herbal formula
• Jin Gui Shen Qi Tang (Tonifies and warms Kidney yang)
• You Gui Wan (Tonifies and warms Kidney yang)
• Li Zhong Tang (Tonifies and warms Spleen yang)
Relevant advice
If there is xu Cold, the person should eat food and drinks that are both physically and
energetically warm, such as ginger, cinnamon, garlic, lamb, venison, basil, chestnuts,
shrimp, walnuts and so on. They should try to utilise cooking methods such as baking
and grilling, which are more warming than steaming and boiling the food. Small
changes in the diet can often make a big difference in the long run. They will, for
example, benefit from eating lamb instead of pork and we can recommend that they use
warming spices such as cinnamon, cloves, ginger and curry powder in their cooking.
Furthermore, they should avoid foods and drinks that are physically and energetically
cold, especially in the autumn and winter when yang is most challenged. In practice,
this means avoiding eating fruit unless it is boiled or baked, avoiding salad and raw
vegetables and drinking cold water. Although they are physically hot, mint tea,
chamomile tea and elderflower tea are cooling in their energy, so the person should
avoid these and drink beverages such as ginger tea. Green tea is cooling, whereas black
tea is more warming, which means the latter will be preferable for a person who is
yang xu. In the same way that a person who is yin xu should be careful not to challenge
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their yin in the evening by using computers, smartphones and so on, a person who is
yang xu should avoid straining their yang in the morning. Therefore, a good way to
start the day would be to eat hot porridge sprinkled with cinnamon instead of yoghurt
or cornflakes with milk. If they do not have Damp-Phlegm, a little cane sugar would
also be good. A cup of black or ginger tea instead of cold orange juice will warm and
support their Spleen yang in the morning instead of weakening it. Hot spices such as
chilli and cayenne pepper are not necessarily good because they make a person sweat
and thereby lose qi. Rebuilding a xu condition is something that takes time and cannot
be forced, therefore making small, long-term changes is the best strategy.
Light exercise, especially in the morning just after waking up, is recommended
because it will activate the lethargic yang and qi. The person must, however, be
careful that they do not exercise to the extent that they become fatigued or feel tired
afterwards. This means that they should not run long distances, swim 30 lengths of
the swimming pool or spend hours in the gym. Again, yoga, tai ji and qi gong will
be better for them. They can also cycle or go for walks. As stated, it is important that
they do not exhaust themselves and that they get enough rest.
They will also benefit from a ginger or a mustard foot bath.
Combined Hot and Cold patterns

Combined Hot and Cold patterns have symptoms of Heat and Cold manifesting
simultaneously. These patterns can occur when a person with a state of interior Cold
is invaded by exogenous Heat or vice versa. There will be symptoms from both the
exterior invasion and the interior imbalance.
There can also be a combination of Hot and Cold symptoms when an illness
is changing character. This could, for example, be when Cold in the exterior is
penetrating inwards and becoming yangming Heat.
Pure interior imbalances can also result in combined Hot and Cold patterns.
There can be situations where there is Heat in the upper part of the body and Cold
in the lower part. In this case there will be Heat symptoms in the top half of the
body and Cold symptoms in the lower part. It could also be the other way round,
but usually Heat will rise upwards and Cold will sink downwards due to their yang
and yin dynamics. There can, though, be situations where there is Cold above and
Heat below. This could be when there is an invasion of exogenous Cold in the
Stomach, with such symptoms as watery vomit, abdominal cramps and no thirst,
whilst there is Damp-Heat in the Urinary Bladder, with symptoms such as painful
urination with dark, odorous urine.
Furthermore, there are also extreme situations where there is ‘false Heat and
true Cold’ and ‘false Cold and true Heat’. It is important to differentiate these two
situations from the ones described above, in which there is just concurrent Heat and
Cold. Furthermore, ‘false Heat’ or ‘false Cold’ is not the same as ‘empty or xu Heat’
or ‘empty or xu Cold’. Empty Heat and empty Cold are when there is a deficiency of
either yin or yang, resulting in a relative excess of Heat or Cold. When there is false Heat
and false Cold, yin and yang are in the process of separating. This results in ‘false’
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symptoms of Heat or Cold. When there is, for example, empty Heat (yin xu Heat),
the deficient yin is not able to control Heat. This means that the person is hot at night
and has red cheekbones, night sweats, a red tongue without coating and so on. In
this situation, there is Heat present and it has arisen because yin cannot control yang.
When there is false Heat and true Cold, there is almost no Heat, but the patient still
manifests signs of Heat. This is because yang has become detached from yin and the
little heat that there is rises upwards in an uncontrolled way. The tongue is the most
reliable diagnostic tool in this context, because it will show the underlying imbalance.
It is essential to treat the true state and not the false manifestation. Fortunately, these
situations are rare and not something one encounters in a normal practice but are
more likely to be seen in intensive care units in hospitals.
Xu and Shi imbalances

In xu and shi imbalances, we are differentiating between the relative strengths and
weaknesses of xie qi and the body’s zheng qi. When there is a xu condition, one or
more of the vital substances or internal organs is in a weakened state. There is no xie
qi present. A shi condition is characterised by there being either xie qi present or a
blockage or stagnation of one or more of the vital substances, but the body’s zheng
qi is intact. In clinical practice, there will most often be a combination of xu and shi.
Nevertheless, it is still crucial in these situations to gauge the relative ratio of how
much xu and how much shi there is, and what it is that is xu and what it is that is shi.
Xu conditions
In a xu condition there is a deficiency of one or more of the vital substances. This
will manifest with reduced activity of the body’s physiological processes. How
the symptoms manifest will depend on which substance has been weakened. The
condition will typically be chronic.
Qi xu
A generalised qi xu condition can arise when there is a weakness in one or more
of the qi-producing organs. There may also be a qi xu condition in a single organ,
which is the consequence of an enfeeblement of the organ concerned. In addition
to fatigue, the typical symptoms of a generalised qi xu condition will be a weak or
low voice and disinclination to speak due to a lack of zong qi. Some people with qi
xu may tend to have a poor posture and have difficulty keeping their back straight,
because there is not enough qi to keep the body erect. The face will be pale, as will
the tongue. The pulse will be Weak, reflecting the lack of qi. The fatigue will increase
as the day goes on and will be worst in the afternoon and evening. It will be worse
after physical and mental activity. If there is pain or discomfort, it will be relieved
by pressure. Other symptoms will depend on which organ is weakened. Because the
Lung, Spleen and Kidneys are often involved, there will usually be symptoms and
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signs such as loose stools, poor appetite, shortness of breath, spontaneous sweating
and frequent urination.
As described above, other organs can be qi xu, not just the qi-producing organs.
There will be signs of decreased activity in the organ’s functioning. For example,
Heart qi xu can manifest with symptoms and signs such as palpitations, spontaneous
sweating and shyness. Again, these symptoms and signs of an imbalance in an organ
will be most pronounced when the person is tired and after exertion or activity.
Aetiology
Qi xu arises either because one of the qi-producing organs are weakened or because
the body is burdened by overexertion, lack of rest or disease.
Symptoms and signs

• Fatigue
• Pale face
• Loose stools
• Weak voice
• Reluctance to speak
• Spontaneous sweating
• Frequent urination
• Slumped posture
• Weak and slow movements
• Weak pulse
• Pale tongue
Key symptoms
Fatigue, pale face and a Weak pulse.
Treatment principle
Tonify qi.
Acupuncture points
Choose from: Ren 12, Ren 6, Lu 9, St 36, Sp 3, Sp 6, Kid 3, Kid 7, UB 13, UB 20,
UB 21 and UB 23.
Needle technique
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Explanation
• Ren 12, St 36, Sp 3, Sp 6, UB 20 and UB 21 tonify Spleen qi.
• Lu 9, and UB 13 tonify Lung qi.
• Kid 3, Kid 7 and UB 23 tonify Kidney qi.
• Ren 6 tonifies yuan qi.
Herbal formula
• Liu Jun Zi Tang (Tonifies Spleen qi)
• Bu Zhong Yi Qi Tang (Tonifies and raises Spleen qi)
• Jin Gui Shen Qi Tang (Tonifies Kidney qi)
• Bu Fei Tang (Tonifies Lung qi)
Relevant advice
If a person is qi xu, they will benefit from eating a diet that tonifies qi. They should
eat as much prepared and hot food as possible. They should avoid raw vegetables,
salads, cold drinks and ice cream. They should also avoid food that is unrefined,
coarse and difficult to digest. This means that it is better for them to eat white rice
instead of brown rice and to avoid too many wholemeal products. Even though these
products are richer in minerals, fibre, vitamins and so on, they are more difficult
to digest. They must also avoid foods that create Dampness, such as sweets, dairy
products, bananas, dried fruit, honey, artificial sweeteners, stevia, etc., because they
will further weaken the Spleen. It will be beneficial for the person to base their diet
on soups, stews, steamed, boiled or sautéed vegetables and porridge in the morning,
i.e. food that is easily digestible. They should also chew their food well so that it is
easier to transform.
A person with Lung qi xu will benefit from being out in nature or anywhere
else where there is fresh air. Yoga and qi gong often utilise breathing exercises. These
will have a beneficial effect on Lung qi. It is important that a person with Lung
qi is conscious of their posture, because sitting hunched forward or stooped will
constrain Lung qi.
A person with qi xu must be careful that they do not overexert themselves and
that they get adequate rest.
If a man is Kidney qi xu, he should avoid too much sex and ejaculating. A
woman who is Kidney qi xu should try to avoid becoming pregnant. Both genders
should avoid lifting heavy objects, as this strains the Kidney qi. The Kidneys contain
our energetic reserves. It is therefore vital that a person who is Kidney qi xu does
not overexert themselves, either through work or through sport. They should eat a
diet that strengthens the Kidney (see section on Kidney imbalances on page 546 for
more details).
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Xue xu
When there is too little xue in the body, the tissues will lack nutrition and moisture.
This will manifest with dry, pale skin. This will be most evident in the face, which
will have a sallow complexion, but there will also be dry skin in general on the body.
The hair will also be dry and can shed due to the roots lacking nourishment. Pallor
and dryness will be seen on the tongue and lips, and the tongue will also be thin.
When the muscles in the limbs lack nourishment, numbness, tingling and
muscle cramps can result. Women who are xue xu will often have sparse or even no
menstrual bleeding. Xue xu can also be a cause of infertility.
Xue nourishes the brain. Xue xu will often manifest with dizziness, especially
when the person gets up after sitting or lying down. The lack of nourishment to the
brain can cause a person’s memory to be poor.
A xue xu pulse is usually Choppy or Fine.
There are further symptoms and signs that are specific to Heart xue xu and Liver
xue xu respectively. In practice, both of these organs are almost always affected in
a xue xu condition. This means that there will nearly always be symptoms and signs
of these imbalances when there is a general xue xu. Liver xue nourishes the eyes. Liver
xue xu therefore typically manifests with spots in the visual field, blurred vision and
poor night vision. Liver xue also nourishes tendons and nails. Brittle, weak nails
that fray or nails that are dry and ridged are therefore always a sign of Liver xue
xu. There will often be poor sleep, because the hun is not being anchored by Liver
xue. When the hun is not anchored there can be dream-disturbed sleep. In extreme
cases the person can have the feeling that they leave their body at night. The close
relationship between the hun and Liver can also be observed in someone with Liver
xue xu who has become depressed and has no vision in life because the hun is not
being nourished.
Heart xue xu can be seen in symptoms such as palpitations. This is because
the muscles of the Heart lack sufficient nourishment to be able to carry out their
functioning optimally. At the same time, the shen lacks nourishment and is not
strong enough to control the physical aspects of the Heart (the Emperor is losing
control of the Kingdom). When the shen is not anchored and nourished by Heart
xue, there will be symptoms such as insomnia and a slight feeling of unease or anxiety.
Aetiology
Xue xu can arise when not enough xue is being produced. This will be due to the
person not consuming enough food that nourishes xue or the organs that produce
xue being qi xu.
Xue xu can also arise when the body loses blood through haemorrhaging. This
is typically seen after childbirth, surgery, physical trauma and heavy menstrual
bleeding.
Furthermore, prolonged physical or mental-emotional stress consumes and
thereby weakens xue.
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Symptoms and signs

• Dizziness
• Palpitations
• Pale and sallow complexion
• Dry skin
• Dry and pale lips
• Insomnia
• Frayed, brittle or ridged fingernails
• Scanty or absent menstrual bleeding
• Infertility
• Numbness and tingling
• Muscle cramps
• Poor memory
• Spots in the visual field
• Blurred vision
• Depression
• Mild anxiety or unease
• Pale, thin and dry tongue
• Choppy or Fine pulse
Key symptoms
Pale and sallow complexion, dry skin, scanty menstruation, Choppy or Fine pulse.
Treatment principle
Nourish xue.
Acupuncture points
Choose from: UB 17, UB 20, UB 21, UB 23, Sp 3, Sp 6, St 36, Kid 3, Ren 4, Ren 6
and Ren 12.
• If there is Liver xue xu, add: Liv 3, Liv 8 and UB 18.
• If there is Heart xue xu, add: He 7 and UB 15.
Needle technique
Tonifying. Moxa is recommended, especially on St 36, Sp 6 and UB 17.
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Explanation
• UB 17 nourishes xue.
• UB 20, UB 21, Sp 3, Sp 6, St 36 and Ren 12 tonify Spleen qi, which is
needed to produce gu qi.
• UB 23, Ren 4, Ren 6 and Kid 3 nourish jing and tonify yuan qi.
• Liv 3, Liv 8 and UB 18 nourish Liver xue.
• He 7 and UB 15 nourish Heart xue.
Herbal formula
• Si Wu Tang (Nourishes xue)
• Ba Zhen Tang (Tonifies Spleen qi and nourishes xue)
• Bu Gan Tang (Nourishes Liver xue)
• Gui Pi Tang (Tonifies Spleen qi, nourishes xue and calms shen)
Relevant advice
It is important that a person who is xue xu eats a diet that is rich in food that
nourishes xue. It will be good for them to eat foods that are rich in blood, such as
red meat, bone marrow and blood sausages. Eating organic liver will be particularly
good.18 Green leafy vegetables will also be beneficial due to their high iron content.
Other foods that nourish xue are beetroot, eggs, seaweed, watercress, avocado, dates
and beans, particularly aduki beans, black beans and kidney beans. A person who is
xue xu should avoid sugar, stimulants such as coffee and too much alcohol. Nettle
tea will be good for them.
As well as being rich in xue-nourishing foods, their diet should strengthen their
Spleen qi, as the Spleen must transform the ingested food into gu qi, the raw material
of xue. This means they should consume warm, prepared food that is not cold in its
energy and that does not create Dampness.
Yin xu
Yin, like xue, is nourishing and moistening and anchors shen. This means that there is
a similarity in some of the manifestations of yin xu and xue xu. Dryness, for example,
is a manifestation of both yin xu and xue xu. When there is yin xu, the dryness will
be apparent in the mucous membranes of the orifices, especially the vagina, lips,
mouth, nose and throat. The dryness often manifests as a slight thirst, but the thirst
will not be as intense as it is when there is shi Heat. There will be a need to sip a glass
of water, especially during the evening and at night, rather than drink a large glass in
one go.
Yin controls yang. If there is yin xu, the uncontrolled, ascendant yang can cause
night sweats and the person to feel hot at night. If shen is not anchored by yin,
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there can also be insomnia. When yang Heat is not controlled by yin, it will ascend
to the head and visibly manifest as red cheekbones.
Dizziness can arise because there is not enough yin to nourish the brain and
because if there is too little yin it can fail to anchor yang, which then ascends in an
uncontrolled way up to the head causing dizziness.
The lack of moisture in the body that is characteristic of yin xu can also mean
that the stools are very dry and that there is constipation.
Because yin is substantial, a person who is yin xu will typically have a thin,
slender body. The tongue will also be thin. There can be a lack of coating on the
tongue, as well as cracks in the surface of the tongue. If yin xu has resulted in xu
Heat, the tongue will also be red, due to the Heat. The pulse will be Fine or Empty.
If there is xu Heat, the pulse will be Rapid.
The person’s movements can be restless and fidgety, especially if there is xu Heat.
This is because the rootless Heat and yang will agitate qi in the muscles.
As was the case with qi xu, yin xu can be a generalised condition and it can be
more specifically related to certain organs. The organs that typically are yin xu are the
Kidneys, Liver, Lung, Heart and Stomach. Again, it will be possible to observe signs
that indicate that there is a disturbance of their functioning. The reader is referred to
Section 8 on zangfu imbalances for a more detailed analysis of the symptoms, signs
and treatment of yin xu conditions in these specific organs.
Aetiology
Prolonged illness, stress, overexertion, working at night, coffee, narcotics, some
forms of medicine such as steroids, a diet that is heating or stimulating, congenital
weakness and old age can all weaken yin. Prolonged Fire imbalances and chronic xue
xu will also injure yin.
Symptoms and signs

• Insomnia
• Dry mucous membranes
• Dry skin
• Night sweats
• Feeling warm in the evening and at night
• Malar flush
• Thin body
• Restless movements
• Dizziness
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• The tongue can be thin, dry and lacking coating, possibly with cracks in the
surface; if there is xu Heat, the tongue will be red
• Fine or Empty pulse; if there is xu Heat, the pulse can be rapid
Key symptoms
Dry mucous membranes, insomnia, malar flush, Fine or Empty pulse.
Treatment principle
Nourish yin.
Acupuncture points
Choose from: Kid 3, Kid 6, Ren 4, UB 23, UB 52, Sp 6 and Lu 7.
Needle technique
Tonifying. No moxa.
Explanation
• UB 23, UB 52, Ren 4, Kid 3 and Sp 6 nourish Kidney yin.
• Lu 7 and Kid 6 in combination open ren mai and yin qiao mai and thereby
nourish Kidney yin.
Herbal formula
• Liu Wei Di Huang Tang (Nourishes Kidney yin)
• Zou Gui Wan (Nourishes Kidney yin)
Relevant advice
It is crucial that a person who is yin xu gets enough rest and relaxation. This means
that they must get ample sleep and go to bed early at night. They must not work
too hard or spend too much time in front of the computer, using a smartphone or
watching television, as these stimulate the mind and thereby consume yin. A person
who is yin xu should also avoid stimulants such as coffee, which will stress their
system. Alcohol is not good for them because it is both spreading and heating in its
dynamic. They should generally try to avoid food and beverages that are stimulating
and heating, especially hot spices such as chilli and garlic. The way that food is
prepared will affect its temperature. Raw food is the coldest, then steamed, boiled,
sautéed, fried, baked, grilled, roasted and deep fried, which is the most warming. If
there is yin xu Heat, the person should avoid the more heating cooking methods.
Baked food can also be drying, which is not good for yin xu. Soups and stews will be
the best preparation method, as these are not drying.
Concentrated proteins, green leaf vegetables, cereals and root vegetables will
help to replenish yin. Foodstuffs that are rich in oil and minerals, for example nuts
and seeds, will also nourish yin.
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Sweating is to be avoided, because it will make the person lose body fluids.
This means that they should not use saunas, Turkish baths or practise ‘hot yoga’.
Ordinary yoga, qi gong and tai ji are, on the other hand, beneficial forms of activity
that nourish yin, whilst circulating qi. Dynamic activities such as aerobics or action
sports will not be good and should be discouraged because they will further strain a
person’s yin. Shiatsu, massage and meditation are also good, because they bolster
peace and tranquillity in the body and thereby replenish yin.
Men should avoid having too much sex, including masturbation, because there
they lose jing, and thereby Kidney yin, when they ejaculate.
Yang xu
When there is yang xu, the body’s fundamental warming, activating and energising
aspect is weak. This will manifest as tiredness, feeling cold and lacking motivation.
The person will be mentally and physically lethargic. Their body movements will
be slow and limp and they will possibly drag their feet slightly when walking. The
deficient yang will fail to lift the body upwards and counter gravity. This means
that the person might be slightly slouched or that they will have a poor posture, the
upper part of the body being slumped forward.
A person who is yang xu will need to wear warmer clothes than other people in
order to keep warm. They will typically have cold limbs. The lack of heat in the body
will manifest with a preference for hot food and beverages. Their face will typically
have a pale colour, due to the lack of warmth and because yang qi is not strong
enough to send xue up to the head.
Transformation and transportation of fluids in the body will be impaired when
there is yang xu and yang is not capable of performing its functions. This will result
in there being an increased volume of urine, which is clear in colour. There will be
frequent urination because of the increased volume of urine and because Kidney
yang is too weak to keep the urine inside the Urinary Bladder. Yang qi also helps to
keep the sweat inside the body. Yang xu can therefore manifest with spontaneous
sweating or sweating on light activity. The disruption of fluid physiology will also be
seen in a lack of thirst and there can be a tendency to oedema.
Yang is utilised in the transformation of food that has been ingested. If yang is
deficient, the person may have not only loose stools, which is typical of qi xu, but
also watery stools, possibly containing undigested food particles. This is because the
food and liquids consumed have not been transformed.
The tongue will be swollen and pale, and the pulse will be Deep and Weak.
The organs that are most likely to be yang xu are the Kidneys, Spleen and Heart.
There will be tangible symptoms and signs that specifically relate to these organs’
active functions if they are yang xu.
Aetiology
Yang xu can arise when yang has been overstrained through prolonged overexertion,
old age, recurring cold invasions, improper diet, disease or congenital weakness.
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Symptoms and signs

• Feeling cold or an aversion to cold
• Cold limbs
• Clear and copious amounts of urine
• Oedema
• Loose, watery stools, possibly containing undigested food
• Mental and physical fatigue
• Slow and lethargic body movements
• Slumped posture
• Lack of thirst
• Preference for hot drinks and hot food
• Pale, white face
• Pale, swollen and possibly wet tongue
• Deep or Weak pulse
Key symptoms
Aversion to Cold, fatigue, pale and swollen tongue, Deep or Weak pulse.
Treatment principle
Tonify and warm yang.
Acupuncture points
Choose from: Du 4, UB 23, Ren 4, Ren 6, Kid 3 and Kid 7.
Needle technique
Explanation
• UB 23, Du 4, Ren 4, Ren 6, Kid 3 and Kid 7 tonify and warm Kidney yang.
Herbal formula
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Relevant advice
A person who is yang xu should consume a diet that is warm, both in its physical
temperature and energetic dynamic. They should try to avoid completely food that
has a cooling quality, including food and beverages that are physically cold. This is
especially relevant during the winter. This means that they should avoid fruit, unless
it is stewed or baked and have no salads, raw vegetables or cold drinks. They should
try to use more warming cooking methods, such as baked and grilled dishes. A good
start to the day would be to eat hot porridge with a sprinkling of cinnamon. Hot
spices such as chilli and cayenne pepper are not necessarily a good idea though, as
they will cause the person to sweat and thereby lose heat and yang qi. Replenishing
a xu condition is something that takes time and cannot be forced. Generally, spices
in the diet will be beneficial, as they will awaken yang.
Exercise is important, but care must be taken. Light exercise is beneficial when
there is yang xu, because it will activate yang and qi. However, the person must be
careful that they do not train too hard, otherwise they will consume their yang qi.
Starting the day with activities that can awaken and get qi moving, such as stretching
and shaking the body, is a good idea.
Keeping warm is important, especially the lumbar area and the area just below
the navel. Something that can be recommended is for the patient to wear a woollen
‘belly-warmer’; alternatively they can tie a scarf or a shawl around their abdomen. No
matter what, they should try to avoid these areas becoming exposed to the cold or
draughts. A ginger or mustard foot bath is also something that can be recommended.
It will also be beneficial for them to drink ginger tea during the day.
Patients who are Kidney yang xu should avoid activities that weaken the Kidneys
and weaken yang. Apart from the general advice given above, men should avoid
having too much sex, including masturbation, because yang is expended in the
ejaculation and because the semen contains jing, which in the end is the root of
Kidney yang. Lifting heavy objects weakens Kidney yang, so this should be avoided
as much as possible.
Difference between Shi conditions and Xu conditions

Shi conditions Xu conditions
Xie qi is present or there is a stagnation of qi, xue Deficiency of qi, xue, jinye, yin or yang
or jinye
Can be either acute or chronic Usually chronic
Over-activity or a stagnation of an organ’s qi or a Lower level of functional activity in an
vital substance organ or of a vital substance
If there is fatigue, it will be relieved by activity Fatigue, exacerbated by activity
Symptoms often improve with physical activity Symptoms often worsen with physical
activity and when the person is tired
Severe symptoms Milder symptoms
Strong pulse Weak pulse
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Shi conditions Xu conditions

Thick tongue coating Normal tongue coating or a lack of tongue
coating
Pain or discomfort that is exacerbated by palpation Pain and discomfort relieved by palpation
Loud voice Weak voice
Shi conditions
Shi conditions are characterised by the presence of xie qi in the body. Xie qi will
either be exogenous or internally generated. Furthermore, stagnation conditions are
also defined as being shi conditions. The body’s zheng qi is theoretically intact in
a shi condition. In practice, though, a shi condition can be such a burden on a
person’s zheng qi, that it will often develop into combined xu and shi conditions. Shi
conditions can also arise from xu conditions. These will therefore also be defined as
being xu/shi conditions.
Shi conditions that are caused by invasions of exogenous xie qi will be acute,
whereas internally generated xie qi is usually more chronic in its nature. Even though
a condition is chronic, it can still flare up with acute symptoms.
The symptoms and signs seen in shi conditions tend to be more intense than
those seen in xu conditions, which tend to be milder. For example, vomiting in a shi
condition is often explosive, whereas regurgitation is more typical in xu conditions.
If there is pain or discomfort, they will be more extreme. The pain will not be
alleviated by palpation in the local area, but will usually be better with movement.
The voice of a person with a shi condition will be louder than if there is a xu
condition. There is also less likelihood of fatigue. A person may feel fatigued when
there are stagnation conditions, but this is a spurious form of fatigue. The fatigue
that the person experiences is due to their qi not circulating around the body.
When there is spurious fatigue, the person will usually feel fresher and more energetic
after physical activity.
The pulse will be. powerful and the tongue will often have a thicker coating
when there is a shi condition.
Shi conditions will often generate xie Heat in the body. This means that signs
such as a red face, irritability, rough breathing and constipation are often seen.
In general, though, it can be difficult to generalise about how shi conditions will
manifest. This is because there is so much variation in the types of xie qi that can
be excessive. The reader is therefore referred to the relevant parts on shi Heat and
shi Cold in this section (pages 271 and 280) and to the relevant parts of Section 6,
‘Diagnosis According to Xie Qi’.
Shi conditions can be summarised as follows: invasions of exogenous xie qi,
interior Cold, interior Heat, interior Wind, ascending yang, Dampness, Phlegm, qi
stagnation, accumulation of fluids and xue stagnation.
Aetiology
Shi conditions arise when the body is invaded by exogenous xie qi, when there is
internally generated xie qi or when there is a stagnation.
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Symptoms and signs

• Symptoms that are acute (chronic symptoms can, though, sometimes also
be shi in nature)
• Intense or severe symptoms
• Pain or discomfort that is not relieved by palpation
• Symptoms that are relieved by activity and movement
• Loud voice
• Heavy breathing
• Full pulse
• Thick coating on the tongue
Treatment principle
Expel, drain or transform xie qi, spread or dissolve stagnations.
Acupuncture points, herbal formula and relevant advice

See the relevant sections for the various types of xie qi and stagnation conditions.
Yin and yang imbalances

The categories of yin and yang can, in general, be seen as encompassing the other six
categories. The differentiation of yin and yang can also be used as a specific diagnosis
in certain situations. In general, the differentiations of exterior, Heat and shi can
be defined as being yang qualities. Interior, Cold and xu, on the other hand, are
yin qualities. In practice, though, it can often be difficult to say whether something
is purely yin or yang. Wind-Cold, for example, is an exterior condition and a shi
condition, both of which are defined as being yang, as is Wind, but Cold is yin. Liver
Fire is an interior condition, i.e. yin, but it is also a Fire condition, which is yang.
Although it is often difficult to define a condition as being purely yin or yang, in
situations where we are in doubt about our diagnosis we can simplify the diagnosis
by taking a step backwards and asking ourselves whether the condition is essentially
a yin or a yang condition and treat it as such.
We can also utilise yin and yang differentiation to be specific and focused when
we want to define an imbalance precisely. For example, it is not enough to diagnose
a person as being Kidney xu, but through the symptoms and signs that they are
manifesting, we can explicitly define the imbalance as being either Kidney yin xu or
Kidney yang xu.
The differentiation of yin and yang is especially relevant when diagnosing yin xu
and yang xu conditions. Yin shi and yang shi conditions are generally the same as shi
Cold and shi Heat but also encompass conditions’ various other imbalances such as
Dampness and internally generated Wind.
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Yang xu Yang shi Yin xu Yin shi

Facial colour Matt, white Red Red cheekbones Bright white
Energy level Tired and Restless or manic Tired or restless
lethargic
Movements Sluggish and slow Fast, powerful and Quick, restless Stiff and rigid
hyperactive and fidgety
Mental state Sluggish and lacks Manic, irritable, Mental Can have
motivation aggressive, restlessness, difficulty thinking
Slow thinker restless, difficulty nervousness, clearly and
concentrating due unease focusing when
to a cascade of there is Damp-
thoughts Phlegm
Stools Loose stools or Constipation Constipation Diarrhoea or loose
watery diarrhoea stools
(it is possible
that there is
constipation when
yang qi is too
weak to move the
stool through the
Intestines)
Urination Frequent Dark, scanty urine Dark, sparse urine Either inhibited
Copious amounts Possibly painful and painful
of clear urine urination urination or
copious amounts
of clear urine
The voice and Weak and soft Loud voice Nervous, quick Can be nasal
speech voice Garrulous and Soft, weak and
Talks slowly talks quickly ‘dry’ voice
Reluctance to
speak
Pulse Slow, Deep and Large, Full and Empty and Tight
Weak Rapid Superficial or Fine
Possibly Rapid
Tongue Pale, swollen and Red with yellow Thin, red, cracked Pale with a thick
wet coating and/or peeled white coating
Body Aversion to cold, Fever or aversion Hot in the Feels the cold
temperature freezes easily, cold to heat evening and at The skin feels cold
limbs The skin feels hot night
Palms of the hand
and the soles of
the feet can feel
hot
Apart from yin xu, yang xu, yin shi and yang shi, there are also two conditions known
as ‘collapse of yin’ and ‘collapse of yang’. These are perilous and the life-threatening
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conditions in which yin and yang are separating from each other. These are therefore
very serious conditions and often occur just before death.
Collapse of yin
Aetiology
Yin collapses when there is an extreme condition of yin xu Heat and yin is exhausted.
This could be the end result of an initial invasion of xie qi that has penetrated down
to the xue level of the Four Levels.
Symptoms and signs

• Profuse sweating
• The skin feels very hot
• Hot limbs
• Very dry mouth
• Dark, scanty urine that is difficult to void
• Constipation
• Mental restlessness and anxiety
• Thin, emaciated body
• Thin, short, dark red tongue without coating
• Fine, Superficial and Rapid pulse
Key symptoms
Hot skin, hot limbs, thin, dark red tongue without coating, Rapid and Fine pulse.
Treatment principle
Rescue yin.19
Acupuncture points
Acupuncture will not be enough in itself, but the following points can be tried.
Choose from: St 36, Ren 4, Ren 6, Kid 3 and Kid 6.
Needle technique
Tonifying.
Explanation
• St 36, Kid 3, Kid 6 and Ren 4 nourish yin.
• St 36 and Ren 6 tonify qi.
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Herbal formula
• Da Bu Yin Wan (Rescues collapsed yin and controls yin xu Heat)
Collapse of yang
Aetiology
Yang collapses when yin and yang are separating. This could happen when exogenous
xie qi has penetrated to the deepest energetic aspects of the body and yang is exhausted.
Symptoms and signs

• Extreme sensitivity to cold
• The skin feels cold and clammy
• Cold limbs
• Shallow breathing
• Profuse sweating with beads of sweat like pearls
• Frequent urination or incontinence; the urine is clear
• Loose stools or faecal incontinence
• Mental confusion or loss of consciousness
• Pale, short and wet tongue
• Hidden, Slow pulse
Key symptoms
Cold and clammy skin, extreme sensitivity to cold, profuse sweating, Hidden pulse.
Treatment principle
Rescue yang.20
Acupuncture points
Choose from: St 36, Ren 4, Ren 6 and Ren 8.
Needle technique
Large amounts of moxa must be used.
Explanation
• Ren 4, Ren 6 and Ren 8 rescue yang.
• St 36 tonifies qi.
Herbal formula
• Shen Fu Tang (Rescues collapsed yang)
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Section 6
DIAGNOSIS ACCORDING TO XIE QI
In this diagnostic model, the symptoms and signs that are manifesting and the
aetiological factors that are creating the symptoms and signs are one and the same.
This means that when we diagnose say ‘Dampness’, there is an understanding
both that the person will be manifesting specific symptoms and signs that are
characteristic of the presence of Dampness and that the cause of the imbalance is
that the person has been exposed to some form of qi that is intrinsically Damp in
its nature or that some other aetiological factor or internal imbalance has resulted
in the presence of internal Dampness. This stands in contrast to other aetiological
factors and imbalances. Anger, for example, which is one of the seven internal or
emotional causes of illness, is not a pattern of imbalance. Anger can be a cause of an
imbalance, such as Liver Fire, but anger is not a pattern of imbalance with specific
signs and symptoms. Liver Fire, on the other hand, is a pattern of imbalance with
specific symptoms and signs that are characteristic of extreme Heat in the Liver, but
Liver Fire is not an aetiological factor.
Like most medical systems, Chinese medicine has a shamanistic past. Initially it
was believed that disease arose because the body was invaded by evil spirits. These
spirits could, for example, be the person’s ancestors who were dissatisfied with the
person’s behaviour or rootless spirits that were present in the local surroundings.
Treatment at that time was based on either expelling the evil spirit from the body or
trying to appease the disgruntled ancestor. These evil spirits that caused disease were
termed xie qi. Xie can be translated as evil or perverse. These spirits were a perverse
or evil form of qi because they were qi that only had a negative and disruptive effect
on the body. This is in contrast to the body’s own qi, which is exclusively benevolent,
possessing only positive properties. Xie qi can also be translated as ‘pathological
qi’, ‘pathogenic qi’ or simply ‘pathogen’, because it is a form of qi that can result
in disease.
Many of the places where xie qi gathered and was predominant were places that
were dark, damp or cold – places people instinctively feel are unpleasant. It was
observed that people more often fell ill or developed disorders when they stayed
in such places. Similar observations could also be made in other places where the
climate was more extreme. Over time the perception started to change. Evil spirits
were seen as the cause of illness less and instead the climate itself was viewed as being
the culprit. The relationship between an individual and the world surrounding them
became more apparent. The perception changed increasingly to being that people
who dwelt in cold, dark, damp places became ill because of these conditions and not
because they were where evil spirits resided. The dampness and the cold were the
xie qi.
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As analytical observers, Chinese scientists, scholars and doctors saw that there
was a relationship between people becoming ill and being exposed to extreme or
prolonged climatic influences. They also became aware that the condition of a person’s
own qi played an important role in their being susceptible to being affected by these
climatic influences. It had already been observed that certain climatic conditions
such as cold, dampness, heat and so on had specific, unique characteristics. These
various forms of climatic qi were already known to affect the physical world in
specific and thus predictable ways. For example, if there is an extreme or prolonged
period of cold weather, water will freeze. Cold temperatures will also cause matter
to contract due to the yin nature of cold. Yang heat, on the other hand, has a very
drying quality and desiccates things that are moist. It was observed that when people
were exposed to prolonged or extreme climatic influences, their body reacted in a
similar way to the world outside the body. For example, it was observed that when
the body was exposed to cold weather, qi stagnated in the same way that water does
when it freezes.
The designation xie was not discarded though, because it was still an appropriate
term. The idea is the same – the body is affected by a form of qi and this qi has
negative characteristics and a pathological influence on body’s own qi. Whereas
before it was an evil spirit that had invaded the body, the new concept was that it was
a form of negative qi that was disrupting the body’s physiology. This is very typical
for Chinese medicine and its way of thinking. An old theory is not rejected but is
instead assimilated into the new understanding of how the body works.
Each xie qi has its own specific and unique qi dynamic. Qi dynamic is the
directional movement that the qi has and the way in which it affects other forms
of qi. This qi dynamic is a reflection of its relative yin or yang nature. For example,
Heat is a yang form of qi. Heat’s yang quality can be seen in the fact that it’s a form
of qi that ascends; it desiccates and it creates over-activity in the internal organs
and the vital substances it is in contact with – it agitates. These qi dynamics are of
great importance in relation to how the various xie qi affect qi in the body and what
reactions they create. It is through observation of these changes that a diagnosis
is made.
As stated, an invasion of exogenous xie qi is defined on the basis of its origin, i.e.
how it has arisen. For example, you can be invaded by Damp-Cold if you get cold
and wet after being drenched by the rain in winter. Xie qi, though, is also defined
by how it manifests, i.e. how it affects the body’s qi. If something affects the body
in the same way as, for example, exogenous Cold does, it will be defined as being
exogenous Cold even though the person has not been exposed to climatic cold. In
general, there is no discrepancy between the way that symptoms and signs manifest
and the climatic influences that a person has been exposed to. However, there are
circumstances in which there has been no exposure to a climatic influence, yet the
person still manifests symptoms and signs of an external invasion of xie qi. Allergic
rhinitis is a typical example of this. This is because all pathogens, like climatic qi,
have specific qi dynamics. This is of great importance when treating people who
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Diagnosis According to Xie Qi
have been infected with bacteria, viruses and other ‘invisible’ forms of infection and
when people react negatively to food additives, chemicals and allergens. If exposure
to a particular virus makes the body temperature rise, the eyes become red, the thirst
increase and the pulse beat faster, this virus is defined and thereby treated as Heat
xie qi. This is because these physiological reactions are the reactions that occur when
Heat is present in the body. Conversely, if a person feels very cold, has cramping
intestinal and gastric pain and watery diarrhoea, this physiological reaction will
instead be defined as being a Cold reaction. This will therefore indicate the presence
of xie Cold in the body, even though the person has not necessarily been exposed to
anything cold.
Something that is also important to remember is that when exogenous xie qi
invades the body it can change character and transform into something else. It is, for
example, very typical for invasions of Cold to transform into Heat patterns when the
Cold has penetrated into the body.
As stated, each of the six exogenous forms of xie qi has its own unique symptoms
and signs, which are manifestations of its specific qi dynamic. There are, however,
some symptoms and signs that will be seen in all invasions of exogenous xie qi. This
is because exogenous xie qi will have a disruptive effect on the body’s wei qi. When
xie qi invades the exterior aspect of the body, there will often be an aversion to cold
and chills, even if the invasion of exogenous xie is Heat. This is because exogenous
xie qi blocks wei qi so that it can no longer warm the skin. There can also be a
slight fever or febrile sensation even though it is a Cold pathogen. This is because
the conflict between xie qi and wei qi and the subsequent stagnation that arises will
generate Heat. The febrile sensation may not be particularly pronounced and may
well not be measurable with a thermometer. In Chinese medicine, fever is defined
by the patient’s own subjective sensation of warmth or the therapist observing signs
of Heat, such as a red colour in the face or the skin feeling warm on palpation. An
important diagnostic sign in invasions of exogenous xie qi is that chills and febrile
sensations manifest simultaneously. In invasions of exogenous xie qi, the pulse will
usually be Superficial.
An invasion of the body by exogenous xie qi will be due to one or more of the
following factors:
• Zheng qi is weak or weakened: If zheng qi, including wei qi, is weak, the
body will more easily be invaded. This is because the body will not be able
to protect and defend itself. This means that xie qi does not need to be as
strong or to have affected the body for a prolonged period of time. A weak
or weakened zheng qi is typically seen in infants, older people, people who
are physically run down and people who have been ill. To illustrate this,
imagine that an old lady and a young man have to go out from their house
to the corner shop, which is 400 metres away. It is freezing cold and both of
them are only wearing a thin coat. It is much more likely that the old lady
will catch a cold as a result of this trip than the young man. Her wei qi is not
strong enough to withstand the onslaught of the wind and cold. It is typical
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that some people catch every bug that is going around whilst others rarely
fall ill. This is usually a reflection of the relative strengths of their wei qi.
• Xie qi is very strong: If the body is subjected to a very strong influence of
xie qi, it will have difficulty keeping it out, even though the wei qi is robust.
Returning to the young man from the previous analogy – walking down to
the shop in a thin jacket in winter will probably not result in him catching a
cold or becoming ill. This is because his wei qi is robust. However, it is highly
likely that he will catch a cold or fall ill if he falls through the ice on a lake
into the freezing cold water below. Even though there is no difference in the
length of time he is exposed to the cold, there is a difference in the intensity
of the cold he is exposed to. This is also seen in some virulent diseases, where
the majority of the population, including strong, healthy individuals, fall ill
when exposed to the disease.
• Prolonged exposure to xie qi: A prolonged exposure to a certain form of xie
qi will wear down the body’s defences. Imagine the same young man – he
will not become sick from walking to the shops in freezing weather in a thin
jacket, but if he had to walk around town in freezing weather with only a thin
jacket for two hours, it is more likely that he would become ill afterwards.
This time it is not the strength of the cold that is crucial but the prolonged
exposure to it. Imbalances that arise as a consequence of prolonged exposure
to a certain type of xie qi are seen, for example, in people who live or work
in an environment that is characterised by a particular climate, such as living
or working in a place that is cold and damp.
• Sudden exposure to xie qi: Illnesses can arise when seasons change or when
the weather is atypical for the season. It is as if wei qi does not have time
to adjust to this atypical, climatic influence; as if it has prepared itself to
protect the body against something that is, for example, yin, and all of a
sudden there is something that is yang. We often see people catch a cold
when there is a period of mild weather in winter or during a cold and wet
period in summer. This is also the reason that many people get sore throats
and colds from air-conditioning, especially in hot climates. The pores of the
skin are wide open due to the heat and then they come into a building
that is quite cold and the air-conditioning also creates a draught (Wind). In
addition, many people fall ill in the transition from summer to autumn and
from winter to spring – the classic spring cold.
• Presence of imbalances in the body: A person is more likely to be adversely
affected by a specific form of xie qi if they already have a similar imbalance.
A person with yang xu will be invaded by Cold more quickly than a person
with shi Heat. A person with Spleen imbalances is more rapidly affected if
there is Dampness than a person who is yin xu.
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There are six exogenous forms of xie qi. Five of these forms of xie qi can also be
internally generated. Summer-Heat is the only form of xie qi that is exclusively
exogenous. Where exogenous xie qi can invade the body when it comes into contact
with climatic influences, bacteria, viruses, allergens and so on, internally generated
xie qi arises when there are internal imbalances in the body, especially zangfu organ
imbalances. It is important to remember that xie qi is defined by its origin, but
also how it manifests. This means that when an internal imbalance manifests with
a person having a red face, being excessively thirsty, being mentally restless and
having a Rapid pulse and a red tongue, this imbalance will be defined as Heat. The
Heat here though has been internally generated, i.e. it is Heat that has arisen due to
internal conditions and not because the person has been in contact with exogenous
xie qi. As can be seen in this example, internally generated xie qi is in many ways
similar to exogenous xie qi. The important difference being, as we saw previously,
that internally generated xie qi is an aetiological factor in itself.
As well as there being a difference in their aetiology, the symptoms and signs of
internally generated xie qi and exogenous xie qi are different in quality, intensity and
duration. Exogenous xie qi tends to be acute and the symptoms more pronounced.
The symptoms and signs of internally generated xie qi will usually be chronic and
less intense. Exogenous xie qi will usually manifest with symptoms and signs relating
to the exterior aspects of the body – wei qi, skin, muscles, joints and channels. There
will probably be an aversion to cold and a slight febrile sensation. Internally generated
xie qi can affect specific organs or vital substances or it can be systemic. There are,
however, also situations where exogenous xie qi can manifest in the interior of the
body. This will be because exogenous xie qi has penetrated deeper into the body or
there has been a direct invasion of exogenous xie qi into the interior.
As stated, only five of the six forms of exogenous xie qi are generated in the
interior. Furthermore, in addition to internal Heat, Cold, Wind, Dampness and
Dryness, there are other forms of internally generated xie qi that do not exist as
exogenous xie qi. These are Phlegm, xue stagnation and food stagnation, which are
also classified as forms of xie qi. Like the other forms of internally generated forms
of xie qi, Phlegm, xue stagnation and food stagnation are not defined as aetiological
factors. This is because they themselves have resulted from one or more of the
internal, external or miscellaneous aetiological factors.
Diagnosis according to xie qi in relation to diagnosis

according to the Eight Principles
Xie qi imbalances are generally shi imbalances. This is because when there is xie
qi, there is something extra present in the body. However, this does not exclude
the possibility that there can be a combined xu and shi condition. This is seen, for
example, when there is an invasion of Wind-Cold that has arisen because there is wei
qi xu or when Phlegm-Dampness is generated because there is Spleen qi xu.
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Xie qi imbalances can be both exterior and interior. When there is an invasion of
exogenous xie qi, it will be an exterior imbalance, but if xie qi is internally generated,
it will be defined as being an interior imbalance.
Wind
Wind is a very yang form of xie qi. Wind is the ‘prevailing qi in spring’, although
invasions of Wind are not exclusive to this season. Both Wind and spring do have
a powerful resonance with the Wood Phase and its dynamic – young yang energy.
Wind’s yang nature is seen in its mobility and speed. Wind has an expansive and
thereby spreading dynamic. Imagine a pile of leaves lying in a heap on the ground:
heat, dampness and cold will only result in the leaves drying out, becoming heavy
and soggy or freezing into a solid mass, but a gust of wind will spread them in
all directions and set them in motion. This ability of Wind to spread things apart
enables it to penetrate through wei qi, whilst drawing other forms of xie qi into
the body. This is the reason it is said that Wind is the spearhead that conveys other
forms of xie qi into the body. This is very important for yin forms of xie qi, such
as Cold. Cold has a contracting nature and therefore results in the pores in the
skin contracting and closing, blocking its entry. Wind can spread open the pores
and thereby lead Cold through the skin and into the body. This is similar to a
draughty cabin in winter. If the temperature is sub-zero outside but it is completely
windless, it is possible to warm the cabin with a small stove. If, on the other hand,
the temperature is 10 degrees centigrade, it is still difficult to keep the cabin warm
if the wind is blowing outside. This is because the wind will drive the cold into the
cabin through the cracks in the walls.
Wind’s yang nature means that it has a tendency to affect the head and the upper
part of the body, as well as the outer aspects of the body, i.e. the wei qi aspect. Wind’s
dynamic yang nature also means that the symptoms and signs that are manifesting
can have a tendency to migrate from place to place and to be variable in character.
This is characteristic of the form of bi known as Wind bi, where the pain in the
joints constantly changes character and location. Wind’s yang nature also manifests
in a sudden onset of its symptoms and signs. Wind creates movement because it is
yang. Wind can often manifest as tremors, spasms and itching. Extreme stiffness and
paralysis can also be a symptom of Wind, because when something vibrates very
strongly and quickly, it becomes stiff and rigid.
Wind has a resonance with the jueyin aspect. This is shown by people’s eyes
watering when it is windy. Both the eyes and tears relate to the Liver through the
Five Phases, as does Wind. Internally generated Wind can arise as a consequence
of Liver imbalances. Many of the symptoms of internally generated Wind and
exogenous Wind are similar, but the aetiology and the treatment principles will be
very different.
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The Liver is not the only zang organ to have a relationship with Wind. The
Lung is easily affected by Wind, as it is the only zang organ that is in direct contact
with the environment outside of the body. The Lung also controls wei qi. This means
that the invasions of exogenous Wind will often affect the Lung and its sensory
organ, the nose. Furthermore, if there is Lung qi xu, wei qi will also be xu and the
person will be easily invaded by exogenous Wind.
Invasion of exogenous Wind

The patterns seen when there is an invasion of exogenous Wind are: Wind-Cold,
Wind-Heat, Wind-Dampness, Wind-Water, Wind-Cold-Damp bi.
An invasion of exogenous Wind will nearly always be an acute pattern. The
exception to this is Wind bi, which will often have developed into a chronic pattern.
Invasions of exogenous Wind will generally be relatively short-lived. The xie qi
will either be expelled again or it will penetrate deeper into the body.
Aetiology
The invasion is due to there being a virulent xie qi, which has been strong enough
to break through the defences of the body’s wei qi. This could be when a person has
been exposed to climatic wind, but it can also be that they have been exposed to an
artificial indoor climate such as air-conditioning. Furthermore, some allergens and
viruses can manifest as an exogenous Wind pattern.
There can also be an underlying wei qi xu, which means that xie Wind does not
have to be that strong to be able to break through the defensive qi.
Symptoms and signs

The specific symptoms and signs will depend on the individual patterns.
Typical symptoms and signs that are seen when there is an invasion of exogenous
Wind are:
• acute symptoms that arise suddenly
• stiffness, numbness, tremor and itching or tingling sensations in the skin
• pain in the joints
• pain that migrates from place to place and is variable in character
• headache
• aversion to cold and wind
• a disturbance of the functioning of the Lung, resulting in coughing and
sneezing
• Superficial pulse.
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Symptoms and signs of specific exogenous Wind pattern

Wind-Cold Aversion to cold and wind; chills; headache; stiffness in the shoulders and neck;
lack of sweating; coughing; sneezing; clear secretions from the nose; slight or no
fever; itchy throat; no thirst; Superficial, Tight, Slow pulse.
Wind-Heat Less aversion to cold than when there is Wind-Cold; chills; mild or high fever;
thirst; red eyes; red and sore throat; yellowish secretions from the nose; cough,
possibly with yellowish sputum; Superficial and Rapid pulse; the tongue may
have a red tip or a yellowish coating.
Wind-Damp Itchy skin disorders; skin diseases where there is swelling; aversion to wind and
cold; heaviness in the arms and legs; heavy and painful muscles and joints; slight
or no fever; Superficial and Slippery pulse; wet tongue.
Wind-Water Acute oedema, especially in the face and around the eyes; cough with very
watery sputum; wheezing; no thirst; Superficial and Slippery pulse; wet tongue.
Wind-Dryness Dry throat; dry lips; dry mouth; dry eyes; dry skin; dry mucous membranes; dry
tongue; Superficial pulse.
Wind bi This is bi syndrome where Wind, Dampness and Cold have invaded the channel
or the joint. Wind is the predominant of the three xie qi. There will be painful
joints. The pain will be provoked by the wind or by drafts. The pain can migrate
from joint to joint, be erratic and change character (sometimes sharp, sometimes
throbbing, sometimes numb, sometimes heavy and so on). The pain can come
and go very suddenly and will mainly affect the upper part of the body. There
will often be aversion to wind, cold and drafts. There may be a slight fever and
sweating. The pulse will be Superficial.
Invasion of Wind-Cold can invade the channels in the face. It will often be the yangming
Wind-Cold in channels that are affected. The invasion of Wind-Cold in the face will result in
the face pain and especially paralysis of the facial muscles. The pulse will be Superficial
and Tight.
Treatment principle
Expel Wind.
Acupuncture points
Choose from: UB 10, UB 12, LI 4, Lu 7, Du 14, Du 16, SJ 5 and GB 20.
• If there is Wind-Cold, add: SI 3 and UB 62.
• If there is Wind-Heat, add: LI 11.
• If there is Wind-Dampness, add: Sp 6 and Sp 9.
• If there is Wind-Water, add: Sp 9 and Ren 9.
• If there is Wind-Dryness, add: Kid 6 and Sp 6.
• If there is Wind bi, add: Local and distal points on the relevant channels.
• If the invasion of Wind is in the face, add: Local and distal points along the
channels.
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Needle technique
Draining technique. Moxa and cups are recommended.
Explanation
• UB 10, UB 12, LI 4, Lu 7, Du 14, Du 16, SJ 5 and GB 20 activate wei qi
and expel Wind.
• UB 62 and SI 3 expel xie qi from the taiyang aspect.
• LI 11 expels Wind-Heat.
• Sp 6 transforms Dampness, drains water and can nourish jinye and yin.
• Sp 9 transforms and drains Dampness and water.
• Kid 6 nourishes yin and jinye.
Herbal formula
• Ma Huang Tang (Expels Wind-Heat)
• Huo Xiang Zheng Qi Tang (Expels Wind-Cold and Dampness).
• Xing Su San (Expels Wind-Cold and Dryness)
• Sang Xing Tang (Expels Wind-Heat and Dryness)
• Juan Bi Tang (Expels Wind-Cold and circulates qi in the channels)
Relevant advice
to consume drinks that are spicy and diaphoretic to open the exterior and expel xie
qi. This could be ginger, garlic, whisky, brandy and chilli if there is an invasion of
exogenous Wind-Cold or mint, chamomile or elderflower if there is an invasion
of exogenous Wind-Heat. It is also advised to abstain from eating or to only eat
soups, for example such as onion soup. There are two reasons for this. First, when
temporarily fasting qi will not be used to transform food and therefore can be
used to combat the invading xie qi. Second, some sources say that the downward
movement of food and qi in the Stomach can draw the exogenous xie qi inwards
from the surface.
as they are cold and drain downwards.
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It is important that the person protects themselves from drafts and exposure to
the elements.
Invasion of Wind can be caused by the following pattern of imbalance

• Wei qi xu
Invasion of Wind can result in the following pattern of imbalance

• This will depend on the individual pattern.
Internally generated Wind

The difference between internally generated and exogenous Wind is that internally
generated Wind arises as a consequence of zangfu and xue imbalances. Invasions
of Wind are seen when the body is invaded by exogenous xie qi. This difference is
extremely important in relation to treatment strategies and treatment techniques.
When there is exogenous Wind, you must ‘open to the exterior’ and expel xie
qi. When there is Internally generated Wind, you must ‘extinguish Wind’ and treat
the underlying zangfu or xue imbalance.
Wind in the body is similar to wind in nature in several ways and it can be just as
destructive. There may be a slight breeze that just manifests with symptoms such as
tics or a mild dizziness, or it can be like a hurricane and cause paralysis, spasms and
stroke. This is particularly the case when the Wind has resulted from Heat; this can
have very destructive and sometimes fatal consequences. One of the major problems
with Wind is that it can whirl up Phlegm and send it up to the head, blocking
the ‘orifices’. This can result in the person losing their ability to talk and make the
tongue stiff. The Phlegm can also block the channels and result in paralysis. Some
of the disorders in Western medicine that are manifestations of internally generated
Wind are meningitis, tetanus, febrile convulsions, epilepsy and stroke.
Wind can cause gentle movements, such as when a flag flaps gently back and forth
on a summer’s day, but it can also make the flag stand rigidly in the air, not moving
to either side, such as in an autumn storm. In both scenarios it is characteristic
that the flag’s movements are involuntary, and this is the same in the body. All
involuntary movements of the muscles and all forms of cramping and spasms will
be due to Wind.
Aetiology
This will depend on the specific imbalances that have led to the generation of internal
Wind (see the section on Liver imbalances on page 590 for the aetiology of these
patterns).
Symptoms and signs

• Symptoms can be mild such as tremors, tics, numbness and dizziness.
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• Symptoms can be more extreme, such as loss of consciousness, aphasia,

extreme vertigo, coma, convulsions, paralysis.
• There will also be symptoms of the underlying imbalance.
Treatment principle
Extinguish Wind and harmonise the underlying imbalance.
Acupuncture points
Choose from: Du 20, Du 16, UB 10, GB 20 and Liv 3, as well as points to treat the
underlying imbalance.
Needle technique
This depends on whether it is a xu or shi pattern of imbalance.
Explanation
• Du 20, Du 16, UB 10, GB 20 and Liv 3 all calm and extinguish Wind.
Herbal formula
• Tian Ma Gou Teng Yin (Extinguishes Liver Wind)
Relevant advice
This will depend on the underlying imbalance.
Internally generated Wind can be caused by

the following patterns of imbalance
• Invasion of exogenous xie qi
• Liver Fire
• Ascending Liver yang
• Liver yin xu
• Liver xue xu
Internally generated Wind can result in the following pattern of imbalance

• Phlegm-Wind
Cold
Cold is referred to as ‘the prevailing qi of winter’. This is because cold is the dominant
climate at this time of year. This does not mean that Cold cannot or will not invade
the body at other times of the year but that Cold is most prevalent in winter.
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Cold is extremely yin in nature. This means that Cold can easily damage yang.
Cold’s yin nature can be seen in its qi dynamic, which is contracting. Its contracting
nature means that Cold creates stagnations and blocks the movement of yang. This
is seen in the world around us, where cold freezes water and stops it from moving;
Cold does the same in the body. Cold will stagnate qi, jinye and xue, because it
blocks their free movement. There is an aphorism in Chinese medicine: ‘Where
there is stagnation, there is pain, where there is free movement, there is no pain’
(‘Bu tong ze tong, tong ze bu tong’). This means that pain is a key symptom signifying
the presence of Cold. The character of pain in Cold is typically cramping or biting
in nature. Other typical symptoms are stiffness and a pronounced aversion to cold.
Exogenous xie Cold will often invade the body through the skin, where it will
disrupt the circulation and the activities of the body’s wei qi. This means that the
symptoms and the signs of an invasion of Cold will be most apparent in the body’s
external aspects. Because Cold blocks the movement of wei qi, it will also block wei
qi in its ability to open the pores and there will be a lack of sweating. Each of the six
climatic qi has a resonance with specific organs and channels in the body. Cold has
a resonance with the taiyang channel. Taiyang is the most exterior channel and it is
in these channels that the initial reactions to an attack of Cold manifests according
to ‘Six Stage’ theory.
Cold is often involved in the aetiology of bi syndromes. Here, Cold is combined
with Dampness and Wind and will block the movement of qi, xue and jinye in the
channels and in the joints.
There can be situations where exogenous xie Cold manifests with symptoms and
signs in the interior of the body. This will typically be when there is an invasion of
Cold in the Stomach and Intestines, Urinary Bladder or Uterus. An invasion
of Cold in the interior is due to either climatic Cold penetrating through the skin
to the channels or the consumption of food, liquids or medicaments that have a
Cold nature.
Cold can block the movement and activity of yang and thereby prevent it from
transforming and transporting fluids. This can result in clear, watery exudations
from the nose, vagina or respiratory passages. Diarrhoea caused by Cold will also be
watery.
The above are all shi Cold conditions. Shi Cold does not usually exist for very
long. It will usually transform into Heat or it will weaken the yang and xu Cold will
develop. Xu Cold may also arise from a condition of yang xu. The symptoms and
signs of xu and shi Cold are very similar, but pain is more intense and the symptoms
are more acute when there is shi Cold. The tongue will also have a thicker coating
and the pulse will be Tight. Xu Cold pain is less intense and is more chronic. The
tongue coating will be thinner. The principles of treatment are also different. When
there is xu Cold, yang must be tonified and warmed. When there is shi Cold, the
Cold must be expelled.
Aetiology
Exposure to Cold.
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Symptoms and signs

• Pain that is biting or cramping in character
• Stiffness and soreness in the muscles and joints
• Aversion to or fear of Cold
• Chills
• No thirst
• White facial complexion
• Lack of sweating
• Stiff or impaired body movements
• No thirst
• Whitish, watery or clear secretions
• Tight pulse
Symptoms and signs of specific invasions of Cold patterns

Wind-Cold Aversion to cold and wind; chills; headache; stiffness in the shoulders and neck;
lack of sweating; coughing; sneezing; clear, watery secretions from the nose; slight
or no fever; itchy throat; no thirst; Superficial, Tight and Slow pulse.
Cold bi This is bi syndrome where cold is the predominant pathogen. The movement of
the joints are inhibited and there will be severe pain due to the stagnation of qi
and xue. The pain will be localised and will be intense. The pain is ameliorated by
heat and motion and worse when exposed to cold and when there is inactivity.
There will be a general aversion to cold, no sweating and therefore increased
urination, chills and possibly muscle twitching. There will be a Superficial, Tight
and Slow pulse.
Cold in the Acute epigastric pain; explosive vomiting of clear fluids; acute sensitivity to
Stomach cold. The symptoms will be provoked by the ingestion of cold foods and drinks,
which often lead to vomiting. The symptoms are alleviated by heat. The Stomach
area will feel cold on palpation. The tongue will have a thick, white coating and
the pulse will be Deep, Tight, Confined and Slow, especially in the right guan
positions.
Cold in the Acute pain in the abdomen; painful, watery diarrhoea; acute sensitivity to
Intestines cold; the skin of the abdomen may feel cold on palpation; there may be cold
extremities; thick, white tongue coating; Deep, Tight, Confined and Slow pulse,
especially in the chi positions.
Cold in the Cramping and biting menstrual pain; long menstrual cycle; brown menstrual
Uterus blood containing clots that look like coffee grounds; infertility; the area above the
pubic bone will feel cold on palpation; thick, white tongue coating; Deep, Tight,
Confined and Slow pulse, especially in the chi positions.
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Treatment principle
Expel Cold.
Acupuncture points
• If there is Wind-Cold: Lu 7, LI 4, SI 3, UB 62, Du 14, GB 20, UB 10 and
UB 12.
• If there is Cold bi: LI 4, Ren 6 and Du 14, as well as local and distal
acupuncture points along on the appropriate channel.
• If there is Cold in the Stomach: St 21, St 34, Sp 4, Ren 6, Ren 13, UB 21
and Pe 6.
• If there is Cold in the Intestines: St 25, St 36, St 37, Ren 6, Ren 8, Sp 4, Sp
9 and UB 25.
• If there is Cold in the Uterus: Ren 4, Ren 6, Du 4, UB 23, Kid 3, Kid 7,
Kid 13 and St 29.
Needle technique
Explanation
• Lu 7, LI 4, SI 3, UB 62, Du 14, GB 20, UB 10 and UB 12 all expel Wind
and Cold, as well as activating wei qi.
• Kid 3, Kid 7, Du 4, Ren 4, Ren 6 and Ren 8 warm and activate yang qi.
• St 21, St 25, St 34, St 37, UB 21 and UB 25 expel Cold and regulate qi in
the Stomach and Intestines.
• Sp 4 regulates qi in the Stomach and Intestines.
• Pe 6 regulates qi in the middle jiao.
• Sp 9 drains Damp-Cold.
• Kid 13 and St 29 expel Cold from the Uterus.
Herbal formula
• Juan Bi Tang (Expels Wind-Cold-Damp and activates the channels)
• Huo Xiang Zheng Qi Tang (Expels Wind and Cold from the Stomach and
Intestines)
• Li Zhong Tang (Warms the Stomach and Spleen, expels Cold)
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• San Wu Bei Ji Wan (Warms the interior and drains Cold downwards)
• Wen Jing Tang (Warms and expels Cold from the Uterus)
Relevant advice
When there is Cold, it is best to avoid consuming food and beverages that are
physically cold or have a cooling energy. It is beneficial to drink ginger tea or ingest
other spices that have a warming and diaphoretic energy. It is important that the
body is kept warm and dry.
Invasions of Cold can be caused by the following patterns of imbalance

• Wei qi xu
• Yang xu
Invasions of Cold can result in the following pattern of imbalance

• Yang xu
Dampness and Damp-Heat

A distinction is made in Chinese medicine between internally generated Dampness
and exogenous Dampness, despite the fact that many of the symptoms are very
similar. Exogenous Dampness is the result of climatic influences, such as living or
working in a damp environment. Internally generated Dampness can arise when
there is a xu condition in the Spleen or when there has been an excessive consumption
of food and beverages that produce Dampness in the body.
If the Spleen does not transform the food and beverages consumed as it
should, it will not separate the pure from the impure. The impure qi in the form
of Dampness will be extracted from the food and liquid that has been consumed,
whilst pure qi will be sent down to the Intestines and out of the body. Dampness
will accumulate and initially disrupt the qi mechanism in the middle jiao, especially
the functioning of the Spleen. Dampness, which is yin, will tend to seep downwards
and accumulate in the lower jiao.
Exogenous Dampness often invades the body through the yin channels in the
legs and can be drawn up into the body, again accumulating in the lower jiao.
The symptoms and signs of Dampness are varied and will depend on whereabouts
in the body the Dampness is located and which organs are affected.
Dampness is extremely yin. It’s heavy and sticky and creates stagnation. Damp-
ness will block the movement of qi and burden yang. The Spleen loathes Dampness,
which will rapidly block its qi mechanism. The accumulation of qi in the middle
jiao will result in nausea and a loss of appetite. Fatigue arises because the production
of qi in the middle jiao is disrupted and because qi is hindered in its movement by
the Dampness. This will often result in a sensation of heaviness in the arms and legs.
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Because the Spleen is disturbed in its transformation of the food, and because the
body attempts to get rid of the accumulated Dampness, there is often loose stools or
diarrhoea when there is Dampness.
Dampness will seep down to the lower jiao due to its yin nature. This can be seen
in, amongst other things, increased vaginal discharge and cloudy urine. Dampness
could also block the qi mechanism in the Urinary Bladder and this will result in
difficult or blocked urination.
If Dampness is transformed into Damp-Heat, the secretions and exudations
from the body become sticky, yellowish and odorous.
If Dampness is transported up to the head, it can block the shen and the Heart’s
orifices in the head. This will manifest with a fuzzy and heavy sensation in the head,
as if the brain is wrapped in cotton wool.
Some skin disorders can have an aspect of Dampness. If there are vesicles,
weeping skin or itching skin, this can be a sign that there is Dampness. Damp-Heat
will make the vesicles and the exudation from the skin yellow, and the skin itself
may be red.
If Dampness invades the channel system, the joints will be swollen and the pain
will be dull or heavy. Dampness blocks the movement of qi. This can make joints
feel numb. The pain will be localised to a single joint and it will not migrate from
joint to joint.
As stated, distinction is made between exogenous Dampness and internally
generated Dampness, but within each of these two categories there are several
sub‑categories depending on where the Dampness is located.
Exogenous Dampness
Exogenous Dampness can invade the exterior aspects of the body, i.e. wei qi and
the channels and it can directly invade certain internal fu organs. Dampness can be
Cold, neutral or Hot.
Aetiology
Exogenous Dampness can arise from an invasion of climatic Dampness or due to
consuming a Damp-producing diet.
Contact with certain bacteria and viruses can result in Damp-Cold and
Damp‑Heat conditions. This could be anything from consuming spoiled food to
cholera and salmonella. A pattern is defined by the symptoms and signs that are
manifesting. If the symptoms and signs are those seen when there is Dampness,
whatever has caused the imbalance will then be defined as Dampness and will be
treated accordingly.
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Symptoms and signs

Symptoms and signs of specific Exogenous Dampness patterns
Invasion of Damp- Fever that is worst in the afternoon; aversion to cold; heaviness in the
Heat in wei qi level arms and legs; no thirst; sticky taste in the mouth; skin feels warm on
palpation; swollen glands in the neck; heavy and throbbing headache;
head feels like a tight, wet towel has been wrapped around it; heaviness
and obstructed sensation in the chest; sticky tongue coating; Slippery,
Superficial or Soggy pulse.
Invasion of Wind- Itchy and swollen skin; aversion to wind and cold; heaviness in the
Damp arms and legs; heavy and painful muscles and joints; little or no fever;
Superficial and Slippery pulse; wet tongue.
Invasion of Bloating; nausea; vomiting; loss of appetite; heaviness in the body and
Dampness in the head; fatigue; loose stools or diarrhoea that is watery and odourless;
Stomach sticky taste in the mouth; no thirst; greasy white tongue coating;
Slippery pulse. All symptoms and signs will be acute.
Invasion of Diarrhoea or loose stools that are watery and odourless; borborygmi;
Dampness in the heavy and blocked feeling in the abdominal cavity; bloating; nausea;
Intestines vomiting; no thirst; thick, white greasy coating on the tongue; Slippery
pulse. All symptoms and signs will be acute.
Invasion of Damp- Diarrhoea that is explosive; sticky, odorous stools; burning or stinging
Heat in Intestines sensation in the rectum; the stool may be bloody; thirst with no desire
to drink; odorous flatulence; dark urine; oily or sticky sweat; Rapid and
Slippery pulse; sticky, yellowish tongue coating. All symptoms and signs
will be acute.
Invasion of Cloudy or oily urine; difficult or obstructed urination; frequent but
Dampness in the scanty urination; heaviness, tightness or obstructed sensation above
Urinary Bladder the pubic bone; white, oily coating on the root of the tongue; Slippery
or Tight pulse in the left chi position. All symptoms and signs will be
acute.
Invasion of Damp- Dark, cloudy, odorous urine; there may be blood in the urine; frequent,
Heat in the Urinary scanty and burning urination; yellowish and oily coating at the root of
Bladder the tongue; Rapid and Slippery pulse, especially in left chi position. All
symptoms and signs will be acute.
Invasion of Damp- Acute pain under the ribs; sensation of heaviness; nausea; sticky, bitter
Heat in the Gall taste in the mouth; yellowish thick coating on one side of the tongue;
Bladder Rapid, Slippery or Tight pulse, especially left guan postion.
Invasion of the Thin, watery, whitish vaginal discharge; vaginal discharge that is
Damp-Cold in the odourless or smells like fish; sticky white coating on the root of the
Uterus tongue; Slippery pulse, especially in the chi positions. All symptoms and
signs will be acute.
Invasion of Damp- Yellowish, sticky discharge from the vagina that is odorous and smells
Heat in the Uterus like leather; there may be vaginal itching and the mucous membranes
may be red; sticky, yellowish coating on the root of the tongue; Rapid,
Slippery pulse, especially in the chi positions. All symptoms and signs
will be acute.
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Invasion of This is bi syndrome where Dampness is the predominant pathogen. The

Dampness in the pain will be heavy and dull and there will often be numbness. There
channels or joints will usually be swelling around the joint, possibly with puffiness or
oedema. The pain is not sharp and will usually have arisen gradually.
The symptoms will be affected by humid climates and locations. There
will generally be fatigue and heaviness. The tongue can be wet with a
thick, sticky coating. The pulse can be Slippery or Soggy. All symptoms
and signs will be acute.
Invasion of Damp- Often, several joints at once will be affected. The joints will be sore,
Heat in the joints painful, swollen and red, and they will feel hot when palpated. The
person will often have additional characteristic Heat signs, such as a red
face, thirst, Rapid pulse and red tongue. All the symptoms and signs
will be acute.
Treatment principle
Expel and transform Dampness, regulate qi and possibly drain Heat.
Acupuncture points
Choose from: Sp 6, Sp 9, Ren 9 and UB 22.
• If there is an invasion of Damp-Heat in the wei level, add: SJ 5, LI 4, LI 11,
Du 14 and UB 12.
• If there is an invasion of Wind-Damp, add: Lu 7, LI 4, SJ 6, GB 31 and
UB 12.
• If there is an invasion of Damp in the Stomach, add: St 21, St 34, St 36 and
Ren 12.
• If there is an invasion of Damp-Heat in the Stomach, add: St 21, St 34, St
36, St 44, LI 11 and Ren 12.
• If there is an invasion of Damp in the Intestines, add: St 25, St 37 and St 39.
• If there is an invasion of Damp-Heat in Intestines, add: St 25, St 37, St 39,
St 44 and LI 11.
• If there is an invasion of Dampness in the Urinary Bladder, add: Ren 3.
• If there is an invasion of Damp-Heat in the Urinary Bladder add: Ren 3, UB
39 and LI 11.
• If there is an invasion of Damp-Heat in the Gall Bladder, add: GB 24, GB
34 and GB 36.
• If there is an invasion of Damp in the Uterus, add: Pe 6, SJ 5, GB 26, GB
41 and Ren 2.
• If there is an invasion of Damp-Heat in the Uterus, add: LI 11, Pe 6, SJ 5,
GB 26, GB 41 and Ren 2.
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• If there is Damp bi, add: Local and distal points on the relevant channel. If
there is Heat, also add LI 11 and Du 14.
Needle technique
Draining.
Explanation
• Sp 6, Sp 9, Ren 9 and UB 22 all drain and transform Dampness.
• Lu 7, SJ 5, LI 4, LI 11, Du 14 and UB 12 expel exogenous xie qi and activate
wei qi.
• GB 31 and SJ 6 expel Wind from the skin and stop itching.
• St 21, St 34, St 36 and Ren 12 regulate Stomach qi.
• St 25, St 37 and St 39 regulate qi in the Intestines.
• LI 11 expels and drains Damp-Heat.
• St 44 drains Damp-Heat.
• Du 14 drains Heat.
• Ren 3 drains Dampness and Damp-Heat from the Urinary Bladder.
• UB 39 drains Damp-Heat from the Urinary Bladder.
• GB 24, GB 34 and GB 36 drain Damp-Heat from the Gall Bladder and
regulate Gall Bladder qi.
• SJ 5 and GB 41 open dai mai and drain Dampness and Damp-Heat.
• GB 26 drains Dampness and Damp-Heat from dai mai.
• Ren 2 drains Dampness and Damp-Heat from the Uterus.
Herbal formula
• Huo Xiang Zheng Qi Tang (Expels Wind Dampness from the exterior,
regulates Stomach and Intestine qi, transforms and drains Dampness)
• Juan Bi Tang (Expels Wind-Cold-Dampness and circulates qi in the channels)
• San Ren Tang (Expels and drains Damp-Heat)
• Huang Qin Tang (Drains Damp-Heat from the Intestines)
• Bai Tou Weng Tang (Drains Damp-Heat and Toxic-Heat from the Intestines)
• Long Dan Xie Gan Tang (Drains Damp-Heat from the Gall Bladder)
• Bei Xie Shen Shi Tang (Drains Dampness and Damp-Heat from the vagina)
• Ba Zheng Wan (Drains Damp-Heat from the Urinary Bladder)
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Relevant advice
When there is an invasion of Dampness, it is important that the person does not
consume food and beverages that can contribute to the condition of Dampness. This
means that they should not consume dairy products, cold drinks, ice cream, sweets,
dried fruit, cakes, wheat flour, sugar, lettuce, cucumber, tomato, melon, avocado
and tropical fruit. Furthermore, if there is Damp-Heat, they should avoid alcohol,
hot spices including chilli and fried food.
An invasion of Dampness can be caused by the following pattern of imbalance

• Spleen qi xu
An invasion of Dampness can result in the following patterns of imbalance

• Spleen qi xu
• Phlegm
Internally generated Dampness

Internally generated Dampness is primarily a consequence of Spleen qi xu or Spleen
yang xu. It can also result from consuming foods, beverages and medicine that
produce Dampness or Damp-Heat.
As with exogenous Dampness, it is important to differentiate between whether
there is Damp-Cold or Damp-Heat, as well as where in the body the Dampness is.
Aetiology
Internally generated Dampness can arise when the Spleen or the Kidneys are too
weak to carry out their functions of transforming and transporting fluids in the
body. Dampness can also result from a prolonged or excessive consumption of foods,
beverages and medicine that produce Dampness or Damp-Heat. Dampness can start
as an acute invasion of exogenous Dampness that has penetrated into the interior
and become a chronic interior condition.
Symptoms and signs

The general symptoms and signs of internally generated Dampness are:
• nausea
• loss of appetite
• heaviness in limbs
• fatigue
• abdominal bloating
• loose stools or diarrhoea
324
• increased vaginal discharge

• cloudy urine
• sticky taste in the mouth
• lack of thirst
• slippery pulse
• thick and sticky tongue coating.
Symptoms and signs of specific internally generated Dampness patterns

Stomach Poor appetite; no appetite in the morning; nausea; blocked or replete sensation
and Spleen in the epigastric region or abdomen; loose stools or diarrhoea; sticky taste in the
Dampness mouth; lack of thirst; loss of sense of taste; heaviness in the arms and legs; white,
sticky discharge from the vagina; oedema; fatigue; heaviness in the body and
head; fuzzy thinking or feeling as if the head is full of cotton wool; dull, pale
complexion; thick, white, sticky tongue coating on a pale tongue (in a chronic
pattern the coating may not be so thick); Slippery, Slow pulse.
Dampness in Diarrhoea or loose stools that are watery and odourless; borborygmi; heavy,
the Intestines uncomfortable or replete sensation in the abdominal cavity; abdominal bloating;
nausea; vomiting; lack of thirst; thick, white greasy coating on the tongue;
Slippery pulse, especially in the chi positions.
Damp-Heat in Explosive diarrhoea; sticky, odorous stools; burning sensation in the rectum;
the Intestines the stool may be bloody; thirst without desire to drink; flatulence; odorous
flatulence; dark urine; oily or sticky sweat; sticky, yellowish tongue coating;
raised red papillae on the root of the tongue; Rapid and Slippery pulse,
especially in the chi positions.
Dampness in Turbid or oily urine; difficult or obstructed urination; frequent but scanty
the Urinary urination; heaviness, tightness or obstructed sensation above the pubic bone;
Bladder white, oily coating on the root of the tongue; Slippery and Tight pulse,
especially in the left chi position.
Damp-Heat Dark, cloudy, odorous urine; there may be blood in urine; frequent, scanty
in the Urinary urination with burning sensation; yellowish and oily coating on the root of the
Bladder tongue; there may be raised red papillae on the root of the tongue; Rapid and
Slippery pulse, especially in the left chi position.
Dampness in Watery, whitish discharge from the vagina that is odourless or smells like fish;
the Uterus sticky white tongue coating on the root of the tongue; Slippery pulse, especially
in the chi positions.
Invasion of Yellowish, sticky discharge from the vagina that is very odorous and smells of
Damp-Heat in leather; there may be vaginal itch and the mucosa may be red; sticky yellowish
the Uterus coating on the root of the tongue; Rapid and Slippery pulse, especially in the chi
positions. All symptoms and signs will be acute.
Dampness in Sore, painful or swollen genitalia; weeping sores or itching in the genital region;
the Liver hypochondriac tension; vaginal discharge; difficult urination; impotence; sticky
coating on the root of the tongue; Slippery or Wiry pulse, especially in the left
guan positions.
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Dampness Costal pain; heaviness; nausea; sticky taste in the mouth; thick coating on one
in the Gall side of the tongue; Slippery or Wiry pulse, especially in the left guan positions.
Bladder
Damp bi This is bi syndrome in which Dampness is the predominant pathogen. The pain
will be heavy and dull and there often will be numbness. There will usually be
swelling around the joint, possibly also oedema. The pain is never sharp and will
usually have arisen gradually. The symptoms will be affected by humid climates
and environments. There will be a general sensation of fatigue and heaviness.
The tongue can be wet with a thick, sticky coating. The pulse will be Slippery or
Soggy.
Damp-Heat in There will often be several joints that are simultaneously affected. The joints will
the joints be sore, painful, swollen and red and will feel warm when palpated. The person
will often have additional characteristic Heat signs such as a red face, thirst,
rapid pulse and red tongue.
Dampness in Exuding skin disorders.
the skin
Treatment principle
Drain and transform Dampness, tonify the Spleen, regulate qi and possibly drain
Heat.
Acupuncture points
Choose from: Sp 6, Sp 9, Ren 9, UB 20, UB 22, St 36 and Ren 12.
• If there is Stomach and Spleen Damp, add: UB 21 and Sp 3.
• If there is Dampness in the Intestines, add: St 25, St 37 and St 39.
• If there is Damp-Heat in Intestines, add: St 25, St 37, St 39, St 44 and LI 11.
• If there is Dampness in the Urinary Bladder, add: Ren 3.
• If there is Damp-Heat in the Urinary Bladder, add: Ren 3, UB 39 and LI 11.
• If there is Dampness in Gall Bladder, add: GB 24, GB 34 and GB 36.
• If there is Dampness in the Liver, add: Liv 8 and Liv 14.
• If there is Dampness in the Uterus, add: SJ 5, GB 26, GB 41 and Ren 2.
• If there is Damp-Heat in the Uterus, add: LI 11, Pe 6, SJ 5, GB 26, GB 41
and Ren 2.
• If there is Damp bi, add: Local and distal points on the relevant channel. If
there is Heat, also add LI 11 and Du 14.
Needle technique
Drain Sp 9 and Ren 9, tonify the rest.
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Explanation
• Sp 9 and Ren 9 drain and transform Dampness.
• Sp 3, Sp 6, St 36, Ren 12, UB 20, UB 21 and UB 22 tonify Stomach and
Spleen qi and transform Dampness.
• St 25, St 37 and St 39 regulate qi in the Intestines.
• LI 11 expels and drains Damp-Heat.
• St 44 drains Damp-Heat.
• Ren 3 drains Dampness and Damp-Heat from the Urinary Bladder.
• UB 39 drains Damp-Heat from the Urinary Bladder.
• GB 24, GB 34 and GB 36 drain Damp-Heat from the Gall Bladder and
regulate Gall Bladder qi.
• SJ 5 and GB 41 open dai mai and drain Dampness and Damp-Heat.
• GB 26 drains Dampness and Damp-Heat from dai mai.
• Ren 2 drains Dampness and Damp-Heat from the Uterus.
• Liv 8 drains Dampness from the Liver channel.
• Liv 14 regulates the Liver channel.
Herbal formula
• Ping Wei San (Transforms Dampness in the middle jiao)
• Er Chen Tang (Dries Dampness and transforms Phlegm)
• Huo Xiang Zheng Qi Tang (Expels Wind Dampness from the exterior,
regulates Stomach and Intestine qi, transforms and drains Dampness)
• Wei Ling Tang (Drains Dampness from the middle and lower jiao)
• San Ren Tang (Expels and drains Damp-Heat)
• Huang Qin Tang (Drains Damp-Heat from the Intestines)
• Bai Tou Weng Tang (Drains Damp-Heat and Toxic-Heat from the Intestines)
• Long Dan Xie Gan Tang (Drains Damp-Heat from the Gall Bladder)
• Bei Xie Shen Shi Tang (Drains Dampness and Damp-Heat from the vagina)
• Ba Zheng Wan Yu Dai Wan (Drains Dampness and Damp-Heat from the
vagina)
• Si Miao San (Drains Damp-Heat)
• Xiao Feng San (Expels Wind, Dampness and Heat from the skin)
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Relevant advice
When there is Dampness, a person should avoid foods and beverages that are both
energetically cold and cold in their temperature. They should also avoid consuming
foodstuffs and beverages that produce Dampness. Food and beverages that they
should pay particular attention to avoiding are: dairy products, physically cold
drinks, ice cream, sweets, dried fruits, honey, artificial sweeteners, cakes, wheat
products, sugar, lettuce, cucumber, tomato, melon, avocado and tropical fruit. They
will benefit from eating food that is prepared and warm in its energy. Ginger will be
particularly good.
If there is Damp-Heat, they should also avoid alcohol, hot spices including chilli
and garlic.
It is not good for a person with a pattern of Dampness to reside or work in
places where the air is humid. This also includes buildings where there is a fungal
infestation such as dry rot. These can often be an aggravating factor in their disorder
or even an obstacle to therapy.
Dampness can be caused by the following pattern of imbalance

• Spleen qi xu
Dampness can result in the following patterns of imbalance

• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
• Phlegm
Summer-Heat
This pathogen is yang in nature. It is ‘the prevailing qi of summer’, but the major
difference between Summer-Heat and the other forms of climatic qi is that
Summer‑Heat is the only form of xie qi that is exclusively associated with a specific
season. The other forms of exogenous xie qi can invade the body all year round, but
Summer-Heat invasions are solely seen in the summer. Furthermore, all of the other
five forms of climatic qi can manifest with related internal imbalances in the body.
For example, signs of Cold manifest in a yang xu condition or signs of Heat manifest
in a yin xu condition. This is not the case with Summer-Heat, which is exclusively
an exogenous form of xie qi.
Summer-Heat can arise when a person has been over-exposed to the Sun,
especially on their head. A contributing factor can be that the person has overexerted
themselves in the Sun and has thereby weakened their zheng qi, which includes the
wei qi. It is usually seen in people who physically overexert themselves playing sport,
working, etc. on days when the Sun is very strong or in elderly people whose wei qi
is weak.
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There are three different kinds of Summer-Heat: Summer-Heat Warmth;

Summer-Heat-Dampness and Summer-Heat Stroke. Summer-Heat is a very yang
pathogen and has an upward and outward dynamic, which means that it tends to
affect the head. Most of the signs of Summer-Heat are almost identical to Heat
signs, because Summer-Heat is a Heat pathogen. Summer-Heat will therefore also
injure yin. Typical symptoms and signs of an invasion of Summer-Heat are high
fever, aversion to cold, profound thirst, excessive sweating, red face, headache, rapid,
shallow breathing, mental restlessness and agitation. Summer-Heat will result in the
heartbeat increasing and therefore a Rapid pulse. The pulse will also be Superficial.
A sign of Summer-Heat that may require further explanation is that there is often
an aversion to cold despite the fact that the person has extreme Heat signs and
symptoms. This is because the Summer-Heat will have invaded the exterior
and disrupted the circulation of the body’s wei qi. This is the same pathomechanism
that is seen in an invasion of Wind-Heat. Exogenous xie qi disrupts wei qi in its
function of circulating and warming the area below the skin. The other symptoms
all relate to Heat damaging yin and fluids in the body.
Although Summer-Heat is located in the wei aspect, it can quickly penetrate
deeper into the body. It can penetrate down to the Pericardium blocking a person’s
shen. This can result in a loss of consciousness, incoherent speech or agitation. This is
seen when there is Summer-Heat Stroke. The Heat is so intense here that it generates
Wind in the body and the person may also have cramps and spasms.
If the weather or the environment is very humid while the sun is very intense, or
if the person consumes large amount of cold fluids, the Dampness can combine with
the Summer-Heat and create the pattern of Summer-Heat-Dampness. Here there
will be symptoms and signs resulting from the exposure to Heat from the Sun, but
at the same time there will also be perceptible signs that Dampness has disrupted the
movement of qi, especially in the middle jiao.
Aetiology
Exposure to intense sunlight in the summer.
Symptoms and signs

• Fever
• Thirst
• Red face
• There may be aversion to cold
• Headache
• Dark urine
• Rapid and Superficial pulse
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Symptoms and signs of specific types of Summer-Heat invasions

Summer-Heat High fever; profuse thirst; profuse sweating (or no sweating if the body’s fluids
Warmth have been damaged by Heat); red face; headache; rapid, shallow breathing;
restlessness and agitation; Rapid and Full pulse.
Summer-Heat Persistent low fever; no strength; heaviness in the arms and legs; bloated
Dampness abdomen; nausea; loose stools; sparse and yellowish urine; thick, greasy, yellow
tongue coating; Rapid, Full and Slippery pulse.
Summer-Heat Dizziness; headache; tightness in the chest; dry mouth; thirst; fatigue; nausea;
Stroke in extreme cases there may be a loss of consciousness, spasms or convulsions;
Rapid and Wiry pulse.
Treatment principle
Expel Summer-Heat.
Acupuncture points
Choose from: UB 40, LI 4, LI 11, SJ 5, Du 14 and Du 20.
• If the person has lost consciousness, bleed: Pe 9 and He 9.
Needle technique
Draining. Bleeding on Du 14, Pe 9 and He 9.
Explanation
• LI 4, LI 11 and SJ 5 expel Summer-Heat from the exterior.
• UB 40 and Du 14 clear and expel Summer-Heat.
• Du 20 sinks xie Heat from the head.
• Pe 9 and He 9 drain Heat from the Heart and revive consciousness.
Herbal formula
• Bai Hu Tang (Drains Summer-Heat Warmth)
• Qing Luo Yin (Expels Summer-Heat)
• San Shi Tang (Clears Heat and drains Dampness)
• An Gong Niu Huang Wan (Clears the Heat from the Pericardium, opens the
orifices and revives consciousness)
Relevant advice
With these patterns, prevention is important. This means that it is important to
avoid prolonged exposure to strong sunlight, especially on the head. It is therefore
advisable to wear a hat or scarf on the head in the summer. It is also important to
consume ample fluids when it is hot in the summer. This is because if you become
dehydrated, or jinye xu in Chinese medicine, Heat will more easily create an
imbalance and further injure yin. Chrysanthemum tea is particularly recommended.
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Summer-Heat can be caused by the following pattern of imbalance

• Wei qi xu
Summer-Heat can result in the following pattern of imbalance

• Internally generated Wind
Heat and Fire

Before discussing Heat and Fire imbalances, it is important to differentiate
between pathological Heat and physiological heat. All of the body’s qi functions are
dependent on physiological heat. There would not be any kind of transformation
or transportation in the body without this heat. Physiological heat is an aspect of
the body’s yang qi. Pathological Heat does not have any beneficial physiological
qualities; on the contrary, pathological Heat only has a negative effect on the body.
Pathological Heat, which includes Fire, will over-activate the functioning of various
organs. It will agitate shen and xue, as well as desiccating and injuring yin substances
in the body. Furthermore, Fire can generate Wind and create Phlegm.
The difference between Heat and Fire is mainly a question of intensity. Fire is
a stronger and more aggressive form of Heat. Fire is described as being more ‘solid’
than Heat. It is more drying, damages body tissues and can agitate xue to such an
extent that the walls of the vessels rupture, resulting in bleeding. Fire will also agitate
shen to a greater extent than Heat does.
There are various forms of pathological Heat and Fire in the body. I will briefly
outline the various forms and how they arise, before going into detail and describing
their specific signs and symptoms.
Heat can arise from an exogenous invasion, such as when the body is invaded
by Wind-Heat, Damp-Heat and Summer-Heat. Furthermore, exogenous xie qi such
as Cold and Dampness can transform and become internal Heat or Fire when they
penetrate deeper into the body. This is because of the clash between zheng qi and
xie qi. The body itself is warm in nature. This means that xie qi will eventually be
affected by, and take on the character of, its host and its surroundings.
Heat and Fire can also arise from internal imbalances. Consuming food or drink
that is hot in its dynamic, such as alcohol and hot spices, will generate shi Heat or
Fire. Smoking can also result in internal Heat. Heat and Fire can also arise from
emotional imbalances, particularly when qi stagnates over a period of time. Any
stagnation in the body, whether it is qi, Dampness, Phlegm or xue stagnation, will in
the end begin to generate Heat. The difference will be in how intense and systemic
heat is.
Fire and Heat are desiccating and will injure fluids and yin in general. Therefore
there will be symptoms and signs such as thirst, a dry mouth, dark urine, dry stools
and constipation. Other classic Heat signs are a red face, sweating (because body
fluids are driven upwards and outwards), a Rapid pulse and a red tongue.
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Another form of pathological Heat is yin xu Heat. It is extremely important to

differentiate between xu and shi Heat. This is because the treatment strategies for
each are very different. Yin xu Heat does not arise due to the presence of shi Heat,
but the presence of shi Heat will certainly accelerate the process. Yin xu Heat arises
when the body or specific organs are yin xu. Yin when it is weak is unable to control
Heat, which then up flares up. There are some fundamental differences in how the
two types of Heat manifest in the body and this can be seen in the table below.
When there is shi Heat, the treatment must be aimed at draining the pathogenic
Heat. This means that the acupuncture points used need to have a Heat-draining
action and draining needle techniques should be used. In herbal medicine, herbs
and prescriptions that either drain or expel Heat should be used.
When there is yin xu Heat, the treatment aim is primarily to nourish yin. This
means that acupuncture points that nourish yin are used. These points should be
stimulated with a tonifying needle technique. In herbal medicine prescriptions,
herbs that are yin nourishing are used together with herbs that clear the xu Heat.
Apart from differentiating between xu and shi Heat, it is also important to
identify where in the body the Heat is and which organs are affected. This applies
to both xu and shi Heat.
Differences between shi and xu Heat

Shi Heat Xu Heat
Constant sensation of heat in the body Sensation of heat primarily in the evening and
at night
The entire face is red Only the cheekbones are red
The person either sweats all the time or not at The person sweats at night
all
The person sweats all over the body and The person sweats mainly on the palms of the
especially on the head hands and the soles of the feet
The entire hand feels warm when palpated Only the palm feels warm when palpated
Strong thirst with a desire for cold drinks, The person experiences a dry mouth and throat,
which are drunk in large gulps which is most apparent at night
They will generally sip water
Bitter taste in the mouth No bitter taste in the mouth
Mental restlessness, agitation, manic behaviour Mild restlessness or unrest in the evening
The pulse is Full and Rapid The pulse is Fine and Rapid
The tongue is red and has a yellowish coating The tongue is red and lacks coating
Another form of pathological Heat that must be mentioned here, is Toxic-Fire.

Toxic‑Fire is a very intense form of Fire. The Fire is so intense that it damages not only
the fluids in the body, but also tissue. All conditions in which there is inflammation
with pus, greenish secretions or erosion of the skin or mucous membranes are
defined as being Toxic-Fire. There will often be some degree of swelling in the area.
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The area itself will be extremely red in colour and the skin above the area will be
hot to the touch. Due to the concentration of extreme yang Heat in the area, the
pain will often have a different characteristic and will be very intense. Toxic-Fire can
arise from chronic internal conditions and acute invasions in the exterior, such as by
staphylococcal infection, mumps, herpes and so on.
Shi Heat and Fire

Aetiology
Shi Heat can arise in several ways. It will mainly result from dietary and emotional
influences.
Hot food and beverages such as hot spices, lamb, alcohol, fried food and so on
will create Heat. These will generate Heat in the Liver, Stomach and Intestines
in particular.
Prolonged emotional imbalances such as stress, frustration and anger will
typically generate Heat in the Heart and Liver.
Tobacco smoking creates Heat in the Lung.
Exogenous xie Heat can directly invade the body. The invasion can be located in
the exterior, but there can also be direct invasions of exogenous Heat into the interior.
Yin pathogens can transform and turn into Heat. Invasions of Cold can transform
into interior Heat, whilst Dampness can transform and turn into Damp-Heat.
Symptoms and signs

• Thirst
• Aversion to heat, unless the pathogenic Heat is in the wei aspect, in which
case there will be an aversion to cold
• The skin may feel warm on palpation
• The face can be red
• Secretions and exudations can change colour and become yellowish or
greenish
• Secretions and exudations become thicker and more sticky
• Secretions and exudations can become odorous or taste strongly
• Pain that is throbbing, stinging or burning
• Excessive sweating or no sweating
• Constipation
• Red tongue
• Rapid pulse
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Symptoms and signs of specific Fire and Heat patterns

Heat in the Mild or high fever; thirst; red eyes; red and sore throat; yellowish secretions from
exterior the nose; cough, possibly with yellowish sputum; aversion to cold; shivering;
Superficial and Rapid pulse; possibly a red tip to the tongue or yellowish coating
on the tongue.
Stomach Thirst; excessive appetite; stinging or burning sensations in the Stomach;
Fire indigestion; bad breath; bleeding gums; mouth ulcers; constipation; red tongue
with dry, yellow coating; Rapid and Full pulse, especially in the right guan position.
Liver Fire Thirst; irritability; anger; headache; bitter taste; red eyes; dizziness; red sides of
the tongue; dry, yellow coating; Fast and Wiry pulse, especially in the left guan
position.
Heart Fire Mental agitation; restlessness; mania; insomnia; palpitations; ulcers on the tongue;
thirst; red tongue tip; Rapid pulse, especially in the left cun position.
Lung Fire Cough; thick; sticky and yellowish sputum that possibly contains blood; thirst;
redness in the front third of the tongue; Rapid, Full and Slippery pulse, especially
in the right cun position.
Heat in the Constipation; pain or discomfort in the abdomen; the abdomen is distended and
Intestines tense; dry, yellow coating on the tongue; Rapid and Full pulse, especially in the chi
positions.
Heat in the Dark, yellowish urine that is odorous; the urine may contain blood; frequent scanty
Urinary and burning urination; yellowish coating on the root of the tongue with raised, red
Bladder papillae; Rapid and Full pulse, especially in the left chi position.
Toxic-Fire Inflammation with pus or greenish secretions; erosion of the skin or mucous
membrane; swelling in the area that will be extremely red in colour and feel warm
on palpation; the area will be painful; red tongue with a dry and yellowish coating;
Rapid and Wiry pulse.
Treatment principle
Expel or drain Heat.
Acupuncture points
Choose from: Erjian (Ex-HN 6), Du 14 and LI 11.
• If there is Heat in the exterior, add: Du 16, LI 4, SJ 5, Lu 7, Lu 11 and
GB 20.
• If there is Heat in the Lung, add: Lu 1, Lu 5, Lu 10 and UB 13.
• If there is Heat in the Heart, add: He 8, Pe, 5, Pe 7, Pe 8, UB 14, UB 15
and Ren 15.
• If there is Heat in the Liver, add: Liv 2, Liv 14 and UB 18.
• If there is Heat in the Stomach, add: St 43, St 44, St 45, Ren 12, UB 21 and
Ren 13.
• If there is Heat in the Intestines, add: St 25, St 37, St 39 and St 44.
• If there is Heat in the Urinary Bladder, add: UB 28, UB 32 and Ren 3.
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Needle technique
Draining. If there is extreme Heat, Du 14 and Erjian (Ex-HN 6) can be bled.
Explanation
• Erjian (EX-HN 6), LI 11 and Du 14 drain and expel Heat.
• Du 16, Lu 7, LI 4, SJ 5 and GB 20 expel Heat from the exterior.
• Lu 1, Lu 5, Lu 10, Lu 11 and UB 13 drain Heat from the Lung.
• He 8, Pe 5, Pe 7, Pe 8, UB 14, UB 15 and Ren 15 drain Heat from the Heart.
• Liv 2, Liv 14 and UB 18 drain the Heat from the Liver.
• St 43, St 44, St 45, UB 21 and Ren 12 drain Heat from the Stomach.
• St 25, St 37, St 39 and St 44 drain Heat from the Intestines.
• UB 28, UB 32 and Ren 3 drain Heat from the Urinary Bladder.
Herbal formula
• Yin Qiao San (Expels Wind-Heat and drains Toxic-Heat)
• Huang Qin Tang (Drains Heat from the Intestines)
• Long Dan Xie Gan Tang (Drains Heat from the Liver and Gall Bladder)
• Ba Zheng Tang (Drains Heat from the Urinary Bladder)
• Huang Lian Tang (Drains Heat from the Intestines and drains Toxic-Fire)
• Dao Chi San (Drains Heat from the Heart)
• Qing Wei San (Drains Heat from the Stomach)
Relevant advice
A person with shi Heat must avoid food and drinks that have a Hot energy. They
must also avoid stress. When there is Heat in the exterior, it is recommended to
drink mint, chrysanthemum, elderflower or chamomile tea.
Heat and Fire can be caused by the following patterns of imbalance

• Invasions of xie qi
• Qi stagnation
Heat and Fire can result in the following patterns of imbalance

• Yin xu
• Phlegm
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• Wind
• Xue Heat
Xu Heat
Aetiology
Yin is weakened by old age, physical, mental and emotional overexertion (including
stress), disease, shi Heat conditions, too much sex, dietary imbalances, blood loss
and excessive sweating.
Symptoms and signs

• Malar flush
• Fever or warm sensation in the body in the evening and at night
• Night sweats
• Sweating or hot sensation in the palms of the hands, soles of the feet and the
centre of the chest
• Thirst with desire to sip water
• Nervous, fidgety movements
• Restlessness and unease
• Slight sensation of anxiety
• Palpitations
• Nervous, rapid speech, talks a lot
• Red tongue with little or no coating, possibly with cracks in the surface
• Rapid, Fine and possibly Superficial pulse
Key symptoms
Malar flush, evening fevers or night sweats, dry mouth and throat, red tongue with
little or no coating.
Treatment principle
Nourish yin and control Heat.
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Acupuncture points
Choose from: Kid 2, Kid 3, Kid 6, Ren 4, UB 23, UB 52, Sp 6 and He 6.
Needle technique
Tonifying apart from Kid 2, which should be drained.
Explanation
• Kid 2, Kid 3, Kid 6, Ren 4, UB 23 and UB 52 nourish Kidney yin, which is
the foundation of all yin in the body.
• Sp 6 nourishes yin.
• He 6 nourishes Heart yin.
Herbal formula
• Zhi Bai Di Huang Tang (Nourishes Kidney yin and clears xu Heat)
Relevant advice
When there is xu Heat, the person should avoid food and drinks that have a Warming
energy such as alcohol, garlic and chilli. They should also avoid stimulants such as
drinks that contain caffeine. Furthermore, they should avoid too many spices in the
diet. Stress and overwork will weaken yin. It is important that a person who is yin xu
goes to bed early and gets enough sleep.
Xu Heat can be caused by the following patterns of imbalance

• Shi Heat
• Xue xu
Xu Heat can result in the following pattern of imbalance

• Internally generated Wind
Dryness
Dryness is ‘the prevailing qi in autumn’. Whilst it is quite logical that Cold is defined
as being the prevailing qi in winter, it seems less logical in North-Western Europe
that Dryness should be the prevailing qi in the autumn. Autumnal weather in Britain
is often very damp. The reason that Dryness has been ascribed this definition is that
in autumn many parts of China are extremely dry, because the prevailing wind is
from the West. The Gobi Desert is located in West China, which means that the
air is extremely dry. Furthermore, autumn is the season of the Metal Phase and
west is the compass direction of this phase. Dryness is extremely deleterious for the
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Lung, which is the Metal Phase organ. In addition, dryness has a resonance with the
yangming aspect, which the Metal organs and channels are a part of. Constipation
and dry stools are a classic symptom of Dryness in the body.
The British Isles have a damp climate because of their geographical location. This
means that external Dryness has not traditionally been a problem here. Invasions of
Dryness can, however, be observed in people who live and work in buildings that
have a very dry indoor climate such as buildings made of concrete.
Dryness is defined as being yang. This is because the dominant negative effect
that Dryness has is that it desiccates and injures fluids, i.e. Dryness injures yin. The
most typical manifestations of an invasion of Dryness are dry mucous membranes,
dry throat, dry eyes, dry mouth, dry nose, dry stool and sparse urinations.
A distinction is made between the exogenous and internally generated Dryness.
Interior Dryness is a precursor of yin xu.
Exogenous Dryness
Aetiology
Exposure to an excessively dry climate.
Symptoms and signs

• Dry throat
• Dry lips
• Dry mouth
• Dry eyes
• Dry skin and mucous membranes
• Dry tongue
• Superficial pulse
Key symptoms
Dry mucous membranes, Superficial pulse.
Treatment principle
Expel Dryness.
Acupuncture points
Choose from: LI 4, LI 20, Lu 7, Kid 6 and GB 20.
Needle technique
Draining, apart from Kid 6, which is tonified.
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Explanation
• LI 4, Lu 7 and GB 20 expel exogenous xie qi and activate wei qi.
• LI 20 circulates qi and jinye in the nose and expels xie qi.
• Kid 6 nourishes yin and jinye.
Herbal formula
• Xing Su San (Expels Wind-Cold and Dryness)
Relevant advice
The person should avoid places where the air is very dry.
Exogenous Dryness can be caused by the following patterns of imbalance

• Wind-Heat
• Yin xu
Exogenous Dryness can result in the following pattern of imbalance

• Yin xu
Internal Dryness
The aetiology here will be different from Exogenous Dryness, but the way the
symptoms and signs manifest will be almost the same.
Aetiology
Exposure to an excessively dry climate, smoking, eating foods that are drying such
as baked food, talking a lot and excessive sex.
Symptoms and signs

• Dry throat
• Dry lips
• Dry mouth
• Dry eyes
• Dry skin and mucous membranes
• Dry stool
• Scanty urination
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• Dry tongue
• Superficial pulse
Key symptom
Dry mucous membranes.
Treatment principle
Nourish yin and jinye.
Acupuncture points
Choose from: Lu 7, Kid 6, Sp 6 and Ren 4.
Needle technique
Tonifying.
Explanation
• Lu 7 and Kid 6 open ren mai.
• Ren 4 and Sp 6 nourish yin and jinye.
Herbal formula
• Mai Men Dong Tang (Nourishes yin and moistens Dryness)
Relevant advice
When there is internally generated Dryness, the person should avoid places where
the air is very dry. They should limit their consumption of baked food or spices,
as these can be drying.
Internal Dryness can be caused by the following patterns of imbalance

• Heat and Fire
• Yin xu
Internal Dryness can be the result of the following pattern of imbalance

• Yin xu
Phlegm
Phlegm is a very comprehensive concept in Chinese medicine. Phlegm is both an
aetiological factor and a pathological condition.
Phlegm can be difficult to diagnose for novices. This is because Phlegm symptoms
and signs are often not as tangible as they are in other patterns. Phlegm signs can be
as varied as they are subtle. Phlegm is often involved in, or is directly responsible for,
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many complex and chronic conditions. In Chinese medicine there are a couple of
relevant aphorisms: ‘Phlegm is the root of the 100 disorders’ and ‘All the strange
symptoms and diseases are caused by Phlegm’.
The signs and symptoms of Phlegm can be difficult to recognise in the beginning
because they are so subtle and varied. Textbooks that are published in China,
and those that are inspired by these textbooks, tend to describe only a few, gross
Phlegm symptoms and signs, but Phlegm is not usually as obvious as this. Phlegm
is something you have to train yourself to see. It is often difficult to define precisely
why there is a diagnosis of Phlegm; it is usually the sum of many small, subtle signs.
Phlegm is fluids that have congealed, coagulated or thickened. Because these
body fluids have changed their form or structure, they have none of the nourishing
or moistening qualities that jinye has. They have thus gone from being an aspect of
zheng qi to becoming a form of xie qi.
Phlegm can be substantial, i.e. it can be seen, or insubstantial, i.e. it is not visible
to the naked eye. Substantial Phlegm can be observed as sputum and mucus in
the respiratory passages, stool or menstrual blood. Non-substantial Phlegm can
be observed or palpated below the surface of the skin as nodules, ganglion cysts,
deformations of bones and cartilage, uterine fibroids, lumps and other physical
accumulations in the tissues such as gallstones and kidney stones. Non-substantial
Phlegm can also manifest as a sensation of heaviness in the body and the head,
numbness, fatigue, mental confusion, depression, dizziness, nausea and chest
oppression. The pulse can be Slippery or Wiry. The tongue can be swollen and have
a greasy coating.
Phlegm is a heavy and sticky yin pathogen. It shares characteristics with Dampness,
but Phlegm is stickier and even more disruptive of the body’s qi ji (qi mechanisms),
because both Phlegm and Dampness block the cou li (the space between the body
tissue and between the cells, i.e. the space in which qi moves). This has important
consequences. First, it will result in the blockage of qi, xue and jinye. This means
that there may be signs of stagnation – of these substances in general and of the
various qi ji around the body. This could be symptoms and signs such as nausea,
loss of appetite and a heaviness in the chest, as if there is a large stone on top of the
chest. Phlegm’s blockage of qi in the upper jiao can also result in palpitations and a
shortness of breath. The stagnation of qi can cause the person to feel fatigued and
lack energy. The feeling of fatigue will be worst in the morning, because the lack of
movement of qi during the night will increase the stagnation of Phlegm. They will
often feel very tired in the morning and can have difficulty waking up. The fatigue
and heaviness can also result in an increased need for sleep. The problem is that
the person will often find that the more they sleep, the more tired and heavy they
feel. This is because Phlegm will stagnate even more whilst they are lying down. As
well as fatigue, they may feel that they are a bit fuzzy and heavy-headed and are not
fully present mentally. This will be especially apparent in the mornings, when they
will often be slightly absent and go around in a bubble. They may also lack appetite
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in the morning, and if they have a cough it will also be worst in the mornings.
Once they get going and are physically active, the signs and symptoms will improve.
Phlegm can also manifest with areas of skin that are numb, because Phlegm will
block xue, and thereby shen, so that it does not circulate in an area. This is also why
Phlegm can result in numbness elsewhere in the body.
As well as stagnation, the body can be characterised by heaviness. This will also
be seen on the mental and emotional level, because Phlegm will block the Heart’s
‘orifices’. This means that shen is restricted in its movement, which is why Phlegm can
often be a contributing factor when a person suffers from depression. When Phlegm
is very pronounced it can be seen in the person’s eyes. There can be a tendency to
have blobs of sleep in the eyes and the eyes can seem glazed. The shen in their eyes
is not bright and lucid. It can be difficult to make clear eye contact. They may look
into space whilst they are talking to you, which is not because they are shy and have
difficulty looking you directly in the eye, as is the case when there is Heart and Gall
Bladder qi xu, or because their gaze is restless and shifting, as it is when there is Heart
Fire or Phlegm-Fire, rather, it is because their shen is smothered and blocked and
they are in a bubble of their own. Their vision ‘does not come out of their head’.
These eyes and gaze can be observed when someone has drunk excessive alcohol or
taken narcotics.
They may also have the feeling that they are in a bell jar. It’s a feeling most people
will have experienced when they have a heavy cold. Because shen is blocked, the
person may seem confused and unclear in their thinking. They may have difficulty
finding words. If the blockage is severe, they will have incoherent speech or will
think one thing but say something else. In extreme cases, for example in some mental
illnesses, a person can sit and talk to themselves or to a person who is not there.
A person with a lot of Phlegm will have difficulty concentrating. There is a
difference in how a difficulty in concentrating manifests itself in various imbalance
patterns. When there is Heat, the person will find it hard to concentrate because
they are mentally and physically very restless. New thoughts and ideas will constantly
arise, which makes it hard for them to remain focused. When there is Heart xue xu
and Spleen qi xu, shen will lack nourishment, resulting in the mind feeling empty.
When they read something, they cannot remember what they have just read. When
there is Phlegm, it is hard to concentrate because the head feels as if it is full of
cotton wool and the thoughts are very blurred. It is difficult to think clearly. Again,
this can be recognised from when you have had a heavy cold or a bad hangover.
Due to its obstructive nature, Phlegm can also be a cause of dizziness. The
difference between dizziness in a xu condition and Phlegm is that when there is
Phlegm there will also be a heavy sensation in the head and possibly even nausea.
Moreover, the dizziness can arise completely at random and it often feels as if the
room is spinning round. The dizziness will often feel worse when the person is lying
down, or lying down will not ameliorate the condition.
Physically, Phlegm can be seen in a person’s skin and the flesh below, which
appears dough-like and lacks tone. This can sometimes be seen in the face. The skin
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will be ‘pasty’. There may be a lack of lustre to the skin. The skin and the hair can
also be greasy or oily.
There can be a tendency to be slightly overweight or even obese. The person may
be stocky and portly without being muscular. There can also be excessive growth of
body hair. This will be especially noticeable in women.
The fingers of a person with chronic Phlegm may be a little too thick and appear
to be slightly chubby.
Phlegm, because it blocks the movement of xue, can manifest with a dark, sooty
colour around the eyes.
A person with Phlegm can sometimes have a special odour. The odour is difficult
to describe precisely, but it is easily recognisable when it has been smelt a couple of
times. The smell is heavy and lingers in the air a long time after the person has left
the room. It can sometimes smell a bit like a wet leather jacket.
The saliva in the mouth will be thicker and stickier. The person can have a sticky
taste or sensation in their mouth.
Phlegm can also manifest with a gravelly voice or the person can can be slightly
nasal. There can be a need to clear the throat a lot.
The tongue can be swollen or slightly limp and can have an oily or sticky coating.
The pulse is usually Wiry or Slippery.
Symptoms and signs that are triggered or provoked by perfume, petrol or solvents
will be due to Phlegm-Dampness. This is because Phlegm has a heavy and greasy
nature. The above substances dissolve and dilute things that are oily and they will
dissolve and dilute Phlegm in the body. This will result in Phlegm that was previously
stagnant and embedded in the body’s tissues being set in motion and circulating
around the body. Although this dilutes the Phlegm, it still has a disrupting and
obstructive affect. Phlegm-Dampness can also be provoked by scents and odours
that are heavy, such as certain perfumes and flowers like hyacinths and lilies. Phlegm-
Dampness symptoms are also often provoked by weather fronts, especially when
there is low pressure, thundery weather and very humid weather. Symptoms that
are triggered or exacerbated by consuming Phlegm- or Damp-producing food and
drinks will, of course, indicate that there is Phlegm.
Looking through the symptoms and signs can give the impression that we and
most of our clients have Phlegm. This is not far from the truth. Both the climate
and diet in northern Europe mean that there can be a tendency to develop Phlegm-
Dampness, but Phlegm is also something that accumulates throughout life and is
often a consequence of most chronic patterns of imbalance. Therefore, the older you
get, the more Phlegm you will probably have in your body.
Aetiology
Phlegm often arises when Heat thickens and condenses body fluids, when Spleen qi
xu creates Dampness, when there is stagnation of qi or xue resulting in a stagnation
of the body’s fluids or when there is lack of yang to transport and transform
fluids. Phlegm can also be a consequence of the diet that a person consumes.
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This could be foods that weaken the Spleen, create Dampness or Heat or have a
Phlegm‑producing dynamic.
Symptoms and signs

• Fatigue that is worse in the morning
• Difficulty getting going, and being mentally absent in the morning
• Increased need for sleep
• Lack of appetite, especially in the morning
• Nausea or vomiting
• Heaviness in the chest
• Cough in the morning, the sputum can be loose or sticky depending on
whether or not there is Heat present
• Shortness of breath
• Dizziness
• Heaviness in the head
• Glazed vision and dull eyes
• Sleep in the eyes
• Dark, sooty colour around the eyes
• Depression, melancholy
• Mental confusion and difficulty thinking, especially in the morning
• Incoherent speech or talking to themselves
• Difficulty concentrating
• Skin and flesh tissue can lack tone and be ‘doughy’
• The skin lacks lustre
• The fingers can be thick and chubby
• Increased growth of body hair
• Tendency to obesity and plumpness
• Symptoms and signs that are triggered or provoked by weather changes,
perfume, petrol or solvents
• Symptoms that are provoked by consuming Phlegm-producing foods and
beverages
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• Numbness
• Greasy or oily skin and hair
• Sticky taste or sensation in the mouth
• Thick saliva or saliva in the mouth
• Mucus in the menstrual blood
• Fibroids and nodules
• Fat nodules under the skin
• Deformed joints
• Heavy, sticky odour
• Repeated need to clear the throat
• Gravelly or nasal voice
• Swollen tongue, a tongue that lacks tone, sticky or greasy tongue coating
• Slippery or Wiry pulse
Key symptoms
Fatigue and mental absence in the mornings, lack of appetite in the morning, sticky
sensation in the mouth, symptoms and signs that are triggered or provoked by
weather changes, perfume, petrol or solvents.
Treatment principle
Transform and drain Phlegm.
Acupuncture points
Choose from: St 40, St 36, Ren 12, Sp 3, Sp 6, Sp 9, UB 20 and UB 21.
Needle technique
Drain St 40 and Sp 9. Tonifying on the rest of the points.
Explanation
• St 40 drains Phlegm.
• Sp 9 drains Dampness.
• Sp 3, Sp 6, St 36, Ren 12, UB 20 and UB 21 tonify Spleen qi and transform
Phlegm.
Herbal formula
• Er Chen Tang (Drains and transforms Phlegm)
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• Wen Dan Tang (Drains and transforms Phlegm-Heat)

• Qin Qi Hua Tan Tang (Drains Phlegm-Heat from the Lung)
• Di Tan Tang (Transforms and clears Phlegm misting the orifices)
Relevant advice
The relevant advice will depend on which individual patterns have been involved
in the creation of Phlegm. Nevertheless, there are some general guidelines that
are relevant for all individuals who present with Phlegm imbalances. Diet is very
important, and the patient should avoid foodstuffs and beverages that produce
Dampness and Phlegm. This will include avoiding dairy products, bananas, sugar,
things that taste sweet such as dried fruits, honey, stevia and so on, wheat, fried
food and alcohol. Nuts are interesting in this context, because eating too many nuts
creates Phlegm, but eating small amounts of almonds or walnuts can transform
Phlegm in the Lung. In general, a person with Phlegm will benefit from eating foods
that have a slightly spicy flavour such as watercress, radishes, turnips, daikon, garlic,
pepper, herb and so on. It is also important that they do not eat too much at a time
and do not eat too late in the evening.
Physical activity and movement are important to counteract Phlegm’s tendency
to stagnate.
Phlegm can be caused by the following patterns of imbalance

• Spleen qi xu
• Lung qi xu
• Dampness
• Yang xu
• Yin xu
• Heat
• Cold
• Qi stagnation
• Xue stagnation
• Food stagnation
Phlegm can result in the following patterns of imbalance

• Heat
• Qi stagnation
• Xue stagnation
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• Spleen qi xu
• Lung qi xu
Xue stagnation
Xue should flow freely and unhindered throughout the body. Xue can stagnate for a
variety of reasons. Xue and qi have an extremely close relationship, with xue being
dependent on qi for its movement. This means that qi stagnation can result directly
in xue stagnation. Qi xu can also be a cause of xue stagnation when qi lacks the
strength to circulate and spread xue. In this way, xue xu can also be the cause of xue
stagnation. The movement of xue can also be blocked by Phlegm and by physical
traumas, including surgery, because when there is physical trauma or surgery xue
will leave the vessels, will no longer be circulated by qi and will therefore stagnate.
Heat can ‘condense’ xue so that it becomes sticky and clots. Cold can freeze and
congeal xue.
Just as Phlegm and Dampness have none of the moistening or lubricating
qualities that jinye has, xue stagnation has none of the moistening and
nourishing qualities that physiological xue has. In fact, stagnant xue blocks the
passage of qi and xue in the cou li (the microscopic spaces in the tissue) and thereby
prevents fresh, nutritious xue from circulating to or through an area. This means that
some of the symptoms and signs of xue stagnation and xue xu can be very similar.
There is, though, a significant difference between them, which is that the signs of
xue xu will be limited to a very localised area and will not be systemic, as is the case
when there is xue stagnation.
In China, many doctors focus on treating xue stagnation in elderly patients. This
is because xue stagnation is part of the ageing process and xue stagnation is often a
consequence of most chronic imbalances. The consequences of xue stagnation can
often be observed in elderly patients. Their movements can be stiff and painful, and
they often have visible signs of xue stagnation in the form of spider naevi and visible
purple capillaries in the skin.
Like Phlegm, xue stagnation is something that is very common, but many
people overlook it when they diagnose. This is because, like Phlegm, the symptoms
and signs that are described in Chinese textbooks are slightly over-simplified and
gross. In reality, a diagnosis of xue stagnation will be based on many small signs and
symptoms that are less tangible and thus more difficult to spot unless you consciously
search for them
One of the main symptoms that Chinese textbooks define as being characteristic
of xue stagnation is pain that is stabbing, sharp or piercing in character. The pain
will be fixed, localised to a specific place and will not move about. The pain has
this character because xue stagnation creates a physical blockage that prevents the
movement of qi, xue and jinye. This results in qi accumulating in a small and limited
area where it cannot circulate. Where there is stagnation, there is pain. The pain in
xue stagnation is unlike qi stagnation pain. Qi stagnation pain is more fluctuating
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and less fixed. When there is qi stagnation, there will be stagnation in a much larger
area, but qi will be able to move about within this area. It means that the pain is more
undulating and spasmodic. The pain will also be able to move slightly from place
to place. Qi stagnation will also manifest with a more tense or distended sensation.
Xue stagnation can manifest as physical accumulations, lumps or hard knots in the
muscle or tissue. This is because there is a stagnation of physical substance. Fibroids
and myoma are examples of xue stagnation, but it is important to remember that
Phlegm can also create lumps in the tissue. This is because Phlegm is also a physical
substance. The difference between lumps and accumulations that are manifestations
of xue stagnation and Phlegm is that xue stagnation accumulations will be harder
and have more clearly defined but rougher edges. Phlegm accumulations are less
clearly defined and smoother. Furthermore, xue accumulations will be more painful.
The menstrual cycle is totally dependent on xue flowing freely and unhindered.
Xue stagnation will therefore often manifest with a disruption of the menstrual cycle.
The cycle may be longer because xue does not flow freely and thereby stagnates in
chong mai. There will be dysmenorrhoea and the menstrual blood will be dark and
clotted. There can also be heavy or extended bleeding, with the bleeding continuing
for longer than the normal four to six days. Xue stagnation can be a factor in bleeding
anywhere in the body, because stagnated xue will create a blockage in a vessel. This
will lead to an increase of pressure in the vessel, because xue and qi cannot get past
the blockage. Eventually, the pressure becomes so great that the wall of the vessel
ruptures. When there is bleeding – whatever the cause – it will itself become a
further source of a xue stagnation, because when xue exits the vessels and channels
it is no longer circulated and governed by Heart qi. It will then stagnate and further
disrupt the movement of qi, xue and jinye.
The Heart has the function of governing xue. The Heart can easily be affected by
xue stagnation, which will manifest as a sharp pain in the chest and a disturbance of
the cardiac rhythm.
Stagnated xue does not have any of the nourishing qualities of xue; on the
contrary, xue stagnation blocks fresh, nutritious xue from circulating through an
area. This can result in the skin above an area where there is stagnated xue being dry,
flaking or thickened. There may also be changes in skin pigmentation. By blocking
the circulation of xue in area, xue stagnation will prevent shen – which is anchored by
and thereby circulates together with xue – from flowing through the area. This can
result in a sensation of numbness. This is typically seen when there is scar tissue. The
stagnated xue from the trauma or the operation will have accumulated in the tissue
around the operation site or the injured area. The tissue is often hard and thickened,
and there is either numbness or sensory disturbance in the area, all of which are
characteristic of xue stagnation.
Stagnated xue moves more slowly, if at all and is therefore less oxygenated. This
can be seen in generalised signs such as a dark facial complexion, dark lips, dark
or purple nails, purple tongue and swollen veins on the underside of the tongue.
Wherever there is tissue, skin or blood vessels that are purple in colour, this is a sign
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of xue stagnation. Typical examples of this are bruising, varicose veins and spider
naevi, but it could also be the tissue around a joint.
The pulse can be Choppy, Wiry or Confined when there is xue stagnation. It can
also be Knotted if there is Heart xue stagnation.
On the mental-emotional level, xue stagnation can impede the movement
of shen. This may mean that the person is psychotic, depressed or has difficulty
staying awake.
One way of testing whether someone has xue stagnation is to fold their ear and
squeeze it tightly together with your fingers. The more stagnation of xue there is, the
more painful it will be. You can also press your fingers into the skin in the area where
you suspect that there may be xue stagnation and then release them again. The more
stagnation there is, the longer it will take before the white imprint of the fingers in
the colour of the skin fades away.
Aetiology
Xue stagnation can arise as a consequence of virtually all chronic patterns of
imbalance. Qi stagnation, Heat, Cold, Phlegm, qi xu and xue xu are often precursors
to xue stagnation. Physical traumas and operations will always create a stagnation
of xue.
Symptoms and signs

• Sharp pain that is localised in one place, pain that is sharp, piercing or
stabbing
• Pain that is worse at night or after the person has been physically inactive
• Limited or stiff movements
• Bleeding
• Long menstrual cycle
• Painful menstrual bleeding
• Dark and clotted menstrual blood
• Sharp chest pains
• Irregular cardiac rhythm
• Dark facial complexion
• Altered pigmentation
• Dark lips
• Dark nails
• Rough, flaky, thickened or dry skin
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• Physical lumps and knots in the body’s tissue

• Numbness or sensory disturbances
• Purple skin, purple blood vessels, spider naevi or varicose veins
• Psychosis
• Depression
• The ear is tender or painful when it is bent double and squeezed
• Purple or dusky tongue
• Swollen, purple sub-lingual veins
• Choppy, Wiry, Confined or Knotted pulse
Key symptoms
Sharp, piercing or stabbing pain, limited or stiff movements, dark lips, swollen,
purple sub-lingual veins.
Treatment principle
Circulate xue, disperse xue stagnation.
Acupuncture points
Choose from: UB 17, Sp 6, Sp 10, jing-well points and local points.
Needle technique
Draining. Bleed jing-well points and small purple vessels in the skin. The use of
cupping, moxa, gua sha and seven-star needles is also relevant.
Explanation
• UB 17, Sp 6 and Sp 10 move xue in general.
• Jing-well points activate xue in their own channel when they are bled.
• Bleeding spider naevi and stagnated blood vessels disperse xue stagnation in
the local area.
Herbal formula
There are a great many relevant formulas. The choice of formula will be dependent
on, amongst other things, where the xue stagnation is and what the root cause is. The
following are examples of some of these formulas.
• Tao Hong Si Wu Tang (Spreads xue)
• Tao He Cheng Qi Tang (Invigorates and disperses xue stagnation in the lower
jiao)
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• Xue Fu Zhu Yu Tang (Invigorates and disperses xue in the upper jiao)
• Shao Fu Zhu Yu Tang (Invigorates and disperses xue and dispels Cold in the
lower jiao)
• Gui Zhi Fu Ling Tang (Invigorates and disperses xue and Phlegm
accumulations in the lower Uterus)
• Shen Tong Zhu Yu Tang (Invigorates qi and xue in the channels and collaterals)
Relevant advice
As with Phlegm, it is vital that the underlying pattern that has been involved in the
creation of xue stagnation is addressed.
Xue stagnation can prevent the circulation of wei qi in an area where there has
been a physical trauma. It is therefore important that this area is protected from the
environment so Wind, Cold and Dampness cannot invade the area. It is typical that
joints that have been injured or operated on are often sensitive to changes in the
weather.
Physical activity is beneficial because it will circulate qi and xue, but it is also
important not to overburden the area or force a joint to move more than it will. A
joint or a limb should not be forced to move beyond the spot where there is a sharp
pain, because doing so may cause further xue stagnation.
Xue stagnation can be caused by the following patterns of imbalance

• Qi stagnation
• Phlegm
• Xue xu
• Qi xu
• Cold
• Heat
Xue stagnation can result in the following patterns of imbalance

• Qi stagnation
• Heat
• Phlegm
• Xue xu
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Food stagnation
Food stagnation is similar to xue stagnation and Phlegm in that it is often overlooked.
Food stagnation tends to be a contributory factor to other imbalances rather than
being a consequence of them. However, several imbalances can lead directly to
food stagnation.
As with xue stagnation and Phlegm, the symptoms and signs of food stagnation
can be easily overlooked. This is because you have to ask about specific signs and
symptoms that the client often does not even realise that they have or they do not see
as relevant, because it is something they have always had and regard as being normal.
Food stagnation can be seen on the tongue and in the pulse, but these signs are often
overlooked because they get interpreted as Dampness, Phlegm or qi stagnation.
Food stagnation arises when food physically and energetically accumulates in the
middle jiao. Food stagnation generally has two consequences that can lead to further
imbalances and complications. Food stagnation can block the qi ji (qi dynamic)
of the middle jiao and it can create Heat. By physically and energetically blocking qi
in the middle jiao, food stagnation will disrupt and burden the Stomach and Spleen’s
qi ji. This can lead to Stomach and Spleen qi xu, rebellious Stomach qi, Dampness,
Damp-Heat and Phlegm. In addition, a blockage of qi in the middle jiao can disrupt
the communication of qi between the lower and upper jiao and between the Kidneys
and the Heart. Food stagnation can also disrupt Liver qi in its spreading function.
Heat will quickly arise as a consequence of Food stagnation. This can initially lead
to Stomach Fire and Stomach yin xu and contribute to the creation of Damp-Heat
and Phlegm-Heat.
When food stagnates in the Stomach, it will manifest with a turgid and distended
sensation in the epigastric region. Food stagnation creates Heat. At the same time, it
blocks the Stomach qi from descending. Both of these factors can cause the Stomach
qi to rebel. This can manifest as burping, heartburn and acid regurgitation a while
after eating. The belching will usually taste of the food that has been consumed and
sometimes will also be accompanied by a small amount of semi-digested food. The
disruption of the Stomach and the Spleen qi ji can result in nausea or poor appetite.
When the food is stagnant, it will not be transformed properly and will instead have
a tendency to rot and ferment. The combination of untransformed food and Heat
can also result in the stool being loose and sticky. The stool can also smell rotten like
sewage. Food stagnation can cause constipation by stagnating qi in the Stomach and
the Intestines.
Food stagnation can manifest on the tongue with a thick, greasy coating in the
middle of the tongue. The pulse will often be Wiry and Slippery in the middle or
guan positions.
Aetiology
Food stagnation can arise as an acute imbalance when too much food is consumed
at one time, when food is eaten too frequently or too late in the evening or when
inappropriate food is eaten, i.e. food that is difficult to transform. Food stagnation
can also be a chronic condition due to the Spleen and Stomach being too weak
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to be able to perform their respective functions. Dampness, Phlegm and Liver qi

stagnation can also be involved. In this case, even smaller amounts of food and
even more types of food will result in Food stagnation. The foundation for food
stagnation can have been laid very early when the person was a baby due to the diet
they were fed and the way they were fed. Many babies and toddlers are fed food
that is too coarse and unrefined, is too sweet, creates Dampness and Phlegm and is
too cold. Moreover, many babies are often fed too frequently. This is problematic
because their Spleen is not capable of transporting and transforming optimally. This
can lead to food stagnation, a subsequent weakening of the Spleen and the formation
of Dampness, Heat and Phlegm.
Symptoms and signs

• Stuffed or turgid sensation in the Stomach after consuming food
• Abdominal distension after eating
• Discomfort after eating
• Loss of appetite
• Nausea
• Acid reflux
• Belching
• Belching or burping with the taste of previously ingested food
• Hiccup
• Bad breath
• Loose stools, stools with undigested food particles, constipation
• Stools smell rotten
• Thick, greasy coating in the middle of the tongue
• The pulse is Slippery or Wiry in one or both guan positions
Key symptoms
Full sensation or discomfort in the epigastric region, belching that tastes of previously
ingested food, thick, greasy tongue coating.
Treatment principle
Disperse and dissolve Food stagnation, tonify and regulate qi in the middle jiao.
Acupuncture points
Choose from: Ren 11, Ren 12, Ren 13, Ren 22, St 21, St 34, St 36, Sp 4 and Pe 6.
• If there is Heat, add: LI 11 and St 44.
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Needle technique
Draining or even.
Explanation
• Ren 11, Ren 12, Ren 13, Ren 22, St 21, St 34, St 36, Sp 4 and Pe 6 regulate
Stomach qi and qi in the middle jiao.
• LI 11 and St 44 drain heat from the Stomach and Intestines.
Herbal formula
• Bao He Wan (Dissolves Food stagnation)
• Jian Pi Wan (Dissolves Food stagnation and tonifies Spleen qi)
Relevant advice
A person with food stagnation should avoid eating too quickly, too much at a
time, late in the evening and foods that are difficult to transform. They must chew
their food thoroughly. They will benefit from massaging their abdomen with light
downward strokes from Ren 16 down to Ren 8 immediately after they have eaten.
They can also massage the abdomen in a clockwise direction a few times throughout
the day. As well as avoiding the consumption of foods that are difficult to transform,
they will benefit from using aromatic herbs in their diet and possibly consuming a
little bit of cardamom, aniseed and other aromatic seeds immediately after they have
eaten. This will help the Stomach and Spleen to move qi in the middle jiao.
Food stagnation can be caused by the following patterns of imbalance

• Stomach and Spleen qi xu
• Dampness
• Qi stagnation
Food stagnation can result in the following patterns of imbalance

• Qi stagnation
• Heat
• Damp-Heat
• Dampness
• Phlegm
• Spleen qi xu
• Stomach yin xu
• Stomach Fire
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Section 7
QI, XUE AND JINYE IMBALANCES
In this diagnostic model, patterns are differentiated in relation to changes in the

qualities, amounts and functioning of qi, xue or jinye.
From an Eight Principles point of view, these imbalances will, by definition, be
interior imbalances and they can be either xu or shi.
Differentiating in relation to the vital substances alone is usually not precise
enough to be able to treat a patient effectively. When there is, for example, qi xu, it
is important to determine which organs are qi xu and what type of qi is deficient.
This, however, works both ways. It is not enough to know that there is a Heart
imbalance. For the treatment to be effective, we have to determine whether there is a
Heart qi, Heart xue, Heart yin, Heart yang, Cold or Phlegm imbalance. This though
is still not precise enough. If we determine there is a Heart qi imbalance, we need
to know whether there is Heart qi xu or Heart qi stagnation. Similarly, if there is a
Heart xue imbalance, we need to determine whether there is Heart xue xu or Heart
xue stagnation or whether xue Heat is agitating the Heart. These differentiations are
important, because the treatments required in each situation will be different, as will
the advice that is given to the client.
Diagnosis in relation to the vital substances is a key aspect of other diagnostic
models, especially the diagnosis according to zangfu organs.
The treatment strategy is implicit in a diagnosis according to qi, xue and jinye.
When something is xu, it must be tonified or nourished. When there is a stagnation,
that which is stagnant must be dispersed and circulated. If qi is rebellious, it must
be regulated, etc.
The following patterns are differentiated in the model ‘diagnosis according to qi,
xue and jinye’.
There are four kinds of qi imbalances:
• qi xu
• qi sinking
• stagnant qi
• rebellious qi.
There are four kinds of xue imbalances:
• xue xu
• xue loss
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• xue stagnation
• xue Heat.
There are four kinds of jinye imbalances:
• jinye xu
• accumulation of fluids
• Damp
• Phlegm.
Qi imbalances
When there are qi imbalances, there will be signs that there is a disturbance of one
or more of qi’s functions in the body. These signs will arise either because there is too
little qi available for qi to be able to perform its tasks – qi xu – or because there is qi
stagnation. Qi stagnation can prevent the free movement of qi, xue and jinye. This
will often result in pain, discomfort, bloating and so on.
Qi can also move in the wrong direction, i.e. the opposite direction that it
should be moving in. For example, when there is harmony, the Stomach sends its
qi downwards. If Stomach qi is rebellious, Stomach qi will ascend upwards. This
will manifest with symptoms such as nausea, vomiting, hiccups, belching and
acid regurgitation.
If there is ‘qi sinking’, qi is no longer able to lift and hold things in place. Qi lifts
and holds structures in the body in place, so if there is qi xu, there can be prolapse
of organs or a sinking, downward-dragging sensation in the body.
Qi xu
Any zang organ can be qi xu, but when there is a diagnosis of qi xu, there will usually
be a xu condition in one or more of the qi-producing organs – the Lung, the Spleen
and the Kidneys. This does not mean that other organs cannot be qi xu – Heart qi xu
is, for example, a very common pattern of imbalance, but in this case the condition
of qi xu is related to a specific organ’s functioning and it will not necessarily affect the
state of qi and the functioning of the body in general. When there is a diagnosis of qi
xu, there is a systemic deficiency or lack of qi, and this is seen in the accompanying
symptoms and signs in the whole body. When a specific organ is qi xu, there will
be symptoms and signs that this organ is unable to perform its functions properly due
to a lack of qi. This condition will, though, be differentiated as a zangfu imbalance.
A generalised condition of qi xu will arise when more qi is consumed than the body
is able to produce. This may be due to overusing and straining qi, such as when there is
illness, overwork, excessive sport and fitness training, excessive physical and mental
activity, too much sex and lack of sleep. Qi xu will also arise when not enough food has
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Diagnosis According to Qi, Xue and Jinye Imbalances
been consumed or if the food that has been consumed and air that has been inhaled
are of poor quality, so that sufficient qi to replenish the qi that has been consumed is
not produced. There can also be a deficiency or weakness of jing, the inherited essence
that is the foundation of qi. Finally, qi xu can be due to a weakness of one of the three
qi-producing organs, i.e. Kidney qi xu, Spleen qi xu or Lung qi xu, or a combination
of these. For a more detailed analysis of the aetiology of xu conditions in these organs,
please see the relevant parts of Section 8 on zangfu imbalances.
The key symptom of qi xu is fatigue, but even though qi xu will always result in
fatigue, not all fatigue is the result of qi xu or a xu condition at all. The fatigue will
manifest both physically and mentally.
Apart from fatigue, the person may have a pale face. This is because there will
be too little qi to send xue up to the head. That is why the tongue will also be pale.
Fluids will not be transported and transformed as they should be; this will manifest
with the tongue being swollen or having teeth marks on the sides.
Qi is needed to maintain control of the pores in the skin. Therefore, if there is a
lack of qi, there can be spontaneous sweating or perspiration on light activity.
A person who is qi xu will often be short of breath and quickly become breathless.
This is because the Lung is too weak to disseminate qi. Zong qi can also be weakened
and this will be apparent when a person has a weak voice and a disinclination to talk.
They can also have a sunken chest and poor posture, because zong qi is not strong
enough to expand and open the thorax.
The Spleen is supposed to transform the food and beverages that are ingested. If
there is Spleen qi xu, the Spleen will fail to perform these functions adequately. This
can be seen when a person has a poor appetite and loose stools.
Dizziness can also be seen when there is qi xu. This is because qi and xue are not
able to ascend up to the head and nourish the brain.
The pulse will be Weak, because there is not enough qi to drive xue through
the vessels.
Aetiology
Qi xu can arise when the body uses more qi than it is able to produce. This will be
because the person places too great a demand on their qi or they are not able to
produce sufficient qi.
Qi can be burdened by working too much and too hard or by being too physically
active, for example by playing too much sport or doing too much fitness training, as
well as through excessive sex.
Illnesses, both chronic and acute, will strain and weaken qi, because qi is used
to combat the xie qi, but also because xie qi can disrupt the production of qi.
The Lung, Spleen and Kidneys are all involved in the production of qi. If one or
more of these organs are out of balance, it will affect qi production and thereby the qi
levels in the whole body. For a more detailed explanation of the aetiology of imbalances
in these organs, please see the relevant parts of Section 8 on zangfu imbalances.
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Poor production of qi can also be due to the quality and quantity of the food and
beverages consumed and poor-quality air being breathed in.
The person may be born jing xu, which will negatively affect the quality and
quantity of their qi. Jing xu can also arise or be exacerbated if a man has too many
ejaculations. Chronic qi xu and xue xu conditions will also deplete jing.
Symptoms and signs

• Pale face
• Sweating on light activity
• Poor appetite
• Loose stools
• Weak voice
• Dizziness
• Pale and swollen tongue
• Weak pulse
Key symptoms
Fatigue, pale tongue and Weak pulse.
Treatment principle
Tonify qi.
Acupuncture points
Choose from: St 36, Sp 3, Sp 6, UB 13, UB 20, UB 21, UB 23, Lu 9, Kid 3, Ren 4,
Ren 6, Ren 12 and Ren 17.
Needle technique
Explanation
• St 36, Sp 3, Sp 6, UB 20, UB 21 and Ren 12 tonify the Spleen and thereby
the production of post-heaven qi.
• Lu 9, Ren 17 and UB 13 tonify the Lung and thereby the production of
post-heaven qi.
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• Kid 3, UB 23 and Ren 4 tonify the Kidneys and thereby pre-heavenly qi.
• Ren 6 tonifies yuan qi.
Herbal formula
• Liu Jun Zi Tang (Tonifies Spleen and Lung qi)
Relevant advice
When there are qi xu conditions, it is important that the person ensures that the
air that they breathe and the food that they eat are qi tonifying. They must ensure
that they do not consume more qi than they produce. In practice, this means that
they need to eat a diet and eat in a way that tonifies Spleen qi, i.e. foods that are fresh,
easily digestible, prepared and warm. They should eat small, frequent meals. They
should avoid foods that are cold and hard-to-digest and have not been prepared.
Soups, puréed vegetables and stews are particularly recommended. They must also
eat slowly and chew their food well. Lung qi is tonified by fresh air and breathing
exercises. Qi gong, tai ji and yoga will be beneficial, as they tonify and circulate qi
at the same time. Caution should otherwise be observed with regards to physical
activity, fitness training and sport. It is important that the person does not engage
in activities that make them feel tired. On the whole, they must ration their energy
and avoid working too much and for too long. Men who are Kidney qi xu should
avoid having ejaculations.
Qi xu can be caused by the following patterns of imbalance

• Lung qi xu
• Spleen qi xu
• Kidney qi xu
• Xue xu
• Phlegm-Dampness
• Yang xu
• Jing xu
Qi xu can result in the following patterns of imbalance

• Xue xu
• Phlegm-Dampness
• Qi stagnation
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• Xue stagnation
• Yang xu
• Yin xu
Qi sinking
When there is ‘qi sinking’, there is not enough yang qi to rise and ascend. Rather
than being a specific pattern of imbalance, it should perhaps be seen as an aspect of
qi xu, where qi is not able to perform one of its functions – lifting. In this pattern,
there may be prolapse of organs and a heavy, sinking or dragging-down sensation in
the body. It will mainly be Spleen qi that is deficient in this pattern.
Aetiology
The aetiology for this pattern is the same as for qi xu.
Symptoms and signs

• Dizziness
• Prolapse of organs (stomach, uterus, intestines, anus, vagina or urinary
bladder)
• A feeling of heaviness or sinking in the body
• Bleeding
• Bruising
• Stooping posture
• Pale, swollen tongue
• Weak pulse
Key symptoms
Organ prolapse, sensation of heaviness, Weak pulse.
Treatment principle
Raise and tonify qi.
Acupuncture points
Choose from: Du 20, Ren 6, Ren 12, St 36, Sp 3, UB 20 and UB 21.
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Needle technique
Tonifying. Moxa can be used on Du 20 and Ren 6.
Explanation
• Du 20 and Ren 6 raise qi in the whole the body when treated with moxa.
• St 36, Sp 3, Ren 12, UB 20 and UB 21 tonify Spleen qi.
Herbal formula
• Bu Zhong Yi Qi Tang (Tonifies and lifts Spleen qi)
Relevant advice
In addition to the advice given above for qi xu, the person must avoid lifting and
carrying heavy objects, and they should avoid standing up too much.
Qi sinking can be caused by the following patterns of imbalance

• Qi xu
• Spleen qi xu
• Spleen yang xu
Qi sinking can result in the following pattern of imbalance

• Yang xu
Qi stagnation
When there is qi stagnation, qi is not flowing as it should. There can be a local
stagnation of qi in a specific place in the body or the stagnation of qi can be general
and systemic.
A local stagnation of qi can manifest as tension and spasmodic or fluctuating
pain that is not completely fixed in its location. There can be a feeling of distension
or bloating in the area. When there is qi stagnation, the feeling of distension or
bloating is more dominant than the pain itself. However, this does not mean that
the pain experienced when there is qi stagnation cannot be very intense. There can
be a physical swelling in the area, but it can also simply be a subjective sensation of
bloating and distension.
A generalised qi stagnation will often cause symptoms such as abdominal
bloating, irritability, mental depression and mood swings.
There can often be a need to yawn or to sigh. This is the body attempting to
disperse the stagnant qi. By yawning or sighing the body draws in extra air or da qi
and thereby can create more zong qi, which can move and disperse the stagnant qi.
Belching or breaking wind can relieve qi stagnation in the digestive system.
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An important symptom seen in qi stagnation is fatigue. Even though there is

in reality enough qi in the body, fatigue is experienced because the qi is stagnated.
It will be experienced as fatigue and lack of energy, and also as a lack of motivation
and laziness. When there is qi stagnation, the fatigue will usually be the worst in the
morning and after the person has been sitting still for a long while, because the lack
of physical movement will also cause qi to stagnate. This type of tiredness should
not be confused with qi xu fatigue. Qi xu fatigue gets worse during the day as qi
is consumed. Qi stagnation fatigue is often worse during periods when the person is
under emotional strain or faced with situations that they are dissatisfied with.
Not only can a person with qi stagnation have difficulty getting going in the
mornings due to feeling tired, they can also be more irritable in the morning until
the qi starts flowing more harmoniously.
Qi xu may be a contributing factor in qi stagnation. In the same way that water
in a stream can stop flowing if the water level becomes too low, qi can stagnate in the
channel system when there is too little qi.
The symptoms and signs seen in qi stagnation are characterised by whether there
is a localised stagnation of qi in the channel system, for example elbow pain, or when
the qi stagnation is on the zangfu level. When the qi stagnation is on the zangfu
level, the symptoms are characterised by signs that organs are not carrying out their
functions optimally. When there is a general state of qi stagnation, the Liver will
usually be involved. This is because one of the primary functions of the Liver is to
ensure the free and unhindered movement of qi in the whole body. Stagnant Liver
qi can also invade other organs, especially the Stomach, Spleen, Lung and Intestines.
This invasion of Liver qi will disrupt the functioning of these organs. One must,
however, be careful not to diagnose all qi stagnations as Liver qi stagnation. The qi
of other organs can also be stagnated without the Liver being involved.
Aetiology
Qi stagnation can arise when there is emotional turmoil, frustrations, unresolved
emotions, repressed anger and irritation or stress. It can also arise from a lack of
physical activity. Many other patterns of imbalance can directly lead to qi stagnation,
such as food stagnation, Cold, Dampness, Phlegm and so on.
Localised qi stagnation will usually be due to a physical trauma or when xie qi
blocks the movement of qi in the channel system.
Symptoms and signs

• Bloating and distension
• Distending, spasmodic or throbbing pain, which can come and go
• Pain that is not localised to a particular spot
• Physical or subjective sensation of swelling in an area
• Irritability
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• Mood swings
• Depression
• A need to yawn or sigh
• Symptoms that are relieved by belching, passing wind or yawning
• Fatigue, especially in the morning and when physically inactive
• The sides of the tongue may be swollen
• Wiry pulse
Key symptoms
Distension, swelling, Wiry pulse.
Treatment principle
Spread qi.
Acupuncture points
Choose from: LI 4, Liv 3, Liv 14, GB 34, SJ 6, UB 18, Ren 6, Ren 17 and local
points.
Needle technique
Draining.
Explanation
• The combination of LI 4 and Liv 3 spreads stagnant qi and xue in the whole
body.
• Liv 14, GB 34 and UB 18 spread Liver qi.
• SJ 6 circulates qi in all three jiao.
• Ren 6 circulates qi in the middle and lower jiao.
• Ren 17 circulates qi in the upper jiao.
Herbal formula
• Chai Hu Shu Gan Tang (Spreads stagnant Liver qi)
Relevant advice
When there is stagnant qi, it is important that the person gets enough physical
activity. Exercise and dynamic exercise will help the body to move the stagnant qi
physically. Massage and stretching will also be beneficial.
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If there are emotional issues beneath the imbalance, whenever possible the
person must try to resolve these. If it is not possible to resolve these issues, reaching
a position of acceptance is important.
Qi stagnation can be caused by the following patterns of imbalance

• Liver qi stagnation
• Qi xu
• Xue stagnation
• Damp
• Phlegm
• Accumulation of fluid
Qi stagnation can result in the following patterns of imbalance

• Xue stagnation
• Heat
• Phlegm
Rebellious qi
In this pattern there are symptoms and signs indicating that an organ’s qi is moving
in the wrong direction. It is always necessary to differentiate which organ is involved.
Qi can become rebellious when:
• it is forced to move in the wrong direction (usually upwards by Heat)
• it is prevented from moving in the right direction (usually because it is
blocked by xie qi)
• an organ is too weak to send its qi in the right direction (a qi xu condition).
Aetiology
This will mainly depend on which organ is involved. It will often be due to invasions of
exogenous xie qi, consuming too much or the wrong foods or emotional imbalances.
Heat, qi stagnations and qi xu conditions are often involved.
Symptoms and signs

When there is rebellious Lung qi:
• coughing
• sneezing
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• tightness of the chest

• shortness of breath.
When there is rebellious Stomach qi:
• belching
• reflux and acid regurgitation
• nausea
• vomiting
• hiccups.
When there is rebellious Spleen qi:
• diarrhoea
• organ prolapse
• dragging or sinking sensation.
When there is rebellious Liver qi:
• headache
• dizziness
• nausea
• abdominal bloating
• alternating diarrhoea and constipation.
Treatment principle
Regulate qi.
Acupuncture points
• If there is rebellious Lung qi: UB 13, Ren 22, Ren 17, Lu 1 and Lu 7.
• If there is rebellious Stomach qi: Ren 13, St 21, St 34, St 36 and Pe 6.
• If there is rebellious Spleen qi: Sp 3, St 36, Ren 6 and Du 20.
• If there is rebellious Liver qi: LI 4, Liv 2, Liv 3, Liv 14, GB 20, GB 34 and
GB 43.
Needle technique
Draining, with the exception of the points for rebellious Spleen qi, which should be
tonified and heated with moxa.
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Explanation
• UB 13, Ren 22, Ren 17, Lu 1 and Lu 7 regulate Lung qi.
• Ren 13, St 21, St 34, St 36 and Pe 6 regulate Stomach qi.
• Sp 3, St 36 and Ren 6 tonify and lift Spleen qi.
• Du 20 lifts qi.
• LI 4, Liv 3, Liv 14 and GB 34 regulate Liver qi.
• Liv 2, GB 20 and GB 43 drain Liver yang.
Herbal formula
• Ding Chuan Tang (Regulates Lung qi, clears Heat and resolves Phlegm)
• Su Zi Jiang Qi Tang (Regulates Lung qi and tonifies Kidney yang)
• Ban Xia Hou Po Tang (Regulates Stomach qi)
• Ju Pi Zhu Ru Tang (Regulates Stomach qi and tonifies Stomach qi)
• Bu Zhong Yi Qi Tang (Raises and tonifies Spleen qi)
• Chai Hu Shu Gan Tang (Regulates Liver qi)
Relevant advice
This will depend on which organs are affected and the relevant aetiology. Please see
the relevant parts of Section 8 on zangfu imbalances.
Rebellious qi can be caused by the following patterns of imbalance

• Qi stagnation
• Qi xu
• Xue stagnation
• Phlegm
• Food stagnation
• Heat
• Cold
• Yang xu
• Yin xu
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Xue imbalances
When there are xue imbalances, there will be observable disturbances in one or
more of the functions performed by xue in the body. It will either be because there
is too little xue to perform the function, i.e. xue xu, or because xue has stagnated
and therefore cannot fulfil its functions. Stagnations of xue will also prevent the free
passage of qi, xue and jinye, and this will often result in pain.
Xue can also become too hot – xue Heat – and there can be a physical loss of xue
through bleeding – loss of xue.
Xue xu
As we saw with qi xu, there can be a general condition of xue xu with accompanying
signs and symptoms, as well as a xue xu condition in specific organs – Liver xue xu
and Heart xue xu. In this section I will discuss a general condition of xue xu. For a
detailed discussion of Liver xue xu and Heart xue xu, please see the parts of Section 8
on zangfu imbalances.
The main function of xue is to nourish and moisten the tissues of the body and
to nourish and anchor shen. This means that when there is a condition of xue xu, any
of the following signs and symptoms could be experienced.
The skin, especially the skin in the face, can be pale, sallow and dry. This is due
to a lack of moisture and nourishment. Shen is anchored and thereby circulates
together with xue. Xue xu can therefore also result in the complexion lacking lustre
and radiance.
The lack of nourishment and moisture can also manifest with: dry hair; ridged,
brittle or soft fingernails; pale and dry lips. The hair can also be very fine and there
can be a tendency to lose hair due to the hair roots lacking nourishment.
Dizziness is often seen when there is xue xu, especially when the person gets
up from a sitting or lying position. The dizziness arises because the brain lacks
nourishment. The brain’s lack of nourishment can also manifest as a poor memory.
This is, for example, a common complaint of women whilst they breastfeed their
baby. The breast milk is produced from xue, so they are often xue xu as a consequence.
When there is xue xu, there can be insufficient xue to nourish the extremities.
Shen (consciousness) is anchored by xue and thereby circulates together with xue. The
lack of xue in the extremities can therefore result in numbness, sensory disturbance
and tingling sensations in the extremities. There can also be muscle cramps in the
legs in the evenings when xue returns to the Liver.
The eyes are nourished by Liver xue. A person who is xue xu can have poor vision
(especially at night), difficulty focusing their eyes when they are tired, spots in front
of the eyes, and a sensitivity to bright light.
Women who are xue xu will often have scanty menstrual bleeding or even
amenorrhoea.
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If there is Heart xue xu, there can be palpitations, as well as insomnia, anxiety
or a sense of unease and nervousness. This is because shen is not being anchored and
nourished by xue.
The tongue will be pale, thin and dry because it is not saturated by xue. The pulse
will be Fine or Choppy.
Aetiology
There are three main causes of xue xu: there may be an inadequate intake of food that
creates xue; there may be a xu condition in one or more of the xue-producing organs,
i.e. the Spleen or Kidneys; there may be loss of xue through bleeding or because it is
consumed by mental or physical over-activity.
Symptoms and signs

• Pale or sallow complexion
• Dry skin
• Dry and pale lips
• Dry hair
• Hair loss
• Fine, thin hair
• Numbness, tingling sensations or sensory disturbance in the arms and legs
• Dizziness
• Poor memory
• Visual disturbances, spots in the visual field
• Night blindness
• Difficulty focusing the vision
• Sensitivity to bright light
• Ridged, soft or brittle fingernails
• Palpitations
• Insomnia
• Nervousness or anxiety
• Scanty or absent menstrual bleeding
• Thin, pale and dry tongue
• Fine or Choppy pulse
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Key symptoms
Pale, sallow complexion, dry skin, scanty menstrual bleeding, dizziness, Fine or
Choppy pulse.
Treatment principle
Nourish xue.
Acupuncture points
Choose from: St 36, Sp 3, Sp 6, Ren 4, Ren 12, UB 17, UB 20 and UB 21.
Needle technique
Tonifying. Moxa is recommended and should be used on UB 17.
Explanation
• St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21 tonify the Spleen and thereby
the production of xue.
• Ren 4 nourishes jing and thereby xue.
Herbal formula
• Ba Zhen Tang (Nourishes xue and tonifies Spleen qi)
Relevant advice
It is important that a person who is xue xu eats a diet that is rich in foods that nourish
xue, such as red meat, chicken, liver, green leafy vegetables, beetroot, seaweed, dates,
nettles, aduki beans, kidney beans and black beans. Furthermore, they should eat a
diet that tonifies Spleen qi.
Xue xu can be caused by the following patterns of imbalance

• Xue loss
• Spleen qi xu
Xue xu can result in the following patterns of imbalance

• Spleen qi xu
• Xue stagnation
• Yin xu
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Xue stagnation
Xue should flow freely and unhindered throughout the body. Xue can stagnate for
a variety of reasons. Xue and qi have an extremely close relationship, with xue being
dependent on qi for its movement. This means that qi stagnation can directly result in
xue stagnation. Qi xu can also be a cause of xue stagnation when qi lacks the strength to
circulate and spread xue. Xue xu can, in this way, also be the cause of xue stagnation. The
movement of xue can also be blocked by Phlegm and by physical traumas, including
surgery, because when there is a physical trauma or surgery, xue will leave the vessels
and no longer be circulated by qi and will therefore stagnate. Heat can ‘coagulate’ xue
so that it becomes sticky and clots. Cold can freeze and congeal xue.
Just as Phlegm and Dampness have none of the moistening or lubricating
qualities that jinye has, xue stagnation has none of the moistening and nourish-
ing qualities that physiological xue has. In fact, stagnant xue blocks the passage of
qi and xue in the cou li (the microscopic spaces in the tissue) and thereby prevents
fresh, nutritious xue from circulating to or through an area. Therefore, some of
the symptoms and signs of xue stagnation and xue xu can be very similar. There is,
though, a significant difference between them, which is that the signs of xue xu will
be limited to a very localised area and will not be systemic, unlike in xue stagnation.
The treatment of xue stagnation is often relevant in elderly patients. This is
because xue stagnation is part of the ageing process and xue stagnation is often a
consequence of most chronic imbalances. The consequences of xue stagnation can
often easily be observed in elderly patients. Their movements can be stiff and painful
and they often have visible signs of xue stagnation in the form of spider naevi and
visible purple capillaries in the skin.
As we saw with Phlegm, xue stagnation is very common but is often overlooked
in diagnosis. This is because, like Phlegm, the symptoms and signs that are
described in Chinese textbooks are crude and slightly over-simplified. In reality, a
diagnosis of xue stagnation will be based on many small signs and symptoms that are
less tangible and thus more difficult to spot unless you consciously search for them.
One of the main symptoms that Chinese textbooks defines as being characteristic
of xue stagnation is pain that is stabbing, sharp or piercing in character. The pain
will be fixed and localised in a specific place and will not move about. The pain has
this character because xue stagnation creates a physical blockage preventing the
movement of qi, xue and jinye. This results in qi accumulating in a small and limited
area, because it cannot circulate here. Where there is stagnation, there is pain. The
pain in xue stagnation is unlike qi stagnation pain. Qi stagnation pain is more
fluctuating and less fixed. When there is qi stagnation, there will be stagnation in a
much larger area, but qi will move about within this area. It will mean that the pain
is more undulating and spasmodic. The pain will also be able to move slightly from
place to place. Qi stagnation will manifest with a tense or distended sensation.
Xue stagnation can manifest as physical accumulations, lumps or hard knots in the
muscle or tissue. This is because there is a stagnation of a physical substance. Fibroids
and myoma are examples of xue stagnation, but it is important to remember that
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Phlegm can also create lumps in the tissue. This is because Phlegm is also a physical
substance. The difference between lumps and accumulations that are manifestations
of xue stagnation and Phlegm is that xue stagnation accumulations will be harder and
have more clearly defined but rougher edges. Phlegm accumulations are less clearly
defined and are smoother. Furthermore, xue accumulations will be more painful.
The menstrual cycle is dependent on xue flowing freely and unhindered. Xue
stagnation will therefore often manifest with a disruption of the menstrual cycle.
The cycle may be longer because xue does not flow freely and thereby stagnates in
chong mai. There can be dysmenorrhoea and the menstrual blood can be dark and
clotted. There can also be heavy or extended bleeding, with the bleeding continuing
for longer than the normal four to six days. Xue stagnation can be a factor in bleeding
anywhere in the body. This is because stagnated xue will create a blockage in a vessel.
This will lead to an increase of pressure in the vessel, because xue and qi cannot
get past the blockage. Eventually, the pressure becomes so great that the wall of
the vessel ruptures. When there is bleeding, whatever the cause, the bleeding will
itself become a further source of a xue stagnation, because when xue exits the vessels
and channels, it will no longer be circulated and governed by Heart qi. It will then
stagnate and further disrupt the movement of qi, xue and jinye.
The Heart has the function of governing xue, and can easily be affected by xue
stagnation. This will manifest as a sharp pain in the chest and a disturbance of the
cardiac rhythm.
Stagnated xue does not have any of the nourishing qualities of xue. On the
contrary, xue stagnation blocks fresh, nutritious xue from circulating through an
area. This can result in the skin above an area, where there is stagnated xue, being dry,
flaking or thickened. There may also be changes in skin pigmentation. By blocking
the circulation of xue in area, xue stagnation will prevent shen, which is anchored by
and thereby circulates together with xue, from flowing through the area. This can
result in a sensation of numbness. This is typically seen when there is scar tissue.
The stagnated xue from the trauma or the operation will have accumulated in tissue
around the operation site or the injured area. The tissue is often hard and thickened
and there is either numbness or sensory disturbance in the area, all of which are
characteristic of xue stagnation.
Stagnated xue moves more slowly, if at all, and is therefore less oxygenated. This
can be seen in generalised signs, such as a dark facial complexion, dark lips, dark
or purple nails, purple tongue and swollen veins on the underside of the tongue.
Wherever there is tissue, skin or blood vessels that are purple in colour, this will be
a sign of xue stagnation. Typical examples of this are bruising, varicose veins and
spider naevi.
The pulse can be Choppy, Wiry or Confined when there is xue stagnation. It can
also be Knotted if there is Heart xue stagnation.
On the mental-emotional level, xue stagnation can impede the movement of
shen. This may mean that the person is psychotic or depressed or that they may have
difficulty staying awake.
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A way of testing whether someone has xue stagnation is to fold their ear and
squeeze it tightly together with your fingers. The more stagnation of xue there is, the
more painful it will be. You can also press your fingers into the skin in area where
you suspect that there may be xue stagnation and then release them again. The more
stagnation there is, the longer it will take before the white imprint of the fingers in
the colour of the skin fades away.
Aetiology
Xue stagnation can arise as a consequence of virtually all chronic patterns of imbalance.
Qi stagnation, Heat, Cold, Phlegm, qi xu and xue xu are often precursors of xue
stagnation. Physical traumas and operations will always create a stagnation of xue.
Symptoms and signs

• Sharp pain that is localised to one place, pain that is sharp, piercing or
stabbing
• Pain that is worse at night or after the person has been physically inactive
• Limited or stiff movements
• Bleeding
• Long menstrual cycle
• Painful menstrual bleeding
• Dark and clotted menstrual blood
• Sharp chest pains
• Irregular cardiac rhythm
• Dark facial complexion
• Altered pigmentation
• Dark lips
• Dark nails
• Rough, flaky, thickened or dry skin
• Physical lumps and knots in the body’s tissue
• Numbness or sensory disturbances
• Purple skin, purple blood vessels, spider naevi or varicose veins
• Psychosis
• Depression
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• The ear is tender or painful when it is bent double and squeezed

• Purple or dusky tongue
• Swollen, purple sub-lingual veins
• Choppy, Wiry, Confined or Knotted pulse
Key symptoms
Sharp, piercing or stabbing pain, limited or stiff movements, dark lips, swollen,
purple sub-lingual veins.
Treatment principle
Circulate xue, disperse xue stagnation.
Acupuncture points
Choose from: UB 17, Sp 6, Sp 10, jing-well points and local points.
Needle technique
Draining. Bleed jing-well points and small purple vessels in the skin. The use of
cupping, moxa, gua sha and seven-star needles is also relevant.
Explanation
• UB 17, Sp 6 and Sp 10 move xue in general.
• Jing-well points activate xue in their own channel when they are bled.
• Bleeding spider naevi and stagnated blood vessels disperse xue stagnation in
the local area.
Herbal formula
• Tao Hong Si Wu Tang (Spreads xue)
• Tao He Cheng Qi Tang (Invigorates and disperses xue stagnation in the lower
jiao)
• Xue Fu Zhu Yu Tang (Invigorates and disperses xue in the upper jiao)
• Shao Fu Zhu Yu Tang (Invigorates and disperses xue and dispels Cold in the
lower jiao)
• Gui Zhi Fu Ling Tang (Invigorates and disperses xue and Phlegm
accumulations in the lower Uterus)
• Shen Tong Zhu Yu Tang (Invigorates qi and xue in the channels and collaterals)
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Relevant advice
As with Phlegm, it is vital that the underlying pattern that has been involved in the
creation of xue stagnation is addressed.
Xue stagnation can prevent the circulation of wei qi in an area where there has
been a physical trauma. It is therefore important that this area is protected from
the environment, so Wind, Cold and Dampness cannot invade the area. It is
typical that joints where there has been an injury or an operation are often sensitive
to changes in the weather.
Physical activity is beneficial because it will circulate qi and xue, but it is also
important not to overburden the area or force a joint to move more than it will. A
joint or a limb should not be forced to move beyond a spot where a sharp pain is
experienced. Doing so may cause further xue stagnation.
Xue stagnation can be caused by the following patterns of imbalance

• Qi stagnation
• Phlegm
• Xue xu
• Qi xu
• Cold
• Heat
Xue stagnation can result in the following patterns of imbalance

• Qi stagnation
• Heat
• Phlegm
• Xue xu
Xue Heat
Xue Heat can arise when exogenous xie qi invades the body and penetrates into the
interior or it can be internally generated. Like xue stagnation, xue Heat will manifest
with symptoms and signs that indicate that xue has lost its physiological properties
and now has a pathological influence on the body.
One of the main negative effects that Heat in general has is that it agitates
xue. This can cause xue to become frenetic and rupture the walls of the vessels,
resulting in bleeding. Bleeding anywhere in the body can be due to xue Heat, but
it is especially prominent in heavy and prolonged menstrual bleeding or bleeding
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mid-cycle. The menstrual blood will be bright red in colour, sticky and usually with
fresh, shiny clots, because it is Heat that is causing xue to stagnate.
Xue normally anchors and nourishes shen. If there is xue Heat, shen becomes
agitated. This will manifest as mental restlessness, irascibility and insomnia. If xue
Heat is more extreme, there can be manic behaviour, delirium or even coma.
Many skin disorders are a direct result of xue Heat, or xue Heat is a major
contributing factor. This is because xue should nourish and moisten the skin. If
there is xue Heat, xue will no longer be able to perform these functions and it will
instead negatively affect the skin. This can be seen in skin disorders, where the skin
is dry, red and swollen and feels hot to the touch. The Heat can generate Wind. This
will cause the skin to be itchy.
Xue Heat, in common with other forms of shi Heat, can manifest with a sensation
of heat in the body, fever or an aversion to heat. When there are invasions of xie qi
that have penetrated into the interior, the sensation of heat or fever will be worst at
night, because the yin aspect of the body is injured.
Xue Heat will also cause a person to be thirsty, because the Heat injures and
desiccates the fluids in the body.
The tongue will be red and the pulse will be Rapid.
Aetiology
Xue Heat can arise when an invasion of exogenous Heat penetrates from the exterior
aspect of the body down to the ying or xue level in the Four Levels. There can also
be a residue from previous invasions of xie qi that have not been expelled from
the body or from vaccinations. These residues or residual xie qi can generate Heat
in the xue. The Liver is a reservoir for xue. If the Liver is Hot, it will cause xue to
become Hot. This means that factors such as consumption of food and beverages
that are energetically hot, particularly alcohol, and emotional imbalances can be
contributing factors.
Symptoms and signs

• Skin disorders where the skin is red, hot, dry, swollen or itchy
• Bleeding
• Short menstrual cycle
• Prolonged menstrual bleeding or mid-cycle bleeding
• Heavy menstrual bleeding
• Menstrual blood that is bright red, sticky and possibly clotted
• Mental restlessness
• Mania or delirium
• Coma
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• Insomnia
• Fever, which may be worse at night
• Thirst
• Red facial colour
• Red tongue
• Rapid pulse
Key symptoms
Red complexion, bleeding, bright red menstrual blood, mental restlessness,
Rapid pulse.
Treatment principle
Drain xue Heat.
Acupuncture points
Choose from: UB 17, UB 18, UB 40, Du 14, Sp 10, LI 11, Liv 2 and Pe 3.
Needle technique
Draining. Bleed UB 40, Pe 3 and Du 14.
Explanation
• UB 17, UB 18, UB 40, Du 14, Sp 10, LI 11, Liv 2 and Pe 3 all drain xue
Heat.
Herbal formula
• Xi Jiao Di Huang Tang (Drains Heat from the xue level)
• Qing Ying Tang (Clears Heat from the ying level and cools xue)
• Si Sheng Wan (Drains xue Heat and stops bleeding)
• Long Dan Xie Gan Wan (Drains Heat from the Liver and thereby cools xue)
• Xiao Feng San (Drains xue Heat, drains Dampness and expels Wind in skin
disorders)
Xue Heat can be caused by the following patterns of imbalance

• Invasions of exogenous xie qi
• Liver Fire
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• Stomach Fire
• Heart Fire
Xue Heat can result in the following patterns of imbalance

• Liver Fire
• Stomach Fire
• Heart Fire
• Yin xu
• Xue stagnation
• Xue loss
Xue loss
This differentiation includes all forms of abnormal bleeding, whether it is from
the nose, the gastrointestinal system, the urinary system, the respiratory system or
menorrhagia.
There are three main causes of bleeding:
• The walls of vessels are not strong enough to keep xue within the vessels –
Spleen qi xu.
• Xue is agitated and frenetic in its movement, so it ruptures the walls of the
vessels – shi or xu Heat.
• There is a blockage in the vessel, which results in a build-up of pressure in
the vessel, which finally bursts – xue stagnation.
Often, there will actually be a combination of two or more of these factors at the
same time. There will be a difference in the quality, colour and amount of the blood
that is lost depending on the cause.
Bleeding usually leads to xue xu, and if the bleeding is internal, it will create xue
stagnation in the local area.
When there is blood loss, it is important to not only treat the underlying pattern
of imbalance that has led to the bleeding, but also to invigorate xue. This is because
the bleeding will have created a local condition of xue stagnation. Furthermore,
it is important to subsequently nourish xue in order to replenish the xue that has
been lost.
Aetiology
For a detailed aetiology, see the parts on Spleen qi xu, yin xu Heat, shi Heat and xue
stagnation in Sections 6 and 8.
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Symptoms and signs

• Bleeding and blood loss.
When there is qi xu bleeding:
• bleeding and blood loss
• the blood will be paler and more watery
• pale tongue
• Weak pulse.
When there is shi Heat bleeding:
• the blood will be fresh red or bright red and possibly sticky
• heavy blood loss
• red tongue
• Rapid and Full pulse.
When there is xu Heat bleeding:
• the blood will be a fresh red colour
• low volume blood loss
• red tongue without coating
• Rapid and Fine pulse.
When there is xue stagnation bleeding:
• the blood will be dark and probably clotted
• low volume blood loss
• dark purple and swollen sub-lingual veins
• Choppy or Confined pulse.
Key symptom
Blood loss.
Treatment principle
Stop the bleeding.
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Acupuncture points
Choose from: Sp 1, Sp 8, Sp 10, UB 17, Liv 1 and Kid 8, as well as points relevant
to the underlying pattern of imbalance.
Needle technique
Even technique. Moxa should be used on Sp 1 and Liv 1.
Explanation
• Sp 1 and Liv 1 are points that, empirically, can stop bleeding.
• Sp 10 and UB 17 stop bleeding and invigorate xue.
• Sp 8 and Kid 8 stop bleeding from the Uterus.
Herbal formula
• Shi Hui San (Drains Fire and Heat and stops bleeding)
• Si Sheng Wan (Drains xue Heat and stops bleeding)
• Huang Tu Tang (Tonifies Spleen qi and stops bleeding)
Relevant advice
This will depend on the underlying pattern of imbalance – please see the relevant
sections for specific advice. It is important that a person who has suffered from
bleeding makes sure that they eat a diet that nourishes xue, i.e. red meat, chicken,
liver, green leafy vegetables, beetroot, seaweed, dates, nettles, aduki beans, kidney
beans and black beans. They should also eat a diet that tonifies Spleen qi.
Xue loss can be caused by the following patterns of imbalance

• Spleen qi xu
• Yin xu Heat
• Shi Heat
• Xue stagnation
Xue loss can result in the following patterns of imbalance

• Xue xu
• Xue stagnation
• Yin xu
• Jinye xu
• Qi xu
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Jinye imbalances
Jinye imbalances include patterns where jinye is weakened or stagnated, but also
patterns where jinye has transformed into Dampness or Phlegm.
Jinye xu
More than being a pattern in itself, jinye xu is involved in and is a consequence of
other imbalances. Jinye is an aspect of yin. Yin xu and jinye xu are like the chicken
and the egg. They often lead to one another. The lack of body fluids means that the
body dries up and this injures yin. There will be symptoms and signs such as a dry
mouth, dry lips, dry throat, dry skin, dry cough, constipation and scanty urination
due to the lack of moisture.
The tongue will be thin and dry. The pulse will be Fine.
Aetiology
Jinye xu can arise when there has been profuse sweating, acute Heat in the body
(as in a high fever), chronic Heat imbalances, bleeding, xue xu, frequent and heavy
urination, vomiting and diarrhoea, as well as excessive consumption of spicy food or
medicine that has a spicy dynamic.
Symptoms and signs

• Dry mouth
• Dry lips
• Dry skin
• Dry eyes
• Dry throat
• Dry cough
• Dry nose
• Constipation
• Thin and dry tongue
• Fine pulse
Key symptoms
Dry mouth, dry eyes, dry throat, dry mucous membranes, dry tongue.
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Treatment principle
Nourish jinye.
Acupuncture points
Choose from: Lu 7, Kid 6, Sp 6, Ren 4 and Ren 12.
Needle technique
Tonifying.
Explanation
• Lu 7 and Kid 6 open ren mai and yin qiao mai.
• Sp 6, Ren 4 and Ren 12 nourish Stomach and Kidney yin.
Herbal formula
• Mai Men Dong Tang (Moistens Dryness)
Relevant advice
As well as following the appropriate advice that is relevant for the underlying patterns
of imbalance, a person who is jinye xu must also make sure that they consume
adequate fluids, avoid drinks that are diuretic and avoid sweating.
Jinye xu can be caused by the following patterns of imbalance

• Yin xu
• Shi Heat
• Xu Heat
• Xue xu
• Stomach Fire
• Stomach yin xu
Jinye xu can result in the following patterns of imbalance

• Yin xu
• Xue xu
Accumulation of fluids
If there is a disturbance of the Lung, Spleen or Kidney’s functions with respect to
the transformation and, especially, the transportation of fluids, these will stagnate
and accumulate in the body. This will correspond to a condition of oedema in
Western medicine.
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Accumulation of fluids can also occur when there is qi stagnation. This will be
because qi does not move the fluids, which will cause them to stagnate, creating
Dampness and Phlegm, which in themselves can block the movement of fluids.
If the condition is due to a disorder of the Lung, there will most often be oedema
in the face and the upper part of the body. This condition is often acute and will
usually be due to an invasion of exogenous xie qi.
Spleen yang xu can result in oedema accumulating in the middle of the body and
in the limbs.
Kidney yang xu can manifest with oedema that is predominantly in the ankles
and legs. Both Kidney yang xu and Spleen yang xu oedema will be chronic conditions.
One way to distinguish whether the oedema is due to a xu condition of the
Lung, Spleen or Kidneys and oedema that is due to qi stagnation or Damp is by
pressing a finger down into the area where there is oedema. If the oedema has arisen
because of a Kidney, Spleen or Lung xu imbalance, an imprint of the finger will
remain after the pressure is released.
Aetiology
This condition arises when there is a disturbance in the transportation and
transformation of fluids in the body. Acute oedema is usually seen when the
Lung’s function of spreading fluids is disrupted by exogenous xie qi. More chronic
conditions of oedema usually arise from Spleen and/or Kidney yang xu, qi stagnation
or Phlegm-Dampness conditions. For a description of the aetiology of these patterns,
please see the relevant parts of Sections 6 and 8 where these patterns are discussed.
Symptoms and signs

• Oedema
• The tongue will be swollen and wet
• The pulse will be Slippery
Key symptom
Oedema.
Treatment principle
Drain fluids.
Acupuncture points
Choose from: Ren 9, Sp 6, Sp 9 and UB 22.
• If there is invasion of exogenous xie qi in the Lung, add: GB 20, Lu 7, LI 4
or LI 6.
• If there is Spleen yang xu, add: Sp 3 and St 36.
• If there is Kidney yang xu, add: Kid 7 and Du 4.
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• If there is qi stagnation add: Liv 3 and LI 4.

• If there is Phlegm and Damp stagnation add: St 40.
Needle technique
Drain Ren 9, Sp 6, Sp 9, Lu 7, LI 4, GB 20 and UB 22. Tonify the remaining points.
Moxa is recommended on Sp 3, St 36, Kid 7 and Du 4.
Explanation
• Ren 9, Sp 6, Sp 9 and UB 22 drain fluids and Dampness.
• GB 20, Lu 7, LI 4 and LI 6 expel exogenous xie qi and regulate the water
passages.
• Sp 3 and St 36 tonify Spleen yang.
• Kid 7 and Du 4 tonify Kidney yang.
• Liv 3 and LI 4 disperse stagnant qi.
• St 40 transforms Phlegm.
Herbal formula
• Wu Ling San (Drains Dampness and expels Wind-Cold)
• Wu Pi San (Drains Dampness and regulates qi)
• Ji Sheng Shen Qi Wan (Tonifies Kidney yang and drains Dampness)
• Fang Ji Huang Qi Tang (Tonifies Spleen qi, expels Wind and drains Dampness)
Relevant advice
This will depend on the underlying pattern of imbalance. Please see the appropriate
sections for advice.
Accumulation of fluid can be caused by the following patterns of imbalance

• Invasion of xie qi
• Lung qi xu
• Spleen yang xu
• Kidney yang xu
• Qi stagnation
• Dampness
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Accumulation of fluid can result in the following patterns of imbalance

• Spleen yang xu
• Kidney yang xu
• Dampness
• Phlegm
Internally generated Dampness

Internally generated Dampness will often but not always be the result of Spleen
qi xu or Spleen yang xu. It can also result from the excessive consumption of
Damp‑generating substances.
There may be a general condition of Dampness or there may be Dampness in
specific organs. In this section I will only discuss Dampness as a general condition.
For discussions on Damp-Heat, Damp-Cold and Dampness in specific organs,
please see the relevant parts for these in Section 6, ‘Diagnosis According to Xie Qi’.
Aetiology
Internally generated Dampness may be due to the Spleen or Kidneys being too
weak to carry out their functions of transforming and transporting fluids. It can
also be the result of excessive consumption of food, beverages or medicine that have
a Damp dynamic. Furthermore, Dampness can initially have started as an acute
exogenous invasion that has penetrated into the interior and become a chronic
interior imbalance.
Symptoms and signs

• Nausea
• Heaviness in limbs
• Fatigue
• Abdominal bloating
• Loose stools or diarrhoea
• Increased vaginal discharge
• Cloudy urine
• Sticky taste in the mouth
• No thirst
• Slippery pulse
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• The tongue will have a thick and sticky coating
Key symptoms
Poor appetite, fatigue, heaviness in limbs, sticky tongue coating, Slippery pulse.
Treatment principle
Drain and transform Dampness, tonify the Spleen.
Acupuncture points
Choose from: Sp 3, Sp 6, Sp 9, Ren 9, UB 20, UB 21, UB 22, St 36 and Ren 12.
Needle technique
Drain Sp 9 and Ren 9, tonify the other points.
Explanation
• Sp 9 and Ren 9 drain and transform Dampness.
• Sp 3, Sp 6, St 36, Ren 12, UB 20, UB 21 and UB 22 tonify Stomach and
Spleen qi and transform Dampness.
Herbal formula
• Ping Wei San (Tonifies Spleen qi and transforms Dampness)
Relevant advice
When there is Dampness, a person should avoid food and drinks that are cold, both
energetically and in their temperature. They should also avoid consuming anything
that generates Dampness. Food and drinks they must pay particular attention to
avoiding are: dairy products, cold drinks, ice cream, sweets, dried fruit, stevia,
artificial sweeteners, cakes, wheat products, sugar, lettuce, cucumber, tomato, melon,
avocado and tropical fruit. They will benefit from eating foods that are prepared and
warming in their energy. Ginger will be particularly beneficial.
Furthermore, when there is Damp-Heat, they should avoid alcohol, fried food
and hot spices including chilli.
When there is Dampness it is best to avoid living and working in humid
environments. This will also include buildings with fungal damage, such as dry rot.
These can often be an aggravating factor or can even be an obstacle to the therapy.
Internally generated Dampness can be caused by

• Spleen qi xu
• Spleen yang xu
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Internally generated Dampness can result in

• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
• Phlegm
Phlegm
Phlegm is a very comprehensive concept in Chinese medicine. Phlegm is both an
aetiological factor and a pathological condition.
Phlegm can be difficult for novices to diagnose. This is because the symptoms
and signs are often not as tangible as they are in other patterns. Phlegm signs can be
as varied as they are subtle. Phlegm is often involved in, or is directly responsible for,
many complex and chronic conditions. In Chinese medicine there are two relevant
aphorisms: ‘Phlegm is the root of the 100 disorders’ and ‘All the strange symptoms
and diseases are caused by Phlegm’.
The signs and symptoms of Phlegm can be difficult to recognise in the beginning
because they are so subtle and varied. Textbooks that are published in China,
and those that are inspired by these textbooks, tend to describe only a few, gross
Phlegm symptoms and signs, but Phlegm is not usually as obvious as this. Phlegm
is something you have to train yourself to see. It is often difficult to define precisely
why there is a diagnosis of Phlegm; it is usually the sum of many small, subtle signs.
Phlegm is fluids that have congealed, coagulated or thickened. Because these
body fluids have changed their form or structure, they have none of the nourishing
or moisturising qualities that jinye has. They have thus gone from being an aspect of
zheng qi to becoming a form of xie qi.
Phlegm can be substantial, i.e. it can be seen, or insubstantial, i.e. it is not visible
to the naked eye. Substantial Phlegm can be observed as sputum and mucus in
the respiratory passages, stool or menstrual blood. Non-substantial Phlegm can
be observed or palpated below the surface of the skin as nodules, ganglion cysts,
deformations of bones and cartilage, uterine fibroids, lumps and other physical
accumulations in the tissues such as gallstones and kidney stones. Non-substantial
Phlegm also manifests as a sensation of heaviness in the body and the head, numbness,
fatigue, mental confusion, depression, dizziness, nausea and chest oppression. The
pulse can be Slippery or Wiry. The tongue can be swollen and have a greasy coating.
Phlegm is a heavy and sticky yin pathogen. It shares characteristics with Dampness,
but Phlegm is stickier and even more disruptive of the body’s qi ji (qi mechanisms),
because both Phlegm and Dampness block the cou li (the space between the body
tissue and between the cells, i.e. the space in which qi moves). This has important
consequences. First, it will result in the blockage of qi, xue and jinye. This means
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that there may be signs of stagnation – of these substances in general and of the
various qi ji around the body. This could be symptoms and signs such as nausea,
loss of appetite and a heaviness in the chest as if there is a large stone on top of the
chest. Phlegm’s blockage of qi in the upper jiao can also result in palpitations and a
shortness of breath. The stagnation of qi can cause the person to feel fatigued and
lack energy. The feeling of fatigue will be worse in the morning, because the lack of
movement of qi during the night will increase the stagnation of Phlegm. They will
often feel very tired in the mornings and can have difficulty waking up. The fatigue
and heaviness can also result in an increased need for sleep. The problem is that
the person will often find that the more they sleep, the more tired and heavy they
feel. This is because Phlegm will stagnate even more whilst they are lying down. As
well as fatigue, they may feel that they are a bit fuzzy and heavy-headed and are not
fully present mentally. This will be especially apparent in the mornings, when they
will often not be fully present and will go around in a bubble. They may also lack
appetite in the morning, and if they have a cough it will be worse in the mornings.
Once they get going and are physically active, the signs and symptoms will improve.
Phlegm can also manifest with areas of skin that are numb, because Phlegm will
block xue and thereby shen, so that it does not circulate in the area. This is also why
Phlegm can result in numbness elsewhere in the body.
As well as stagnation, the body can be characterised by heaviness. This will also
be seen on the mental and emotional level, because Phlegm will block the Heart’s
‘orifices’. This means that shen is restricted in its movement, which is why Phlegm can
often be a contributing factor when a person suffers from depression. When Phlegm
is very pronounced it can be seen in the person’s eyes. There can be a tendency to
have blobs of sleep in the eyes and the eyes can seem glazed. The shen in their eyes
is not bright and lucid. It can be difficult to make clear eye contact. They may look
into space whilst they are talking to you, not because they are shy and have difficulty
looking you directly in the eye, as is the case when there is Heart and Gall Bladder
qi xu, or because their gaze is restless and shifting, as it is when there is Heart Fire
or Phlegm-Fire, rather, it is because their shen is smothered and blocked and they
are in a bubble of their own. Their gaze ‘does not come out of their head’. These
eyes and their vision can be observed when someone has drunk excessive alcohol or
taken narcotics.
They may also have the feeling that they are in a bell jar. It’s a feeling most people
will have experienced when they have had a heavy cold. Because shen is blocked, the
person may seem confused and unclear in their thinking. They may have difficulty
finding words. If the blockage is severe, they will have incoherent speech or think
one thing but say something else. In extreme cases, for example in some mental
illnesses, a person can sit and talk to themselves or to a person who is not there.
A person with a lot of Phlegm will have difficulty concentrating. There is a
difference in how a difficulty in concentrating manifests itself in various imbalance
patterns. When there is Heat, the person will find it hard to concentrate because they
are mentally and physically very restless. New thoughts and ideas will constantly
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arise, which makes it hard for them to remain focused. When there is Heart xue xu
and Spleen qi xu, shen will lack nourishment, resulting in the mind feeling empty.
When they read something, they cannot remember what they have just read. When
there is Phlegm, it is hard to concentrate because the head feels as if it is full of
cotton wool and the thoughts are very blurred. It is difficult to think clearly. Again,
this can be recognised from when you have had a heavy cold or a bad hangover.
Due to its obstructive nature, Phlegm can also be a cause of dizziness. The
difference between dizziness in a xu condition and Phlegm is that when there is
Phlegm there will also be a heavy sensation in the head and possibly even nausea.
Moreover, the dizziness can arise completely at random and it often feels as if the
room is spinning round. The dizziness will often feel worse when the person is lying
down, or lying down will not ameliorate the condition.
Physically, Phlegm can be seen in a person’s skin and the flesh below, which
appears dough-like and lacks tone. This can sometimes be seen in the face. The
complexion will be ‘pasty’ and the skin slightly loose. There may be a lack of lustre
to the skin. The skin and the hair can also be greasy or oily.
There can be a tendency to be slightly overweight or even obese. The person may
be stocky and portly without being muscular.
The fingers of a person with chronic Phlegm may be a little too thick and appear
to be slightly chubby.
There can be increased growth of body hair.
Phlegm, because it blocks the movement of xue, can manifest with a dark, sooty
colour around the eyes.
A person with Phlegm can sometimes have a special odour. The odour is difficult
to describe precisely, but it is easily recognisable when it has been smelt a couple of
times. The smell is heavy and lingers in the air a long time after the person has left
the room. It can sometimes smell a bit like a wet leather jacket.
The saliva in the mouth will be thicker and stickier. The person can have a sticky
taste or sensation in their mouth.
Phlegm can also manifest with a gravelly voice, a slightly nasal quality to the
voice or the need to clear the throat a lot.
The tongue can be swollen or lacking in tone and can have an oily or sticky
coating.
The pulse is usually Wiry or Slippery.
Symptoms and signs that are triggered or provoked by perfume, petrol or
solvents will be due to Phlegm-Dampness. This is because Phlegm has a heavy and
greasy nature. The above substances dissolve and dilute things that are oily and they
will dissolve and dilute Phlegm in the body. This will result in the Phlegm that was
previously stagnant and embedded in the body’s tissues being set in motion and
circulating around the body. Although this dilutes the Phlegm, it still has a disrupting
and obstructive effect. Phlegm-Dampness can also be provoked by scents and odours
that are heavy, such as certain perfumes and flowers such as hyacinths and lilies.
Phlegm-Dampness symptoms are also often provoked by weather fronts, especially
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when there is low pressure, thundery weather and very humid weather. Symptoms
that are exacerbated by consuming Phlegm- or Damp-producing food and drinks
will, of course, also indicate that there is Phlegm.
Looking through the symptoms and signs can give the impression that we and
most of our clients have Phlegm. This is not far from the truth. Both the climate
and diet in northern Europe mean that there can be a tendency to develop Phlegm-
Dampness, but Phlegm is also something that accumulates throughout life and is
often a consequence of most chronic patterns of imbalance. Therefore, the older you
get, the more Phlegm will probably have in your body.
Aetiology
Phlegm often arises when Heat condenses body fluids, when Spleen qi xu creates
Dampness, when there is stagnation of qi or xue that stagnates the body’s fluids or
when there is lack of yang to transport and transform fluids. Phlegm can also be
created by the diet that a person consumes. This could be foods that weaken the
Spleen, create Dampness or Heat or have a Phlegm-producing dynamic.
Symptoms and signs

• Fatigue that is worse in the morning
• Difficulty getting going and being mentally absent in the morning
• Increased need for sleep
• Lack of appetite, especially in the morning
• Heaviness in the chest
• Cough in the morning, the sputum can be loose or sticky, depending on
whether there is Heat present
• Dizziness
• Heaviness in the head
• Blurred vision and dull eyes
• Sleep in the eyes
• Dark, sooty colour around the eyes
• Depression, melancholy
• Mental confusion and difficulty thinking, especially in the morning
• Incoherent speech or talking to themselves
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• Skin and flesh tissue can lack tone and be ‘doughy’
• The skin lacks lustre
• The fingers can be thick and chubby
• Increased growth of body hair
• Tendency to obesity and plumpness
• Symptoms and signs that are triggered or provoked by weather changes and
perfume, petrol or solvents
• Symptoms that are provoked by consuming Phlegm-producing foods and
drinks
• Numbness
• Greasy or oily skin and hair
• Sticky taste or sensation in the mouth
• Thick saliva or saliva in the mouth
• Mucus in the menstrual blood
• Fibroids and nodules
• Fat nodules under the skin
• Deformed joints
• Heavy, sticky odour
• Repeated need to clear the throat
• Gravelly voice
• Nasal voice
• Swollen tongue, tongue that is limp or has a flabby tone, sticky or greasy
tongue coating
• Slippery or Wiry pulse
Key symptoms
Fatigue and mental absence in the mornings, lack of appetite in the morning, sticky
sensation in the mouth, symptoms and signs that are triggered or provoked by
weather changes, perfume, petrol or solvents.
Treatment principle
Transform and drain Phlegm.
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Acupuncture points
Choose from: St 40, St 36, Ren 12, Sp 3, Sp 6, Sp 9, UB 20 and UB 21.
Needle technique
Drain St 40 and Sp 9. Tonify the rest of the points.
Explanation
• St 40 drains Phlegm.
• Sp 9 drains Dampness.
• Sp 3, Sp 6, St 36, Ren 12, UB 20 and UB 21 tonify Spleen qi and transform
Phlegm.
Herbal formula
• Er Chen Tang (Drains and transforms Phlegm)
• Wen Dan Tang (Drains and transforms Phlegm-Heat)
• Di Tan Tang (Transforms and clears Phlegm misting the orifices)
Relevant advice
The relevant advice will depend on which individual patterns have been involved
in the creation of Phlegm. Nevertheless, there are some general guidelines that
are relevant for all individuals who present with Phlegm imbalances. Diet is very
important, and they should avoid foods and beverages that produce Dampness and
Phlegm, including dairy products, bananas, sugar, things that taste sweet such as
dried fruits, honey, stevia and so on, wheat products, fried food and alcohol. Nuts
are interesting in this context, because eating too many nuts creates Phlegm, but
eating a small, limited amount of almonds or walnuts can transform Phlegm in the
Lung. In general, a person with Phlegm will benefit from eating foods that have a
slightly spicy flavour, such as watercress, radishes, turnips, daikon, garlic, pepper,
herbs, etc.
It is also important that they do not eat too much at a time and do not eat too
late in the evening.
Phlegm can be caused by the following patterns of imbalance

• Spleen qi xu
• Lung qi xu
• Dampness
• Yang xu
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• Yin xu
• Heat
• Cold
• Qi stagnation
• Xue stagnation
• Food stagnation
Phlegm can result in the following patterns of imbalance

• Heat
• Qi stagnation
• Xue stagnation
• Spleen qi xu
• Lung qi xu
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Section 8
ZANGFU ORGAN PATTERNS
In this diagnostic model, patterns are differentiated in relation to changes in the

functioning of the zangfu organs. What has elicited these changes can both be
external influences, such as climate, diet, emotions and lifestyle, as well as internally
generated imbalances, such as Heat, Dampness, yang xu, etc., that are affecting the
functioning of the organ. When a zangfu organ is negatively affected it will manifest
symptoms and signs that relate to a disturbance of its physiology, as well as signs
and symptoms that relate to the tissues, sense organs, emotions, vital substances, etc.
that are influenced by this organ. The diagnosis will be based both on changes in the
organ’s physiological processes and changes that are manifesting on the exterior of
the body, such as changes in the skin colour, sound of the voice, pulse, tongue, etc.
Zangfu diagnoses are often central to most TCM diagnoses.
Lung imbalances
The Lung has several functions, the most important being that it controls qi and
respiration. Along with the Kidneys and Spleen, the Lung is responsible for the
production of qi in the body. Zong qi, which is created by the Lung, is the foundation
for zhen qi. This means that all the organs are dependent on the Lung as well as the
Kidneys and the Spleen. If the Lung qi is weak, it will affect all other organs of
the body.
The Lung is the only zang organ that is in direct contact with the world outside
of the body. The Lung is in contact with the environment through the upper
respiratory tract and through its related tissue, namely the skin. Wei qi, which is
spread by the Lung, circulates under the skin and is the first aspect of qi that is affected
when there are invasions of exogenous xie qi. This makes the Lung vulnerable to
exogenous influences. It is for this reason that the Lung is called the ‘sensitive’ or the
‘delicate’ organ.
The aetiology of Lung imbalances

As described above, the Lung is in direct contact with the environment through the
respiratory tract, the skin and wei qi. This means that exogenous xie qi can be a very
important aetiological factor in Lung imbalances. Wind is the spearhead that can
pierce through wei qi and lead other forms of exogenous xie qi into the body. Xie qi
will initially be combated by, but will also block, wei qi. Because it is the Lung that
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spreads wei qi, the blockage of wei qi will have a stagnating effect on the Lung qi.
If xie qi is not expelled, it can penetrate deeper and affect the Lung more directly.
Wind, Cold, Damp and Heat are the forms of exogenous xie qi that we most often
meet in the clinic in North-Western Europe. It is important to remember that the Lung
is also very vulnerable to Dryness, because it is a zang organ that is in direct contact
with the air. If the air is dry, it can desiccate the Lung and injure Lung yin. Although
this has not traditionally been a problem in a maritime climate, it is something that
has become more relevant over the years due to the interior environment of modern
buildings, especially buildings made of concrete. Furthermore, it may be a problem in
very cold regions where the air can be very dry in the winter.
Damp and Phlegm in the Lung can arise when exogenous xie qi condenses and
congeals jinye in the Lung so that it transforms into Phlegm. Chronic Phlegm in the
Lung, though, is often the result of an imbalance in the Spleen. There is a Chinese
medicine saying: ‘Phlegm accumulates in the Lung, but is created in the Spleen.’
This is because the Spleen sends gu qi up to the upper jiao, where the Lung creates
zong qi. If there is Spleen qi xu or if Cold or Damp- and Phlegm-creating foods are
excessively consumed, the Damp and Phlegm that are generated will ascend together
with the pure qi up to the Lung from the middle jiao. This has great importance in
relation to the treatment strategy when treating Lung Phlegm imbalances.
Food and drinks that create Heat in an organ can also affect the Lung, due to
its physical position in the body. The Lung is a ‘canopy’ that arches across the other
organs in the top of the body. If these organs are affected by Heat or if there is Heat
generated by one of these organs, the Heat can rise up to the Lung, due to the yang
nature of Heat.
The spicy flavour is very dynamic and moves from the centre to the periphery.
The spicy flavour is therefore used, amongst other things, to ‘open to the exterior’,
i.e. the spicy flavour can induce a sweat. This is fine when wei qi is blocked by
exogenous xie qi, but if the spicy flavour is excessively consumed it will weaken Lung
qi and Lung yin.
Lack of nourishment, such as eating too little or eating food that is of poor
quality, can lead to a generalised qi xu condition and thereby also Lung qi xu.
The Lung inhales air from the environment. This air is known as ‘da qi’ or
‘great qi’ in English. This means that the quality of the air that is inhaled is of great
importance for the Lung, as Lung qi is dependent on whether the air is fresh and
pure. This is the reason that people get tired and sleepy in rooms where the air is
heavy. Air pollution can also create imbalances in the Lung. This can be seen in
allergic reactions, as well as in chronic ailments. Although air pollution does not fall
within the traditional Chinese categories of exogenous xie qi, it can still be defined
in relation to these imbalance categories by analysing how it affects the body. If an
allergen or a pollutant creates symptoms and signs, such as those seen in Wind-Heat
for example, this allergen or pollutant will be defined as having a Warm nature and
will be treated accordingly. In this context, it is appropriate to mention tobacco
smoke. This is a form of pollution that many patients will have been exposed to,
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Diagnosis According to Zangfu Organ Patterns
both voluntarily and involuntarily. Tobacco smoke is warming and drying in its
energy. This means that it is likely to injure Lung yin, create Heat in the Lung
and boil fluids in the Lung so that they congeal into Phlegm. Furthermore, the
combination of Heat and Phlegm can lead to the creation of xue stagnation and
Toxic-Fire in the Lung. Xue stagnation, Toxic-Fire and Phlegm in the Lung, are three
of the most important precursors to Lung cancer.
The Lung descends and spreads qi and jinye throughout the body. When there is
an inhalation, the chest opens and qi is sent downwards and outwards. Poor posture
can impede this function. If a person sits or stands in a stooped way with a sunken
chest, this will burden the Lung, because it has to use more force to spread qi out
from the chest.
The Lung is emotionally affected by sorrow, melancholy and worry. These
emotions encompass many other and more nuanced emotions, but common to
many of these is that they debilitate and bind Lung qi. Therefore, emotions such as
a powerful, prolonged or unprocessed grief, worry or speculation can weaken Lung
qi and stagnate qi in the chest.
The Lung cooperates closely with several of the other zang organs, as well as its
partner organ, the Large Intestine. There are, therefore, often combined patterns
when there is a chronic Lung imbalance. The Lung and Liver are both involved in
spreading qi and thereby also xue through the body. Disturbances of these organs’ qi
can therefore affect one and the other. Furthermore, Liver Fire can invade the Lung.
The Heart and the Lung have a very close relationship, in terms of their physical
location, and especially in relation to zong qi and moving xue through the channels
and vessels. The Kidneys, Urinary Bladder and Lung cooperate in relation to fluid
physiology, and Lung yin is nourished and moistened by Kidney yin. Furthermore,
Lung qi is grasped by Kidney yang. The Spleen, Stomach and Lung are closely
involved in the transformation and transportation of qi and jinye. Finally, the Lung
and the Large Intestine’s relationship is seen not only in that Lung qi xu can lead to
constipation, but also in that constipation can disrupt the Lung’s sinking function,
leading to difficulty in breathing.
Lung imbalance pattern’s pathology

If exogenous xie qi invades the body, wei qi is the first aspect or level to be attacked.
Wei qi is controlled and spread by the Lung. This means that when wei qi is disturbed
in its activity and movement, Lung qi is also disturbed. This can lead to the Lung
not descending and spreading qi as it should. Lung qi will then accumulate and
eventually become rebellious and ascend upwards. This rebellious Lung qi can
manifest as coughing and sneezing. The Lung also spreads jinye throughout the
body. When Lung qi is impaired it can no longer spread these fluids, which will then
accumulate in the Lung and form thin Phlegm. When Lung qi becomes rebellious,
this will force the thin Phlegm up to the nose, resulting in an exudation of thin,
clear, watery mucus as a consequence. The stagnated fluids and thin Phlegm will also
be driven up to the face by the rebellious Lung qi and can give a slight puffiness to
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the face. This puffiness is often apparent in the area around the eyes. The disturbance
of the Lung’s ability to transform and spread fluids can be so extreme that as well
as there being oedema and thin, watery sputum in the Lung, there can be problems
with urination because the Lung is not sending fluids down to the Urinary Bladder.
If Heat is present in the Lung because Wind-Heat has invaded the Lung,
exogenous xie qi has penetrated down to the qi level or Heat has been transmitted
to the Lung from another organ, the fluids in the Lung can be condensed by the
Heat. This will result in the fluids becoming thicker and sticky. If the Heat is mild,
the Phlegm will be viscous and white. If the Heat is more intense, the Phlegm will
be yellowish or greenish. The Heat can be so intense that it causes vessels in the Lung
to rupture. If this is the case, there will be blood in the sputum. Shi Heat will also
cause the upward movement of the rebellious qi to be more powerful. This will mean
that the cough will be louder and barking. Heat can ascend to the nose, throat and
eyes and cause these to become red and irritated.
When there are invasions of exogenous xie qi, wei qi will be blocked, as described
above. When qi stagnates, pain arises. In this situation there will be aches and stiffness
in the muscles and joints. Because wei qi circulates in the taiyang aspect and because
Wind tends to invade the upper parts of the body, the soreness and stiffness will be
most pronounced in the neck and shoulders where the taiyang channels traverse.
The blockage of qi in the taiyang channels can also result in there being a headache.
As well as protecting the body against invasions of exogenous xie qi, wei qi warms
the skin. If wei qi is blocked, especially by exogenous Cold, wei qi will not be able
to warm the skin, even though there is sufficient heat in the body itself. This will
manifest with the characteristic symptom of a person freezing and not being able to
get warm, even though they pack themselves into clothes and under blankets. This
is in contrast to yang qi xu where the person cannot generate enough warmth in the
body and is very sensitive to the cold, but if they put on sufficient warm clothing
they will not feel cold. The inability to warm the skin when there are invasions of
exogenous xie qi will manifest with a pronounced aversion to Cold. This is most
marked when there is Wind-Cold and less so when there are invasions of Wind-
Heat. When wei qi is weak, as is typically the case when a person is Lung qi xu, the
person will be vulnerable to invasions of exogenous xie qi and Wind. This will mean
that they have an aversion to drafts in particular and to cold in general. They will
also suffer from frequent colds and other respiratory disorders.
The Lung controls the pores in the skin via its relationship to wei qi. When wei
qi is blocked by exogenous Cold, it will not be able to open the pores. It is actually
through the pores that wei qi should expel the exogenous xie qi. This means that one
of the key symptoms of an invasion of Wind-Cold is that the person does not sweat.
Conversely, if there is Lung qi xu and wei qi is thereby weak, the pores in the skin
will not be controlled and the person will sweat spontaneously or on light exertion.
Invasions of exogenous xie qi take place in the exterior aspect of the body. This
is reflected in the pulse, which will be Superficial. As an invasion of exogenous xie
qi is an acute condition, there will not normally be major changes in the tongue
presentation.
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The Lung is very sensitive to Dryness. This can be exogenous Dryness or Dryness
that arises when there is yin xu. Dryness arises when there is yin xu because jinye is an
aspect of yin. If the Lung become desiccated, its qi mechanism will become disrupted
and Lung qi will become rebellious. This will manifest with a dry, ticklish cough,
with no sputum or only small amounts of thick, rubbery sputum that is difficult
to expectorate. When there are yin xu conditions, the cough will also be weak, due to
the lack of qi. In these situations, the cough will be worse in the evening and at night
or when the person speaks. Dryness will also be seen in the fact that the skin can be
dry. The voice will often be hoarse and the throat will feel dry.
Shi Heat coughs are explosive and loud. This is because there is an accumulation
of xie qi in the Lung and because Heat has an ascending nature. This means that
there is a more powerful and more dynamic, ascending movement of rebellious qi
in the Lung. At the same time, Heat condenses jinye in the Lung so it turns into
Phlegm. This will manifest as sputum that is usually sticky, yellow or green, but it
can also be white, thick and viscous. The cough will usually be worse in the morning
because Phlegm will have accumulated and stagnated in the Lung during the night.
The Phlegm will often be difficult to expectorate because the sputum is so thick and
sticky, even though it is copious. A smoker’s cough is a typical example of this type
of cough.
Both xu and shi Heat can agitate xue so much that the vessels in the Lung rupture,
which produces bloody sputum.
Damp-Phlegm or Phlegm-Cold will also disrupt the qi mechanism in the Lung
and result in a cough. The sputum here will be thinner and more fluid. This type of
sputum will be easy to expectorate.
If the Lung is blocked by Phlegm-Fluids, which is a very watery form of Phlegm,
there will be very thin, watery sputum that is easily expectorated. There will also be
wheezing. The sputum will be so thin that the person will find it difficult to lie flat
on their back, as they will quickly feel suffocated. They will also vomit thin, frothy
mucus when they cough.
If the Lung is too weak to send qi downwards, qi will eventually become rebellious
and rise upwards. This will manifest with a weak cough, because the deficiency of qi
will mean that there is not much force behind it.
The Lung descends and spreads qi. If this qi mechanism is disrupted, the person
will be breathless or they will have superficial, shallow respiration. They can also
have a stuffy, distended or oppressed sensation in the chest. There will, however,
be differences in how and when these symptoms are experienced, depending upon
whether it is a xu or shi condition. When there are xu conditions, the Lung will lack
the strength to be able to descend and spread qi. This will mean that the person
quickly becomes breathless, even on light exertion. When there is Lung qi or Phlegm
stagnation, they will also be breathless, but it will feel as if there is something that
is blocking their breathing. When qi stagnates in the chest, it can be hard to inhale
fully and it will feel as if there is a strap or an elastic band around the chest, making
it difficult for them to inhale deeply. When there is Phlegm stagnation, it will feel as
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if there is a heavy weight, like a rock, that is lying on top of their chest. They will,
therefore, find it difficult to inhale deeply and get enough air into the chest.
The voice is created by zong qi and is thereby affected by the state of the Lung.
If there is Lung qi xu, the person’s voice will be weak. They will often be disinclined
to talk. This is not the same as when there is Heart qi xu. When there is Heart qi
xu, their taciturnity is due to shyness, rather than talking requiring an effort. Lung
yin xu can cause the voice to be low or weak. The voice will also sound dry or hoarse
when there is Lung yin xu. When there is Phlegm-Heat, the voice can be loud but
also gravelly or hoarse.
Because the Lung is fundamentally involved in the production of qi, a key
symptom of Lung qi xu is fatigue. There can also be a pale face because the weakness
of qi will result in less xue circulating in the skin of the face. When there are Cold
conditions, the face will be a brighter white that is almost shiny rather than just
lacking colour as it does when there is Lung qi xu. When there are Heat conditions,
the face can be red either only on the cheekbones, as is seen when there is Lung yin
xu, or the entire face can be red or ruddy when there are shi Heat conditions. Heat
will also make the person thirsty because it consumes and injures fluids.
There is a close relationship between the Lung and its partner organ, the Large
Intestine. This is seen in the process of defecation. The Large Intestine is dependent
on the Lung sending qi downwards to expel the stool out of the body. If there is Lung
qi xu, the person will have difficulty defecating. They will feel exhausted and they
will often sweat afterwards. They will often feel that the defecation was incomplete.
The Lung resonates with the emotions of sorrow and melancholy. These emotions
will affect the Lung qi. At the same time, if the Lung is qi xu, the person can also
experience an underlying or pervasive sense of sorrow and melancholy.
General symptoms and signs of a Lung imbalance

• Cough
• Runny or blocked nose
• Sweating disturbances
• Fatigue
• Chest oppression
Shi patterns
Invasion of Wind-Cold in the Lung
An invasion of Wind-Cold is an acute pattern that does not usually last for extended
periods of time, the Wind-Cold either being quickly expelled from the body or
transforming into Heat and penetrating deeper into the body. It is nevertheless
important to diagnose and treat this condition correctly.
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Furthermore, it is important to remember that it is the symptoms that define

a pattern of imbalance. If a person manifests with symptoms of Wind-Cold, then
there is Wind-Cold. This is relevant, for example, in the diagnosis of hay fever and
other allergic reactions.
Aetiology
There will be a powerful xie qi that has been potent enough to pierce the body’s wei
qi. The invasion can arise if the person has been exposed to climatic Wind or Cold,
but it can also arise after exposure to artificial air-conditioning. Furthermore, some
allergens and pollutants can also provoke a Wind-Cold pattern of imbalance.
There may be an underlying wei qi xu, which means that xie qi does not require
the same strength to be able to penetrate the body’s defences.
Symptoms and signs

• Acute headache
• Stiffness in the neck and upper back
• Joint pain
• Skin and muscle aches
• Aversion to cold and wind
• Lack of sweating in a shi condition and perspiration that does not relieve the
symptoms when there is wei qi xu
• Possibly a slight fever
• Coughing
• Sneezing
• Slight breathlessness
• Itchy throat
• The person will pack themselves into warm clothing
• Stooped posture
• Thin, white, moist coating on the tongue
• Superficial and Tight pulse
Key symptoms
Sore, aching muscles and joints, aversion to cold, Superficial and Tight pulse.
Treatment principle
Open to the exterior, expel Wind and Cold, activate wei qi.
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Acupuncture points
Choose from: Lu 7, LI 4, GB 20, UB 10, UB 12, UB 62 and SI 3.
Needle technique
Draining. Vacuum cups on UB 12 or gua sha on the upper back is recommended.
Explanation
• Lu 7 and LI 4 regulate the Lung’s function of descending and spreading,
activate wei qi and expel Wind and Cold.
• GB 20, UB 10 and UB 12 expel Wind and activate wei qi.
• SI 3 and UB 62 expel exogenous xie qi from the taiyang aspect.
Herbal formula
• Chuan Xiong Cha Tiao Tang (Expels Wind-Cold and relieves headache)
• Gui Zhi Tang (Expels Wind-Cold and harmonises wei and ying qi)
Relevant advice
When there are invasions of Wind-Cold, it is advisable to consume beverages that
are hot and spicy to open the exterior and expel xie qi. This could be, for example,
ginger, garlic, whisky, brandy or chilli. Fasting is also advisable or only eating soup,
such as onion soup. There are two reasons for this. First, when temporarily fasting qi
will not be used to transform food and therefore can be used to combat the invading
xie qi. Second, some sources say that the downward movement of food and qi in the
Stomach can draw the exogenous xie qi inwards from the surface.
Invasion of Wind-Cold can be caused by the following pattern of imbalance

• Lung qi xu
Invasion of Wind-Cold can result in the following patterns of imbalance

• Wind-Heat
• Phlegm-Heat in the Lung
• Phlegm-Fluid in the Lung
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• Lung Heat
• Yangming Heat
• Shaoyang disorders
Invasion of Wind-Heat
Like an invasion of Wind-Cold, an invasion of Wind-Heat is usually an acute
pattern. Whilst an invasion of Wind-Cold will often, but certainly not always, arise
from climatic influences such as Cold or drafts, an invasion of Wind-Heat can be
caused by exposure to climatic influences and also by infectious pathogens, such
as bacteria and viruses. Where Wind-Cold invades the body via wei qi in the skin,
Wind-Heat can also invade the body via the mucous membranes in the nose and
mouth. Again, allergens and other influences from the outside of the body can give
rise to a Wind-Heat reaction and, as described earlier, it is the symptoms and signs
that define the pattern.
Aetiology
Exposure to climatic factors or to bacteria, viruses, allergens and so on that have a
Wind-Heat dynamic. There may be an underlying Lung qi xu, which makes it easier
for exogenous xie qi to invade the body.
Symptoms and signs

• Cough
• Sore throat, the throat is red and there are possibly swollen tonsils
• Blocked nose or sinuses
• Sticky, yellowish mucus
• Headache
• Sweats easily
• Fever21
• Thirst
• Aversion to cold (not as pronounced as it is when there is Wind-Cold)
• The nose or the area around the nose may be red
• The forehead may feel warm when palpated
• The eyes may be red or irritated
• The tongue can be slightly red on the front third and have a thin yellow
coating
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• Rapid, Superficial pulse especially in the right cun position
Key symptoms
Fever, aversion to cold, Rapid and Superficial pulse.
Treatment principle
Expel Wind-Heat, activate wei qi, regulate Lung qi.
Acupuncture points
Choose from: Lu 7, LI 4, SJ 5, LI 11, UB 12, Du 14 and GB 20.
Needle technique
Draining. Vacuum cups can be used on UB 12 or gua sha on the upper back.
Explanation
• Lu 7 and LI 4 regulate the Lung’s function of descending and spreading.
They enable wei qi and expel Wind and Heat.
• GB 20, SJ 5 and UB 12 expel Wind and activate wei qi.
• LI 11 and Du 14 expel Heat.
Herbal formula
Relevant advice
to consume beverages that are cooling and spicy, such as mint, chamomile,
chrysanthemum or elderflower, to open the exterior and expel Wind-Heat. Fasting
is also advisable. Fasting temporarily means that qi will not be used to transform
food and can therefore be used to combat the invading xie qi. Furthermore, some
sources are also of the opinion that the downward movement of food and qi in the
Stomach created by eating food can draw the exogenous xie qi inwards from
the surface.
Invasion of Wind-Heat can be caused by the following pattern of imbalance

• Lung qi xu
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Invasion of Wind-Heat can result in the following patterns of imbalance

• Wind-Heat
• Lung Heat
• Yangming Heat
• Shaoyang disorders
Invasion of Wind-Water
This is also an acute pattern. The difference between this pattern and an Invasion
of Wind-Cold is that exogenous xie qi has blocked wei qi and the Lung’s ability to
spread and transform fluids. This will be apparent in the oedema and the disruption
of urination. The urination will be scanty, because the Lung is not sending impure
fluids down to the Urinary Bladder.
Aetiology
Exposure to climatic influences such as Wind, Cold and Damp.
Symptoms and signs

• Facial oedema
• Puffy eyes
• Aversion to wind, cold and dampness
• Breathlessness
• Cough
• Puffy and shiny face
• Greasy, white tongue coating
• Superficial and Slippery pulse
Key symptoms
Facial oedema, aversion to cold, Superficial and Slippery pulse.
Treatment principle
Expel Wind, Damp and Cold, activate wei qi, open the water passages, regulate
Lung qi.
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Acupuncture points
Choose from: Lu 7, LI 4, LI 6, GB 20, UB 12, UB 62, SI 3, Ren 9 and Sp 9.
Needle technique
Draining.
Explanation
• Lu 7 and LI 4 regulate the descent and spreading function of the Lung. They
activate wei qi and expel Wind, Damp and Cold.
• SI 3 and UB 62 expel exogenous xie qi from the taiyang aspect.
• GB 20 and UB 12 expel Wind and activate wei qi.
• LI 6 and Ren 9 regulate the water passages.
• Sp 9 drains Damp.
Herbal formula
Relevant advice
When there are invasions of Wind-Water it is advisable to fast and consume spicy,
hot (both energetically and in their temperature) beverages to induce a sweat. This
could, for example, be a hot whisky toddy with ginger or a ginger and garlic infusion.
It will be particularly beneficial to use the skin of the ginger in these infusions when
there is acute oedema and urinary blockage due to an invasion of Wind-Cold.
Invasions of Wind-Water can be caused by the

following pattern of imbalance
• Lung qi xu
Invasion of Wind-Water can result in the following patterns of imbalance

• Phlegm-Fluids in the Lung
• Damp and Phlegm
Damp-Phlegm in the Lung

This pattern can occur when the qi mechanism of the Lung is disrupted by repeated
invasions of exogenous xie qi or when the Spleen is not able to separate the pure
from the impure, resulting in Damp and Phlegm arising in the middle jiao, which
are then sent upwards along with the pure gu qi to the Lung. According to Chinese
medicine, ‘Phlegm is created by the Spleen and stored in the Lung.’ This means that
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in chronic conditions when there is Damp-Phlegm in the Lung, the Spleen must
also be tonified at the same time.
The presence of Damp-Phlegm will block the Spleen and Lung’s qi mechanism
and this blockage can then lead to the further formation of Phlegm-Dampness.
Aetiology
Damp-Phlegm in the Lung can arise from invasions of exogenous xie qi that disrupt
Lung qi and block the transformation and spreading of fluids.
As described above, Spleen qi xu and Dampness are often at the root of an
accumulation of Damp-Phlegm in the Lung. The Spleen is particularly burdened
when the diet contains a lot of food that has a Cold or Damp energy or when the
food and liquids consumed are physically cold. The pattern can also arise through
the use of medicines that are energetically Cold.
Posture can be a contributing factor. If the person has a tendency to sit stooped
or slumped, it will block both the Spleen and Lung qi mechanisms. This will lead
to the formation of Damp-Phlegm in the middle jiao and the accumulation of
Damp‑Phlegm in the upper jiao.
Emotional factors such as sorrow or worry can affect the Lung and Spleen and
this may be a contributing factor to this pattern.
Symptoms and signs

• Chronic cough with loose sputum
• Copious amounts of white sputum that is easy to expectorate
• There may be a sensation as if there is a heavy weight or a rock lying on the
chest
• The symptoms are worse in the supine position
• Mucus or sputum in the throat
• The voice may be slightly gravelly or nasal
• Wheezing
• Dull, pale complexion
• The flesh in the face may be slightly doughy
• The flesh in general may be doughy
• Difficulty thinking clearly
• Tiredness and heaviness of the body
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• Nausea or poor appetite

• Swollen tongue with white greasy coating
• Floating and Slippery pulse
Key symptoms
Cough with loose sputum, sputum is clear or white in colour, greasy white tongue
coating.
Treatment principle
Transform and drain Dampness and Phlegm, regulate Lung qi.
Acupuncture points
Choose from: Lu 1, Lu 5, Lu 7, Lu 9, Ren 12, Ren 17, Ren 22, Sp 3, Sp 9, St 36, St
40, UB 13 and UB 20.
Needle technique
Tonifying on Lu 7, Lu 9, Sp 3, St 36, UB 20 and Ren 12. Draining or even technique
on the other points. Moxa is applicable to Sp 3, St 36 and UB 20.
Explanation
• Lu 1, Lu 5, Lu 9, UB 13 and Ren 22 drain Phlegm and regulate Lung qi.
• Lu 7 and Ren 17 regulate Lung qi.
• Ren 12, UB 20, Sp 3 and St 36 tonify Spleen qi and transform Damp and
Phlegm.
• Sp 9 drains Damp.
• St 40 drains Phlegm and opens the chest.
Herbal formula
• San Zi Yang Qin Tang (Descends Lung qi and resolves Phlegm)
• Er Chen Tang (Drains and transforms Damp-Phlegm)
• Ling Gan Wu Wei Jiang Xin Tang (Resolves Phlegm and fluids and tonifies
Spleen yang)
Relevant advice
It is essential that a person with Damp-Phlegm in the Lung avoids consuming Damp-
and Phlegm-creating foods and beverages, especially dairy products, sweets, wheat,
sugar, bananas, avocados, dried fruit and so on. They should also avoid consuming
cold, refrigerated foods, foods that have not been cooked and eating irregularly, as
these will strain the Spleen and can lead to the formation of Dampness and Phlegm.
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Correct body posture and exercise are important in order to avoid stagnation
and blockage of the qi mechanism in the upper and middle jiao.
Repeated invasions of exogenous xie qi can be a contributing factor in the
formation of Dampness and Phlegm in the Lung. This means that the patient must
make sure that they are suitably dressed and do not expose themselves to invasions
of exogenous xie qi.
Beating the chest and the upper back with a loose fist or a wooden spoon will
help to activate qi in the chest and thereby help to resolve stagnations of Phlegm
and Dampness.
Damp-Phlegm in the Lung can be caused by

• Lung qi xu
• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
• Invasions of exogenous xie qi in the Lung
Damp-Phlegm in the Lung can result in the

following patterns of imbalance
• Lung qi xu
• Spleen qi xu
Phlegm-Fluids blocking the Lung

The difference between this pattern and the previous one is that the Phlegm here is
very watery, not thick as in the previous pattern. This pattern often has its root in a
condition of yang xu.
Aetiology
Old age and long-term physical overexertion. The ingestion of Cold and Phlegm-
creating foods can lead to the formation of this pattern. Repeated invasions of Wind,
Cold and Damp can also be contributing factors.
Symptoms and signs

• Cough with thin, watery and frothy sputum
• Wheezing
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• Superficial breathing
• Vomiting of white foamy mucus
• Fuzzy sensation in the head
• Dizziness
• Lack of thirst
• Scanty but pale urine
• The patient feels suffocated if they lie on their back and must sit upright in
bed
• Bright white complexion
• Wet and white tongue coating
• Slippery, Wiry or Soggy pulse
Key symptoms
Cough with watery sputum, cannot lie flat on their back, chest oppression.
Treatment principle
Drain Phlegm-Fluids from the Lung, regulate Lung qi, tonify yang.
Acupuncture points
Choose from: Lu 5, Lu 9, Ren 9, Ren 12, Ren 17, UB 13, UB 23, UB 43, Kid 7,
St 36, St 40, Sp 3 and Sp 9.
Needle technique
Tonifying, moxa is recommended, except on Lu 5, St 40, Sp 9 and Ren 9, which
should be drained.
Explanation
• Lu 9, UB 13 and UB 43 tonify Lung qi and transform Phlegm.
• Lu 5 drains Phlegm from the Lung and regulates Lung qi.
• Ren 9, Sp 9 and St 40 drain Phlegm and fluids.
• Ren 17 regulates Lung qi.
• Ren 12, St 36 and Sp 3 tonify Spleen yang and transform Phlegm and fluids.
• Kid 7 and UB 23 tonify Kidney yang and transform fluids.
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Herbal formula
• Xiao Qing Long Tang (Transforms Phlegm-Fluids in the Lung)
• Su Zi Jiang Qi Tang (Regulates Lung qi, transforms Phlegm and tonifies
Kidney yang)
Relevant advice
The advice that was given for Damp-Phlegm in the Lung is relevant here. The person
should also try to strengthen their yang qi. They can do this by consuming foods that
are warm and avoiding cooling foods and cooling of the body in general.
Phlegm-Fluids blocking the Lung can be caused

by the following patterns of imbalance
• Lung yang xu
• Spleen yang xu
• Kidney yang xu
• Invasions of Wind, Cold and Damp
Phlegm-Fluids blocking the Lung can result in

• Lung yang xu
• Spleen yang xu
• Kidney yang xu
• Kidney yang xu, Water overflowing to the Heart
Phlegm-Heat in the Lung

Phlegm-Heat in the Lung will often have developed from other Lung imbalances.
Damp-Phlegm in the Lung can easily transform into Phlegm-Heat in the Lung,
because either there is already Heat in the Lung or the stagnation that is created by
the Phlegm will generate Heat in the Lung. The difference between this pattern and
Damp-Phlegm in the Lung is that there are Heat symptoms and signs.
The pattern of Lung Heat can also be a precursor of this, because Heat in the
Lung can condense fluids and thereby lead to the formation of Phlegm-Heat.
It is important to note that Phlegm-Heat does not necessarily manifest with
yellow or green sputum. The sputum can be white, thick and sticky. This is due to
the Heat condensing fluids so that they become thick and sticky. When the Phlegm
is yellow or greenish, the Heat will be more intense.
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Aetiology
Phlegm-Heat in the Lung can arise if there is an excessive consumption of foods that
create Phlegm or Heat. Examples of these foods are dairy products, sweets, sugar,
alcohol, wheat, fried food, too much red meat, spicy food and chocolate. Very cold
food and beverages or raw vegetables can be involved indirectly, because they can
weaken Spleen yang and qi thereby leading to the creation of Dampness and Phlegm.
Invasions of exogenous xie qi can create both Phlegm and Heat in the Lung.
Air pollution, especially tobacco smoke, can be an important aetiological factor.
This is seen in many people who smoke tobacco developing a ‘smoker’s cough’,
having difficulty breathing and easily becoming breathless.
Stress can create Heat in the body, and emotions such as anger, irritation and
frustration can generate Heat in the Liver that then rises to the Lung and creates
Heat here.
Symptoms and signs

• Loud and noisy cough with sticky sputum, the cough is worst in the mornings
• Yellow or greenish sputum, the sputum can also sometimes be white, but it
will not be watery or loose, the sputum is thick and sticky
• There may be blood in the sputum
• Sensation of a heavy weight or a stone lying on the chest
• Shallow breathing or wheezing
• Shortness of breath or slight breathlessness
• Gravelly or hoarse voice
• Phlegm in the throat
• Thirst
• Foggy or heavy sensation in the head, especially in the morning
• Red face
• Red lips
• Red tongue with thick, sticky, yellowish coating
• Fast, Slippery and Full pulse, especially in the right guan position
Key symptoms
Loud, productive cough, shortness of breathing, yellow sticky tongue coating.
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Treatment principle
Drain Phlegm and Heat from the Lung, regulate Lung qi.
Acupuncture points
Choose from: Lu 1, Lu 5, Lu 7, Lu 10, LI 11, UB 13, Du 12, Du 14, St 40 and
Ren 17.
Needle technique
Draining.
Explanation
• Lu 1, Lu 5 and UB 13 regulate Lung qi and drain Phlegm and Heat from
the Lung.
• Lu 10 and Du 12 drain Heat from the Lung and regulate Lung qi.
• LI 11 and Du 14 drain Heat.
• St 40 transforms Phlegm and opens the chest.
Herbal formula
• Qing Qi Hua Tan Tang (Drains Phlegm-Heat from the Lung and regulates
Lung qi)
Relevant advice
A person with Phlegm-Heat in the Lung should avoid consuming food that creates
Heat, Dampness and Phlegm. This includes dairy products, sweets, dried fruits,
sugar, alcohol, fried food, chilli, pepper, garlic, chocolate and lamb.
Smoking should be discouraged and the person should avoid other forms of air
pollution.
Phlegm-Heat in the Lung can be caused by

• Damp-Phlegm in the Lung
• Lung Heat
• Spleen qi xu
Phlegm-Heat in the Lung can result in the following patterns of imbalance

• Spleen qi xu
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• Xue stagnation
• Lung yin xu
Lung Heat
This can be both an acute and a chronic pattern. Acute patterns will be caused by
invasions of exogenous xie qi that have penetrated into the ‘qi level’.
Aetiology
Invasions of exogenous xie qi can directly generate Heat in the Lung. Smoking or
exposure to tobacco smoke can also create Lung Heat.
Ingestion of food and beverages that are Hot can indirectly create Heat in
the Lung.
Symptoms and signs

• Barking cough
• Dry throat
• Painful lungs
• Flaring nostrils
• Rapid and shallow breathing
• Bitter or metallic taste in the mouth
• Intense thirst
• Red face
• Red lips
• Dark and scanty urine
• Constipation
• Restlessness
• Red tongue with yellow coating
• Rapid and Full or Rapid and Superficial pulse, especially in the right cun
position
Key symptoms
Barking cough, thirst, aversion to heat, red tongue and Rapid pulse.
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Treatment principle
Drain Heat from the Lung, regulate Lung qi.
Acupuncture points
Choose from: Lu 1, Lu 5, Lu 7, Lu 10, LI 11, UB 13, Du 12, Du 14 and Ren 17.
Needle technique
Draining. Bleed Du 14.
Explanation
• Lu 1, Lu 5, Lu 10, Du 12 and UB 13 regulate Lung qi and drain Heat from
the Lung.
• LI 11 and Du 14 drain Heat.
Herbal formula
Relevant advice
A person with Heat in the Lung should avoid eating or drinking anything that has
a hot dynamic.
Tobacco smoke is hot and drying so the person should avoid exposure to this.
Lung Heat can be caused by the following patterns of imbalance

• Liver Fire
Lung Heat can result in the following patterns of imbalance

• Lung yin xu
Xu patterns
Lung qi xu
Lung qi xu can arise independently, but will most often be seen together with Spleen
qi xu or Heart qi xu. When there is Lung and Spleen qi xu, there will be a general
condition of qi xu characterised by a poor production of qi, whereas Lung and Heart
qi xu will be a more emotional imbalance with sorrow, grief and a lack of joy as the
dominant symptoms.
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Aetiology
Lung qi xu can be caused by a respiratory illness in childhood.
Poor posture, where the person sits slumped forwards, can inhibit the qi
mechanism of the Lung and thereby weaken Lung qi over time. Furthermore, a lack
of exercise will mean that the qi mechanism in the upper jiao is not supported by
physical movement.
Lung qi can be weakened by repeated invasions of exogenous xie qi or if there
has been an invasion of exogenous xie qi that has not been properly resolved, for
example through the use of antibiotics.
The Lung is emotionally affected by grief, sorrow and melancholy. If the person
has experienced repeated or excessive grief and sorrow, especially if the grief remains
unresolved, it will bind and weaken Lung qi.
Lung qi is weakened by excessive talking or singing. This is because zong qi is
used to create the volume of the voice. This means that teachers, lecturers, actors and
singers can have a tendency to develop Lung qi xu.
Excessive consumption of spicy food can spread and expel Lung qi through the
pores in the skin.
Finally, as described above, Lung qi can be an aspect of other qi xu patterns and
therefore their aetiology can also be involved in the generation of Lung qi xu.
Symptoms and signs

• Fatigue
• Slight cough, possibly with watery sputum
• Weak voice
• Sweating spontaneously or sweating on slight exertion
• Aversion to cold and drafts
• Frequent colds and respiratory infections
• The person may have a slouching posture, the chest can appear sunken and
the shoulders slumped forwards
• Pale or normal-coloured tongue, the front third of the tongue can be
depressed and hollow
• Deep and Weak pulse, especially in the right cun position
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Key symptoms
Fatigue, slight breathlessness, spontaneous sweating, weak voice and a Weak pulse.
Treatment principle
Tonify Lung qi.
Acupuncture points
Choose from: Lu 1, Lu 7, Lu 9, UB 13, St 36, Sp 3, Ren 6 and Ren 17.
Needle technique
Tonifying. Moxa can be used.
Explanation
• Lu 1, Lu 7, Lu 9 and UB 13 tonify Lung qi and regulate Lung qi.
• St 36, Sp 3 and Ren 6 tonify qi in general.
• Ren 17 tonifies zong qi and regulates qi in the upper jiao.
Herbal formula
• Bu Zhong Yi Qi Tang (Tonifies Lung and Spleen qi)
Relevant advice
Because this is a qi xu condition, the advice given for Spleen qi xu and Kidney qi
xu will also apply here, i.e. the person should eat a diet that is nutritious but does
not weaken the Spleen. Food that is white in colour will often have an affinity with
the Lung and can be used to focus qi tonics on the Lung. The person should avoid
consuming food that is very spicy because it will spread and thereby weaken Lung qi.
Foods that particularly strengthen Lung qi are: turnips, daikon, radishes, parsnips,
parsley, onion, garlic, tofu, herring, walnuts, almonds, cauliflower, dates, figs, duck,
tuna, grapes, thyme and ginseng. Ginger tea will also be beneficial.
It is important that a person who is Lung qi xu does not strain their voice,
because it will weaken the Lung qi.
A person with Lung qi xu must ensure that they get enough rest and do not
overexert themselves. However, light exercise and movement will be beneficial
because they will open the chest and support the Lung’s qi mechanism. Going for
walks in fresh air will be salutary because the person will get some light exercise and
the fresh air will nourish the Lung. Yoga and qi gong often utilise breathing exercises
that have a beneficial effect on Lung qi. It is important that a person who is Lung
qi xu is conscious of their posture, because a slouched, slumped posture and sunken
chest will strain Lung qi.
If there is an emotional aspect to the Lung qi xu, the person should try to resolve
these issues.
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Lung qi xu can be caused by the following patterns of imbalance

• Spleen qi xu
• Heart qi xu
• Kidney qi xu
• Stagnation of qi in the upper jiao
Lung qi xu can result in the following patterns of imbalance

• Spleen qi xu
• Heart qi xu
• Kidney qi xu
• Wei qi xu
• Lung yin xu
• Phlegm in the Lung
Lung yang xu
Lung yang xu is seen when the Lung lacks the necessary activating heat to perform
its activities and functions. It is a pattern that is not commonly described or listed in
many textbooks, its symptoms and signs being attributed to the combined pattern
of Lung qi xu and Kidney yang xu. Treating these two patterns simultaneously will
also provide excellent results.
Aetiology
Lung yang xu will arise from the same aetiological factors that cause Lung qi xu.
Factors such as repeated invasions of exogenous Cold, overexertion and consuming
cooling foods will often be involved.
Symptoms and signs

• Fatigue
• Breathlessness
• Oedema in the face, arms and hands
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• Frequent urination with copious amounts of pale urine

• Cold limbs
• The person is sensitive to Cold and has an aversion to draughts
• The person wears warmer clothes than is normal for the season or room
temperature
• Weak voice
• Sunken chest or slumped posture
• Pale lips
• Frequent colds and respiratory infections
• Pale or normal coloured tongue with a wet coating, the front third of the
tongue may be hollow
• Deep and Weak pulse, especially in the right cun position
Key symptoms
Aversion to cold, fatigue, breathlessness, spontaneous sweating and a pale and wet
tongue.
Treatment principle
Tonify and warm Lung yang.
Acupuncture points
Choose from: Lu 1, Lu 9, UB 13, Du 4, Du 12, Ren 6, Ren 17, Kid 3 and Kid 7.
Needle technique
Tonifying. Moxa is recommended on Lu 9, Du 4, Du 12 and Kid 3.
Explanation
• Lu 1, Lu 9, Du 12 and UB 13 tonify Lung qi and Lung yang.
• Kid 3, Du 4 and Ren 6 tonify yang in general.
• Ren 17 tonifies zong qi.
• Kid 7 tonifies Kidney yang, thereby helping to transform and transport
fluids in the body.
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Herbal formula
• Gan Jiang Ling Zhu Tang (Warms and tonifies Spleen and Lung yang)
• Li Zhong Tang (Warms yang in the middle jiao, but three of the four herbs
also directly tonify the Lung)
• Su Zi Jiang Qi Tang (Regulates Lung qi and tonifies Kidney yang)
Relevant advice
In addition to the advice that is relevant for Lung qi xu, it is important that the
person keeps warm, avoids consuming cold foods and drinks (both physically and
energetically cold) and does not overexert themselves physically. They will benefit
from getting enough rest and drinking ginger tea.
Lung yang xu can be caused by the following patterns of imbalance

• Kidney yang xu
• Lung qi xu
Lung yang xu can result in the following patterns of imbalance

• Kidney yang xu
• Phlegm-Cold in the Lung
• Damp-Phlegm in the Lung
• Phlegm-Fluids in the Lung
Lung yin xu
Unlike most yin xu patterns of imbalance, Lung yin xu can be both a chronic and
a more acute and temporary condition. This is because the Lung is a ‘delicate’ zang
organ and its yin aspect can be easily injured by Dryness and Heat, for example when
there is a shi Heat condition in the Lung, such as an invasion of exogenous xie Heat.
Aetiology
Lung yin can be injured by exogenous xie qi, for example Dryness and Heat.
Exogenous Dryness can invade the Lung when a person lives or works in a building
with a dry interior climate, such as buildings made of concrete. Lung yin will also
be injured by a condition of shi Heat in the Lung. Tobacco smoke is both Hot and
Dry. This means that smoking can be an aetiological factor in chronic Lung yin
xu patterns.
Prolonged use of the voice can strain Lung yin, which can be a problem for
teachers and singers.
Lung yin will eventually be adversely affected by the same emotions that are
involved in the generation of Lung qi xu, i.e. sorrow and melancholy.
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Old age will weaken Kidney yin and can therefore be a factor.
Symptoms and signs

• Dry, ticklish cough that is worse at night or on exertion
• Sticky or rubbery sputum in the Lung that is difficult to expectorate, there
can even be blood in the sputum
• Insomnia
• Dry mouth, nose and throat
• Weak or hoarse voice
• Dry skin
• Fatigue
• Thin body, with a thin or sunken chest
• Thin, dry tongue with a lack of coating on the front third
• Superficial and Fine pulse, especially in the right cun position
If there is Lung yin xu Heat, there may also be:
• malar flush
• hot sensation in the palms of the hands, soles of the feet and chest
• night sweats
• slight fever or sensation of heat in the evening and at night
• red, thin and dry tongue
• Rapid, Fine and possibly Superficial pulse.
Key symptoms
Dry, ticklish cough, hoarse voice, dry throat.
Treatment principle
Nourish Lung yin, possibly control xu Heat.
Acupuncture points
Choose from: Lu 7, Lu 9, UB 13, UB 43, Sp 6, Kid 6 and Ren 4.
• If there is xu Heat, add: Lu 10.
Needle technique
Tonifying, except Lu 10, which should be drained.
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Explanation
• Lu 9, UB 13 and UB 43 nourish Lung yin.
• Sp 6 and Ren 4 nourish yin in general.
• Kid 6 combined with Lu 7 opens ren mai and yin qiao mai and thereby
nourishes yin, regulates Lung yin and opens communication between the
Kidneys and the Lung.
• Lu 10 drains xu Heat from the Lung.
Herbal formula
• Sha Shen Mai Men Dong Tang (Nourishes Kidney and Lung yin)
• Bai He Gu Jin Tang (Nourishes Lung yin and drains Phlegm-Heat from the
Lung)
Relevant advice
A person who is Lung yin xu should not smoke and they should avoid others’ smoke.
Living and working in concrete buildings or other buildings or places where there is
a dry climate will injure their Lung yin. Like a person who is Lung qi xu, a person
who is Lung yin xu must be careful not to overuse their voice. In general, they should
avoid straining their body and make sure that they get enough rest and sleep.
Strong and spicy foods promote sweating and expel qi. The excessive consumption
of spicy food should therefore be avoided. This is especially important if there is xu
Heat, as many spices are also Hot. Milk nourishes Lung yin, but caution should be
exercised as it also can create Phlegm in the Lung.
Lung yin xu can be caused by the following patterns of imbalance

• Lung Dryness
• Lung qi xu
• Kidney yin xu
• Stomach yin xu
• Lung Heat
Lung yin xu can result in the following pattern of imbalance

• Kidney yin xu
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Lung Dryness
The Lung is the only zang organ that is in direct contact with the environment
outside of the body. This means that the Lung is very vulnerable to Dryness, because
it will injure the fluids and the yin aspect of the Lung. In many parts of China the
climate in the autumn is very dry. This resonates with autumn being the season
where Lung imbalances can be more common.22
Lung Dryness is a precursor of Lung yin xu, the difference being that in Lung
Dryness there are signs of Dryness without there being decidedly yin xu symptoms.
Aetiology
In North-Western Europe, Lung Dryness is not specifically related to a particular
season; it can be experienced in northern Scandinavia and mountainous areas in
the winter when the air is extremely dry and when it is very cold. Dryness can
be experienced throughout the year in buildings with very dry indoor climates,
especially in concrete buildings with central heating.
Symptoms and signs

• Dry cough, possibly with dry and sticky sputum
• There may be pain in the chest if the cough is bad
• Dry mouth
• Dry throat
• Dry skin
• Thirst
• Hoarseness
• Dry tongue
• The pulse can be Rapid or it may be Fine in the right cun position
Key symptoms
Dry, ticklish cough, hoarseness, dry mouth, dry nose and dry throat.
Treatment principle
Moisten the Lung and nourish Lung yin.
Acupuncture points
Choose from: Lu 7, Lu 9, Ren 4, Ren 12, Kid 6 and St 36.
Needle technique
Tonifying.
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Explanation
• Lu 9 nourishes Lung yin and jinye.
• Ren 4 and Kid 6 nourish yin and jinye.
• Ren 12 and St 36 nourish Stomach yin, which is the root of jinye.
• Lu 7 and Kid 6 open ren mai and yin qiao mai, nourish yin and thereby lead
yin fluids up to the Lung, mouth, throat and respiratory passages.
Herbal formula
• Bai He Gu Jin Tang (Nourishes Lung yin, cools the Lung and resolves dry
Phlegm in the Lung)
Relevant advice
The advice given for patterns of Lung yin xu will also be relevant when there is Lung
Dryness, especially the advice not to stay in places where the air is very dry.
Lung Dryness can be caused by the following patterns of imbalance

• Stomach yin xu
• Lung yin xu
Lung Dryness can result in the following pattern of imbalance

• Lung yin xu
Combined patterns
Lung and Spleen qi xu
The Lung and the Spleen create zong qi and zhen qi together. It is very common to
see a combined pattern of Lung and Spleen qi xu where a deficiency in one of the
organs will be instrumental in the creation of a deficiency in the other due to the
resultant decrease in the production of qi.
Aetiology
As described above, this pattern will usually start with a deficiency of either Lung or
Spleen qi, while the decreased production of qi and the resultant qi deficiency will
lead to a weakening of the other organ. Otherwise, the aetiology is the same as that
seen in Lung qi xu and Spleen qi xu.
Lung qi is weakened by poor posture, repeated or unresolved invasions of
exogenous xie qi and excessive use of the voice.
Spleen qi xu arises from consuming foods and beverages that are cold in nature and
temperature, raw foods and foods and beverages that create Dampness. Eating too
422
much at a time or too quickly will also strain the Spleen. Excessive consumption of
spicy food can weaken Lung qi.
The Lung and Spleen are affected by emotions such as sorrow, melancholy, worry
and pondering.
Prolonged illness and overexertion of the body can weaken both Lung and
Spleen qi, because they then have to work harder to replenish the qi.
Symptoms and signs

• Fatigue
• Loose stools
• Pale face
• Disinclination to speak and the voice lacks strength
• Breathlessness
• Bloating after meals
• Feeling drowsy after meals
• Poor appetite or no appetite in the morning
• Spontaneous sweating or sweating on light activity
• Weakness or fatigue in the limbs
• Craving for sweets
• Aversion to cold and draughts
• The person looks tired and worn out
• Possibly slumped posture
• Excessively worries and speculates about things, difficulty letting go of
thoughts
• Pale, swollen tongue, possibly with teeth marks on the sides or near the
front, the tongue can also be sunken in the front third
• Weak pulse, especially in the right guan and cun positions
Key symptoms
Fatigue, loose stools, breathlessness, pale complexion, pale tongue with teeth marks
and a weak pulse.
Treatment principle
Tonify Lung and Spleen qi.
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Acupuncture points
Choose from: Lu 9, St 36, Sp 3, Sp 6, Ren 12, UB 13, UB 20 and UB 21.
Needle technique
Explanation
• Lu 9 and UB 13 tonify Lung qi.
• St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21 tonify Spleen qi.
Herbal formula
• Bu Zhong Yi Qi Tang (Tonifies Lung and Spleen qi)
Relevant advice
The advice given for both Lung qi xu and Spleen qi xu is relevant here.
The diet should ideally consist of foods that are slightly warming (both in
temperature and energetically) and prepared (boiled, steamed, stir-fried, baked and
so on), and the diet should not be Damp and Phlegm creating.
Fresh air and breathing exercises will strengthen the Lung.
Both the Lung and Spleen will benefit from good posture and gentle exercise,
because they will support their qi mechanisms.
Lung and Spleen qi xu can be caused by the following patterns of imbalance

• Lung qi xu
• Spleen qi xu
Lung and Spleen qi xu can result in the following patterns of imbalance

• Wei qi xu
• Spleen yang xu
• Spleen qi sinking
• Spleen qi not holding xue inside the vessels
• Heart qi xu
• Phlegm-Damp in the Lung
• Food stagnation
• Damp
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• Phlegm
• Xue xu
• Lung qi xu
• Heart qi xu
Lung and Heart qi xu

There is a very close relationship and cooperation between the Lung and the Heart.
They support each other in their functions. Lung qi is used to circulate xue around
the body and in the Heart. Heart xue nourishes the Lung. Furthermore, both the
Lung and Heart are dependent on zong qi. Therefore, a qi xu condition of either zong
qi, Lung qi or Heart qi can result in this pattern.
Aetiology
There are two main aetiological factors in this pattern. One of the main elements
will often be emotional imbalances that affect the Lung and Heart. Grief, sorrow
and melancholy will have a negative impact on both organs. Grief, sorrow and
melancholy bind and stagnate Lung qi and thereby zong qi. The stagnation of zong
qi will have a negative effect on both the Lung and the Heart. The Heart will also
be weakened by the lack of joy that is characteristic for these emotional conditions.
Overexertion generally exhausts qi. When qi xu arises, all organs in the body
can become qi xu. Excessive talking and overusing the voice directly burden zong qi.
People whose work requires them to use their voice a lot, such as singers, actors and
teachers, can have a tendency to develop this pattern.
Symptoms and signs

• Palpitations
• Weak cough
• Insomnia
• Being easily startled
• Tendency to have sorrow and melancholy
• Lack of joy
• Depression
• Poor posture
• Hollow chest
• Fatigue
425
• Low or weak voice

• Fatigue in their voice
• Pale face
• Pale tongue
• Weak pulse in both cun positions
Key symptoms
Weak voice, disinclination to talk, sunken chest, palpitations, Weak cun pulse on
both sides.
Treatment principle
Tonify Lung and Heart qi.
Acupuncture points
Choose from: Ren 17, Lu 7, Lu 9, He 5, He 7, Pe 6, UB 13 and UB 15.
Needle technique
Explanation
• Ren 17 tonifies zong qi.
• Lu 7, Lu 9 and UB 13 tonify Lung qi.
• He 5, He 7, Pe 6 and UB 15 tonify Heart qi and calm shen.
Herbal formula
• Sheng Mai San (Tonifies Lung qi and Heart qi)
• Bu Zhong Yi Qi Tang (Tonifies Lung qi and zong qi)
Relevant advice
Lung and Heart qi xu should be tonified on both the emotional and physical plane.
On the emotional level, it is important that the person tries to address the
emotional issues that may be present. It is also important that the person cultivates
joy in their lives. They can try to spend some time each day doing something that
gives them pleasure or sit and meditate on something that they associate with joy.
Lung qi can be tonified through the use of breathing exercises, and fresh air in
general will be salutary. Tonifying qi will also benefit the patient, which could be
done through the diet, fresh air and by getting enough rest and avoiding overexertion.
426
Light exercise, yoga, tai ji and qi gong will be beneficial, as they will help to
circulate qi in the upper jiao. This is important, as the deficiency of Heart and Lung
qi can also lead to a stagnation of qi in the upper jiao.
Lung and Heart qi xu can be caused by the following patterns of imbalance

• Lung qi xu
• Heart qi xu
• Spleen qi xu
• Kidney qi xu
• Gall bladder qi xu
• Heart qi stagnation
• Xue xu
• Damp-Phlegm
Lung and Heart qi xu can result in the following patterns of imbalance

• Heart yang xu
• Lung qi xu
• Spleen qi xu
• Damp-Phlegm
• Heart yin xu
• Heart xue xu
Liver Fire invades the Lung

See Liver imbalance patterns (page 590).
Large Intestine imbalance

The Large Intestine’s functions are to receive the dross that remains after the food and
beverages that have been ingested have been transformed by the other organs, extract
the last usable fluids out of the remaining contents and send the untransformed
residues out of the body as faeces. These functions are influenced by the Spleen,
the Stomach and the Kidneys. This means that the Large Intestine is the stage in
which these activities take place, but a disruption of these functions will usually be
addressed by treating an imbalance in the Spleen, Stomach or Kidneys whilst using
points that directly influence the Large Intestine.
427
The Large Intestine can also be affected negatively without other organs being
involved. This is seen when there has been an invasion of exogenous xie qi. Invasions
of exogenous Cold or Damp will disrupt the movement of qi in the Large Intestine.
The blockage of qi will manifest with pain. An invasion of exogenous Cold can
result in constipation, because Cold can block the movement of the stool through
the Large Intestine, but also the blockage of qi can mean that exogenous Cold and
Damp prevent the Large Intestine from extracting fluids from the stool and in these
situations the invasion of Cold will manifest with watery diarrhoea.
Damp-Heat can also invade the Large Intestine. This will also cause diarrhoea,
but the diarrhoea in this situation will be sticky and odorous. The Heat will
scorch the mucous membranes, resulting in a stinging, burning sensation in the
rectum. The Heat can be so intense that xue is agitated to the extent that the walls of
the Large Intestine rupture. This can result in blood in the stools.
When qi stagnates in the Large Intestine, it will result in abdominal bloating,
distension or pain. In a purely shi condition, the pain will be alleviated by the passing
of stools, because the stagnation will thereby be alleviated. Qi in the Large Intestine
can stagnate when there are invasions of exogenous xie qi or when stagnated Liver
qi invades the Large Intestine, interfering with the downward movement of qi in
the Large Intestine. Xue stagnation in the Large Intestine can also block the free
downward movement of qi and stools.
There is close cooperation between the Large Intestine and its partner organ,
the Lung. The Large Intestine is dependent on Lung qi being sent down so that it
can force the faeces out of the rectum. Lung qi xu can manifest with there not being
enough force to expel the stool from the body. In these situations, the person will
typically feel very exhausted after they have passed the stool and will possibly sweat
spontaneously afterwards.
A condition of yang xu can lead to Cold more easily invading the Large
Intestine and to there not being enough yang qi to move the stool through the
Large Intestine. This will result in constipation.
General symptoms and signs of a Large Intestine imbalance

• Constipation or diarrhoea
• Abdominal pain
Shi patterns
Damp-Heat in the Large Intestine
This pattern will frequently be combined with other patterns – usually Spleen
and Stomach imbalances. What makes this pattern difficult to treat is that there is
yin and yang xie qi, which are bound together. Exactly how the symptom picture
manifests will depend on which of these two elements is dominant.
428
Damp-Heat in the Large Intestine will be defined in an Eight Principle diagnosis

as an ‘interior shi Heat’ condition. The pattern can arise when there has been an
invasion of exogenous Damp-Heat, for example after the ingestion of spoiled food.
In this case, it will be a purely shi condition. Usually, however, the pattern arises in the
background of Spleen qi xu or Spleen yang xu conditions. This makes the situation
more complicated because there will be a condition of interior shi Heat that has
arisen from a concurrent ‘interior xu’ condition (which will in fact be an interior xu
Cold condition if there is Spleen yang xu). This requires a treatment strategy that
will require both tonification and draining at different stages, as well as the clearing
of Heat and the warming of yang.
Aetiology
Diet plays a significant role in this pattern. The diet itself can directly create Damp-
Heat when foods that create Dampness and Heat are excessively consumed. The diet
can, though, also create imbalances in the middle jiao that subsequently result in
the generation of Dampness. The Damp stagnation will then begin to ‘ferment’ or
combine with an existing Heat condition. This is typical when Liver qi stagnation
Heat is also present.
The pattern can also occur after consumption of foods that are spoiled or
infected, for example with salmonella.
Summer-Heat can directly invade the Large Intestine and create Damp-Heat.
Worry and speculation can bind and weaken Spleen qi, leading to the generation
of Dampness, which can then transform into Damp-Heat. Anger and frustration
can create Heat or stagnate Liver qi, which then invades the Spleen.
Symptoms and signs

• Diarrhoea
• Frequent defecations
• The stools are sticky, malodorous and possibly contain blood or mucus
• The defecation may be explosive
• Stinging or burning sensation in the rectum
• Abdominal pain that is not alleviated by the passing of stools
• The abdomen feels tight or distended when palpated
• Thirst with no desire to drink
• Fever, feeling feverish or an aversion to heat
• Heaviness in the body
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• Red tongue with a yellow sticky coating on the root, possibly with elevated,
red papillae on the root
• Rapid and Slippery pulse, possibly Full in both chi positions
Key symptoms
Diarrhoea with strong-smelling, sticky stools, yellowish sticky tongue coating.
Treatment principle
Drain Damp-Heat from the Large Intestine.
Acupuncture points
Choose from: LI 11, St 25, St 27, St 37, St 44, Sp 6, Sp 9, UB 22 and UB 25.
• If there is blood in the stool, add: Sp 1 and Sp 10.
Needle technique
Draining. Moxa on Sp 1.
Explanation
• LI 11, St 25, St 27, St 37, St 44 and UB 25 drain Damp-Heat from the
Large Intestine.
• Sp 6, Sp 9 and UB 22 drain Dampness.
• Sp 1 and Sp 10 stop bleeding.
Herbal formula
• Huang Lian Jie Du Tang (Drains Damp-Heat from the Intestines)
• Bai Tou Weng Wan (Drains Damp-Heat from the Intestines)
• Shao Yao Tang (Drains Damp-Heat from the Intestines)
Relevant advice
If there is Damp-Heat in the Large Intestine, the patient should avoid consuming
food and beverages that create Dampness, Heat or Damp-Heat. Deep-fried foods,
alcohol, hot spices, dairy products and sugar should be avoided completely.
Damp-Heat in the Large Intestine can be caused

• Spleen qi xu
• Spleen yang xu
• Food stagnation
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Damp-Heat in the Large Intestine can result in

• Spleen qi xu
• Qi stagnation in the Intestines
• Xue stagnation
Heat in the Large Intestine

Unlike the previous pattern, this will always be a pure shi pattern of imbalance.
All the symptoms and signs will be due to the presence of Heat, which desiccates
and scorches.
Aetiology
Heat can arise in the Large Intestine due to prolonged intake of substances that have
a Hot energy, such as lamb, alcohol, chilli and fried food.
Exogenous xie qi can penetrate into the yangming aspect and generate Heat in
the Large Intestine.
Symptoms and signs

• Constipation with dry stool
• Burning sensation in the rectum
• Bloated abdomen that resists pressure when palpated
• Thirst
• If the condition is due exogenous xie qi that has sunk to the qi level, there
will be profuse sweating
• Fever or aversion to heat
• Scanty, dark urine
• Dry mouth
• Red tongue with dry yellow, brown or black coating
• Rapid and Full pulse
Key symptoms
Constipation with dry stools, yellow, brown or black tongue coating.
Treatment principle
Drain Heat from the Large Intestine.
Acupuncture points
Choose from: LI 11, St 25, St 27, St 37, St 44, SJ 6 and UB 25.
431
Needle technique
Draining.
Explanation
• LI 11, St 25, St 27, St 37, St 44 and UB 25 drain Heat from the Large
Intestine.
Herbal formula
• Ma Zi Ren Wan (Drains Heat and moistens the Large Intestine)
Relevant advice
If there is Heat in the Large Intestine, the patient should avoid consuming food and
beverages that are hot in their energy. Spinach, bean sprouts, bananas, cucumber,
fig, rhubarb and bamboo shoots all drain Heat from the Large Intestine and are
therefore beneficial. Spinach is especially salutary because it moistens and lubricates
the Large Intestine. This will enable the stool to move more easily through the
Large Intestine.
Heat in the Large Intestine can be caused by

• Stomach Heat
Heat in the Large Intestine can result in the

• Yin xu
• Ying level Heat
• Xue stagnation
Damp-Cold in the Large Intestine

This is, again, a purely shi pattern of imbalance, but there may well be an underlying
yang xu condition which means that the body has difficultly protecting itself from
exogenous Cold or transforming Cold foods that have been ingested.
Aetiology
The Large Intestine can be directly invaded by exogenous xie qi through the skin
if the person, for example, has had cold, wet clothes on the abdomen after they have
been swimming or has sat on the cold, wet earth.
Damp-Cold can also result from consuming cold or cooling food and beverages
(both thermally or energetically cold).
432
Symptoms and signs

• Diarrhoea
• Stools are watery and explosive
• Borborygmi
• Cramping pain in the abdomen
• The skin of the abdomen feels cold when palpated
• The abdomen can feel tense or distended when palpated
• Thick, white and wet tongue coating
• Slow and possibly Tight pulse
Key symptoms
Watery diarrhoea, cramping pain in the intestines.
Treatment principle
Drain Damp and Cold from the Large Intestine.
Acupuncture points
Choose from: St 25, St 36, St 37, Ren 8, Sp 4, Sp 9 and UB 25.
Needle technique
Draining, except for Ren 8, which should be treated with moxa. Moxa or a moxa
box on the abdomen is recommended.
Explanation
• St 25, St 36, St 37, Sp 4, Sp 9 and UB 25 drain the Damp-Cold from the
Large Intestine.
• Ren 8 with moxa expels Dampness and Cold from the Large Intestine.
Herbal formula
• Huo Xiang Zheng Qi Tang (Expels Wind, Damp and Cold and regulates qi
in the Intestines)
• San Wu Bei Ji Wan (Vigorously purges Cold downwards)
Relevant advice
When there is Damp-Cold in the Large Intestine, the person should avoid consuming
food and beverages that are cold or have a cooling energy. They will benefit from
433
drinking ginger tea or other spices that are warming and spreading in their dynamic.
It is important to keep the abdomen warm and dry.
Damp-Cold in the Large Intestine can be caused

by the following pattern of imbalance
• Spleen yang xu
Damp-Cold in the Large Intestine can result in

the following pattern of imbalance
• Yang xu
Xu patterns
Large Intestine Dryness
This imbalance pattern is a precursor of yin xu. There will be perceptible symptoms
and signs of Dryness but not decidedly yin xu symptoms and signs.
Aetiology
This pattern may be due to exogenous Dryness, which can arise when a person is
living in a very hot and dry climate. The most common cause, though, is irregular
diet. Eating late, eating whilst working, irregular eating or eating whilst stressed will
all injure the Stomach yin, which is the root of jinye.
Symptoms and signs

• Dry, pellet-like stools
• Difficulty defecating
• Dry skin
• Thin body
• Fine pulse
Key symptoms
Dry, pellet-like stools.
Treatment principle
Moisten and activate the Large Intestine.
Acupuncture points
Choose from: St 25, St 36, St 37, Sp 6, Sp 15, Ren 4, Ren 12, Kid 6 and UB 25.
434
Needle technique
Tonifying.
Explanation
• St 25, St 37, Sp 15 and UB 25 moisten and activate the Large Intestine.
• St 36 and Ren 12 nourish Stomach yin.
• Sp 6, Kid 6 and Ren 4 nourish yin.
Herbal formula
• Run Chang Wan (Moistens and lubricates the Large Intestine)
Relevant advice
When there is Large Intestine Dryness, the patient should eat foods that are
moistening and lubricating. This includes foods that are rich in oils and fats, such
as nuts and seeds, as well as vegetable oil. Prunes, bananas, avocados, spinach and
plants from the cabbage family moisten and lubricate the Intestines.
Large Intestine Dryness can be caused by the

• Stomach yin xu
Large Intestine Dryness can result in the following pattern of imbalance

• Yin xu
Large Intestine xu Cold

The difference between this pattern and Damp-Cold in the Large Intestine is
that this is a xu pattern of imbalance, whereas Damp-Cold in the Large Intestine is a
shi pattern. The stools here will not be explosive and there will not be cramping pain
in the abdomen. Instead, the pain will be a dull, nagging pain that is not alleviated
by the passing of a stool.
Aetiology
This pattern can arise due to excessive consumption of food and beverages that are
cold or cooling (both energetically and thermally) or from prolonged exposure to
climatic cold and repeated invasions of exogenous Damp-Cold. Physical and sexual
overexertion can also be involved in the generation of the underlying yang xu patterns.
Symptoms and signs

• Unformed stools
• Dull, nagging or gnawing pain in the abdomen that is not alleviated by the
passing of stools
435
• Borborygmi
• Frequent urination with a large quantity of pale urine
• The skin of the abdomen feels cold on palpation
• The abdomen does not feel tense or hard on palpation
• Cold limbs
• Pale tongue
• Deep and Weak pulse
Key symptoms
Unformed stools. Deep and Weak pulse.
Treatment principle
Warm and tonify the Large Intestine.
Acupuncture points
Choose from: St 25, St 36, St 37, Sp 4, Ren 6 and UB 25.
Needle technique
Explanation
• St 25, St 36, St 37, Sp 4 and UB 25 warm and tonify the Large Intestine.
• Ren 6 warms and tonifies yang.
Herbal formula
• Fu Zi Li Zhong Tang (Warms and tonifies Spleen yang)
• Zhen Ren Yang Zang Tang (Warms and tonifies Kidney and Spleen yang,
astringes and transforms Dampness from the Intestines)
Relevant advice
When there is Large Intestine xu Cold, it is beneficial to consume warm, cooked
or baked food. It is advisable to eat foods that have a warming energy. Baked root
vegetables, stews, soups, lamb, chicken, onions and leeks are all examples of warming
food. Spices that will be beneficial are cloves, cinnamon, ginger, basil, rosemary and
nutmeg.
Large Intestine xu Cold can be caused by the

• Spleen yang xu
436
• Kidney yang xu
Large Intestine xu Cold can result in the following pattern of imbalance

• Damp-Cold in the Large Intestine
Stomach imbalances
The Stomach is the only fu organ directly involved in the production of qi, xue and
jinye. This is because the Stomach is the organ that receives the food and liquids that
have been ingested through the mouth that will be transformed into gu qi and jinye.
The Stomach ‘rots and ripens’ the ingested food, preparing it for transformation
by the Spleen. The Stomach also has the important function of sending qi downwards
together with the impure residues that are left behind after the transformation process.
The Spleen simultaneously sends its qi upwards together with the pure qi that has
been extracted from the food and liquids. This qi mechanism is of great importance,
not only for the movement of qi in the middle jiao, but also throughout the body, as
all communication passes thorough this area. It is crucial for the entire production
of vital substances in the body that the Stomach is capable of emptying and filling.
If the Stomach cannot send the impure residue down to the Small Intestine, there
will not be any space in the Stomach to receive new food or liquids. This will initially
be experienced as a loss of appetite, nausea, bloating or a stuffed sensation in the
epigastric region, because the Stomach and Spleen qi ji has ground to a halt and
there is an accumulation of qi, food and liquids in the area. When the qi stagnates,
it can also manifest with pain and discomfort. If the qi from the Stomach cannot
descend, it can become rebellious and ascend upwards. This can give symptoms such
as hiccups and belching, but it can also become so rebellious that there is vomiting.
If the rebellious qi has arisen from a xu pattern, there will not be the explosive
vomiting that characterises shi patterns, but instead involuntary regurgitation.
Disruption and disturbance of the Stomach’s descending function can also
manifest as constipation. This is because the Intestines are partly dependent on the
downward dynamic of the Stomach qi.
If the disruption of the Stomach and Spleen qi ji becomes a chronic condition.
It will affect the production of the vital substances and this will manifest with
symptoms such as fatigue and weakness of the muscles.
Because the Stomach is the organ that receives all the food and liquids that have
been consumed, what has been ingested will have a significant influence on the
Stomach. The Stomach has a preference for moist, damp substances and is damaged
by Dryness. This stands in contrast to the Spleen, which abhors Dampness. The
Stomach is easily damaged by Heat and has a tendency to develop Heat patterns of
imbalance. Again, the Spleen is the opposite. The Spleen is injured and burdened by
Cold and prefers warmth. All of this means that the Stomach is harmed by food and
beverages that are energetically hot and that its yin aspect is easily injured by spicy
food, because this is often hot and because the spicy flavour itself can injure yin.
437
If there is an excess of Heat in the Stomach, as there is with Stomach Fire, the
food will be ‘burnt up’ in the Stomach and the person will experience a gnawing
or insatiable hunger because the Stomach is constantly empty. The Fire can be so
intense that it begins to damage the organ itself. This will be perceived as a searing
pain or burning sensation in the Stomach. Due to its inherent yang dynamic, Fire
ascends upwards. This can cause Stomach qi to become rebellious and flow upwards.
This will manifest as hiccups, acid reflux, heartburn and belching. Heat tends to
make things become odorous, and this, combined with the ascending qi from the
Heat, can manifest as bad breath.
Stomach yin xu Heat will not result in the same intense hunger as when there is
Stomach Fire. When yin xu creates xu Heat, there will be an increased hunger but,
unlike when there is Stomach Fire, the person will be quickly satiated. Yin xu will not
cause the Stomach qi to becomes rebellious and there will not be the same burning
pain in the abdomen. There can be more of a dull, stinging discomfort in the organ.
Heat will also make the person thirsty. If there is Stomach Fire, there will be an
intense thirst with a desire to drink large quantities of cold beverages in large gulps.
Yin xu Heat will also result in thirst, but in this case there will not be the same need to
drink large gulps, more a preference for sipping water. Often there is only a dryness
of the mouth and throat when there is Stomach yin xu, not because of the Heat
but because the Stomach is the root of yin fluids. Stomach yin xu can therefore lead
to dryness throughout the body. The dryness can also manifest with constipation,
due to the stools being dry. Stomach Heat, both xu and shi, can similarly manifest
with constipation.
Both xu and shi Heat can result in bleeding. Stomach Heat can often ascend up
to the mouth, which is the sensory organ that is associated with the Earth Phase. The
Stomach channel also traverses the gums. This means that bleeding gums and similar
problems are often a sign of Stomach Heat and Stomach Fire. This problem can be
further complicated if there is a concurrent condition of Spleen qi xu. Spleen qi xu
can result in the Spleen not being able to hold xue inside the vessels. In addition to
bleeding gums, Stomach Fire can cause blisters and mouth ulcers to form and Stomach
Fire can be involved in dental problems such as paradentosis or tooth abscesses.
Despite the fact that the Stomach tends to have Heat and yin xu imbalances,
it can also be negatively affected by exogenous Cold and cold food. This is because
Cold can damage Spleen yang, thereby reducing the transformation of food in
the Stomach, and also because Cold will stagnate and block Stomach qi. This
disturbance of the Stomach qi will result not only in pain and discomfort in the
Stomach, but also in nausea and vomiting. The difference between the vomiting that
is experienced when there is Cold and when there is Heat is that vomit resulting
from Cold conditions will be watery and contain undigested food matter. This is
due to the food and liquid that have been ingested not being transformed due to the
Cold. Heat, on the other hand, will manifest with vomit that is sour and sticky in
consistency. Vomit resulting from shi conditions will usually alleviate nausea or pain
and discomfort in the Stomach.
438
Xu and shi Cold in the Stomach will manifest with an attraction to warm food
and hot drinks. The person will also have a marked aversion to ingesting anything
that is cold in temperature, possibly also things that are energetically cold.
It is not only the energetics of the food consumed that can have an influence on
a person, the Stomach is also disturbed by the amount of food eaten and the way it
is eaten. Negative eating habits can result in food stagnation. Food stagnation can
arise from eating meals too quickly, eating too much food at a time, eating food that
is difficult to transform or eating food too late in the evening. The evening is also
the yin period of the day. If a person eats too much in the evening, there will not
be the same resources of yang qi available to transform the food. The transformation
of the food stops at night. This means that if food is eaten late in the evening, it
will tend to lie and rot in the Stomach overnight. In relation to the horary clock,
the Stomach and Spleen are at their weakest between 7pm and 11pm, which is why
the main meal should be eaten before noon. As well as blocking the qi mechanism,
food stagnation will generate Dampness and Heat. The stagnation of qi will create
distension and discomfort in the abdomen. Heat will also rise upwards from the
stagnant food, agitating the Heart and shen. This, and the discomfort caused by
the stagnation, will disturb the sleep and the person will wake frequently during the
night, often with a sensation of Heat in the body or sweating profusely.
The Stomach should regularly fill and empty throughout the day. If a person
constantly snacks, the Stomach will never have the opportunity to empty completely.
This will lead to the stagnation of Stomach qi and create Food stagnation. Eating
whilst working, driving, on the run and so on will stagnate Stomach qi and can lead
to the Stomach qi becoming rebellious.
Patients with a history of anorexia and bulimia may have problems with their
Stomach qi, because it has either been weakened by the lack of nourishment or
become rebellious due to the repeated vomiting.
The Stomach is affected by the same emotions as the Spleen. Worry, speculation
and vexation bind and thereby stagnate Stomach qi. Thinking too much and mental
strain will also weaken the Stomach qi.
Frustration, irritation and unresolved emotions can stagnate Liver qi, which
can then build up and ‘invade’ the Stomach, disrupting the descent of Stomach qi.
Stagnant Liver qi can create Heat, which can invade the Stomach and create Heat
in the Stomach.
General symptoms and signs of Stomach imbalances

• Pain or discomfort in the Stomach or epigastric region
• Poor or excessive appetite
• Belching, hiccups, or acid reflux
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Shi patterns
Stomach Fire
Patterns of Stomach Fire can vary in intensity. There can be mild patterns of Stomach
Heat and there can be intense patterns of Stomach Fire.
Aetiology
Like most Stomach and Spleen imbalances, Stomach Fire usually has its roots
in dietary imbalances. Consuming food and beverages that have a hot energetic
dynamic can create Stomach Fire. Alcohol, too much meat (especially lamb), fried
food, grilled food and hot spices are among the most common factors contributing
to Stomach Fire. Tobacco can also be factor, as it is Hot and affects both the Lung
and the Stomach.
Food stagnation can be a cause of Stomach Fire. Therefore, eating too much at
a time, eating too quickly, eating too late in the day and eating food that is difficult
to transform can be an aspect of this pattern’s aetiology.
Stress, repressed anger, frustration and irritation can generate Liver Fire, which
can then invade the Stomach, creating Stomach Fire. Furthermore, prolonged anxiety
and worry can stagnate Stomach qi, which can eventually generate Stomach Fire.
Symptoms and signs

• Searing, burning epigastric pain
• Insatiable or gnawing hunger
• Intense thirst, with a desire for cold beverages, the person will often drink
in large gulps
• Acid reflux
• Constipation
• Nausea
• Vomiting of sour vomit
• Malodorous breath
• Blisters or ulcers in the mouth
• Bleeding gums
• Paradentosis
• Sour or bitter taste in the mouth
• Dark urine
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• Dry, parched lips

• The person may seem unsettled and restless
• The person may tend to be ebullient and talk quickly
• Red face
• Redness in the middle of the tongue, with a dry, yellowish or brownish
tongue coating
• Rapid and Full pulse, especially in the right guan and possibly cun positions
Key symptoms
Insatiable hunger, bad breath, thirst, acid reflux and redness in the middle of
the tongue.
Treatment principle
Drain Stomach Fire.
Acupuncture points
Choose from: St 21, St 34, St 40, St 44, Ren 12, Ren 13, Sp 6, LI 11 and UB 21.
Needle technique
Draining, except for Sp 6, which should be tonified.
Explanation
• St 21, St 40, St 44, Ren 12, Ren 13 and UB 21 all drain the Stomach Fire
and regulate Stomach qi.
• LI 11 drains Stomach Fire.
• St 34 drains Stomach Fire and stops bleeding from the gums.
• Sp 6 nourishes and protects Stomach yin.
Herbal formula
• Qing Wei San (Drains Stomach Fire, especially when it affects the teeth and
gums)
• Huang Lian Jie Du Pian (Drains Fire from the middle jiao)
Relevant advice
When there is Stomach Fire the person should avoid all foods that are hot in their
energy. They should eat cooling or neutral foods, especially boiled or steamed
vegetables and foods that are moist or glutinous in their consistency, such as porridge.
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This will help protect the Stomach’s yin aspect. The ingestion of umeboshi plums
will have a neutralising effect on Stomach Fire and can be used in acute conditions.
If food stagnation is involved in the generation of Stomach Fire, it is important that
the person follows the dietary advice for this pattern.
Stomach Fire can be caused by the following patterns of imbalance

• Stomach qi stagnation
• Liver Fire
• Food stagnation
Stomach Fire can result in the following patterns of imbalance

• Phlegm-heat
• Stomach yin xu
• Xue stagnation in the Stomach
Stomach qi stagnation
Stomach qi has a descending dynamic. If Stomach qi is disrupted by food stagnation,
xie qi or imbalances in other organs, the Stomach will not be able to send its qi
downwards. Initially, the stagnation of Stomach qi will cause pain, discomfort and
bloating in the abdomen. With time, Stomach qi can become rebellious and ascend
upwards, with symptoms such as belching, hiccups or vomiting as a consequence.
Aetiology
Eating too quickly, eating whilst stressed, working or eating whilst on the go will
stagnate Stomach qi. Food, particularly spices, which have an ascendant dynamic,
will disrupt the downward dynamic of Stomach qi.
Liver qi should support the Stomach in sending its qi in the correct direction.
Stress, irritation, unresolved emotions, anger and so on can stagnate Liver qi. This will
initially result in the Liver not supporting the descent of Stomach qi. Subsequently,
Liver qi can invade and block the Stomach’s qi mechanism.
Symptoms and signs

• Discomfort or pain in the Stomach or epigastric region
• Bloating
• The upper abdomen can feel tense or bloated on palpation
• Irritability
• Hiccups, belching or regurgitation
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• Nausea
• The tongue can be a little red or swollen in the middle
• Wiry pulse on the right guan position
Key symptoms
Pain or discomfort in the epigastric region, belching and regurgitation.
Treatment principle
Regulate Stomach qi.
Acupuncture points
Choose from: St 21, St 34, St 36, Ren 11, Ren 12, Ren 13, Ren 22, SJ 6, Pe 6 and
UB 21.
Needle technique
Draining.
Explanation
• St 21, St 34, St 36, Ren 11, Ren 12 and UB 21 regulate Stomach qi.
• Pe 6 and SJ 6 regulate qi in the middle jiao.
• Ren 13 and Ren 22 descend rebellious Stomach qi.
Herbal formula
• Ban Xia Hou Po Tang (Regulates Stomach qi)
Relevant advice
When there is Stomach qi stagnation, it is important that the person eats slowly,
doesn’t eat too much at a time and doesn’t eat constantly. They should chew their
food well and avoid foods that are difficult to transform. If stress and emotional
frustrations, irritations and anger create Liver qi that invades the Stomach, the
person should try and resolve these issues.
It is important that the person does not sit still for extended periods of time
and that they do not sit in a slumped posture. Walking or stretching after meals is
recommended. Physical exercise in general will be beneficial. Stroking downwards
with the fingers from Ren 16 to Ren 8 will help Stomach qi to descend.
Stomach qi stagnation can be caused by the following patterns of imbalance

• Spleen qi xu
• Stomach qi xu
• Stomach yin xu
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• Food stagnation
Stomach qi stagnation can result in the following patterns of imbalance

• Food stagnation
• Stomach Fire
• Stomach yin xu
• Phlegm-Fire
• Stomach xue stagnation
Food stagnation
Food stagnation is often an overlooked aspect of a diagnostic picture, particularly
in chronic and complex cases where there are many patterns intertwined with
each other. Food stagnation, like Phlegm and xue stagnation, is often a cause and
consequence of many chronic patterns of imbalance. This is because many patterns of
imbalance can directly or indirectly disrupt the Stomach and Spleen’s qi mechanism.
Chronic food stagnation will also, in the long term, directly and indirectly lead to
imbalances in many other places in the body. The foundation of food stagnation is
often laid as early as the first year of a person’s life. This will be the case if there was
an improper diet and if the baby was repeatedly fed before the Stomach had been
emptied of food.
There will often be vague and subtle signs of food stagnation rather than outright
symptoms. Typically, the patient will have a slight sensation of fullness in the belly
or bloating for some time after they have eaten, will burp or belch and will have
discomfort in the epigastric region.
There can often be a vicious circle where food stagnation causes the creation of
Stomach Heat, which results in a gnawing hunger. The person then eats constantly
and the Stomach never completely empties, so even more stagnation of food in the
Stomach will arise.
Aetiology
Food stagnation arises directly from eating too much at a time, eating too fast, not
chewing the food properly, eating too late at night, constant snacking, eating whilst
stressed or whilst working, eating whilst sitting in a twisted position and eating food
that is difficult to transform.
If the Spleen and Stomach are also qi xu, food will not be transformed. If there is
Damp and Phlegm, this will weaken the Spleen and block the Stomach and Spleen
qi mechanism, so that the food stagnates. Liver qi stagnation can also disrupt the
Stomach and Spleen qi mechanism, with food stagnation as a result. Yang xu can
mean that there is not enough physiological heat to transform the food. Yin xu and
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Heat can lead to the formation of Phlegm that will then block the Stomach and
Spleen’s qi mechanism.
Symptoms and signs

• Lack of appetite
• A full sensation in the epigastric region
• Epigastric discomfort
• Bad breath
• Belching that often tastes or smells of the food that has been eaten earlier
• Acid reflux
• Vomiting
• Discomfort when palpating on the upper abdomen
• Bloating and abdominal discomfort that is relieved by vomiting
• Insomnia or dream-disturbed sleep
• Feeling hot at night
• Loose stools or constipation
• The stools smell rotten or of sewage
• Odorous flatulence
• Thick and greasy tongue coating
• Slippery or Wiry pulse, especially in the right guan position
Key symptoms
Full sensation or discomfort in the epigastric region, belching that tastes of previously
ingested food, thick, greasy tongue coating.
Treatment principle
Dissolve food stagnation, regulate Stomach qi.
Acupuncture points
Choose from: St 19, St 21, St 34, St 36, St 44, Sp 4, Ren 12, Ren 13 and Pe 6.
Needle technique
Draining.
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Explanation
• St 19, St 21, St 34, St 36, Sp 4, Ren 12 and Ren 13 regulate Stomach qi and
dissolve food stagnation.
• St 44 dissolves food stagnation, regulates the Stomach qi and drains Heat.
Herbal formula
• Bao He Wan (Dissolves Food stagnation)
• Jian Pi Wan (Dissolves Food stagnation and tonifies Spleen qi)
Relevant advice
It is crucial that a person with food stagnation regulates the way they eat and what
they eat. They should not eat too quickly or too much at a time. They should sit
upright when eating and chew their food well. They should eat food that is easy
to transform and they should not eat too late in the evening. Stroking downwards
with the fingers from Ren 16 to Ren 8 will help Stomach qi and the ingested food
to descend. Walking or stretching after meals is recommended. Physical exercise in
general will be beneficial.
Food stagnation can be caused by the following patterns of imbalance

• Spleen qi xu
• Stomach qi xu
• Spleen yang xu
• Stomach yin xu
• Damp
• Phlegm
Food stagnation can result in the following patterns of imbalance

• Spleen qi xu
• Stomach qi xu
• Stomach Fire
• Stomach yin xu
• Damp
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• Damp-Heat
• Phlegm
• Phlegm-Fire
Invasion of Cold in the Stomach

This will be an acute pattern resulting from climatic, dietary or pharmaceutical
influences.
Aetiology
Exogenous Cold can invade the Stomach, either via the mouth or through the skin
of the abdomen. If the invasion takes place through the mouth, it will be due to
the consumption of food that has a very cold temperature or energy. This could, for
example, be ice cream, ice water or other cold beverages, but it could also be due to
the consumption of drugs or herbs that have a very cold energy.
Invasions of Cold via the skin will be due to contact with cold climatic influences,
particularly if the abdomen is cooled down by wearing wet clothes.
Symptoms and signs

• Acute pain in the abdomen or epigastric region
• Vomiting of clear fluids
• Nausea
• Aversion to cold and cold beverages and food
• Hiccups
• The ingestion of cold substances will aggravate the symptoms
• Desire for warm food or beverages
• Pale urine
• The epigastric region feels cold when palpated
• Pale complexion
• Thick, white tongue coating
• Slow, Tight and Full pulse
Key symptoms
Acute abdominal pain, vomiting of clear fluids, thick and white tongue coating.
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Treatment principle
Expel Cold from the Stomach, regulate Stomach qi.
Acupuncture points
Choose from: St 21, St 34, Sp 4, Ren 13 and Pe 6.
Needle technique
Draining. Moxa can be used with the needles.
Explanation
• St 21 and Ren 13 expel Cold from the Stomach and regulate Stomach qi.
• Sp 4 regulates Stomach qi.
• St 34 regulates Stomach qi and alleviates pain in the Stomach.
Herbal formula
• Da Jian Zhong Tang (Warms the middle jiao, expels Cold, regulates qi)
Relevant advice
When there is an invasion of Cold in the Stomach, the person will benefit from
eating and drinking food and beverages that have a warming and spicy dynamic and
that are thermally hot, such as ginger tea. If the invasion is due to climatic influences
or wet clothes, a ginger poultice on the abdomen can help to expel the Cold.
The person should avoid consuming food and beverages that are cold in their
temperature and energy.
The upper abdomen should be kept warm and dry.
Invasion of exogenous Cold in the Stomach can be

caused by the following patterns of imbalance
This is an acute disorder, therefore there will not usually have been a previous pattern.
However, the following patterns can have predisposed the person to an invasion of
exogenous Cold:
• Spleen yang xu
• Kidney yang xu
• Wei qi xu
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Invasion of exogenous Cold in the Stomach can result

in the following patterns of imbalance
• Damp
• Stomach qi xu and Cold
• Xue stagnation in the Stomach
Xue stagnation in the Stomach

This is always a chronic pattern that will have arisen from other Stomach imbalances.
Aetiology
The aetiology will depend on which patterns of imbalance are involved in the
generation of xue stagnation.
Symptoms and signs

• Sharp, stabbing, piercing gastric pain
• Pain that is worse on palpation
• Pain that is aggravated by eating
• Vomiting of dark blood that looks like coffee grounds
• Dark blood in the stool
• Nausea
• The middle of the tongue or the entire tongue can be purple, the sub-lingual
veins may be swollen and purple
• Choppy or Wiry pulse, especially in the right guan position
Key symptoms
Stabbing and piercing gastric pain, vomiting of dark blood, purple colour in the
middle of the tongue.
Treatment principle
Invigorate xue, dissolve xue stagnation in the Stomach, regulate Stomach qi.
Acupuncture points
Choose from: St 21, St 34, St 36, Pe 6, Ren 10, Ren 12, Ren 13, Sp 4, Sp 10, UB 17
and UB 21.
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Needle technique
Draining.
Explanation
• St 21, St 36, Ren 10, Ren 12, Ren 13 and UB 21 regulate Stomach qi and
invigorate xue in the Stomach.
• St 34 invigorates xue in the Stomach and stops pain.
• UB 17 and Sp 10 invigorate xue.
• Sp 4 and Pe 6 together open chong mai, invigorate xue and regulate Stomach
qi.
Herbal formula
• Ge Xia Fu Zhu Yu Tang (Invigorates xue below the diaphragm)
Relevant advice
This will depend on which imbalances underlie the xue stagnation in the Stomach.
Xue stagnation in the Stomach can be caused by

• Stomach Fire
• Phlegm-Fire
• Liver qi invading the Stomach
• Invasions of Cold in the Stomach
• Stomach yin xu
• Stomach qi xu
Xue stagnation in the Stomach can result in

• Food stagnation
Damp-Heat in the Stomach

This pattern is very similar to Damp-Heat in the Spleen and the two patterns are
often closely related to each other. The difference between them is that when there is
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Damp-Heat in the Stomach, there will be signs that Stomach qi is disrupted or that
there is Heat in the Stomach channel.
Aetiology
Invasions by exogenous Damp-Heat, such as the ingestion of spoiled or infected
food, living or working in warm and humid conditions and contact with viruses,
bacteria, fungi and so on that have a Damp-Heat dynamic. Excessive consumption
of foods that generate Damp-Heat, such as fried foods and alcohol.
Damp-Heat can often arise as a consequence of chronic Spleen qi xu and
Damp conditions.
Symptoms and signs

• Heaviness and pain in the abdomen
• Nausea
• Vomiting
• Sticky sensation in the mouth
• Heaviness in the arms and legs
• Sinusitis
• Jaw pain
• Nasal congestion
• Yellowish, sticky mucus in the nose and sinuses
• Yellowish complexion
• Yellow sclera
• Pimples, spots or sores around the mouth, on the forehead or on the cheeks,
which are red with yellowish pus
• Dark, yellow urine
• Yellow, greasy tongue coating, the tongue may be red in the middle
• Fast and Slippery pulse
Key symptoms
Discomfort or pain in the abdomen, heaviness, yellow, greasy tongue coating.
Treatment principle
Drain Dampness and Heat, regulate Stomach qi.
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Acupuncture points
Choose from: St 21, St 34, St 44, LI 11, Sp 6, Sp 9, Ren 9 and Ren 13.
Needle technique
Draining. No moxa.
Explanation
• St 21, St 34 and Ren 13 regulate Stomach qi.
• St 44 and LI 11 drain Damp-Heat.
• Sp 6, Sp 9 and Ren 9 drain Dampness.
Herbal formula
• San Ren Tang (Clears Heat and Drains Dampness)
• Huang Lian Jie Du Tang (Drains Damp-Heat)
Relevant advice
It is crucial that a person with chronic Damp-Heat in the Stomach avoids foods
and beverages that create Heat, Dampness or Damp-Heat. Ideally, alcohol, fried
foods, chocolate, hot spices such as chilli, dairy products, sugar and sweets should be
avoided completely. The person should also consume a diet that tonifies the Spleen,
which often is the root cause of the Damp.
Damp-Heat in the Stomach can be caused by

• Spleen qi xu
• Spleen yang xu
• Damp-Cold invading the Spleen
• Stomach Fire
Damp-Heat in the Stomach can result in the

• Spleen qi xu
• Phlegm
• Phlegm-Fire
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Xu imbalances
Stomach yin xu
It is important to remember that this pattern is often seen in combination with
other patterns, such as Spleen qi xu or Spleen yang xu. This means that some of the
symptoms and signs will not be as obvious because they are ‘veiled’ by the symptoms
and signs of the other pattern and vice versa.
Aetiology
Eating irregularly, eating late in the evening and eating whilst working or stressed
will all injure the Stomach yin. An excessive consumption of spicy food and food
that is hot in its energy can harm the Stomach yin. Some medicines will also have an
energy that injures the Stomach yin.
There may be a congenital tendency to have Stomach yin xu.
Invasions of exogenous xie qi can penetrate to qi level or create Heat in the
yangming organs. This excess of Heat can injure Stomach yin.
Heat from the Liver can damage Stomach yin over time.
Symptoms and signs

• Poor appetite
• Constipation
• Dry mouth and throat, especially in the afternoon and evening
• Dry stool
• Dull pain, slight burning sensation or discomfort in the epigastric region
• Thin body
• Dry tongue, with cracks or lacking coating in the middle, the coating on the
tongue can be rootless
• Fine, Empty or Superficial pulse in the right guan position
When there is Stomach yin xu Heat, there can also be:
• fever or a feeling of heat in the body in the evening and at night
• a hot sensation in the palms of the hands and soles of the feet
• restlessness at night
• night sweats
• bleeding gums
• a slight thirst with a desire to sip only small amounts at a time
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• red and dry tongue or a tongue that is red in the middle, the tongue may lack
coating and have cracks in the middle
• Rapid, Fine or Empty pulse, especially in the right guan position.
Key symptoms
Dry mouth and throat, dry stool, discomfort in the abdomen, dry tongue that lacks
coating in the middle.
Treatment principle
Nourish Stomach yin.
Acupuncture points
Choose from: St 36, Sp 6, Ren 4, Ren 12, Kid 3, Kid 6, UB 20 and UB 21.
Needle technique
Tonifying.
Explanation
• St 36, Sp 6, Ren 12, UB 20 and UB 21 nourish Stomach yin.
• Ren 4, Kid 3 and Kid 6 nourish Kidney yin, thereby supporting Stomach
yin.
Herbal formula
• Sha Shen Mai Dong Tang (Nourishes Stomach yin)
• Shen Ling Bai Zhu Wan (Tonifies Stomach qi and yin)
Relevant advice
When there is Stomach yin xu, it will be beneficial to eat foods that are wet and
sticky. Things such as porridges, purées, soups and stews will therefore nourish
Stomach yin. Foods that are dry in their consistency or in their energetic dynamic
will do the opposite and have a negative effect on Stomach yin. Foods that are drying
in their energy are those that are very spicy (the spicy taste disperses and dries)
or have been baked in the oven for a long time. This means that a person with
Stomach yin xu should try to avoid crackers, rice cakes, toast, baked vegetables and
similar items.
Deep-fried and grilled foods have a very hot energy and this can also injure
Stomach yin. Alcohol, too much meat (especially lamb) and spices such as chilli,
garlic, pepper and so on all have a hot dynamic, which can damage Stomach yin in
the long term.
Apart from being aware of what they eat, a person who is Stomach yin xu should
pay close attention to how they eat. They should try to eat in as tranquil surroundings
454
as possible, which means that they should not eat whilst working or driving, when
they are stressed or whilst they are doing something else. They also need to rest and
not exert themselves after they have eaten. They should not eat late in the evening
and they should not eat too much at a time.
Stomach yin xu can be caused by the following patterns of imbalance

• Stomach qi xu
• Stomach Fire
• Liver Fire
Stomach yin xu can result in the following patterns of imbalance

• Kidney yin xu
• Spleen yin xu
• Heart yin xu
• Liver yin xu
• Lung yin xu
Stomach qi xu
This pattern is very similar to Spleen qi xu, both in its symptoms and in its aetiology.
In fact, the two patterns often overlap and are commonly diagnosed together in
clinical practice.
Aetiology
Eating too much at a time, eating too little, eating too often, eating whilst working
or when stressed or eating irregularly are all factors that can weaken Stomach qi.
Stomach qi will be debilitated by prolonged overwork and stress. Chronic
illnesses will particularly enfeeble both Stomach and Spleen qi.
Symptoms and signs

• Fatigue
• Discomfort in the abdominal area
• Loose stools
• Fatigue after meals
• Pale face
• Poor sense of taste
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• Weak limbs or tiredness of the limbs
• Craving for the sweet flavour
• Tendency to gain weight
• The person looks tired and emanates weariness
• Slumped posture
• Worries a lot or constantly speculates about things
• Pale, swollen tongue, possibly with teeth marks on the sides
• Weak pulse, especially in the right guan position
Key symptoms
Fatigue, loose stools, pale tongue with teeth marks and a Weak guan pulse.
Treatment principle
Tonify Stomach qi.
Acupuncture points
Choose from: St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21.
Needle technique
Explanation
• St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21 tonify Stomach qi.
Herbal formula
• Liu Jun Zi Tang (Tonifies Stomach qi)
• Shen Ling Bai Zhu Tang (Tonifies Stomach qi)
Relevant advice
Dietary changes are alpha and omega in the treatment of Stomach qi xu. It is
important that the person focuses on what and particularly how they eat. They
should eat enough food and not fast or go on diets where they do not consume
sufficient food. At the same time, they should not eat too much at a time, as this
will result in food stagnation. Constant snacking will also weaken the Stomach qi.
The patient should try to eat as calmly as possible. This means that they should
not eat whilst working or driving, when they are stressed or whilst they are doing
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something else. They should also ensure that they get enough rest and do not exert
themselves after they have eaten. They should not eat too late at night. Walking
around or lightly stretching the front of the body after eating will support the qi
mechanism in the middle jiao and thereby support the Stomach qi.
The person will benefit from eating porridge in the morning, soups, mashed or
puréed vegetables, stews, steamed or boiled vegetables, i.e. easily digestible food. The
use of aromatic herbs in the diet will help to circulate qi and thereby help to prevent
Food stagnation.
It is important that the person does not sit still for extended periods of time
and that they do not sit in a slumped posture. Walking or stretching after meals is
recommended. Physical exercise in general will be beneficial. Stroking downwards
with the fingers from Ren 16 to Ren 8 will help Stomach qi to descend.
Stomach qi xu can be caused by the following pattern of imbalance

• Spleen qi xu
Spleen qi xu can result in the following patterns of imbalance

• Spleen qi xu
• Stomach yin xu
• Spleen yang xu
• Food stagnation
• Damp
• Phlegm
• Xue stagnation
Stomach qi xu and Cold

This is a sub-pattern of the Stomach qi xu. In these cases, there is both Stomach qi
xu and an aspect of yang xu. In addition to Stomach qi xu symptoms, there will be
signs that the transformation of food and liquids is not functioning optimally due
to a lack of physiological heat.
Aetiology
In addition to the factors discussed under Stomach qi xu, there can also be an excessive
consumption of food and beverages that have a cold energy or are physically cold.
These can create Cold in the Stomach. Typical examples of these are things like ice
cream, iced water, salads, raw vegetables and tropical fruits.
Invasions by exogenous Cold can damage Stomach qi when there have been
repeated invasions or if the Cold has not been completely expelled.
Medicine that has a cold dynamic can also be involved in the generation of
this pattern.
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Symptoms and signs

• Watery vomit
• Preference for warm food and beverages
• Lack of thirst
• Cold and weak limbs
• Discomfort in the abdomen
• Fatigue
• Pale face
• The epigastric region can feel cold when palpated
• The person may dress warmer than is normal for the season
• Pale, wet and swollen tongue
• Deep, Weak and Slow pulse, especially in the right guan position
Key symptoms
Cold limbs, a preference for warm food and beverages, fatigue and a pale tongue.
Treatment principle
Warm and tonify Stomach qi.
Acupuncture points
Choose from: St 36, Sp 6, Ren 6, Ren 12, UB 20 and UB 21.
Needle technique
Explanation
• St 36, Sp 6, Ren 12, UB 20 and UB 21 tonify Stomach qi.
• Ren 6 warms yang.
Herbal formula
• Li Zhong Tang (Warms and tonifies the middle jiao, expels Cold)
Relevant advice
In this pattern, it is advisable to consume food and beverages that are both nutritious
and warming. The use of ginger is particularly recommended. The patient should
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try to eat frequently and regularly. They should avoid eating too much at a time, so
they don’t create a stagnation of the food in the Stomach. Similarly, they should try
not to snack constantly and nibble at food. They should also, as far as possible, avoid
consuming food and beverages that are cold, both physically or energetically, such as
ice cream, ice water and cold drinks, salad and raw vegetables, as well as too much
fruit, especially tropical fruits.
Stomach qi xu and Cold can be caused by the

• Stomach qi xu
• Spleen qi xu
• Spleen yang xu
• Invasions of exogenous Cold
Stomach qi xu and Cold can result in the following patterns of imbalance

• Spleen yang xu
• Phlegm
• Food stagnation
• Xue stagnation
Combined patterns
Stomach and Spleen qi xu
This is discussed in the section on Spleen imbalance patterns below.
Liver qi invading the Stomach

This is discussed in the section on Liver imbalance patterns (page 590).
Spleen imbalances
The Spleen and its partner organ, the Stomach, are located in the middle of the
body, both physically and energetically. Physically, the Spleen and Stomach occupy
the middle jiao, which means that they are the central axle around which everything
revolves. All movement of qi, xue and fluids and all communication between the
body’s lower and upper jiao have to pass through the middle jiao. The Spleen sends its
qi upwards and the Stomach its qi downwards. If this mechanism is disrupted or gets
blocked, it will have implications for the movement and communication of qi, xue
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and fluids throughout the whole body. For example, the Small Intestine and Large
Intestine are completely dependent on the Stomach and Spleen qi mechanism, and
organs such as the Lung are also dependent on the Spleen sending qi and jinye up to
it. If the Spleen is not able to perform its functions of transforming and transporting
as it should, Dampness will arise. Initially the Dampness will accumulate and
stagnate in the middle jiao. This will inhibit the movement of qi through the middle
jiao and can thus interfere with the functioning of many other organs.
As well as their central role in the movement and transport of vital substances,
the Stomach and Spleen, together with the Kidneys and Lung, are fundamental
in the production of qi, xue and jinye.
The Spleen transforms the food and beverages that are ingested, separating the
pure qi aspects from the impure. The Spleen then sends these pure aspects upwards
to the upper jiao, whilst its partner organ, the Stomach, sends the remaining dregs
downwards for further transformation and finally expulsion from the body. If
the Spleen is weak, there will only be a limited production of qi, xue and jinye.
This will affect the whole body and all the other organs, as well as the movement,
transformation and transportation of these substances.
The aetiology of Spleen imbalances

It is said that ‘the Spleen detests Dampness’ and that it ‘prefers dryness’. This
means that the Spleen’s qi mechanism is easily disrupted when there is Dampness.
The Dampness can be exogenous or it can be internally generated. Invasions of
exogenous Dampness are usually due to climatic influences, such as when a person
spends time in a damp environment or is exposed to wet, humid weather. Invasions
of exogenous Dampness have traditionally been a major aetiological factor in
North‑Western Europe, because this area has a cold and humid climate. In the old
days, these aetiological factors were even more predominant, due to poorer standards
of housing. At the same time, a greater proportion of the population was employed
in occupations where they were more exposed to the elements. Exogenous Dampness
is, however, still a problem, despite the improvement in housing and changes in the
labour market. This is because the air is still generally quite damp and humid and
people are exposed to the elements when cycling, walking, jogging and so on. It is
therefore important that people are properly dressed and that they quickly change
into dry clothes if they get wet. Dampness can enter the body through the legs’
yin channels, so people, especially women, should ensure that they are adequately
clothed on their legs and wear appropriate footwear when it is cold and damp.
Furthermore, living in buildings that have fungal infections such as dry rot can
provoke or generate symptoms of Dampness in some clients. Mould and other fungi
will therefore often be considered to be a form of exogenous Dampness.
Dampness can also be internally generated. This will occur because there is Spleen
qi xu and the Spleen is unable to transform the food and liquids that have been
consumed. The resulting Dampness will then in itself further burden the Spleen.
Dampness can also arise from an excessive consumption of foods and beverages
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that have a Damp nature, such as dairy products, sweets, sugar, bananas, beer and
wheat flour. One of the tasks that Spleen yang performs is that of transformation
and transportation. If there is an excessive consumption of food and beverages that
are cold, either in their energetic dynamic or in their temperature, this will strain
the Spleen yang. Therefore, an immoderate consumption of raw vegetables, salad,
fruit, cold water, ice cream and so on can have a negative effect on the Spleen. It is
especially detrimental for the Spleen yang if cold water is drunk with meals.
In general, the diet and the way it is eaten is the single most important factor
in the development of Spleen-related imbalances. People often eat and drink products
that are too cold (both energetically and in their temperature), things that are too
sweet or foods that in themselves create Dampness and Phlegm. They eat food that is
too coarse and raw. They eat too quickly, too much at a time, late at night and food
that is of poor quality. The tendency to have Spleen qi xu and Phlegm-Dampness
is often initiated in the first years of a person’s life. Giving a baby or a toddler the
wrong diet or feeding them incorrectly can easily burden and weaken the Spleen,
which is not fully developed and therefore vulnerable. This will create a fundamental
tendency to have Spleen qi xu and for Dampness and Phlegm to form, which further
compromises the Spleen qi, creating a vicious circle.
Although eating too much, too fast and too late are often cited as causes of Spleen
and Stomach imbalances, it is important to remember that eating too little will also
damage Spleen qi. Malnutrition due to starvation and hunger is not as big a problem
in North-Western Europe as it was historically. Nevertheless, it is still a problem
when someone has an eating disorder, eats a strict diet or eats a very one-sided
diet. Furthermore, some people eat too much, but the food they eat is of very poor
quality. All of these factors can lead to Spleen qi xu. Unfortunately, many people who
are overweight and go on strict diets quickly put on weight when they start eating
normally again. This is because the strict diet will have weakened their Stomach and
Spleen qi and thereby led to the creation of Dampness and Phlegm. Patients who
have a history of anorexia and bulimia will often have seriously damaged their Spleen
and Stomach qi. This is due to the extreme malnutrition that is a consequence of
their disorder fundamentally weakening their Spleen and Stomach qi, but also the
repeated and forced vomiting will disrupt the Stomach and Spleen qi mechanism
and these organs then have difficulty sending their qi in the right direction.
Some forms of pharmaceutical medicine, for example antibiotics, have a very
cooling and Damp-producing energy. The use of these medicines can therefore
injure Spleen yang.
Spleen yang is supported by Kidney yang and mingmen, but if these are weak
Spleen yang will also become weakened and will not be able to fulfil its functions in
relation to the transformation and transportation of qi and fluids in the body.
If the Spleen and Stomach qi mechanism is to function optimally, it is important
physically that there is an open passage through which qi can be sent up and down
from the middle jiao. If the person sits with a twisted midriff or sits slouched and
slumped in a chair, it will physically block the movement of qi. Physical activity
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and exercise help to support the circulation of qi in the middle jiao. Therefore, a

person who leads a very sedentary life will tend towards having a stagnation of qi in
the middle jiao.
Worry, speculation, thinking too much and studying can ‘bind’ and stagnate the
Spleen’s qi. This can lead to a weakening of the Spleen qi. If a person reads, watches
television, writes on the computer, surfs the internet and so on whilst they eat, it will
weaken the Spleen qi. This is because the Spleen must use its qi to digest or separate
the pure from the impure, both intellectually and physically. In general, studying
and reading too much strains Spleen qi and can lead to Spleen qi xu.
Chronic illnesses, physical overexertion of the body and heavy bleeding or
haemorrhaging can lead to Spleen qi xu. This is because the Spleen will have to
overwork to create sufficient gu qi to replenish the chronic xu condition.
The pathology of Spleen imbalances

If the Spleen is not able to transform the food and fluids that are ingested adequately,
the pure qi will not be separated from the impure dregs. This will result in pure qi
being conveyed downwards along with the impure residue. This means that the
person will lack qi and they will therefore feel tired and fatigued. When there is only
a partial transformation of the consumed substances, Dampness will arise. This is
because some of the impure residue that should have been separated from the pure
qi will be sent upwards along with the pure qi, instead of being sent downwards to
the Small Intestine. This can often be seen on the tongue, which develops a greasy
or sticky coating.
Dampness can result in fatigue, because the Spleen is overburdened and thereby
produces less qi and because the Dampness will inhibit the movement of qi in the body.
When there is Dampness, the fatigue will often be most pronounced in the morning
and after consuming Damp-producing foods. If there is Spleen qi xu, the fatigue
becomes more pronounced as the day goes on. Both Dampness and Spleen qi xu can
manifest with fatigue and sleepiness after meals. This is because the Spleen qi that
is available is used to transform the food and because the Dampness that arises as a
result of the inadequate transformation or was already present will block the pure
yang qi from ascending up to the head. Furthermore, Damp-Phlegm can settle like
a fog and block the shen.
If the transformation of the food has been incomplete or if there is Dampness,
the stool can be loose and formless. If there is Spleen yang xu or if there has been an
invasion of exogenous Damp-Cold that extinguishes the Spleen’s physiological fire,
the transformation of the ingested food and liquids will be so limited that the stools
are watery and contain undigested food. If there is Damp-Heat, the Heat can cause
the stool to become sticky and odorous. There may well be a stinging or burning
sensation in the rectum. The Heat can be so intense that it agitates xue so much that
it bursts the walls of the vessels, resulting in blood in the stool. Blood in the stool can
also be seen when there is Spleen qi xu, because one of the Spleen’s tasks is to hold
xue inside the vessels. If there is Spleen qi xu, there can be bleeding in the Intestines,
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and in fact all forms of bleeding can be the result of Spleen qi xu. It is typical, for
example, that mid-cycle spotting and prolonged or heavy menstrual bleeding in
women can be a manifestation of Spleen qi xu. Furthermore, the inability to hold
the xue inside the vessels can mean that Spleen qi xu manifests with easy bruising.
Spleen qi not only holds xue inside the vessels, it also lifts and holds organs
in place. Thus, when there is Spleen qi xu, and particularly Spleen yang xu, it can
manifest with organ prolapse, hernias, haemorrhoids and a sensation of heaviness or
that everything is dragging downwards in the body.
If there is a reduction in the production of gu qi, it will not only result in fatigue,
but it can also lead to xue xu, because xue is created from gu qi.
Furthermore, a poor production of qi and xue can cause the muscles, especially
in the arms and legs, to feel weak or feeble, because the muscles lack nourishment.
Dampness can manifest with a sensation of heaviness in the arms and legs. The limbs
feel heavy because Dampness is a yin pathogen and because it inhibits the movement
of qi. Damp-Heat, on the other hand, can make the muscles feel painful. If there
is Spleen yang xu, the arms and legs can feel cold, because when there is yang xu
there is not enough physiological heat in the body to warm the limbs. This lack
of physiological heat is why the stool can be watery and contain undigested food.
Watery stools and coldness of the limbs are key signs when differentiating Spleen
yang xu in relation to Spleen qi xu.
When the Spleen and Stomach do not send their qi upwards and downwards
respectively, it will stagnate in the middle jiao. This will manifest as abdominal
bloating and distension. The distension and bloating will be most apparent after
the ingestion of food. The qi stagnation in and around the Stomach and Spleen
can also often manifest with a reduction in the appetite or nausea. Poor appetite is
actually an interesting sign. In the Chinese textbooks, poor appetite is a key sign
when diagnosing Spleen qi xu. Nevertheless, the majority of clients who are Spleen
qi xu report that they have a healthy appetite. There can be several reasons why
they respond in this way. First, there are several mechanisms that result in a person
wanting or needing to eat. As well as ingesting food being a fundamental necessity
in order to provide nourishment to the body, eating is a form of pleasure, a way of
comforting the psyche and something to do when you are bored. Consequently, one
or more of these mechanisms can result in a desire to put food into the mouth, even
if the Stomach does not feel particularly hungry. Furthermore, many people with
Spleen qi xu also have Heat in the Stomach. This means that they have an increased
appetite. A useful question to ask patients is whether they have an appetite in the
morning. Many people who are Spleen qi xu have no appetite in the morning and
often skip breakfast. This is because the Spleen and Stomach are too weak to send
their qi up and down, and the circulation of qi in and around the middle qi will
only start functioning when there has been sufficient physical activity to activate
it. This is even worse if there is Damp. Dampness tends to stagnate in and around
the Stomach and Spleen when the person has been lying still all night, and this will
block the already weakened movement of qi.
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People who are Spleen qi xu will often have a craving to eat things that are
sweet. This is because the sweet flavour tonifies the Spleen. Therefore, the Spleen
being qi xu will cause the body to crave the sweet flavour in an attempt to tonify the
Spleen. The problem is that most people react to this signal by consuming sweets,
chocolates, cakes and other things that are very sweet. The sweet flavour here is
very concentrated – so much so that the Spleen can have difficulty transforming it,
resulting in Dampness and thereby a further weakening of the Spleen. This gives rise
to a new craving for the sweet flavour to tonify the Spleen and a vicious cycle arises.
As well as the appetite being reduced when there are Spleen imbalances, the
resultant Dampness means that there will be an increased amount of fluid, which
can result in reduced thirst. The person can ‘forget’ to drink. The problem is that
Dampness is a form of xie qi, and being xie qi, it has none of the moistening,
lubricating and cooling qualities that jinye has. When there is Damp-Heat, the
paradoxical situation can arise in which Heat causes the person to be thirsty but the
Damp aspect means that the person does not feel like drinking.
Because Damp is a condensed form of body fluid, there can be a sticky sensation
in the mouth. When there is Damp-Heat, there can also be a bitter taste in the
mouth if the Heat aspect is intense.
If the Spleen is not able to perform its functions of transforming and transporting
fluid in the body, oedema can arise. The oedema will be chronic and it will often be
aggravated by consuming certain foods. Moreover, the oedema can also arise in the
premenstrual period if stagnant Liver qi ‘invades’ the Spleen. Other symptoms and
signs that Liver qi is invading the Spleen in the premenstrual period are abdominal
bloating or distension, a craving for sweets and loose stools.
As stated, Dampness and Phlegm can arise as a consequence of Spleen qi xu. This
can result in a tendency to put on weight. Dampness can manifest with the person
developing a pear-shaped body, because Dampness seeps downwards to the lower
jiao due to its yin nature. It is very typical for women to develop this type of body
shape from the age of 35 years onwards, because when women enter the sixth jing
cycle, mingmen decreases in intensity. At the same time, their Spleen qi is decreasing
in strength because it has been working hard for 21 years to replenish the xue that
has been lost through menstrual bleeding. Men do not start to gain weight due to
the decrease in mingmen until they are 40 years old and enter their sixth jing cycle.
Also, because men are more yang, the weight gain sits higher up around the belly.
Spleen qi xu does not necessarily lead to a gain in weight. Spleen qi xu can also
be a cause of weight loss and a body that is too lean. The reduced production of gu
qi that is a consequence of Spleen qi xu can lead to qi xu and xue xu, resulting in the
muscles and tissues not receiving sufficient nutrition.
A person who is Spleen qi xu will often have a slightly pale face, because there
can be a genuine lack of xue, due to the reduced production of gu qi, and not enough
qi to carry xue up to the face. When there is Dampness, the face and possibly also
the eyes can have a yellowish tinge or hue.
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Constant worrying, speculating, ruminating and thinking too much in general

will stagnate and bind, thereby ultimately weakening the Spleen qi. Conversely,
if the Spleen is qi xu, this can manifest with a tendency to worry excessively or
unnecessarily, the person also having difficulty in letting go of thoughts. This is
because they are not able to transform information and extract the relevant from the
irrelevant. Their yi stagnates and they start to think in rings. In extreme cases this
can become obsessive, as in obsessive–compulsive disorder (OCD), or it can become
a depressive condition. Spleen qi xu can also result in a person having difficulty
studying and learning. This is especially noticeable if there is Damp-Phlegm,
because it will cloud the shen and the person will have difficulty concentrating. It
will feel as if their head is full of cotton wool or there is mental fog. Furthermore,
the reduced production of gu qi can lead to xue xu and the brain not being nourished
by Heart xue.
General symptoms and signs of a Spleen imbalance

• Fatigue, especially after meals
• Loose stools
• Poor appetite
Shi patterns
Damp-Cold invading the Spleen
This pattern can be both acute and chronic. If it is an acute pattern, it will be due
to an invasion of exogenous xie qi. It will, however, still be classified as an interior
imbalance, because the xie qi is located in the interior.
Aetiology
Damp-Cold can invade the Spleen when a person has been living or working in a
cold and humid environment, has been wearing wet clothes or has been consuming
medicine, food or beverages that are cold and damp, in either their temperature or
energy. Damp-Cold can also invade the body via the Spleen channel in the feet and
legs, if the person has walked bare foot on cold and damp surfaces or has worn shoes
that are not warm and dry enough.
Coming into contact with certain bacteria and viruses can result in Damp-Cold
conditions. This can be anything from eating food that has gone off to cholera.
This is because a pattern of imbalance is defined by its symptoms and signs. If
the symptoms and signs are those that are seen in Damp-Cold, then that which
has caused the imbalance will by definition be Damp-Cold in nature and will be
treated accordingly.
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Symptoms and signs

• Poor appetite
• Nausea
• Abdominal distension or sensation of fullness in the abdomen
• Loose stools or diarrhoea
• Sticky taste in the mouth
• Lack of thirst
• Loss or reduction in the sense of taste
• Heaviness of the arms and legs
• White, sticky vaginal discharge
• Oedema
• Cold sensation in abdomen
• Fatigue
• Heaviness in the body and head
• Brain fog, difficulty thinking clearly or a sensation that the head is full of
cotton wool
• Dull, white complexion
• Thick, white and greasy tongue coating on a pale tongue, in chronic patterns
the coating will not necessarily be as thick
• Slippery and Slow pulse, when there is an invasion of exogenous xie qi, the
pulse will be fuller
Key symptoms
Loose stools, no appetite, no thirst, slippery pulse and white greasy tongue coating.
Treatment principle
Transform and drain Dampness and Cold.
Acupuncture points
Choose from: St 8, Sp 6, Sp 9, Ren 6, Ren 8, Ren 9, Ren 11 and UB 22.
• If there is also Spleen qi xu, add: Sp 3, St 36, Ren 12, UB 20 and UB 21.
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Needle technique
Tonify St 36, Sp 3, Ren 12, UB 20 and UB 21. Draining or even technique on St
8, Sp 6, Sp 9 and UB 22. Moxa on Ren 6 and Ren 8; moxa can also be used on the
other points.
Explanation
• St 8 drains Damp-Phlegm from the head.
• Ren 9, Sp 6, Sp 9 and UB 22 drain Dampness.
• Ren 6 and Ren 8 with moxa expel Damp-Cold from the middle jiao.
• Ren 11 regulates qi and drains Dampness from the middle jiao.
• St 36, Sp 3, UB 20 and UB 21 tonify Spleen qi, transform Dampness and
regulate qi in the middle jiao.
Herbal formula
• Hou Po Wen Zhong Tang (Dispels Cold, transforms Dampness and regulates
the Stomach and Spleen qi)
Relevant advice
A person with Damp-Cold invading the Spleen should avoid food and beverages
that are cold, both energetically and in their temperature. They should also avoid
consuming anything that produces Dampness. This means that dairy products, cold
drinks, ice cream, sweets, cake, dried fruit, wheat, sugar, lettuce, cucumber, tomato,
melon and tropical fruit should be avoided. They will benefit from consuming foods
that are cooked, baked and roasted and have a warming energy. Ginger will be
particularly good, as it is warming but also spicy and thereby expels exogenous xie qi.
Keeping the abdomen warm and dry is also vital in this pattern of imbalance.
Damp-Cold invading the Spleen can be caused

• Spleen qi xu
• Spleen yang xu
Damp-Cold invading the Spleen can result in

• Spleen yang xu
• Phlegm-Dampness
• Damp-Heat
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Damp-Heat invading the Spleen

The major difference between this and the previous pattern is the presence of Heat
symptoms and signs. Like Damp-Cold invading the Spleen, this pattern can be
both acute and chronic. An acute condition will occur when there is an invasion
of exogenous xie qi, whereas a chronic condition is usually the result of Spleen qi
xu creating Dampness or consuming food and beverages that create Dampness
or Damp-Heat. Dampness, when it stagnates, will generate Heat and transform
into Damp-Heat. This process is accelerated if there is already Heat present in the
body. This will typically be Liver qi stagnation Heat.
This pattern is often characterised by there being a chronic condition of latent
Damp-Heat, which flares up every time food or beverages are consumed that
generate Damp, Heat or Damp-Heat.
In general, the symptoms will be milder and less pronounced when there is a
chronic condition.
Aetiology
Invasions of exogenous Damp-Heat, such as the ingestion of contaminated food,
living or working in hot and humid conditions and direct contact with viruses,
bacteria and other pathogens that have a Damp-Heat nature. The excessive intake
of foods that have Damp-Heat-generating energy can be both a root cause and an
aggravating factor.
Damp-Heat can often arise as a consequence of chronic Spleen qi and Damp
conditions.
Symptoms and signs

• Loose or sticky stools
• Odorous stools
• Burning or stinging sensation in the rectum when defecating
• Oppressive or blocked sensation in the epigastric region or the lower part of
the abdominal cavity
• Epigastric or abdominal pain
• Flatulence that is odorous
• Greasy or oily skin
• Smoky or dull yellowish sheen to the facial complexion
• Poor appetite
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• Bitter taste or sticky sensation in the mouth
• Oily or sticky sweat
• Odorous sweat
• Slight fever or sensation of heat
• Aversion to heat or to hot, humid environments
• Red, itchy, inflamed or weeping skin diseases
• Oppressive headache or heaviness in the head
• Blurred sensation in the head as if the head is full of cotton wool
• Yellowish sclera
• Yellowish, sticky tongue coating possibly with red elevated papillae, the
tongue may be red but it is often pale or normal coloured in chronic
conditions where there is an underlying xu condition
• Rapid and Slippery pulse
Key symptoms
Sticky and odorous stools, yellowish sticky tongue coating and Slippery pulse.
Treatment principle
Drain Damp-Heat.
Acupuncture points
Choose from: St 25, St 28, St 44, LI 11, Sp 6, Sp 9 and UB 22.
• If there is also Spleen qi xu, add: Sp 3, St 36, Ren 12 and UB 20 and utilise
a tonifying needle technique.
Needle technique
Draining.
Explanation
• St 25, St 28, St 44 and LI 11 drain Damp-Heat from the Stomach and
Intestines.
• Sp 6, Sp 9 and UB 22 drain Dampness.
• St 36, Sp 3, UB 20 and Ren 12 tonify Spleen qi, transform Dampness and
regulate qi in the middle jiao.
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Herbal formula
• San Ren Tang (Clears Heat and Drains Dampness)
Relevant advice
It is essential that a person with chronic Damp-Heat invading the Spleen avoids, as
far as possible, food and beverages that create Damp-Heat, Dampness or Heat. It
is usually not enough to avoid sugar, sweets, cake and so on; they should also avoid
dried fruits, stevia, artificial sweeteners and anything else that has a concentrated
sweet flavour. Alcohol, hot spices including chilli, pepper, chocolate and garlic will
also be problematic, as will dairy products. Whilst they should avoid things that
create Damp-Heat, they should try to consume a diet that is beneficial for the Spleen.
Damp-Heat invading the Spleen can be caused

• Spleen qi xu
• Spleen yang xu
• Damp-Cold invading the Spleen
• Stomach Fire
Damp-Heat invading the Spleen can result in

• Spleen qi xu
• Phlegm
• Phlegm-Fire
Xu imbalances
Spleen qi xu
Spleen qi xu is, alongside Liver qi stagnation, probably the most common pattern
one meets in the clinic. This is mainly a consequence of the diet that many people
consume and the way in which they eat their food, which often puts a great strain
on the Spleen qi.
Most patterns of Spleen imbalances are simply variations of Spleen qi xu.
Furthermore, Spleen qi xu is often central in the creation of patterns of imbalance
in many other organs. Several of these combined patterns become self-generating,
where one pattern results in the creation of the other and vice versa.
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Aetiology
The primary cause of Spleen qi xu is consuming food and beverages that are cold (in
both their temperature and energy), raw foods and food that is unrefined or Damp
producing. Eating too much at a time, eating too quickly or not chewing the food
enough will also burden the Spleen. Although eating several small meals is better for
the Spleen, constantly snacking will also strain the Spleen because it will constantly
have to transform the ingested food.
Spleen qi can also be weakened by excessive worrying, speculating, studying and
ruminating.
Prolonged illness, excessive bleeding and overexertion are also a burden on the
Spleen, because it has to replenish the qi and xue that have been consumed or lost.
Chronic Liver qi stagnation will often lead to a disturbance, and thereby a
weakening, of Spleen qi.
Finally, living or working in a humid environment can strain the Spleen, because
the Spleen abhors Dampness.
Symptoms and signs

• Fatigue
• Loose stools
• Abdominal bloating after meals
• Pale complexion
• Weak limbs or tiredness in the limbs
• Craving for sweetness
• Flatulence that is not odorous
• The person emanates fatigue and a lack of energy
• Poor posture
• The skin or muscles may seem slightly doughy and lack tone
• Excessive worrying
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Key symptoms
Fatigue, loose stools, pale tongue with teeth marks and a Weak pulse.
Treatment principle
Tonify Spleen qi.
Acupuncture points
Needle technique
Explanation
Herbal formula
• Liu Jun Zi Tang (Tonifies Spleen qi and transforms Phlegm-Dampness)
Relevant advice
Dietary changes are alpha and omega in the treatment of Spleen qi xu. This
encompasses both what is eaten and how it is eaten.
A person who is Spleen qi xu should eat as much prepared and warm food as
possible. They should avoid raw vegetables, salads, food that is very coarse, cold
drinks, ice cream and food that generates Dampness, such as sweets, dried fruit,
artificial sweeteners, honey, stevia, dairy products, bananas, avocados and so on. They
should avoid eating too quickly, too much at a time and whilst reading, watching
television or working. They should chew their food well and avoid drinking too
much at mealtimes. They will benefit from eating soups, mashed vegetables, purées,
porridge in the morning, stews, steamed or boiled vegetables and baked vegetables,
i.e. food that is easily digestible and, preferably, warm. The weaker their Spleen qi
is, the more digestible their food should be, as long as it does not create Dampness.
Drinking a small cup of ginger tea at mealtimes will help to fortify Spleen yang,
thereby assisting the Spleen in its transformation of the food. The use of herbs in the
diet, especially aromatic spices like black pepper, ginger, cardamom, garlic, cumin,
caraway and nutmeg, will also assist in circulating qi, dispersing Food stagnation
and transforming Dampness, thereby alleviating the burden on the Spleen.
Foods that are particularly beneficial are: rice, oats, barley, most vegetables
especially root vegetables, squash, sweet potatoes and those that are yellow or orange
in colour, red lentils, tofu, chickpeas and chicken.
It is important that the person does not regularly sit still for extended periods of
time and that they do not sit in a slumped posture. Walking or stretching after meals
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is recommended. Physical exercise in general will be beneficial, as long as the person

does not overexert themselves. Stroking downwards with the fingers from Ren 16 to
Ren 8 will help Stomach qi to descend.
Meditation is interesting in the context of Spleen qi xu. Often we recommend
yin activities like meditation rather than physical activity when there are qi xu
conditions. However, meditation where you sit still for long periods of time can
burden the Spleen and excessive mental focus can consume Spleen qi. This does not,
though, mean that meditation in itself is negative when there is Spleen qi xu, it just
requires taking certain factors into consideration. If you are able to meditate with an
empty mind then it will be beneficial. Meditation is also an excellent tool to reduce
the tyranny of worry, speculation and repetitive thoughts. Walking meditation will
generally be a better option for a person who is Spleen qi xu, as walking circulates
qi in the middle jiao, while sitting still can cause qi to stagnate in the middle jiao.
Spleen qi xu can be caused by the following patterns of imbalance

• Chronic xue xu
Spleen qi xu can result in the following patterns of imbalance

• Spleen yang xu
• Food stagnation
• Dampness
• Phlegm
• Xue xu
• Lung qi xu
• Heart qi xu
Spleen yang xu
Spleen yang xu is often a development of Spleen qi xu, but it can be the consequence
of other imbalances. The symptoms and signs that define this pattern are very similar
to those seen when there is Spleen qi xu. There will, though, also be signs of xu Cold
in this pattern.
Aetiology
An excessive consumption of cold or cooling food and beverages (both in their
temperature and energy), the consumption of antibiotics and repeated invasions of
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Dampness and Cold in the middle jiao can all damage Spleen yang. Spleen yang will
also be adversely affected by living or working in a cold and humid climate.
Spleen yang xu and Kidney yang xu are often seen together and one will often
lead to the generation of the other. In the end, it becomes difficult to determine
which is the root cause.
Symptoms and signs

• Fatigue
• Loose stools or watery stools containing undigested food
• Cold arms and legs
• Poor appetite
• Craving sweet flavours
• Preference for warm food and beverages or a pronounced aversion to cold
drinks and salads
• Pale face
• Desire to lie down
• Poor posture
• Tendency to wrap their arms around themselves in an attempt to keep warm
• Can be dressed in warmer clothes than other people
• Cold limbs
• Weakness or fatigue in the arms and legs
• Oedema
• Tendency to put on weight
• Pale, swollen and wet tongue, possibly with teeth marks on the sides
• Deep, Weak pulse, especially in the right guan position
Key symptoms
Fatigue, loose stools, aversion to cold, cold limbs and Weak pulse.
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Treatment principle
Tonify and warm Spleen yang.
Acupuncture points
Choose from: St 36, Sp 3, Sp 6, Ren 6, Ren 12, UB 20 and UB 21.
Needle technique
Explanation
• St 36, Sp 3, Sp 6, Ren 6, Ren 12, UB 20 and UB 21 tonify Spleen yang.
Herbal formula
• Li Zhong Tang (Tonifies and warms Spleen yang)
Relevant advice
The advice given for Spleen yang xu is the same as that given for Spleen qi xu.
When there is Spleen yang xu, it is even more important that the person avoids
food, beverages and drugs that are cold in their energy or temperature, as well as
consuming things that have a warming energy, such as cinnamon, ginger, cloves,
lamb and so on.
Spleen yang xu can be caused by the following patterns of imbalance

• Spleen qi xu
• Kidney yang xu
• Invasions of Damp-Cold
Spleen yang xu can result in the following patterns of imbalance

• Kidney yang xu
• Food stagnation
• Damp
• Damp-Cold
• Phlegm
• Xue xu
• Lung qi xu
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• Heart qi xu
• Heart yang xu
Spleen qi sinking
Spleen qi sinking is almost the same as Spleen qi xu. The difference between the
two patterns is that when there is Spleen qi sinking, there are specific symptoms
that relate to Spleen qi failing to carry out its function of lifting and holding
organs and structures in the body in place. This can manifest in anything from
a mild dragging sensation in the body to a prolapse of organs or structures, for
example hernias and rectal prolapse. Spleen qi is also needed to hold a foetus in
the Uterus during pregnancy. Spleen qi sinking can therefore also manifest with
spontaneous miscarriages.
Aetiology
Apart from the relevance of the same aetiological factors that can result in Spleen qi
xu, factors such as repetitive lifting of heavy objects will weaken Kidney yang, which
supports the Spleen in its function of lifting and holding things in place in the body.
Symptoms and signs

• Organ prolapse – such as uterine prolapse, rectal prolapse, hernias,
haemorrhoids and so on
• Dragging sensation as if the insides are about to fall out of the body
• Fatigue
• Loose stools
• Poor posture
• Difficulty sitting up straight
• Desire to lie down
• Limp muscles in the arms and legs
• Facial muscles appear weak so the cheeks are hanging
• Poor appetite
• Disinclination to speak
• Pale, swollen tongue with swollen sides and teeth marks
• Deep and weak pulse, especially in the right guan position
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Key symptoms
Organ prolapse, dragging or sinking sensation, fatigue and weak pulse.
Treatment principle
Tonify and raise Spleen qi.
Acupuncture points
Choose from: St 36, Sp 3, Sp 6, Ren 6, Ren 12, Du 20, UB 20 and UB 21.
Needle technique
Tonifying. Moxa should be used on Ren 6 and Du 20.
Explanation
• St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21 tonify Spleen yang.
• Ren 6 and Du 20 together raise and lift qi throughout the body when used
with moxa.
Herbal formula
Relevant advice
As well as following the advice that is recommended when there is Spleen qi xu, it is
important that the patient avoids heavy lifting.
Spleen qi sinking can be caused by the following patterns of imbalance

• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
Spleen qi sinking can result in the following patterns of imbalance

• Kidney yang xu
Spleen qi not holding xue inside the vessels

This is again a variation of Spleen qi xu. In this pattern, the Spleen is not able
to perform its function of keeping xue inside the vessels. This will manifest in
bleeding and bruising. The bleeding can take many forms; it may be different kinds
of menstrual disorders, such as mid-cycle spotting, heavy menstrual bleeding or
prolonged menstrual bleeding, or there may be nosebleeds, blood in the urine
or blood in the stools. It is, however, important to remember that ‘Spleen qi not
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holding xue inside the vessels’ is just one of several patterns that can result in
bleeding. Bleeding can also occur when there is xu or shi Heat and when there is
xue stagnation. There will usually be a combination of more than one pattern at a
time. Furthermore, it is important to remember that these patterns will lead to the
development of xue xu over time.
Milder cases of Spleen qi not holding xue inside the vessels are seen in people
who have a tendency to bruise easily.
Aetiology
The aetiology of this pattern is identical to that of Spleen qi xu.
Symptoms and signs

• Heavy or prolonged menstrual bleeding
• Spotting or bleeding in the middle of the menstrual cycle
• Blood in the urine
• Blood in the stool
• Nosebleeds
• A tendency to bruise easily
• Fatigue
• Loose stools
• Weakness or fatigue in the limbs
• Pale complexion
• Pale tongue
• Weak or Fine pulse, especially in the right guan position
Key symptoms
Bleeding, fatigue, pale tongue and weak pulse.
Treatment principle
Tonify Spleen qi and astringe the vessels.
Acupuncture points
Choose from: St 36, Sp 1, Sp 3, Sp 6, Sp 10, Kid 8, Ren 12, UB 17, UB 20 and
UB 21.
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Needle technique
Tonifying. Moxa can be used on all points and must be used on Sp 1.
Explanation
• Sp 10 stops bleeding.
• Sp 1 with moxa stops bleeding.
• Kid 8 stops uterine bleeding.
Herbal formula
• Gui Pi Tang (Tonifies Spleen qi and nourishes xue)
Relevant advice
The advice given in the section on Spleen qi is also relevant here.
Spleen qi not holding xue inside the vessels can be

• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
Spleen qi not holding xue inside the vessels can

result in following patterns of imbalance
• Xue stagnation
• Xue xu
• Yin xu
Spleen yin xu
Most modern textbooks refer to yin xu conditions in the Heart, Liver, Lung and
Kidneys but not in the Spleen. Nevertheless, there have historically been discussions
and disputes as to whether the Spleen also has a yin xu pattern. Many authors
argue that the Spleen cannot be yin xu for the simple reason that the Spleen detests
Dampness and prefers Dryness, while others believe that the Spleen yin xu is not
only seen in practice but can also be justified theoretically.23 Spleen yin xu will often
be diagnosed as the combined pattern of Spleen qi xu and Stomach yin xu. From an
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acupuncture perspective, the differentiation between these two patterns and Spleen
yin xu will only have academic interest, as the treatment will be largely the same.
Aetiology
Spleen yin xu can arise through chronic overexertion. An excessive consumption of
hot, spicy food and medicines can injure the Spleen yin.
Spleen yin xu can be both a consequence and the root cause of yin xu in other
organs. This is because the condition will impair the Spleen’s transformation of the
fluids that have been ingested and this is the first stage in the production of jinye.
Symptoms and signs

• Bloated abdomen after meals
• Easily sated and can only eat small meals
• Epigastric fullness
• No or poor sense of taste
• Dry lips
• Dry mouth
• Oral ulcers
• Thirst that is easily quenched
• Burning sensation in the stomach or the abdomen
• Matt complexion
• Weight loss or lean body
• Dry stools
• Weak or fatigued limbs
• Sensation of heat in the palms of the hands and soles of the feet
• Red and dry tongue that lacks coating, possibly red and peeled in the central
area, there may be cracks on the tongue
• Fine and Rapid pulse
Key symptoms
Dry mouth and lips, easily sated, the central area of the tongue is red and lacks
coating.
Treatment principle
Nourish Spleen yin.
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Acupuncture points
Choose from: Sp 6, Ren 12, St 36 and UB 20.
Needle technique
Tonifying.
Explanation
• Sp 6, Ren 12, St 36 and UB 20 nourish Spleen yin.
Herbal formula
• Yi Pi Tang (Nourishes Spleen yin)
Relevant advice
A person who is Spleen yin xu should avoid eating food that is hot and spicy. They
will benefit from eating food that has a slightly sweet flavour, but they must also be
careful that they do not create Dampness. This is a fine balance because Spleen yin
should be moistened and nourished, but as this is a Spleen xu condition, Dampness
can easily arise.
Spleen yin xu can be caused by the following patterns of imbalance

• Stomach yin xu
• Stomach Fire
• Kidney yin xu
• Lung yin xu
• Heart yin xu
• Liver yin xu
Spleen yin xu can result in the following patterns of imbalance

• Stomach yin xu
• Kidney yin xu
• Liver yin xu
• Lung yin xu
• Heart yin xu
• Dampness
• Food stagnation
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Combined patterns
Stomach and Spleen qi xu
Stomach and Spleen qi xu is extremely common; in fact, it is probably more common
than a pure Spleen qi xu pattern.
Aetiology
The aetiology here is the same as that seen in Stomach qi xu and Spleen qi xu, i.e.
consuming foods that are cold or uncooked, that create Dampness and that are
unrefined. Eating too much at a time or too quickly will also put a strain on the
Spleen and Stomach qi. Eating too little or eating a diet that lacks nutrients will
weaken the Stomach and Spleen qi.
Although eating several small meals is beneficial for the Spleen, constantly
snacking will place a strain on the Spleen qi because the Spleen will be constantly
active.
Spleen qi and Stomach qi can also be weakened by worrying, constantly
speculating, studying and thinking too much.
Prolonged illness, excessive bleeding and overexertion can weaken the Spleen
qi and Stomach qi, as they will constantly have to replenish the qi and xue that has
been consumed or lost.
Chronic Liver qi stagnation will often disrupt the functioning of and weaken the
Stomach and Spleen qi.
Finally, working or living in a damp, humid climate or housing will burden the
Spleen.
Symptoms and signs

• Fatigue
• Abdominal discomfort
• Loose stools
• Pale complexion
• Deteriorated sense of taste
• Poor appetite or a lack of appetite in the mornings
• Weak or tired limbs
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• Tendency to put on weight

• The person emanates a sense of tiredness and fatigue
• Poor posture
• A tendency to worry excessively or easily worry about things
Key symptoms
Fatigue, loose stools, pale tongue with teeth marks and a Weak pulse.
Treatment principle
Tonify Stomach and Spleen qi.
Acupuncture points
Needle technique
Explanation
• St 36, Sp 3, Sp 6, Ren 12, UB 20 and UB 21 tonify Stomach and Spleen qi.
Herbal formula
• Liu Jun Zi Tang (Tonifies Stomach and Spleen qi)
• Shen Ling Bai Zhu Tang (Tonifies Stomach and Spleen qi)
Relevant advice
See Spleen qi xu.
Stomach and Spleen qi xu can be caused by the

• Stomach qi xu
• Spleen qi xu
• Food stagnation
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Stomach and Spleen qi xu can result in the following patterns of imbalance

• Stomach yin xu
• Spleen yang xu
• Food stagnation
• Dampness
• Phlegm
• Xue xu
• Lung qi xu
• Heart qi xu
Spleen qi xu and Liver xue xu

These two patterns frequently occur together and Spleen qi xu will often be the
underlying cause of Liver xue xu. It can therefore sometimes be appropriate to regard
them as a common pattern.
Aetiology
Spleen qi xu often arises from the excessive consumption of cooling, Damp-producing
or difficult-to-digest foods, such as dairy products, raw vegetables, wheat products,
sugar, sweets and so on. Eating too much at a time or eating too little will weaken
Spleen qi. Worrying or speculating excessively, as well as studying and thinking too
much, will burden the Spleen.
Spleen qi xu will result in a poor production of gu qi. Gu qi is the post-heaven
root of xue. This means that Spleen qi xu can lead directly to Liver xue xu. The
situation is often further complicated by Liver xue xu being a contributing factor
in the generation of Liver qi stagnation, which then invades and thereby weakens
Spleen qi, and a vicious cycle arises.
A long-term condition of Liver xue xu can in itself also lead to Spleen qi xu, because
the Spleen will be strained by constantly having to replenish the deficient xue.
Apart from Spleen qi xu, bleeding and a diet that does not contain sufficient xue-
nourishing foods can also be root causes of Liver xue xu.
Symptoms and signs

• Fatigue
• Loose stools
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• Dizziness, especially when getting up from sitting or lying down
• Difficulty focusing the eyes
• Visual disturbances such as floaters
• Dry eyes or a sensation of having grit in the eyes
• Pale, sallow complexion
• Pale, dry lips
• Poor appetite or no appetite in the mornings
• The person emanates a sense of fatigue and tiredness
• Poor posture
• The skin may be dry and the flesh below may lack tone
• Weak muscles and fatigue in the arms and legs
• Depression, sadness or lack of vision in life
• Constant worrying or speculating over minor issues
• A tendency to be weepy and to be extra sensitive in the premenstrual phase
• Scanty or lack of menstrual bleeding
• Ridged fingernails or weak and fragile fingernails
• Pale, swollen tongue, possibly with teeth marks on the sides, the tongue may
be dry, pale or orange sides to the tongue
• Fine, Weak or Choppy pulse, especially in both guan positions
Key symptoms
Fatigue, loose stools, pale complexion, dizziness, scanty menstruation, pale tongue.
Treatment principle
Tonify Spleen qi and nourish Liver xue.
Acupuncture points
Choose from: UB 17, UB 18, UB 20, UB 21, St 36, Sp 6, Liv 3, Liv 8, Ren 12 and
Ren 4.
Needle technique
Tonifying. Moxa can be used on all the points and should be used on UB 17.
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Explanation
• UB 17 nourishes xue in general.
• Liv 3, Liv 8, Sp 6 and UB 18 nourish Liver xue.
• Sp 6, St 36, Ren 12, UB 20 and UB 21 tonify Spleen qi.
• Ren 4 tonifies yuan qi and thereby increases production of xue.
Herbal formula
• Gui Pi Tang (Tonifies Spleen qi and nourishes xue)
Relevant advice
A person who is Spleen qi xu and Liver xue xu should eat a nutritious diet that
includes a large proportion of green-leafed vegetables, beetroot, black beans, kidney
beans, red meat, liver, bone marrow and other products that are rich in blood. The
food should be well prepared and eaten hot. They should avoid dairy products,
sugar, sweets and too many raw vegetables and salads.
Spleen qi xu and Liver xue xu can be caused by

• Liver xue xu
• Spleen qi xu
• Stomach qi xu
• Food stagnation
Spleen qi xu and Liver xue xu can result in the

• Qi xu
• Xue xu
• Spleen qi xu
• Spleen yang xu
• Heart xue xu
• Liver yin xu
• Kidney jing xu
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Spleen and Lung qi xu

This pattern is discussed in the section on Lung imbalance patterns (page 393).
Spleen and Kidney yang xu

This pattern is discussed in the section on Kidney imbalance patterns (page 546).
Spleen qi xu and Heart xue xu

This pattern is discussed in the section on Heart imbalance patterns (page 487).
Liver qi invading the Spleen

This pattern is discussed in the section on Liver imbalance patterns (page 590).
Heart imbalances
The Heart is an interesting organ. In Western medicine, the heart and the brain are the
two most important organs in the body. A person is declared dead when these organs
are no longer functioning. The Western medicine heart and brain can be considered
to be aspects of the same organ in Chinese medicine. Even though the brain is one
of the six extraordinary fu organs and is created from Kidney jing, it is nourished by
Heart xue and much of its functionality in Western medicine relates to the shen, which
has its residence in the Heart. This makes the Heart the most important organ in the
body in Chinese medicine. The Heart is described as being the Emperor in the body.
The Heart is a true emperor – it does not do that much in the physical day-to-day
functioning of the empire, but its balance and health are crucial for the functioning
of the whole realm. If you look at the functions it performs, the Heart does very little
compared with, for example, the Spleen. Yet it is the body’s most important organ. Just
like an emperor, shen is conscious of everything that is going on in the whole realm.
Every detail is reported back to it. Events occur in the various organs and body parts,
but it is shen that makes us aware that these have happened. For example, when we
burn our finger, it is the tissue and skin of the fingers that are burnt, but it is our brain
that perceives and interprets the signals that it receives from the nerve receptors in the
fingers. In the same way, it is our shen that makes us conscious of the sensations our
body experiences. This also happens on the emotional level. All emotional influences
will have an impact, not only on the organs that these emotions resonate with, but also
on the Heart. The Emperor has responsibility for the whole empire, therefore he must
be omniscient so that he knows what needs to be done in all situations and at all times.
It is his responsibility that the empire is harmonious and functions perfectly. Without
his guiding hand, there would be chaos and rebellion in the empire. The whole empire
would disintegrate. If the Emperor becomes weak or insane, he will not be able to rule
his kingdom. The same is true of the Heart. If the Heart loses its stability, havoc will
start to arise in the body. Therefore, there are many protective agencies around the
Heart, including the Pericardium. It is important that an invasion does not penetrate
into the Emperor’s residence.
487
The aetiology of Heart imbalances

Due to its responsibility and importance, the Heart needs to be protected from
attacks by exogenous xie qi. Heat that has been caused by invasions of exogenous xie
qi can penetrate as deep as the Pericardium, which protects the Heart, but does not
enter the Heart itself. This does not mean that the Heart cannot be disturbed by xie
qi but that the xie qi that disrupts the Heart will be internally generated. The Heart
is, for example, especially sensitive to all forms of internally generated Heat, both xu
and shi. Due to its yang nature, Heat tends to rise upwards in the body and therefore
it will often end up affecting the Heart, which is located in the upper jiao.
Invasions of exogenous Cold will not directly invade the Heart, but they can
create a stagnation of Heart xue, which can affect the functioning of the Heart.
The Heart is particularly affected by feelings and emotions. Although the
individual emotions affect specific organs, it is the shen that makes us conscious of
these feelings and the effects that they have. Anger, for example, affects the Liver, but
it is our shen that makes us aware that we are angry. When we are angry, the anger
causes our Liver qi to ascend upwards and it can generate Heat in the Liver. When
we are very angry, we are conscious of these changes, for example, the tension in the
shoulders, neck and head due to the qi rushing upwards. We are also conscious of
our emotional state. We are aware that we are angry. If anger affected only the Liver
and not the Heart, these changes would take place without us being conscious of
them. This means that any prolonged or extreme emotional influences will always
have an impact on Heart qi and shen. The Heart itself is directly influenced by
joy, and joy can be an aetiological factor that can be involved in the creation of
Heart imbalances. It can seem strange that joy could be something that creates an
imbalance in a person. Nevertheless, joy, or the lack of it, is a major aetiological
factor in Heart imbalances. First, joy has a nourishing effect on the Heart and shen.
A lack of joy in a person’s life will lead to the creation of a xu condition of the Heart
due to it being malnourished. This is also why several of the other emotions that
are ascribed to other organs directly affect the Heart qi. Melancholy, sorrow, worry,
fear and anger can all encompass an aspect of not being happy, of not being content.
Second, there can also be too much joy. This does sound paradoxical, but joy not
only nourishes the Heart, it also stimulates it. Too much stimulation of the Heart
will dissipate and thereby weaken the Heart qi. This is typically seen when a person
parties too much and is too ecstatic, especially if they consume stimulants and drugs
or there is unbridled hedonism. This constant stimulation of the Heart’s yang aspect,
the shen, will exhaust Heart qi and, particularly, Heart yin.
Furthermore, several of the other emotions will have an indirect effect on the
Heart by disrupting the functioning of their own organ. Anger, particularly when it
is suppressed, i.e. frustration and irritation, can stagnate Liver qi. This can cause qi
to stagnate in the chest and the Heart. Liver qi stagnation can also generate Fire in
the Liver, which can rise up to the Heart and generate Heart Fire. Melancholy and
sorrow will, apart from directly affecting the Heart, bind and weaken Lung qi. This
can lead to qi stagnation, qi xu and the accumulation of Phlegm in the upper jiao
488
and thereby in the Heart. Speculation and worry will bind and thereby weaken the
Spleen qi. This can lead to qi xu, xue xu and Phlegm-Dampness, all of which will
ultimately have an influence on the Heart. Fear weakens Kidney qi and can thus
disrupt the cooperation and communication between the Kidneys and the Heart, as
well as influencing the production of qi and xue.
Shock has a direct effect on the Heart. Shock dissipates and thereby significantly
weakens Heart qi.
The Heart is nourished by joy in all its manifestations. These include love and
affection. A lack of these, particularly in early childhood when the Heart, like other
organs, is not stable, can lead to a person developing deep-rooted Heart imbalances
that can affect them for the rest of their lives.
Stress is not an emotion in itself, but it is a condition that consists of several
emotional aspects. The composition of stress and the relative amounts of
these emotional aspects will be different from person to person and from stress
situation to stress situation. Nevertheless, stress will always affect the shen and
consume Heart qi and yin.
Dietary causes of Heart imbalances fall into two categories: those that affect
the Heart directly and those that affect the Heart indirectly. Food, beverages and
medicine that have a hot energy can directly create Heat in the Heart. Stimulants,
such as recreational drugs, coffee and some types of pharmaceutical medicine
drugs, can overstimulate the Heart, thereby spreading and consuming Heart qi and
injuring the Heart yin. Foods, drinks and medicines that have a hot dynamic can, as
well as creating Heat in other organs that will ascend upwards creating Heat in the
Heart, lead to the formation of Phlegm. Phlegm can also arise through the excessive
consumption of substances that in themselves produce Dampness and Phlegm.
Heat from food stagnation in the Stomach can also ascend and agitate the Heart.
Food stagnation can arise when food is consumed that is difficult to transform
because of eating too much, too quickly or too late in the evening.
The diet needs be nutritious enough to produce sufficient qi and xue; if it isn’t,
the Heart can become qi xu or xue xu.
Overworking, both mentally and physically, will weaken the Heart. Physical
exertion and strain, such as working too much and too hard, illness, too much sex
and so on, will weaken the qi and yang in the body. This can have both a direct
and indirect impact on the Heart. Mental and emotional strain, such as studying,
mental concentration, thinking a lot, working with a computer, excessive use of a
smartphone and stress, will all consume Heart yin and xue.
Blood loss, such as heavy menstrual bleeding, childbirth and operations can
lead to Heart xue xu. A significant loss of blood or fluids (such as extreme diarrhoea,
vomiting or sweating) can weaken Heart yang.
Old age is characterised by a depletion of qi, yin and yang, as well as an increased
accumulation of Phlegm and xue stagnation. These can all directly and indirectly
affect the Heart.
489
Some Heart imbalances that manifest as mental-emotional disorders can be

congenital, especially those that fall within the category of Phlegm blocking the shen.
There are several aetiological factors that by their nature are not traditionally
described in Chinese medicine. Computers and televisions can have a debilitating
effect on Heart yin because they overstimulate shen and consume Heart xue. This is
compounded when they are used in the evening or at night as relaxation activities.
The evening and night are the yin part of the day, when our shen should reduce
its activity and become more passive and reflective. This means the use of things
that stimulate and activate the shen will have a stronger negative impact when they
are used in this period of the day. That we are so active and awake in the evening
and at night is a modern challenge for our yin. Staying up and being mentally and
physically active was not so much of an option before the advent of electricity and it
has consequences for our yin aspects, particularly the Heart and Kidney yin.
The Heart has close relationships with several organs, and imbalances in these
organs can lead to imbalances in the Heart. Liver xue and Heart xue are closely
related and a xu condition of one of these will often result in a xu condition in the
other. The same is true of Liver qi and Heart qi. A stagnation of one will often lead to
a stagnation of the other. Gall Bladder qi and Heart qi do not have a close functional
activity on the physical plane, but there is a relationship on the psychological level.
A person who is Gall Bladder qi xu will also be Heart qi xu. Lung and Heart qi
cooperate closely in relation to zong qi, and a xu condition in the Lung will affect
the Heart and vice versa. The Heart and Kidneys have a yin and a yang relationship
to each other. Kidney yin nourishes Heart yin and thus helps to control the Heart’s
fire aspect. The Heart’s fire aspect helps to warm and activate Kidney yang, and
Kidney yang supports Heart yang. Furthermore, jing is the material basis for shen.
Heat from the Stomach can rise up to the Heart and create Heart Fire. Urinary
Bladder imbalances can arise when there are Heart imbalances, even though these
two organs do not have a direct connection, either physically or functionally. Xie
Heat from the Heart can be transmitted via the Heart’s partner organ, the Small
Intestine, to the Urinary Bladder, which has a taiyang channel relationship to the
Small Intestine. Furthermore, the Urinary Bladder divergent channel also connects
to the Heart.
The pathology of Heart imbalances

When the Heart is imbalanced, this can manifest with changes in both its physical
functions, such as the heartbeat, and how the shen is manifesting.
The Heart is the most yang organ in the body and the shen is the most yang
aspect of the body’s qi. This means that the Heart and in particular the shen are very
sensitive to xie Heat due to its yang nature. On the physical level, Heat will over-
activate the Heart, causing it to beat faster. This can manifest with palpitations and
a rapid pulse. It is perhaps important to point out here that palpations in Chinese
medicine means the subjective sensation that the physical heart is beating stronger
and faster than normal. If the Heart is in balance, you are not aware of the heartbeat;
it is not something you actually feel. Palpitations in Chinese medicine encompasses
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everything from being aware that the heartbeat is slightly more pronounced and
is noticeable, on the one hand, to outright disorders such as atrial fibrillation,
on the other. It is important to be conscious of this when interviewing a client,
because many patients have a sensation of their heartbeat sometimes being slightly
stronger, without them thinking of this as being palpitations. This is, nevertheless,
an indication that there is a Heart imbalance in Chinese medicine, and it is an
important sign.
Cold can also affect the Heart. The Heart as an organ cannot be directly invaded
by exogenous Cold. Exogenous Cold can, however, stagnate Heart xue and Cold
can therefore be a factor when there are Heart xue stagnation patterns. Yang xu
conditions can also result in the Heart not performing its functions optimally.
Like most Heart imbalances, Heart yang xu can manifest with palpitations. Where
palpitations in Heat imbalances are the result of the Heart qi being agitated and
over-activated, palpitations that are due to Heart yang xu, will be the result of
Heart yang losing control of the rhythmical pumping function of the Heart. This
is the same mechanism that results in palpitations when there is Heart qi xu. Heart
xue and Heart yin should anchor the Heart’s yang aspects, which include Heart yang
qi and shen. If there is Heart yin xu or Heart xue xu they will not be able to anchor
these yang aspects. This can, again, result in palpitations, due to the Heart no longer
being able to control its rhythmic pumping, but this time there will also be a slight
emotional unrest or anxiety that manifests concurrently with the palpitations, due
to the shen not being anchored.
If there is a significant disruption of the physical functioning of the Heart, such
as when there is Heart xue stagnation, there will not only be a disruption of the
rhythm and strength of the heartbeat, but there will also be cardiac pain or pain in
the thoracic region. The pain will be a fixed stabbing or piercing pain. If there is qi
stagnation, there will not be the same sensation of pain but more of a sensation of
chest oppression and tightness. It will feel as if there is an iron rim or a strong elastic
stretched around the chest. Phlegm stagnation will manifest with a similar but
different sensation. There will, again, be chest oppression, but Phlegm will manifest
with a heavy, blocked sensation in the chest as if there is a great weight, such as a
rock, lying on top of the thorax.
Because the Heart and the Lung have a very close relationship, a disturbance
of the Heart qi will also manifest with the breathing being affected. Similarly, zong
qi helps to drive xue through the vessels. If there is dysfunction in the Heart or
if zong qi is weak or stagnated, xue will not reach out to the extremities. This can
manifest in white, cold fingers and toes. This is typically seen when there is Heart
qi xu and Heart yang xu. Purple fingernails are seen in conditions where there is xue
stagnation, including Heart xue stagnation.
Shen encompasses the Western concepts of the mind and consciousness. When
there are Heart imbalances, they will nearly always manifest with changes in the
person’s shen, which can be anything from almost unperceivable, subtle changes
to severe personality disorders. Shen is nourished and anchored by Heart yin and
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Heart xue. If these are weak, shen will lack nourishment and rooting. The person
will be easily startled and unsettled, due to their shen lacking stability. Often,
the lack of anchoring will also cause the person to have difficulty sleeping or be
nervous, uneasy and restless. This will be more extreme if there is Heat due to yin xu.
The agitation and restlessness will not only be mental, but it will also manifest
physically with the person fidgeting and having nervous movements, especially
when they are uneasy.
Shen is, in general, very sensitive to Heat. Shi Heat in particular agitates the
shen. When the shen is agitated, the person will be mentally restless and feel uneasy.
Their shen becomes too active. The difference between xu and shi Heat will often
be seen in the intensity and severity of these manifestations. If there is shi Heat, the
person will seem to be more stressed, their mental unrest will be more pronounced
and they will be more irritable. If the Heat is intense, there will not only be mental
unrest, but also actual mania.
As stated, a deficiency of Heart yin and Heart xue can manifest with insomnia,
because the shen is not anchored at night, resulting in the person being awake and
conscious. Excess Heat in the Heart, such as when there is Heart Fire or Phlegm‑Heat,
can also result in insomnia. In these situations, even though Heart yin and xue are
not weak, they are not able to root the shen because it is being agitated by the
shi Heat.
The Heart is responsible for and controls communication and contact with
others. If there is an excess of Heat, the person can become too communicative. They
will be too open. These are the people who share their whole life story with complete
strangers, without the stranger even having shown any particular interest in hearing
it. In the clinic, these clients can be difficult to interview, because they talk too much
and give you far too many details, without you asking for them. They will usually
also talk more quickly, because Heat over-activates the shen, resulting in a cascade of
thoughts. The opposite of these patients are people who are uncommunicative and
taciturn. They can also be difficult in a clinical setting, because it can be a problem
drawing information out of them. This is usually a manifestation of the Heart qi
stagnating or being blocked. Phlegm can also obscure the shen by enshrouding it
in a blanket or lying like a mist around it. These people are not completely present.
It can be difficult to create and maintain contact with them. Their communication
can be a bit confused and their voice may sound slurred. If the Phlegm is very
concentrated, the shen can become so obscured that they talk nonsense, saying
one thing but meaning something completely different, or they are completely
enclosed in their own world and talk to themselves. The blocking and shrouding of
their shen will mean that their comprehension is impeded and they will also have
difficulty concentrating.
The memory and concentration will also be affected by other Heart Imbalances.
If shen lacks nourishment, for example if there is Heart xue xu, the memory and
concentration will be poor. Heat can also result in poor concentration, although
the dynamics are completely different. Heat will agitate shen so the mind is easily
distracted, and there will be too many thoughts arising in the head making it difficult
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to maintain focus and concentrate on one thing at a time. The activity and agitation
will also mean that their memory will often be poor because the information never
had a chance to settle and thereby be stored. Phlegm blocking the shen will also
result in difficulty concentrating. There is a mental fog and the person will have
difficulty thinking clearly and comprehending what is going on around them.
Shen manifests in the eyes. This means that when the shen is affected it is possible
to observe deviations here. Ideally, when the shen is in balance, the eyes will be
clear and bright. There will be good eye contact between you and the patient.
Heat agitates shen and can cause the person’s eyes to dart about and they can have
difficulty maintaining eye contact. When it is there, the eye contact will be clear
and even intense. A person who is Heart qi xu will find it difficult to maintain eye
contact, but this will be due to shyness or nervousness and their eyes will lack vitality
and sparkle. Phlegm can cause the eyes to be dull and matt; the person’s shen cannot
shine through the mist. When there is Heart qi stagnation, it is as if the person’s
vision becomes introverted and does not extend outwards from their eyes. It is as if
they lack vision and only look inwards towards themselves. When there is shi Heat,
the opposite happens and the eyes can be very intense.
One of shen’s functions is to ensure that we conform to society around us and
that our behaviour and responses are normal. If shen is agitated by Heat or blocked
by Phlegm, this function is disturbed. This can result in a person saying and doing
things that other people think are strange or weird. Their appearance may also seem
peculiar to others. People whose shen is disturbed can often be recognised by their
attire, their hair and their general appearance. Their clothes can be gaudy, discordant
or just muddled. It is important, however, to remember that what seems abnormal
to many people can be quite normal in a particular subculture; in this case the
person’s shen is in fine balance, they have just adopted different standards.
A person’s shen is an individual refraction of the universal shen. If their shen is
in harmony, they have a fundamental sense of belonging, a sense of tranquillity and
security. When shen is agitated, blocked or undernourished, the person can lose this
sensation and they can feel unease, anxiety or a fundamental loneliness.
A person who is Heart qi xu and whose shen is undernourished can have low
self-esteem and lack self-confidence.
The tongue is controlled by the Heart. If there is Heart Fire, the tongue will not
just be red, as is usual in Fire conditions, but there can also be ulcers and sores on the
tongue. The difference between these ulcers and those seen in Stomach and Spleen
imbalances is that when there is Heart Fire, the ulcers will be triggered or aggravated
by stress or emotional pressure. When there are Stomach and Spleen imbalances, the
ulcers are related to the diet. Furthermore, the ulcers will be more red and elevated
when there is Heart Fire.
The tongue is also used in communication with others. As explained above,
the Heart has a great influence on this communication and on our speech. Heart
imbalances can also affect the tongue in other ways; stuttering and stammering can be
due to the Heart qi being disrupted, meaning the Heart loses control of the tongue.
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Heart Fire can manifest with a bitter or metallic taste24 in the mouth in the
morning. When there is Liver Fire, the bitter or metallic taste will be experienced
throughout the day.
The Heart is nourished by and manifests with joy. If the Heart is qi xu or if there
is qi stagnation, the person can seem doleful, unhappy and lacking in vitality.
The voice should also have vitality. This is not dissimilar to the tongue, pulse,
skin and so on. These should have the quality of shen, i.e. a quality of vitality. The
same is true of the voice, but there are not the same connotations. When there are
xu conditions or stagnations in the Heart, the voice will lack a certain quality. This
quality isn’t volume and it isn’t necessarily joy, but it is related more to movement.
The voice should vary and change as they talk, especially as the subject area changes.
This reflects the natural movement of the shen. The voice should not be stuck in a
certain gear. No sound or emotion in the voice is wrong or inappropriate; it can
only be inappropriate to what is being said or to the conversation in general. In the
same way that the pulse should have shen, so should the voice. When the pulse is
soft, yet firm and solid and is rhythmic in its beating, it tells us about the quality of
the Heart. The voice should have an even flow and not be stuttering or confused, its
tone should go up and down and it should have the sound of joy and happiness in it.
If there is no joy, i.e. if Heart qi and shen are either blocked or undernourished, there
will be a flatness and maybe even a tone of sadness in the voice. On the other hand,
if there is too much Heat in the Heart, there can be too much of these qualities of
joy and happiness. The voice can be unnaturally glad. This is the ‘life and soul of the
party’ voice. Here, the voice will often be voluble and accompanied by too much
laughter and the person can seem elated and unnaturally happy. Also, there will
often be too many, and sometimes inappropriate, jokes. It may manifest with a
constant need to create laughter by repeatedly telling funny stories and making
jokes. All this indicates that there is too much Heat in the Heart. Heart yin xu Heat
will, though, result in a voice that is not voluble and the person will have more of a
nervous laugh or giggle while talking. There may be a short, nervous laugh that ends
their sentences, like a sort of inappropriate punctuation mark.
Although the Heart has no direct influence on the physiology of fluids, it can
nevertheless be involved in urinary imbalances. As well as urine becoming dark and
odorous when there are Heat conditions in general, Heart Fire can drain down to
the Urinary Bladder via its partner organ the Small Intestine. This can result in dark
urine that may contain blood and a painful or burning sensation on urination.
General symptoms and signs of Heart imbalances

• Palpitations
• Restlessness and mental agitation
• Sleep disturbances
• Shen disturbances
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• Mental-emotional symptoms
• Changes to the tip of the tongue
Shi patterns
Heart qi stagnation
Heart qi stagnation can be a distinct pattern of imbalance, but it is most often seen
as a consequence of, and together with, Liver qi stagnation. The pattern arises almost
exclusively from emotional causes.
Aetiology
Emotional imbalances where feelings are not expressed or where there is a prolonged
presence of a particular emotion can lead to Heart qi stagnation.
Symptoms and signs

• Palpitations
• Tightness of the chest, chest oppression or the feeling that there is a tight
band or rim around the chest
• Tension in and around the solar plexus
• A need to yawn or sigh
• A sensation of there being a lump in the throat
• Poor appetite
• Disinclination to lie down
• Weak and cold hands
• Purple lips
• Insomnia
• Mental unrest
• Sadness
• The person is particularly uncommunicative and seems very closed and
emotionally repressed
• The voice can be sad or flat
• Mood swings
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• Depression
• Slightly purple or swollen edges on the front third of the tongue
• Wiry pulse in the left cun position, the pulse can be Knotted
Key symptoms
Palpitations, tightness of the chest, a need to sigh, the person gives the impression of
being emotionally repressed.
Treatment principle
Spread Heart qi and open the chest. Activate shen.
Acupuncture points
Choose from: He 5, He 7, Pe 6, UB 14, UB 15, UB 17, Liv 14, Ren 17, Ren 14,
Du 11 and St 40.
Needle technique
Spreading technique.
Explanation
• He 5, He 7, Pe 6, Ren 14, Du 11, UB 14 and UB 15 spread Heart qi and
activate shen.
• Liv 14, Ren 17 and St 40 disperse qi in the chest.
Herbal formula
• Ban Xia Hou Po Tang (Disperses qi in the chest)
Relevant advice
Physical activity such as sport and exercise will help to circulate qi in the chest.
Beating the chest with a loose fist or the upper back with a wooden spoon will help
to invigorate the qi in the chest. Rolling the shoulders and swinging the arms can
also be recommended. Due to the emotional aspects that are often at the root of this
imbalance, it is important that the person addresses the underlying emotional issues.
Breathing exercises that involve slowly inhaling deeply and then quickly exhaling
with force whilst making a loud noise will help to release stagnant qi.
Heart qi stagnation can be caused by the following patterns of imbalance

• Heart qi xu
• Heart xue stagnation
• Heart xue xu
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• Food stagnation
Heart qi stagnation can result in the following patterns of imbalance

• Heart yin xu
• Heart xue xu
• Phlegm
Heart xue stagnation

Heart xue stagnation is characterised by cardiac pain and pain in the chest. Only this
pattern and ‘Blocked Heart vessels’ manifest with cardiac pain. Heart qi stagnation
and Phlegm stagnation will manifest with a tight and a heavy, oppressed sensation
in the chest respectively.
Heart xue stagnation can be a purely shi pattern and a combined xu and shi
pattern, depending on the underlying pathology.
Aetiology
Heart xue stagnation can arise from chronic Heart imbalance patterns, especially qi
stagnation, Cold and Phlegm. Xu patterns such as Heart xue xu or Heart yang xu can
also be causes of Heart xue stagnation.
Symptoms and signs

• Piercing or stabbing chest pains or cardiac pain
• Tightness in the chest
• Palpitations
• Pain or tingling sensation in the left arm
• Cold hands
• Matt and purple facial complexion, the face can be white when there is acute
pain
• Blue or purple lips
• Purple tongue, purple or swollen sides on the front third of the tongue,
swollen, purple sub-lingual veins
• Choppy or Wiry pulse, the pulse can be Knotted
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Key symptoms
Cardiac pain, chest pain, blue or purple lips.
Treatment principle
Invigorate Heart xue.
Acupuncture points
Choose from: He 5, Pe 4, Pe 6, UB 14, UB 15, UB 17, Sp 10, Ren 17 and Ren 14.
Needle technique
Spreading or tonifying, depending on whether there is a xu or a shi condition. Moxa
can be used.
Explanation
• He 5, Pe 4, Pe 6, Ren 14, UB 14 and UB 15 invigorate Heart xue.
• Sp 10 and UB 17 invigorate xue.
• Ren 17 invigorates qi and xue in the upper jiao.
Herbal formula
• Xue Fu Zhu Yu Tang (Invigorates xue in the Heart and the upper jiao)
Relevant advice
See the relevant advice in the sections dealing with the underlying patterns of
imbalance.
Heart xue stagnation can be caused by the following patterns of imbalance

• Heart xue xu
• Heart yang xu
• Phlegm
Heart xue stagnation can result in the following pattern of imbalance

• Phlegm
Blocked Heart vessels

This is a combined pattern that will have its root in several patterns, with the
common feature that they block qi and xue in and around the Heart. The most
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common patterns that are the cause of this imbalance are Heart qi stagnation, Heart
xue stagnation, Cold and Phlegm.
Aetiology
Emotional stress and long-term emotional imbalances can stagnate Heart qi and
eventually Heart xue. Overwork, too much sex and sweating whilst exposed to the
cold will all weaken Heart yang and can thereby stagnate Heart xue.
Consuming Damp-producing foods can lead to the formation of Phlegm, which
can block the movement of qi and xue in the Heart.
Symptoms and signs

• Piercing and stabbing cardiac pain, the pain is usually worse when the person
is exposed to the cold
• Palpitations
• Tight or heavy sensation in the chest
• Purple, matt or white and pale complexion
• Mental unrest or unease
• Depression
• Mental and physical fatigue with an oppressive feeling
• Dizziness
• Heavy headedness or headache
• Pulmonary sputum
• Cold hands
• Purple nails
• The tongue may be pale and swollen with a greasy coating, it can be purple
in the front third
• Wiry, Choppy or Slippery pulse, the pulse can be Knotted
Key symptoms
Sharp or stabbing chest pain, purple lips and breathlessness.
Treatment principle
Invigorate Heart qi and xue, transform Phlegm, expel Cold and calm the shen.
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Acupuncture points
Choose from: Pe 5, Pe 6, He 5, Ren 14, Ren 15, Ren 17, UB 14, UB 15, UB 17,
Sp 10 and St 40.
Needle technique
Spreading technique.
Explanation
• He 5, Pe 6, Ren 14, Ren 15, UB 14 and UB 15 invigorate Heart qi and
Heart xue.
• Sp 10 and UB 17 invigorate xue.
• Ren 17 circulate qi and xue in the upper jiao.
• Pe 5 and St 40 transform Phlegm and move qi in the chest.
Herbal formula
• Dan Shen Yin (Invigorates xue in the Heart and the upper jiao) combined
with herbs relevant to the underlying pattern of imbalance
Relevant advice
Light physical activity will be beneficial, however it is important that the person
does not overexert themselves if there is an underlying xu pattern. Beating the chest
and the upper back with a loose fist or a wooden spoon or rolling the shoulders and
swinging the arms can also be recommended. As well as getting adequate exercise, it
is also important that they get sufficient rest and relaxation. They should avoid stress
and overexerting themselves physically. If they play sports, it is important that they
do not expose themselves to the cold when they sweat.
They should avoid foods that create Dampness and Phlegm.
Blocked Heart vessels can be caused by the following patterns of imbalance

• Phlegm
• Cold
• Spleen qi xu
• Spleen yang xu
• Kidney yang xu
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Blocked Heart vessels can result in the following patterns of imbalance

• Phlegm
• Qi xu
• Yang xu
Phlegm obscuring the shen

Where the previous patterns manifest with both physical and mental symptoms
and signs, this and the following patterns are much more mental-emotional in their
manifestations.
Aetiology
Diet is often a major factor in the formation of Phlegm. This can also be the case
here, where consuming Damp- and Phlegm-producing foods and foods that have
a cold or hot energy can lead to the formation of Dampness or Phlegm. Chronic
emotional imbalances can stagnate Heart qi and lead to Phlegm obscuring the shen.
Heat conditions can condense fluids and thereby create Phlegm. Chronic yang
xu and xue stagnation can lead to fluids accumulating and forming Phlegm.
Certain medicines can create Phlegm that then obscures shen.
Phlegm obscuring shen may be a congenital pattern in children.
Symptoms and signs

• Mental confusion
• Slow thinking and comprehension
• Blurred, foggy sensation in the head, as if it is full of cotton wool
• Heavy sensation in the head
• Loss of consciousness
• Mental fatigue
• Forgetfulness
• Depression
• Dull, matt eyes
• Inability to maintain eye contact
• The person seems absent and not fully present
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• Incoherent speech, talks nonsense or has difficulty formulating sentences

• Muttering or talking to themselves
• The voice may be slurred
• Difficulty maintaining a structure in their lives
• Lack of motivation
• Increased need to sleep
• Nausea
• Heavy breathing or wheezing
• Rattling sound in the throat
• Vomit of sputum in extreme cases
• Swollen, flaccid tongue, possibly with a greasy coating
• Slippery pulse
Key symptoms
Mental confusion, foggy sensation in the head, difficulty concentrating, swollen
tongue with greasy coating.
Treatment principle
Transform Phlegm, open the Heart.
Acupuncture points
Choose from: St 8, St 40, Du 20, Pe 5, St 36, Ren 12, Ren 14, UB 15 and UB 20.
If there is loss of consciousness: He 9 and Du 26.
Needle technique
Draining, except on Ren 12, St 36 and UB 20.
Explanation
• St 8 and Du 20 drain Phlegm from the head and brighten the shen.
• Pe 5, St 40, Ren 14 and UB 15 transform Phlegm in the Heart and brighten
the shen.
• St 36, Ren 12 and UB 20 transform Phlegm.
• Du 26 and He 9 revive consciousness.
Herbal formula
• Di Tan Tang (Resolves Phlegm and opens the Heart’s orifices)
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Relevant advice
The patient should avoid eating a diet that is Damp and Phlegm producing. They
should ensure that they get a lot of fresh air and physical activity. As there is often
a significant emotional aspect linked to this pattern, they should also try, whenever
possible, to address the underlying emotional themes.
Phlegm obscuring the shen can be caused by

• Spleen qi xu
• Damp
• Phlegm
• Heat conditions
• Xue stagnation
• Yang xu
Phlegm obscuring the shen can result in the following patterns of imbalance
• Phlegm-Heat in Heart
• Spleen qi xu
Phlegm-Heat agitating the Heart

This pattern is similar in some ways to the previous one. The difference is that
in this pattern Heat also agitates the shen. The Heat can have arisen due to the
Phlegm stagnation itself or the Heat may have been one of the factors contributing
to Phlegm being created.
Aetiology
The aetiology of Phlegm-Heat agitating the Heart is very similar to the aetiology of
Phlegm obscuring shen. Diet will play a significant role, especially the consumption
of food and beverages that have a hot dynamic, as well as those that directly generate
Dampness and Phlegm. Emotional imbalances can create a stagnation of qi in
the Liver and the Heart. Heat can simultaneously agitate the shen and lead to the
creation of Phlegm. Phlegm stagnation can in itself lead to the generation of Heat.
Spleen qi xu or yang xu can also have contributed to the formation of Phlegm.
This means that the aetiological factors that can lead to these conditions may also be
involved in the evolution of this pattern.
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Symptoms and signs

• Mental unrest and unease
• Mania
• Depression or mood swings
• Aggression, both verbal and physical
• Spontaneous and ill-considered actions
• Rapid body movements
• Difficulty sitting still and being settled
• Talking a lot and talking quickly
• Loud voice or shouting
• Incoherent speech, talking nonsense or having difficulty maintaining the
structure of a conversation
• The voice may sound slurred
• Uncontrolled laughing or crying
• Laughing while talking
• Talking to themselves
• Inability to maintain eye contact
• The person may lack a sense of reality
• Red face
• Weird or peculiar attire or hair
• Palpitations
• Tightness, oppression or unrest in the chest
• Thirst
• Insomnia
• Dream-disturbed sleep, possibly with nightmares
• Rattling sound in the throat
• Rapid breathing
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• Dark urine
• Red tongue with red swollen tip, greasy yellowish coating, there can be a
crack in the tip of the tongue
• Full, Rapid and Wiry or Full, Rapid and Slippery pulse
Key symptoms
Mania, talking quickly, mental restlessness, red tongue with yellow greasy coating
and a Full pulse.
Treatment principle
Drain Phlegm-Heat, calm the shen and open the Heart.
Acupuncture points
Choose from: Pe 5, Pe 7, Pe 8, He 8, He 9, St 8, GB 13, St 40, Du 20, Du 24,
Ren 15 and UB 15.
Needle technique
Draining.
Explanation
• St 8, GB 13, Du 20 and Du 24 drain Phlegm from the head and calm shen.
• Pe 5 and St 40 transform Phlegm and calm shen.
• Pe 7, Pe 8, He 8, Ren 15 and UB 15 drain Heat from the Heart and calm
shen.
Herbal formula
• Wen Dan Tang (Transforms Phlegm, drains Heat and calms shen)
Relevant advice
The patient should avoid consuming anything that creates Heat, such as chilli,
pepper, garlic, dark chocolate, alcohol, too much red meat especially lamb, fried
food such as crisps, chips, falafel, and so on. They should also avoid Phlegm- and
Damp-producing foods such as sweets, sugar, wheat, dairy products, bananas,
avocados, dried fruit and so on.
It is important that the shen is not agitated further by stimulants such as coffee.
Phlegm-Heat agitating the Heart can be caused

• Phlegm patterns
• Fire patterns
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• Spleen qi xu
Phlegm-Heat agitating the Heart can result in

• Spleen qi xu
• Yin xu
• Xue stagnation
• Qi stagnation
• Qi xu
Heart Fire
Shi Heat will agitate shen and this is reflected in the symptoms and signs, which will
be pronounced. In this pattern shen is not blocked or smothered in the same manner
as it is in ‘Phlegm-Heat agitating the Heart’, so there will not be the same mental
confusion, blurred thinking and poor sense of reality.
It is also important to differentiate this pattern from Heart yin xu Heat; the
symptoms of this pattern will be much more pronounced. When there is shi Heat,
there will be mania and mental agitation rather than just mental restlessness. A
Heart yin xu pulse will be weaker.
Heat from the Heart can drain downwards to the Urinary Bladder via the Small
Intestine and create symptoms of Heat in the Urinary Bladder, such as burning pain
when urinating and blood in the urine.
Aetiology
Excessive consumption of energetically hot food, medicine and beverages will
generate Fire in the body, as will invasions of exogenous xie qi, qi stagnation and
Phlegm stagnation.
Fire and Heat from other organs can rise up to the Heart due to the yang nature
of Heat, agitating the Heart.
Long-term and powerful emotional imbalances can eventually lead to Heart qi
stagnation that can create Heat in the Heart.
Symptoms and signs

• Insomnia
• Dream-disturbed sleep
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• Red face
• Mental unrest and unease
• Mental and physical agitation
• Mania
• Aggression, both verbal and physical
• Irritability
• Rapid body movements
• Difficulty sitting still and being settled
• Talking a lot and talking quickly
• The person is very easy to connect with but has a tendency to give you too
much and irrelevant information
• Palpitations
• Physical unease in the chest
• Tongue ulcers
• Dark urine or blood in the urine
• Burning pain on urination
• Uncontrolled laughing
• Laughs while talking
• Talks to themselves
• Difficulty maintaining eye contact because the eyes constantly dart about
• Thirst
• Insomnia
• Rapid breathing
• Red tongue with red swollen tip, dry yellow tongue coating, there may be
ulcers on the tongue
• The pulse can be Rapid and Flooding or Skipping
Key symptoms
Red face, palpitations, talks quickly, ebullience, thirst, bitter taste and red tongue.
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Treatment principle
Drain Heart Fire and calm the shen.
Acupuncture points
Choose from: Pe 6, Pe 7, Pe 8, He 8, He 9, Ren 15, Du 14, Du 20, Du 24, UB 15
and Kid 1.
Needle technique
Draining technique. Even technique on Kid 1.
Explanation
• Pe 6, Pe 7, Pe 8, He 8, He 9, Ren 15 and UB 15 drain Fire from the Heart
and calm the shen.
• Du 20 and Du 24 calm shen.
• Kid 1 drains Fire downwards, tonifies Kidney Water and calms shen.
Herbal formula
• Xie Xin Tang (Drains Heart Fire)
Relevant advice
The patient should avoid all food and beverages that create Heat. This will include
things such as alcohol, lamb, chilli and other hot spices, deep fried foods, dark
chocolate, garlic and so on.
The Heart is already overstimulated in this pattern and therefore it should not
be further stimulated. This means that coffee, black and green tea and anything that
contains caffeine or other stimulants must be avoided.
Heart Fire can be caused by the following patterns of imbalance

• Liver Fire
• Stomach Fire
• Xue Heat
Heart Fire can result in the following patterns of imbalance

• Phlegm-Heat agitating the Heart
• Heart yin xu
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• Kidney yin xu
• Liver Fire
• Stomach Fire
Xu imbalances
Heart yin xu
Where Kidney yin xu will often reflect and manifest with weakness of jing, Heart
yin xu has a similar relationship with shen. The Heart’s yin aspects nourish and
anchor shen.
Aetiology
Heart yin is weakened by prolonged mental and emotional stress, anxiety, worry and
fear. Lack of sleep, excessive thinking and use of the brain and general overexertion
will all deplete Heart yin.
Heart yin is also depleted by the overuse of stimulants, such as coffee. Some
medicines have a hot and spicy dynamic. This could injure Heart yin. An excessive
consumption of food and beverages that have a hot or spicy dynamic, such as alcohol
and chilli, will also injure yin.
Partying, too many late nights and too much exhilaration will consume Heart yin.
The use of computers and smartphones and watching television over-activate the
mind and thereby consume Heart yin. This effect will be even more pronounced in
the evening, when Heart yin should be tranquil.
Heat from Fire and shi Heat conditions in the body can rise up to the Heart and
injure Heart yin. Heat and Fire conditions may be internally generated or the result
of invasions of exogenous xie qi.
There can also be an inherent tendency to have Heart yin xu. Heart yin xu can
also be a consequence of the ageing process and the general weakening of Kidney
yin. In general, Kidney and Heart yin cooperate closely. Kidney yin should nourish
Heart yin, ensuring that Heart Fire does not become excessive and uncontrollable.
Kidney yin xu often results in Heart yin xu.
Yin xu in one or more of the other organs may eventually weaken yin generally
in the body and thereby lead indirectly to Heart yin xu.
Symptoms and signs

• Insomnia
• Waking often at night and difficulty falling asleep due to restless thoughts
• Palpitations
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• Mental unease and restlessness

• Physical restlessness and agitation
• Anxiety
• Poor memory
• Night sweats
• Hot at night
• Thin body
• Depression
• Dizziness
• Nervous voice or nervous chattering
• Nervous laugh while talking
• Dark urine
• Red speckled tip or red tip of the tongue, crack in the tip of the tongue
• Empty or Fine pulse, especially in the left cun position
If there is Heart yin xu Heat, the following symptoms and signs may be seen:
• malar flush
• sensation of heat or fever late in the afternoon, the evening and at night
• hot sensation in the palms of the hands, soles of the feet and the chest
• mental restlessness and agitation
• talks a lot
• talks quickly
• thirst especially in the evening and at night, there is a need to sip small
mouthfuls of water rather than to drink large gulps of cold water
• being easily stressed
• dark urine
• constipation or dry stools
• thin, red tongue with red tongue tip
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• Empty or Fine and Rapid pulse, especially in the left cun position.
Key symptoms
Palpitations, insomnia, night sweats, mental unrest, being hot at night, being easily
stressed.
Treatment principle
Nourish Heart yin and control Heat.
Acupuncture points
Choose from: He 6, He 7, Ren 14, Ren 4, UB 15, UB 23, Sp 6, Kid 6 and Kid 7.
Needle technique
Tonifying technique.
Explanation
• He 7, Ren 14 and UB 15 nourish Heart yin.
• He 6 and Kid 7 control night sweats and nourish Kidney and Heart yin.
• UB 23, Ren 4, Kid 6 and Sp 6 nourish Kidney yin.
Herbal formula
• Tian Wang Bu Xin Dan (Nourishes Heart and Kidney yin, calms shen)
Relevant advice
The patient should avoid stress, both in their work and emotionally. They should
not work too much and they should get enough sleep and go to bed early. Coffee
and other stimulants should be avoided, because they over-activate shen and thereby
deplete Heart yin. Alcohol, hot spices and grilled and fried food should be avoided,
as they can create Heat in the Heart and injure yin.
Using a computer or a smartphone and watching television in the evening is
detrimental for Heart yin. This is because they activate shen, thereby consuming
Heart yin at a time when shen and yin are supposed to be tranquil and dormant.
If Heart yin is already weakened, it will be even harder for it to anchor and root shen
in the evening.
The patient should try to create balance and harmony in their emotions and
cultivate tranquillity and relaxation. Meditation can be a great help for these patients.
The Heart is nourished and tonified by joy. The patient will benefit from doing or
looking at things that make them happy. They can try to do something every day that
gives them pleasure or to meditate, focusing on something that gives them joy. Too
much stimulation of the senses and exhilaration, on the other hand, depletes Heart
yin. Whilst looking at flowers, beautiful vistas or art nourishes Heart yin, going to
nightclubs, partying, taking drugs or just being excited depletes Heart yin.
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Heart yin xu can be caused by the following patterns of imbalance

• Kidney yin xu
• Liver yin xu
• Stomach yin xu
• Lung yin xu
• Heart xue xu
• Fire
• Shi Heat
Heart yin xu can result in the following patterns of imbalance

• Heart yin xu Heat
• Liver yin xu
• Kidney yin xu
• Phlegm
Heart xue xu
The patterns of Heart yin xu and Heart xue xu are very similar in their symptoms and
signs, because Heart xue is an aspect of Heart yin. The differentiation between the
two patterns is based mainly on the presence or absence of yin xu or xue xu signs in
the symptom picture. Otherwise, the symptoms and signs are very similar.
Aetiology
Xue xu arises for three main reasons: xue is lost either through bleeding or over-
consumption, such as excessive physical training or excessive mental activity; there is a
poor production of xue; the diet is not rich enough in food that directly nourishes xue.
Blood loss, such as in childbirth, heavy menstrual bleeding, bleeding disorders,
operations and so on, may result in Heart xue xu. These factors can be relevant for a
long time, in some cases several years after the loss of blood has occurred.
Excessive exercise, such as physical training, will consume xue. In some cases,
excessive mental and emotional activity can also consume Heart xue.
A poor production of xue will be due to deficient conditions in the organs involved
in the production of xue, in which case aetiological factors that weaken the Spleen
and Kidneys will be involved. Even though the Spleen and Kidneys are in balance,
Heart xue xu can arise if the person’s diet is deficient in xue-nourishing foods.
Heart xue xu is often seen simultaneously with, or as a consequence of, Liver
xue xu.
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Symptoms and signs

• Insomnia
• Palpitations
• Fatigue
• Dizziness
• Poor memory
• Being mentally absent
• Anxiety
• Sallow, pale face
• Pale, dry lips
• Pale, dry and thin tongue
• Fine or Choppy pulse, the pulse may be weakest in the left cun position
Key symptoms
Palpitations, insomnia, poor memory, pale lips and a pale tongue.
Treatment principle
Nourish Heart xue.
Acupuncture points
Choose from: He 7, Ren 14, Ren 15, Ren 4, UB 17, St 36, Sp 6, UB 15, UB 17
and UB 20.
Needle technique
Tonifying. Moxa can be used, particularly on UB 17.
Explanation
• He 7, Ren 14, Ren 15 and UB 15 nourish Heart xue.
• Ren 4, UB 17, St 36, Sp 6 and UB 20 nourish xue.
Herbal formula
• Gui Pi Tang (Nourishes Heart xue and Spleen qi, calms shen)
• Ba Zhen Tang (Nourishes xue)
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Relevant advice
When there is Heart xue xu, it is important to eat a diet that nourishes xue. Things
that nourish xue include green leafy vegetables, beetroot, seaweed, dates, kidney
beans, black beans, aduki beans, red meat, bone marrow, blood sausages, heart
and liver.
The patient should avoid sugar, stimulants such as coffee and too much alcohol.
Nettle tea will be beneficial for them to drink.
The patient should not only eat a diet that is rich in xue-nutritious foods, but they
should also eat a diet that is beneficial for their Spleen qi. This means eating warm,
prepared food, such as soups, stews, baked vegetables and so on and avoiding salads,
raw food and food and beverages that have a cold energy or produce Dampness.
The advice given in the section on Heart yin xu will also be relevant here.
Heart xue xu can be caused by the following patterns of imbalance

• Liver xue xu
• Spleen qi xu
• Spleen yang xu
Heart xue xu can result in the following patterns of imbalance

• Heart yin xu
Heart qi xu
This pattern has symptoms and signs that are specific to the Heart, such
as palpitations, whilst also manifesting general qi xu symptoms and signs, such as
fatigue. This pattern can be physical or mental-emotional, with the person lacking
self-esteem, self-confidence or happiness.
There is a close relationship between the Heart and Lung in their functioning.
This means that there will usually be tangible symptoms and signs of Lung qi xu
when there is Heart qi xu. Heart qi will also be weakened by prolonged or excessive
sorrow and melancholy, which also affects the Lung negatively because even though
these emotions affect the Lung directly, shen and thereby the Heart will register
and be conscious of these emotions and thereby also be affected by them. When a
person experiences sorrow and melancholy, there is also a lack of joy. This means
that Heart qi will lack nourishment. Heart qi in general is nourished by joy and
love. A person whose life lacks joy, love and a sense of companionship and belonging
will often become Heart qi xu. This can particularly be the case if the person did
not experience enough love and attention or if they felt ostracised in childhood. In
childhood the organs are not fully stable and their qi is more volatile. This means
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that the internal organs can be easily affected by aetiological factors such as the seven
emotions. These factors will have a greater effect in childhood than they will in later
life and can permanently influence the organ in question.
Aetiology
Blood loss, prolonged illness, physical strain and emotional imbalances. A lack of
joy in life or loneliness can particularly lead to Heart qi xu. Shock scatters Heart qi,
thereby weakening it.
The Heart controls sweating. Excessive sweating can deplete Heart qi.
The consumption of recreational drugs and some medicines can open the Heart
and thereby spread Heart qi. This can weaken Heart qi xu over time.
Symptoms and signs

• Palpitations
• Slight shortness of breath
• Pale complexion
• Mental, physical and/or emotional fatigue
• Sadness, melancholy, lack of joy, feelings of loneliness, depression
• Low self-esteem or lack of self-confidence
• The person may seem very quiet, diffident or shy
• Speech impediments such as stammering
• The voice may sound flat and lack vitality or tone variation
• Lack of sparkle in the eyes
• Pale or normal-coloured tongue
• Deep and Weak, especially in the left cun position, the pulse may be Knotted
Key symptoms
Palpitations, fatigue, sadness, lack of self-confidence and a Weak pulse.
Treatment principle
Tonify Heart qi.
Acupuncture points
Choose from: He 5, He 7, UB 15, Ren 6, Ren 14, Ren 15, Ren 17 and St 36.
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Needle technique
Explanation
• He 5, He 7, Ren 14, Ren 15 and UB 15 tonify Heart qi.
• Ren 17 tonifies qi in the upper jiao.
• Ren 6 and St 36 tonify qi.
Herbal formula
• Ding Zhi Wan (Tonifies Heart qi and calms shen)
• Sheng Mai San (Tonifies Heart qi and yin)
Relevant advice
Heart qi is best tonified on the emotional level. It is important that the person
cultivates joy in their life. Of course, this is easier said than done. As well as working
with their emotions, the person can try to spend some time each day doing something
that gives them genuine pleasure or they can sit and meditate on something that
for them is beautiful.
Tonifying qi in general will also benefit the patient. This can be done through
the diet, access to fresh air and breathing exercises, as well as getting enough rest and
avoiding overexertion.
Heart qi can be depleted through excessive sweating. This means that the use of
saunas and steam baths is not something that is recommended for these patients.
The patient should avoid the use of recreational drugs, medicines and experiences
that spread Heart qi.
Heart qi xu can be caused by the following patterns of imbalance

• Spleen qi xu
• Lung qi xu
• Kidney qi xu
• Gall Bladder qi xu
• Xue xu
Heart qi xu can result in the following patterns of imbalance

• Heart yang xu
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• Heart yin xu
• Heart xue xu
• Lung qi xu
Heart yang xu
Heart yang xu and Heart qi xu have a lot of symptoms and signs in common. Heart
yang xu will, though, manifest with characteristic yang xu symptoms and signs.
Heart yang xu can be a consequence of yang xu conditions in other organs, such as
the Kidneys and the Spleen.
Aetiology
Heart yang xu can arise after a person has been sweating profusely. This will weaken
the Heart’s yang aspect. It can also arise when there have been other types of excessive
fluid loss, such as severe diarrhoea, vomiting or bleeding.
Furthermore, aetiological factors that may lead to Spleen and Kidney yang xu
can also be relevant. This could be things like overwork, too much sex, disease,
old age, congenital weakness, an excessive intake of cold food, cold drinks and
cold medicine.
Symptoms and signs

• Palpitations
• Slight shortness of breath
• Fatigue
• Depression
• Cold hands
• Pale or white face
• Slightly dark lips
• Lack of enthusiasm for life
• Mental lethargy
• Slow speech
• Poor posture
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• Pale, wet, swollen tongue

• Slow, Deep pulse, the pulse may be Weak in the left cun position
Key symptoms
Palpitations, cold hands, Deep and Weak pulse.
Treatment principle
Warm and tonify Heart yang.
Acupuncture points
Choose from: He 5, He 7, UB 15, Ren 14, Ren 17, Ren 6, Du 4 and Du 14.
Needle technique
Tonifying technique. Moxa is recommended.
Explanation
• He 5, He 7, Ren 14 and UB 15 tonify Heart yang.
• Ren 17 tonifies qi and yang in the upper jiao.
• Ren 6, Du 4 and Du 14 tonify yang.
Herbal formula
• Zhen Wu Tang Tang (Tonifies and warms Kidney, Spleen and Heart yang)
Relevant advice
It is important that yang is protected and not further burdened when there is
Heart yang xu. This means that the patient should avoid consuming food and
beverages that have a cold energy or temperature. At the same time, they must not
overexert themselves and men should avoid having too much sex.
Heart yang can be damaged by excessive sweating, therefore saunas and steam
baths are something that is not recommended for these patients.
Heart yang xu can be caused by the following patterns of imbalance

• Heart qi xu
• Kidney yang xu
• Spleen yang xu
Heart yang xu can result in the following patterns of imbalance

• Heart yang collapse
• Phlegm obscuring the shen
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• Qi stagnation in the chest
• Kidney yang xu, overflowing Water
Heart yang collapse

Heart yang collapse is a more extreme and more serious condition than Heart yang
xu. Yang is now too weak to move xue and body fluids. Heart yang collapse may be
a consequence of Kidney yang xu or Heart yang xu.
Aetiology
The aetiology of Heart yang collapse will be the same as that described for Heart
yang xu.
Symptoms and signs

• Palpitations
• Cold limbs
• Grey or white complexion
• Possible loss of consciousness
• Pale or bluish tongue, the tongue may be short
• Deep, Weak or Hidden pulse
Key symptoms
Blue or purple lips, palpitations, Hidden pulse.
Treatment principle
Rescue Heart yang.
Acupuncture points
This is a severe and acute condition in which Western medical intervention is
required. If this is not available, you can choose from: Ren 4, Ren 6, Ren 8, Du 4,
Du 14, Du 20, UB 15, St 36 and Pe 6.
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Needle technique
Tonifying, no retention of the needles. Moxa must be used. Direct moxa or moxa on
ginger slices on Ren 4, Ren 6 and Ren 8 is necessary.
Explanation
• UB 15 tonifies Heart yang.
• Pe 6 circulates qi in the upper jiao.
• Du 4 and Du 14 tonify yang.
• Du 20 raises yang.
• St 36, Ren 4, Ren 6 and Ren 8 rescue yang.
Herbal formula
• Zhen Fu Tang (Rescues yang)
Relevant advice
This is usually an acute pattern, therefore lifestyle and dietary advice is not so
relevant. It is important that the patient does not sweat, because this will further
weaken Heart yang.
Heart yang collapse can be caused by the following patterns of imbalance

• Kidney yang xu
• Heart yang xu
Heart yang collapse can result in the following patterns of imbalance

• Collapse of yang
Combined patterns
Heart xue xu and Spleen qi xu
This pattern is very common, especially in women. The pattern can arise from Heart
xue xu or Spleen qi xu. One pattern can lead to the other and they will eventually
become self-generating. Heart xue xu puts a strain on Spleen qi, because the Spleen
has to work harder to constantly try and replenish xue. Spleen qi xu is the post‑heaven
root of xue and can therefore lead to Heart xue xu. The reason that this pattern
is more common in women than men is that women lose xue through menstrual
bleeding and childbirth and thus tend to be more xue xu in general.
520
Aetiology
This pattern can occur when there has been blood loss, such as through heavy
menstrual bleeding, childbirth, surgery or physical trauma. The menorrhagia may
in itself be due to Spleen qi xu when the Spleen is too weak to hold xue inside the
vessels. The other causes of bleeding could be xu or shi Heat or xue stagnation.
The aetiology of this pattern can therefore also include factors that lead to these
conditions, and these patterns should be addressed in the treatment strategy, either
immediately or in subsequent treatments.
Xue xu can also arise through excessive physical training where the need for xue
to nourish the muscles exceeds the body’s ability to produce xue. Excessive mental
activity can also weaken Heart xue directly, as Heart xue nourishes the shen and
the Brain.
The Spleen qi xu aspect can arise because the Spleen has to work extra hard
to create more gu qi to replenish the lack of Heart xue. Spleen qi xu can also arise
independently if the diet is of poor quality or if there is an excessive consumption
of food and beverages that have a cold energy or temperature or that produce
Dampness. If the diet lacks food that is directly xue nourishing, this in itself can lead
to or worsen the Heart xue xu aspect of this pattern.
Spleen qi xu can also be a consequence of physical overexertion or disease.
Worry, speculation, studying and thinking too much can not only bind Spleen qi
and thereby weaken it, but also affect the Heart. Grief, sadness and anxiety will also
be factors that can have a direct negative impact on the Heart.
Symptoms and signs

• Palpitations
• Fatigue
• Dizziness
• Poor memory
• Pale and sallow face
• Pale, dry lips
• Loose stools
• Poor appetite
• Being bloated immediately after eating
• Insomnia
• Anxiety
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• Scanty menstrual bleeding

• The person may be absentminded or not quite present
• Weak or low voice
• Pale tongue
Key symptoms
Insomnia, palpitations, fatigue, loose stools and scanty menstrual bleeding.
Treatment principle
Tonify Spleen qi, nourish Heart xue and calm shen.
Acupuncture points
Choose from: He 7, St 36, Sp 3, Sp 6, Ren 12, Ren 14, UB 15, UB 17 and UB 20.
Needle technique
Tonifying. Moxa is recommended on UB 17 and St 36.
Explanation
• He 7, Ren 14 and UB 15 nourish the Heart xue and calm shen.
• St 36, Sp 3, Ren 12 and UB 20 tonify Spleen qi.
• Sp 6 tonifies Spleen qi, nourishes xue and calms shen.
Herbal formula
• Gui Pi Tang (Tonifies Spleen qi, nourishes the Heart xue and calms shen)
Relevant advice
If there is Spleen qi xu and Heart xue xu, a diet that is rich in food that both nourishes
Heart xue and tonifies Spleen qi is recommended. This means that the person should
eat a lot of green, leafy vegetables, beetroot, seaweed, dates, kidney beans, aduki
beans, black beans, red meat, bone marrow, blood sausages, nettle tea, heart and
liver. The food should be prepared, i.e. boiled, steamed, baked and so on, and it
should be eaten warm. They should avoid raw vegetables, cold drinks, ice cream,
sugar, stimulants such as coffee or too much alcohol. It is important that they chew
their food slowly and thoroughly, and that they eat in calm surroundings, focusing
on what they are eating.
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Light exercise is beneficial, as it will help support the Spleen’s qi mechanism. On

the other hand, they should avoid sitting still for long periods of time or sitting with
a slumped posture, especially after meals.
Profuse sweating should also be avoided, because it will weaken Heart xue.
Heart xue xu and Spleen qi xu can be caused by

• Spleen qi xu
• Heart xue xu
• Liver xue xu
• Kidney yang xu
• Damp
• Phlegm
Heart xue xu and Spleen qi xu can result in the

• Spleen yang xu
• Kidney yang xu
• Kidney yin xu
• Lung qi xu
• Liver xue xu
• Stomach qi xu
• Damp
• Phlegm
• Heart yin xu
• Heart qi xu
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Heart and Lung qi xu

This pattern is discussed in the section on Lung imbalance patterns (page 393).
Heart and Kidney yin xu

This pattern is discussed in the section on Kidney imbalance patterns (page 546).
Heart and Liver xue xu

This pattern is discussed in the section on Liver imbalance patterns (page 590).
Heart and Gall Bladder qi xu

This pattern is discussed in the section on Gall Bladder imbalance patterns (page 580).
Small Intestine imbalance

The main function of the Small Intestine is to receive the untransformed dross from
the Stomach and separate the pure aspects that are still present from the impure
waste. The pure fluids and qi that are extracted in the Small Intestine are transmitted
upwards via the san jiao, and the impure fluids and solids are sent to the Urinary
Bladder and the Large Intestine respectively. Although these processes take place in
the Small Intestine, they do so under the influence and control of the Spleen and
Kidney yang. This means that most signs of imbalance in the Small Intestine are
viewed as being Spleen and Kidney imbalances and treated accordingly. For example,
in the treatment of diarrhoea, Spleen and Stomach points will typically be used, not
Small Intestine points. When the Small Intestine is treated in these situations, it is
usually through the use of its lower he-sea point St 39.
Small Intestine imbalance patterns can arise when the Small Intestine is directly
invaded from the exterior. This can occur through either the skin of the abdomen or
the mouth and the Stomach. Cold can invade through the skin of the abdomen when
this area has been exposed to the climate, for example when a person has worn too
little or worn wet clothes. Damp-Heat, Damp-Cold or exogenous Cold can invade
the Small Intestine via the mouth and Stomach when food that is contaminated or
has gone off has been ingested or when food that is energetically very cold or hot,
produces Dampness or has a very cold temperature has been ingested.
The long-term consumption of food and beverages that are energetically or
physically cold will weaken Spleen yang and Kidney yang. Damp-Heat, Damp-Cold
and yang xu can all disrupt the Spleen’s ability to transform and transport. This can
manifest with changes in the stool and/or pain in the abdomen. The consumption
of energetically hot food, as well as emotional imbalances, can create Stomach Fire
or Heart Fire, which can then be transmitted to the Small Intestine, creating Heat.
Parasitic worms are defined as aetiological factors that are ‘neither exterior nor
interior’. A person can have been infected through contact with contaminated food
524
or dirt. Worms will enter the body through the mouth. The worms will block the
movement of both qi and solids in the Small Intestine. By inhibiting the separation
of the pure and the impure, worms will lead to malnutrition.
Qi stagnation in the Small Intestine can arise when qi stagnates in the middle
and lower jiao. Qi stagnation in the Small Intestine could affect the stool and cause
intestinal pain. There are several factors that can lead to qi stagnation here. Liver
qi stagnation can arise due to emotional frustrations, stress, repressed anger and
irritation. The stagnant Liver qi can accumulate and block the movement of qi
through the Intestines. Worry, speculation and thinking too much will bind and
thereby stagnate Spleen and Stomach qi so their qi mechanism grinds to a halt, with
the result that qi movement through the Intestines is impaired. Qi stagnation in the
Small Intestine can also be a consequence of too little exercise, poor posture and a
general lack of physical movement. If a person spends too much time sitting still,
especially if their posture is poor or they sit with a twisted midriff, it will physically
prevent the movement of qi through the Intestines. This is a particular problem
when a person eats whilst they are working on the computer.
Shi Heat can drain down to the Small Intestine from its partner organ, the
Heart. This means that all of the aetiological factors that can lead to Heart Fire can
be relevant here. Heat will disrupt the Small Intestine functions in relation to fluid
physiology. The Heat can thereby be transmitted to the Urinary Bladder, resulting
in symptoms such as painful or burning urination, dark urine and possibly blood in
the urine.
In some cases, deafness can result from xie qi, for example Fire disrupting the
flow of qi in the Small Intestine channel.
General symptoms and signs of a Small Intestine imbalance

• Abdominal pain
• Diarrhoea
• Constipation
• Borborygmi
Shi patterns
Shi Heat in the Small Intestine
Heat from the Heart or the Stomach can be transmitted to the Small Intestine.
The Heat can then manifest with symptoms relating to the Small Intestine, and also
to the Urinary Bladder, with which the Small Intestine has a functional and taiyang
relationship.
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Aetiology
Emotional imbalances and influences can create Heart Fire. The excessive
consumption of food and beverages that are energetically hot, such as alcohol, fried
and grilled food, lamb, hot spices and so on, can create Stomach and Heart Fire. The
Fire in these organs can be transmitted to the Small Intestine.
Symptoms and signs

• Mental agitation or restlessness
• Insomnia
• Ulcers in the mouth and on the tongue
• Deafness
• Sore throat
• Turmoil in the chest
• Abdominal pain
• Thirst with a desire for cold drinks
• Dark, scanty urine with a burning sensation on urination
• Red face
• The person talks quickly or talks a lot
• Red tongue with a red swollen tip and yellowish coating
• Fast, Flooding pulse, Wiry in the left hand chi position
Key symptoms
Abdominal pain, dark and painful urine, red tongue tip possibly with ulcers on the
tongue.
Treatment principle
Drain Heat from the Heart and Small Intestine. Promote urination.
Acupuncture points
Choose from: SI 2, SI 5, He 5, He 8, St 39, Ren 3 and UB 28.
Needle technique
Draining.
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Explanation
• SI 2, SI 5 and St 39 drain Heat from the Small Intestine.
• He 5 and He 8 drain Heart Fire.
• Ren 3 and UB 28 drain Heat from the Urinary Bladder.
Herbal formula
• Dao Chi San (Drains Heart Fire via the Small Intestine and the Urinary
Bladder)
Relevant advice
Food and beverages that have a hot energy should be avoided.
Shi Heat in the Small Intestine can be caused by

• Heart Fire
• Stomach Fire
Shi Heat in the Small Intestine can result in

• Urinary Bladder Heat conditions
• Heart Fire
Small Intestine qi stagnation

The Small Intestine receives the untransformed residues from the Stomach. After
further processing, the turbid fluids are sent to the Urinary Bladder and the impure
dregs are sent down to the Large Intestine. Stagnation of qi in the Small Intestine can
inhibit the descent of qi in the Small Intestine and thereby disrupt the transformation
of fluids that takes place here, as well as causing pain and discomfort. This pattern
is usually a pure shi pattern, but there can be a xu aspect as well when Spleen and
Stomach qi xu result in stagnation in the Small Intestine.
Aetiology
Frustration, irritation, repressed anger, pent-up emotions and stress can all stagnate
Liver qi. Stagnant Liver qi can then invade the Small Intestine and interfere with
its qi mechanism. Worry, speculation and excessive thinking can bind Spleen qi
and disrupt the Stomach and Spleen’s qi mechanism. This can then disrupt the
movement of qi and the functioning of the Small Intestine.
Excessive sitting and sitting in a twisted or slumped posture will physically block
the movement and functioning of the Small Intestine qi.
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An excessive consumption of food and beverages that are energetically and

physically cold or that produce Dampness can weaken Stomach and Spleen qi
and thereby the Small Intestine.
Symptoms and signs

• Abdominal bloating, discomfort at palpation of the abdomen
• Pain in the lower abdomen, which can radiate to the back, the pain is
aggravated by pressure
• Discomfort when wearing tight clothing on the abdomen
• Borborygmi
• Flatulence
• Intestinal pain that is relieved by passing wind
• Constipation
• Testicular Pain
• There may be signs of Liver qi stagnation
• White tongue coating
• Wiry pulse, especially in chi positions
Key symptoms
Abdominal pain, borborygmi, Wiry pulse.
Treatment principle
Regulate and move qi in the Small Intestine, possibly regulate Liver qi.
Acupuncture points
Choose from: Ren 6, SJ 6, GB 34, Liv 3, Liv 13, St 27, St 29, Sp 4, Sp 6 and St 39.
Needle technique
Spreading. Moxa can be used.
Explanation
• Ren 6, SJ 6, St 27 and St 29 move and regulate qi in the Small Intestine.
• GB 34, Liv 3 and Liv 13 spread Liver qi.
• Sp 4 and Sp 6 tonify Spleen qi and regulate qi in the Small Intestine.
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Herbal formula
• Chai Hu Shu Gan Tang (Spreads Liver qi and regulates Small Intestine qi)
Relevant advice
As well as addressing any emotional issues that may lie behind their qi stagnation,
the patient must ensure that they get enough exercise. A short walk after eating is
recommended. If this is not possible, stretching and light abdominal massage would
be beneficial. Abdominal massage where the movement is in a clockwise direction
will help circulate qi in the Intestines. Posture is important, especially when the
person eats and immediately afterwards. Sitting straight and standing erect ensures
that there is a free passage through the abdominal cavity.
Small Intestine qi stagnation can be caused by

• Food stagnation
• Cold stagnation
Small Intestine qi stagnation can result in the

Small Intestine qi bound

This pattern is an acute pattern. Acute appendicitis will fall within this category.
The difference between this pattern and the previous one is that in this pattern
there is not only a stagnation in the movement of qi, but also an actual blockage.
When there is a stagnation of qi, the movement of qi is impeded, disrupted or
irregular. When there is a blockage, there is no movement at all.
Aetiology
An invasion of exogenous Cold will block the movement of qi down through the
Small Intestine. The Cold can have entered through the mouth, such as when food
or beverages that are cold in their temperature or energy are ingested. The Cold can
also have invaded through the skin of the abdomen or through the yin channels in
the legs. This will happen if the person has been exposed to climatic cold or worn
inadequate or wet clothing.
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Symptoms and signs

• Acute and intense abdominal pain that is aggravated by pressure
• Constipation
• Vomiting
• Borborygmi
• Flatulence
• Painful facial expression
• Inhibited or limited body movements
• The pain is ameliorated by warmth
• Cold abdominal skin
• Thick, white and greasy tongue coating
• Wiry pulse in the chi positions
Key symptoms
Intense abdominal pains, constipation, thick, white and greasy tongue coating.
Treatment principle
Expel Cold and disperse qi in the Small Intestine.
Acupuncture points
Choose from: Ren 6, SJ 6, GB 34, Liv 3, Liv 13, St 25, Sp 4, Sp 6, St 39 and
Lanweixue (Ex-LE 7).
Needle technique
Explanation
• Ren 6, SJ 6, St 25 and St 39 invigorate and regulate qi in the Small Intestine.
• GB 34, Liv 3 and Liv 13 spread Liver qi.
• Sp 4 and Sp 6 tonify Spleen qi and regulate qi in the Small Intestine.
• Lanweixue is an empirical point for acute pain and blocking of the intestines.
530
Herbal formula
• Tian Tai Wu Yao San (Regulates qi and expels Cold from the Intestines)
Relevant advice
This is an acute pattern, therefore diet and lifestyle advice will have a limited effect.
The person will benefit from eating or drinking things that are warm and spicy in
their dynamic, such as ginger or turmeric.
Small Intestine qi bound can be caused by the

• Invasion of Cold in the Stomach
• Small Intestine xu Cold
Small Intestine qi bound can result in the following patterns of imbalance

• Spleen yang xu
Worms in the Small Intestine

This pattern cannot be treated with acupuncture.
Aetiology
Ingestion of contaminated food, poor hygiene and inadequate cooking of food.
Symptoms and signs

• Abdominal pain
• Weight loss and poor growth in children
• Vomiting of worms
• Strange cravings
• Anal or nasal itching
• Insatiable hunger
Key symptoms
Weight loss, lack of growth in children, insatiable appetite.
531
Treatment principle
Kill and expel parasites.
Herbal formula
• Li Zhong An Hui Tang (Warms the middle jiao and kills worms)
• Wu Mei Wan (Drains Stomach Heat, warms the Intestines, tonifies qi and
kills worms)
Relevant advice
Better hygiene and preparation of food.
Urinary Bladder imbalances

In Chinese physiology, the Urinary Bladder plays a wider role than it does in Western
medicine physiology. In Western medicine, the Urinary Bladder stores and expels
urine. It also does this in the Chinese medicine physiological model but here it
has the additional function of helping to transform the impure body fluids that
it receives from the Lung and Small Intestine.
For the Urinary Bladder to be able to fulfil these functions, it is dependent on
Kidney yang qi. The Kidney yang warms and activates the Urinary Bladder and
provides it with the necessary qi and warmth to be able to transform the impure
fluids and transmit the pure fluids upwards through the san jiao, as well as enabling
the Urinary Bladder to retain the urine until it is expelled out of the body. The
expulsion of the urine from the Urinary Bladder is again dependent on the strength
of the Kidney yang qi. This means that when the Urinary Bladder is incapable of
performing its functions, it is not due to a xu condition in the Urinary Bladder but
is because of either a deficiency of Kidney yang or the presence of xie qi.
If there is Kidney yang xu, the Urinary Bladder will lack the necessary qi and
heat to be able to carry out its functions of transforming the impure fluids, sending
pure fluids upwards and retaining and expelling urine. This will manifest with an
increased volume of urine that is pale. There will be frequent voiding of copious
amounts of clear and pale urine, because fluids that have not been transported will
have seeped down to the lower jiao. The urine can also be cloudy due to the fluids
not having been transformed.
Urination will also be more frequent and there may even be incontinence when
there is Kidney yang xu, because Kidney yang will not be able to hold the urine
inside the Urinary Bladder. On the other hand, there can also be problems voiding
urine when there is Kidney yang xu. Kidney yang is the force behind this voiding
function, expelling the urine from the Urinary Bladder. Kidney yang xu can therefore
manifest with symptoms such as incomplete emptying of the Urinary Bladder, a
weak stream of urine or post-urination dribbling. Although these symptoms are due
532
to a dysfunction of the Urinary Bladder, the treatment will be aimed at tonifying

Kidney yang, because this is where the root of the problem lies.
As well as a deficiency of Kidney yang, another cause of urinary disturbances is the
qi mechanism of the Urinary Bladder being obstructed or disrupted by certain types
of xie qi. Damp is often involved in shi patterns of imbalance in the Urinary Bladder,
as it inhibits the movement of qi and can block the qi mechanism in the Urinary
Bladder, which impedes the transformation and transportation of fluids and blocks
the excretion of urine. The blockage will manifest in difficulty in urinating. There
can be difficulty voiding the urine or in emptying the Urinary Bladder completely.
The Dampness can also result in the urine becoming cloudy. In extreme cases, the
accumulation of Dampness in the Urinary Bladder can lead to the formation of
sand or stones in the Urinary Bladder. The lack of transformation and transporting
of body fluids can result in an increased amount of urine in the Urinary Bladder,
thus there may be more frequent or urgent urination with copious amounts of pale
or cloudy urine.
The Dampness can be combined with Cold or Heat. If there is Cold present,
it will further block the Urinary Bladder’s qi mechanism and burden the Kidney’s
yang aspect, which will hamper the transformation and transportation of fluids. Due
to its contracting nature, Cold can cause problems with voiding the urine, as well
as difficulties in emptying the Urinary Bladder completely. The Dampness and the
accumulation of fluids can result in the person having no thirst.
Heat can also combine with Dampness. When there is Heat, it can ‘boil’ the
urine, so that the urine is dark, concentrated and odorous. In contrast to Cold,
Heat has an expansive nature and creates over-activity. Heat can therefore force the
urine out of the Urinary Bladder. There will then be a frequent urge to urinate, but
because the Heat has evaporated and condensed the urine, there will only be small
quantities of dark urine. This will be further exacerbated by the Dampness, which
will in itself block the urination. Besides difficult and frequent urination, Heat will
typically also manifest with a stinging and burning pain upon urination. The Heat
can also cause the vessels to burst, so there can be visible blood in the urine. Heat can
also result in fever and an increased thirst. Although there is thirst, the Damp aspect
and the accumulation of fluids in the body can mean that there is no desire to drink.
This is characteristic of Damp-Heat conditions.
Damp is yin in nature and seeps downwards. Therefore, when there is Dampness,
there can be a heavy, sinking sensation in the lower jiao. This is most characteristic
when there is Damp-Cold. The expansive nature of Heat means that Urinary Bladder
Damp-Heat has a tendency to manifest with tension or distension in the lower jiao,
especially in the area just above the pubic bone. This can be a subjective sensation or
something that can be felt on palpation.
Damp can be both exogenous or internally generated. Internally generated
Dampness is usually the result of Spleen and Kidney xu patterns or excessive
consumption of food and beverages that produce Dampness. Exogenous Damp,
like Cold, can invade the body when the person has been exposed to climatic cold
533
and dampness. Dampness can invade directly through the skin, typically when the
person has worn inadequate or wet clothing, for example a wet bathing costume.
Damp and Cold can also enter the body via the yin channels in the legs.
Damp-Heat can arise in several ways. Damp-Cold will typically transform
into Damp-Heat. This process is accelerated if there is already Heat present in the
body. Damp-Heat can also be caused by the excessive consumption of food and
beverages that directly create Damp-Heat, for example alcohol and fried food.
Damp-Heat can invade the body from the exterior. This may be due to exogenous
xie qi invading the body via the mucous membranes, i.e. bacterial infections in
Western medicine terminology.
Heat can also be caused by emotional imbalances. There is a connection from the
Heart via the Small Intestine channel to the Urinary Bladder. The Urinary Bladder
also has a divergent channel that connects to the Heart. Heart Fire can therefore be
transmitted to the Urinary Bladder, where it will combine with Dampness, resulting
in Urinary Bladder Damp-Heat. Emotional imbalances that affect the Liver can also
interfere with the Urinary Bladder. This is because the Liver channel passes around
the urethra and the Urinary Bladder.
Invasions of exogenous xie qi can disrupt the functioning of the Lung so that it
does not send fluids down to the Urinary Bladder. These fluids will accumulate in
the body’s tissue and there will be a lack of fluids in the Urinary Bladder. This will
result in acute oedema and concurrent inhibited urination. This is not a Urinary
Bladder pattern of imbalance but is discussed under Lung imbalances as ‘Invasion
of Wind-Water’ (page 403).
In addition, all of the aetiological factors that deplete Kidney yang can be
involved in Urinary Bladder imbalances due to the mechanisms described above.
General symptoms and signs of Urinary Bladder imbalances

• Urinary difficulties (problems with voiding, frequent or urgent urination,
incontinence, painful urination)
• Cloudy, pale or dark urine
• Increased or decreased volume of urine
• Distension, tightness or pain in the area above the pubic bone
Shi patterns
Urinary Bladder Damp-Heat
Urinary Bladder Damp-Heat is typically an acute disorder. It can often develop into
a chronic condition with acute episodes. Many women find that they suffer from
recurrent urinary tract infections and that these infections increase in frequency.
These infections are often treated with Western medication. Unfortunately, these
534
pharmaceutical products often have a double negative effect. The Western

medication clears the Heat aspect of the disorder, but does not address the Damp
aspect. This means that there will remain a lingering Damp pathogen, which will
start to generate Heat, resulting in symptoms of a new infection. Furthermore,
due to its Cold nature, the medicine weakens Kidney and Spleen yang, resulting in
additional Dampness that seeps down to the lower jiao, laying the foundation for a
new Damp-Heat condition in the Urinary Bladder. This is again treated with Cold
medication that does not drain the xie qi completely out of the Urinary Bladder but
increases Dampness, and a vicious cycle is started.
Damp-Heat, as stated above, often arises when Damp-Cold transforms into
Damp-Heat. This transformation will accelerate if there is already Heat present in
the body. An excessive consumption of food and beverages that are energetically hot,
stress and qi stagnation Heat are typical contributing factors.
Aetiology
Invasions of exogenous Damp, Cold and Heat. Dietary factors that produce
Dampness and Damp-Heat, as well as the repeated use of medicines that are
energetically cold. Stress, emotional frustrations, pent-up anger, hatred, jealousy and
irritation can cause Liver qi stagnation Heat or Heart Fire, which can drain down to
the Urinary Bladder.
Symptoms and signs

• Burning, stinging sensation during urination
• Frequent, urgent, but scanty urination
• Difficulty urinating or in fully voiding the Urinary Bladder
• Dark, yellowish, turbid and odorous urine
• Possibly blood in the urine
• Tightness and distension above the pubic bone
• Fever or feeling of heat in the body
• Yellowish, greasy coating on the root of the tongue
• Raised, red papillae on the root of the tongue
• Rapid and Wiry or Rapid and Slippery pulse, the chi positions may be Full
Key symptoms
Burning sensation upon urination, urgent but scanty urination, dark and cloudy
urine, greasy yellow coating on the root of the tongue.
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Treatment principle
Drain Damp-Heat from the Urinary Bladder.
Acupuncture points
Choose from: Ren 2, Ren 3, Sp 6, Sp 9, LI 11, UB 22, UB 28 and UB 32.
Needle technique
Draining.
Explanation
• Ren 2, Ren 3, UB 28 and UB 32 drain Damp and Heat from the Urinary
Bladder.
• Sp 6, Sp 9, UB 22 and LI 11 drain Damp-Heat.
Herbal formula
• Ba Zheng Tang (Drains Damp-Heat from the Urinary Bladder)
• Bei Xie Fen Qing Yin II (Drains Damp-Heat from the Urinary Bladder)
Relevant advice
When there is Urinary Bladder Damp-Heat, the person should avoid foods and
beverages that generate Damp or Heat. They should avoid exposure to climatic
influences that can result in Damp, Heat or Cold invading the body. They should
also avoid stress and situations that can result in emotional frustrations.
Urinary Bladder Damp-Heat can be caused by

• Damp-Cold
• Damp
• Liver qi stagnation and Urinary Bladder qi stagnation
• Heart Fire
• Kidney yang xu
• Spleen qi xu
Urinary Bladder Damp-Heat can result in the

• Kidney yin xu
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• Phlegm
• Urinary Bladder xue stagnation
• Qi stagnation
Urinary Bladder Damp-Cold

Urinary Bladder Damp-Cold will be either an acute condition or a chronic condition
with acute episodes. It will typically alternate with, or develop into, Urinary Bladder
Damp-Heat. It is a fundamental principle that xie qi takes on the characteristic of its
host. The human body is yang and hot in relation to the environment around it. Our
body temperature is 37 degrees Celsius. This means that yin xie qi will eventually
turn into Heat. This is the same dynamic that happens when a person falls into
the sea in winter or into boiling water: their body temperature will be influenced
by their surroundings. Furthermore, the stagnation that Damp-Cold creates will
itself generate Heat. Both Dampness and Cold will block the Urinary Bladder’s
qi mechanism.
Aetiology
Invasions of exogenous Damp and/or Cold. An excessive consumption of food
and beverages or medicine that are energetically cold or damp, for example dairy
products, raw foods, salads and ice cream.
Factors that weaken the Spleen or Kidney yang can also be involved, because
Kidney yang xu and Spleen yang xu conditions can result in fluids not being optimally
transformed and transported, giving rise to Dampness. Kidney yang xu will also
result in the body being more vulnerable to invasions of exogenous Cold and Damp.
Symptoms and signs

• Difficult or painful urination
• Weak urinary flow
• Incomplete voiding of the Urinary Bladder
• Cloudy or oily urine
• Distension or tightness in the lower jiao
• Lumbar soreness
• Pale tongue with thick, white, greasy coating on the root
• Slippery pulse
537
Key symptoms
Cloudy or oily urine, distension in the lower jiao, difficult urination, white, greasy
tongue coating.
Treatment principle
Drain Damp-Cold from the Urinary Bladder.
Acupuncture points
Choose from: Ren 3, St 28, Sp 6, Sp 9, UB 22, UB 28 and UB 32.
Needle technique
Explanation
• Ren 3, St 28, UB 28 and UB 32 drain Dampness from the Urinary Bladder.
• Sp 6, Sp 9 and UB 22 drain Dampness from the Urinary Bladder.
Herbal formula
• Bei Xie Fen Qing Yin I (Warms and tonifies yang, drains Damp from the
Urinary Bladder)
Relevant advice
A person with Urinary Bladder Damp-Cold should avoid food and beverages that
can result in Cold or Dampness. They should avoid exposure to cold or damp
environments and keep warm and dry, dressing appropriately for the weather.
The person must be careful about what kinds of exercise and sports they practise.
Swimming is not recommended and they should definitely remove their swimming
costume immediately upon getting out of the water. Likewise, jogging or cycling in
the rain is problematic, as are sports where the person sweats whilst they are exposed
to the cold.
Urinary Bladder Damp-Cold can be caused by

• Spleen yang xu
• Kidney yang xu
• Damp
• Cold
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Urinary Bladder Damp-Cold can result in the

• Urinary Bladder Damp-Heat
• Kidney yang xu
Urinary Bladder xue stagnation

This is a chronic pattern that can arise from chronic patterns of imbalance in the
Urinary Bladder. Chronic conditions of Dampness can impede the movement of
qi, which can result in the stagnation of xue over time. Heat can condense xue so
it becomes sticky and starts to stagnate. Stagnations of Liver qi can affect the qi
mechanism in the Urinary Bladder, causing a stagnation of qi. When qi stagnates it
can fail to circulate xue.
The stagnation of xue can also arise independently of other patterns, for example
after surgery in the lower jiao.
Aetiology
Xue stagnation can be the result of physical trauma, surgery or medical investigations.
Emotional issues such as frustration, irritation, repressed emotions and stress can
lead to the stagnation of Liver qi, which can affect the movement of qi in the
Urinary Bladder. Over time this can lead to the stagnation of xue. Heat that boils
xue so it becomes sticky and stagnates can be due to emotional issues creating a
stagnation of qi that generates Heat or dietary imbalances that lead to the generation
of Heat or Dampness.
Symptoms and signs

• Difficult or painful urination
• Inhibited urinary flow
• There can be blood in the urine
• Tightness, pain or distension in the area above the pubic bone
• Small, visible, purple blood vessels or spider naevi
• Purple or dark spots on the root of the tongue, swollen, purple sub-lingual
veins
• Choppy or Wiry pulse, especially in the left chi position
Key symptoms
Inhibited or difficult urination, distension in the lower jiao.
539
Treatment principle
Invigorate xue in the Urinary Bladder.
Acupuncture points
Choose from: Ren 3, Sp 6, Sp 10, St 28, UB 17, UB 28 and UB 32.
Needle technique
Draining.
Explanation
• Ren 3, St 28, UB 28 and UB 32 invigorate xue in the Urinary Bladder.
• Sp 6, Sp 10 and UB 17 invigorate xue.
Herbal formula
• Shao Fu Shu Yu Tang (Invigorates xue and removes stasis in the lower jiao)
Relevant advice
This will depend on the underlying pattern of imbalance. If there is Heat or
Dampness, the patient should avoid consuming food and beverages that generate
these. Any underlying emotional issues or stress should be addressed.
Physical exercise and movement will help to circulate qi and xue. It can be
beneficial if the exercises focus on circulating qi in the lower jiao. Hula-hoops,
sit-ups and rowing machines can help to do this. Massaging the lower jiao is
also recommended.
Urinary Bladder xue stagnation can be caused by

Urinary Bladder xue stagnation can result in

• Urinary Bladder stones
Urinary Bladder stones

This will be a chronic pattern that has arisen as a consequence of other chronic
patterns of imbalance. Heat will usually be the precursor – ‘boiling’ the urine so it
eventually forms small stones or sand.
Dampness can coagulate and form Phlegm, which can manifest as stones and
sand in the urine.
540
Aetiology
Chronic patterns of Heat that usually underlie this pattern can be due to a residual
pathogen. This will usually be due to the use of Western medication that has not
fully cleared the pathogen. Both Dampness and Heat can lead to the formation
of Phlegm. This means that aetiological factors, such as a diet that creates Heat or
Dampness, can be involved. Likewise, emotional factors can lead to the creation of
Heart Fire that can drain down to the Urinary Bladder and ‘boil’ the urinary fluids,
resulting in stones.
Symptoms and signs

• Sudden or recurrent painful and blocked urination
• Inhibited urinary flow
• Piercing or cutting pain in the urethra that is better when urine flows freely
• Small stones or sand in the urine
• The tongue impression will depend on the underlying pattern of imbalance
• Wiry or Confined pulse in the left chi position
Key symptoms
Small stones or sand in the urine, painful urination.
Treatment principle
Expel stones and circulate qi in the Urinary Bladder.
Acupuncture points
Choose from: Ren 3, St 28, UB 28 and UB 32.
Needle technique
Draining. Electro-acupuncture is recommended.
Explanation
• Ren 3, St 28, UB 28 and UB 32 activate qi and expel stones from the Urinary
Bladder.
Herbal formula
• Shi Wei San (Dissolves stones and promotes urination)
541
Relevant advice
This will depend on the underlying pattern of imbalance. If there is Heat or
Dampness, the patient should avoid consuming food and beverages that generate
these. Any underlying emotional issues or stress should be addressed.
Physical exercise and massage, where the focus is on circulating qi in the lower
jiao, will be beneficial. Hula-hoops, sit-ups and rowing machines can help to do this.
Urinary Bladder stones can be caused by the

Urinary Bladder stones can result in the following pattern of imbalance

• Urinary xue stagnation
Xu patterns
Urinary Bladder xu Cold
If there is Kidney yang xu, the Kidneys may not be able to carry out their activities
in relation to fluid physiology and the storage and expulsion of urine.
Urinary Bladder xu Cold is therefore Kidney yang xu with signs that there is a
disturbance of the Urinary Bladder’s functioning.
Aetiology
Kidney yang can be weakened by disease, as well as food, drinks and medicine that
have a cold dynamic or temperature. Congenital weakness, old age, climatic cold,
hard physical work, lifting heavy objects, standing for long periods of time and too
much sex can weaken Kidney yang.
Symptoms and signs

• Frequent or urgent urination
• Copious amounts of pale, clear urine
• Nocturia or enuresis
• Incontinence
• Cold limbs
• Shiny, white facial colour
542
• Pale, swollen, wet tongue with white coating

• Deep and Weak pulse
Key symptoms
Frequent urination, aversion to cold, pale swollen tongue.
Treatment principle
Warm Kidney yang, astringe the Urinary Bladder.
Acupuncture points
Choose from: Kid 3, Kid 7, Ren 3, Ren 4, Ren 6, UB 23, UB 28 and Du 4.
Needle technique
Explanation
• Kid 3, Kid 7, Ren 6, UB 23 and Du 4 tonify Kidney yang.
• Ren 3 and UB 28 drain Dampness from the Urinary Bladder.
Herbal formula
• Suo Quan Wan (Tonifies and warms Kidney yang and astringes the urine)
Relevant advice
See Kidney yang xu.
Urinary Bladder xu Cold can be caused by the

• Kidney yang xu
• Spleen yang xu
• Spleen qi xu
• Cold
• Damp
Urinary Bladder xu Cold can result in the following patterns of imbalance

• Urinary Bladder Damp-Cold
• Kidney yang xu
• Spleen yang xu
• Damp
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Combined patterns
Liver qi stagnation and Urinary Bladder qi stagnation
This will usually be a recurrent chronic pattern with acute flare-ups that are
triggered by stress and emotional issues, resulting in a stagnation of Liver qi. Instead
of supporting the functioning of the Urinary Bladder by ensuring the free flow of
qi in the body, stagnant Liver qi means that there is a general tendency to have qi
stagnation in the body as a whole and it can specifically disrupt the qi mechanism
in the Urinary Bladder, resulting in a disruption of the functioning of the Urinary
Bladder. This is because the Liver channel traverses the external genitalia and the
Urinary Bladder.
Aetiology
Liver qi stagnation often arises as a consequence of stress, irritation, emotional
frustrations and pent-up emotions. Lack of exercise and physical movement can also
be factors. Dietary factors or blood loss can result in Liver xue xu, which can be the
underlying cause of Liver qi stagnation.
Symptoms and signs

• Inhibited or difficult urination
• Incomplete urination
• Urinary disturbances that are provoked or aggravated by stress or emotional
factors
• Urinary disturbances that are worse or occur in the premenstrual period
• Hypochondriac tension
• Irregular menstrual cycle
• Premenstrual tension
• Cold hands and feet
• Slight swelling along the edge of the tongue
• Wiry pulse, especially in the left guan and chi positions
Key symptoms
Urinary disturbances that are aggravated by emotional factors or that manifest in the
premenstrual period, Wiry pulse.
Treatment principle
Spread Liver qi and spread qi in the lower jiao and Urinary Bladder.
544
Acupuncture points
Choose from: Liv 3, LI 4, Ren 3, SJ 6, Sp 6, St 28, UB 18 and UB 28.
Needle technique
Spreading.
Explanation
• Liv 3, LI 4 and UB 18 spread Liver qi.
• Ren 3 and UB 28 spread qi in the Urinary Bladder.
• Sp 6, SJ 6 and St 28 circulate qi in the lower jiao.
Herbal formula
• Tian Tai Wu Yao San (Spreads Liver qi and expels Cold)
Relevant advice
When Liver qi stagnation is a significant aspect of the imbalance, it is important to
address the underlying causes of this pattern. There will often be emotional issues
involved in the generation of this pattern. If possible, the patient should try and
address these issues.
If Liver qi stagnation is a consequence of Liver xue xu, the diet should be adjusted
to address this aspect.
Physical exercise and movement will help to circulate qi in general. It will
be especially beneficial if the exercises focus on circulating qi in the lower jiao.
Hula‑hoops, sit-ups and rowing machines can help to do this. Massaging the lower
jiao is also recommended.
Liver qi stagnation and Urinary Bladder qi can be

• Liver xue xu
Liver qi stagnation and Urinary Bladder qi can result

• Urinary Bladder stones
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Kidney imbalances
The aetiology of Kidney patterns of imbalance
The Kidneys encompass the most fundamental aspects of the body’s qi. It is in the
Kidneys that jing is stored and it is between the Kidneys that mingmen is located.
In contrast to other organs, the Kidneys do not have any shi patterns of imbalance.
This is because the Kidneys comprise the fundamental yin and yang, and these can
only become xu. A xu condition in the Kidneys can easily result in the emergence
of shi conditions elsewhere in the body, but the Kidneys themselves can only be xu.
Because the Kidneys store jing and create yuan qi, they will be weakened when more
qi is consumed than the body is capable of producing. This means that long‑term
illness, stress, working too much or too hard, a weakening of one of the other
qi‑producing organs and bleeding can all put a strain on the Kidneys. Working too
hard physically will mainly weaken the Kidney’s yang aspect, whereas stress, working
too much mentally or working late in the evening or at night and sleeping too little
will burden Kidney yin. Yin is replenished at night whilst we sleep and when we rest.
A person who sleeps too little and works or parties at night weakens their yin.
The pre-heaven aspect of Kidney jing is inherited from the parents. This means
that the health of the parents at the time of conception and the mother’s health
during pregnancy will have a significant effect on the quality of a person’s jing. The
age of the parent also plays a role. The older they are, the weaker their jing is and
thereby the quality of the jing that they pass on to the child. In addition, there is a
progressive weakening of Kidneys over the years as a person gets older. At the age
of 40, half of a person’s yin has been consumed. Old age is characterised by signs that
the Kidneys are deficient. The hair turns grey or falls out, the teeth loosen, the bones
are fragile, the hearing is poorer, the libido and fertility decrease, the memory fades,
there is incontinence and so on.
Too much sex is an aetiological factor in many Kidney patterns of imbalance.
This is because men lose jing and yang when they ejaculate. In fact, it is not only
ejaculation that weakens the Kidneys, because when you become sexually aroused,
mingmen flares up. This is why the cheeks, lips and nail beds become redder and
you feel warmer. When mingmen flares up, it consumes jing. Some sources believe
that all forms of desire activate mingmen. This means that desire will weaken the
Kidneys in both men and women. Where men mainly lose jing through ejaculation,
women lose jing through births, ovulation and menstruation. The eggs are jing
and women therefore lose jing when eggs are released during ovulation. Jing is also
used to nourish the foetus during pregnancy. Finally tian gui (heavenly water) or
menstrual blood is jing that has been transformed by mingmen and Heart fire.
Standing and lifting weaken the Kidneys, especially Kidney yang. People whose
work involves a lot of lifting or lifting heavy objects and people who stand for long
periods of time will strain their Kidney yang.
Invasions of exogenous xie qi do not directly affect the Kidneys. On the other
hand, repeated invasions of exogenous Cold will weaken Kidney yang. Invasions
of exogenous xie qi, no matter whether they are Hot or Cold, can eventually lead
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to the generation of internal Heat. This will injure the Kidney yin, as will all Fire
conditions. Chronic disease and recurrent illness will be a burden on the zheng qi
and thereby also the Kidneys.
Emotionally, the Kidneys are affected by fear, anxiety and shock. If these emotions
are very intense or are a chronic condition, they will weaken the Kidneys. This is
often a vicious cycle: fear and anxiety weaken the Kidneys, but a person whose
Kidneys are weak will often be excessively and unnecessarily fearful and anxious.
Treatment of disease can also weaken the Kidneys. This can happen if the
medication used has a very hot or a cold dynamic. Improper or inadequate treatment
can also draw exogenous xie qi deeper into the body or lock a remnant of the xie qi
in the body. This can injure the Kidneys in the long term, either by generating Heat,
which injures yin, or by weakening qi and yang in general.
Excessive consumption of an energetically hot or cold diet can burden Kidney
yin and Kidney yang respectively.
Kidney yin xu and Kidney yang xu can both result in, and be the cause of, yin xu
or yang xu conditions in other organs, because Kidney yin and Kidney yang are the
root of yin and yang in the whole body. If they are weak, they will not nourish or
support the yin and yang aspects of the other organs. On the other hand, if an organ
is yin xu or yang xu, it will consume that aspect of the Kidneys so that it eventually
also becomes weakened. Kidney yin has an especially close relationship with Liver,
Heart, Lung and Stomach yin. Kidney yang has a similarly close relationship with
Spleen, Lung and Heart yang.
The pathology of Kidney patterns of imbalance

If the Kidneys are out of balance, it will manifest with a weakening or dysfunction
of one of the aspects or physiological functions that relate to the Kidneys. Kidney
imbalances can be reduced or simplified to two main imbalances – Kidney yin xu and
Kidney yang xu. Kidney yin encompasses Kidney jing and Kidney yang encompasses
mingmen and Kidney qi.
Kidney jing is used to create bones, cartilage, teeth and hair. If there is a congenital
jing xu, the person will often have a weak bone structure, weak teeth and thin hair.
The growth and the transition to puberty, etc. are controlled by jing. Jing xu can be
seen when there is slow development, poor growth, mental underdevelopment and a
child enters puberty late or not at all. A girl who does not start menstruating or only
starts menstruating late in puberty may well be jing xu.
Jing also manifests in the sperm and eggs. Infertility and low sperm counts can
therefore be a manifestation of jing xu.
The brain is ‘a flower blossoming on the spine’ and it is created from jing. Jing
therefore has an influence on the brain’s activity and structure. Congenital problems
that manifest with poor development of the mental faculties are often related to jing
xu. In fact, most congenital problems and genetic defects have a jing xu aspect. If
the brain is not nourished by Kidney jing, it can cause problems with the memory,
concentration and dizziness. Kidney yin nourishes Heart yin, helping to anchor
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the shen. Kidney yin xu can therefore manifest with insomnia, as well as anxiety,
mental restless and a sense of unease.
The Kidneys have a great influence on the bones, especially in the lumbar region
and the knees. The bones are created and nourished by Kidney jing. Kidney yang
in turn strengthens the bones and warms the lumbar and knees. This means that
weakness, soreness and a cold sensation in the lower back and knees can be seen in
Kidney imbalances.
Fluid physiology is dependent on the Kidneys. Kidney yang is used to transform
and transport fluids in the body. When there is Kidney yang xu, the deficiency of
yang will affect these processes, resulting in oedema or increased urination. The
increased frequency and volume of urination that is characteristic of Kidney yang xu
is due to this failure to transform and transport fluids optimally, as well as Kidney
yang being used to hold urine in the Urinary Bladder. This means that incontinence,
enuresis and nocturia can also be a manifestation of Kidney yang xu. Kidney yang
is also the force behind the expulsion of urine out of the Urinary Bladder. Kidney
yang xu can manifest with urinary difficulties, a weak stream of urine or dribbling
when urinating.
The poor transformation and transport of fluids in the body when there is Kidney
yang xu will result in the untransformed fluids seeping down to the lower jiao due
to their yin nature. These fluids will accumulate in the Urinary Bladder, increasing
the amount of urine and diluting it so that it is paler in colour. The urine will be a
darker yellow colour and more scanty when there is Kidney yin xu, because there will
be less fluid in the body, making the urine more concentrated. If there is yin xu Heat,
the Heat will further concentrate the urine and make it even more dark and sparse.
Kidney yang also affects other aspects of fluid physiology. Kidney yang is the root
of wei qi. If Kidney yang is weak or deficient, there may be problems controlling
the pores in the skin. Spontaneous perspiration or sweating upon light activity
can therefore be a sign of Kidney yang xu.
Kidney yin xu can also result in sweating disturbances. Night sweats are a classic
manifestation of Kidney yin xu, because yin has become too weak to control Heat,
especially at night, when yin should be more powerful than yang. The resultant yang
Heat will expand upwards and outwards, driving fluids up to the surface of the skin.
At night, wei qi circulates in the interior and therefore cannot keep the sweat inside
the body.
The Kidneys controls the body’s lower orifices. As discussed above, an impairment
of the Kidney’s functioning can result in urinary incontinence. It is not only the
urinary system’s orifice, though, that the Kidneys control the opening and closing
of, Kidney qi xu can also result in increased discharge from the vagina. As it is a yang
xu condition, the vaginal discharge will be watery and clear. In extreme cases, the
Kidneys can be so weak that there will be faecal incontinence. This is seen in some
elderly patients whose Kidney qi is weakened by old age.
Kidney qi is also used to hold the foetus inside the body and hold the
Uterus closed during pregnancy. Kidney qi xu, can therefore manifest with
spontaneous miscarriages. Kidney jing xu can also mean that the foetus does not
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develop as it should. This can be a factor when there is a history of recurrent

miscarriages.
The Kidneys should also hold the sperm back and keep them inside the body.
Both Kidney yin xu and the Kidney yang xu can manifest with premature ejaculation
and nocturnal emissions. The mechanism is different when there is Kidney yin xu to
when there is Kidney yang xu. When there is Kidney yang xu, the Kidney yang is not
strong enough to hold the sperm back and when there is Kidney yin xu, the resultant
Heat can drive the semen out of the body. As well as controlling and producing
semen and sperm, the Kidneys have a significant influence on a person’s libido. If
Kidney yang is weakened, a person can lack sexual desire. Kidney yang xu can also
manifest with impotence. This is because there can be a lack of sexual desire, but
also because Kidney yang is necessary to create an erection. It is, however, important
to remember that other organs also have an influence on potency and the libido,
especially the Heart and Liver. When there is Kidney yin xu Heat, there can be an
increased libido. If Heat is not controlled by yin, mingmen can flare up and there will
be an increase in sexual desire.
Kidney yang receives and grasps the qi that is sent down from the Lung. Kidney
yang xu and qi xu conditions can therefore result in dyspnoea and shortness of breath.
The Kidneys influence their sense organ, the ears. Kidney jing xu can manifest
with ears that are very small or misshapen. Kidney yin and jing nourish the ears. If
there is Kidney jing xu or Kidney yin xu, there can be hearing problems, such as
tinnitus and deafness, especially if these are congenital or have developed gradually.
Again, it is important to remember that other organs, such as the Liver, also affect
the ears and thereby tinnitus.
Willpower, or zhi in Chinese, has its residence in the Kidneys. If the Kidneys
are strong, a person has the willpower and determination to carry out the projects
they have envisioned, i.e. that the Liver and hun have visualised. It is this willpower
to grow that is seen in a seedling that has germinated. It is determined to grow up
into the light, no matter what obstacles it meets. A person with weak Kidneys will
sometimes lack the willpower and determination to complete projects. They will give
up when they encounter resistance or become tired. The weak zhi can also result in
depression, because the person loses the will to live.
Memory is also an aspect of the Chinese character zhi. This makes sense when
we take into account that the brain is nourished by and created from jing.
As described, the Kidneys are the root of all yin and yang in the body. This
means that when there are generalised yin xu and yang xu symptoms in the body,
the Kidneys will usually be the focus of treatment.
General symptoms and signs of Kidney imbalances

• Knee problems
• Lumbar problems
• Tinnitus and hearing problems
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• Urinary problems
• Problems with sexual function and libido
• Problems with fertility
• Hair loss
• Dyspnoea
• Oedema
• Weak pulse in the chi positions
• General yin xu and yang xu signs
Xu patterns
Kidney yin xu
Kidney yin xu is a weakening of yin at the deepest level. It could be caused by a
chronic condition of yin xu in another organ or by the long-term overstraining of
the body, mind or psyche. Because Kidney yin is such a deep and a fundamental
aspect of the body, the imbalance will usually have built up gradually over time.
Furthermore, because it is such a deep and fundamental deficiency and because
Kidney yin also relates to jing, the treatment of this imbalance will also take longer
than other imbalances that have a more superficial nature.
Aetiology
Long-term physical, emotional and mental overexertion, chronic stress, prolonged
illness, working at night, using medications that are hot or spicy in their energy,
excessive sex, a diet that includes an excess of food or drinks that are hot or spicy, too
much coffee and other stimulants, congenital weakness and old age can all weaken
yin.
Kidney yin xu will often occur as a consequence of chronic imbalances in the
body. For example, a chronic xue xu condition will weaken yin. Similarly, prolonged
or intense Fire conditions and febrile diseases can injure the fluids and thereby Kidney
yin. Kidney yin is the root of all yin in the body. When Kidney yin is weakened, yin
xu conditions in other organs can also arise.
Symptoms and signs

• Insomnia
• Dry skin
• Night sweats
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• Poor memory
• Nocturnal emissions
• Premature ejaculation
• Infertility
• Tinnitus
• Poor hearing or deafness
• Dry eyes
• Weak or sore knees
• Lumbar weakness or soreness
• Thin or slender body
• Sparse and dark urine
• Dry stool or constipation
• Mild feeling of anxiety
• Depression
• Dizziness
• Thin, dry tongue that lacks coating and possibly has cracks in the surface of
the tongue
• Fine or Empty pulse, the pulse may be relatively weak in the chi positions
Key symptoms
Night sweats, sore lower back, absent tongue coating.
Treatment principle
Nourish Kidney yin.
Acupuncture points
Choose from: UB 23, UB 52, Ren 4, Sp 6, Kid 3, Kid 6 and Lu 7.
Needle technique
Tonifying.
Explanation
nourish Kidney yin.
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Herbal formula
• Liu Wei Di Huang Tang (Nourishes Kidney yin)
• Zou Gui Wan (Nourishes Kidney yin)
Relevant advice
It is essential that a person who is Kidney yin xu gets enough rest and relaxation. This
means that they must get ample sleep and go to bed early at night. They must not
work too hard, neither should they spend too much time watching television and or
staring at a computer screen. They should avoid stimulants, such as coffee, as these
will stress their system. Alcohol is not good either, because it is both spreading and
hot in its energy.
Sweating too much will mean that they lose body fluid. Therefore, a person who
is Kidney yin xu should avoid saunas or steam baths.
Men, in particular, should limit how much sex they have, including masturbation,
because jing is lost when ejaculating.
Shiatsu, massage and meditation are beneficial because they promote calmness
and tranquillity in the body and mind, thereby nourishing yin.
Dynamic activities such as aerobics or action sports are not beneficial and should
be discouraged, because they will further consume the person’s yin. Lighter and more
meditative activities such as qi gong, yoga and tai ji nourish yin, whilst activating qi.
Dietary advice includes avoiding food and beverages that are stimulating or hot
in their dynamic. This includes coffee, black, green and white tea, alcohol, sugar
and hot spices like chilli and garlic. The way food is prepared will affect its dynamic.
Baked food, as well as being more warming in its dynamic, will be dynamically
drier. The consumption of baked food should therefore be limited when there is
a yin xu condition. Soups, stews and boiled vegetables, on the other hand, should
be recommended. Concentrated proteins, green leafy vegetables, cereals and root
vegetables nourish yin in general, as do things that are rich in minerals, such as
seaweed. Oil and products that have a high oil content, for example nuts and seeds,
will nourish and moisten yin. Foods that specifically nourish Kidney yin include:
alfalfa sprouts, asparagus, potatoes, green beans, nettles, aduki beans, black beans,
kidney beans, coconut milk, sesame seeds, walnuts, octopus, oysters, duck, kidneys,
pork and egg yolks.
Kidney yin xu can be caused by the following patterns of imbalance

• Liver yin xu
• Heart yin xu
• Lung yin xu
• Stomach yin xu
• Liver xue xu
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• Kidney yang xu
• Fire
• Heat
• Xue xu
Kidney yin xu can result in the following patterns of imbalance

• Xu Heat
• Liver yin xu
• Heart yin xu
• Lung yin xu
• Stomach yin xu
• Liver xue xu
• Kidney yang xu
• Kidney jing xu
• Phlegm
• Xue stagnation
Kidney yin xu Heat

In time, Kidney yin xu will develop into Kidney yin xu Heat. This will happen more
quickly if there is already Heat present in the body. Symptoms will be the same as
when there is Kidney yin xu, but there will also be more symptoms and signs of Heat.
Aetiology
See Kidney yin xu.
Symptoms and signs

• Insomnia
• Dry skin
• Thirst, particularly at night, with a desire to drink in small sips
• Night sweats
• Feeling hot in the evening and at night
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• Sensation of heat in the palms of the hands, soles of the feet and chest
• Hot flushes
• Malar flush
• Tinnitus
• Poor hearing or deafness
• Dry eyes
• Lumbar weakness or soreness
• Thin or slender body
• Aching or pain in the bones
• Anxiety
• Constipation
• Poor memory
• Increased libido
• Mental anxiety and restlessness
• Restless or fidgeting body movements
• Talking quickly or talking a lot, but the voice is not loud
• Red, thin and dry tongue that lacks coating and possibly has cracks in the
surface
• Rapid, Fine or Empty pulse, the pulse may be relatively weak in the chi
positions
Key symptoms
Night sweats, hot at night, malar flush, red tongue without coating.
Treatment principle
Nourish Kidney yin and control Heat.
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Acupuncture points
Choose from: UB 23, UB 52, Ren 4, Kid 1, Kid 2, Kid 3, Kid 6, Kid 7, Sp 6, He 6
and Lu 7.
Needle technique
Tonifying, except Kid 2, which can be drained.
Explanation
• Kid 1 and Kid 2 control yin xu Heat.
• He 6 and Kid 7 control night sweats and nourish Kidney and Heart yin.
nourish Kidney yin.
Herbal formula
• Zhi Bai Di Huang Tang (Nourishes Kidney yin and controls yin xu Heat)
• Da Bu Yin Wan (Nourishes Kidney yin and controls yin xu Heat)
Relevant advice
See Kidney yin xu.
Kidney yin xu Heat can be caused by the following patterns of imbalance

• Kidney yin xu
• Fire
• Heat
Kidney yin xu Heat can result in the following patterns of imbalance

• Liver yin xu
• Heart yin xu
• Lung yin xu
• Stomach yin xu
• Liver xue xu
• Kidney yang xu
• Kidney jing xu
• Phlegm
• Xue stagnation
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Kidney yang xu
In the same way that Kidney yin xu is a deficiency of the deepest aspect of yin, Kidney
yang xu is a deficiency of the body’s deepest yang aspect. The strength of Kidney yang
is inextricably related to the strength of mingmen. When there is Kidney yang xu,
mingmen will be weaker and thereby so will the production of yuan qi. This has
implications for many of the body’s physiological processes.
Aetiology
Kidney yang is weakened by food, beverages and medications that are cold in their
energy or temperature, congenital weakness, chronic disease, old age, exogenous
Cold, hard physical work and overexertion, lifting heavy objects, standing for long
periods of time and too much sex. Kidney yang is also weakened by chronic yang xu
conditions in other organs.
Symptoms and signs

• Soreness, weakness, fatigue or a sensation of cold in the lumbar region
• Sore, weak or cold knees
• Cold limbs
• Frequent or urgent urination
• Copious amounts of pale-coloured urine
• Oedema
• Loose, watery stools
• Indifference and lack of vitality
• Wearing warmer clothing than others
• Tinnitus
• Dizziness
• Infertility
• Poor sperm motility
• Pale complexion
• Slow and languid body movements
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• Poor posture
• Weak libido
• Lack of thirst
• Desire for hot drinks and hot food
• Pale, swollen and possibly wet tongue
• Deep and Weak pulse, the pulse may be relatively weak in the chi positions
Key symptoms
Sore or weak lumbar region, frequent urination or nocturia, aversion to cold. Pale
tongue and Deep pulse.
Treatment principle
Warm and tonify Kidney yang.
Acupuncture points
Choose from: UB 23, Du 4, Ren 4, Ren 6, Kid 3 and Kid 7.
Needle technique
Tonifying. Moxa is strongly recommended.
Explanation
• UB 23, Du 4, Ren 4, Ren 6, Kid 3 and Kid 7 tonify and warm Kidney yang.
Herbal formula
Relevant advice
The patient should consume a diet that is warm in both its temperature and its
energetic dynamic. They should completely avoid foods and beverages that have a
cold dynamic and that are cold in their temperature, especially in winter. In practice,
this means avoiding fruit unless it is boiled or baked, salad, raw vegetables and cold
drinks. They should try to use more warming cooking methods when preparing
food, such as oven-baked and grilled dishes, which are more warming than steamed
and cooked dishes.
Hot spices such as chilli are not necessarily salutary because they will cause the
person to sweat and thereby lose heat. Tonifying a xu condition is something that
takes time and cannot be forced. The use of spices in general is helpful, though,
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as they can activate yang. Spices that warm and tonify Kidney yang are cinnamon,
cloves, fennel, basil, sage, fenugreek, horseradish, rosemary and black pepper.
Foods that specifically tonify Kidney yang are oysters, smoked fish, salmon, tuna,
lobster, trout, mussels, shrimp, lamb, venison, duck, roast pork, kidney, chestnut,
walnuts, pistachio, black sesame seeds, quinoa, oats, buckwheat, millet, aduki beans,
black beans, de Puy lentils, raspberry and cherry. Green tea is cooling, so black tea
will be better. Otherwise, ginger tea, fennel tea, yogi tea and jasmine tea will all
be good.
A person who is Kidney yang xu must ensure that they get enough exercise.
Light exercise is beneficial when there is yang xu because it will activate yang and qi.
They must, however, be careful that they do not train so intensely that they become
fatigued or tired, because this will further drain their yang. It is a good idea to start
the day with physical activities that can activate and circulate qi.
Keeping warm is important, especially in the lumbar region and the area below
the navel. Wearing a belly-warmer or a woollen stomach scarf around the midriff and
lumbar can be recommended. Protecting this area from drafts should be a priority. A
ginger foot bath is also beneficial, as is drinking ginger tea.
Patients who are Kidney yang xu should avoid activities that weaken the Kidneys
and yang in general. Besides the above advice, men should limit how much sex they
have, including masturbation, as Kidney yang is expended upon ejaculation. Lifting
heavy objects and standing weakens Kidney yang and should be avoided as much
as possible.
Kidney yang xu can be caused by the following patterns of imbalance

• Spleen yang xu
• Kidney yin xu
• Damp
• Cold
Kidney yang xu can result in the following patterns of imbalance

• Spleen yang xu
• Kidney yang xu
• Heart yang xu
• Kidney qi not grasping Lung qi
• Kidney yang xu, overflowing water
• Damp
• Phlegm
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• Cold
• Xue stagnation
• Qi xu
• Xue xu
Kidney qi xu
Kidney qi xu is similar in many ways to Kidney yang xu, because Kidney qi is an
aspect of the Kidney yang. When there is Kidney qi xu there are symptoms that
specifically relate to the functions of Kidney qi, such as the control of the lower
orifices in the body and raising qi in the lower jiao. There will be fewer signs of xu
Cold in this pattern.
Aetiology
In men Kidney qi is weakened by too much sex and in women it is weakened by
giving birth and menstruation. Furthermore, hard physical work also weakens
Kidney qi. Like other Kidney patterns of imbalance, Kidney qi xu is also a result of
the ageing process.
Symptoms and signs

• Sore, weak or cold lumbar region
• Cold limbs
• Clear and copious urine
• Weak flow of urine
• Post-urination dripping
• Incontinence
• Watery or white vaginal discharge
• Recurrent miscarriages
• Uterine prolapse
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• Distension in the lower jiao

• Slow and languid body movements
• Poor posture
• Pale tongue
• Deep and Weak pulse in the chi positions
Key symptoms
Weak stream of urine, post-urination dripping, watery or whitish vagina discharge
and a sore lower back.
Treatment principle
Stabilise and tonify Kidney qi, raise Kidney yang.
Acupuncture points
Choose from: Ren 4, Ren 6, Du 4, Du 20, Kid 3, Kid 7, Kid 13, UB 23 and UB 32.
Needle technique
Tonifying. Moxa is recommended and is necessary on Ren 6 and Du 20.
Explanation
• UB 23, Du 4, Ren 4, Kid 3 and Kid 7 tonify Kidney qi.
• Kid 13 and UB 32 stabilise Kidney qi and the Urinary Bladder.
• Ren 6 and Du 20 raise yang.
Herbal formula
• Jin Gui Shen Qi Tang (Warms and tonifies Kidney yang)
• You Gui Wan (Warms and tonifies Kidney yang)
Relevant advice
Men should avoid ejaculating and women should avoid becoming pregnant. The
patient should avoid lifting heavy objects and working too hard or placing a physical
strain on the body. They should eat a diet that strengthens Kidney yang.
Kidney qi xu can be caused by the following patterns of imbalance

• Spleen yang xu
• Kidney yang xu
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Kidney qi xu can result in the following pattern of imbalance

• Kidney yang xu
Kidney qi not grasping Lung qi

The Kidneys are responsible for grasping the qi that the Lung sends down. If Kidney
qi or Kidney yang is weak, the Kidneys will not be able to grasp and hold down the
Lung qi. This will disrupt the functioning of the Lung and there will be dyspnoea.
Aetiology
There may be a congenital weakness of the Kidneys and Lung. Working too hard
physically, lifting and standing for long periods of time weaken the Kidney qi. Too
much sex, chronic illness and old age are also possible factors.
Symptoms and signs

• Shallow, superficial breathing
• Difficulty inhaling
• Lumbar weakness, fatigue or soreness
• Sore or weak knees
• Dizziness
• Pale complexion
• Fatigue, both mental and physical
• Puffy face or puffiness around the eyes
• Pale tongue
• Deep and Weak pulse, especially in the chi positions
Key symptoms
Dyspnoea, lumbar soreness, deep and weak pulse in the chi positions.
Treatment principle
Tonify and warm the Kidneys, strengthen the Kidneys’ ability to grasp qi, regulate
Lung qi.
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Acupuncture points
Choose from: Kid 3, Kid 4, Kid 7, Kid 25, Ren 4, Ren 6, Ren 17, Du 4, Lu 7, Lu 9,
UB 13 and UB 23.
Needle technique
Explanation
• UB 23, Du 4, Ren 4, Ren 6, Kid 3 and Kid 7 tonify Kidney qi.
• Kid 4 tonifies the Kidney’s ability to grasp Lung qi.
• Kid 25, Ren 17, Lu 7, Lu 9 and UB 13 regulate Lung qi.
Herbal formula
• Su Zi Jiang Qi Tang (Regulates Lung qi, transforms Phlegm and warms
Kidney yang)
Relevant advice
Men should avoid having too many ejaculations and women should avoid becoming
pregnant. Both sexes should avoid lifting heavy objects and overworking. Light
physical exercise is okay, but the patient should avoid training excessively and
exhausting physical activity. Fresh air and breathing exercises will be beneficial. The
patient should eat foods that tonify Kidney yang (see the section on Kidney yang xu
on page 556).
Kidney qi not grasping Lung qi can be caused by

• Spleen qi xu
• Spleen yang xu
• Lung qi xu
• Kidney yang xu
Kidney qi not grasping Lung qi can result in

• Lung qi xu
• Phlegm
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Kidney yang xu, overflowing water

When there is a significant Kidney yang xu, it may result in the transformation
and transportation of fluids becoming so poor that fluids accumulate in the flesh
under the skin. In some situations, the imbalance is not limited to the Kidneys
and will also affect the Heart or the Lung. If the Heart is involved, there can also
be palpitations and cold hands. If the Lung is involved, there will be watery, foamy
sputum, coughing and/or difficulty breathing.
Aetiology
Kidney yang xu, overflowing water can arise when there is a deficiency in one or more
of the following organs: Kidneys, Spleen, Lung and Heart. Kidney yang is weakened
by disease, cold food, congenital weakness, old age, exogenous Cold, overwork,
lifting heavy objects, standing for long periods of time and too much sex. Spleen
yang is particularly weakened by food that is cold in its energy and temperature and
cold medicine. Heart yang xu can have been influenced by emotional imbalances
and Lung yang can be weakened by invasions of exogenous Cold.
Symptoms and signs

• Oedema, especially in the legs
• Abdominal bloating and oppression in the lower part of the abdominal cavity
• Lumbar soreness, weakness or fatigue
• Sore or weak knees
• Puffy eyelids
• Cold limbs
• Pale or white face
• Sparse but pale-coloured urine
• Swollen, pale and wet tongue
• Deep, Weak and Slow pulse, the pulse may be relatively weak in the chi
positions
If there is overflowing water that affects the Lung, there can also be:
• clear, watery, frothy sputum
• difficulty breathing
• shortness of breath
• cough with loose, thin sputum.
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If there is overflowing water that affects the Heart, there can also be:
• palpitations
• shortness of breath
• cold hands.
Key symptoms
Oedema, sparse, but clear and pale urine, swollen, pale and wet tongue, Deep and
Weak pulse.
• If the Lung is affected: watery sputum.
• If the Heart is affected: palpitations
Treatment principle
Tonify and warm Kidney yang, transform and drain fluids. Possibly tonify the Heart
or the Lung.
Acupuncture points
Choose from: Kid 3, Kid 7, Ren 4, Ren 6, Ren 9, Du 4, UB 20, UB 22, UB 23,
Sp 6, Sp 9, St 28 and St 36.
• If there is overflowing water that affects the Lung, add: Lu 7, UB 13 and
Du 12.
• If there is overflowing water that affects the Heart, add: Du 14, UB 15, Du
11 and Ren 17.
Needle technique
Tonifying, except on Ren 9, St 28, Sp 6 and Sp 9, which should be drained. Moxa
is recommended.
Explanation
• UB 23, Du 4, Ren 4, Ren 6 and Kid 3 tonify and warm Kidney yang.
• Kid 7 tonifies and warms Kidney yang and regulates the water passages.
• Ren 9 and St 28 regulate the water passages and drain Dampness.
• UB 20 and St 36 tonify Spleen yang.
• Sp 6 and Sp 9 drain Dampness.
• Lu 7, UB 13 and Du 12 regulate Lung qi and open the water passages.
• Du 14 tonifies yang.
• UB 15, Du 11 and Ren 17 regulate Heart qi and open the water passages.
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Herbal formula
• Zhen Wu Tang Tang (Warms yang and drains water)
Relevant advice
The person should avoid eating foods and drinks that have a cold energy or
temperature. They will benefit from drinking ginger tea or using ginger and
cinnamon in their cooking. They should avoid lifting heavy objects, standing too
much and physical strain. Men should avoid having too many ejaculations.
Kidney yang xu, overflowing water can caused by

• Spleen yang xu
• Kidney yang xu
• Lung qi xu
• Heart yang xu
• Heart qi xu
• Damp
• Cold
Kidney yang xu, overflowing water can result in

• Heart yang xu
• Lung qi xu
• Phlegm
• Xue stagnation
• Damp
• Spleen yang xu
• Qi xu
Kidney jing xu
Kidney jing is an aspect of Kidney yin, but it is also a distinct imbalance with specific
symptoms and signs. Because Kidney jing is such a fundamental and basic aspect of
the body’s constitution, and is in part a form of qi that is inherited from the parents,
a jing xu condition is an imbalance that is difficult to rectify. Some believe that you
cannot replenish deficient jing, only improve the quality of remaining jing.
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Aetiology
Kidney jing is partially inherited from the parents. This means that their age and
health at the time of conception have crucial implications for the quality of a
person’s jing. Jing can also be weakened by chronic diseases, chronic stress, mental
and physical overexertion, excessive sex, births, pregnancies and old age.
Symptoms and signs

• Frail constitution
• Weak teeth
• Porous or fragile bones
• Slender or thin body
• Mental or physical underdevelopment in children
• Deafness
• Tinnitus
• Dizziness
• Poor memory
• Delayed or absent development of secondary sexual characteristics in puberty
• Prematurely grey or white hair
• Infertility
• Lumbar weakness
• Weak knees
• Amenorrhoea
• Poor concentration
• Weakened mental capacity
• Hollow, depressed area in the root of the tongue
• Weak pulse in the chi positions
Key symptoms
Frail constitution, weak teeth and bones, infertility, depressed area on the root of
the tongue.
Treatment principle
Nourish Kidney jing.
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Acupuncture points
Choose from: Kid 3, Kid 6, Kid 13, Ren 4, UB 23, UB 52, UB 11 and GB 39.
Needle technique
Tonifying.
Explanation
• Kid 3, Kid 6, Ren 4, UB 23 and UB 52 tonify Kidney jing.
• UB 11 and GB 39 tonify the bones.
Herbal formula
• Zou Gui Wan (Nourishes Kidney jing)
Relevant advice
A person who is Kidney jing xu must ensure that they get enough rest and relaxation
and they should not drive themselves too hard mentally or physically. Men who are
jing xu should avoid having too much sex. Pregnancy and childbirth will further
weaken the jing in a woman who is jing xu. They should avoid stimulants, especially
coffee and caffeine. Foods that are attributed jing-nourishing qualities are royal jelly,
eggs, roe/caviar, seeds, nuts, propolis/pollen, bone marrow, brain, kidney, oysters,
seaweed and algae, artichokes, raw milk, nettles and oats.
Kidney jing xu can be caused by the following patterns of imbalance

• Kidney yin xu
• Kidney yang xu
• Qi xu
• Xue xu
Kidney jing xu can result in the following patterns of imbalance

• Kidney yin xu
• Kidney yang xu
• Qi xu
• Xue xu
Combined patterns
There can be combined patterns that do not just manifest simultaneously but in
fact have become a joint pattern. This is particularly relevant with regards to Kidney
imbalances, as Kidney yin and Kidney yang are the foundation of yin and yang in the
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whole body. When Kidney yin and Kidney yang are out of balance, the imbalance
will usually encompass other organs. When there is a chronic imbalance in another
organ, it will often end up affecting the Kidneys.
Kidney yin xu and Kidney yang xu

As discussed in the introduction, unlike other organs, the Kidneys do not have any
shi patterns of imbalance and can quite easily be yin xu and yang xu concurrently.
Kidney yin xu and Kidney yang xu often arise as a consequence of each other,
because they are mutually dependent and, in reality, are just aspects of each other.
This means that when one aspect is xu, the other aspect will also become xu over
time. One of the aspects, however, will always be more xu than the other. This aspect
will therefore be the primary focus of the treatment, but the other aspect will also
be treated at the same time. The patient will manifest with a combination of both
Kidney yin xu and Kidney yang xu symptoms and signs. The tongue and pulse will be
crucial factors that determine which imbalance is the most dominant. The treatment
of Kidney yin xu and Kidney yang xu with needles is relatively straightforward, as
the points used are generally the same, but the major difference is the use of moxa
when there is Kidney yang xu. When employing herbs or pre-prepared pills, the
situation is slightly more complex. It is important to determine which aspect is to be
the primary focus of the treatment. One approach that can be utilised when treating
with pre-prepared pills is to prescribe more of one type of pills than the other. For
example, if Kidney yin xu is more pronounced than Kidney yang xu, the patient
could be prescribed six Liu Wei Di Huang pills and two Jin Gui Shen Qi pills three
times a day. Another approach is to administer the pills to treat Kidney yang xu
in the morning and the pills to treat Kidney yin xu in the evening. It is, of course,
possible to combine both these two approaches.
The aetiology, symptoms and treatment of the two patterns are described above
in the sections discussing Kidney yin xu and Kidney yang xu.
Kidney yin xu and Liver yin xu

Kidney yin and Liver yin have a common root, which means that a xu condition in
one can easily lead to a xu condition in the other.
Aetiology
Kidney and Liver yin xu can result from ageing, mental and physical overexertion,
chronic illness, too little sleep, emotional stress and problems, frustrations and
pent‑up emotions, too much sex, too much coffee, dietary factors and medicines
that are warming or spreading in their energy, long-term xue xu or Heat conditions
and chronic yin xu conditions in other organs.
Symptoms and signs

• Dry eyes
• Blurred vision
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• Night blindness
• Nagging headache
• Dizziness
• Insomnia
• Night sweats
• Numbness or tingling in the limbs
• Leg cramps in the evening and at night
• Thin body
• Poor hearing
• Dry hair and skin
• Dry stools
• Sparse or absent menstrual bleeding
• Infertility
• Thin tongue with a lack of coating, possibly cracks in the surface of the
tongue
• Fine or Empty pulse, the pulse may be relatively weak in the left chi and guan
positions
If Liver and Kidney yin xu have resulted in xu Heat, there can also be:
• hot flushes
• heat in the evening and at night
• a hot sensation in the palms of the hands, soles of the feet and centre of the
chest
• a thirst with a desire to drink in small sips
• a red and dry tongue that lacks coating, possibly with cracks in the surface
• Fine and Rapid pulse, and possibly a Superficial pulse.
Key symptoms
Dry eyes and throat, insomnia, night sweats, lack of tongue coating, being warm in
the evening or hot at night. If there is xu Heat, there can be hot flushes.
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Treatment principle
Nourish Kidney and Liver yin, possibly control xu Heat.
Acupuncture points
Choose from: Kid 3, Kid 6, Kid 13, Sp 6, Liv 3 inserted through to Kid 1, Liv 8,
Ren 4, UB 18, UB 23 and UB 52.
Needle technique
Tonifying.
Explanation
• Kid 1, Kid 3, Kid 6, Kid 13, Ren 4, UB 23 and UB 52 nourish Kidney yin.
• Sp 6 nourishes Kidney and Liver yin.
• Liv 3 and UB 18 nourish Liver yin.
Herbal formula
• Liu Wei Di Huang Tang (Nourishes Kidney and Liver yin)
• Qi Ju Di Huang Tang (Nourishes Kidney and Liver yin and controls Liver
yang)
• Zou Gui Wan (Nourishes Kidney and Liver yin)
Relevant advice
See Kidney yin xu and Liver yin xu.
Kidney yin xu and Liver yin xu can be caused by

• Kidney yin xu
• Liver xue xu
Kidney yin xu and Liver yin xu can result in

• Yin xu Heat
• Kidney yang xu
Kidney yin xu and Heart yin xu

This pattern is also known as ‘Kidney and Heart not harmonised’, because it reflects
a disharmony in the fundamental balance between Fire and Water that these two
organs are a resonance of. Water, in the form of Kidney yin, should nourish Heart yin
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and thereby control the Heart’s yang fire aspect. If Kidney and Heart yin are weak,
there will be an imbalance between Fire and Water. As it is a xu condition, there will
not be the same intense and aggressive signs that shen is disturbed as when there is
Heart Fire. When there is yin xu, shen will be more unsettled than agitated.
Aetiology
Heart and Kidney yin xu can arise from the following aetiological factors: ageing,
mental and physical overexertion, chronic illness, too little sleep, emotional stress,
anxiety, shock, depression, sadness, too much sex, too much coffee, dietary factors
and medicine that are hot or spreading in their energy, chronic xue xu or Heat
conditions and chronic yin xu conditions in other organs.
Symptoms and signs

• Insomnia
• Mental unrest
• Anxiety
• Poor memory
• The person talks quickly and a lot
• Restlessness
• Restless or nervous movements
• Dizziness
• Tinnitus
• Poor hearing
• Palpitations
• Lumbar soreness or weakness
• Hot flushes
• Feeling of heat in the evening and at night
• Night sweats
• Hot sensation in the palms of the hands, soles of the feet and chest
• Malar flush
• Dark urine and scanty urination
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• Dry stools
• Thin body
• Thin, red tongue that lacks coating, red tongue tip, possibly cracked in the
surface of the tongue
• The pulse is Fine or Empty, the left chi and cun positions may be weaker than
the rest of the pulse, the pulse may be Rapid.
Key symptoms
Insomnia, palpitations, restlessness, night sweats, red tongue tip and malar flush.
Treatment principle
Nourish Kidney and Heart yin. Control Heat and calm the shen.
Acupuncture points
Choose from: Kid 3, Kid 6, Kid 7, Kid 9, Ren 4, Ren 15, He 5, He 6, He 7, UB 15,
UB 23 and UB 52.
Needle technique
Tonifying.
Explanation
• Ren 15, He 5, He 6, He 7 and UB 15 nourish Heart yin.
Herbal formula
• Tian Wang Bu Xin Dan (Nourish Heart and Kidney yin, calms shen)
Relevant advice
See Kidney yin xu and Heart yin xu.
Kidney yin xu and Heart yin xu can be caused by

• Kidney yin xu
• Heart yin xu
Kidney yin xu and Heart yin xu can result in

• Xue Heat
• Liver yin xu
• Phlegm
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Kidney yin xu and Lung yin xu

The Lung is the ‘delicate organ’. It is the only yin organ that is in direct contact
with the environment outside of the body, which makes the Lung vulnerable to
invasions of exogenous xie qi. The consequence of this is that Dryness and Heat can
damage Lung yin. The Lung and the Kidneys cooperate closely with regards to the
physiology of fluids in the body. One of the functions of the Kidneys is to moisten
the Lung. This means that Kidney yin xu can injure Lung yin, and a chronic Lung
yin xu will place a strain on Kidney yin.
Aetiology
Kidney and Lung yin xu can be a consequence of respiratory diseases, poor indoor
climate with dry air, tobacco smoke, air pollution, ageing, mental and physical
overexertion, chronic illness, stress, worry, unresolved or prolonged sorrow, too little
sleep, too much sex, too much coffee, dietary factors and medicines that are hot
or spreading in their energy, chronic xue xu or Heat conditions and chronic yin xu
conditions in other organs.
Symptoms and signs

• Dry or tickling cough that is worse in the evening and at night or when the
person is tired, the cough is weak
• Dry throat
• Ticklish sensation in the throat
• Shortness of breath on exertion
• Dry skin
• Lumbar soreness
• Sore knees
• Insomnia
• Night sweats
• Tinnitus
• Dizziness
• Poor hearing
• Thin body
• Thin tongue with a lack of coating. There may be two small diagonal cracks
in the front portion of the tongue
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• Fine or Empty pulse, the pulse may be relatively weak in the right cun and
left chi positions
Key symptoms
Dry cough, dry throat, lack of tongue coating.
Treatment principle
Nourish Kidney and Lung yin.
Acupuncture points
Choose from: Kid 3, Kid 6, Kid 7, Kid 9, Ren 4, Ren 17, Lu 1, Lu 9, UB 13, UB 23
and UB 52.
Needle technique
Tonifying.
Explanation
• Lu 1, Lu 9 and UB 13 nourish Lung yin and regulate Lung qi.
Herbal formula
• Mai Wei Di Huang Tang (Nourishes Lung and Kidney yin)
Relevant advice
See Kidney yin xu and Lung yin xu.
Kidney yin xu and Lung yin xu can be caused by

• Kidney yin xu
• Lung yin xu
• Lung dryness
• Lung Heat
Kidney yin xu and Lung yin xu can result in

• Phlegm
• Liver yin xu
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Kidney yang xu and Spleen yang xu

Spleen yang is reliant on heat from Kidney yang and mingmen to transform and
transport the food and liquids that are consumed. If Spleen yang is weakened by the
consumption of cold or raw foods, cold drinks or cold medicine, or if the Spleen is
affected by the accumulation of Dampness, the weakening of the Spleen will place a
burden on Kidney yang. This is because Kidney yang will have to work harder to heat
and support Spleen yang. Conversely, a weak Kidney yang will not support Spleen
yang and this will place a greater demand on the Spleen yang, thereby weakening it.
Aetiology
Spleen and Kidney yang are weakened by the following factors: Cold- or Damp-
creating foods, raw food, cold drinks, cold medicine, physical overexertion, standing
for long periods of time, lifting heavy objects, too much sex, invasions of exogenous
Cold, ageing and congenital weakness.
Symptoms and signs

• Diarrhoea or watery stools that contain undigested food
• Watery stools early in the morning
• Frequent urination with large amount of clear, pale-coloured urine
• Cold limbs
• Oedema
• Lack of thirst
• Lumbar soreness
• Cold lumbar region
• Impotence
• Low libido
• Poor sperm quality
• Infertility
• Watery vaginal discharge
• Depression
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• Indifference and indolence

• Poor appetite
• Disinclination for cold drinks or foods
• Pale complexion
• Dressing warmer than is normal for the season
• Pale, swollen and wet tongue with a white coating
• Deep and Weak pulse, right guan and chi positions may be relatively weak
Key symptoms
Watery stools containing undigested food, frequent urination with clear and
copious amounts of urine, aversion to cold, sore lower back, sore knees and a Deep,
Weak pulse.
Treatment principle
Warm and tonify Kidney and Spleen yang.
Acupuncture points
Choose from: Kid 3, Kid 7, Sp 3, St 25, St 36, St 37, Ren 4, Ren 6, Ren 8, Ren 12,
UB 20, UB 21, UB 23 and Du 4.
Needle technique
Tonifying. Moxa is strongly recommended.
Explanation
• Kid 3, Kid 7, Ren 4, Du 4 and UB 23 tonify Kidney yang.
• Sp 3, St 36, Ren 12, UB 20 and UB 21 tonify Spleen yang.
• St 25 and St 37 tonify Spleen qi and regulate the Intestines.
• Ren 6 tonifies yang.
• Ren 8 warms the middle jiao.
Herbal formula
• Li Zhong Tang (Warms and tonifies Spleen yang)
• Jin Gui Shen Qi Tang (Warms and tonifies Kidney yang)
Relevant advice
See Kidney yang xu and Spleen yang xu.
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Kidney yang xu and Spleen yang xu can be caused

• Kidney yang xu
• Spleen yang xu
• Spleen qi xu
• Cold
• Damp
Kidney yang xu and Spleen yang xu can result in

• Spleen qi xu
• Kidney yang xu, overflowing water
• Kidney qi not grasping Lung qi
• Damp
• Phlegm
• Xue stagnation
• Qi stagnation
• Qi xu
Pericardium and san jiao imbalances

There is often no description of san jiao patterns of imbalance in textbooks, apart
from in those that use the diagnostic model ‘diagnosis according to san jiao’. The only
Pericardium pattern of imbalance that is usually discussed is Pericardium Heat in the
diagnostic models ‘diagnosis according to the Four Levels’ and ‘diagnosis according
to san jiao’. This is because most authors consider the Pericardium and Heart to be
very closely integrated, so they only differentiate Heart imbalance patterns.
Maciocia (2005) lists six specific Pericardium patterns of imbalance, one of which
is the aforementioned Pericardium Heat. Maciocia argues that if there are symptoms
and signs that can be related to the Pericardium channel and its connections and
relationship with the chest, i.e. the Lung channel and the Liver channel, and not
only to Heart organ symptoms and signs, you should diagnose a Pericardium pattern
of imbalance (Maciocia 2005, p.487).
I have chosen to discuss only the pattern of Pericardium Heat. This is because
the other patterns are so similar to the patterns already differentiated in the section
on Heart imbalances in terms of their symptoms, aetiology and treatment, I feel that
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further differentiating these patterns has only academic rather than practical interest.
I will only discuss the aetiology and pathology that is relevant to Pericardium Heat.
For a more detailed discussion of the aetiology and pathology that is relevant to the
other Heart and Pericardium patterns, the reader is referred to the section on Heart
patterns of imbalance (page 487).
San jiao diagnosis is discussed in Section 9, ‘Diagnosis According to the Six
Stages, Four Levels and San Jiao’.
Shi patterns
Heat blocking the Pericardium
This is not something that you would normally meet in an ordinary clinical setting.
When Heat has penetrated down to this level, the patient will usually be treated with
Western medicine and will probably be hospitalised.
If the body is invaded by exogenous Heat, the Heat will initially affect the wei
level or the qi level. In some cases, xie Heat can penetrate to the ying level. The
ying level is the superficial aspect of xue. When the disease has penetrated this far
down down to the ying level, it is deeper and more serious than when the disease was
at the qi level. Xie Heat can penetrate to the ying level if xie qi is sufficiently virulent
or if it is treated incorrectly or inadequately. Furthermore, xie qi can penetrate
directly from the wei level to the ying level, because the Lung and Pericardium both
have their residence in the upper jiao. Xie qi will, therefore, be able to transmit
directly from Lung wei qi for Pericardium ying qi.
Ying qi is the qi aspect of xue. Xue Heat will agitate the shen, which has its
residence in the Heart. This will result in restlessness and insomnia. The Heat can
be so intense that it creates Phlegm. The Phlegm and the Heat will block and agitate
the shen so the person may be delirious or raving or they may lose consciousness.
The Heat will also injure yin. This is why the tongue lacks coating, the pulse is
Fine and the symptoms are worse at night.
There can be a rash or petechiae because the Heat has agitated xue, rupturing the
walls of the vessels.
Normally, the hands and feet would feel hot when there is so much Heat present.
This is not the case in this pattern, as the extremities are cold because xie Heat blocks
the body’s physiological heat from reaching the extremities. This is called ‘True Heat,
False Cold’.
Even though there is intense Heat, there is no thirst. This is because the Heat is
so intense that it forces fluids upwards in the body to the mouth.
Aetiology
The pattern will be due to an invasion of exogenous xie qi.
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Symptoms and signs

• High fever that is worse at night
• Insomnia
• Mental and physical restlessness
• No thirst
• Petechiae
• Red or purple skin rashes (erythema and purpura)
• Delirium
• Unconsciousness or coma
• The skin feels hot when palpated
• Dark red, dry tongue without coating
• Rapid and Fine pulse
Key symptoms
Dry mouth and no thirst, high fever but cold hands, unconsciousness, red tongue
without coating.
Treatment principle
Drain Heat from the Pericardium.
Acupuncture points
Choose from: Pe 3, Pe 8, Pe 9, Sp 10, UB 40, LI 11, Du 14 and Du 26.
Needle technique
Draining. Bleed Pe 3, Pe 9, UB 40 and Du 14.
Explanation
• Pe 3, Pe 8 and Pe 9 drain Heat from the Pericardium.
• UB 40, LI 11, Du 14 and Sp 10 drain xue Heat.
• Du 26 revives consciousness.
Herbal formula
• Qing Ying Tang (Drains ying level Heat)
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Relevant advice
This is an acute pattern, therefore advice regarding diet or lifestyle is not relevant.
The patient must be seen by a Western doctor.
Heat blocking the Pericardium can be caused by

• Wei qi-level Heat
• Qi-level Heat
Heat blocking the Pericardium can result in

• Xue-level Heat
Gall Bladder imbalances

The Gall Bladder is an interesting organ. It is a regular fu organ but is also one of the
six extraordinary fu organs. It differs from other fu organs in that it does not receive
and excrete impure products but stores bile, which is regarded as a pure substance.
However, it is on the mental-emotional level that the main difference lies. The Gall
Bladder plays a major role in decision making. It is the Gall Bladder that enables
us to make a decision and at the same time it gives us the courage to carry out
the decisions we have taken. It cooperates closely with its partner organ, the Liver,
which controls making plans and strategies. It is not enough to have a vision and to
define a strategy, there must also be the determination and the courage to take the
decision and carry it out. The Gall Bladder is the only fu organ with a pattern of
imbalance that manifests primarily on the mental-emotional level. If there is Gall
Bladder and Heart qi xu, the person will be timid and nervous and have difficulty
making decisions. They will lack the courage to pursue their dreams. The Chinese
say that a person who is brave has a ‘big gall bladder’ whilst a person with a ‘small
gall bladder’, is a person who is cowardly and lacking in courage.
Apart from collaborating in making plans and taking decisions, the Liver and
Gall Bladder cooperate closely in relation to bile. The Gall Bladder receives bile that
it stores and later secretes when it is used for the digestive process. This secretion of
bile is dependent on Liver qi and its free movement.
The Gall Bladder and the Liver have such a close relationship that they can
almost be seen as being each other’s yin and yang aspects. This means that many
of the shi patterns that are seen in the Liver manifest with symptoms in the Gall
Bladder channel.
The Gall Bladder is affected negatively when Dampness and Damp-Heat block
the free movement of qi and bile. The Dampness and Heat can be exogenous in the
form of climatic factors or can be due to the diet if there is an excessive consumption
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of food and beverages that create Damp and Damp-Heat, typically fried food and
food with a high fat content. Dampness and Damp-Heat can also be generated
internally when there is imbalance in other zangfu organs. Jaundice may be a sign of
Damp or Damp-Heat in the Gall Bladder. Yellowing of the skin, yellow sclera, etc.
are always a sign of the presence of Damp or Damp-Heat. In this situation, Damp
blocks the free movement of qi and bile from the Gall Bladder. Because there is
stagnation of qi, there will often be pain in the region and the Damp will also give
rise to a sensation of heaviness. Damp will often manifest with a sticky sensation in
the mouth. The person can also have a bitter taste if there is also Heat.
When there is Damp-Heat, the Heat aspect will result in the person being thirsty,
but the Damp aspect will mean that they do not want to drink anything.
Damp can also manifest with a heavy headache and difficulty in thinking
clearly. The urine can be cloudy due to Dampness, but also dark and sparse due to
the presence of Heat. The stools can be either loose or constipated, depending on
whether Dampness or Heat is the dominant form of xie qi. When Dampness blocks
the qi ji or qi mechanism in the middle jiao, there can be symptoms such as nausea,
vomiting or lack of appetite.
The combination of Dampness, Heat and qi stagnation can lead to the formation
of Phlegm in the Gall Bladder. This will result in the formation of gallstones, which
will then further block the free movement of the bile and qi in the Gall Bladder.
Emotionally, the Gall Bladder is affected by the same factors as the Liver, i.e.
anger, frustration, irritation and unresolved emotions. This is because these emotions
can lead to the stagnation of Liver qi, on which the Gall Bladder depends to carry
out its duties. The stagnation of qi can also generate Heat in the Gall Bladder. The
pattern Gall Bladder and Heart qi xu will often be a congenital pattern or a pattern
that has arisen in early childhood. It is often a consequence of a shock in utero or
in childhood, a lack of love, attention or recognition or bullying or prolonged fear.
Small children are particularly vulnerable because their organs are still developing
and their qi is not stable. Children are yang and lack the stability of yin. This means
that the Heart and Gall Bladder qi can easily be dissipated or depleted. Adults who
have been subjected to an extreme shock or violent experiences may also develop
a similar pattern. Post-traumatic stress syndrome is an aspect of this pattern. This
person will also be afraid and anxious and have difficulty making decisions.
General symptoms and signs of Gall Bladder imbalances

• Digestive problems
• Difficulty making decisions
• One-sided coating on the tongue
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Gall Bladder Damp-Cold

This pattern and Gall Bladder Damp-Heat are very similar in their aetiology and
pathology. There can also be a progression from the one to the other. The tongue
and pulse will be some of the most crucial factors in differentiating between these
two patterns.
Aetiology
Dampness in the Gall Bladder can arise when there has been an excessive consumption
of fried food or food with a high fat content such as dairy products, fatty meat and
so on. Exogenous Damp can also invade the body and disrupt the functioning of
the Gall Bladder.
Damp can be internally generated when there is Spleen qi xu. If there is Liver qi
stagnation, this will exacerbate the stagnation that is caused by the Dampness.
Symptoms and signs

• Yellowish coloured skin
• Costal pain or distension
• Nausea or vomiting, especially after intake of fatty food
• Sensation of heaviness in the body
• Heavy headache
• Sticky sensation in the mouth
• Lack of thirst
• Loose or putty-like stools that may be clay coloured or very pale
• Thick, greasy or sticky tongue coating that is either one-sided or has a wide
stripe of coating on each side of the tongue
• Slippery and Wiry pulse
Key symptoms
Yellow skin and eyes, tightness, pain or distension below the ribs, sticky, white
tongue coating.
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Treatment principle
Drain Dampness from the Gall Bladder and spread qi.
Acupuncture points
Choose from: GB 24, GB 34, GB 41, Sp 6, Sp 9, SJ 5, SJ 6, Liv 14, Dannangxue
(Ex-LE 6), UB 18, UB 19, UB 22 and Du 9.
Needle technique
Draining.
Explanation
• GB 24, GB 34, Du 9 and UB 19 drain Dampness from the Gall Bladder and
spread Gall Bladder qi.
• GB 41 and SJ 5 open dai mai and drain Dampness from the Gall Bladder.
• UB 22, Sp 6 and Sp 9 drain Dampness.
• Liv 14 and UB 18 spread Liver qi.
• SJ 6 circulates qi in all three jiao.
• Dannangxue is an empirical point for the treatment of Gall Bladder disorders.
Herbal formula
• Yin Chen Zhu Fu Yu Tang (Transforms Dampness and warms and tonifies
the Spleen yang)
Relevant advice
It is important to avoid consuming foods that produce Dampness, especially foods
that are rich in fat and oil. Gall Bladder Damp-Cold can be negatively affected by
climatic influences. This means that the person should ensure that they are properly
dressed and do not live or work in damp places. If Spleen qi xu or Liver qi stagnation
is part of the picture, the relevant advice for these imbalances should also be followed.
Gall Bladder Damp-Cold can be caused by the

• Invasions of Damp and Cold
• Spleen qi xu
Gall Bladder Damp-Cold can result in the following patterns of imbalance

• Gall Bladder Damp-Heat
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• Phlegm
• Xue stagnation
Gall Bladder Damp-Heat

As described above, Gall Bladder Damp-Cold and Gall Bladder Damp-Heat appear
to be very similar in their aetiology, pathology and symptoms. The difference in this
pattern is signs of Heat that were not apparent in Gall Bladder Damp-Cold.
Aetiology
The aetiology is the same as described in the previous pattern, as well as the
consumption of food and beverages that directly generate Damp-Heat, such
as alcohol and fried food. Factors such as stress, repressed anger and unresolved
emotions can create a stagnation of Heat or Fire in the Liver, which can then generate
Heat in the Gall Bladder.
Symptoms and signs

• Yellowish skin
• Hypochondriac tension, bloating or pain below the costal
• Costal pain or distension
• Nausea or vomiting, especially after consuming greasy food
• Sense of heaviness in the body
• Heavy headache
• Bitter taste in the mouth
• Thirst without a desire to drink
• Dark or scanty urine
• Constipation or sticky stools that may be clay coloured
• Irritability and anger
• Dizziness
• Thick, yellowish, greasy or sticky tongue coating that is either one-sided or
has two stripes of coating on each side of the tongue
• Slippery, Wiry and Rapid pulse
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Key symptoms
Yellow skin and eyes, hypochondriac tightness, pain or bloating, sticky yellow tongue
coating, Rapid, Wiry or Slippery pulse.
Treatment principle
Drain Dampness and Heat from the Gall Bladder and spread qi.
Acupuncture points
Choose from: GB 24, GB 34, GB 41, GB 43, Sp 6, Sp 9, SJ 5, SJ 6, Liv 14,
Dannangxue (Ex-LE 6), UB 18, UB 19, UB 22, LI 11 and Du 9.
Needle technique
Draining.
Explanation
• GB 24, GB 34, GB 43, Du 9 and UB 19 drain Damp-Heat from the Gall
Bladder and spread Gall Bladder qi.
• GB 41 and SJ 5 open dai mai and drain Damp-Heat from the Gall Bladder.
• UB 22, Sp 6 and Sp 9 drain Damp-Heat.
• Liv 14 and UB 18 spread Liver qi.
• SJ 6 circulates qi and drains Heat in all three jiao.
• LI 11 drains Damp-Heat.
Herbal formula
• Long Dan Xie Gan Tang (Drains Heat and drains Liver and Gall Bladder
Damp-Heat)
Relevant advice
The patient should avoid consuming alcohol and foods that generate Dampness and
Heat, especially foods that are rich in fat. Damp-Heat in the Gall Bladder can be
affected negatively by climatic influences. The patient should therefore avoid living
and working in humid conditions. If Spleen qi xu or Liver qi stagnation are part of
the picture, the relevant advice for these imbalances should also be followed.
Gall Bladder Damp-Heat can be caused by the

• Gall Bladder Damp-Cold
• Invasions of Damp and Heat
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• Spleen qi xu
• Liver qi stagnation Heat
• Liver Fire
Gall Bladder Damp-Heat can result in the following patterns of imbalance

• Phlegm
• Xue stagnation
Combined patterns
Liver and Gall Bladder Damp-Heat
When there is Damp-Heat in the Liver and Gall Bladder, there will be symptoms
and signs of both Damp-Heat in the Liver and Gall Bladder Damp-Heat.
Aetiology
The consumption of food and medicine that create Dampness or are hot in
their energy.
Emotional imbalances that weaken the Spleen, such as worry and pensiveness,
or emotions such as frustration, pent-up anger and irritation that stagnate Liver qi,
thereby generating Heat in the Liver.
There can also be direct invasions of exogenous Damp-Heat, especially in
tropical climates.
Symptoms and signs

• Blocked or stuffy sensation in the chest and below the ribs
• Sensation of heaviness and fatigue in the body
• Yellow skin colour and yellowish sclera
• Red and weeping skin disorders, rashes and sores
• Itching, burning or stinging skin, sores or rashes
• Genitals ulcers or ulcers around the mouth
• Copious, yellowish, sticky discharge from the vagina that is odorous
• Swollen or red and painful genitals
• Irregular menstrual cycle or spotting
• Yellow, sticky sweat
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• Bitter or sticky taste in the mouth

• Dark and sparse urine, the urine may be odorous
• Burning sensation on urination
• Lack of appetite
• Nausea or vomiting, especially after consuming greasy food
• Headache
• Constipation or sticky stools that may be clay coloured
• Irritability and anger
• Thirst without a desire to drink
• Red tongue with even redder sides, greasy, yellowish coating possibly only on
one side or two bilateral yellow stripes
• Fast, Slippery and/or Wiry pulse, a Wiry pulse in the left guan position
Key symptoms
Sensations of heaviness and fatigue, bitter or sticky taste, nausea, yellow skin, dark
urine and yellow greasy tongue coating.
Treatment principle
Drain Damp-Heat from the Liver and Gall Bladder.
Acupuncture points
Choose from: Liv 2, Liv 14, UB 18, UB 19, GB 24, GB 34, GB 41, SJ 5, Dannangxue
(Ex-LE 6), LI 11, Sp 6 and Du 9.
Needle technique
Draining.
Explanation
• Liv 2, Liv 14, GB 24, GB 34, UB 18, UB 19 and Du 9 drain Damp-Heat
from the Liver and Gall Bladder.
• GB 41 and SJ 5 together open dai mai and drain Damp-Heat.
• Sp 6 and Sp 9 drain Dampness.
• LI 11 drains the Damp-Heat.
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Herbal formula
• Long Dan Xie Gan Tang (Drains Damp-Heat from the Liver and Gall
Bladder)
Relevant advice
When there is Damp-Heat in the Liver and Gall Bladder, the patient should avoid
consuming substances that create Heat or Dampness, especially if these substances
have an affinity with the Liver. Alcohol, hot spices, fried food and too much red meat
should particularly be avoided, as well as foods such as dairy products, sugar, sweets,
nuts, bananas and avocados. A Liver that is burdened by pharmaceutical medicine,
alcohol, chemicals, heavy metals and other pollutants will have difficulty carrying
out its metabolic functions, so caution should be exercised and the consumption of
all kinds of medicine, including dietary supplements and herbal remedies, should be
limited as much as possible.
Stress and pent-up emotions, especially anger and frustration, can create Heat
in the Liver. A person with Damp-Heat in the Liver and the Gall bladder should
try and address these emotional issues. Exercise, sport and physical training will be
beneficial, as physical activity will help to circulate and spread stagnant Liver qi,
which is often involved in the creation of Heat in the Liver.
Liver and Gall Bladder Damp-Heat can be caused

• Spleen qi xu
• Damp-Heat
• Gall Bladder Damp-Cold
Liver and Gall Bladder Damp-Heat can result

• Liver Fire
• Phlegm
• Liver xue stagnation
Heart and Gall Bladder qi xu

Heart and Gall Bladder qi xu arises because a person is born with an unstable shen or
their shen has been disturbed and unsettled by a significant shock or prolonged anxiety.
The person’s mother may have been exposed to shock, excessive sadness, anxiety
or other emotional influences during the pregnancy and this might have affected
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foetal qi. The person may also have grown up in a family or an environment where
there has been a lack of love or there has been outright neglect. Severe shock, fright
and fear in adults can spread the Heart qi and weaken Gall Bladder qi. This can be
seen in post-traumatic stress syndrome.
The unsettled and unstable shen will mean that the person is anxious, skittish
and easily frightened. The weak Gall Bladder qi will also mean that they are
nervous and have difficulty making decisions.
When it is congenital, the person will have always been very shy and easily
frightened.
Aetiology
Powerful shock, anxiety, lack of love in childhood or congenital character traits.
Symptoms and signs

• Easily startled, nervous and lacks courage
• Frequent anxiety attacks
• Shyness
• Indecision
• Palpitations, mainly caused by shock, fright, anxiety and nervousness
• Wakes up early in the morning
• Frequent nightmares, waking with anxiety
• Fatigue
• Possibly a thin crack on the tip of the tongue
• Deep, Weak pulse, especially on the left-hand side
Key symptoms
Nervousness, shyness, lack of determination.
Treatment principle
Tonify Heart and Gall Bladder qi.
Acupuncture points
Choose from: UB 15, UB 19, Ren 15, yintang (Ex-HN 3), GB 40 and He 7.
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Needle technique
Tonifying.
Explanation
• UB 19 and GB 40 tonify Gall Bladder qi.
• UB 15 and He 7 tonify Heart qi and calm shen.
• Ren 15 and yintang calm shen.
Herbal formula
• Gan Mai Da Zao Tang (Nourishes the Heart and calms the shen)
Relevant advice
Psychotherapy may be relevant, since much of the aetiology of this pattern lies on
the psycho-emotional level and probably dates from early childhood. Some clients
may feel that they will benefit from healing or similar therapies.
It is important that a person with Heart and Gall Bladder qi xu avoids shock or
stressful situations.
Meditation, yoga and mindfulness will be beneficial.
Heart and Gall Bladder qi xu can be caused by

This is more a constitutional pattern so there will not necessarily be any previous
patterns.
Heart and Gall Bladder qi xu can result in the

• Heart qi xu
• Heart yin xu
Liver imbalances
The Liver is not directly involved in the production of qi, xue or jinye, so there
are very few Liver xu patterns of imbalance. The Liver has the important function
of ensuring that qi flows freely and unhindered throughout the whole body. This
means that the Liver has a determining influence on the movement of qi and xue
in the body, and Liver imbalances will often be involved in imbalances in other
organs. There is often a focus on Liver qi stagnation when analysing pathological
conditions and the way in which Liver qi disrupts and blocks other organ’s qi ji or
qi mechanisms. It is, however, important to remember that this is a pathological
condition. When the Liver is in balance, it has the important function of supporting
the other organ’s qi ji and the movement of qi and xue in the body in general.
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The Liver is also a reservoir for xue. This means that xue imbalances often affect
the Liver and xue can be affected by Liver imbalances.
The Liver is the General, whose task it is to plan and create strategies. This task
is closely related to the Liver’s shen aspect, the hun. One of the aspects of the hun is
that it enables us to have vision, to imagine something in the future that has not
happened yet. This is what we utilise when we lay out plans and strategies. We have a
vision of how the future might be. People with a strong hun have a clear idea of what
they want. They have goals and they pursue them, whatever the cost.
The Liver also defines our boundaries. If the Wood Phase is strong, a person can
set their boundaries in relation to others. If the Liver is weak, a person often gets
stepped on and they have difficulty saying ‘no’ or ‘stop’ to others. If the Liver is xu, the
person lacks a strong vision of what they want for themselves or they lack the courage
to pursue their goals. When they meet someone with a more powerful hun, they get
brushed aside by this person’s momentum, or they give up when somebody criticises
them or has a different meaning. On the other hand, if a person has an over-active
Liver, they do not respect other people’s boundaries. Their needs come first, because
they have a vision of what they want. They do not care about other people’s visions
if they conflict with theirs. Liver qi should ideally be flexible like a young tree. It
should have the strength to grow upwards and outwards to fulfil its potential but at the
same time be flexible enough to be able to bend and withstand pressure when the wind
blows or when there are physical obstacles in its way. It should not be stiff and brittle
as this will eventually cause it to snap, but it should not be weak and limp, letting itself
be overshadowed and crowded out by others. As humans, we are social beings and we
should be flexible enough to accommodate the visions and needs of others, not just
steamroller everyone and everything that stands in our path, but we should also be
determined enough to accomplish our own dreams and visions.
Most politicians and business leaders have a strong hun. They have a clear vision
of how they think things should be and a strategy to achieve these aims. They have
no problem sacrificing other people if it helps them achieve their own goals. On the
other hand, their Liver qi stagnates violently when there is someone or something
that blocks them from achieving what they want. Artists are another group that have
a strong hun. They can look at a lump of clay or a blank canvas and see a piece of art,
which they are then able to bring forth. Many athletes also have a strong hun. This is
what enables them to be able to push themselves beyond their physical limits. They are
able to overcome both fatigue and pain in order to achieve their goals. This tendency
can be recognised in some clients. They push themselves harder than their bodies (i.e.
qi and jing) are able to sustain in the long run. These people often develop Kidney
xu imbalances because they consume more qi than they can produce. It is often these
Kidney xu symptoms that are the reason that they seek treatment.
The aetiology of Liver patterns of imbalance

Due to its dynamic ascendant and expansive energy, the Liver is adversely affected by
limitations. This is particularly evident on the mental-emotional level. All kinds of
frustration, irritation and suppressed or unresolved emotions will stagnate Liver qi.
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It is the ability of the Liver and the hun to have a vision and a goal whilst
also having the dynamic to move towards this goal, which is the Liver’s strength.
Unfortunately, it is also its weak point. Frustration, and thereby Liver qi stagnation,
arises every time you are prevented from doing what you want to and every time you
are forced to do something you do not want to or do not like, i.e. each time the hun
is prevented from fulfilling its vision. When we live in a society with other people,
we will constantly be impinged upon by other people’s visions and ideas. This means
that you will, to a greater or lesser degree, have to make compromises and not do
what you would ideally like to.
Every movement in life is either towards what you want or want to do or away
from what you don’t want or don’t want to do. It may be that you are trying to achieve
some goal or it may be that you are trying to avoid something unpleasant. Each time
you are blocked in this movement towards pleasure and satisfaction, or away from
suffering or pain, it will stagnate the Liver qi. There is a significant difference between
how much your vision or ideal of yourself and your life is obstructed and how much
you will be subjected to other people’s visions and how much you can determine
your own life or the number and size of the compromises that you have to make. It
can be anything from having to live with a tyrannical husband or having a boss who
humiliates and harasses you, to having to spend Sunday afternoon with your in‑laws,
do the washing-up or just stand in a queue. Anything that prevents you from doing
or being what you want or being where you want to be will stagnate Liver qi. The
extent to which these things stagnate a person’s Liver qi is also determined by how
good they are at accepting the circumstances of their life. Two people faced with the
same intransigent situation will have different degrees of dissatisfaction, depending
on their ability to accept the reality they are confronted with.
This is important to remember when treating chronically ill patients. Being ill
and not being able to live life as they would like, whilst having physical or emotional
pain, will stagnate a person’s Liver qi. This means that even though Liver qi stagnation
was not necessarily a part of their diagnostic picture in the beginning, it will often
have become an element of their imbalance dynamic by the time that we meet them
in the clinic.
Anger, which is the feeling or emotion that has a resonance with Liver and the
Wood Phase, can affect the Liver negatively in two ways. Anger has a very strong
yang dynamic. Anger causes Liver qi to ascend upwards. This means that anger can
aggravate and trigger conditions caused by ascending Liver yang or Liver Fire. On
the other hand, because anger is so dynamic and powerful in its energy, it will have
an equally powerful stagnating effect on the Liver qi if it is not expressed.
As well as consuming qi and yin, stress can have a stagnating effect on Liver
qi. This is because stress can be extremely frustrating. It is said that stress does not
arise from all the things that you have to do but from all the things that you don’t
have time to do. Frustration at not achieving your objectives and goals, as well as
feeling inefficacious, will stagnate Liver qi. Stagnation of Liver qi, combined with
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the consumption of the Kidney and Heart yin, which is often another consequence
of stress, can lead to the generation of Heat in the body.
The Liver organ is not particularly vulnerable to invasions of exogenous xie qi,
yet climatic wind, which resonates with the Wood Phase, can have an effect on
the Liver. Exposure to the wind can cause the eyes, which are controlled by the
Liver, to water. People with Liver imbalances can be more irritable when there are
strong winds. Some even claim that the rate of homicide rises when the sirocco wind
blows in Spain. The resonance between wind and the Liver can be seen in the Liver
imbalances that can result in internally generated Wind. Here, the Wind can be a
symptom that the Liver is out of balance as opposed to an aetiological factor.
Even though the Liver organ is not particularly vulnerable to exogenous invasions
of xie qi, the Liver channel can be invaded by Dampness and Cold. This can happen
if a person has walked around barefoot on cold and damp surfaces or has worn
insufficient clothing or shoes on their legs and feet.
Although it is the sour taste that resonates with the Liver, food and beverages
that are energetically hot are most often an aetiological factor in Liver imbalances.
Unfortunately, many people with Liver imbalances are often attracted to things such
as alcohol and hot spices, because their spicy flavour will spread stagnant Liver qi.
The problem is that they also have a hot energy and this will create Heat in the Liver.
Alcohol is particularly bad, because as well as being energetically hot, it often has a
sour flavour that will lead the Heat directly to the Liver. This is seen, for example,
when red wine triggers a migraine in people who have a tendency to have ascending
Liver yang or Liver Fire. It is also why people can get a loud, resonant voice or
become aggressive when they drink alcohol.
Consuming food that produces Dampness, especially if it is also warm or hot
in its energy, can create Damp-Heat in the Liver. The diet can also result in xu
imbalances in the Liver. This is seen if the diet does not contain sufficient xue-
nourishing foods, resulting in the person becoming Liver xue xu.
Liver xue will also be weakened when blood is lost through heavy menstrual
bleeding, childbirth, surgery and physical trauma.
The Liver has, by virtue of its qi-spreading function, an important influence on
other organs in the body. Liver qi stagnation can often be an aetiological factor in
the generation of other imbalances in other organs, but the Liver is also negatively
affected by imbalances in other organs. A vicious cycle can arise where imbalances
in the various organs eventually become self-generating. For example, Liver qi
stagnation can disrupt the Spleen in its functioning. This can result in a diminished
production of xue, leading to the Liver becoming xue xu. Liver xue xu can then result
in the Liver becoming stiff and rigid and thereby leading to a stagnation of Liver qi,
which then disrupts the Spleen. The Spleen then produces less xue, which makes the
Liver xue xu and so on.
Heat in the body can create xue Heat. Because xue is stored in the Liver, xue Heat
can create Heat in the Liver.
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The Liver and Heart cooperate closely in relation to xue, and Liver xue xu
and Heart xue xu usually manifest together. The hun and shen also have a close
relationship, following each other in their ‘entering and exiting’.
The Lung and Liver collaborate in relation to qi: The Lung descends qi and
spreads qi through the channels and vessels, whilst the Liver ensures the free
movement of qi in the whole body. Kidney yin and Liver yin have a common root,
which means that if there is Kidney yin xu, Liver yin xu will often develop as a
consequence and vice versa.
The pathology of Liver imbalances

Anger in all its forms affects the Liver and when the Liver is imbalanced it often
manifests with the person being irascible and easily angered. Anger is extremely yang
in nature. It rises to the head and it is explosive. People with Liver shi imbalances
can have a short fuse and be bad tempered. When there is Liver qi stagnation, the
person can internalise their anger and frustration for a long time. When they do
finally release their anger, it is often the wrong people who bear the brunt. The more
Heat that there is, the more irritable the person will be and the shorter their fuse.
Due to its ascendant dynamic, anger can aggravate or trigger symptoms that are
manifestations of ascending Liver yang or Liver Fire. This will typically be things like
headaches, pain behind or in the eyes, tinnitus or vertigo.
Stagnation of Liver qi can also manifest with the person being irascible or bad
tempered. When there is Liver qi stagnation, the person will easily feel frustrated and
they will often be impatient. There will frequently be mood swings when the Liver qi
is not flowing freely and unhindered as it should do when the Liver is harmonious.
If the hun is blocked, as can be the case when there is Liver qi stagnation or
Liver xue stagnation, or if the hun lacks nourishment, such as when there is Liver
yin xu or Liver xue xu, it can result in depression, with the person having difficulty
seeing a future for themselves. This can be seen in the eyes. It is as if they do not
look outwards and instead their vision is turned inwards. This is because Liver qi
stagnation prevents the hun from being able to ‘exit and enter’ freely.
At night the hun returns to the Liver. If the hun is not anchored by Liver yin and
Liver xue or is agitated by Heat, it will create visions or dreams. A person mainly
dreams in rapid eye movement (REM) sleep. In REM sleep the hun is active, which
can be seen in the characteristic rapid movements of the eyes whilst the person is
sleeping. When the hun is not anchored by Liver xue, the person can dream a lot and
suffer from insomnia. If there is Heat in the Liver, it will agitate the hun at night
and the person will sleep restlessly. They will have many, and sometimes violent,
dreams or nightmares. Heat in the Liver, particularly Heat from Liver qi stagnation,
can cause the person to wake early and have difficulty falling asleep again.
The sound in the voice that is a manifestation of the Liver is shouting, which can
be heard when a person is angry. This can also be a more permanent quality in some
people’s voices. The harshness will not be as extreme as when a person is angry, but
there will be a slight hardness and resonance in the voice. This will usually indicate
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a shi pattern of imbalance in the Liver. If there is Liver qi stagnation, the person can
have a staccato voice that sounds a bit like a machine gun. This type of voice arises
through the combination of the hardness in the voice that is characteristic of Liver
shi imbalances and the unevenness and juddering that is the result of the Liver qi
not flowing freely. When there are xu conditions in the Liver, the voice will lack the
shouting quality; it will be too soft and lack clout. This will be especially noticeable
in situations where the person is angry or when the voice is raised.
Liver shi imbalances will often manifest with symptoms and signs in the Liver’s
partner channel, the Gall Bladder channel. In these cases, the symptoms and signs
will typically be hemilateral. Migraines or throbbing headaches are a typical example
of this. Another characteristic of Liver shi symptoms is that they are triggered or
aggravated by stress, anger, frustration and similar emotional influences and often
manifest in the premenstrual period in women.
In general, symptoms and signs that have a close relationship with the menstrual
cycle can indicate that there is a Liver imbalance. Whereas Liver shi symptoms
typically manifest in the premenstrual period, Liver xue xu and Liver yin xu signs
and symptoms can be more pronounced immediately after or towards the end of
menstrual bleeding.
The Liver has a significant influence on the menstrual cycle. This is due to the Liver’s
close relationship with the movement of qi and xue, and because the Liver is a reservoir
for xue and supplies the chong mai with xue, thereby enabling menstrual bleeding.
If there is Liver xue xu, there can be too little xue to create menstrual bleeding. This
will result in either amenorrhoea, scanty menstrual bleeding or a long menstrual
cycle. The cycle can also be longer when there is a stagnation of Liver xue. In these
cases, the stagnation of xue will not only delay the menstrual bleeding, but also the
menstruation will be painful with a sharp, stabbing pain that is constant and fixed in
its location. The menstrual blood will be dark and clotted, and the passing of clots
will often ameliorate the pain. Dysmenorrhoea can also be a manifestation of Liver qi
stagnation. In these cases, the pain will be more spasmodic and cramping in nature.
The cycle can be irregular when there is Liver qi stagnation. This is due to qi and xue
not flowing smoothly and rhythmically. The stagnation of qi in the Liver channel
can result in the breasts being tender or swollen. Mood swings in the premenstrual
period are another classic sign of Liver qi stagnation, especially if the woman is more
irritable than normal. Liver xue xu can manifest with a woman being weepy and
sensitive during this period. The stagnation of Liver qi in the premenstrual period
can also disrupt the functioning of the Spleen and the Stomach. This means that
there can be abdominal bloating, irregular or loose stools, oedema and an increased
craving for sweets during the premenstrual phase. Stagnated Liver qi can become
rebellious and ‘invade’ the organs in the middle jiao, disrupting their qi dynamic.
If the Liver qi is stagnated or if the Stomach and/or Spleen qi is weak, the Liver
can ‘invade’ these organs. This will lead to symptoms such as abdominal pain or
bloating, alternating constipation and loose stools or belching. Liver Fire can invade
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the Lung, resulting in a cough with yellowish or bloody sputum, dyspnoea and
chest oppression.
Bloating, distension and pressure are some of the main characteristics of Liver
qi stagnation. When qi stagnates, it creates a greater tension or pressure in the area.
This can give a sensation of being distended or bloated, and it is this sensation that
is critical, not whether there is actual physical bloating. If the area is bloated or
swollen, this will just be a confirmation that there is a stagnation of qi in the area. As
well as disrupting the middle jiao, Liver qi stagnation can cause costal pain or chest
oppression, where there will be a sensation of the chest being bound by a strong
elastic or a metal rim. The stagnation of qi in the upper jiao can result in difficulty
with breathing deeply.
The Liver is physically located just below the costal margin. The Liver and
Gall Bladder channels traverse this area. This means that when Liver qi stagnates,
there can be tension in the hypochondriac region. This is interesting because it is
a defining sign of Liver qi stagnation in Chinese medicine textbooks, however not
many Western patients report it. If, on the other hand, you ask Western patients
whether they have tension in the diaphragm and the solar plexus, they will often say
yes when there is Liver qi stagnation.
Liver qi stagnation will often, over time, generate Heat in the Liver. This can
ultimately lead to Liver Fire, but in milder cases it will just result in the emergence of
Heat signs such as thirst, a rapid pulse, red sides of the tongue, irritability and so on.
Heat conditions in the Liver can also manifest with redness of the eyes. This is
because the eyes are the Liver’s sense organ, and the Gall Bladder channel starts its
course in the corner of the eyes and Liver shi conditions tend to manifest themselves
in the Gall Bladder channel.
The eyes are nourished and moistened by Liver xue and Liver yin. If there is Liver
xue xu, the lack of nourishment of the eyes can cause the person to have trouble
focusing or there may be floaters or spots in the field of vision. If there is Liver yin
xu, the eyes can be dry and feel gritty because they are not moistened by Liver
yin. Ascending Liver yang or Liver Fire can increase the pressure inside the eye and
this will cause pain inside or behind the eyes.
When there is Liver qi stagnation, the body will often try to disperse the
stagnation by yawning or sighing. When the body inhales a large amount of air,
as you do when you yawn or sigh, it will increase the strength of the zong qi. This
will help to increase the force behind the qi in the channels and vessels and thereby
spread the stagnant qi.
When Liver qi stagnates, it can lead to the accumulation of Phlegm in the throat.
This will give the characteristic sensation of having a lump in the throat that cannot
be swallowed. The sensation may not be constant but will typically be influenced by
the person’s emotions. The Chinese describe this sensation as feeling as if there is a
plum stone stuck in the throat and call it ‘plumstone qi’.
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Headaches and dizziness can arise when there is too much qi ascending to the
head, which is typical in Liver shi conditions, or when there is too little xue ascending
to the head, which is a consequence of Liver xue xu.
The Liver channel passes around the genitals. If the Liver is invaded by exogenous
Cold or if there is stagnation of qi in the Liver channel, the person can have pain or
tension in or around the genitals. That is also why Liver qi stagnation can result in
impotence in men. Damp-Heat in the Liver can also mean that there may be red,
weeping sores on or around the genitals. Damp-Heat in the Liver can manifest with
red and suppurating ulcers elsewhere along the Liver channel.
Liver xue nourishes the tendons. This means that the tendons, sinews and joints
in general can become stiff when there is Liver xue xu. The nails are a type of tendon
in Chinese medicine anatomy. A classic sign of Liver xue xu is fingernails that are
soft or brittle or break easily. The fingernails are often ridged and can be very dry
when there is Liver xue xu. The lack of nutrition from Liver xue may mean that the
muscles in general lack strength and suppleness, whereas Liver qi stagnation will
manifest with muscles that are stiff and tense. When there is Liver xue xu, there
can also be a tingling sensation or numbness in the arms and legs. This is because
the muscles and tendons lack nourishment. Xue returns to the Liver and leaves the
muscles when they are inactive and at night. This means that some people who are
Liver xue xu or yin xu experience unrest and cramping in their legs in the evening
and at night.
When the Liver generates internal Wind, it will make the muscles extremely stiff
and rigid or they will spasm and cramp. This can be seen when there are fever cramps
in small children or a rigid neck muscle in meningitis, but it could also just be tics
in the facial muscles.
Heat in the Liver, like Heat elsewhere in the body, can injure fluids and desiccate
the body. When there is Liver qi stagnation Heat or Liver Fire, there can be tangible
signs that the fluids are being consumed by Heat such as thirst, dark urine and dry
stools. Furthermore, there will often be a bitter taste in the mouth when there is
Liver Fire.
General symptoms and signs of Liver imbalances

• Menstrual disorders
• Mood swings
• Irritability
• Bloating or tension
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Shi patterns
Liver qi stagnation
Liver qi stagnation is rarely seen as a distinct pattern but usually occurs in conjunction
with other patterns, where it is either the precipitating pattern or the consequence of
another pattern of imbalance. Often the two patterns become mutually generating.
Liver qi stagnation is usually a consequence of the way we live. It is almost endemic
in society. Everybody has some degree of Liver qi stagnation, but the important issue
is how great a degree of stagnation there is and how it manifests. Modern society,
with all the demands, stress factors and expectations that it presents us with or,
perhaps correctly, that we place on ourselves, together with all the compromises and
conformance that are necessary when coexisting with other people, will inevitably
create varying degrees of Liver qi stagnation. Every time we are prevented from
doing or being exactly what we want, our Liver qi will stagnate. Not being able to be
or do exactly what you want is a consequence of social interaction. There is, though,
a difference in how much a person accepts these limitations and how much they are
frustrated by them. Unfortunately, the more Liver qi stagnation that there is, the
more easily a person is frustrated and they thereby have more difficulty accepting
limitations. This creates a vicious cycle.
The stagnation will be greatest in a person who is shi and yang in their energy.
This means that Liver qi stagnation is more explicit in men. In men, Liver qi
stagnation manifests as aggressiveness and irascibility. If the person is more xu, the
Liver qi stagnation will not be expressed as much, but this can be more destructive
and disruptive because it is not released as outbursts of anger, but is internalised,
thereby disrupting the functioning of other organs.
Aetiology
The main cause of Liver qi stagnation is frustration, irritation, accumulated anger,
pent-up emotions, stress and a person’s boundaries not being respected. There can
often be an underlying Liver xue xu in women when there is Liver qi stagnation,
because the Liver is not lubricated and moistened by xue and therefore becomes stiff
and inflexible. Stagnation of qi, xue, Phlegm or food can impede the free movement
of qi in the body and thereby block the spreading function that Liver qi has.
Symptoms and signs

• Cold hands and feet, the buttocks and tip of the nose can also be cold
• Abdominal distension or tightness
• Chest oppression or difficulty breathing deeply
• Hypochondriac tension or tension in the solar plexus area
• Mood swings
• Depression
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• Irritability
• Irregular menstrual cycle
• Menstrual pain
• Premenstrual syndrome (PMS)
• Breast tenderness in the premenstrual period
• Frequent yawning or sighing
• Sensation of having a lump in the throat
• Alternating constipation and loose stools
• Incomplete defecation
• Pebble-like stools that look like goat droppings
• Lack of movement in the facial muscles
• Stiffness and lack of movement in the body when the person is talking
• Hard or staccato voice
• The person may seem inflexible or rigid in their attitude
• The person can be difficult to engage when being interviewed
• Lack of energy or tiredness, especially in the morning and if they have been
inactive
• Grumpiness in the mornings
• There are often no changes in the tongue when there is Liver qi stagnation
but there may be slightly swollen edges on the sides of the tongue; if the
stagnation of Liver qi has generated Heat, the sides of the tongue could be
red or red speckled; the tongue can sometimes have a slightly mauve tinge
• Wiry pulse, especially in the left guan position
Key symptoms
Wiry pulse, mood swings, bloating, irritability, PMS, irregular or painful periods.
Treatment principle
Spread Liver qi.
Acupuncture points
Choose from: Liv 3, Liv 13, Liv 14, UB 18, GB 34, LI 4 and Pe 6.
Needle technique
Draining.
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Explanation
• Liv 3, particularly in combination with LI 4 spreads Liver qi.
• Liv 13 spreads Liver qi in the middle jiao, especially when it invades the
Spleen.
• Liv 14 spreads Liver qi in the middle and upper jiao, especially when it
invades the Stomach or when qi stagnates in the upper jiao.
• GB 34 spreads Liver qi, especially when it affects the muscles and tendons.
• UB 18 spreads Liver qi.
• Pe 6 calms shen and spreads Liver qi, especially in the middle and upper jiao.
Herbal formula
• Chai Hu Shu Gan Tang (Spreads Liver qi)
• Xiao Yao San (Spreads Liver qi, nourishes Liver xue and tonifies the Spleen)
Relevant advice
When there is Liver qi stagnation, it is best, whenever possible, to address and work
with any mental-emotional factors that can lead to the Liver qi stagnating. Stress
should be avoided.
Physical activity is beneficial because it circulates qi and thereby spreads Liver qi.
People whose Liver qi stagnates often train a lot or work out. This is a form of self-
medication where they consciously or subconsciously try to relieve or prevent their
symptoms. The danger is, though, that some people begin to train excessively and
damage their xue and yin as a consequence. A person whose Liver qi stagnates should
possibly be wary of playing competitive sports, because the competition aspect may
aggravate their condition when they lose or when their teammates do not do what
they think they should. Dancing, aerobics, running, swimming or cycling are good
options, because they can dynamically activate and circulate qi. Gentler forms of
movement such as tai ji, qi gong and yoga are also salutary because they help qi to
flow, but these can be perceived as being too slow and boring for people when there
is Liver qi stagnation. The resulting frustration and impatience can aggravate
their Liver qi stagnation. More dynamic activities are therefore often a better idea, at
least in the beginning. Dancing will be a particularly good way to physically activate
Liver qi, because it is usually a pleasurable activity and will therefore simultaneously
nourish the Heart. It is very important that the activities in which the person engages
do not feel like things that have to be done, thereby becoming a source of frustration
and further stagnating the person’s Liver qi. Shouting or singing are good ways to
spread Liver qi, especially because singing is pleasurable and thereby also nourishes
Heart qi.
It can be a good idea to incorporate physical activity into the daily routine, for
example by cycling or walking to work instead of driving, taking the stairs instead
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of the elevator or getting off the bus a stop earlier and walking the last part of
the journey.
Breathing exercises that involve slowly inhaling deeply and then quickly exhaling
with force whilst making a loud noise will help to release stagnant qi.
A person whose Liver qi stagnates should try to avoid eating too much at one time
or eating rich food, especially concentrated proteins such as meat, dairy products,
nuts and food that has a high oil content, because this will create further stagnation.
Aromatic spices, herbs and foods that are slightly spicy will move qi, care must be
taken if these also have a warm or hot energy because qi stagnations tend to create
Heat. Unfortunately, people with Liver qi stagnation are often attracted to alcohol
and spices, such as chilli, precisely because their spicy flavour spreads the stagnant
qi. Unfortunately, this often results in the generation of Heat.
Going for a walk after eating will help to circulate qi in the body.
A teaspoon of vinegar or lemon juice and a teaspoon of honey in a glass of warm
water will help to temporarily relieve Liver qi stagnation.
Liver qi stagnation can be caused by the following patterns of imbalance

• Liver xue xu
• Liver yin xu
• Stagnation conditions elsewhere in the body
Liver qi stagnation can result in the following patterns of imbalance

• Liver qi invading the Spleen
• Liver Fire
Liver qi stagnation Heat

Liver qi stagnation Heat occurs when stagnant Liver qi starts to generate Heat in
the Liver.
Aetiology
The aetiology here is the same as that of Liver qi stagnation. Drinking alcohol
and eating spicy food, fried food and food that is warming in its energy can be
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Symptoms and signs

The symptoms and signs are the same as those seen in Liver qi stagnation, with the
difference that there will also be Heat signs, for example thirst, dark urine, a red
face and restlessness. Several of the symptoms and signs described for Liver qi
stagnation will be more pronounced. Where Liver qi stagnation can result in a
person internalising their emotions, a person with Liver qi stagnation Heat will be
more irascible and irritable and have a quick temper. The Heat will often also result
in them being impatient. Their face may be red. The sides of the tongue will be red
or there will be red speckles on the sides.
Key symptoms
These are the same as for Liver qi stagnation, plus red sides of the tongue, thirst, a
quick temper and irritability.
Treatment principle
Spread Liver qi and drain Heat from the Liver.
Acupuncture points
Choose from: Liv 2, Liv 3, Liv 13, Liv 14, UB 18, GB 34, LI 4 and Pe 6.
Needle technique
Draining.
Explanation
• Liv 2 drains Heat from the Liver and spreads Liver qi.
• Liv 3, particularly in combination with LI 4, spreads Liver qi in general.
• Liv 13 spreads Liver qi in the middle jiao, especially when it invades the
Spleen.
• Liv 14 spreads Liver qi the middle and upper jiao, especially when it invades
the Stomach or when qi stagnates in the upper jiao.
• GB 34 spreads Liver qi, especially when it affects the muscles and tendons.
• UB 18 spreads Liver qi and clears Heat from the Liver.
• Pe 6 calms shen and spreads Liver qi, especially in the middle and upper jiao.
Herbal formula
• Chai Hu Shu Gan Tang (Spreads Liver qi)
• Jia Wei Xiao Yao Wan (Drains Liver Heat, spreads Liver qi, nourishes Liver
xue and tonifies the Spleen)
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Relevant advice
The advice that was given for Liver qi stagnation is applicable, as well as advising the
client to avoid foods and beverages that have a warming energy, especially alcohol.
Liver qi stagnation Heat can be caused by the

Liver qi stagnation Heat can result in the following patterns of imbalance

• Liver qi invading the Spleen
• Liver yin xu
• Liver Fire
• Phlegm
Liver xue stagnation

The Liver has a significant influence on the movement of xue in the body. This is
because the Liver is responsible for the free flow of qi and thereby xue in the body
and because the Liver is a reservoir where xue is stored.
Aetiology
Qi invigorates xue and the Liver ensures the free flow of qi in the body. This means
that chronic Liver qi stagnation can develop into Liver xue stagnation. Liver xue
stagnation will always be a more chronic and more serious condition than Liver
qi stagnation. The aetiological factors that can lead to Liver qi stagnation will be
relevant here. In addition, Cold and Heat conditions in the body can lead to the
stagnation of xue, so aetiological factors that result in Heat and Cold can also
be relevant.
Symptoms and signs

• Dysmenorrhoea, the pain is piercing or stabbing
• Dark, clotted menstrual blood
• Irregular menstrual bleeding
• Abdominal pain
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• Lumps in the abdominal cavity

• Vomiting of blood
• Costal pain
• Hypochondriac pain
• Purple nails
• Purple lips
• Dark complexion
• Purple and swollen sub-lingual veins
• Purple tongue or purple sides on the tongue, possibly purple spots on the
side of the tongue
• Wiry or Choppy pulse
Key symptoms
Swollen, purple, sub-lingual veins, dark and clotted menstrual blood, piercing or
stabbing menstrual pain, Wiry or Choppy pulse.
Treatment principle
Spread Liver qi and invigorate xue.
Acupuncture points
Choose from: Liv 3, Sp 6, Sp 10, UB 17, UB 18, GB 34, Pe 6 and Sp 4.
Needle technique
Draining.
Explanation
• Liv 3 and GB 34 spread Liver qi and thereby invigorate Liver xue.
• Sp 6 spreads Liver qi and invigorates xue.
• Sp 10 and UB 17 invigorate xue throughout the body.
• UB 18 spreads Liver qi and invigorates Liver xue.
• Pe 6 and Sp 4 together open chong mai. Chong mai regulates the movement
of xue in the small luo vessels. It is supplied with xue from the Liver, and it
sends xue down to the Uterus (bao).
Herbal formula
• Ge Xia Zhu Yu Wan (Invigorates xue below the diaphragm)
• Yan Hu Suo San (Invigorates qi and xue in the Uterus)
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Relevant advice
Physical activity is important when there is Liver xue stagnation. This is because the
physical movement will activate qi and xue and promote their circulation. If the
underlying pattern is Liver qi stagnation, the advice given for this pattern should
be followed. If Cold or Heat are the root cause, the advice given for these patterns
should be followed.
Liver xue stagnation can be caused by the following patterns of imbalance

• Heat
• Cold
Liver xue stagnation can result in the following patterns of imbalance

• Phlegm
• Qi stagnation
Ascending Liver yang

Liver qi is very yang in its dynamic and therefore already has a tendency to ascend. If
there is a deficiency of yin or an excess of yang in the Liver, its qi will rise upwards. Yang
qi has an expansive nature. This means that symptoms of ascending Liver yang are
often distending or throbbing in nature. The symptoms will typically occur suddenly
and they will often be related to factors such as stress and emotional influences.
Wind is an aspect of Liver yang so there will be an overlap between Liver Wind
symptoms and signs and those seen when there is ascending Liver yang. There is
also a marked similarity between ascending Liver yang and Liver Fire, with many of
the symptoms and signs being the same. The difference between these two patterns
is the presence of Heat. The treatment of these two patterns with acupuncture is
largely the same, but the herbal treatment will be different.
Aetiology
Ascending Liver yang is never seen alone, but it will always be combined with other
Liver patterns of imbalance. It is correct to say that ascending Liver yang has its root
in a Liver yin xu condition where the deficient Liver yin is unable to control and
anchor Liver yang. It is important to keep in mind that Liver xue is an aspect of Liver
yin. Therefore, the aetiological factors that are relevant for both Liver yin xu and
Liver xue xu can have relevance here. Liver yin xu evolving from a purely xu pattern
to a xu/shi pattern will require the presence of other factors that can cause Liver yang
to ascend, such as the consumption of substances that are warming or ascending in
their energy, for example alcohol and strong spices. Anger causes qi to rise upwards
and can therefore be a relevant factor. Accumulation of stagnant qi in the Liver, as
is the case in Liver qi stagnation, can force the Liver yang to rise. This means that
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aetiological factors such as frustration, irritation and repressed emotions can also
have relevance here. Stress is frustrating and can cause qi to stagnate. At the same
time, being stressed is something that consumes Kidney yin and thereby also Liver
yin. A vicious cycle can soon develop. When Liver yang is excessive, it will consume
and injure Liver yin. The more deficient Liver yin is, the less able it will be to control
Liver yang, which then becomes excessive.
There is a big difference in how ascending Liver yang imbalances manifest
themselves, which depends on how xu Liver yin is and how shi Liver yang is. For some
clients, their Liver yin is just too weak to anchor the Liver yang. In others, Liver yang
is so excessive that it will require a very robust Liver yin aspect to anchor it. There
will usually be a clear dominance of ascending Liver yang in younger clients due to
their yin still being relatively strong and their Liver yang becoming excessive due
to their lifestyle and diet. Older people, on the other hand, tend to be more yin xu,
so there will be a greater xu aspect in their ascending Liver yang condition.
The difference between how much xu and shi there is will influence the
treatment strategy. The more Liver yin xu there is, the more focus there will be in
the treatment on nourishing Liver yin. Conversely, if ascending Liver yang is the
dominant aspect, there will be more focus on draining and controlling Liver yang.
Symptoms and signs

• Hemilateral headache that is throbbing in nature
• Pain behind the eyes, the pain will be throbbing or distending
• Dizziness
• Tinnitus and deafness
• Irritability, aggression, quick temper and anger
• Insomnia
• The voice can have a shouting quality or have a harsh tone
• The muscles can be hard or tense
• The eyes may appear fixed and staring
• The tongue may have swollen sides, red sides or red speckling along the sides
• Wiry pulse, especially in the left guan position
Key symptoms
Headache, irritability and a Wiry pulse.
Treatment principle
Descend and control ascendant Liver yang.
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Acupuncture points
Choose from: Liv 3, SJ 5, LI 4, GB 20, GB 21, GB 38, GB 43, Du 20 and UB 18.
Needle technique
Draining.
Explanation
• Liv 3 descends Liver yang and nourishes Liver yin.
• LI 4 in combination with Liv 3 spreads Liver qi and thereby soothes the Liver.
• SJ 5 drains Liver yang, especially when symptoms are manifested in the
shaoyang channels.
• GB 38 and GB 43 drain Liver yang from the head, especially when the
symptoms manifest in the Gall Bladder channel.
• GB 20 drains Liver yang from the head and calms Liver Wind.
• GB 21 sends Liver yang downwards.
• Du 20 descends yang from the head.
• UB 18 calms the Liver.
Herbal formula
• Tian Ma Gou Teng Yin (Controls ascending Liver yang and Liver Wind)
Relevant advice
The advice given for Liver yin xu is also relevant here. It will be advisable for the
person to avoid consuming substances that create Heat in the Liver or cause the Liver
yang to rise. Alcohol will frequently have a negative impact, in particular red wine, as
the sour taste will channel its effect directly to the Liver.
Anger causes qi to rise, so the person must try to avoid getting into situations
where they can become angry. As described above, stress will also have a negative
effect.
Exercise and dynamic activities will activate and spread Liver qi. This will reduce
the ‘pressure’ in the Liver, which may have helped to force Liver yang upwards.
Ascending Liver yang can be caused by the following patterns of imbalance

• Liver yin xu
• Kidney yin xu
• Liver xue xu
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Ascending Liver yang can result in the following patterns of imbalance

• Liver yin xu
• Liver Fire
• Liver Wind
Liver Fire
Liver Fire and ascending Liver yang are very similar in their aetiology and pathology.
The difference between them is that in Liver Fire there are signs of Heat and Liver qi
stagnation or dietary reasons are more likely to be the root cause of the imbalance.
Aetiology
Prolonged emotional imbalances can lead to the stagnation of Liver qi. In time,
the stagnant Liver qi will generate Fire in the Liver. Unfortunately, many people
use alcohol as a way to loosen their stagnated Liver qi. The alcohol will quickly
dissipate stagnant Liver qi, but it will also generate Heat in the Liver. Strong spices
such as chilli have a similar effect. Consuming foods that have a hot energy can
either directly generate Heat in the Liver or indirectly create Heat in the Liver by
creating Fire in the Stomach or xue Heat that then transmits to the Liver and creates
Heat there.
Symptoms and signs

• Thirst
• Red face
• Red eyes
• Red ears
• Sensation of heat in the head
• Aversion to, or discomfort from, heat
• Constipation
• Dark urine
• Bleeding
• Hemilateral headache that is throbbing in nature
• Throbbing pain or distension behind the eyes
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• Dizziness and vertigo

• Tinnitus and deafness
• Irritability, aggressiveness, a quick temper and anger
• Impatience
• Insomnia
• The voice can have a shouting quality or have a hard tone
• The eyes may be fixed and staring
• Red tongue with even redder sides and a yellowish dry coating
• Wiry and Rapid pulse
Key symptoms
Headache, irritability, red sides of the tongue, bitter taste and Wiry and Rapid pulse.
Treatment principle
Drain Liver Fire and calm the Liver.
Acupuncture points
Choose from: Liv 2, GB 20, GB 43, Du 14, UB 18 and Pe 7.
Needle technique
Draining.
Explanation
• Liv 2 and GB 43 drain Liver Fire.
• Du 14 drains the Fire and Heat.
• Pe 7 drains jueyin Heat.
• GB 20 drains yang qi from the head.
• UB 18 calms the Liver.
Herbal formula
• Long Dan Xie Gan Tang (Drains Liver Fire)
Relevant advice
The patient should avoid consuming substances that create Heat in the Liver. In
particular, alcohol, hot spices, fried food and too much red meat should be avoided.
Stress and pent-up emotions, especially anger and frustration, create Heat in the
Liver. When there is Liver Fire it is advisable to try to resolve these emotions.
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Physical activity, such as sport, running, swimming or dancing will be beneficial,

because it will disperse stagnant Liver qi, which is often involved in the creation of
Liver Fire.
Liver Fire can be caused by the following patterns of imbalance

• Liver yin xu
• Kidney yin xu
• Stomach Fire
• Xue Heat
Liver Fire can result in the following patterns of imbalance

• Liver yin xu
• Liver Wind
• Phlegm
• Heart Fire
• Stomach Fire
• Lung Heat
• Xue Heat
Liver Wind
Liver Wind can arise as a consequence of four different imbalances: extreme Heat
in the whole body, for example when a fever creates xue Heat, which then creates
Heat in the Liver; chronic ascendant Liver yang, which will often be the cause
of Liver Wind in elderly patients; Liver xue xu, where Liver xue, which is an aspect of
Liver yin, is not able to anchor Liver Wind, which is an aspect of Liver yang; Liver
Fire, where the Fire burns so intensely that it generates Wind.
I will describe the symptoms and treatment of these four patterns separately.
Wind in the body is similar to climatic wind in several ways and it can be just as
destructive. It can be as mild as a light breeze and cause only mild symptoms such
as tics or a slight dizziness or it can be as wild as a hurricane and cause paralysis,
spasms and a cerebrovascular accident, particularly when Wind is created by Heat.
It can be very destructive and sometimes even fatal. One of the dangerous aspects of
Wind is that it can stir up Phlegm, swirl the Phlegm up to the head and block the
‘orifices’. This will cause the person to lose consciousness and the ability to talk and
make the tongue stiff. Phlegm can also block the channels so the person becomes
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paralysed. Some of the disorders in Western medicine caused by internally generated

Wind are meningitis, tetanus, febrile convulsions, epilepsy and a stroke.
Wind can create a gentle movement like a flag fluttering gently back and forth
on a summer day, but it can also make the same flag stand rigid and stiff in the air,
moving to neither one side nor the other, as in an autumn storm. In both cases it
is characteristic that the movements are involuntary, and this is also the case in the
body, with all involuntary movement of the muscles, twitches, cramps and spasms
being due to Wind.
Extreme Heat generating Liver Wind

If there is extreme Heat in the body, such as when there is an invasion of exogenous
xie qi for example, the xie qi can generate so much Heat that it affects the Liver,
with the Heat in the Liver generating Wind. This is comparable to a forest fire:
when there is a forest fire, the hot air will rise upwards, the vacuum this creates will
draw in the air in from the surrounding area and this creates a strong wind that
rushes upwards.
The symptoms of this imbalance will be acute and they will often be extreme.
In Western medicine, diseases such as febrile seizures, tetanus and meningitis fall
within this category.
Aetiology
Exposure to exogenous xie qi is the main cause of this pattern. If there is already
Heat present in the body or the person is yin xu, this pattern will arise quickly. This
is typical in babies, as they are relatively yang, with a warm constitution but
their yin is weak. They therefore have a greater tendency to develop febrile seizures
than adults when there are invasions of exogenous xie qi. This means that they are
very vulnerable when there are epidemic diseases.
Symptoms and signs

• High fever
• Extreme thirst
• Red face
• The skin feels quite hot when palpated
• Dry, red lips
• Seizures
• Muscle spasms
• Extreme stiffness in the neck and back, the back can be stretched and bent
like a bow
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• Involuntary clenching of the hands and toes

• Shaking or involuntary movements of the limbs, such as in epilepsy
• The jaw may be locked
• In extreme cases, coma
• The eyes may be closed, staring or upwardly staring
• Extremely red tongue that is stiff and motionless, possibly veering to one
side, there will be a dry and yellowish or black coating
• Rapid and Wiry pulse
Key symptoms
Tremors, spasms, high fever and a Rapid, Wiry pulse.
Treatment principle
Calm Liver Wind and drain Heat.
Acupuncture points
Choose from: Liv 2, Liv 3, Shixuan (Ex-UE 11), jing-well points, Du 8, Du 14,
Du 16, Du 20, GB 20 and LI 11.
Needle technique
Draining. Shixuan (Ex-UE 11) and jing-well points should be bled.
Explanation
• Liv 2, Liv 3 and Du 8 calm the Liver and extinguish Liver Wind.
• Shixuan (Ex-UE 11) and jing-well points drain xue Heat and extinguish
internally generated Wind.
• Du 14 drains the Fire and extinguishes internally generated Wind.
• Du 16, GB 20 and Du 20 extinguish internally generated Wind, especially
when the symptoms affect the head.
• LI 11 drains Heat.
Herbal formula
• Ling Jiao Gou Teng Yin (Drains Heat from the Liver and extinguishes Wind)
Relevant advice
This is an acute condition that is caused by an invasion of exogenous xie qi that has
penetrated to the xue level. Dietary and lifestyle advice are therefore of less relevance.
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Extreme Heat generating Liver Wind can be caused

Extreme Heat generating Liver Wind can result

in the following pattern of imbalance
• Phlegm-Wind
Liver Fire generating Liver Wind

The extreme Heat generated by Liver Fire can be so intense that it can generate
Wind.
Aetiology
The aetiology is the same as for Liver Fire.
Symptoms and signs

• Dizziness
• Tremors
• Muscle spasms
• Hemilateral throbbing headache
• Red eyes
• Irritability
• Irascibility and anger
• Tinnitus
• Acute deafness
• Thirst
• Bitter taste
• Dark urine
• Constipation
• Bleeding
• Violent dreams and nightmares
• Restless sleep
• Fixed and staring eyes
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• Shouting quality to the voice, loud voice

• Red tongue that is stiff and motionless, possibly veering to one side, the
tongue will have a dry and yellowish coating
• Rapid, Wiry pulse
Key symptoms
Tremors and spasms, hemilateral throbbing headache, irritability, bitter taste, Rapid
and Wiry pulse.
Treatment principle
Calm Liver Wind and drain Liver Fire.
Acupuncture points
Choose from: Liv 2, Liv 3, Du 8, Du 14, Du 16, Du 20, GB 20 and GB 43.
Needle technique
Draining.
Explanation
• Liv 2, Liv 3 and Du 8 calm the Liver, drain Heat from the Liver and
extinguish Liver Wind.
• Du 14 drains Fire and extinguishes internally generated Wind.
when the symptoms manifest in the head.
• GB 43 drains Liver Fire.
Herbal formula
• Ling Jiao Gou Teng Yin (Drains Heat from the Liver and extinguishes Wind)
Relevant advice
See Liver Fire.
Liver Fire generating Liver Wind can be caused

• Liver Fire
Liver Fire generating Liver Wind can result in

• Phlegm-Wind
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Ascending Liver yang generating Liver Wind

This pattern will always have its root in either Liver yin xu or Liver xue xu. There will
be minor variations in some of the symptoms depending on whether it is Liver yin
xu or Liver xue xu that is the underlying cause. Furthermore, there are differences
between Liver xue xu leading to the pattern ‘Ascending Liver yang generating Wind’
and the next pattern ‘Liver xue xu generating Wind’. The former is a combination
of a xu and a shi pattern, whereas the latter is an exclusively xu pattern. This means
that the symptoms will be milder and less extreme when it is a purely xu pattern.
Aetiology
The aetiology is the same as for the pattern Ascending Liver yang.
Symptoms and signs

• Dizziness
• Tremors
• Hemilateral throbbing headache
• Irritability
• Tics
• Tinnitus
• Dry eyes
• Dry skin
• Insomnia
• Poor memory
If the condition is due to Liver yin xu or Liver and Kidney yin xu, there can also be:
• deafness
• dry mouth and throat
• malar flush
• night sweats
• feeling hot at night
• dark urine
• lumbar soreness or fatigue
• restlessness
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• thin tongue that lacks coating, the tongue may be red

• Wiry or Fine pulse.
If the condition is due to Liver xue xu, there can also be:
• dry lips
• pale complexion
• difficulty focusing the eyes
• spots or floaters in the visual field
• scanty menstrual bleeding
• numbness in the arms and legs
• tingling sensation in the arms and legs
• weak, frayed or ridged fingernails
• pale and thin tongue
• Choppy, Fine or Wiry pulse.
Key symptoms
Dizziness, tremors, insomnia, dry eyes.
Treatment principle
Calm Liver Wind and nourish Liver yin and xue.
Acupuncture points
Choose from: Liv 3, Liv 8, Du 16, Du 20, GB 20, UB 18 and Sp 6.
• If there is Liver yin xu, add: Kid 3, Kid 6, Ren 4 and UB 23.
• If there is Liver xue xu, add: St 36, Ren 12 and UB 17.
Needle technique
Draining technique on Du 16, Du 20 and GB 20, even technique on Liv 3 and
UB 18 and tonifying technique on the rest of the points.
Explanation
• Liv 3 and UB 18 nourish Liver yin and Liver xue and extinguish Liver Wind.
• Liv 8 and Sp 6 nourish Liver yin and Liver xue.
• Kid 3, Kid 6, Ren 4 and UB 23 nourish Kidney yin. Kidney yin and Liver
yin have a common root.
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• St 36 and Ren 12 together with Sp 6 tonify the Spleen and thereby the
production of xue.
Herbal formula
• Zhen Gan Xi Feng Tang (Calms Liver Wind and nourishes Kidney and Liver
yin)
• Da Ding Feng Zhu (Nourishes Liver xue and extinguishes Wind)
Relevant advice
See Ascending Liver yang, as well as Liver yin xu and Liver xue xu.
Ascending Liver yang generating Liver Wind can be

caused by the following pattern of imbalance
• Liver yin xu
• Liver xue xu
Ascending Liver yang generating Liver Wind can

result in the following pattern of imbalance
• Phlegm-Wind
Liver xue xu generating Liver Wind

This condition will arise when Liver xue, which is an aspect of the Liver yin, is too
weak to anchor Liver Wind, which is an aspect of Liver yang. When there is xue
xu it is as if xue does not completely fill the vessels, so a vacuum in the vessels
arises through which Wind can move. This is similar to the gusts of wind that blow
thorough underground railway tunnels, where the vacuum created by the train in
the tunnel draws in air that then rushes around the tunnels. Similarly, Wind can
rush around the vessels and channels when there is a vacuum created by xue xu.
Aetiology
The aetiology is the same as for Liver xue xu.
Symptoms and signs

• Dizziness
• Tremors
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• Muscle spasms
• Tics
• Tingling sensation or numbness in the limbs
• Floaters or spots in the visual field
• Insomnia
• Poor memory
• Sparse or no menstrual bleeding
• Pale lips
• Dry lips
• Weak, hesitant voice that lacks resonance
• Pale, thin and dry tongue with pale sides
Key symptoms
Dizziness, flickering in front of the eyes, shaking, pale sides of the tongue.
Treatment principle
Nourish Liver xue and calm Liver Wind.
Acupuncture points
Choose from: Liv 3, Liv 8, UB 17, UB 18, Sp 6, St 36, LI 4, Du 16, Du 20 and
GB 20.
Needle technique
Tonifying except on LI 4, Du 16, GB 20 and Du 20, which are drained.
Explanation
• Liv 3 and UB 18 nourish Liver xue and extinguish internally generated
Wind.
• Liv 8, UB 17, St 36 and Sp 6 nourish xue.
• LI 4 calms yang and thereby internally generated Wind.
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Herbal formula
• E Jiao Ji Zi Huang Tang (Nourishes Liver xue and extinguishes Wind)
Relevant advice
See Liver xue xu.
Liver xue xu generating Liver Wind can be caused

• Liver xue xu
Liver xue xu generating Liver Wind can result

• Phlegm-Wind
Damp-Heat in the Liver

When there is Damp-Heat in the Liver, there are signs and symptoms of a generalised
Damp-Heat condition, as well as specific Liver symptoms and signs. It is important
to note that Damp-Heat in the Liver can be a relatively serious condition. It is often
seen when the liver in Western medicine physiology is not able to break down and
excrete bilirubin as it should. Symptoms of Damp-Heat in the Liver can indicate
that there has been a significant reduction in the liver function due to some form of
liver failure.
Aetiology
Excessive consumption of food and medicine that are hot in their energy or produce
Dampness.
Emotional imbalances that weaken the Spleen or stagnate Liver qi and thereby
generate Heat in the Liver. This could be worries and speculation that bind and
thereby weaken Spleen qi or unresolved emotions, frustration, repressed anger,
irritation and so on that stagnate Liver qi.
Exogenous Dampness can invade the Liver channel in the legs and be transmitted
via the channel to the Liver organ. There can also be direct invasions of exogenous
Damp-Heat, especially in tropical climates.
The condition can also arise when there is latent heat from an unresolved
pathogen in the Liver. This can lead to chronic conditions such as hepatitis in
Western medicine.
Symptoms and signs

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• Costal tension or pain

• Sense of heaviness and fatigue in the body
• Yellow skin colour and yellowish sclera
• Red and suppurating skin diseases, rashes and sores
• Itching, burning or stinging skin, sores or rashes
• Genital sores or sores around the mouth
• Copious, odorous, yellow, sticky vaginal discharge
• Swollen or red and painful genitals
• Irregular menstrual bleeding, spotting
• Yellow, sticky sweat
• Bitter taste or sticky sensation in the mouth
• Dark and scanty urine, the urine may be odorous
• Burning urination
• Poor appetite
• Nausea
• Red tongue with even redder sides, greasy, yellow tongue coating
• Rapid, Slippery and/or Wiry pulse, Wiry pulse in the left guan position
Key symptoms
Feelings of heaviness and fatigue, bitter or sticky taste, nausea, yellow skin and sclera,
dark urine and yellow greasy tongue coating.
Treatment principle
Drain Damp-Heat from the Liver.
Acupuncture points
Choose from: Liv 2, Liv 5, Liv 8, Liv 14, UB 18, UB 22, GB 34, GB 41, SJ 5, Sp 6
and Du 9.
Needle technique
Draining.
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Explanation
• Liv 2, Liv 14, GB 34 and UB 18 drain Damp-Heat from the Liver.
• Liv 5 and Liv 8 drain Damp-Heat from the lower jiao, especially the genitals.
• GB 41 and SJ 5 open dai mai and drain Damp-Heat.
• UB 22, Sp 6 and Du 9 drain Damp-Heat.
Herbal formula
• Long Dan Xie Gan Tang (Drains Damp-Heat from the Liver)
Relevant advice
When there is Damp-Heat in the Liver, the person should avoid consuming
substances that create Heat or Dampness, especially if these substances have an
affinity with the Liver. Alcohol, hot spices, fried food and too much red meat
should be avoided. Foods such as dairy products, sugar, sweets, nuts, bananas and
other Damp-producing foods should be also avoided. A Liver that is burdened by
medication, alcohol poisoning and so on will have difficulty metabolising chemicals,
therefore caution should be exercised in the consumption of all kinds of medicine,
including dietary supplements and herbal remedies.
Stress and pent-up emotions, especially anger and frustration, create Heat in the
Liver. It is therefore important to address these emotions when possible.
Physical activity, such as sport and fitness, tai ji, yoga or qi gong, will be beneficial
because it will help to disperse stagnant Liver qi, which is often involved in the
creation of Damp-Heat in the Liver.
Damp-Heat in the Liver can be caused by the

• Spleen qi xu
• Damp-Heat
Damp-Heat in the Liver can result in the following patterns of imbalance

• Liver Fire
• Phlegm
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Stagnation of Cold in the Liver channel

The yin channels in the legs are vulnerable to invasions of Dampness and Cold and
this imbalance will often arise when the person has been wearing too little or wet
clothing on the legs and feet. The condition will usually be acute.
Aetiology
Invasions by exogenous xie qi.
Symptoms and signs

• Distension, tightness or pain in the groin or around the bladder
• Pain or shrinkage of the genitalia
• Distension, tightness or pain in the area above the pubic bone in the
hypochondriac region
• Pain that is ameliorated by heat
• Headache at the vertex
• Nausea
• Explosive, watery vomiting
• Wet and white tongue coating
• Slow, Deep and Confined or Tight pulse, especially in the left guan and chi
positions
Key symptoms
Pain above the pubic bone and around the genitals, aversion to cold, Wiry and Slow
pulse.
Treatment principle
Expel Cold and course qi in the Liver channel.
Acupuncture points
Choose from: Ren 1, Ren 2 and Ren 3, Liv 1, Liv 3, Liv 5 and LI 4.
Needle technique
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Explanation
• Ren 1, Ren 2 and Ren 3 drain Dampness from the lower jiao and resolve
stagnations of qi in and around the genitals.
• Liv 1, Liv 3 and Liv 5 circulate qi in the Liver channel.
• LI 4 expels Cold.
Herbal formula
Tian Tai Wu Yao San (Regulates Liver qi, warms and expels Cold from the Liver
channel, stops pain)
Relevant advice
If the stagnation of Cold in the Liver channel is a chronic or recurring pattern,
the person must make sure that they wear adequate and appropriate clothing and
footwear. They should avoid exposure to the cold and damp.
Stagnation of Cold in the Liver channel can be caused

Stagnation of Cold in the Liver channel can result

• Qi stagnation in the lower jiao
• Xue stagnation in the lower jiao
Xu patterns
Liver xue xu
The Liver has a very close relationship with xue. Liver qi helps to ensure that there is
free movement of xue in the body and it is in the Liver that xue is stored. The Liver
constantly ensures that the correct amount of xue is circulating in the body at any
given time. During physical activity xue is sent out into the body and when the body
is resting xue returns to the Liver. At night xue is mainly gathered in the Liver, where
it helps to anchor the hun.
Xue, for its part, helps to nourish and moisten the Liver. Therefore it is essential
that there is sufficient Liver xue to keep the Liver soft and flexible, otherwise Liver qi
will have a tendency to stagnate.
Liver xue is an aspect of Liver yin, so there will be an overlap of symptoms and
signs between these two patterns but there are also important differences.
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Due to menstruation and childbirth, women have a greater tendency to be Liver

xue xu than men.
Aetiology
The are three main causes of Liver xue xu: poor production of xue; insufficient
consumption of food that nourishes xue; loss of xue through bleeding. Excessive
physical training can also consume xue meaning that xue xu arises.
Blood loss during childbirth, heavy menstrual bleeding, bleeding disorders,
operations, physical trauma and so on can lead to Liver xue xu. The condition can
still be present a long time after the blood loss; in some cases this can be years later.
Excessive physical activity, especially in women who train hard, can lead to Liver
xue xu. This does not only affect professional sportswomen or dancers, but can also
affect women who train to run marathons, triathlons or Ironman events, because
the excessive training consumes xue, which is used to nourish the muscles. This is
why many women who play sport, dance and train at a high level stop menstruating.
Poor production of xue will be due to weakness of the organs involved in xue
production. This will be due to aetiological factors that weaken the Spleen and
Kidneys and will eventually lead to Liver xue xu.
Even if the Spleen and Kidneys are strong enough, Liver xue xu can still arise if
the person’s diet is deficient in foods that directly nourish xue.
Symptoms and signs

• Dizziness, especially when getting up from a seated or lying position
• Spots or floaters in the vision
• Dry eyes or a sensation of grit in the eyes
• Eyes that water in the wind
• Poor night vision
• Insomnia
• Pale and dry lips
• Dry skin
• Ridged fingernails or weak and frayed fingernails
• Dry hair
• Hair loss
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• Weak muscles
• Leg cramps or restless legs, especially in the evening and at night
• Amenorrhoea or scanty menstrual bleeding
• Tendency to be weepy and very sensitive during the premenstrual phase
• Indecisiveness
• The voice may lack resonance and be hesitant
• The voice may lack resonance even when they are angry
• Thin, pale and dry tongue, pale or orange sides of the tongue
Key symptoms
Dizziness, floaters in the vision, scanty menstrual bleeding, ridged or weak fingernails
and pale sides of the tongue.
Treatment principle
Nourish Liver xue.
Acupuncture points
Choose from: UB 17, UB 18, UB 20, UB 21, St 36, Sp 6, Liv 3, Liv 8 and Ren 4.
Needle technique
Tonifying. Moxa can be used and should be used on UB 17.
Explanation
• Sp 6, St 36, UB 20 and UB 21 tonify Spleen qi and thereby the production
of xue.
• Ren 4 tonifies yuan qi and thereby the production of xue.
Herbal formula
• Bu Gan Tang (Nourishes Liver xue)
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Relevant advice
It is important that a person who is Liver xue xu eats a diet that nourishes xue. They
will benefit from eating red meat, bone marrow and blood sausages. Eating organic
liver25 will be especially salutary, because it nourishes both xue and the Liver directly.
Green-leafed vegetables will also be beneficial, because they have a high iron content
and because their green colour has a resonance with the Liver. Other foods that
nourish xue are beetroot, seaweed, dates, kidney beans, black beans, aduki beans,
goji berries, angelica and nettle tea. A person who is Liver xue xu should avoid sugar,
stimulants such as coffee and too much alcohol.
The patient should eat a diet that not only directly nourishes Liver xue, but also
tonifies Spleen qi, i.e. warm, prepared food that is not cold in its energy and does
not produce Dampness.
Lying down for 20 minutes in the middle of the day is recommended, as it
enables xue to return to the Liver.
Excessive training should be discouraged.
Liver xue xu can be caused by the following patterns of imbalance

• Xue xu
• Spleen qi xu
• Spleen yang xu
• Kidney yin xu
Liver xue xu can result in the following patterns of imbalance

• Spleen qi xu
• Heart xue xu
• Liver yin xu
• Kidney jing xu
Liver yin xu
It is rare to see this pattern alone. It will usually be a consequence of, or result in,
Kidney yin xu, so there will usually be a combined pattern of Liver and Kidney yin
xu. Liver yin xu is also frequently an aspect of other Liver patterns such as ascending
Liver yang and Liver Wind.
Liver yin encompasses Liver xue. This means that there will be similar symptoms
and signs as those that are present in Liver xue xu, but there will also be specific yin
xu signs. Liver xue xu is often a precursor of this pattern.
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Aetiology
The aetiology will be the same as for Liver xue xu, especially since Liver xue xu can
often be a precursor of Liver yin xu. Furthermore, factors that weaken Kidney yin and
yin in general can be contributing factors. Chronic illness, stress, physical, emotional
and mental overexertion, drugs, excessive sex, working at night, too little sleep, a
diet that is hot or drying in its dynamics, too much coffee and other stimulants,
congenital weakness and old age can all weaken yin. Kidney yin xu will often arise as
a consequence of chronic imbalances in the body.
Chronic Liver Fire can injure Liver yin.
Symptoms and signs

• Dizziness
• Dry eyes
• Matt, pale face with red cheeks
• Insomnia
• Dry skin
• Dry hair
• Dry or weak fingernails
• Cramps or restless legs in the evening and at night
• Tingling or numbness in the arms and legs
• Sparse menstrual bleeding or amenorrhoea
• The person may appear to be slightly restless
• Depression or lack of initiative
• The person may seem indecisive and cannot figure out what they want
• Thin, dry tongue without coating and possibly with cracks.
• Empty or Fine pulse
If Liver yin xu has led to xu Heat there can also be:
• night sweats
• feeling hot in the evening and at night
• a sensation of heat in the palms of the hands and soles of the feet
• malar flush
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• anxiety
• thirst with a desire to sip water
• dry mouth and throat
• menorrhagia or metrorrhagia
• a red, thin tongue that lacks coating
• a Rapid and Fine or Empty pulse.
Key symptoms
Dry eyes, dry skin, lack of tongue coating and a Fine pulse.
Treatment principle
Nourish Liver yin.
Acupuncture points
Choose from: UB 18, UB 23, UB 52, Liv 3, Liv 8, Ren 4, Sp 6, Kid 3 and Kid 6.
Needle technique
Tonifying.
Explanation
• Liv 3, Liv 8, UB 18 and Sp 6 nourish Liver yin.
• UB 23, UB 52, Ren 4, Kid 3 and Kid 6 nourish Kidney yin, which is the
root of Liver yin.
Herbal formula
• Liu Wei Di Huang Tang (Nourishes Kidney and Liver yin)
• Zhi Bai Di Huang Tang (Nourishes Kidney and Liver yin and clears xu Heat)
Relevant advice
It is essential that a person who is Liver yin xu gets enough rest and relaxation. This
means that they must have ample sleep and go to bed early at night. They must
not work too hard nor spend too much time watching television and staring at
computer screens. They should avoid stimulants such as coffee, which would stress
their system. Alcohol is not good for them because it is both spreading and warming
in its energy and creates Heat in the Liver, which can injure Liver yin.
Dynamic activities such as aerobics or action sports will be detrimental and
should be discouraged, because they will further consume yin. The person should
instead cultivate gentler and more meditative forms of motion such as qi gong, yoga
628
and tai ji. Massage and meditation are especially beneficial because they increase
peace and tranquillity in the body and thereby benefit yin.
The client should try to avoid foods that are stimulating and warming. This
includes coffee, alcohol, dark chocolate and hot spices like chilli. Generally,
concentrated proteins, cereals and root vegetables nourish yin. Green, leafy vegetables
will be especially good, because the green colour will resonate with the Liver and
thereby directly tonify Liver yin.
Using a lot of water in the preparation of food, especially soups and stews, is
preferable to baking things in the oven, which is more drying. Oil and products
that have a high oil content, such as nuts and seeds, will nourish and moisten yin.
Foods that specifically nourish Liver yin are: artichokes, beetroot, tomato, avocado,
seaweed, dates, grapes, lemon, nettles, olive oil, lima beans, mung beans, kidney
beans, pine nuts, sesame seeds, tahini, crab, oysters, beef, liver and rabbit.
Liver yin xu can be caused by the following patterns of imbalance

• Liver xue xu
• Kidney yin xu
• Liver Fire
Liver yin xu can result in the following patterns of imbalance

• Kidney yin xu
• Heart yin xu
Combined patterns
Liver qi invading the Spleen
When there is pronounced and chronic Liver qi stagnation, Liver qi can ‘invade’
the Stomach and the Spleen. In these situations the Liver qi will no longer support the
Stomach and Spleen qi ji and instead will block it. This will often lead to symptoms
such as rebellious qi in the Stomach. The Intestines and the abdomen can become
bloated due to the stagnation of qi. Crucial to diagnosing Liver qi stagnation in
these cases is whether the symptoms get worse or are triggered by emotional factors
or stress and whether the symptoms are worse during the premenstrual phase rather
than being triggered by the ingestion of certain foods.
This is a combined xu/shi pattern. Therefore, it is important to establish, both
in this and in the subsequent pattern, whether Liver qi stagnation is the dominant
aspect or the Spleen or Stomach are weak and have let themselves be invaded.
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Aetiology
Some of the most common reasons that Liver qi stagnates are frustration, irritation,
accumulated anger, pent-up emotions and stress. Women can often have an
underlying condition of Liver xue xu, which means that the Liver is not moistened
sufficiently and becomes stiff and inflexible. Food stagnation and Dampness can
prevent the free movement of qi in the body and thereby block the Liver’s function
of spreading qi.
Another important aspect of this pattern will be factors that weaken the
Spleen, such as the consumption of food and liquids that are cold or have a cooling
energy and foods that are difficult to digest because they are too coarse or are raw.
Eating irregularly and eating whilst working or when stressed can also often be
Symptoms and signs

• Abdominal bloating, especially if the bloating is affected by stress or
emotional influences
• Hypochondriac tension or tightness in the solar plexus region
• Alternating constipation and loose stools – if Liver qi stagnation is the
dominant aspect, there will be increased tendency to have constipation;
conversely, if Spleen qi xu is dominant, there will be a tendency to have
loose stools
• Flatulence
• Fatigue
• Craving for the sweet flavour
• Poor appetite in the mornings
• Nausea
• Cold hands and feet, the buttocks and tip of the nose may also be cold
• Irritability
• Mood swings
• Tendency to worry and think in circles
• The person may have a hard or staccato voice
• Pale, swollen tongue with teeth marks, the sides of the tongue may be red
or red speckled
• Wiry pulse in the left guan position and Weak pulse in the right guan
position, sometimes the pulse is also Wiry in the right guan position
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Key symptoms
Abdominal bloating, alternating stools, Wiry pulse.
Treatment principle
Harmonise the Liver and Spleen by spreading Liver qi and tonifying Spleen qi.
Acupuncture points
Choose from: Sp 3, Sp 6, St 36, Ren 6, Ren 12, Liv 3, Liv 13, Liv 14, Pe 6, GB 34,
UB 18 and UB 20.
Needle technique
Draining technique on Liv 3, Liv 14, UB 18, Pe 6 and GB 34. Tonifying technique
on Sp 6, St 36, Ren 12 and UB 20. Even technique on Liv 13.
Explanation
• Sp 3, Sp 6, St 36, Ren 12 and UB 20 tonify Spleen qi.
• Liv 3, Liv 14, UB 18, Pe 6 and GB 34 spread stagnated Liver qi and soothe
the Liver.
• Liv 13 regulates qi in the middle jiao and harmonises the Spleen and Liver.
• Ren 6 regulates qi in the middle jiao.
Herbal formula
• Xiao Yao Wan (Harmonises the Liver and Spleen)
Relevant advice
A person with Liver qi stagnation should, where possible, try and resolve any
emotional causes of their Liver qi stagnation. They should avoid stress.
Physical activity is beneficial because it circulates Liver qi. People with Liver qi
stagnation may train a lot, which can be a conscious or subconscious form of self-
medication. There is a risk that people with Liver qi stagnation train excessively and
end up weakening their xue and yin.
It is important that the activities in which the person engages do not become
chores that they ‘have to do’, as this will further stagnate their Liver qi.
They should eat a diet that tonifies and does not weaken the Spleen. This entails
eating warm, prepared food. They should avoid too much salad, raw vegetables and
fruit. They should also avoid sweets, sugar, honey and artificial sweeteners. Dairy
products create Dampness and thereby burden the Spleen, so they should be avoided.
A person whose Liver qi stagnates should try to avoid eating too much at a time or
eating rich food, especially concentrated proteins such as meat, dairy products, nuts
and food that has a high oil content, because this will create further stagnation.
Aromatic spices, herbs and foods that are slightly spicy will move qi, but they must
be careful if these also have a warm or hot energy, because qi stagnations tend to
631
create Heat. Unfortunately, people with Liver qi stagnation are often attracted to
alcohol and spices such as chilli, precisely because their spicy flavour spreads the
stagnant qi, but this often results in the generation of Heat.
It is not only what is eaten that is important, but also how the food is eaten. It
is detrimental to eat when in a rush, whilst working or whilst discussing issues that
can stagnate Liver qi. The person should preferably sit straight and upright whilst
they eat and get some light movement, go for a walk or stretch after meals to support
the Spleen’s qi dynamic. Alternatively, they can lightly massage their abdomen to
circulate qi.
Liver qi invading the Spleen can be caused by

• Spleen qi xu
• Spleen yang xu
• Food stagnation
Liver qi invading the Spleen can result in the

• Spleen qi xu
• Xue xu
• Damp
• Phlegm
• Food stagnation
Liver qi invading the Stomach

This pattern is very similar to the previous pattern in its pathological mechanisms
and aetiology. There will also be an overlap between the two patterns and both
patterns can be seen in the same patient.
Aetiology
The difference between this pattern and the previous one is that in this pattern the
Stomach will be more influenced by foods that are hot and ascending in their energy
and will be less affected by food that is physically cold or has a cooling energy. Food
can stagnate in the Stomach if it is too difficult to transform, if too much is eaten
at a time or if it is eaten too quickly or too late in the evening. This will create food
stagnation and thereby Heat in the Stomach, which may cause the Stomach qi to
become rebellious. Otherwise, the aetiology will be the same as in Liver qi invading
the Spleen.
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Symptoms and signs

• Abdominal bloating and abdominal pain that occur or are exacerbated by
stress and emotional influences
• Hypochondriac tension or tightness in the solar plexus region
• Cold hands and feet, the buttocks and tip of the nose may also be cold
• Nausea
• Acid regurgitation or heartburn
• Vomiting
• Burping
• Hiccups
• Irritability
• Mood swings
• The person may have a hard or staccato voice
• Pale tongue with red sides or red speckled sides
• Wiry pulse in the left guan position and Weak pulse in the right guan
position, sometimes the pulse is Wiry in the right guan position
Key symptoms
Abdominal bloating, cold hands and feet, belching and a Wiry pulse.
Treatment principle
Harmonise the Stomach and Liver by tonifying Stomach qi and spreading Liver qi.
Acupuncture points
Choose from: St 21, St 36, Ren 10, Ren 11, Ren 12, Ren 13, Liv 3, Liv 14, Pe 6,
GB 34, UB 18 and UB 21.
Needle technique
Draining technique on Liv 3, Liv 14, Pe 6, GB 34, Ren 13, St 21 and UB 18.
Tonifying technique on St 36, Ren 10, Ren 11, Ren 12 and UB 21.
Explanation
• Liv 3, UB 18 and GB 34 spread stagnant Liver qi.
• Pe 6 and Liv 14 spread Liver qi and regulate qi in the middle jiao.
• Ren 13 and St 21 regulate rebellious Stomach qi.
• St 36, Ren 10, Ren 11, Ren 12 and UB 21 tonify and regulate Stomach qi.
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Herbal formula
• Ban Xia Hou Po Tang (Regulates Liver qi and Stomach qi)
Relevant advice
The advice that was given for the pattern Liver qi invading the Spleen is relevant
here.
The person should also avoid food that has an ascending dynamic, for example
chilli. They should also avoid eating food that creates food stagnation, eating too late
at night, eating too quickly or eating too much at a time.
Stroking the fingers down the Ren channel from Ren 15 down to Ren 9 after a
meal can help descend Stomach qi.
Liver qi invading the Stomach patterns can be caused

• Stomach qi xu
• Spleen qi xu
• Food stagnation
• Damp
Liver qi invading the Stomach patterns can result

• Stomach Fire
• Stomach yin xu
• Spleen qi xu
• Food stagnation
• Damp
• Phlegm
Liver Fire invading the Lung

The Liver is anatomically immediately below the Lung. This means that if there
is Liver Fire, the Fire can rise upwards and invade the Lung. This will create Heat
in the Lung and interfere with the Lung’s descending of qi. In this pattern there will
be symptoms and signs of Liver Fire, as well as symptoms and signs indicating that
the functioning of the Lung is disturbed.
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Aetiology
Foods and beverages that have a hot energy can also create Liver Fire, including
alcohol, fried foods, too much red meat, especially lamb, and spices such as chilli
and pepper.
Chronic emotional imbalances can create Liver qi stagnation, which is often
a root cause of Liver Fire. Xue Heat can also be an underlying cause, because the
Liver is a reservoir for xue and the Heat from the xue can cause the Liver itself to
become hot.
Symptoms and signs

• Shortness of breath or difficulty breathing
• Cough with yellowish or bloody sputum
• Constipation
• Throbbing headache
• Dizziness
• Red eyes
• Anger, irritability and anger
• Intense, slightly staring eyes
• Appears to be stiff or slightly distended in the chest region
• Sparse, dark urine
• Red face
• Burning urination
• Thirst
• Red tongue with even redder sides and red front. Dry yellowish tongue
coating
• Rapid and Wiry pulse
Key symptoms
Cough with yellow sputum, dyspnoea, hypochondriac tension, headache, Rapid
and Wiry pulse.
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Treatment principle
Drain Liver Fire, regulate Lung qi.
Acupuncture points
Choose from: Liv 2, Liv 14, Ren 17, Ren 22, Lu 5, Lu 7, Pe 6 and LI 11.
Needle technique
Draining.
Explanation
• Liv 2 drains Liver Fire.
• Liv 14 and Pe 6 spread Liver qi and regulate qi in the chest.
• Ren 17 and Ren 22 regulate qi in the upper jiao.
• Lu 5 drains Heat from the Lung and regulates Lung qi.
• Lu 7 regulates Lung qi.
• LI 11 drains Heat.
Herbal formula
• Long Dan Xie Gan Wan (Drains Liver Fire)
Relevant advice
Because Liver Fire is the root cause of this imbalance, the person must avoid
consuming substances that create Heat in the Liver. In particular, alcohol, hot spices,
fried food and too much red meat should be avoided. Stress and pent-up emotions,
especially anger and frustration, create Heat in the Liver. A person with Liver Fire
should therefore try to resolve these issues or, if this is not possible, try and reach
an acceptance of the situation. Physical exercise is recommended, because it will
help spread and disperse stagnant Liver qi, which is often involved in the creation
of Liver Fire.
Liver Fire invading the Lung can be caused by

• Liver Fire
Liver Fire invading the Lung can result in the

• Lung Phlegm-Heat
• Phlegm-Heat
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• Lung yin xu
• Xue stagnation
• Heart Fire
Liver and Heart xue xu

When there is Liver xue xu, it will often lead to Heart xue xu, because the Liver
and Heart have a very close relationship to xue. The Liver stores xue and the Heart
governs xue. Furthermore, the Liver xue anchors and nourishes the hun, whilst the
Heart xue anchors and nourishes the shen. The hun is ‘that which follows the shen
in its entering and exiting’. Insomnia will be an important sign of Liver and Heart
xue xu.
Aetiology
There are three main causes of Liver and Heart xue xu: poor production of xue;
insufficient consumption of food that nourishes xue; the loss of xue through
bleeding or the consumption of xue through excessive physical training and excessive
mental activity.
Poor production of xue will be due to weakness of the organs involved in xue
production. This is will be due to aetiological factors that weaken the Spleen and
Kidneys and will eventually lead to Liver and Heart xue xu.
Even if the Spleen and Kidneys are strong enough, Liver and Heart xue xu can
still arise if the person’s diet is deficient in foods that directly nourish xue.
Blood loss during childbirth, heavy menstrual bleeding, bleeding disorders,
operations, physical trauma and so on can lead to Liver and Heart xue xu. The
condition can still be present a long time after the blood loss; in some cases this can
be years later.
Excessive physical activity, especially in women who train hard, can lead to Liver
xue xu. This does not only affect professional sportswomen or dancers, but can also
affect women who train to run marathons, triathlons or Ironman events, because
the excessive training consumes xue, which is used to nourish the muscles. This is
why many women who play sport, dance and train at a high level stop menstruating.
Symptoms and signs

• Palpitations
• Dizziness, especially when getting up from a sitting or lying position
• Floaters in the eyes
• Difficulty in focusing the eyes
• Dry eyes or a feeling that there is grit in the eyes
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• Poor night vision

• Poor memory
• Poor concentration
• Insomnia
• Anxiety
• Nervousness
• Pale lips
• Dry skin
• Ridged fingernails or weak and frayed fingernails
• Dry hair
• Hair loss
• Weak muscles
• Cramps or restless legs, especially in the evening and at night
• Scanty menstrual bleeding or amenorrhoea
• A tendency to be weepy and extra sensitive during the premenstrual phase
• Indecisiveness
• Lack of charisma
• Excessively apologetic or self-deprecating
• The voice can lack resonance and have a hesitant quality
• Thin, pale and dry tongue, Pale or orange sides of the tongue
Key symptoms
Palpitations, insomnia, dizziness, floaters, sallow complexion, scanty menstrual
bleeding and pale sides of the tongue.
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Treatment principle
Nourish Liver and Heart xue.
Acupuncture points
Choose from: UB 15, UB 17, UB 18, UB 20, UB 21, Ren 14, He 7, St 36, Sp 6,
Liv 3, Liv 8 and Ren 4.
Needle technique
Tonifying. Moxa can be used and should be used on UB 17.
Explanation
• He 7, Ren 14 and UB 15 nourish the Heart xue.
• Sp 6, St 36, UB 20 and UB 21 tonify Spleen qi and thereby the production
of xue.
• Ren 4 tonifies yuan qi and thereby the production of xue.
Herbal formula
• Gui Pi Tang (Nourish Heart xue and Spleen qi)
Relevant advice
It is important that a person who is Liver and Heart xue xu eats a diet that nourishes
xue. They will benefit from eating red meat, bone marrow and blood sausages. Eating
organic liver26 will be especially salutary because it nourishes both xue and the Liver
directly. Green-leafed vegetables will also be beneficial, because they have a high
iron content and because their green colour has a resonance with the Liver. Other
foods that nourish xue are beetroot, seaweed, dates, kidney beans, black beans, aduki
beans, goji berries, angelica and nettle tea. A person who is Liver and Heart xue xu
should avoid stimulants such as coffee and alcohol.
As well as eating a diet that directly nourishes Liver xue, the patient should eat
a diet that tonifies Spleen qi, i.e. warm, prepared food that is not cold in its energy
and does not produce Dampness.
Lying down for 20 minutes in the middle of the day is recommended so xue can
return to the Liver.
Meditation is recommended as it can tonify the Heart.
Excessive training should be discouraged.
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Liver and Heart xue xu can be caused by the

• Liver xue xu
• Heart xue xu
• Spleen qi xu
Liver and Heart xue xu can result in the following patterns of imbalance
• Liver yin xu
• Heart yin xu
• Kidney yin xu
Heart and Kidney yin xu

This is discussed in the section on Kidney patterns of imbalance (page 546).
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Section 9
DIAGNOSIS ACCORDING
TO THE SIX STAGES, FOUR
LEVELS AND SAN JIAO
The three diagnostic theories: diagnosis according to the Six Stages; diagnosis
according to the Four Levels and diagnosis according to san jiao are three separate
theories that explain how diseases arise and develop after the body has been invaded
by exogenous xie qi. The three theories explain both the mechanisms of the disease,
and at the same time they are used as a template to determine the level and location
in the body where the xie qi is present.
The theories are used to analyse the relative strength of the xie qi (pathogenic qi)
in relation to the body’s zheng qi (anti–pathogenic qi), as well as giving an idea of the
direction the disease is moving in, whether there is an improvement or deterioration
in the condition. Disease is a dynamic process. It is something which is constantly
changing and developing. This means that the treatment strategy must also be
something that is being constantly adapted to the match the situation, taking into
account the current situation and in which direction the disease is developing.
The three theories are not contradictory and are used in different situations,
depending on amongst other things, the character of the xie qi. The theories can
sometimes also be used alongside each other or consecutively, depending on how the
situation develops. It requires flexibility in one’s mindset and the ability to let go of
Western medicine’s either/or mentality.
Historical overview
Even though the three diagnostic approaches of ‘The Six Stages, Four Levels and
san jiao’ all chart the development of imbalances resulting from the invasion of
exogenous xie qi, the first approach is more than 1,500 years older than the other two
theories. The oldest theory, which still has great relevance to this day, is the theory
of the Six Stages. This theory was formulated by one of Chinese medicine’s most
important figures Zhang Zhong Jing in 220 ce in the classical text Shang Han Lun
(Discussion on Cold-induced Diseases). This book is still one of the cornerstones of
Chinese medical education in China. The herbal formulas from this book are still
some of the most used prescriptions today. Zhang Zhong Jing analysed how the
initial symptoms of an invasion manifest and how the symptoms develop depending
on the relative strengths and relationship between the body’s zheng qi and the xie
qi. He described how disease can develop when exogenous xie qi penetrates via
the energetic aspects of the body, that are defined by the six great channels and their
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corresponding organs. Taiyang being the most superficial and exterior aspect and
jueyin the deepest. Zhang Zhong Jing explained the body’s febrile reactions and the
corresponding Heat signs, as the result of the struggle between zheng qi and xie qi.
What had been the catalyst in the development of Zhang’s work was that within
10 years, two–thirds of the inhabitants of his village had died in epidemics, especially
cholera. This made it both imperative to find cures, but it also provided a rich basis
for observing how diseases evolved, how the symptoms changed from day to day and
observing whether various treatment strategies worked in practice.
Even though the treatment approach set forth in the Shang Han Lun was very
effective, there were however also holes in the theory and this became more and
more apparent, especially around 14–1500 ce when China was plagued by several
epidemics including the bubonic plague. Zhang Zhong Jing’s theories assumed that
the body had been exposed to climatic influences, especially Cold. His theories
could not explain how people could infect each other just by their mere proximity
to each other. It could also not satisfactorily explain how symptoms manifested with
Heat from the very beginning.
Ye Tian Shi (1667–1746 ce) devoted his life to studying febrile diseases. His
theories were published after his death in the classic text Wen Re Lun (The Classic of
Heat Diseases). In this model, disease is differentiated in relation to four energetic
levels, the deeper the level, the more severe the condition. It introduces for the
first time the concept that exogenous xie qi can be transmitted from person to
person and that exogenous xie qi can invade the body via the mucous membranes
in the mouth, nose and genitals. The invading xie qi will be energetically hot from
the beginning, which means that the symptoms manifest as Heat and rapidly
injure the fluids in the body and injure yin.
The theories in Wen Re Lun were further developed in the book Wen Bing Tiao
Bian (The Text on Differentiation and Treatment of Heat Disorders) written by Wu
Ju Tong in 1798 ce. In this work, Heat disorders and their development are analysed
in relation to a san jiao model instead of four energetic levels.
Diagnosis according to the Six Stages

In the theory of the Six Stages the body is divided into six energetic levels that can be
affected by exogenous xie qi. The deeper the level that exogenous xie qi has penetrated
to, the more serious the condition is. The relationship between the strength of the
invading xie qi and the body’s zheng qi will have an influence on how deep the xie
qi penetrates.
The six energetic stages are:
• taiyang – Urinary Bladder and Small Intestine
• shaoyang – Gall Bladder and san jiao
• yangming – Stomach and Large Intestine
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Diagnosis According to the Six Stages, Four Levels and San Jiao
• taiyin – Lung and Spleen

• shaoyin – Kidney and Heart
• jueyin – Liver and Pericardium.
Taiyang is the most superficial aspect and jueyin is the deepest. Exogenous xie qi can
penetrate deeper into the body in the following ways:
• by continuing sequentially through the various stages
• by skipping over one or more stages
• by penetrating from the channel down to its internal organ or its partner’s
channel organ.
There may be overlapping patterns where there are symptoms and signs of two stages
simultaneously.
If is there already a xu condition in an organ or an aspect, xie qi will more easily
penetrate to this level. For example, if there is Kidney yang xu and the person is
invaded by Wind-Cold in the taiyang aspect, the Cold can penetrate directly to the
shaoyin aspect due to the yin yang relationship between the Urinary Bladder (taiyang)
and the Kidneys (shaoyin).
In the Six Stages model, it is Cold that has invaded the body and created
imbalances. Heat can, though, arise when Cold penetrates deeper into the body.
When there are apparent Heat symptoms and signs without any preceding Cold
signs, this is explained as being being a consequence of ‘latent Heat’. Latent Heat
can arise when Cold invades the body in the winter. The Cold will be inactive and can
later transform and turn into Heat. In spring yang will begin to rise upwards and
outwards. This movement of yang will result in the latent Heat being driven upwards
and outwards to the exterior, where it will activate the body’s defence mechanisms.
There will therefore be signs of Heat without the person having been exposed to
xie qi. Signs and symptoms of Heat can also quickly manifest in an invasion of
Wind‑Cold if there is Heat already present in the body.
Diagnosis in relation to the Six Stages analyses the relative strengths of zheng
qi and xie qi, whether the disease is advancing or retreating. Distinction is made
between Heat and Cold, xu and shi, and whether xie qi is located in the interior and
the exterior. This determines the treatment, for example whether xie qi should be
drained or expelled, or whether zheng qi should be tonified.
The Six Stages diagnosis differentiates the following:
• Where the disease is: Whether the disease is in the interior or the exterior
and if it is only on the channel level or the zangfu organs are affected. In
relation to an Eight Principles diagnosis, the taiyang stage is an exterior
imbalance; shaoyang stage is half interior, half exterior; and the rest are
interior imbalances.
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• What the nature of the disease is: Whether the disorder is xu or shi, Hot or
Cold. When zheng qi is strong, there will be a shi condition. In general, it is a
shi condition when the disorder is in the taiyang and yangming stages and a xu
condition when the disorder is in one of the three yin stages. Shaoyang stage
is often a combined xu/shi condition. Taiyang stage is usually characterised
as being Cold. When xie qi is in the yangming aspect, there is Heat; shaoyang
can be either a Hot condition or a combination of Heat and Cold. The yin
stages can be either Hot or Cold, depending on whether it is yin or yang that
is injured.
• How the disease is developing: Disease development is a dynamic process
that is in a process of constant change, especially in the initial stages. The
theory of the Six Stages can be used to determine if the disease is improving
or deteriorating. It does this by assessing the relative strength of zheng qi
and xie qi and in which direction the disease is moving. If it is penetrating
downwards from one of the exterior aspects, this is a negative sign. Conversely,
if the symptoms change and the pattern changes from one of the deeper
stages to one of the more exterior stages, it is a positive sign.
• The treatment principle: The Six Stage diagnosis determines the nature
of a disorder. This then dictates the way in which the disorder should be
treated. For example, if xie qi has invaded the taiyang aspect, this is a shi
condition and the treatment principle will be to ‘open to the exterior and
expel xie qi’ using a draining needle technique on points that expel Wind-
Cold. Conversely, if there is a yang xu condition in the taiyin aspect, Spleen
yang should be ‘tonified and warmed’ using a tonifying needle technique and
preferably moxa on points that tonify Spleen qi and yang.
In the three yang stages, it is the yang organs and channels that are affected. The
symptoms and signs generally reflect that is a shi condition. The three yin stages are
more xu in nature because in the preliminary stages zheng qi is relatively strong, and
this will result in more powerful symptoms due to the struggle between a strong
zheng qi and the xie qi. When xie qi penetrates to the yin stages, zheng qi will have
become weakened and is no longer able to withstand the xie qi.
It is important to keep in mind that even though the interior xu patterns in the
Six Stages are ostensibly the same as zangfu patterns of diagnosis, such as Spleen yang
xu for example, the disorder in the Six Stages has primarily arisen due to an invasion
of exogenous xie qi and not necessarily due to diet and lifestyle. They may well be
involved, but they are not the primary reasons for the imbalance.
Taiyang stage
This is the most superficial aspect of the Six Stages and the invasion at this stage
is relatively superficial. There are four main patterns that can be differentiated at
this stage. Two of them are channel-level imbalances and are therefore pure exterior
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imbalances, but there are also two fu organ imbalances, where the exogenous xie qi
has penetrated into the interior. In one of these imbalances there will still be clear
signs that the xie qi is present in the exterior aspect.
The two channel-level imbalances are the taiyang patterns most often seen in the
clinic and in everyday life. Zhang Zhong Jing distinguished between an invasion of
Wind-Cold in the taiyang aspect where Cold is the dominant xie qi and an invasion
of Wind-Cold where Wind is dominant. The difference between the two situations
is essentially that in the first scenario it is a pure shi condition, whereas when Wind is
dominant there is a xu/shi condition.
The key symptoms that characterise the taiyang stage are a Superficial pulse,
headache and stiffness in the neck and shoulders and an aversion to wind and cold.
The taiyang channels helps to govern and control wei qi. Wei qi, as well as
protecting the body against exogenous xie qi, warms the skin and controls the
sweat pores. This has significant implications for how many of the symptoms
manifest themselves.
In the taiyang stage, exogenous xie qi has invaded the body by penetrating the
wei qi. It is usually Wind and Cold that have invaded the body. Cold by itself can
have difficultly penetrating through the wei qi. This is because the Cold has a yin,
contracting dynamic and this will cause the pores in the skin to close. Wind, though,
has a yang and a very scattering dynamic. Wind can therefore scatter wei qi and open
the pores. Wind is therefore termed the spearhead that leads other forms of xie qi
into the body.
Exogenous xie qi can succeed in overcoming and breaking through the body’s
wei qi in three ways.
• If wei qi is very powerful it will not require long-term exposure to the xie
qi before it can invade the body. This could, for example, be when a person
has fallen through the ice and has been strongly chilled by the cold water.
Although it is only a short-term exposure to the cold, the cold is so powerful
that it is able to pierce through the wei qi, even in a person whose wei qi is
strong and powerful.
• Exogenous xie qi can also penetrate the wei qi if there is a prolonged exposure
to the xie qi. In this case the xie qi does not need to be as intense as in the
first case, but because there is a continued and persistent influence, the xie qi
will over time break through. An example of this could be a person who has
cycled home in the rain and sleet and been thoroughly drenched and cooled
down. If they cycled two kilometres and then changed into dry clothes
afterwards they would not become ill. If, on the other hand, they cycled
15 kilometres and did not have the opportunity to change into dry clothes
afterwards, they may well catch a cold.
• The final scenario where xie qi can invade the taiyang stage is when wei qi is
deficient. This will typically be a person who is qi xu. This could be an elderly
person, a very small child, a person who has just been ill or a person who
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is physically run down. In these situations, the xie qi does not need to be
very strong for it to be able to overcome the wei qi. The wei qi is simply too
weak to protect the body. If a person with a strong wei qi goes for a walk for
15 minutes without a jacket on in the winter, their wei qi is strong enough
to withstand the cold. But if a person who is very qi xu did the same, they
may well catch a cold or fall ill. This is why elderly people have to wear more
clothes than young people and are generally more sensitive to draughts and
open windows.
Even if a person has strong wei qi, xie qi can easily invade the body if the person
sweats whilst they are exposed to wind and cold. This is because the pores will
be open, which allows exogenous xie qi to enter. That is why it is very important
that people cover themselves with warm clothes after they have, for example, been
running or done other forms of physical activity that have caused them to sweat. It
is also the reason people catch colds when there is air-conditioning.
The taiyang stage can be differentiated into two channel patterns, one that is shi
and one that is xu. In addition, there are two fu patterns.
Invasion of Wind-Cold in the taiyang aspect – Cold is dominant

In this pattern, xie qi has been so virulent that it has been strong enough to penetrate
the body’s wei qi. Zheng qi is relatively strong. This means that the symptoms and
signs will be more pronounced than in the pattern ‘Invasion of Wind-Cold in the
taiyang aspect – Wind is dominant’.
The symptoms are characterised by xie qi inhibiting the spreading and circulation
of wei qi. It means that there is a very pronounced aversion to cold. This is because
xie qi is blocking the circulation of wei qi so that it cannot warm the skin. This
aversion to cold is different to that which is experienced when there is yang xu.
When there is yang xu the person is not capable of generating warmth in the body.
This means that if a person who is yang xu wraps themselves up in warm clothes
and blankets, they can get warm and maintain their sensation of warmth. When
Cold has invaded the body, the person is capable of generating warmth, but wei qi
is simply not able to circulate the heat out to the skin and the muscles. This means
that even if the person wraps themselves up in warm clothes and packs themselves
under quilts, they still do not feel warm.
The stagnation of Cold will also prevent the pores in the skin from opening,
due to the contracting nature of Cold. At the same time, Cold will block wei qi,
which opens and closes the pores. This means that a defining sign in this pattern
is the inability to sweat. A priority in the treatment principle is therefore to ‘open
to the exterior’, which in this context means to induce a sweat, thereby expelling the
invasion of exogenous xie qi.
The headache, joint pain and stiffness of the shoulders and the neck is due to xie
qi blocking the circulation of qi in the taiyang channels. The stagnation of qi causes
pain and discomfort: ‘Bu tong ze tong, tong ze bu tong’ (‘Where there is no flow, there
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is pain. Where there is free flow, there is no pain’). The headache will feel tight in
character.
Wei qi is an aspect of the Lung and it is the Lung that spreads wei qi throughout
the body. When xie qi blocks wei qi, it will also disrupt the functioning of the Lung.
This can be observed when there are signs that the Lung’s descending and spreading
function of qi is disturbed and there is coughing and sneezing. This disruption of
the Lung’s functioning can also be seen when fluids are not spread as they should be.
There will initially be a slight oedema of the face, especially a puffiness around the
eyes. This is in fact one of the reasons that people can immediately see that someone
has a cold or is ‘under the weather’. The fluids will accumulate in the Lung or they
will rise upwards along with the rebellious Lung qi to the nose, resulting in a runny
nose with clear watery mucus or with eyes watering.
There may be a slight fever that is the result of the struggle between zheng qi and
xie qi.
The pulse will be Superficial. This is because the struggle is taking place in the
exterior aspect of the body. The pulse will have a tight quality due to Cold blocking
the flow of qi.
Aetiology
Exposure to wind and cold.
Symptoms and signs

• Acute headaches that are tight, the headache will be located in the neck and
along the Urinary Bladder channel
• Stiffness of the neck, shoulders and upper back
• Skin and muscle aches
• Aching joints
• Aversion to cold and difficulty keeping warm
• Aversion to cold, wind and draughts
• Lack of sweating (this is a key symptom when differentiating between a xu
and shi condition)
• Runny nose and watering eyes
• Facial oedema or puffiness around the eyes
• Possible low-grade fever
• Thin, white and wet tongue coating
• Superficial and Tight pulse
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Key symptoms
Aversion to cold, headache and stiffness in the shoulder and neck, lack of sweating,
aching muscles and joints, Superficial and Tight pulse.
Treatment principle
Expel Wind-Cold, activate wei qi.
Acupuncture points
Choose from: SI 3, UB 10, UB 12, UB 62, LI 4, Lu 7, Du 14 and GB 20.
Needle technique
Draining. Cupping and moxa is recommended.
Explanation
• SI 3 and UB 62 open the taiyang channel, activate wei qi and expel Wind
and Cold.
• UB 10 and GB 20 expel Wind and Cold.
• LI 4, Lu 7 and UB 12 activate wei qi, expel Wind and Cold and regulate
Lung qi.
• Du 14 activates wei qi.
Herbal formula
• Ge Gen Tang (Expels Wind-Cold)
Relevant advice
When a person has been invaded by Wind-Cold in the taiyang channels, they should
avoid eating rich food and should preferably only eat soup. They will benefit from
drinking hot, spicy drinks such as a whisky toddy, hot ginger tea or an infusion of
garlic, cayenne pepper and ginger. They should then wrap themselves up in blankets
or quilts to induce a sweat.
Invasion of Wind-Cold in the taiyang aspect – Cold is dominant

can be caused by the following pattern of imbalance
• No previous pattern
Invasion of Wind-Cold in taiyang – Cold is dominant

can result in the following patterns of imbalance
• Taiyang fu pattern
• Yangming stage pattern
• Shaoyang stage pattern
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• Taiyin stage pattern

• Shaoyin stage pattern
Invasion of Wind-Cold in the taiyang aspect – Wind is dominant

In this pattern there is wei qi xu. This means that xie qi does not need to be so potent
to be able to invade the body, and the symptoms and signs will not be as pronounced
as in the previous taiyang shi pattern. Because the person is wei qi xu, they will often
have a strong aversion to sitting in a draught and being exposed to the wind.
A key symptom that can differentiate this from the previous pattern is that in
this pattern the person will sweat spontaneously, but the sweating will not relieve the
condition. The person sweats spontaneously because the deficient wei qi is not able
to control the pores and is not strong enough to expel the xie qi.
The pulse will be weaker in this pattern and it will not be Tight, because the
deficiency of qi means that there is less stagnation. The mechanisms behind the
other symptoms and signs are the same as in the previous pattern.
Aetiology
Exposure to wind and cold.
Symptoms and signs

• Acute headache
• Stiffness in the neck, shoulders and upper back
• Aversion to cold and especially wind and draughts
• Spontaneous sweating, but without it relieving the symptoms
• Sneezing and coughing
• Runny nose and watery eyes
• Facial oedema or puffiness around the eyes
• Possible low-grade fever
• Aching in the muscles and joints
• Thin, white and wet tongue coating
• Superficial and Slow pulse
Key symptoms
Aversion to wind, spontaneous sweating, Superficial pulse.
Treatment principle
Expel Wind-Cold, activate wei qi, tonify wei qi.
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Acupuncture points
Choose from: SI 3, UB 10, UB 12, UB 62, LI 4, Lu 7, Lu 9, St 36, Sp 6, Ren 12
Du 14 and GB 20.
Needle technique
Tonifying technique on Lu 9, St 36, Sp 6 and Ren 12, draining technique on the rest
of the points. Moxa is recommended.
Explanation
• St 36, Sp 6, Ren 12 and Lu 9 tonify post-heaven qi and thereby wei qi.
• SI 3 and UB 62 open the taiyang channel, activate wei qi and expel Wind-
Cold.
• UB 10 and GB 20 expel Wind-Cold.
• LI 4, Lu 7 and UB 12 activate wei qi, expel Wind-Cold and regulate Lung
qi.
• Du 14 activates wei qi.
Herbal formula
• Gui Zhi Tang (Expels Wind-Cold, harmonises ying and wei)
Relevant advice
When a person has been invaded by Wind-Cold in the taiyang channels, they should
avoid eating rich food and should preferably only eat soup. They will benefit from
drinking hot, spicy drinks such as a whisky toddy, hot ginger tea or an infusion of
garlic, cayenne pepper, ginger and honey. They should then wrap themselves up in
blankets or quilts to induce a sweat. They should avoid exposure to draughts and
they should make sure that they are suitably clothed when they are outdoors. They
should preferably rest and stay indoors until they are healthy again.
An invasion of Wind-Cold in the taiyang aspect – Wind is

dominant can be caused by the following patterns of imbalance
• Qi xu
An invasion of Wind-Cold in the taiyang aspect – Wind is

dominant can result in the following patterns of imbalance
• Taiyang fu pattern
• Yangming stage pattern
• Shaoyang stage pattern
• Taiyin stage pattern
• Shaoyin stage pattern
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Taiyang Cold syndrome Taiyang Wind syndrome

No sweating Sweating that does not alleviate the symptoms
Extreme aversion to cold Less aversion to cold, extreme aversion to wind and draughts
Severe headache and stiff neck Milder headache and stiff neck
Tight pulse The pulse is not Tight
Taiyang fu – accumulation of Water

This is one of the two organ patterns that Zhang Zhong Jing differentiated in the
taiyang stage. Xie qi can sometimes transmit directly from the channel level to the fu
organ. There will, though, still be signs that there is an invasion of the exterior aspect
of the body.
Wei qi, which circulates in the exterior aspect of the body, is disrupted, meaning
that the person will have an aversion to cold and the pulse will be Superficial.
The Urinary Bladder, and to some extent the Small Intestine, will have been
disturbed by the presence of exogenous xie qi. This can be seen in the fact that their
functions are disrupted. There can be a retention of urine, painful urination, acute
oedema and watery vomiting after consumption of fluids, because the exogenous
Cold blocks the transformation and transport of fluids in the body.
Cold can transform into Heat. This can result in signs such as fever, thirst and
a Rapid pulse.
Aetiology
Invasion of Wind and Cold.
Symptoms and signs

• Acute oedema
• Slight fever
• Slight thirst
• Watery vomiting after consuming fluids
• Painful urination
• Retention of urine
• Irritability
• Superficial and Rapid pulse
Key symptoms
Acute oedema, retention of urine, aversion to cold, Superficial pulse.
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Treatment principle
Expel Wind-Cold, regulate the Urinary Bladder, drain fluids.
Acupuncture points
Choose from: Ren 3, Ren 9, Lu 7, Sp 9, UB 22 and UB 39.
Needle technique
Draining.
Explanation
• Ren 3, Ren 9, Sp 9, UB 22 and UB 39 regulate the water passages and drain
fluids.
• Lu 7 regulates the water passages and expels Wind-Cold.
Herbal formula
• Wu Ling San (Promotes sweating, warms yang and drains water)
Relevant advice
When there is an invasion of Wind-Cold affecting the taiyang fu, the person should
drink hot, spicy drinks such as a whisky toddy, hot ginger tea or an infusion of garlic,
cayenne pepper, ginger and honey. They should then wrap themselves up in blankets
or quilts to induce a sweat. They should avoid eating heavy meals.
Taiyang fu – accumulation of water can be caused

• Taiyang channel invasion patterns
Taiyang fu – accumulation of water can result in

• Taiyang fu – accumulation of xue
Taiyang fu – accumulation of xue

This is the second of the two organ patterns that were differentiated by Zhang Zhong
Jing in the taiyang stage. The combination of Heat and the stagnation resulting from
the presence of exogenous xie qi can result in xue stagnating in the lower jiao and
specifically in the Urinary Bladder. This is a deeper level than the previous pattern.
The previous pattern will correspond to a qi-level pattern in diagnosis according
to the Four Levels, whereas this pattern will correspond to a xue-level pattern.
Xue stagnation will manifest with pain and discomfort in the area above the
pubic bone. There will be difficult and painful urination. Heat can result in urgent
urination. Both xue stagnation and Heat can result in blood in the urine.
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Heat can also ascend to the Heart, making the person restless and irritable.
The presence of Heat and xue stagnation will also be evident in the person’s
tongue and pulse.
Aetiology
Invasion of Wind and Cold.
Symptoms and signs

• Painful, urgent and difficult urination
• Pain and discomfort in the area above the pubic bone
• Purple-red tongue that lacks coating
• Rapid and Choppy pulse
Key symptoms
Painful, urgent and difficult urination with blood in the urine, purple tongue.
Treatment principle
Spread qi and xue in the Urinary Bladder, drain Heat from the Urinary Bladder.
Acupuncture points
Choose from: Ren 3, Ren 9, Liv 3, Sp 6, Sp 10, UB 17, UB 22 and UB 39.
Needle technique
Draining.
Explanation
• Ren 3 and Sp 6 move xue and drain Dampness from the Urinary Bladder.
• Ren 9, UB 22 and UB 39 regulate the water passages and drain fluids.
• Sp 10 and UB 17 move xue.
• Liv 3 regulates qi in the Urinary Bladder.
Herbal formula
• Tao He Cheng Qi Tang (Breaks up xue stasis and eliminates Heat)
Relevant advice
The person should avoid consuming substances that are hot in their energy, as these
will create further Heat.
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Taiyang fu – accumulation of xue can be caused

• Taiyang channel invasions
Taiyang fu – accumulation of xue can result in

• Taiyang fu accumulation of water
There are also combined taiyang patterns. The most important of these are Invasion
of Wind-Cold combined with internal Heat and Invasion of Wind-Cold combined
with internal Phlegm-Fluids blocking the Lung. In both cases there will be visible
symptoms and signs of both patterns simultaneously.
Yangming stage
If exogenous xie qi is not expelled from the taiyang aspect or if it has been treated
improperly or inadequately, xie qi will penetrate into one of the deeper aspects. The
xie qi will usually penetrate into the yangming aspect. When xie qi is in the yangming
aspect, the disease is no longer in the exterior. This means that many of the signs and
symptoms that characterise the taiyang stage will not be present here. This is because
the clash between zheng qi and xie qi is no longer between the superficial wei qi
and xie qi but is taking place deeper in the body. The body’s zheng qi is still strong,
which means that the struggle, and thereby the resulting symptoms and signs, will
be strong. This is a pure shi condition.
The struggle between zheng qi and xie qi will generate a lot of Heat. Yangming
is ‘rich in qi and xue’. This means that the symptoms in this stage will be especially
ferocious. When xie qi has penetrated into the yangming aspect, the symptom picture
is characterised by the four ‘greats’: a great (high) fever; a great thirst; great (profuse)
sweating; and a great (Flooding) pulse.
The Heat generated by the struggle will cause the person’s body temperature
to rise. At the same time, the intense heat will send qi upwards and outwards in
the body. This rapid, expansive movement of qi will drive fluids to the surface of the
body and out through the pores in the skin, which is why there is profuse sweating
in the initial stages. The intense Heat and sweating will injure the fluids and the
person will therefore develop a great thirst with a desire for cold drinks. The presence
of intense Heat will be reflected in the pulse, which is Flooding and Rapid. The face
will usually be red in colour and the person will feel hot when palpated, especially on
the forehead. The Heat can also affect their shen and cause them to be physically and
mentally restless, have difficulty sleeping and be irritable. If the Heat is very intense,
they may lose consciousness or be delirious and raving. Heat can also agitate qi in
the chest, causing the person to have a sensation of turmoil in the chest.
Heat will also be visible on the tongue, which will be red with a dry
yellowish coating.
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Zhang Zhong Jing mainly differentiated between xie qi located in the channel
and in the organ aspects. The main difference between the two patterns is whether
there is constipation or not. Heat in the Stomach and Large Intestine organs will
desiccate fluids in the organs, resulting in constipation and abdominal pain.
Yangming channel syndrome

The channel pattern is characterised by formless xie Heat that spreads throughout
the body, driving fluids up to the skin.
An important difference between the yangming and taiyang stages is that there
is no aversion to cold in the yangming stage, but there will instead be an aversion
to heat. Whilst xie Cold in the taiyang aspect will have resulted in the person
packing themselves under blankets and quilts in an attempt to warm the skin and
muscles, the person will now kick off the bedding in attempt to cool down. This is
because in the taiyang stage the Wind and Cold will have blocked wei qi so that it
cannot warm the skin and muscles. In this stage the struggle between zheng qi and
xie qi is generating so much Heat that the body is overheating.
Aetiology
Insufficient or incorrect treatment of exogenous xie qi in the taiyang stage or xie qi is
strong enough to penetrate deeper. If the person already has a Heat condition, or if
they are a ‘shi’ person, the symptoms will be more extreme.
Symptoms and signs

• Strong fever but no aversion to cold
• Great thirst with a desire for cold drinks
• Irritability
• Delirium
• Red face
• The skin feels hot
• Dark urine
• Red tongue, yellow and dry tongue coating
• Rapid, Flooding and Full pulse
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Key symptoms
High fever and no aversion to cold, thirst, profuse sweating, constipation, Rapid and
Flooding pulse.
Treatment principle
Drain Heat from the yangming aspect.
Acupuncture points
Choose from: LI 11, St 44, St 43, Ren 12 and Du 14.
Needle technique
Draining.
Explanation
• LI 11, St 44, St 43 and Ren 12 drain yangming Heat.
• Du 14 drains shi Heat.
Herbal formula
• Bai Hu Tang (Drains yangming Heat)
Relevant advice
The patient should eat foods that are cooling and moistening. They should avoid
foods and beverages that have a hot energy.
Yangming channel pattern can be caused by

• Taiyang stage invasion of exogenous xie qi
Yangming channel pattern can result in the following patterns of imbalance

• Yangming organ stage
• Shaoyang stage
• Taiyin stage
• Shaoyin stage
• Jueyin stage
Yangming organ stage

The yangming channel stage can develop into the yangming organ or fu stage when
shi Heat has injured the fluids in the Stomach and Large Intestine. This can result in
xie qi binding and developing ‘form’.
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The struggle between xie qi and zheng qi has decreased, so the symptoms are less
intense than those seen in the yangming channel or jing stage.
Aetiology
Insufficient or incorrect treatment of exogenous xie qi in the taiyang stage or when
xie qi is strong enough to penetrate deeper. If the person already has a Heat condition
or if they are a ‘shi’ person, the symptoms will be more extreme.
Symptoms and signs

• Strong fever, but no aversion to cold
• Great thirst with a desire for cold drinks
• Abdominal bloating and pain that is worse with pressure
• Constipation
• Irritability
• Delirium
• Red face
• The skin feels hot
• Dark urine
• Red tongue, yellow and dry tongue coating
• Rapid, Flooding and Full pulse
Key symptoms
High fever and no aversion to cold, constipation, thirst, profuse sweating, Rapid and
Flooding pulse.
Treatment principle
Drain Heat from the yangming organs, activate and moisten the Intestines.
Acupuncture points
Choose from: LI 11, St 44, St 43, St 25, St 37, Sp 15, Du 14, SJ 6 and Ren 12.
Needle technique
Draining.
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Explanation
• LI 11, St 44, St 43 and Ren 12 drain yangming Heat.
• St 25, St 37 and SJ 6 drain Heat from the Large Intestine organ and activate
qi in the Large Intestine.
• Sp 15 spreads qi in the Intestines.
• Du 14 drains shi Heat.
Herbal formula
• Da Cheng Qi Tang (Purges Heat and moves qi in the yangming organs)
Relevant advice
The patient should eat foods that are cooling and moistening, such as spinach and
cabbage. They should avoid foods and beverages that have a hot energy.
Yangming channel pattern can be caused by the

• Taiyang stage invasion of exogenous xie qi
• Yangming channel stage
Yangming channel pattern can result in the following patterns of imbalance

• Yangming organ stage
• Shaoyang stage
• Taiyin stage
• Shaoyin stage
• Jueyin stage
• Yangming organs stage syndrome can easily develop into xue Heat generating
Wind in small children. This will manifest with febrile convulsions or
meningitis.
• The yangming and taiyin aspects are internally and externally connected. If
yangming Heat is not drained out of the body it can combine with taiyin
Dampness resulting in Damp-Heat. This Damp-Heat can disrupt the
functioning of the Liver and Gall Bladder and lead to Liver and Gall Bladder
Damp-Heat (i.e. jaundice).
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Shaoyang stage
The shaoyang is the pivot or hinge between the interior and the exterior. Xie qi can
get stuck here in its movement in or out of the body. Shaoyang-stage syndromes
usually develop from taiyang or yangming-stage syndrome. It can also arise directly.
When xie qi gets stuck here, it is because the xie qi is not strong enough to penetrate
deeper into the body, but zheng qi is not strong enough to drive it out and up, which
results in a stalemate situation. This type of pattern can be seen in some patients
with chronic fatigue or a state of malaise or illness that they just can’t seem to shake
off. There will typically be an alternation between symptoms and signs that typify
the taiyang and yangming stages, because xie qi is locked in between these two stages
and will move up and down between them.
One of the defining symptoms of the shaoyang stage is the alternation between
fever and feeling cold. When exogenous xie qi is in the exterior aspect of the body,
there is usually a fever with a concurrent aversion to cold. When there is a shaoyang
pattern, the fever and chills are not concurrent but alternate with each other. The
alternating fever and chills arise from the struggle between xie qi and zheng qi and
indicate which of the two are dominant at that time.
The patient can experience a bitter taste in the mouth due to extreme Heat in the
Gall Bladder. The Heat can also cause the throat to feel dry and can manifest with
irritability and dizziness.
There can be tension and tightness of the ribcage and chest when xie qi blocks
the flow of qi in the shaoyang channels. The stagnation of qi can also affect the
Stomach, giving rise to nausea, poor appetite or vomiting.
Shaoyang-stage patterns can often be combined with taiyang and yangming stage
patterns, in which case there will be symptoms and signs of both patterns.
Aetiology
Insufficient or incorrect treatment of xie qi in one of the other stages. It is often a
consequence of the person not having rested enough whilst they were ill or having
started working again before they were fully fit. This can result in xie qi being retained
because the person’s zheng qi is not strong enough to expel the xie qi completely.
Vaccinations can also cause xie qi to get locked in the shaoyang aspect.
Symptoms and signs

• Alternating fever and chills
• Bitter taste
• Tension or tightness in the thorax or costal region
• Poor appetite
• Nausea
• Dry throat
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• Headache
• Dizziness
• Irritability
• The tongue may have a yellowish coating on only one side
• Wiry pulse on the left wrist
Key symptoms
Alternating chills and fever, bitter taste in the mouth, no appetite, Wiry pulse on
the left wrist.
Treatment principle
Harmonise shaoyang and expel xie qi.
Acupuncture points
Choose from: GB 34, GB 41, SJ 5, Du 14, St 36, Sp 3 and Ren 12.
Needle technique
Draining on GB 34, GB 41, Du 14 and SJ 5. Tonifying on St 36, Sp 3 and Ren 12.
Explanation
• SJ 5, GB 34 and GB 41 expel xie qi from the shaoyang aspect.
• St 36, Sp 3 and Ren 12 tonify zheng qi so that it can expel xie qi from the
shaoyang aspect.
• Du 14 activates wei qi and drains Heat.
Herbal formula
• Xiao Chai Hu Tang (Harmonises shaoyang)
Relevant advice
The patient must avoid overexerting themselves and they must try to avoid new
invasions of xie qi.
The shaoyang pattern can be caused by the following patterns of imbalance

• Taiyang stage
• Yangming stage
• Taiyin stage
• Shaoyin stage
• Jueyin stage
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The shaoyang pattern can result in the following patterns of imbalance

• Taiyang stage
• Yangming stage
• Taiyin stage
• Shaoyin stage
• Jueyin stage
Taiyin stage
This is the first of the yin stages and the disease is not life threatening. If properly
treated, the prognosis is good.
When xie Cold invades the taiyin aspect, it will damage the Spleen yang.
The functions of Spleen yang include the transformation of the food and fluids
that are ingested. When the Spleen yang aspect is compromised, the Spleen has
difficulty performing its functions. This dysfunction of Spleen yang combined with
the presence of Damp-Cold will result in a blockage of the qi ji or qi mechanism
in the middle jiao. This will characterise the diagnostic picture, with symptoms and
signs such as watery diarrhoea containing undigested food, watery vomiting, nausea,
a poor appetite, abdominal bloating and fatigue. The person will lack thirst due
to the accumulation of Dampness and stagnant fluids. They will have an aversion
to cold and their skin will feel cold when palpated, because they are yang xu. Because
it is a yang xu condition, they will be able to get warm if they wear sufficient clothes
or lie beneath a blanket. This differentiates the pattern from a taiyang stage pattern,
where the person cannot get warm, despite wearing warm clothes or lying beneath
thick blankets.
Aetiology
The taiyin-stage pattern can arise because exogenous xie qi has directly invaded the
interior in a person who is Spleen yang xu or when exogenous xie qi that has been in
the outer aspects penetrates deeper. Xie qi can penetrate inwards when zheng qi starts
to become deficient or exhausted. Taiyin-stage patterns can also arise due to medical
treatment. This will typically be due to the use of antibiotics, which are cold in their
dynamic and can draw the xie qi inwards and downwards.
This pattern can also combine with patterns from the other stages, for example
taiyang patterns. In these situations, there will be symptoms and signs from
both patterns.
Symptoms and signs

• Nausea
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• Watery vomit
• Watery diarrhoea
• Lack of thirst
• Cold limbs
• The skin feels cold, especially on the abdomen
• Pale complexion
• The person has difficulty keeping warm
• The person is dressed in warm clothing
• The person sits with their arms around themselves or lies curled up
• Fatigue
• Pale tongue with moist, white coating
• Slow, Weak and Deep pulse
Key symptoms
Watery diarrhoea, bloated abdomen, nausea, pale tongue with white, moist coating.
Treatment principle
Tonify Spleen yang.
Acupuncture points
Choose from: Ren 8, Ren 12, St 36, Lu 9, Sp 3, Sp 9, St 21, UB 20 and UB 21.
Needle technique
Tonifying on all points except on Sp 9 and St 21. Moxa must be used.
Explanation
• Ren 8 with moxa expels cold from the middle jiao.
• Ren 12, St 36, Sp 3, UB 20 and UB 21 tonify Spleen yang.
• Lu 9 tonifies taiyin.
• Sp 9 drains Damp-Cold.
• St 21 regulates Stomach and Spleen qi.
Herbal formula
• Li Zhong Tang (Warms Spleen yang and expels Cold)
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Relevant advice
The patient should eat foods that are warm, both in their temperature and energetic
dynamic, for example ginger and other spices. They should eat cooked food and
avoid food and drinks that are cold in their temperature and energy. They must keep
the abdomen warm and avoid getting cold. Because they are qi xu, they must get
enough rest and not overexert themselves.
The taiyin pattern can be caused by the following patterns of imbalance

• Taiyang stage
• Yangming stage
• Spleen yang xu
The taiyin pattern can result in the following patterns of imbalance

• Shaoyin pattern
• Jueyin pattern
• Shaoyang pattern
• Spleen yang xu
Shaoyin stage
The shaoyin stage is more critical than the previous stages. When xie qi has penetrated
this far down, it has started to injure the Heart and Kidneys. These organ’s yang or
yin aspects are weakened and zheng qi is not able to resist xie qi. The shaoyin-stage
pattern can occur because exogenous xie qi has penetrated to this depth from one
of the other stages or when exogenous xie qi directly invades the shaoyin aspect. A
direct invasion can occur if a person who is yang xu or qi xu sweats profusely whilst
being exposed to the cold.
The symptoms and signs that define the shaoyin Cold and shaoyin Heat patterns
are dependent on the nature of the xie qi and on which aspect of the Kidneys are
deficient.
Shaoyin Cold stage

The symptoms and signs in this pattern reflect that Kidney yang is burdened
and weakened. This will be seen in the fact that many of the functions that yang
performs will be compromised. Kidney yang supports Spleen yang in its function
of transforming the food and fluids that have been ingested. This means that there
can be watery diarrhoea containing undigested food when there is shaoyin Cold.
The diarrhoea will typically occur early in the morning, just after the person has
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woken up. It can, in fact, often be the reason that the person wakes up very early in
the morning.
The depletion of yang will weaken the production of qi, resulting in fatigue.
Kidney yang is the fundamental driving force in all fluid physiology. When there
is Kidney yang xu, there will be visible oedema, a lack of thirst and frequent urination
with copious amounts of clear urine. Sometimes the urination and diarrhoea will
be so frequent and copious that the person, instead of lacking thirst, will have a
pronounced thirst due to dehydration.
Yang xu will also be evident in that the person will feel cold, will have an aversion
to cold and will dress warmly. Their arms and legs will feel especially cold. They will
sleep in a curled-up position beneath a thick quilt. The person will have a preference
for warm food and drinks, and they will have an aversion to cold food and drinks,
because the ingestion of cold substances will aggravate their symptoms.
The Heart yang xu aspect will manifest with a lack of motivation, lethargy
and indolence.
Aetiology
The shaoyin Cold syndrome can develop from multiple aetiologies. There can be a
direct invasion of Cold into this aspect of the body, especially if the person is already
Heart yang xu or qi xu and is invaded by exogenous Wind and Cold whilst sweating.
Cold xie qi can sometimes be so powerful that it quickly overcomes the resistance
of the body’s zheng qi and penetrates into the interior aspects of the body. Because
the xie qi is cold in nature, it will damage the body’s yang aspects. If the person is
Kidney or Heart yang xu, this process will be quicker.
There can also have been repeated invasions of exogenous Cold, which eventually
weaken Kidney yang. This is particularly relevant if the person does not rest enough
during and after an illness.
Symptoms and signs

• Sleeps in a curled-up position
• Cold limbs
• Diarrhoea containing undigested food
• Watery vomit
• Nausea
• Fatigue
• Mental lethargy
• Copious amounts of clear urine
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• Lack of thirst with a preference for hot drinks; there can, though, sometimes
be a profuse thirst if severe diarrhoea has damaged fluids
• White or pale face
• Preference for hot drinks and food
• Pale and wet tongue with white coating
• Deep, Weak and Slow pulse
Key symptoms
Aversion to cold, frequent urination, Deep Slow and Weak pulse.
Treatment principle
Warm and tonify Kidney and Heart yang.
Acupuncture points
Choose from: Kid 3, Kid 7, He 5, UB 15, UB 23, Du 4, Ren 4 and Ren 6.
Needle technique
Tonifying. Moxa is necessary.
Explanation
• Kid 3, Kid 7 and UB 23 tonify Kidney yang.
• Du 4, Ren 4 and Ren 6 tonify Kidney yang and yuan qi.
• He 5 and UB 15 tonify Heart yang.
Herbal formula
• Si Ni Tang (Warms and tonifies Kidney yang)
Relevant advice
The patient will benefit from eating and drinking things that are warming in their
energy and temperature, whilst avoiding things that are cooling. Ginger, garlic and
cinnamon will be particularly beneficial. They should ensure that they keep warm
and avoid getting cold. It is important that they rest and do not overexert themselves.
The shaoyin Cold pattern can be caused by the

• Taiyang stage
• Taiyin stage
• Kidney yang xu
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• Heart yang xu
• Spleen yang xu
The shaoyin Cold pattern can result in the following patterns of imbalance
• Jueyin pattern
• Taiyin pattern
• Kidney yang xu
• Heart yang xu
• Spleen yang xu
Shaoyin Heat stage

When the exogenous Cold penetrates deeper into the body, it usually transforms
into Heat. The Heat is especially virulent in the yangming stage. The Heat can be so
intense that it damages yin. Yin can be damaged by a single episode of very intense
xie Heat or by repeated invasions of xie qi, which transform into Heat and injure yin.
This process will be further accelerated if the person is already yin xu.
The Kidney is the root of all yin in the body. This means that if yin is injured,
it will weaken the Kidney’s yin aspect. When the Kidneys are yin xu, xu Heat can
arise. Both yin xu Heat and shi Heat due to xie qi can damage Heart yin and agitate
shen. Kidney yin should also nourish Heart yin and control Heart Fire. This is the
fundamental axis of Water and Fire in the body.
When there is Heat in the Heart, both the physical and shen aspects of the Heart
become agitated. This will manifest with insomnia, irritability and palpitations.
Yin xu can be evident in night sweats, a malar flush, feeling hot in the evening
and at night, a red tongue that lacks coating and a Rapid, Fine pulse.
Aetiology
Invasion of Wind-Cold that has transformed into Heat and damaged yin.
Symptoms and signs

• Irritability
• Insomnia
• Night sweats
• Palpitations
• Malar flush
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• Night fever
• Dryness of the mouth, especially at night
• Red tongue without coating, the tip of the tongue is even more red
• Rapid, Fine pulse
Key symptoms
Night sweats, insomnia, dry mouth, red tongue without coating.
Treatment principle
Nourish Heart and Kidney yin.
Acupuncture points
Choose from: He 6, Kid 3, Kid 6, Kid 7, Ren 4, Ren 14, UB 15, UB 23 and UB 52.
Needle technique
Tonifying.
Explanation
• He 6 and Kid 7 nourish Heart and Kidney yin and control night sweats.
• Kid 3, Kid 6, Ren 4, UB 23 and UB 52 nourish Kidney yin.
• Ren 14 and UB 15 nourish Heart yin.
Herbal formula
• Huang Lian E Jiao Tang (Nourishes yin and descends Fire)
Relevant advice
The patient should avoid overexerting themselves and they must ensure that they
get enough sleep and go to bed early. Coffee and other stimulants or substances
containing caffeine should be avoided because they over-activate the Heart and
thereby consume yin. Alcohol, hot spices and grilled and fried food will all generate
Heat and further injure yin, so they should be avoided.
The shaoyin Heat pattern can be caused by

• Yangming stage
The shaoyin Heat pattern can cause the following pattern of imbalance
• Jueyin stage
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Jueyin stage
This is the deepest level that xie qi can reach. It is very critical when xie qi has
reached this stage. There is an extreme zheng qi xu and the regulation of yin and
yang has become chaotic. At this point yin and yang can start to separate. This will
often manifest with symptoms of extreme Heat or Cold or a violent alternation
between the two. There will often be a symptom of Heat and Cold simultaneously.
The Heat can, for example, manifest in the upper part of the body and the Cold in
the lower part. There may be extreme Heat symptoms in the torso but extreme Cold
symptoms in the extremities.
The Heat will injure the fluids, there can be a strong thirst and the person’s skin
and flesh can be wizened. Ascending yang will manifest with a sensation of heat,
turmoil, and pain in the chest.
The presence of Heat and Cold simultaneously can manifest with a gnawing
hunger but no desire to eat. There may be vomiting and diarrhoea.
A more harmless variant of this pattern is observed, however, when there are
intestinal worms.
Aetiology
Exogenous xie qi that has penetrated into the body’s deepest level and fundamentally
damaged yin or yang. Ingestion of contaminated food.
Symptoms and signs

• Restlessness and turmoil in the chest
• Extreme thirst
• Pain and burning sensation in the cardiac region
• Hunger with no desire to eat
• Cold limbs
• Diarrhoea
• Vomiting
• Vomiting of worms
• Wiry pulse
Key symptoms
Restlessness and heat in the cardiac region, cold limbs, hunger with no desire to eat,
persistent thirst.
Treatment principle
Drain Heat from above and Cold from below, harmonise yin and yang.
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Acupuncture points
Choose from: St 36, Ren 12, Liv 3, Pe 6 and Du 20.
Needle technique
Tonify St 36 and Ren 12, even technique on Liv 3 and Pe 6 and drain Du 20.
Explanation
• Liv 3 harmonises the Liver channel.
• Pe 6 harmonises the Pericardium.
• St 36 and Ren 12 harmonise the Stomach.
• Du 20 lowers rebellious yang qi.
Herbal formula
• Wu Mei Wan (Drains the internal organs, tonifies qi and expels parasites)
• Wu Zhu Yu Tang (Warms and tonifies the Liver and Stomach, drains Heat
and descends rebellious Stomach qi)
Relevant advice
This will depend on how much Heat and Cold is present. It is important that the
patient gets adequate rest and does not overexert themselves.
If there are worms, the person should take medication that kills the worms and
avoid further contact with sources of infection.
The jueyin pattern can be caused by the following patterns of imbalance

• Taiyin stage
• Shaoyin stage
The jueyin pattern can result in the following patterns of imbalance

• Taiyin stage
• Shaoyin stage
Diagnosis according to the Four Levels

In this diagnostic approach, the patterns are differentiated in relation to four
energetic levels rather than six channels. The deeper the level, the more severe the
condition. This diagnostic analysis for the first time introduced the concept that
exogenous xie qi, and thereby disease, can be transmitted from person to person and
that exogenous xie qi can invade the body via the mouth, the nose and the genitals.
In this analysis the exogenous xie qi is energetically hot from the very beginning,
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hence the term wen bing or Heat diseases. In Heat diseases the symptoms will reflect
the presence of Heat and the yin aspects of the body will be rapidly injured. Because
Heat is a yang form of xie qi, it is very dynamic and the symptom picture can rapidly
change. A person can go from being healthy to seriously ill in a very short period
of time. The pathogen’s yang nature can also be seen in the fact that even strong
and healthy people can become ill after being in contact with exogenous xie Heat.
Many highly contagious diseases and epidemics, such as the bubonic plague, ebola,
influenza, measles and so on, are examples of wen bing or Heat diseases.
Wen bing theories differentiate not only between four energetic levels (wei, qi,
ying and xue) but also between different types of Heat, for example Wind-Heat or
Damp-Heat in the wei level and Lung Heat or Stomach Heat, etc. in the qi level.
Diagnosis according to the Four Levels determines the following:
• The disease location: If the xie qi is in the interior or exterior in relation to the
Eight Principles and how deep an aspect of the interior it is that is affected.
• What the nature of the disorder is: Whether it is xu or shi. When zheng
qi is strong, the condition will be defined as being shi. In general, when
exogenous xie qi is in the wei and qi levels, it is a shi condition. When the
ying and xue levels are affected, it is usually a xu condition. In contrast to the
Six Stages, all the patterns of imbalance are Heat imbalances.
• About how the disease develops: Disease development is a dynamic process
that is constantly changing, especially in the beginning. As with the Six
Stages, this diagnosis model is used to assess the relative strength of zheng qi
and exogenous xie qi in relation to each other. It can also be used to gauge
the direction in which the disease is moving. If the disease is penetrating
downwards, it is a negative sign. If, on the other hand, the symptoms change
from one of the deeper levels to symptoms of one of the more superficial
levels, it is a positive sign.
• The treatment principle: The nature of the disorder determines how it should
be treated. If there is Heat in the wei level it must be expelled outwards. If it
is deeper down, it must be drained. If there is a xu condition, that which is
xu needs to be supported and so on.
Wei level
Wei level is the most superficial level and is very similar to the taiyang stage of the
Six Stages. It is the first level that is attacked by an infectious disease. Many of the
symptoms and signs are indications that wei qi has been disrupted in its functions and
activities. Many of the symptoms and signs are the same as those seen in the taiyang
stage, but in this level there is Heat and this means that there are also differences in
the symptom picture.
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Differentiation is made between invasions of different types of xie Heat: Wind-

Heat, Damp-Heat, Dry-Heat and Summer-Heat. Wind-Heat is the most common
and most important differentiation, especially for acupuncturists.
Wind-Heat
At first glance, Wind-Heat appears to be very similar to an invasion of Wind-Cold
in the taiyang stage of the Six Stages, but when there is Wind-Heat, there is less
aversion to cold.
Even though there is less aversion to cold, there is still an aversion to wind and
cold. This is because the invading xie qi blocks the circulation of the warming wei
qi. The disruption of wei qi can also be seen in the fact that there is often little or
no sweating.
There can also be a headache, but where the headache in the taiyang stage was
tight in nature, the headache seen in Wind-Heat imbalances is more pounding or
throbbing. This is due to the expansive dynamic that Heat has.
Heat will cause the person to have a fever or feel feverish without necessarily
having an elevated body temperature. The Heat will often be palpable on the person’s
forehead, which will feel warm to the touch.
Heat will damage the fluids and make the person thirsty. Their pulse will
be Rapid.
Wind-Heat can disturb the functioning of the Lung, resulting in a cough or
sore throat.
Aetiology
Contact with exogenous xie Heat.
Symptoms and signs

• Acute fever with mild aversion to wind and cold
• No or little sweating
• Thirst
• Sore throat
• Red, swollen throat
• Cough
• Irritability
• Restlessness
• Yellowish or dried mucus in the nose
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• The forehead may feel warm when touched

• The tip of the tongue may be red and there may be a thin, yellowish coating
on the front of the tongue
Key symptoms
Fever and aversion to cold, Rapid and Superficial pulse.
Treatment principle
Expel Wind-Heat, activate wei qi.
Acupuncture points
Choose from: Du 14, LI 4, LI 11, Lu 7, Lu 10, Lu 11, UB 12, UB 13 and GB 20.
Needle technique
Draining. Cupping is recommended.
Explanation
• LI 4, LI 11, Lu 7, UB 12 and UB 13 expel Wind and Heat.
• Lu 10 and Lu 11 drain Heat from the Lung and throat.
• GB 20 expels Wind and drains yang from the head.
Herbal formula
• Sang Ju Yin (Expels Wind-Heat)
Relevant advice
When there is an invasion of Wind-Heat, it is best not to eat or to only eat light food.
The person should drink tea that is both cooling and spicy, for example elderflower,
chrysanthemum or mint tea.
An invasion of Wind-Heat can be caused by

An invasion of Wind-Heat can result in the following patterns of imbalance

• Qi-level Heat
• Ying-level Heat
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Damp-Heat
In this pattern there is an invasion of Damp-Heat in the wei level. This is equivalent
to an invasion of Damp-Heat in the upper jiao in diagnosis according to san jiao.
Damp-Heat is heavier and more obstructive than Wind-Heat. This will result in
aching and heaviness of the limbs. Dampness can block the sweat pores so there is
no sweating or the Heat can make the sweat sticky in consistency.
Because there is impure yin in the head and a lack of pure yang, the headache in
this pattern will feel heavier than the one felt in a Wind-Heat pattern and the person
will have difficultly thinking clearly.
Damp-Heat can also block and disturb the movement of qi inside the body,
resulting in poor appetite, nausea and chest oppression. There may be diarrhoea or
constipation, depending on whether Dampness or Heat is the dominant aspect.
Aetiology
Exposure to Damp-Heat xie qi.
Symptoms and signs

• Fever that is worse in the afternoon
• Nausea
• Heavy and aching limbs
• Poor appetite
• Heavy headache
• Lack of sweating or sticky sweat
• Fatigue
• Diarrhoea or constipation
• Greasy, yellow tongue coating
Key symptoms
Heavy headache, heaviness of the limbs, Rapid and Slippery pulse.
Treatment principle
Expel and drain Damp-Heat, activate wei qi.
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Acupuncture points
Choose from: Du 14, LI 4, LI 11, Lu 7, Sp 3, Sp 9, Ren 12 and Pe 6.
Needle technique
Draining.
Explanation
• Du 14 drains Heat and activates wei qi.
• LI 4 and Lu 7 activate wei qi and expel exogenous xie qi.
• LI 11 expels exogenous xie qi and drains Damp-Heat.
• Sp 3 and Sp 9 drain Damp-Heat.
• Ren 12 and Pe 6 regulate the qi ji in the middle and upper jiao.
Herbal formula
• Huo Po Xia Ling Tang (Expels Damp-Heat from the exterior)
Relevant advice
The person should avoid consuming food and beverages that create Damp-Heat. In
general, it is best not to eat or to only eat light meals when there are invasions of
exogenous xie qi in the exterior.
An invasion of Damp-Heat can be caused by

• Damp-Heat
An invasion of Damp-Heat can result in the

• Qi-level Heat
• Ying-level Heat
• Damp-Heat
• Spleen qi xu
Dry-Heat
This pattern has traditionally been prevalent in the autumn in China, when the
climate is extremely dry. In North-Western Europe this pattern can arise due to living
or working in buildings with a very dry indoor climate. An invasion of Dry‑Heat
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can disrupt not only the functioning of wei qi, but also the Lung, because the Lung
is easily damaged by Dryness. The disruption of wei qi can be seen in an aversion to
wind and cold, because the wei qi is no longer able to protect the body against them.
There may be a slight sweat due to the Heat aspect. The presence of Heat and the
struggle between xie qi and zheng qi will result in a slight fever or fever sensation.
The disruption of the Lung’s descending and spreading function can result in
coughing and possibly chest pain due to the stagnation of qi. The Heat will evaporate
fluids in the body, so that rubbery, yellowish sputum is formed.
The Dryness and Heat will injure fluids and lead to the dryness of the nose and
throat, the person will be thirsty and the tongue dry.
Aetiology
Exposure to Dry-Heat xie qi.
Symptoms and signs

• Dry nose and throat
• Fever
• Slight aversion to cold and wind
• Light sweat
• Cough with sticky or rubbery sputum
• The cough can cause chest pain
• Headache
• Thirst
• Dry tongue coating
Key symptoms
Dry nose and throat, fever with aversion to wind and cold. Rapid and Superficial
pulse.
Treatment principle
Acupuncture points
Choose from: Du 14, LI 4, LI 11, Lu 9, Lu 10, UB 12, UB 13, Kid 6 and Sp 6.
Needle technique
Draining.
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Explanation
• Du 14 and LI 11 drain Heat and activate wei qi.
• LI 4, UB 12 and UB 13 activate wei qi and expel exogenous xie qi.
• LI 11 expels exogenous xie qi and drains Heat.
• Kid 6, Sp 6 and Lu 9 moisten the Lung.
Herbal formula
Relevant advice
The person should avoid places where the air is very dry.
An invasion of Dry-Heat may be caused by

An invasion of Dry-Heat can result in the following patterns of imbalance

• Qi-level Heat
• Ying-level Heat
• Lung yin xu
Qi level
Qi-level Heat can arise because there has been a direct invasion of exogenous xie qi
in the qi level or because exogenous xie qi has penetrated deeper from the wei level.
Exogenous xie qi can penetrate deeper to the next level if it is strong enough or if the
previous level has been treated incorrectly or inadequately. This pattern will develop
more rapidly and the symptoms will be stronger in a person who already has a shi
Heat condition.
When there is a qi-level disorder, both xie qi and zheng qi are strong. This
will result in pronounced shi Heat symptoms. Qi-level disorders are differentiated
according to which organ is affected. There are many subcategories, which mainly
have relevance when using herbal medicine. The most relevant patterns for
acupuncturists are described below.
The xie Heat will itself disturb the qi ji in the interior and the Heat will drive
yang qi upwards and outwards. This is further reinforced by the extreme Heat that
arises as a consequence of the struggle between zheng qi and xie qi. This results in
the generalised symptoms and signs that are seen in this level. These are very similar
to the symptoms and signs that are seen in the yangming stage of the Six Stages and
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these two stages and levels are also overlapping. Shaoyang-stage symptoms can also
be differentiated as qi-level Heat.
The generalised symptoms and signs of this level are fever with an aversion to
heat but not to cold. There is no aversion to cold because the xie qi no longer
disrupts the functioning of wei qi. On the other hand, there is so much heat in the
body that the person has an aversion to heat.
Heat injures fluids and this results in a great thirst with a desire for cold drinks.
The urine will be dark.
There may be profuse sweating due to the Heat, but there can also be a lack of
sweating because the fluids are exhausted. The extreme Heat can ascend to the Heart
and agitate the shen. This can be seen when the person is restless and irritable.
There is a bitter taste in the mouth and a thick, dry, yellow coating on the
tongue. The pulse will be Rapid and Full.
Qi-level Heat should be further differentiated with regard to which organ is
affected. Each organ pattern will manifest with specific symptoms and signs that
reflect the disturbance of its functions.
Heat can easily injure yin. This will manifest with symptoms and signs of yin xu.
There can also be simultaneous wei- and qi-level Heat, with a resultant mixture
of symptoms and signs from both levels.
Aetiology
Invasions of exogenous Heat that have not been expelled from the wei level or that
have been treated incorrectly or inadequately. Direct invasions of Heat to the qi level
after being exposed to exogenous xie qi.
Symptoms and signs

• High fever with no aversion to cold
• Profuse sweating (or no sweating if the Heat has damaged fluids)
• Extreme thirst with a desire for cold drinks
• Red face
• Restlessness and irritability
• The skin may feel warm to the touch
• Restless sleep with violent dreams
• Red tongue with dry, yellow coating
• Rapid, Full, Flooding pulse
Key symptoms
High fever with no aversion to cold, profuse sweating and thirst, Rapid and
Flooding pulse.
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Treatment principle
Drain Heat.
Acupuncture points
Choose from: LI 11 and Du 14.
Needle technique
Draining. Bleed Du l4.
Explanation
• LI 11 and Du 14 drain Heat from the qi level.
Herbal formula
• Bai Hu Tang (Drains yangming Heat)
• Da Cheng Tang (Drains Heat from the yangming organs)
• Da Chai Hu Tang (Drains shaoyang Heat)
• Zhi Zi Dou Chi Tang (Drains Heat from the chest and diaphragm)
Relevant advice
The person should avoid consuming food and beverages that will create additional
heat in the body.
Qi-level Heat can be caused by the following pattern of imbalance

• Wei-level Heat
Qi-level Heat can result in the following patterns of imbalance

• Ying-level Heat
• Xue-level Heat
The treatment will be most effective if it is possible to differentiate where in the qi
level the Heat is. The Heat can be located in one or more zangfu organs, in which
case there will be symptoms and signs that are specific to these organs. The treatment
will then be focused on draining Heat from these organs. The most relevant patterns
are discussed below.
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Lung Heat
In addition to the symptoms and signs described above, Heat will have damaged
fluids in the Lung and disrupted the Lung’s qi ji. This will result in a loud, barking
cough, because it is a shi condition. There will be sticky, yellowish sputum that
is difficult to expectorate. Breathing will be impaired because xie qi is blocking
the Lung’s ability to descend and spread qi. The blockage of qi will also result in
chest pains.
Aetiology
Exposure to exogenous xie qi that has either invaded the Lung directly or penetrated
down from the wei level.
Symptoms and signs

• Fever or feeling of heat with no aversion to cold
• Cough with yellow, sticky sputum that is difficult to expectorate
• Thirst
• Chest pain
• Dyspnoea
• Red face
• Restlessness
• Restless sleep
• Rapid pulse
Key symptoms
Fever, cough with yellow sticky sputum, thirst, Rapid pulse.
Treatment principle
Acupuncture points
Choose from: Lu 1, Lu 5, Lu 10, Lu 11, LI 11, Du 14 and UB 13.
Needle technique
Draining. Possibly bleed Du 14.
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Explanation
• Lu 1, Lu 5 and UB 13 drain Heat from the Lung and regulate Lung qi.
• Lu 10 and Lu 11 drain Heat from the Lung.
• Du 14 and LI 11 drain qi-level Heat.
Herbal formula
Relevant advice
Heat in the body. Cigarette smoking is not recommended, because it will create
Heat and Phlegm in the Lung.
Lung Heat can be caused by the following pattern of imbalance

• Wei-level Heat

• Ying-level Heat
• Xue-level Heat
• Lung yin xu
Heat in the chest and diaphragm

In addition to the symptoms and signs discussed under qi-level Heat, there will
be signs and symptoms resulting from the accumulation of Heat in the chest and
diaphragm. The Heat will disrupt and agitate qi in the upper jiao. This will result
in a sense of turmoil in the chest. Heat will agitate the shen, resulting in irritability,
restlessness and insomnia. The Heat can ascend to the throat resulting in a sore
throat. By damaging fluids, the Heat can manifest with an intense thirst, dry mouth
and dry lips, as well as constipation.
Aetiology
Exposure to exogenous xie qi that has either invaded the qi level directly or penetrated
Symptoms and signs

• Persistent fever, no aversion to cold
• Restlessness
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• Burning sensation and/or a sensation of turmoil in the chest and diaphragm

• Insomnia
• Irritability
• Constipation
• Sore throat
• Dry and chapped lips
• Thirst
• Sweats
• The skin may feel hot to the touch
• Red face
• The tongue may be dry in the central area with a yellow, dry coating
• Rapid, Full pulse
Key symptoms
Restlessness, pain or turmoil in the chest and diaphragm, fever and irritability.
Treatment principle
Drain Heat from the upper jiao.
Acupuncture points
Choose from: Du 14, SJ 6, SJ 5, LI 11, Ren 15, Ren 17, UB 16, UB 17, Pe 6 and
Pe 8.
Needle technique
Draining.
Explanation
• Du 14, SJ 6, SJ 5 and LI 11 drain Heat.
• Ren 15, Ren 17, UB 16 and UB 17 drain Heat from the chest and diaphragm.
• Pe 6 and Pe 8 drain Heat from the Pericardium.
Herbal formula
• Zhi Zi Dou Chi Tang (Drains Heat from the chest and diaphragm)
• Qing Qi Hua Tan Tang (Drains Phlegm-Heat from the Lung and chest)
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Relevant advice
Heat in the body.
Heat in the chest and diaphragm can be caused

• Wei-level Heat
Heat in the chest and diaphragm can result in

• Ying-level Heat
• Xue-level Heat
• Heart Fire
Heat in the Stomach and Intestines

This pattern is basically the same as the yangming stage in the Six Stages, and the
pathomechanisms will be the same. The reader is therefore referred to this section
(page 654) for more details.
Aetiology
Exposure to exogenous xie qi, which has either invaded the qi level directly or
penetrated down from the wei level.
Symptoms and signs

• Constipation or green watery diarrhoea (false diarrhoea caused by a blockage
in the Intestines)
• Abdominal bloating and distension, the pain is aggravated by pressure
• Fever, especially in the afternoon, but no aversion to cold
• Restlessness
• Frontal headache
• Bleeding gums
• Red face
• Red tongue with a dry and yellowish coating
• Rapid, Full, Flooding pulse
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Key symptoms
Constipation, bloated abdomen, fever, Rapid and Flooding pulse.
Treatment principle
Drain Heat from the Stomach and Large Intestine.
Acupuncture points
Choose from: LI 11, SJ 6, St 25, St 34, St 37, St 44, UB 21, UB 25 and Du 14.
Needle technique
Draining. Du 14 can be bled.
Explanation
• LI 11, SJ 6, St 25, St 37 and UB 25 drain Heat from the Stomach and Large
Intestine and activate qi in the Intestines.
• St 34, St 44 and UB 21 drain Heat from the Stomach.
• Du 14 drains the qi-level Heat.
Herbal formula
• Da Cheng Qi Tang (Purges Heat and moves qi in the Intestines)
Relevant advice
A person with Stomach and Large Intestine Heat should eat foods that are cooling
and moistening. They should avoid foods and beverages that have a hot energy.
Stomach and Large Intestine Heat can be caused

• Wei-level Heat
Stomach and Large Intestine Heat can result in

• Ying-level Heat
• Xue-level Heat
• Stomach yin xu
Damp-Heat
Dampness and Heat can bind together and are difficult to separate. Invasions
of Damp-Heat often occur in the summer when the weather is rainy and in humid
and hot climates. There is often an underlying Spleen Dampness. It is also mainly
the functioning of the Stomach and Spleen that is disturbed when there are invasions
of Damp-Heat.
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The way that the symptoms manifest will be influenced by whether it is Dampness
or Heat that is the predominant pathogen.
There can be a fever that is most noticeable in the afternoon. This is explained
by Dampness being a yin form of xie qi and yin is on the increase after noon. When
the yin Dampness contains xie Heat, the xie Heat will increase together with yin
in the afternoon. The Heat will often cause the person to sweat. This will temporarily
relieve the fever, but the fever will soon return. The person will often find that the
fever comes in waves.
Dampness blocks the movement of qi creating a sensation of heaviness. This
will be most apparent in the limbs. The Heat aspect will make the muscles feel sore
and ache.
The Stomach and Spleen qi mechanism will be blocked by the Dampness.
This can result in nausea and a loss of appetite. There will also be diarrhoea that
is odorous and sticky. The Heat can cause a stinging or burning sensation in the
rectum during and after bowel movements.
Dampness can also block qi in the upper jiao, resulting in chest oppression.
The Heat’s yang dynamic can ascend the yin Dampness to the head. At the
same time, Dampness can itself block the ascent of clear yang to the head. This will
result in a heavy headache and difficulty in thinking clearly. The Heat will cause the
headache to be pounding or throbbing in nature.
Damp-Heat will be seen in the complexion, which can be yellowish. The skin
and the sweat can be oily.
Restlessness and irritability will arise if the Heat aspect agitates the shen.
Aetiology
Symptoms and signs

• Fever that is reduced by sweating, but soon rises again
• Fever that is worse in the afternoon and comes in waves
• Heavy and aching muscles, especially in the limbs
• Nausea
• Poor appetite
• Loose, sticky, odorous stools
• Heavy and possibly pounding headache
• Difficulty in thinking clearly
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• Oily skin
• Restlessness or irritability
• Red tongue with yellow, sticky coating
Key symptoms
Odorous diarrhoea, fever, yellowish, greasy tongue coating, Rapid and Slippery
pulse.
Treatment principle
Drain Damp-Heat.
Acupuncture points
Choose from: Du 14, LI 11, St 25, St 44, Sp 9, Sp 6 and Ren 12.
Needle technique
Draining.
Explanation
• Du 14 and LI 11 drain qi-level Heat.
• St 25 and St 44 drain Damp-Heat from the Intestines.
• Ren 12 drains Dampness from the middle jiao.
Herbal formula
• San Ren Tang (Drains Damp-Heat)
Relevant advice
The person must avoid consuming foods that produce Dampness or Heat.
Damp-Heat can be caused by the following pattern of imbalance

• Wei-level Heat
Damp-Heat can result in the following patterns of imbalance

• Ying-level Heat
• Xue-level Heat
• Spleen qi xu
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Gall Bladder Heat

This pattern is virtually the same as the shaoyang stage in the Six Stages. The reader is
referred to this section for an explanation of the pathomechanisms of the symptoms
and signs (page 659). The only real difference between the shaoyang stage and qi‑level
Gall Bladder Heat, is that the latter has more Heat and Dampness signs.
Aetiology
Symptoms and signs

• Costal and hypochondriac distension or pain
• No appetite
• Nausea
• Dry throat
• Headache
• Dizziness
• Irritability
• Sensation of turmoil in the chest
• The tongue may have a yellowish coating on one side and a white coating
on the other side
• Wiry pulse, especially on one of the wrists, Rapid pulse
Key symptoms
Alternating fever and chills, bitter taste in the mouth, Rapid and Wiry pulse.
Treatment principle
Drain Gall Bladder Heat.
Acupuncture points
Choose from: GB 34, GB 41, SJ 5 and Du 14.
Needle technique
Draining.
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Explanation
• SJ 5, GB 34 and GB 41 drain Heat from the Gall Bladder.
Herbal formula
• Da Chai Hu Tang (Drains shaoyang Heat)
Relevant advice
A person with Gall Bladder Heat must ensure that they do not overexert themselves
and they must be very careful to avoid new invasions of exogenous xie qi. They
should avoid eating food that creates Heat.
Gall Bladder Heat can be caused by the following pattern of imbalance

• Wei-level Heat
Gall Bladder Heat can result in the following patterns of imbalance

• Ying-level Heat
• Xue-level Heat
Ying level
The ying level is the upper level of xue. It is the qi aspect of xue. When xie qi has
penetrated down to the ying level, it is a deeper and more serious disorder than when
xie qi was in the qi level.
Xie qi can penetrate to the ying level if xie qi is sufficiently virulent or if the
invasion of the qi level has been treated improperly or inadequately. Furthermore,
xie qi can jump directly from the wei level to the ying level. This is because both
the Lung and the Pericardium have their residence in the upper jiao. This means
that exogenous xie qi can be transmitted directly from Lung wei qi to Pericardium
ying qi.
The Heart and Pericardium are easily influenced by xue imbalances, especially
xue Heat. Because xie Heat is affecting an aspect of xue, there will be signs that the
person’s shen is affected. This is because xue is the residence of shen. These signs could
be insomnia or restlessness. The Heat can also have created Phlegm, which can block
the orifices of the Heart. This could mean that the person talks incomprehensibly,
and there can be delirium and even a loss of consciousness or a coma.
The Heat in the Pericardium will also mean that there may be palpitations and a
sensation of turmoil in the chest.
The Heat can agitate xue so much that the walls of the blood vessels rupture.
This can manifest as petechiae. There can also be red skin rashes.
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When xie qi penetrates from the qi level to the ying level, there will be a dramatic
change in the symptom picture. At first glance it could appear to be a positive sign
that the high fever, severe sweating and overflowing pulse that characterises the qi
level have abated, but it is not. This is because the changes that arise are indications
that xie qi is starting to injure the body’s yin aspect. The high fever that the person
had is now replaced by a fever that is only present in the evenings and at night. The
pulse is no longer Rapid, Full and Flooding, which was a consequence of the fierce
struggle between xie qi and zheng qi. Now the pulse is Deep, Rapid and Fine, which
indicates that the zheng qi is weak and that there is now yin xu Heat, rather than
shi Heat. The sweating is no longer profuse, because there is now yin xu Heat rather
than shi Heat and fluids are exhausted and have dried out.
An interesting sign is that the person has a lack of thirst, despite the intense
Heat. This is because the Heat will have driven the fluids upwards in the body to the
mouth so that the person, despite the lack of fluids, does not feel the need to drink.
This is, again, a crucial difference to the symptoms and signs of the qi level.
Observation of the tongue is important when differentiating between xie Heat in
the qi level and the ying level. This is because the tongue will show that the extreme
Heat has damaged yin. The thick and yellowish coating, which is characteristic of
qi-level Heat has vanished and the tongue body proper is much more red in colour.
There can be signs of ‘false Cold’. This will manifest with icy extremities, while
the person’s torso is burning hot. This is due to the extreme Heat ‘binding’ qi, so it
does not reach the hands and feet.
Aetiology
Exposure to exogenous xie qi that has penetrated down to the ying level from the
wei or qi level.
Symptoms and signs

• Fever that worsens at night
• Insomnia
• Restlessness
• Dry mouth but no thirst
• Petechiae
• Red skin rashes
• Delirium
• Raving
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• The skin on the torso feels hot, but the hands and feet are icy cold
• Dark, red tongue without coating
• Fast, Deep, Fine pulse
Key symptoms
Fever that is worst at night, dry mouth but no thirst, red tongue without coating,
Rapid and Fine pulse.
Treatment principle
Drain Heat from the ying Level and nourish yin. Possibly restore consciousness.
Acupuncture points
Choose from: Pe 3, Pe 8, Pe 9, Du 14, Du 26, Kid 6, Sp 10 and UB 40.
Needle technique
Draining. Micro-bleed Pe 9, Du 26 and UB 40.
Explanation
• Du 26 restores consciousness.
• UB 40 and Sp 10 drain xue Heat.
• Kid 6 nourishes yin.
Herbal formula
• Qing Ying Tang (Clears ying-level Heat)
• An Gong Niu Huang Wan (Clears ying Heat and restores consciousness)
Relevant advice
Patients with these conditions will probably be in treatment with Western medicine.
Ying-level Heat can be caused by the following patterns of imbalance

• Wei-level Heat
• Qi-level Heat
Ying-level Heat can result in the following pattern of imbalance

• Xue-level Heat
689
Xue level
In these patterns, xie qi has penetrated down to the deepest level of xue. This is the
final stage in a disease development. The symptoms are serious and complex and
remission is difficult. This is because it is the body’s most fundamental substances,
xue and yin, that are injured.
It is mainly the Liver, Heart and Kidneys that are affected. The Liver and Heart
are affected because they have a relationship with xue and the Kidneys because yin is
seriously injured. The extreme Heat can generate Wind that disrupts the movement
of xue and further injures yin.
Xue-level patterns are included for the sake of completeness. It is unlikely that
you will see these in an ordinary clinical setting. Patients with these symptoms will
usually be admitted to an intensive care unit of a hospital.
Xue Heat agitating xue

The Heat causes xue to become chaotic in its movement and xue is so agitated that it
ruptures the walls of the vessels. The Heat and deficient yin will mean that the shen is
not rooted at night and there will be extreme restlessness and insomnia. The agitation
of shen by the Heat can be so extreme that there is mania or delirium.
Because yin is injured, there can also be classic yin xu signs such as hot palms of
the hands and soles of the feet, night fever, a Rapid but Fine pulse and a red tongue
without coating.
Aetiology
Xie qi that has penetrated from the qi or ying level.
Symptoms and signs

• Bleeding of dark red blood from the mouth, nose, lungs, anus, vagina, under
the skin, etc.
• High fever that is worse at night
• Insomnia
• Restlessness
• Delirium or raving
• Mania
• The palms of the hands and soles of the feet are very hot
• Very red tongue with elevated papillae and no tongue coating
• Very Rapid and Fine pulse
690
Key symptoms
Bleeding from body’s orifices, night fever, very red tongue and a Rapid, Fine pulse.
Treatment principle
Drain xue Heat and stop bleeding.
Acupuncture points
Choose from: Jing-well points, shixuan (Ex-UE 11), UB 17, UB 40, Sp 1, Sp 10,
LI 11, Liv 1, Liv 2, Pe 3 and Du 26.
Needle technique
Draining. Bleed Pe 3, UB 40, jing-well and shixuan points.
Explanation
• Du 26, jing-well and shixuan points drain Heat and restore consciousness.
• Sp 1 and Liv 1 stop bleeding.
• UB 17, UB 40, Sp 10, Liv 2, Pe 3 and LI 11 drain xue Heat.
Herbal formula
• Xi Jiao Di Huang Tang (Drains Heat from the xue level)
Relevant advice
The person will probably be in intensive medical care.
Xue Heat agitating xue can be caused by the following patterns of imbalance
• Qi-level Heat
• Ying-level Heat
Xue Heat agitating xue can result in the following pattern of imbalance
• Yin and xue xu
Xue Heat generating Wind

The extreme Heat and injuring of yin and xue in the Liver can result in the Liver
causing Wind to begin to stir. This can manifest as febrile convulsions, muscle
spasms and tremors, dizziness and neck stiffness. The ascending Heat from the Liver
can cause headaches, red eyes, upwardly staring eyes, the person grinding their teeth
and irritability. The Heat will also result in fever and thirst.
Aetiology
691
Symptoms and signs

• Convulsions
• Stiffness of the neck
• Muscle spasms and tremors
• Grinding teeth
• Headache
• Dizziness
• Red eyes
• The eyes may stare upwards
• Irritability
• Mania
• Fever
• Thirst
• Dark red tongue without coating
• Rapid, Fine or Wiry pulse
Key symptoms
Fever cramps, stiffness in the neck, dark, red tongue and Rapid pulse.
Treatment principle
Drain xue Heat and calm Wind.
Acupuncture points
The person will probably be in intensive medical care. If this is not possible, or whilst
waiting, you can choose from the following points: Jing-well points, shixuan (Ex-UE
11) points, UB 62, SI 3, Sp 10, LI 11, Liv 2, Liv 3, GB 20, Du 16 and Du 20.
Needle technique
Draining. Bleed jing-well and shixuan points.
Explanation
• Jing-well, shixuan points and LI 11 drain Heat.
• Liv 2 and Liv 3 drain Heat from the Liver and calm Wind.
• GB 20, Du 16 and Du 20 descend yang and calm Wind.
692
Herbal formula
• Da Ding Feng Zhu (Extinguishes Wind and nourishes yin and xue)
Relevant advice
Xue Heat generating Wind can be caused by

• Qi-level Heat
• Ying-level Heat
Xue Heat generating Wind can result in the following pattern of imbalance
• Yin and xue xu
Xue Heat injuring yin

In this pattern, the extreme Heat injures yin. There will be classic yin xu symptoms
and signs, but they will be very extreme and the condition will have arisen as a
consequence of an invasion of exogenous xie qi. There may well be an underlying
yin xu condition, which means that when there is Heat, yin has greater difficulty
controlling it and is more easily injured by the Heat.
Aetiology
Symptoms and signs

• Fever that is higher in the evening and at night
• No sweating when the fever has fallen
• Red face
• Sensation of heat in the palms of the hands, soles of the feet and chest (‘five
palm heat’)
• Dry mouth
• Weakness of the body
• Wizened body
• Deafness
• Irritability
• Restlessness
693
• Red tongue without coating

Key symptoms
Fever that is worse at night, ‘five palm heat’, wizened body, Rapid and Fine pulse.
Treatment principle
Rescue yin.
Acupuncture points
Choose from: Jing-well points, UB 40, Sp 10, LI 11, Kid 1, Kid 3, Kid 6 and Ren 4.
Needle technique
Draining on UB 40, Sp 10 and LI 11. Tonifying on Kid 1, Kid 3, Kid 6 and Ren 4.
Explanation
• Jing-well points UB 40, Sp 10 and LI 11 drain xue Heat.
• Kid 1, Kid 3, Kid 6 and Ren 4 rescue yin.
Herbal formula
• Da Bu Yin (Rescues yin)
Relevant advice
Xue Heat injuring yin can be caused by the following patterns of imbalance
• Qi-level Heat
• Ying-level Heat
Xue Heat injuring yin can result in the following pattern of imbalance
• Yin and xue xu
Yin expiring and extreme dehydration

The extreme Heat from the invasion of exogenous xie qi has damaged yin and jinye.
This will cause the body to shrink and wither. The extremities are cold, because there
is ‘false Cold’ due to yin having collapsed and the extreme Heat has bound qi in the
body.
Aetiology
694
Symptoms and signs

• Withered limbs
• Withered lips and tongue
• Dry gums
• Sunken eyes
• Unconsciousness
• Cold extremities
• Red face
• The fingers twist around each other
• Red tongue without coating
• Fine, Weak and Hidden pulse
Key symptoms
Wizened body, wizened limbs and dry gums.
Treatment principle
Rescue yin and drain Heat.
Acupuncture points
Choose from: Jing-well points, UB 40, Sp 10, LI 11, Kid 1, Kid 3, Kid 6 and Ren 4.
Needle technique
Draining on UB 40, Sp 10 and LI 11. Tonifying on Kid 1, Kid 3, Kid 6 and Ren 4.
Explanation
• Jing-well points, UB 40, Sp 10 and LI 11 drain xue Heat.
• Kid 1, Kid 3, Kid 6 and Ren 4 rescue yin.
Herbal formula
• Da Bu Yin (Rescues yin)
Relevant advice
Yin expiring and extreme dehydration can be caused

• Qi-level Heat
• Ying-level Heat
695
Yin expiring and extreme dehydration can result

• Yin and xue xu
Diagnosis according to San Jiao theory

Diagnosis according to san jiao theory was developed by Wu Ju Tong (1758–1836
ce). Whilst he lived, his home region was affected by many epidemics, including
measles, scarlet fever and smallpox. This meant that he focused his energy on the
study of infectious diseases and used the Four Level diagnostic model as his starting
point. Diagnosis according to san jiao theory was not exactly a new theory but
more another way of utilising the diagnostic model of the Four Levels. Where the
Four Levels analyses the progression of disease in relation to the energetic depth
and severity of the symptoms, the san jiao model utilises a more two-dimensional
analysis of the body. In this model, disease is differentiated from where in the body
the disease is located and in which jiao the affected organs are located.
• When exogenous xie qi is in the upper jiao, the wei qi, Lung or Pericardium
is affected. This is equivalent to the wei, qi and ying levels respectively in the
Four Level model.
• The middle jiao patterns are seen when exogenous xie qi affects the yangming
organs and the Spleen. This will be similar to qi-level Heat in the Four Levels.
• The lower jiao patterns are the most serious. In these patterns, the exogenous
xie qi has affected the Kidneys and Liver. This corresponds to xue-level
patterns in the Four Levels.
Upper jiao
When there is an invasion of exogenous xie qi in the upper jiao, it is the Lung
and Pericardium that are affected. The Heart is protected by the Pericardium and
therefore cannot be attacked by the exogenous xie qi.
An invasion of xie qi in the upper jiao may be relatively superficial, such as
when exogenous xie qi disrupts the functioning of wei qi. This will be similar to
the wei level in the Four Level model. Upper jiao Heat can also be deeper than the
wei level in the Four Level model, Lung Heat in the san jiao model being similar to
qi‑level Heat. If the xie qi invades the Pericardium, it is a relatively serious condition
and will correspond to ying-level Heat.
Xie qi can jump directly from the Lung and wei qi aspect to the Pericardium and
the xue aspect. This is due to the close proximity that these two organs have to each
other in the upper jiao.
696
Wind-Heat invasion in the upper jiao

For a description of the symptoms and pathomechanisms in this pattern, the reader
is referred to the section discussing Wind-Heat in the Four Levels (page 671), as
these imbalances are virtually identical.
Aetiology
Exposure to xie Heat.
Symptoms and signs

• Acute fever with mild aversion to wind and cold
• No or little sweating
• Thirst
• Sore throat
• Red, swollen throat
• Cough
• Irritability
• Restlessness
• Yellowish or dried mucus in the nose
• The forehead may feel warm to the touch
• The tip of the tongue may be red and there may be a thin, yellowish coating
on the front
Key symptoms
Fever or feverish sensation and an aversion to cold, Superficial and Rapid pulse.
Treatment principle
Acupuncture points
Choose from: Du 14, LI 4, LI 11, Lu 7, Lu 10, Lu 11, UB 12, UB 13 and GB 20.
Needle technique
Draining. Cupping is recommended.
697
Explanation
• LI 4, LI 11, Lu 7, UB 12 and UB 13 expel Wind and Heat.
• Lu 10 and Lu 11 drain Heat from the Lung and throat.
• GB 20 expels Wind and drains yang from the head.
Herbal formula
Relevant advice
When there is an invasion of Wind-Heat in the upper jiao, it is best not to eat at all
or to only eat light food. The person should drink tea that is cooling and spicy in its
dynamic, such as elderflower, chrysanthemum or mint.
An invasion of Wind-Heat in the upper jiao can be

caused by the following pattern of imbalance
An invasion of Wind-Heat in the upper jiao can

result in the following patterns of imbalance
• Middle jiao Heat
• Lower jiao Heat
• Pericardium Heat
Damp-Heat in the upper jiao

This is an early stage of a Damp-Heat invasion; the Lung and the skin are affected.
For a discussion of the symptoms and pathomechanisms, please see the section
describing Damp-Heat in diagnosis according to the Four Levels (page 673), as
these two imbalances are virtually the same.
Aetiology
Exposure to Damp-Heat xie qi.
Symptoms and signs

• Fever that is highest in the afternoon
• Nausea
698
• Heavy and aching arms and legs

• Poor appetite
• Heavy headache
• Lack of sweating or sticky sweat
• Fatigue
• Diarrhoea or constipation
• Greasy, yellow tongue coating
Key symptoms
Heavy headache, heaviness in the limbs, Rapid and Slippery pulse.
Treatment principle
Expel and drain Damp-Heat, activate wei qi.
Acupuncture points
Choose from: Du 14, LI 4, LI 11, Lu 7, Sp 3, Sp 9, Ren 12 and Pe 6.
Needle technique
Draining.
Explanation
• Du 14 drains Heat and activates wei qi.
• LI 4 and Lu 7 activate wei qi and expel xie qi.
• LI 11 expels xie qi and drains Damp-Heat.
• Ren 12 and Pe 6 regulate the qi mechanism in the middle and upper jiao.
Herbal formula
• Huo Po Xia Ling Tang (Expels Damp-Heat from the exterior)
Relevant advice
When there is an invasion of Damp-Heat, the person should avoid consuming food
and beverages that create Damp-Heat.
699
An invasion of Damp-Heat can be caused by

An invasion of Damp-Heat can result in the

• Lower jiao Heat
• Pericardium Heat
• Spleen qi xu
Lung Heat
This pattern is the same as the one discussed in qi level Heat in the Four Level
diagnostic model; for a description of the symptoms and pathomechanisms, please
see this section (page 676).
Aetiology
Symptoms and signs

• Fever or feeling of heat, without aversion to cold
• Cough with yellow, sticky sputum that is difficult to expectorate
• Thirst
• Chest pain
• Dyspnoea
• Red face
• Restlessness
• Restless sleep
• Rapid pulse
Key symptoms
Fever, cough with sticky sputum, thirst, Rapid pulse.
700
Treatment principle
Acupuncture points
Choose from: Lu 1, Lu 5, Lu 10, Lu 11, LI 4, Du 14 and UB 13.
Needle technique
Explanation
• Lu 1, Lu 5 and UB 13 drain Heat from the Lung and regulate Lung qi.
• Lu 10 and Lu 11 drain Heat from the Lung.
• Du 14 and LI 11 drain shi Heat.
Herbal formula
• Xie Bai San (Drains Lung Heat)
Relevant advice
heat in the body and avoid the inhalation of tobacco smoke.
Lung Heat can be caused by the following patterns of imbalance

• Wind-Heat

• Lower jiao Heat
• Lung yin xu
Pericardium Heat
This corresponds to ying-level Heat in diagnosis according to the Four Levels;
the reader is therefore referred to this section (page 687) for a description of the
symptoms and pathomechanisms.
701
Aetiology
Symptoms and signs

• Fever that is worse at night
• Insomnia
• Restlessness
• Dry mouth but no thirst
• Petechiae
• Skin rashes
• Delirium
• Raving
• The skin on the torso can feel hot, but the hands and feet are icy cold
• Rapid, Fine pulse
Key symptoms
Fever that is worse at night, dry mouth but no thirst, red tongue without coating,
Rapid and Fine pulse.
Treatment principle
Drain Heat from the Pericardium and nourish yin. Possibly restore consciousness.
Acupuncture points
Choose from: Pe 3, Pe 8, Pe 9, Du 14, Du 26, Kid 6, Sp 10 and UB 40.
Needle technique
Draining. Bleed Pe 9, Du 26 and UB 40.
Explanation
• Du 26 restores consciousness.
• UB 40 and Sp 10 drain xue Heat.
• Kid 6 nourishes yin.
702
Herbal formula
• Qing Ying Tang (Clears ying level Heat)
• An Gong Niu Huang Wan (Clears ying Heat and restores consciousness)
Relevant advice
The patient will probably be in biomedical treatment.
Pericardium Heat can be caused by the following patterns of imbalance

• Lung Heat
Pericardium Heat can result in the following pattern of imbalance

• Lower jiao Heat
Middle jiao
The most important differentiation here is whether it is Heat or Damp-Heat that
is the dominant xie qi. If the xie qi has penetrated down to the middle jiao and
generated Heat, the pattern will correspond to Heat in the Stomach in diagnosis
according to the Four Levels or the yangming stage in the Six Stages.
If Damp-Heat is the dominant pathogen, this will corresponds to Damp-Heat
in diagnosis according to the Four Levels.
Yangming Heat
Xie Heat has directly invaded or penetrated down to the Stomach, which will
correspond to the yangming stage and qi-level Stomach and Large Intestine Heat.
The reader is therefore referred to the relevant section in diagnosis according to the
Six Stages (page 642) and diagnosis according to the Four Levels (page 669) for a
description of the symptoms and pathomechanisms.
Aetiology
Symptoms and signs

• Constipation or green watery diarrhoea (false diarrhoea caused by a blockage
of compacted faeces in the Intestines)
• Abdominal bloating and distension that feels worse when palpated
• Fever, especially late in the afternoon, but no aversion to cold
703
• Restlessness
• Frontal headache
• Bleeding gums
• Red face
• Red tongue with a dry, yellow coating
• Rapid, Full and Flooding pulse
Key symptoms
Constipation, bloated abdomen, fever, Rapid and Flooding pulse.
Treatment principle
Drain Heat from the Stomach and Large Intestine.
Acupuncture points
Choose from: LI 11, SJ 6, St 25, St 34, St 37, St 44, UB 21, UB 25 and Du 14.
Needle technique
Explanation
• LI 11, SJ 6, St 25, St 37 and UB 25 drain Heat from the Stomach and Large
Intestine and move qi in the Intestines.
• St 34, St 44 and UB 21 drain Heat from the Stomach.
• Du 14 drains qi-level Heat.
Herbal formula
• Da Cheng Qi Tang (Purges yangming Heat and moves qi in the Intestines)
Relevant advice
The patient should eat foods that are cooling and moistening in their dynamic. They
should avoid foods and beverages that have a hot energy. Boiled or steamed spinach
and cabbage will be beneficial, as will sauerkraut.
Yangming Heat can be caused by the following patterns of imbalance

• Upper jiao Heat
704
Yangming Heat can result in the following pattern of imbalance

• Lower jiao Heat
Spleen Damp-Heat
This pattern corresponds to the qi-level Damp-Heat pattern in the Four Levels; for
a discussion of the symptoms and signs and their pathomechanisms, please see this
section (page 673).
Aetiology
Symptoms and signs

• Fever that is reduced by sweating but soon rises again
• Nausea
• Poor appetite
• Abdominal distension or bloating
• Difficulty in thinking clearly
• Oily skin
Key symptoms
Odorous diarrhoea, fever, yellowish, greasy tongue coating, Rapid and Slippery
pulse.
Treatment principle
Drain Damp-Heat.
Acupuncture points
Choose from: Du 14, LI 11, St 25, St 44, Sp 9, Sp 6 and Ren 12.
705
Needle technique
Draining.
Explanation
• Du 14 and LI 11 drain Heat.
• St 25 and St 44 drain Damp-Heat from the Intestines.
• Ren 12 drains Dampness from the middle jiao.
Herbal formula
• San Ren Tang (Drains Damp-Heat)
Relevant advice
The person should avoid consuming foods that produce Dampness or Heat.
Spleen Damp-Heat can be caused by the following patterns of imbalance

• Upper jiao Damp-Heat
Spleen Damp-Heat can result in the following pattern of imbalance

• Lower jiao Heat
Lower jiao
Xie Heat has penetrated the lower jiao; it will be the Liver or Kidneys that are affected
and the imbalances will correspond to xue-level Heat in diagnosis according to the
Four Levels or the shaoyin Heat stage of diagnosis according to the Six Stages.
There can also be a direct invasion of Damp-Heat in the Large Intestine or
Urinary Bladder.
Damp-Heat in the lower jiao

It is usually the Urinary Bladder and Large Intestine that are affected in Damp-
Heat in the lower jiao. This will resemble Damp-Heat in the middle jiao, but here
there will be signs that the Urinary Bladder’s functions are disrupted or that there is
Damp-Heat in the Large Intestine.
Aetiology
Exposure to xie Damp-Heat.
706
Symptoms and signs

• Fever that is reduced by sweating but soon rises again
• Nausea
• Poor appetite
• Difficult urination
• Painful urination
• Dark, odorous urine
• Burning pain on urination
• Abdominal distension or bloating
• Difficulty thinking clearly
• Oily skin
Key symptoms
Odorous diarrhoea, painful urination, fever, yellowish, greasy tongue coating, Rapid
and Slippery pulse.
Treatment principle
Drain Damp-Heat from the lower jiao.
Acupuncture points
Choose from: LI 11, St 25, St 44, Sp 9, Sp 6, Ren 3, UB 28, UB 32, UB 40 and
UB 53.
Needle technique
Draining.
707
Explanation
• LI 11, St 25 and St 44 drain Damp-Heat from the Intestines.
• UB 28, UB 32, UB 40 and Ren 3 drain Damp-Heat from the Urinary
Bladder.
• UB 53 opens the water passages and disperses stagnation in the Urinary
Bladder.
Herbal formula
• Bai Tou Weng Tang (Drains Damp-Heat from the Intestines)
• Ba Zheng Wan (Drains Damp-Heat from the Urinary Bladder)
Relevant advice
The person must avoid consuming foods that produce Dampness or Heat.
Damp-Heat in the lower jiao can be caused by

• Upper jiao Heat
Damp-Heat in the lower jiao can result in the

• Heat in the Liver or Kidneys
Kidney Heat
If xie Heat is not expelled or is treated improperly or inadequately, the Heat can
damage the Kidney yin. This will result in Kidney yin xu Heat symptoms and signs.
This level corresponds to the shaoyin Heat Stage in diagnosis according to the
Six Stages; for an explanation of pathomechanisms behind the symptoms please see
this section (page 666).
Aetiology
Exposure to exogenous xie Heat that has injured the Kidney yin.
Symptoms and signs

• Irritability
• Insomnia
708
• Night sweats
• Palpitations
• Malar flush
• Evening fever
• Dryness of the mouth, especially at night
• Red tongue without coating, the tip of the tongue is the most red
Key symptoms
Night sweats, insomnia, dry mouth, red tongue without coating.
Treatment principle
Nourish Kidney yin.
Acupuncture points
Choose from: Kid 3, Kid 6, Kid 7, Ren 4, Sp 6, UB 23 and UB 52.
Needle technique
Tonifying.
Explanation
• Kid 3, Kid 6, Kid 7, Ren 4, Sp 6, UB 23 and UB 52 nourish Kidney yin.
Herbal formula
• Da Bu Yin (Nourishes Kidney yin)
Relevant advice
The patient must get sufficient sleep, go to bed early and try not to overexert
themselves. Coffee and other stimulants or caffeine-rich substances should be
avoided because they over-activate the Heart and thereby consume yin. Alcohol, hot
spices and grilled and fried food will all create Heat, which will further injure the yin
and should be avoided.
Kidney Heat can be caused by the following patterns of imbalance

• Upper jiao Heat
709
Kidney Heat can result in the following patterns of imbalance

• Liver Heat generating Wind
Liver Heat generating Wind

In this pattern, exogenous xie qi has injured the Liver’s yin aspect and generated
Heat in the Liver. The Heat causes Liver Wind to stir and the deficient yin cannot
control it. This pattern corresponds to the pattern of xue Heat generating Wind in
the Four Levels diagnostic model and the reader is referred to this section (page 691)
for an explanation of the symptoms and signs and their pathomechanisms.
Aetiology
Exposure to exogenous xie qi that has created Heat in the Liver and injured Liver
yin.
Symptoms and signs

• Seizures and convulsions
• Stiffness of the neck muscles
• Muscle spasms, cramps and tremors
• Grinding of the teeth
• Headache
• Dizziness
• Red eyes
• Upwardly staring eyes
• Irritability
• Mania
• Fever that is worse at night
• Thirst
• Rapid, Fine pulse or Wiry pulse
Key symptoms
Fever cramps, stiffness of the neck muscles, dark, red tongue and rapid pulse.
Treatment principle
Drain Heat from the Liver, nourish Liver yin and calm Wind.
710
Acupuncture points
Choose from: Jing-well points, shixuan (Ex-UE 11) points, UB 62, SI 3, Sp 10, LI 4,
Liv 2, Liv 3, Liv 8, GB 20, Du 16, Du 20 and Sp 6.
Needle technique
Draining, apart from Sp 6 and Liv 8, which should be tonified. The jing-well and
shixuan points should be bled.
Explanation
• Jing-well points, shixuan points and LI 11 drain Heat.
• Liv 2 and Liv 3 drain Heat from the Liver and calm Wind.
• GB 20, Du 16 and Du 20 descend yang and calm Wind.
• Sp 6 and Liv 8 nourish Liver yin.
Herbal formula
• Da Ding Feng Zhu (Extinguishes Wind and nourishes yin and xue)
Relevant advice
Liver Heat generating Wind can be caused by

• Upper jiao Heat
• Kidney Heat
Liver Heat generating Wind can result in the

• Kidney Heat
711
Section 10
THE 12 REGULAR CHANNELS
The channels and organs form a holistic structure where changes in one will affect the
other. This means that the organ imbalances can manifest with a disruption of
the associated channel and vice versa. Although organs and channels are inextricably
linked, there can still be, and often are, imbalances in one without this manifesting
in the other. Diagnostically and therapeutically, it is therefore most appropriate to
diagnose them separately and use diagnosis according to zangfu organs to diagnose
organ imbalances.
Channel imbalances can arise when a channel is invaded by exogenous xie qi,
when there is repetitive movement or strain of a limb or joint, when there is physical
trauma and when there are imbalances in the channel’s related zangfu organ.
Diagnosis in relation to the 12 regular channels is most commonly used in the
diagnosis of musculosceletal problems and bi syndromes.
Diagnosis in relation to the 12 channels focuses on which channels are affected.
Channel diagnosis is, by definition, an exterior imbalance in relation to the Eight
Principles, but the channel diagnosis can relate to an interior zangfu imbalance.
Diagnosis will be based on where in the body changes have manifested themselves.
These changes should be seen in relation to the internal and external pathways of
the 12 regular channels. It is important to determine whether there is a xu or a shi
condition. Palpation of the channel is indispensable in this process. The muscles and
tissue along the path of the channel should be palpated to see if there are any changes
in the tissue. Changes in the tissue could be the presence of nodules, graininess in
the tissue, sponginess, tightness, hardness, softness or weakness. There can also be
changes in the temperature and moistness of the skin along the channel.
The size, depth and hardness of any changes along the path of the channel are
also important diagnostic factors.
Tightness, hardness and tension are usually indicative of a shi condition in the
channel or its associated organ. The more superficial the hardness, the more acute
the condition is likely to be.
Softness and weakness in the tissue along the path of the channel is a sign of a
xu condition in the channel or its associated organ. If there is a xu condition, the
palpation will feel more pleasant for the patient than if there is a shi condition.
Cold and xue stagnation can manifest with nodules that are hard with clearly
defined edges, whereas Phlegm and Dampness nodules will tend to be smoother and
more slippery with less clearly defined edges.
712
Diagnosis According to the 12 Regular Channels
Longer, more stick-like nodules can also be felt along the path of the channel. If
the stick-like nodules are very bumpy and lie along the channel, this is a sign that it
is a chronic condition that can be difficult to treat. Stick-like nodules that can be felt
transverse to the path of the channel are typically acute or are due to stagnations of
qi and are thereby easier to treat.
If the patient reports sensations of numbness whilst an area is being palpated,
this can be due to Phlegm blocking the channel.
Additionally, individual acupuncture points along the channel should be
palpated to see whether there is tenderness or pain or whether the patient feels the
pressure is pleasurable or gives some form of relief.
There can be changes in the temperature of the skin along the channel when
there is Heat or Cold in the channel.
Visual observation of the channel is also important. Heat in the channel can
manifest with redness along the channel’s path or with spots, pimples or other
skin changes.
Observation of the joints is particularly important. This is because it is at the
joints that qi sinks deeper into the interior or rises up to the surface. This means that
it is a place where xie qi tend to accumulate.
Problems with sense organs and the body’s orifices can often result from
imbalances in the channels rather than the zang organ that it is controlled by. For
example, many problems in the ears are due to imbalances in the Small Intestine,
Gall Bladder or san jiao channels and not the Kidney organ.
It is important to remember in diagnosis according to the 12 regular channels,
that it is not only the channel’s main course that is of relevance; the channel’s
internal pathways, the muscle channels, the luo-connecting vessels and the pathways
of the divergent channels must also be taken into account, as well as the channel’s
relationship to its partner channel and its extended channel.
Shi condition in the channel Xu condition in the channel

Tenderness, tightness and tension along the Weakness in the muscles and connective tissues
channel or muscle atrophy along the channel
Tenderness or pain on palpation of the channel Relief of pain or pleasure in palpation of the
channel
Pronounced, cramping or sharp pain in the Soreness, weakness, numbness or fatigue in the
joints along the channel joints along the channel
Red colouration (Heat) or bluish colouration Pale colour along the channel course
(Cold) along the course of the channel
The channel feels warm The channel feels cold
The relevant pulse position is Full The relevant pulse position is Weak
Treated with draining needle techniques Treated with tonifying needle techniques
713
Heat in the channel Cold in the channel

The channel feels warm The channel feels cold
Redness of the skin, pimples, spots or other red Bluish or very white skin along the path of the
colourations along the path of the channel channel
Pimples, spots or other red skin conditions Hard, clearly defined nodules in the tissue
along the path of the channel along the path of the channel
Inflammation, redness, dryness or yellow, sticky Increased, watery discharges from the sense
exudation from the sense organ or orifice that organ or orifice that the channel connects to
the channel connects to
Burning, stinging pain in the sense organ or Cramping, intense pain in the sense organ or
orifice that the channel connects to orifice that the channel connects to
Xue stagnation in the channel

Dark or purple discolouration of the skin along the path of the channel
Sharp, stabbing pain along the path of the channel
Inhibited movement of the joint along the path of the channel
Hard, clearly defined nodules in the tissue along the path of the channel
Treatment of channel problems

The treatment of pain conditions in the channel is mainly based on: the use of local
points along the course of the channel; the use of points in the local area; distal
points at the opposite end of the channel, on the wrist or on the ankle. If there
is a long distance between the distal point and local points, the treatment can be
supplemented by using a powerful ‘supporting point’ somewhere on the channel in
between them. This is called a ‘chain and lock’ treatment. For example, if there is
pain in the shoulder joint corresponding to the Large Intestine channel, LI 4 can
be used as a distal point and LI 15 as a local point, supplemented with the adjacent
points LI 14, LI 16 and SJ 14, as well as LI 10 as a supporting point. A-shi points
are always important in the treatment of pain conditions and blockages of qi and xue
along the path of the channel.
If there is a stagnation in a joint along the course of the channel, the ‘cross channel’
method can be utilised. This very effective method was developed by Dr Zhou Yu
Yan. In ‘cross channel’ theory, acupuncture points are selected on the opposite side
and in the opposite limb according to where the pain is. These acupuncture points
must be located either in a similar area, for example if the pain is in the lateral side
of the right ankle, you will select an equivalent point on the lateral side of the left
wrist, or the cross channel point should be located on the equivalent spot on the
same great channel, for example St 36 on the left side to treat the area corresponding
to LI 10 on the right side, because they are both yangming channel points and are
located in similar positions along the channel.
In addition to acupuncture points on the channel and local points, other points
that are relevant to the diagnosis can be used. If there is Heat, for example, acupuncture
714
points that drain Heat can be used. If there is a qi xu condition in the channel, relevant
qi-tonifying points can be used. This means that LI 10, for example, would be the
relevant point to choose if there is yangming channel shoulder pain that is due to a xu
condition, whereas LI 11 would be chosen if there are signs of Heat in the joint.
Luo-connecting points can also be used to regulate qi in the channel. These
points can allow qi to flow to or from the partner channel. Luo-connecting points
can also be used to regulate qi and xue in the small, superficial luo vessels. This is
especially relevant when there are joint problems along the course of the channel,
because the stagnation is often located in these small, superficial luo vessels.
Lung channel imbalances

Symptoms and signs
• Tenderness, weakness or pain along the course of the Lung channel
• Skin changes along course of the Lung channel
• Dyspnoea
• Sore throat
• Blocked nose
• Tenderness or pain under clavicle
• Pimples around the nose, upper back and chest
Acupuncture treatment
Local, distal and a-shi points on the Lung channel, possibly combined with LI 6.
Large Intestine channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Large Intestine channel
• Skin and tissue changes along the course of the Large Intestine channel
• Sore, red and swollen throat
• Paradentosis
• Tooth pain
• Bleeding gums
• Red and swollen gums
715
• Shoulder pain
• Frozen shoulder
• Elbow pain
• Wrist pain
• Facial paralysis
• Nosebleeds
• Runny or blocked nose
• No sense of smell
• Red and swollen eyes
• Borborygmi
• Abdominal pain
• Ulcers, spots, acne, etc. around the mouth, on the cheekbones, upper back
and chest
Local distal and a-shi points on the Large Intestine channel, possibly combined with
Lu 7.
Stomach channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Stomach channel
• Skin and tissue changes along the course of the Stomach channel
• Red eyes
• Stinging or burning pain in the eyes
• Styes
• Paredentosis
• Toothache
• Bleeding gums
• Mouth ulcers
• Red and swollen gums
• Jaw pain and tension
716
• Nosebleeds
• Tenderness or pain in the breasts
• Sore throat and pain in the oesophagus
• Stomach ache and abdominal pain
• Muscle wasting or muscle weakness in the legs
• Ulcers, spots, acne, etc. around the mouth, on the cheekbones, upper back
and chest
Local distal and a-shi points on the Stomach channel, possibly combined with Sp 4.
Spleen channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Spleen channel
• Skin and tissue changes along the course of the Spleen channel
• Heavy, cold or weak legs
• Abdominal pain
• Vaginal discharge
Local distal and a-shi points on the Spleen channel, possibly combined with St 40.
Heart channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Heart channel
• Skin and tissue changes along the course of the Heart channel
• Chest and cardiac pain
• Pain or other sensations that radiate out from the chest along the arm
• Hot or sweaty palms
Local distal and a-shi points on the Heart channel, possibly combined with LI 7.
717
Small Intestine channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Small Intestine channel
• Skin and tissue changes along the course of the channel
• Ear pain
• Deafness
• Jaw pain or stiffness
• Sore or stiff neck
• Neck and shoulder tension or pain
• Elbow pain
• Fever and aversion to cold
Local distal and a-shi points on the Small Intestine channel, possibly combined with
He 5.
Urinary Bladder channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Urinary Bladder channel
• Sore eyes
• Sinus pain
• Headache
• Sore or stiffness in the neck
• Back pain
• Sore or stiffness in the lower back or sacrum
• Pain along the back of the legs
• Sciatica
• Blocked nose
• Nosebleeds
718
Local distal and a-shi points on the Urinary Bladder channel, possibly combined
with Kid 4.
Kidney channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Kidney channel
• Lumbar soreness
• Sore knees
• Sore ankles
• Sore feet
• Dry throat
Local distal and a-shi points on the Kidney channel, possibly combined with UB 58.
Pericardium channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Pericardium channel
• Cardiac pain
• Chest pain
Local distal and a-shi points on the Pericardium channel, possibly combined with
SJ 5.
San jiao channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the san jiao channel
• Skin and tissue changes along the course of the san jiao channel
• Sore eyes or eye pain
719
• Red eyes
• Ear pain
• Deafness
• Exudation from the ears
• Sore throat
• Stiffness and pain in the shoulders
• Elbow pain
Local distal and a-shi points on the san jiao channel, possibly in combination with
Pe 6.
Gall Bladder channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Gall Bladder channel,
especially when there is pain or soreness of the eyes, ears, jaw, the side of the
head, the neck, shoulders, hip, the side of the ribs and the side of the legs
• Hemilateral headache
• Red eyes
• Exudation from the ears
• Deafness
Local distal and a-shi points on the Gall Bladder channel, possibly combined with
Liv 5.
Liver channel imbalances

Symptoms and signs
• Pain, weakness or tenderness along the course of the Liver channel
• Skin and tissue changes along the course of the Liver channel
720
• Pimples or spots around the mouth up to or during menstruation

• Sores and ulcers around the mouth or the genitals
• Pain or tenderness in the groin
• Incomplete or difficult urination
• Genital pain or tenderness
• Impotence
• Permanent erection
• Abdominal pain
• Painful eyes
• Headache
• Leg cramps
• Lump in the throat
Local distal and a-shi points on the Liver channel, possibly combined with GB 37.
721
Section 11
DIAGNOSIS ACCORDING TO THE

EIGHT EXTRAORDINARY VESSELS
Diagnosis is based on the observation of changes in the functions or structures that

are controlled by the eight extraordinary vessels.
Du mai and ren mai have their own channel points, whereas the other
extraordinary vessels ‘borrow’ points from other channels, and the course of
these extraordinary vessels partly follows the course of more than one regular
channel. This means that they can be treated locally with points that are meeting
points, i.e. acupuncture points where two or more channels meet. GB 20 is, for
example, an acupuncture point on the Gall Bladder channel, but it is also a point
on yang qiao mai, yang wei mai, as well as an acupuncture point where the san jiao
channel meets with the Gall Bladder channel. This means that this acupuncture
point can treat multiple channels at the same time.
As was seen in Section 10, ‘Diagnosis According to the 12 Regular Channels’, it
is important to remember that the channels have both internal and external pathways
and that there can be branches of the channel that separate from the main channel.
This means that there can be symptoms and signs in places other than along the path
of the external vessel.
Treatment of the extraordinary vessels

The most popular approach to activating the extraordinary vessels is to use
combinations of so-called opening points. These acupuncture points, which are not
usually located along the course of the extraordinary vessel, can be understood as
being a key that activates the qi in the extraordinary vessel. In this approach the
opening point will either be used alone to activate the vessel or used in combination
with acupuncture points along the channel.
The opening points that most people agree upon when activating the extraordinary
vessels are as follows.
• Du mai – SI 3
• Ren mai – Lu 7
• Chong mai – Sp 4
• Dai mai – GB 41
• Yang qiao mai – UB 62
• Yin qiao mai – Kid 6
722
Diagnosis According to the Eight Extraordinary Vessels
• Yang wei mai – SJ 5

• Yin wei mai – Pe 6
In addition to using the opening point of an extraordinary vessel, most people
recommend coupling the opening point with a so-called partner point. These
acupuncture points are also opening points, but for one of the other extraordinary
vessels that is believed to have a relationship with the vessel that is to be activated.
The most common approach is to insert the first needle of the treatment in the
opening point of the extraordinary vessel that is to be activated. The next acupuncture
point that is needled will then be the opening point of the partner vessel. Only after
these needles have been inserted, and in this order, will the remaining needles be
inserted in the other acupuncture points that are to be utilised in the treatment.
At the end of the treatment, the needles will be removed again in reverse order, i.e.
the needle inserted in the partner vessel’s opening point will be taken out, as the
penultimate needle to be removed and vessel’s own opening point, last.
Maciocia writes that the opening point should be used on the right-hand side
of women and the partner opening point on the left-hand side (Maciocia 2005,
p.832). This will be reversed in the treatment of men, with the opening point being
activated on the left-hand side and partner opening point on the right-hand side.
Personally, I generally use the opening and partner opening points bilaterally, but
will still insert the first needle in the opening point of the extraordinary vessel on the
left-hand side in men and right-hand side in women, because there is no reason not
to do it in that order.
Below is the most common presentation of opening point/partner opening
point relations among the extraordinary vessels.
• Lu 7 (ren mai)/Kid 6 (yin qiao mai)
• SI 3 (du mai)/UB 62 (yang qiao mai)
• Sp 4 (chong mai)/Pe 6 (yin wei mai)
• GB 41 (dai mai)/SJ 5 (yang wei mai)
As was the case with the regular channels, local and distal points can be used along
the pathway of the vessel to activate qi in the vessel. For example, it is possible to use
Du 3 and Du 4 as du mai local points and Du 26 as a distal point in the treatment
of lower back pain. This can be done both with or without the use of the vessel’s
opening and partner opening point.
Du mai imbalances
Symptoms and signs
• Aches, pains, weaknesses or problems along the path of the vessel, especially
pain in the spine, tail bone, neck
723
• Imbalances along the spine

• Headache
• Nasal problems
• Seizures, convulsions and tremors
• Haemorrhoids
• Rectal prolapse
• Tinnitus
• Manic behaviour
• Depression
• Superficial and Long pulse in the left-hand pulse positions
SI 3, UB 62, local, distal and tender points along the course of the du mai.
Ren mai imbalances

Symptoms and signs
• Soreness, weakness, pain or problems along the path of the vessel, especially
pain in the abdomen, chest and neck
• Infertility
• Irregular menstrual periods
• Amenorrhoea
• Hot flushes
• Night sweats
• Urinary disorders
• Involuntary ejaculation
• Accumulations in the abdominal cavity
• Thin, Tight and Long pulse in both cun positions
Lu 7, Kid 6, local, distal and tender points along the course of the ren mai.
724
Chong mai imbalances

Symptoms and signs
pain in the abdomen, uterus and chest
• Irregular menstrual periods
• Dysmenorrhoea
• Clotted menstrual blood
• PMS
• Purple, painful spots around the mouth during and up to the menstruation
• Restlessness or turmoil rising up from the abdomen to the chest and the
neck (running piglet qi)27
• Anxiety
• Nausea and vomiting
• Infertility
• Palpitations
• Muscular atrophy in the legs
• Warm sensation in the face
• Cold and purple feet
• Hot flushes and night sweats during menopause
• Deep and Confined pulse in both guan positions or in all positions on both
sides. The pulse may also be Wiry in both guan positions
Sp 4, Pe 6, local, distal and tender points along the path of the chong mai.
Dai mai imbalances

Symptoms and signs
pain in the hip and waist region
• A sensation of sitting in a tub of cold water
725
• Vaginal discharge
• Irritability
• Lumbar weakness
• Uterine prolapse
• Miscarriages
• Infertility
• Burning and difficult urination
• Cold feet
• Weakness and muscle atrophy in the legs
• Dragging, heavy menstrual pain
• Cold or moist genitals
• Heaviness and fatigue of the whole body
• Wiry pulse in both guan positions that vibrates from side to side
GB 41, SJ 5, local, distal and tender points along the course of the dai mai.
Yin qiao mai imbalances

Symptoms and signs
problems with the neck and eyes
• Dry throat
• Dry eyes
• Insomnia
• Constipation
• Urinary problems
• Uterine bleeding
• Irregular menstrual bleeding
• Tightness, weakness or atrophy in the muscles of the inner side of the legs
• The feet point inwards
• Uneven hips or one leg is longer than the other
726
• Cramps and spasms at night

• Leg cramps
• Wiry pulse in both chi positions and the pulse vibrates from side to side
Kid 6, Lu 7, local, distal and tender points along the course of the yin qiao mai.
Yang qiao mai imbalances

Symptoms and signs
problems with the neck, lower back, hips, eyes and head
• Insomnia or narcolepsy
• Cramps and spasms
• Hemilateral paralysis
• Headache
• Dizziness
• Tension, weakness or atrophy of the muscles of the outside of the legs
• Sciatic pain where the pain is along both the back and outer side of the leg
• The feet point outwards
• Structural imbalances between the right and left, e.g. one leg is longer than
the other or one shoulder is higher than the other
• Red eyes
• Manic behaviour
• Wiry pulse in both cun positions and the pulse can vibrate from side to side
UB 62, SI 3, local, distal and tender points along the course of the yang qiao mai.
Yin wei mai imbalances

Symptoms and signs
in the heart, chest and ribs
727
• Headache
• Anxiety
• Insomnia
• Mental unrest
• Depression
• Sadness
• Poor memory
• Palpitations
• The pulse in the chi position rolls towards the thumb or up to the cun
position and is deep, wide and shi
Pe 6, Sp 4, local, distal and tender points along the course of the yin wei mai.
Yang wei mai imbalances

Symptoms and signs
along the lateral side of the body and leg
• Dizziness
• Earache
• Deafness
• Tinnitus
• Stiff neck
• The pulse in the chi position rolls towards the little finger or towards the cun
position and is superficial, broad and shi
SJ 5, GB 41, local, distal and tender points along the course of the yang wei mai.
728
Section 12
DIAGNOSIS ACCORDING
TO THE FIVE PHASES
The diagnosis according to the Five Phases is not used much in modern Chinese
medicine. It is, however, used more in countries such as Vietnam, Korea and Japan.
In the West, this diagnosis model is used mainly by students of the JR Worsley Five
Element tradition.
In this diagnostic model, symptoms and signs are differentiated in relation to the
sheng (creative) cycle and the ke (controlling) cycle.
There are three main possibilities for imbalance within this model: a phase
not nourishing and tonifying the subsequent phase in the sheng cycle, for example
Water not nourishing Wood; a phase dominating another phase in the ke cycle, for
example, Fire dominates Metal; a phase that instead of being controlled by another
phase, becomes too strong and ‘insults’ the phase that should have controlled it, for
example Metal ‘insulting’ Fire.
The imbalances are treated by drawing qi via the phase points on the various
channels so that the xu phase is tonified and the shi phase drained.
Sheng phase patterns

In these patterns of imbalance, the mother phase does not nourish the child, i.e. the
next phase in the sheng cycle. There will be signs and symptoms that the organ of
the son phase is xu.
The pattern is treated by using the mother point on the deficient organ’s channel.
For example, if there is a deficiency in the Wood Phase, the mother point of the
Liver channel can be tonified. In this example, Liv 8 would be tonified, as it is the
Water point on the Liver channel.
Wood not generating Fire

This corresponds to the zangfu pattern of Heart and Gall Bladder qi xu.
Symptoms and signs

• Shyness
• Nervousness
729
• Lack of courage
• Indecision
• Insomnia, especially waking early in the morning and not being able to fall
asleep again
• Difficulty making decisions
• Pale face
• Poor memory
• Palpitations
• Weak pulse in the left cun position
He 9, which is the Heart channel’s Wood point, should be tonified.
Fire not generating Earth

This is similar to the zangfu pattern of Kidney and Spleen yang xu.
Symptoms and signs

• Loose stools
• Poor appetite
• Weakness of the arms and legs
• Cold limbs
• Oedema
• Pale complexion
• Weak pulse in the right guan position
Sp 2, which is the Spleen channel’s Fire point, should be tonified.
Earth not generating Metal

This is similar to the zangfu pattern of Lung Phlegm-Dampness caused by Spleen
qi xu.
730
Diagnosis According to the Five Phases
Symptoms and signs

• Cough with loose sputum
• Phlegm in the throat
• Fatigue
• Pale complexion
• Weak pulse in the right cun position
Lu 9, which is the Lung channel’s Earth point, should be tonified.
Metal not generating Water

This is similar to the zangfu pattern of Kidney and Lung yin xu and Kidney qi not
grasping Lung qi.
Symptoms and signs

• Dyspnoea
• Weak voice
• Sparse and dark urination
• Weak knees
• Lumbar soreness
• Dry, tickling cough
• Dry throat
• Weak pulse in the left guan position
Kid 7, which is the Kidney channel’s Metal point, should be tonified.
Water not generating Wood

This is similar to the zangfu pattern of Liver and Kidney yin xu.
731
Symptoms and signs

• Dizziness
• Headache
• Difficulty focusing the eyes
• Dry eyes
• Tinnitus
• Lumbar soreness
• Weak knees
• Emaciated body
• Weak pulse in the left guan position
Liv 8, which is the Liver channel’s Water point, should be tonified.
Ke phase dominating patterns

In these imbalances the ‘controlling’ phase dominates the phase that succeeds it in
the ke cycle. There will be signs and symptoms that the controlling phase is shi and
that the controlled phase is xu.
These patterns will be treated by draining qi from the phase that dominates the
succeeding phase in the ke cycle. For example, if the Metal Phase dominates the Wood
Phase, the Metal Phase’s son point, which is Lu 5, is drained. The deficient phase can
then be tonified via its mother point, in this case Liv 8.
Wood dominates Earth

This pattern corresponds to the zangfu imbalance of Liver qi invading the Spleen.
Symptoms and signs

• Hypochondriac pain or distension
• Irritability
• Loose stools
• Poor appetite
• Nausea
732
• Greenish tinge to the complexion

• Headache
• Flatulence
• Fatigue
• Full pulse in left guan position and a Weak pulse in the right guan position
The Liver’s Fire point, Liv 2, is drained and the Spleen’s Fire point, Sp 2, is tonified.
Earth dominates Water

This pattern is similar to an accumulation of fluids due to Kidney and Spleen yang
xu.
Symptoms and signs

• Oedema
• Lack of thirst
• Difficult or frequent urination
• Yellowish face
• Cold limbs
• Fatigue
• The right guan pulse is Full and right chi pulse is Weak
The Spleen’s Metal point, Sp 5, is drained and the Kidney’s Metal point, Kid 7, is
tonified.
Water dominates Fire

This pattern is similar to the zangfu patterns of Heart and Kidney yang xu,
overflowing water.
Symptoms and signs

• Oedema of the ankles and legs
• Lumbar soreness
733
• Dizziness
• Palpitations
• Cough with watery sputum
• Weak pulse in the left cun position, Full pulse in the left chi position
The Kidney’s Wood point, Kid 1, is drained and the Heart’s Wood point, He 9,
is tonified.
Fire dominates Metal

This pattern corresponds to the zangfu patterns of Lung Heat or Lung Phlegm-Heat.
Symptoms and signs

• Loud cough with yellowish, sticky sputum
• Fever or an aversion to heat
• Thirst
• Red face
• Full pulse in the left cun position and a Weak pulse at the right cun position
The Heart’s Earth point, He 7, is drained and the Lung’s Earth point, Lu 9, is tonified.
Metal dominates Wood

This pattern corresponds to the zangfu patterns Lung and Liver qi stagnation.
Symptoms and signs

• Fatigue
• Irritability
• Hypochondriac tension or chest oppression
• Dyspnoea
• Cough
• White face
• Weak pulse in the left guan position and a Full pulse in the right cun position
734
The Metal’s Water point, Lu 5, is drained and the Liver’s Water point, Liv 8,
is tonified.
Ke phase ‘insulting’ patterns

In these imbalances the ‘controlling’ phase is dominated or ‘insulted’ by the
phase that comes after it in the ke cycle. There will be signs and symptoms that
the phase that should be controlled by the other phase is shi, while the phase that
should be the controlling phase in the ke cycle will be xu.
The imbalance can be treated by draining the son point of the insulting phase’s
channel. For example, if the Wood Phase insults Metal, the Wood Phase’s son point
is drained. In this example, Liv 2 would be drained. The deficient phase can then be
tonified via its mother point, in this case Lu 9.
Wood insults Metal

This pattern is similar to the zangfu pattern of Liver Fire invading the Lung.
Symptoms and signs

• Cough with yellowish or bloody sputum
• Dyspnoea
• Chest oppression and hypochondriac tension
• Irritability
• The left guan pulse position is Full
The Liver’s Fire point, Liv 2, is drained and the Lung’s Earth point, Lu 9, is tonified.
Metal insults Fire

This pattern corresponds to the zangfu patterns of Lung and Heart qi xu.
Symptoms and signs

• Palpitations
• Insomnia
• Lack of joy
• The right cun pulse is Full
735
The Lung’s Water point, Lu 5, is drained and the Heart’s Wood point, He 9,
is tonified.
Fire insults Water

This pattern is similar to the zangfu patterns of Kidney and Heart yin xu Heat.
Symptoms and signs

• Palpitations
• Insomnia
• Dry mouth at night
• Dry throat
• Lumbar soreness
• Malar flush
• Dizziness
• The left cun position is Full and the left chi pulse is Weak
The Heart’s Earth point, He 7, is drained and the Kidney’s Metal point, Kid 7,
is tonified.
Water insults Earth

This pattern corresponds to the zangfu pattern of Spleen and Kidney yang xu.
Symptoms and signs

• Loose stools
• Oedema
• Fatigue
• Weak limbs
• The left chi position is Full and right guan position is Weak
The Kidney’s Wood point, Kid 1, is drained and the Spleen’s Fire point, Sp 2,
is tonified.
736
Earth insults Wood

This pattern corresponds to the zangfu pattern Liver Damp-Heat.
Symptoms and signs

• Jaundice
• Hypochondriac tension or pain
• Nausea
• Loose stools
• The right guan position is Full and the left guan position is Weak
The Spleen’s Metal point, Sp 5, is drained and the Liver’s Water point, Liv 8,
is tonified.
737
Appendix 1
SUPPORTING THE TREATMENT OF

THE PATIENT THROUGH YANGSHEN
In Chinese culture, there is a concept called yangshen – to nurture life. Yangshen includes
all the possible physical and spiritual practices that can be utilised to strengthen and
nourish not only the physical body, but also the shen. Yangshen includes everything from
dietary principles, various forms of exercise such as qi gong and tai ji, and meditation
techniques to diverse sexual practices. Yangshen is relevant to us as practitioners of Chinese
medicine in the West, as there is a concept in Chinese medicine that is summarised in the
saying: ‘Seven parts care and three parts treatment.’ Care in this context denotes dietary
and lifestyle changes. For a patient to get the maximum effect from an acupuncture or
a Chinese medicine herbal treatment, it is important that the patient supports their
treatment through dietary and lifestyle changes. This is because their patterns of imbalance
have not arisen by themselves but are the consequence of various aetiological factors. Many
patterns of imbalance emerge directly and indirectly from dietary factors and through
either too much, too little or incorrect exercise. Furthermore, although diet and exercise
were not directly involved in the creation of the imbalances, they can often be used to
influence the body in a positive direction. The best results will be achieved if the patient
addresses the factors that are helping to create and/or aggravate their patterns of imbalance.
We can treat the patient with as many needles and elegant point combinations as we like,
but if the patient does not address the root cause of their imbalances, the imbalances
will often just regenerate themselves. It is not uncommon that it is only when a patient
begins to comply with the advice that they have been given that there is a significant and
lasting change in their condition. Often the greatest help that we can give our patients is
to give them the tools to heal themselves. This can be acupuncture points that they can
press on or treat themselves with moxa, or it could be advice with regard to diet, exercise,
relaxation, meditation or breathing exercises. By giving the right advice to each individual
patient, we can give this person the power to take control of their own life, so that they
control their patterns of imbalance and their patterns of imbalance do not control them.
To some people, this might sound as if we thereby erode our own economic foundation as
a therapist. First, our primary motivation as therapists should always be to help others in
the most effective way possible and should not be financially determined. Second, you will
achieve quicker and better results when the patient cooperates and makes changes in the
factors contributing to their problem. Patients who get well, particularly patients who get
well quickly, are the best advertising you can get as a therapist.
Cooperating with the patient

Nutrition and lifestyle recommendations are only effective if the patient puts the
recommendations into practice. Even the very best advice will have absolutely no effect
if the patient does not follow these recommendations. In fact, advice that is not put
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Appendix 1: Supporting the Treatment of the Patient through Yangshen
into practice can quickly turn into a guilty conscience, which can itself become an
aetiological factor that creates new, or exacerbates existing, patterns of imbalance in
the patient.
There can be many reasons why patients have difficulty complying with the
recommendations you give them.
Lack of time and energy

This is especially relevant in relation to things such as exercise, meditation and dietary
changes that involve the preparation of food in a different way. Many people ought to be
able to find time during the day to meditate for 20 minutes, but the spare time that they
do have is often consumed by Facebook, watching television, playing games on their
smartphone and so on. However, there are people who literally do not have any free time
due to the pressures of work, family and other obligations. This means that you should
be realistic in the recommendations that you give to them. At the same time, it is often
important that precisely these people do try and create a space for themselves in their
lives. This is because you can hear that these people are constantly active, constantly
yang. These people have an even greater need to have some time while they are awake
where they are in a more yin state.
When people find it difficult to find time during the day to meditate, practice qi
gong or do something similar, you can suggest that they get up 20 minutes earlier each
day. Even though they lose a little sleep, the benefit they receive from the meditation, qi
gong, etc. will often more than offset the lost sleep.
Exercise can also be integrated into the daily routine of people whose time is limited.
You can suggest that they bike to work instead of taking the bus or driving or that they
take the stairs instead of using the elevator and so on.
Other people do actually have the time, but they do not use it ideally. These people
need to have more self-discipline and this may require stricter words from their therapist.
Finally, you can also remind people who say that they are too busy to meditate, of
the Zen proverb: ‘Everyone should meditate for 20 minutes each day, except those who
are too busy. They should meditate for one hour.’
Difficulty adhering to dietary recommendations

When we start to tinker with people’s eating habits, we must be aware that there are
many reasons why people eat. They do not eat only to create qi (or in Western physiology
to ingest nutrients such as carbohydrates, oils, proteins, minerals, vitamins and so on).
We mainly eat for a whole host of other reasons, most of these being psycho-
emotional reasons:
• habit
• social interaction with friends and family
• traditions
• culture
• pleasure
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• business meetings
• social gatherings
• desire
• cravings
• boredom
• comfort
• security
• reward
• procrastination
• curiosity
• fashion and fads
• beliefs
• therapy
• patterns of imbalance such as Stomach Fire.
Something we should keep in mind when we give people dietary advice is the very
first experience this person had when they left the dark, warm, secure and quiet
existence of their mother’s womb and entered into a noisy, scary world. This experience
was to be taken up to their mother’s breast, hear her heartbeat, feel her warmth and
have something sweet enter into their mouth. When they cried as a baby, whether it
was because they were hungry, had pain or were insecure, their mouth and stomach was
filled with sweet breast milk or sweet formula from a bottle. In this way a connection
was formed between the consumption of something sweet and comfort and security at
a time when their psyche was in the process of being formed.
The connection between the consumption of something that tastes good, especially
something sweet, and emotional well-being was reinforced for many people when they
were given something sweet to eat if they had fallen or hurt themselves as a child. A
person may also have been rewarded with something sweet when they had excelled
themselves or been good. Christmas, birthdays and other celebrations were often social
gatherings that were associated with happy memories, but also subconsciously with the
consumption of something sweet.
From a Chinese medicine perspective, not only will the Spleen and thereby gu qi have
been nourished in these situations, but also the sweet taste will have become inextricably
associated with pleasure, comfort and social contact – things that nourish the Heart qi
and the shen. It is therefore no wonder that many people comfort eat, especially cake,
sweets and chocolate when they are sad, are insecure, feel challenged or are just bored.
Furthermore, we know that most of the patients we meet in the clinic are Spleen
qi xu and will therefore also have cravings for the sweet taste. This is because it is the
body’s signal to the mind that it is time to take action and strengthen the Spleen qi.
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Furthermore, people with Stomach Fire, who again form a significant proportion of the
clients we see, will have an increased or an insatiable appetite.
All these factors can make it difficult for the person to control their dietary intake in
a reasonable and appropriate manner.
Conflicting advice
Another problem we have to deal with is that our advice may be in conflict not only
with the advice given to the patient by their Western medical doctor, but also with the
advice they have received from other practitioners of complementary medicine.
Some clients are used to our perception of what is healthy being at odds with the
views of Western medicine, and some even expect this. Unfortunately, it is not rare
that other complementary medicine therapists have given them advice that we do not
necessarily think is appropriate to their condition or their constitution. Fortunately,
there will most often be consistency between our advice and that of others. For example,
it is typical that when there is Damp-Heat and Spleen qi xu, the patient may have been
diagnosed as having a candida imbalance by a naturopath. However, a difference in this
situation could be that we may also have diagnosed Liver qi stagnation. This means that
even though there will be no conflict between the foods we think that they should stay
away from and the foods the naturopath has proscribed, we will often be more flexible
and less restrictive in our recommendations than the naturopath is. This is because we
do not want to create frustration and irritation in the patient by giving them too many
rules and restrictions. Furthermore, we may well also have recommended exercise and
discussed the effect that frustration and irritation can have on their imbalances.
Where we often come into conflict with the advice and opinions of both Western
and complementary medicine practitioners is with regard to how much water a person
should drink and the use of ice when there is a physical injury. In these situations, our
advice can sometimes seem almost heretical.
The problem is that clients with chronic conditions – i.e. those who make up the
bulk of our client base – are often people who see several therapists simultaneously or
consecutively. This can result in confusion when they get conflicting advice from the
different practitioners.
The only things we can do are to try to:
• find a common denominator in the advice that they have been given and our
advice
• be convincing in our explanation of how we comprehend their body’s physiology,
pathology and aetiological factors.
Lack of familiarity with or access to certain foods

It is important to remember that not everyone is familiar with the foods that we
recommend. We may have eaten tofu all our lives, whereas the patient has never even
heard of it. Furthermore, a patient living in the countryside will often not have the same
access to the variety of foods that are available in a large city. This means that we must
be realistic in our dietary advice, tailoring and modifying it so that it is relevant to each
individual client.
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Their children and partner eat differently

It can be difficult for a person to alter their diet radically when they live and eat with
other people, for example a husband and two children. Even though they are willing
to change their eating habits, the rest of the family may not have the same motivation.
It can complicate the situation if several members of the same family are being
treated and they have patterns of imbalance that require conflicting dietary approaches.
Ethical reasons
Some people find it difficult to change the diet in an appropriate direction due ethical
principles. This could be a vegan patient who is extremely xue xu. Our job is to educate
people about the causes and effects of, as well as the possibilities to positively influence,
their imbalances. They can then make their own choices; we should not be the judge
of these choices.
Desire, enjoyment
Our advice will often conflict with a person’s desires and passions. As I just wrote, I
think it is important that we present people with the information that can improve
their condition, but from then on it is their own choice. This is especially important
when people do things that from a Chinese medicine perspective are detrimental
to their health. They often do these things because they give pleasure or because, in
fact, they help to ameliorate another pattern of imbalance. Some people, for example,
do excessive physical training because it relieves their Liver qi stagnation. If they did not
exercise as much they do, the symptoms and signs of their Liver qi stagnation would
be accentuated. This creates a conundrum if they are simultaneously Liver xue xu. The
excessive physical training relieves their Liver qi stagnation but is also an aetiological
factor in their Liver xue xu.
It is also a complicating factor when inappropriate behaviour or diet are sources of
pleasure and enjoyment. By stopping someone from drinking a glass of red wine in the
evening or running 20 kilometres in the woods three times a week, we remove something
from their life that is nourishing their Heart qi. In these cases, it is important to try and
find something else that gives them pleasure or something that they are passionate about
so that we do not exacerbate or create a new pattern of imbalance in their Heart.
Their patterns of imbalance mean that they have

difficulty complying with the recommendations
A person with Spleen qi xu will often have a very sweet tooth. Their craving for sweetness
will make it difficult for them to avoid eating sugar, sweets, cakes, honey, dried fruit and
so on. They could also have a Heart imbalance that means that they comfort eat these
sweet things.
It is important that the patient does not feel that we judge them. They are often very
good at doing this themselves without our help. It is, of course, a balancing act – trying
to be strict enough that they adhere to our recommendations but at the same time not
creating feelings of guilt and inadequacy when they don’t succeed in doing what is best.
We must find a way to support and help them without them feeling judgement on
our part.
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How do you get people to comply with your advice?

The greatest chance of relieving and preventing the recurrence of a disorder in a patient
exists when the person actively participates and cooperates in their treatment by making
relevant changes in their diet and lifestyle. In order to get the patient to assist in their
treatment, it is important to explain to the patient which patterns of imbalance they have
and how these patterns may have arisen; then you can tell them what they can do to help
promote the healing process. Most patients are interested in making relevant changes,
especially when they can see a logic in the advice they are given. When explaining to
patients which patterns of imbalance they have and how these have arisen, it is, of
course, important to explain these concepts so they are understandable to a layman who
has not had a three-year training as an acupuncturist.
As well as there being differences in what advice you would give to each individual
patient, there are also differences in how to present this advice to different people,
especially in relation to the amount and the extent of the changes that they should make.
All of this will, of course, depend upon the patient’s patterns of imbalance. Some clients
will get overwhelmed or give up if you give them too much information and too much
advice in one go; others can accommodate more and will be more motivated to change
their habits and diet. It is often a case of suggesting small, realistic changes. It is difficult
enough to change long-term habits in general, but this is even more complicated with
regards to the diet. This is because there are so many factors that come into play in
relation to why we eat, what we eat and how we eat it. For some, the situation is further
complicated by the fact that they are not fully in control of what they eat. This may be
because they eat in the canteen at work, share their meals with others or frequently have
to eat out.
Implementing 75 per cent changes that are maintained for weeks, months or years
is often not only more realistic but also more beneficial than making a 100 per cent
change for 14 days or three weeks, only to return to the original diet because the
dietary changes were too hard to maintain. It is hoped that when the patient makes
relevant changes in their diet, they will experience an improvement in their symptoms.
Often they will also experience a deterioration of their symptoms when they at some
point do eat what is detrimental for them. This will in itself create a motivation to
continue with the dietary changes. It will also result in a completely different qi dynamic.
They will no longer experience the dietary changes as a set of rules and restrictions
dictated by their therapist, something that may cause their Liver qi to stagnate and
prevent them from consuming things that give them pleasure (i.e. nourishing their
Heart). Now they begin to experience motivation. They, for example, no longer want to
eat wheat and cheese because this will result in a state of discomfort and they feel better
when they don’t. This motivation will have a completely different effect on their qi to
a perceived ban. It may even end up benefiting their Heart because they now feel that
they are doing something that is good for them and are taking care of themselves, which
makes them happy, thereby nourishing their Heart qi. It is enormously important that
our advice does not become an aetiological factor in their imbalances. This is especially
important when they do not live up to their own expectations and their perceptions of
our expectations. This can result in feelings of guilt and a lack of self-esteem, which will
have a negative impact on their Liver and Heart qi.
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Undergoing a course of treatment – any treatment that involves having to make

changes in your diet and lifestyle habits – is something all therapists should try. It helps
to create a sense of understanding when a client has difficulty conforming to the advice
we give them. I sometimes share with my clients my own experiences and failings as a
client of others. It can be a relief for them and their conscience to know that I am not
different from them. It also helps to bring me down from the pedestal that they often
have put me up upon.
There are, though, other types of clients who benefit from a more stern approach
where you are more strict and give them little leeway, either because of the severity
of their condition or because of the type of person that they are. This means that
we must constantly adjust our approach from client to client – sometimes being
strict, sometimes being understanding and accommodating, sometimes being humorous
and sometimes being stern.
The severity of the patient’s condition will usually be a significant factor. A person
who has a slight aching in their lower back will probably be less motivated to make
major changes in their life, than someone who has just been diagnosed with a serious
heart problem.
The verbal strategies you that you utilise in all these situations will depend on your
own character and temperament, as well as that of your client. I do not think there are any
hard-and-fast rules of how to get clients to comply with therapeutic recommendations
and each situation must be tackled individually.
In general, it is best to dose your advice and only give the patient new challenges
once they have implemented the previous ones.
Resistance to giving things up

It is typical for most clients to ask: ‘What can I eat or what can I take that will be good
for me?’ Unfortunately, a lot of the dietary advice that I then give tells them what
they should avoid in their diet, as well as recommending exercise, rest, meditation and
so on. As I list the foods they should avoid, they often exclaim: ‘But there must be
something that will be good for me to eat, something that is beneficial?’ Here we can
see a fundamental problem with our Western consumer mentality. We have developed
an expectation that we can purchase or consume a solution. Every time that we are
dissatisfied or when life does not live up to our expectations, we believe that there must
be something we can buy or at least assume that there will be something that will be
salutary for us to consume – some sort of magical pill or superfood. In general, we have
more difficulty with the more Eastern, esoteric approach that happiness – in this context
healing – is a process of letting go of of things. Eastern philosophies have often focused on
abandoning the bonds of materialism, letting go of bad habits and ultimately letting go
of the ego. Usually, the healing process of the physical body is also about avoiding certain
foods and letting go of bad habits. This is because it is these things that have given rise to
the problematical condition. Simply consuming something new – something additional
– does not remove the causes of the problem. In fact, it increases the risk of creating
a new problem. For example, if a person has a Fire condition, it will be beneficial for
them not to consume things like chilli, alcohol, pepper, garlic, lamb, cinnamon, chips,
crisps, fried food and so on. If they do not drop these things and instead just consume
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foods that are extremely cold in their energy to counteract the Fire condition, they
will risk injuring their Spleen qi without necessarily creating an improvement in their
symptoms, because they are still ingesting things that aggravate the Fire condition. This
is similar to people who believe that by eating some organic carrots, they can continue
to eat chips, cakes, cream puddings and chocolate and drink copious amounts of red
wine. The organic carrots may well be packed with vitamins and minerals, but they do
not counterbalance the other things being consumed. Salutary foods should be instead
of, not at the same time as, at least if you want to create long‑term harmony in the body.
Another thing we often hear when we start telling people which things they ought to
exclude from their diet, is that they exclaim: ‘But that’s everything that I eat!’ Although
in reality they probably do eat other things, there is a reason that they have developed
certain patterns of imbalance, and this is often due to the excessive consumption of an
inappropriate diet that is very one-sided.
The central role of the Stomach and Spleen

Central to all Chinese medicine diet therapy is maintaining the health of the Spleen and
Stomach. No matter what imbalances there are, account should always be taken of what
affects the suggested changes in the diet will have on the Spleen and Stomach. This is
because the Stomach receives all the food that is ingested through the mouth, and the
Spleen yang qi that must transform this food into gu qi and extract the essence out of
it. This means that regardless of what other qualities the food has and no matter what
organs and channels this food affects, it will always also have an influence and an effect
on the Stomach and the Spleen. This therefore means that diet therapy is sometimes a
bit of a balancing act in which you try to achieve a therapeutic effect whilst trying not
to injure the Spleen and the Stomach.
This relates back to some of the very first classes we had in our acupuncture training.
In these classes we learnt about the production of qi. We learnt how the Stomach can
be envisioned as a cauldron that is filled with the food and liquids that we ingest. The
Spleen qi is the flames below the cauldron that transform the ingested food and liquids
into a soup from which rises an aromatic and nourishing vapour. More precisely, we
learnt that the Stomach receives the food and liquids ingested through the mouth and
it ‘ripens and rots’ these, preparing them so that the Spleen can transform the ingested
food and liquid into gu qi and extract the essences from it. Furthermore, because of
their location in the centre of the body and their dynamic of sending qi upwards and
downwards, the Stomach and Spleen will affect the movement and communication
of qi in the whole body. It is therefore paramount that we support the Spleen and
Stomach as much as possible through the diet. This can be done by following a few
basic guidelines. We could call these the ten golden rules of eating in Chinese medicine.
Most of the recommendations actually also make good sense from a Western medicine
physiological perspective.
The 10 golden rules of eating in Chinese medicine

• Chew your food well. This will help the Stomach to mature and rot the ingested
food so that the Spleen can transform it. From a Western perspective, the digestive
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process starts in the mouth. Chewing the food will increase the surface area that
the digestive enzymes in the mouth can work on. Chewing will also help to
physically break down the cell walls and mix the ingested food with the digestive
enzymes. Furthermore, food that is physically cold will also be warmed up before
descending into the stomach. This, as we will see in the second golden rule, is
something that is important from both Western and Chinese perspectives.
• Avoid eating cold food, i.e. food that is physically cold, such as raw vegetables,
salads, cold beverages and food eaten directly from the refrigerator, as well
as food that is energetically cold. From a Western perspective, physically cold
food will negatively affect the digestion, because the gastric enzymes are most
efficacious when the temperature in the stomach is between 37 and 42 degrees
Celsius. When foods and beverages that are physically cold are consumed,
these enzymes will be less effective and the digestion will thereby be weakened.
Chinese medicine states that the Spleen fears cold. The consumption of
energetically and physically cold foods and beverages burdens the Spleen because
the Spleen must expend more yang qi to warm and transform the ingested food.
In the long run, too many cold foods and beverages can lead to Spleen qi xu
and Spleen yang xu.
• Eat as much prepared food as possible, especially things like soups and stews.
This is because if the food has been cooked in some way, the transformation
process has already been initiated, thereby placing less demand on the resources
of the Stomach and Spleen. Even though there are more vitamins and minerals
in a raw carrot, the body will not necessarily be able to access, extract and absorb
as many nutrients from a raw carrot, as it will from a steamed, stir-fried or boiled
carrot. The cooking process helps to break down the cell walls in the food so that
nutrients can be more easily released into the digestive system and absorbed through
the intestinal wall. If the person insists on eating raw or unprepared food, they
should ensure that the food is very finely chopped or grated and that they chew it
thoroughly. Drinking some hot ginger tea with the raw food will also help.
• Do not drink too much water or other beverages, and drink between meals.
Too much liquid will drown the Spleen’s ‘digestive fire’. A single cup of hot water
or tea can, on the other hand, support the process (the Stomach hates dryness).
This also makes sense from a Western perspective. Too much fluid will dilute
and thereby weaken the acidity in the stomach. This will have a negative impact
on the gastric enzymes, which function optimally in an acidic environment.
• Do not eat too much. Eat until you are 75 per cent full, otherwise you will
overburden the Stomach and Spleen, which could cause food stagnation
because the Spleen will not be able to transform so much food in one go and the
Stomach will have difficulty rotting and ripening the food, as well as sending it
downwards after the Spleen has transformed it. From a Western perspective,
it takes a while for the brain to register that the stomach is full. This means
that the stomach is full before you are aware that you are full. It also takes time
for the food to move down through the oesophagus and into the stomach.
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• Eat your main meal as early as possible and avoid eating in the evening
prior to going to bed. Chinese medicine posits that the yang processes of
transformation and transportation halt at night and only begin once more in the
morning, when yang activity in general increases again. This means that if you
eat late at night, the food stagnates and remains untransformed in the Stomach,
where it will begin to generate Heat. In general, the main meal should be eaten
as early in the day as possible. In relation to the Chinese medicine horary clock,
the Stomach and Spleen are at their strongest between seven and eleven in the
morning and therefore at their weakest between seven and eleven in the evening.
In Western medicine physiology, peristalsis and digestion cease at night, so the
food remains undigested in the stomach. Many cultures in fact have sayings
along the lines of: ‘Eat like a king in the morning, a peasant at lunchtime and a
beggar in the evening.’
• Choose foods that have vitality. This can be seen, for example, when the
vegetables are crisp and juicy or when the eyes of a fish are still bright and not
dull.28 In practice, this means as much fresh food as possible. Freshly picked
vegetables, for example, contain many more vitamins than vegetables that have
been transported and stored. Avoid industrially produced food, such as ready-
made meals and canned foods. Not only do they contain very little qi, but
they also usually contain various chemicals and additives such as preservatives,
flavour enhancers, artificial flavourings, emulsifiers and so on, as well as excessive
sugar and salt.
• Enjoy what you eat. This nourishes the Heart. We eat not only to create gu qi,
but also for a variety of emotional reasons such as comfort and security, as well
as the sheer pleasure obtained from the taste, smell and the sight of good food.
This enjoyment is often accentuated by the pleasure of eating with others. Strict,
spartan diets will remove this source of nourishment of the Heart. Frustration
and irritation over dietary restrictions will also stagnate Liver qi. If you are going
to eat something that you know is not good for you, do so without guilt. Guilt
will only increase the negative effect that this food has on the body. Instead,
really enjoy every mouthful, savouring the taste. Even though the food may be
creating Dampness or Heat or whatever, it will at least nourish the Heart.
• Try to eat in as tranquil a state as possible. It is best to sit down and relax
whilst eating and to avoid stress and quarrels. Heated discussions can disrupt
the Liver qi, which may then invade and disrupt the Stomach and Spleen qi ji.
Stress can also disrupt the qi ji in the middle jiao, as will worry and speculation.
It is best not to read, watch television or surf the internet whilst eating. Qi
should be used to digest food and not information during the transformation
of the food.
• Sit upright in a relaxed position and do not twist the trunk or sit in a
slumped position. A twisted or slumped posture will block the free passage of
food and qi in the middle and lower jiao. From a Western medicine perspective,
these postures will hamper the peristalsis of the intestines. Gentle stretching
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exercises or going for a light walk after a meal will help to circulate qi in the
middle jiao, thereby supporting the Stomach and Spleen qi, or, in Western
terms, it will activate the abdominal muscles, thereby supporting peristalsis.
Sun Si Miao recommended that a person walks 100 steps after meals but that
they do not count the number of steps.
Dietary recommendations
It is beyond the scope of this book to discuss and analyse the various qualities attributed to
various foods. In Appendix 2 and throughout the main text I have superficially discussed
certain foods in relation to various types of imbalance. For a more detailed discussion
and understanding of the dynamics of food and how this can be utilised in Chinese
medicine, the reader is referred to the following books. Some of these books can also be
recommended to enthusiastic clients who would like to gain a deeper understanding of
Chinese medicine dietetics:
• Chinese Nutrition Therapy (Kastner 2009)
• Helping Ourselves (Leggett 1994)
• Recipes for Self Healing (Leggett 1999)
• Healing with Whole Foods (Pitchford 1993)
• The Tao of Healthy Eating (Flaws 1995).
Mental and emotional approach to life

Most of us are not trained as psychotherapists. It is therefore important that we are
conscious of our limitations, particularly as many of our clients present with imbalances
that have their roots in psycho-emotional factors. As practitioners of Chinese medicine,
we can try to make people aware of the emotional factors that may be influencing or
generating their patterns of imbalance, we can create a space where they can discuss their
problems without being judged, but we should also encourage them to seek additional
help from relevant professionals when this is relevant.
I often explain clients’ Chinese medicine diagnosis to them and tell them which
emotional aspects Chinese medicine views as being potential aetiological factors in these
patterns of imbalance. Often the client will have already mentioned certain emotional
factors in their life, but if they haven’t it gives them the opportunity to reflect and
possibly recognise emotional factors that could be affecting their physical and emotional
health. I do not start advising the client with regards to how they should act in situations
that are creating these emotional imbalances, but talking about possible aetiology and
the way emotions can affect the dynamic of the body’s qi can help the client to become
conscious of the relevance of these factors. It is then up to the client how they will work
with these emotions and situations. Often the emotional baggage has been created at
a very early age and is difficult to influence. Acupuncture is very good at changing the
way a person and their qi reacts to these influences. It is not uncommon that a person
who has been to counselling or other forms of psychotherapy for years finds that they
748
have a breakthrough or start reacting differently in situations after they have started
acupuncture sessions. This is because acupuncture harmonises the qi imbalances that are
being affected by, but also manifesting as, emotional distress and detrimental behaviour.
When we are in a state of dissatisfaction or distress, especially emotionally, we should
act to rectify the situation in some way and if this is not possible, we should try to reach
a state of acceptance. What we should not do is to constantly live in a state of tension
between these two poles. This is an area where acupuncture can often be of great help.
Harmonising the qi means the person can find the strength or the vision to act or they
can find the peace of mind that helps them to accept situations that cannot be changed.
It can also be relevant to explain to clients that we always have three possibilities in
life when we are not satisfied, whether it is with our present situation or our past. We can
act and try to change the situation. Sometimes this is a possibility; sometimes it is not. If
we have the ability to change anything that we are unhappy with, we should do this.
If, for example, we are dissatisfied with the way a person treats us, we can ask or tell
the person to act differently. We must not remain in a situation that makes us discontent
if we have the possibility or the ability do something about it. Many times, though, it
is not possible to change the situation. In this example, it could be that this person
cannot or will not change the way that they are behaving. If it is not possible to change
the situation itself, you can still act by moving away from the situation or the condition
that is making you discontent. We can get up and leave. This, though, is also not always
an option. There can be many reasons why people have to remain in an unsatisfactory
situation – economic reasons, family relationships, the limitations of the physical body,
chronic illness, fear or because what is creating the emotional pain happened years ago
in childhood. In these and many other situations, changing the situation or leaving it is
not a possibility. This then only leaves the option of acceptance – to accept things as they are
and thereby find peace. This peace of mind will often also mean that it becomes possible
to see what other options and possibilities there are in the situation.
We can illustrate this model by using a couple of examples. If we are dissatisfied with
something banal such as the colour of our bedroom wall, we can just paint it and then
we have rectified the situation that is causing the discontentment. The Danish weather,
though, is something that many people constantly complain about but have no influence
over. They cannot change the weather. Some people have the possibility to move to
another country with a different climate. This means that they can leave the situation
that is causing their dissatisfaction. However, most people do not have this possibility
due to financial reasons, family ties, employment situation, language difficulties and so
on. If they cannot move away from and cannot change the Danish climate, then there
is only one option left and that is acceptance: accepting things as they are and then
working within the options that are left. Through acceptance we will often not only
discover other possibilities, but also recognise what is advantageous or beneficial in the
situation. I am lucky: I love all kinds of weather and I love all seasons. Each season and
each climate has something special and something beautiful about it. Winter is hard for
some people, but the light in the winter in Denmark can be magical and the sensation
of the cold biting into my cheeks is something that I love. If I constantly fought against
the winter and was dissatisfied until the spring, I would not be able to appreciate this.
749
Clothing
Discussing clothing is particularly relevant for patients who are yang xu and wei qi xu
and those who have a tendency to be invaded by exogenous xie qi in certain areas of the
body, for example the knees or the lower back. Being appropriately dressed may sound
very trivial and obvious, but unfortunately this is certainly not the case for all clients.
Factors that may be relevant and can be reasons why clients dress inappropriately are:
• fashion
• poverty
• ignorance.
Unfortunately, it is only the latter that we, as therapists, can do anything about. We can
inform clients of the consequences that inadequate or inappropriate clothing will have
for their patterns of imbalance or their health, for example that exposure to cold and
dampness may be a factor in their knee pain and that it is therefore important that they
wear clothing that keeps their knees warm and dry. We must also, though, accept that
they may prioritise looking smart over keeping their knees warm and dry. What we have
given them is relevant knowledge so that they can make a conscious choice.
Exercise and rest

Exercise is good. However, this does not mean that the more you exercise the better it is.
It is typical of our Western, linear thinking that when something is good, even more of it
will be even better. Unfortunately, many of our clients live by this logic. One can quickly
see flaws in this logic if you replace the word ‘exercise’ with the words ‘eating food’.
Eating food is vital: if we did not eat food we would die, therefore eating food is good
for us. Nobody, though, is of the opinion that constantly eating excessive amounts of
food will benefit their health. However, we do see clients who are exercising themselves
to death because they believe that the more they train, the healthier they will be. We see
women who are extremely yin xu and xue xu running several kilometres a day, as well as
going to the gym, because they are training to do an Ironman event.
What makes things even more complicated is that it is not possible to say how
much exercise is too much or how little exercise is too little. The right amount of
exercise is completely individual and will depend on the person’s constitution, patterns
of imbalance, age and gender and the season, time of day and so on. This is something
that is hard to accept for many patients who are looking for straight guidelines. A rule
of thumb, though, is the more shi their imbalances and the more stagnation there is, the
more exercise and physical activity will be good for them (within reason). Likewise,
the more xu that their imbalances are, the less they should train.
Just as exercise is good, so is rest. Rest and relaxation are extremely important for all
people. This is something that many people do not consider in their attempt to achieve
a healthy lifestyle.
Sleeping, for example, is vital. However, as well as needing sleep, there must be a
balance between yang activity (both mental and physical) and yin rest. How the balance
between yin rest and yang activity should be is dependent on many factors, such as
constitution, age, gender, patterns of imbalance, diet and so on. Once again, there are
750
no fixed rules that people can grasp hold of. It is always a question of dosage – both too
much and too little rest and relaxation are harmful. Too little rest will initially exhaust
qi and yang, and over time it will exhaust xue, yin and finally jing. Too much rest, on the
other hand, and too little activity will stagnate qi initially, and with time it may stagnate
xue and jinye.
Sleeping at night should not be the only yin state a person experiences during a
24-hour period. People need to create spaces in their day when they consciously gear
down, relax and cultivate tranquillity of the mind and body. The more physically and
mentally active a person is, i.e. the more yang that they are, the more yin they need to
be to balance this. Sleep and physical relaxation are a good balance to physical activity,
whilst meditation, mindfulness, introspection and reflection are a good counterbalance
to mental over-stimulation and stress.
Yoga, tai ji and qi gong are physical activities that most people will benefit from. This
is because they combine physical movement of the body, and thereby the movement of
qi and xue, with mental relaxation and mindfulness. They are activities that harmonise
yin and yang at the same time. Furthermore, these forms of movement stimulate the
internal organs and the channel system, thereby increasing the production of qi. A
problem, though, is that they can be too slow for people whose shen is agitated by
Heat, especially when there is Liver qi stagnation Heat. These people will often not have
enough patience and they will experience these forms of movement as being too slow
and boring, which will further stagnate their Liver qi.
Following the natural rhythm of life

The invention of electric lighting has given us the possibility to disrupt the natural circadian
rhythm, which challenges our physiology. The evening and night are yin. These periods
of the day are dark and cool, activity decreases and there is tranquillity. Most animals and
birds go to rest. This is what most people did before the advent of electric lighting. Now
we have the opportunity to be alert and active at night because we have electric lighting
and have also acquired computers, smartphones and televisions, which are extremely shen
stimulating. Televisions, smartphones and computers activate our shen, which is the most
yang aspect of the body and thereby consumes yin. These devices are problematical enough
during the day if used excessively, but they are especially harmful in the evening and at
night, when shen should be calm and placid and we should be in a yin dormant state.
On the other hand, during the day when we should be yang and thereby physically
active, many people no longer work manually using their bodies. A great many people
now have sedentary daytime jobs that involve very little physical activity.
Unfortunately, it is not only the diurnal cycle we have become out of sync with.
December is the darkest and most yin time of year. Many animals hibernate or at least
significantly reduce their physical activity. Plants draw their sap down into their roots
or into a bulb in the ground. Traditionally, people who worked together with nature
would have had a high level of activity in the summer. In summer they would have
worked hard from when the sun rose at dawn until it set in the evening. In the winter
the working day would have been shorter and they would have got up later and gone
to bed earlier than they did in the summer. Winter was also characterised by the winter
solstice and, later on in history, Christmas. These were festivals of light during the dark
751
days of winter (the yang dot of white in the black yin of the taiji symbol). December
was a time for quiet communion and reflection. Now December has become the time
of the year when people run around like headless chickens and are constantly stressed
for a whole month. They rush around juggling Christmas shopping with office parties,
arranging family gatherings and cooking extravagant meals. As soon as Christmas is
over, this excessive yang activity continues with the New Year’s Eve celebrations. All of
this is then counterbalanced by people lying around lazing in the sun in a state of yin
passivity in the yang summer, when they should be physically active! Unfortunately, it is
unlikely that we as therapists are going to be able to rectify these tendencies in society.
Where we can have an influence is to increase people’s awareness of the cycles of
yin and yang. These cycles can be seen throughout life and are something we must accept
and adapt our lives to. When we are young, we have an excess of yang. This means that
it is not only beneficial, but also a necessity, that we are physically quite active. In this
period of life, there is also a more natural tendency to be more extrovert and sociable,
which is also a yang property.
As we age and our yang declines, we become less extrovert and seek more peace and
quiet. We have less energy available for physical exertion and a greater need to get to
bed at a proper time. It is important that we learn to listen to our bodies and our minds
and do not vainly try to fight against windmills by living like a 20-year-old when we
are 50. This is something we must try and make our clients aware of, especially as the
media has a tendency to glorify a yang, youthful lifestyle. Many middle-aged and older
people end up feeling inadequate or that there is something wrong with them, because
they physically cannot maintain, or no longer enjoy, this lifestyle, even though they did
when they were younger.
Acupressure
Acupressure is a good way to involve the client in their own healing process, thereby
creating quicker results. It also helps to give the client the responsibility and the tools to
maintain their own health. We must, however, also remember that most of our clients are
not acupuncturists and are not trained in locating acupuncture points. It can be difficult
for them to remember how many fingerwidths St 36 is located below the kneecap and how
far away from the shin bone. Initially, it can also be difficult to sense where an acupuncture
point is with your fingertips until you have trained and practised for a while. This is why I
usually choose acupressure points that are easy to locate, even though other points would
be more efficacious. So, for example, instead of recommending St 36, I would show them
how to locate and stimulate Sp 3, because it is easier to find. It is better that the client
stimulates an acupuncture point that is not the most effective than pressing the muscle five
centimetres adjacent to a more appropriate point.
Moxa
I sometimes give clients who are qi xu and yang xu a stick-on mini moxa to take home
with them. I give them detailed instruction and training in how to use the stick-on
mini moxa and what to be observant of. I also control them on return at the next
appointment. Like acupressure, the domestic use of moxa will speed up the healing
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process and it will involve the client in the treatment. Again, I only give them points
that are easy to locate and safe to use, as well as strict instructions not to use the moxa
on other places.
Meditation and mindfulness

Meditation is one of the best ways, apart from sleeping, that a client can nourish their
yin. It is not only patients who are yin xu, though, who will benefit from meditation.
As stated earlier, most people are too yang in their lifestyle and we constantly further
activate our yang aspects through the use of computers, smartphones, televisions and so
on in our leisure time. It is important to balance all this yang activity and stimulation
with yin tranquillity. Meditation is an excellent tool to cultivate quietude and something
that I encourage many clients to practise in some form or other.
I’m not an experienced meditation instructor, therefore I usually urge clients to
either find a meditation teacher or buy a meditation CD. I do, however, sometimes give
clients individual instructions. Again, it is important to be realistic in your expectations
and even more important to get the client to be realistic as well. Ten minutes a day, every
day, is far better than an hour’s session every second week.
I also use myself and my own experience as an example – I can find it difficult to
stay focused while I meditate. Sharing this experience is not only a relief, but also an
inspiration to many clients. Most people believe that it is only them who have this
problem and therefore that they are incapable of meditating. If they find out that
others, particularly people they look up to (which people unfortunately tend to do with
therapists), they become more willing to try to carry on, even though it is difficult.
Sometimes I do not use the term ‘meditation’, but instead just call it breathing
techniques and relaxation exercises, where they should sit or lie down, focus on their
breathing, possibly place a hand on their stomach, which should rise and fall each time
they breathe in and out, and relax as much as possible.
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Appendix 2
THE ENERGETIC PROPERTIES

OF CERTAIN FOODS
Cereals
Most cultures’ diet is cereal based. This is also in accordance with Chinese medicine
dietetic theories in which cereals such as rice, millet and corn should constitute the
greatest portion of food that is consumed.
Most grains are relatively neutral in their temperature and generally strengthen qi
and xue. This means that regularly consuming relatively large amounts of them will
generally not create imbalances in the body.
Most cereals also have slight Damp-draining qualities but unfortunately not all.
Modern wheat is particularly problematic. This is because as well as having a cooling
energy, wheat has also been modified to produce a higher yield and to suit the needs of
the baking industry. This has resulted in wheat having a tendency to produce Dampness
in the body. This is particularly problematical, given how many people’s diet is based on
the consumption of bread, pasta and other wheat-based foods.
Barley
Salty, sweet and slightly cooling. Drains Dampness and Heat; Nourishes yin.
Maize/corn
Sweet and neutral. Strengthens qi and xue.
Millet
Sweet, salty and neutral (some sources classify millet as being either slightly warming or
slightly cool). Strengthens the Kidney and Spleen qi; transforms Dampness and Phlegm.
Oats
Sweet, neutral/warm. Strengthens qi and nourishes xue.
Quinoa
Sweet, salty and slightly warm. Strengthens Kidney yang.
Rice
Neutral and sweet. Strengthens qi and xue; harmonises the Stomach and strengthens
the Spleen.
Rye
Bitter and neutral/slightly cooling. Drains Dampness.
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Appendix 2: The Energetic Properties of Certain Foods
Spelt
Sweet and neutral/slightly cooling. Strengthens qi and nourishes xue. Less Dampness
and Phlegm-creating than modern wheat.
Wheat
Sweet, cool or slightly cold. Drains Heat; nourishes the qi and nourishes xue. Has a
tendency to create Dampness and Phlegm.
Dairy products
Generally sweet and cool or neutral (goat and sheep milk is neutral or slightly warming,
which makes it a better option for people who are Spleen qi xu). Dairy products are very
rich in flavour (wei) and therefore can have a tendency to create Dampness.
Fish
Freshwater fish are usually sweet and salty in their flavour, whilst being neutral or
slightly warm in their temperature. Saltwater fish usually have a salty flavour and a cool
temperature. Trout is slightly hot and salmon is warm. A lot of shellfish are warming.
Fruit
Generally sweet, sour and sometimes bitter. Most fruit is cooling in its thermal dynamic.
Exceptions to this are apricot, raspberry and cherry, which are slightly warming. Tropical
fruit is generally cold and should preferably be eaten in warm, yang climates, not in the
autumn and winter in Northern Europe. The sweet and sour taste helps to create fluids,
but the sour taste will bind the fluids in the body, which is not good when there is
Dampness.
Meat
Meat is generally warm. Meat is good at tonifying yang, qi and xue. Because meat is very
rich in its flavour (wei), it can be difficult to transform and it can lead to the creation of
Phlegm and Heat.
The various kinds of organ meats, such as kidney, liver and so on, will tonify the
corresponding zangfu organ in the body. It is, however, highly recommended that the
liver and kidney are organic, due to the use of growth promoters, antibiotics, medicine
and other chemicals used in the production of meat.
Beef
Sweet and neutral or slightly warm.
Chicken
Sweet and warm.
Duck
Sweet, salty and neutral or slightly cooling. Nourishes yin and xue.
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Lamb
Sweet and hot. Strengthens qi and yang, nourishes xue. Can aggravate Heat and Fire
conditions.
Pork
Sweet, salty and neutral or slightly cooling. Nourishes yin and xue. Tendency to create
Dampness and Phlegm.
Venison
Spicy, sweet and hot. Strengthens qi and yang, circulates and invigorates xue. May
aggravate Heat and Fire conditions.
Nuts and seeds

Generally sweet, neutral or warm. Nuts are rich in flavour (wei). This means that they
also have a tendency to produce food stagnation, Dampness and Phlegm if too many
are eaten at a time.
Seaweed
Salt and cold. Nourishes yin; dissolves Phlegm accumulations and drains Heat.
Vegetables
Vegetables are generally neutral or cooling in their dynamic, although there are exceptions
(the onion family, for example, is warm). A rule of thumb is that vegetables that grow
quickly and contain a lot of water, for example lettuce, tomato, cucumber and so on,
are often more cooling. In the past, you could only grow and buy these vegetables in
the summer when their cooling energy was more appropriate to the yang season. Now
people eat them all year round, even in winter and in countries with a very yin climate.
Beans
Generally good for the Kidneys. Nourish xue and tonify qi. Dried beans help to
drain Dampness. Tofu is good for the Lung.
Green, leafy vegetables

Generally nourish xue and strengthen qi. Many of them will also cool the Liver and
nourish Liver yin. Cabbage is especially beneficial for the Intestines. White cabbage
is slightly warming, Chinese cabbage is a little more cooling and drains Damp-Heat.
Spinach soothes the walls of the Intestines and is beneficial when there is Heat or yin xu
in the Stomach and Large Intestine.
Lettuce, tomato, cucumber

Cold in their energy and therefore drain Heat.
756
Appendix 2: The Energetic Properties of Certain Foods
Mushrooms
Many mushrooms drain toxins and transform Phlegm.
Onion family
Warm, spicy and sweet. Due to their spicy flavour, plants from the onion family help to
disperse stagnations and expel exogenous xie qi.
Root vegetables
Generally sweet and generally strengthen the Stomach and Spleen qi. Nourish qi and
xue.
Temperature of common foods

Cold Cool Neutral Warm Hot
Asparagus Apple Alfalfa sprouts Basil Alcohol
Banana Aubergine Almonds Bell pepper Chilli
Bean sprouts Avocado Beans Blackcurrant Chocolate
Celery Barley Beef Butter Cinnamon
Crab Beer Beetroot Cherry Curry
Cucumber Broccoli Carrot Chicken Deep-fried food
Fruit juice Buckwheat Cauliflower Eel Garlic
Lemon Courgette Cheese Fennel Lamb
Melon Marjoram Corn Ginger Paprika
Salt Mushroom Cow milk Goat milk Pepper
Seaweed Orange Duck Ham Trout
Tofu Pea Egg (chicken) Leek Venison
Tomato Pear Goose Lobster Yogi tea
Watermelon Rabbit Grapes Nutmeg
Yoghurt Radishes Hazelnut Oats
Salad Herring Onion
Shrimp Lentil Oregano
Spearmint Mackerel Parsley
Spinach Millet 29
Peach
Strawberry Olive Rosemary
Tea Plum Sage
Wheat Pork Salmon
Potatoes Thyme
Rice Walnut
Rye
Sardines
Sesame
Spelt
757
Appendix 3
HERBAL FORMULAS
An Gong Niu Huang Wan

Niu huang 30g, shui niu jiao 30g, she xiang 7.5g, huang lian 30g, huang qin 30g, zhi
zi 30g, xiong huang 30g, bing pian 7.5g, yu jin 30g, zhu sha 30g, zhen zu 15g (to make
90 pills)
Ba Zhen Tang
Ren shen 9g, bai zhu 12g, fu ling 15g, zhi gan cao 3g, dang gui 15g, shu di huang 18g,
bai shao 15g, chuan xiong 9g
Ba Zheng San
Mu tong 3g, hua shi 21g, che qian zi 12g, qu mai 9g, bian xu 9g, zhi zi 6g, da huang 6g,
deng xin cao 6g, zhi gan cao 3g
Bai He Gu Jin Tang

Bai he 12g, sheng di huang 9g, shu di huang 9g, mai men dong 4.5g, xuan shen 2.4g,
chuan bei mu 4.5g, jie geng 2.4g, dang gui 9g, bai shao 3g, gan cao 3g
Bai Hu Jia Gui Zhi Tang

Shi gao 30g, zhi mu 9g, zhi gan cao 3g, geng mi 6g, gui zhi 9g
Bai Hu Tang
Shi gao 30g, zhi mu 9g, zhi gan cao 3g, geng mi 9g
Bai Tou Weng Tang

Bai tou weng 15g, huang bai 12g, huang qin 6g, qin pi 12g
Ban Xia Hou Po Tang

Ban xia 12g, hou po 9g, fu ling 12g, zi su ye 9g, sheng jiang 12g
Bao He Wan
Shan zha 18g, shen qu 6g, lai fu zi 3g, ban xia 9g, fu ling 9g, chen pi 3g, lian qiao 3g
Bei Xie Fen Qing Yin I

Bei xie 9g, yi zhi ren 9g, wu yao 9g, shi chang pu 9g, fu ling 9g
Bei Xie Fen Qing Yin II

Bei xie 10g, huang bai 3g, shi chang pu 3g, fu ling 5g, bai zhu 5g, lian zi xin 4g, dan
shen 7g, che qian zi 7g
758
Appendix 3: Herbal Formulas
Bei Xie Shen Shi Tang

Bei xie 9g, yi yi ren 15g, huang bai 9g, fu ling 12g, mu dan pi 9g, ze xie 9g, tong cao
6g, hua shi 15g
Bu Fei Tang
Huang qi 18g, shu di huang 18g, ren shen 9g, zi wan 6g, sang bai pi 9g, wu wei zi 6g
Bu Gan Tang
Shu di huang 15g, dang gui 9g, bai shao 12g, chuan xiong 6g, mu gua 6g, suan zao ren
9g, mai men dong 6g, zhi gan cao 3g
Bu Zhong Yi Qi Tang
Huang qi 15g, ren shen 9g, bai zhu 9g, dang gui 9g, chen pi 6g, chai hu 3g, sheng ma
3g, zhi gan cao 3g
Chai Hu Shu Gan Tang

Chai hu 6g, chuan xiong 4.5g, xiang fu 4.5g, chen pi 6g, zhi ke 4.5g, bai shao 4.5g, zhi
gan cao 1.5g
Chuan Xiong Cha Tiao Tang

Chuan xiong 12g, jing jie 12g, bai zhi 6g, qiang huo 6g, xi xin 3g, fang feng 4.5g, bo
he 2.4g, gan cao 6g
Da Bu Yin Wan
Shu di huang 18g, zhi mu 12g, huang bai 12g, gui ban 18g
Da Chai Hu Tang
Chai hu 15g, huang qin 9g, bai shao 9g, ban xia 9g, zhi shi 9g, da huang 6g, sheng jiang
15g, da zao 5pcs
Da Cheng Qi Tang
Da huang 12g, mang xiao 9g, zhi shi 12g, hou po 15g
Da Ding Feng Zhu

Bai shao 18g, e jiao 9g, gui ban 12g, sheng di huang 18g, huo ma ren 6g, wu wei zi 6g,
mu li 12g, mai men dong 18g, ji zi huang 2pcs, bie jia 12g, zhi gan cao 12g
Da Jian Zhong Tang

Hua jiao 6g, gan jiang 12g, ren shen 6g, yi tang 21g
Dan Shen Yin

Dan shen 30g, sha ren 5g, tan xiang 5g
Dao Chi San

Sheng di huang 9g, mu tong 9g, dan zhu ye 6g, gan cao 6g
759
Di Tan Tang
Ban xia 7.5g, dan nan xing 7.5g, fu ling 6g, zhi shi 6g, ju hong 4.5g, shi chang pu 3g,
ren shen 3g, zhu ru 2.1g, gan cao 2.1g
Ding Chuan Tang

Bai guo 9g, ma huang 9g, zi su zi 6g, kuan dong hua 9g, xing ren 6g, sang bai pi 9g,
huang qin 6g, ban xia 9g, gan cao 3g
Ding Zhi Wan

Ren shen 9g, fu ling 9g, yuan zhi 6g, shi chang pu 6g
Du Huo Ji Sheng Tang

Du huo 9g, sang ji sheng 6g, du zhong 6g, niu xi 6g, xi xin 3g, qin jiao 6g, fu ling 6g,
rou gui 6g, fang feng 6g, chuan xiong 6g, ren shen 6g, dang gui 6g, bai shao 6g, sheng
di huang 6g, gan cao 6g
E Jiao Ji Zi Huang Tang

E jiao 6g, bai shao 9g, shi jue ming 15g, gou teng 6g, sheng di huang 12g, mu li 12g,
luo shi teng 9g, fu shen 12g, ji zi huang 2pcs, zhi gan cao 1.8g
Er Chen Tang
Ban xia 15g, chen pi 15g, fu ling 9g, zhi gan cao 5g, sheng jiang 3g, wu mei 1pc
Fang Ji Huang Qi Tang

Fang ji 12g, huang qi 15g, bai zhu 9g, gan cao 6g, sheng jiang 4 slices, da zao 1pc
Fu Zi Li Zhong Tang
Fu zi 6g, ren shen 9g, bai zhu 9g, gan jiang 9g, zhi gan cao 6g
Gan Mai Da Zao Tang

Gan cao 9g, fu xiao mai 15g, da zao 6 pcs
Ge Gan Tang
Ge gen 12g, ma huang 6g, gui zhi 6g, bai shao 6g, sheng jiang 9g, da zao 4pcs, zhi gan
cao 6g
Ge Xia Fu Zhu Yu Tang

Dang gui 9g, chuan xiong 6g, tao ren 9g, hong hua 9g, mu dan pi 6g, chi shao 6g, wu
ling zhi 9g, yan hu suo 3g, wu yao 6g, xiang fu 4.5g, zhi ke 4.5g, gan cao 9g
Gui Pi Tang
Huang qi 12g, ren shen 6g, dang gui 6g, bai zhu 9g, fu ling 12g, long yan rou 9g, suan
zao ren 12g, yuan zhi 6g, mu xiang 4.5g, sheng jiang 6g, da zao 5pcs, zhi gan cao 6g
Gui Zhi Fu Ling Tang

Gui zhi 9g, fu ling 9g, mu dan pi 9g, tao ren 9g, chi shao 9g
760
Gui Zhi Tang

Gui zhi 9g, bai shao 9g, zhi gan cao 6g, sheng jiang 9g, da zao 3pcs
Hou Po Wen Zhong Tang

Hou po 12g, chen pi 12g, fu ling 9g, cao dou kou 6g, mu xiang 6g, gan jiang 4.5g, zhi
gan cao 3g, sheng jiang 3 slices
Huang Lian E Jiao Tang

Huang lian 12g, huang qin 6g, e jiao 9g, bai shao 6g, ji zi huang 2pcs
Huang Lian Jie Du Tang

Huang lian 9g, huang qin 6g, huang bai 6g, zhi zi 9g
Huang Qin Tang

Huang qin 9g, bai shao 9g, zhi gan cao 3g, da zao 4pcs
Huang Tu Tang
Zao xin huang tu 21g, bai zhu 9g, fu zi 9g, sheng di huang 9g, e jiao 9g, huang qin 9g,
gan cao 9g
Huo Po Xia Ling Tang

Huo xiang 6g, hou po 3g, ban xia 4.5g, fu ling 9g, xing ren 9g, yi yi ren 15g, bai dou
kou 3g, zhu ling 4.5g, dan dou chi 9g, ze xie 4.5g, tong cao 12g
Huo Xiang Zheng Qi Tang

Huo xiang 9g, ban xia 6g, bai zhu 6g, chen pi 6g, hou po 6g, jie geng 6g, da fu pi 3g, bai
zhi 3g, zi su ye 3g, fu ling 3g, zhi gan cao 7.5g, sheng jiang 6g, da zao 1pc
Ji Sheng Shen Qi Wan

Shu di huang 6g, shan zhu yu 12g, shan yao 12g, ze xie 12g, fu ling 12g, mu dan pi 12g,
fu zi 6g, rou gui 6g, chuan niu xi 6g, che qian zi 12g
Jian Pi Wan
Ren shen 6g, bai zhu 9g, fu ling 6g, chen pi 3g, shen qu 3g, sha ren 3g, mai ya 3g, shan
zha 3g, shan yao 3g, rou dou kou 3g, mu xiang 3g, huang lian 1.5g, gan cao 3g
Jin Gui Shen Qi Tang

Shu di huang 24g, shan zhu yu 12g, shan yao 12g, ze xie 9g, fu ling 9g, mu dan pi 9g,
fu zi 3g, gui zhi 3g
Ju Pi Zhu Ru Tang
Ju pi 9g, zhu ru 9g, ren shen 3g, sheng jiang 6g, da zao 4pcs, gan cao 3g
Juan Bi Tang
Qiang huo 9g, jiang huang 9g, dang gui 9g, chi shao 9g, fang feng 9g, huang qi 9g, zhi
gan cao 3g, sheng jiang 3g
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Li Zhong An Hui Tang

Ren shen 2.1g, bai zhu 3g, fu ling 3g, hua jiao 0.9g, wu mei 0.9g, gan jiang 1.5g
Li Zhong Tang
Ren shen 6g, gan jiang 6g, bai zhu 9g, zhi gan cao 6g
Ling Gan Wu Wei Jiang Xin Tang

Fu ling 12g, gan jiang 9g, xi xin 3g, wu wei zi 6g, gan cao 6g
Ling Jiao Gou Teng Yin

Ling yang jiao 4.5g, sang ye 6g, gou teng 9g, ju hua 9g, bai shao 9g, chuan bei mu 12g,
sheng di huang 15g, zhu ru 15g, fu shen 9g, gan cao 2.4g
Liu Jun Zi Tang

Ren shen 9g, bai zhu 6g, fu ling 9g, chen pi 6g, ban xia 6g, gan cao 3g
Liu Wei Di Huang Tang

Shu di huang 24g, shan zhu yu 12g, shan yao 12g, fu ling 9g, ze xie 9g, mu dan pi 9g
Long Dan Xie Gan Tang

Long dan cao 6g, huang qin 9g, zhi zi 9g, ze xie 9g, mu tong 9g, che qian zi 9g, dang
gui 3g, sheng di huang 9g, chai hu 6g, gan cao 6g
Ma Huang Tang
Ma huang 9g, gui zhi 6g, xing ren 9g, zhi gan cao 3g
Ma Zi Ren Wan
Huo ma ren 12g, bai shao 6g, zhi shi 6g, da huang 12g, hou po 6g, xing ren 6g
Mai Men Dong Tang

Mai men dong 9g, ban xia 6g, ren shen 6g, geng mi 9g, da zao 8 pcs, gan cao 3g
Ping Wei San

Cang zhu 15g, hou po 9g, chen pi 9g, gan cao 4.5g, sheng jiang 2 slices, da zao 2 pcs
Qi Ju Di Huang Tang
Shu di huang 24g, shan zhu yu 12g, shan yao 12g, fu ling 9g, ze xie 9g, mu dan pi 9g,
gou qi zi 9g, ju hua 9g
Qiang Huo Sheng Shi Tang

Qiang huo 6g, du huo 6g, gao ben 3g, fang feng 3g, chuan xiong 3g, man jing zi 2g,
zhi gan cao 3g
Qing Luo Yin

He ye 6g, jin yin hua 6g, si gua pi 6g, xi gua cui yi 6g, bian dou hua 6g, dan zhu ye 6g
762
Qing Qi Hua Tan Tang

Gua lou ren 9g, dan nan xing 6g, huang qin 6g, ban xia 9g, chen pi 6g, xing ren 6g, zhi
shi 6g, fu ling 6g
Qing Wei San

Sheng di huang 12g, dang gui 6g, huang lian 4.5g, mu dan pi 9g, sheng ma 6g
Qing Ying Tang

Shui niu jiao 60g, xuan shen 9g, sheng di huang 15g, mai men dong 9g, jin yin hua 9g,
lian qiao 6g, huang lian 4.5g, dan zhu ye 3g, dan shen 6g
Run Chang Wan

Huo ma ren 15g, tao ren 9g, dang gui 9g, sheng di huang 12g, zhi ke 6g
San Ren Tang

Xing ren 15g, yi yi ren 18g, bai dou kou 6g, hua shi 18g, tong cao 6g, dan zhu ye 6g,
ban xia 6g, hou po 6g
San Shi Tang

Hua shi 9g, shi gao 15g, han shui shi 9g, xing ren 9g, zhu ru 6g, jin yin hua 9g, jin zhi
1 glass, tong cao 6g
San Wu Bei Ji Wan

Da huang 30g, gan jiang 30g, ba dou 30g (made into pills)
San Zi Yang Qin Tang

Bai jie zi 6g, zi su zi 9g, lai fu zi 9g
Sang Ju Yin
Sang ye 7.5g, ju hua 3g, xing ren 6g, lian qiao 6g, bo he 2.5g, jie geng 6g, lu gen 6g,
gan cao 2.5g
Sang Xing Tang

Sang ye 3g, xing ren 4.5g, sha ren 6g, zhe bei mu 3g, dan dou chi 3g, zhi zi 3g, li pi 3g
Sha Shen Mai Men Dong Tang

Sha shen 9g, mai men dong 9g, yu zhu 6g, sang ye 4.5g, bian dou 4.5g, tian hua fen
4.5g, gan cao 3g
Shao Fu Zhu Yu Tang

Xiao hui xiang 1.5g, gan jiang 2g, yan hu suo 3g, dang gui 9g, chuan xiong 3g, rou gui
3g, mo yao 3g, chi shao yao 6g, pu huang 9g, wu ling zhi 6g
Shao Yao Tang

Bai shao 15g, dang gui 9g, huang lian 9g, bing lang 5g, mu xiang 5g, huang qin 9g, da
huang 9g, rou gui 5g, gan cao 5g
763
Shen Fu Tang
Ren shen 9g, fu zi 6g
Shen Tong Zhu Yu Tang

Qin jiao 3g, chuan xiong 6g, tao ren 9g, hong hua 9g, qiang huo 9g, mo yao 3g, dang
gui 9g, wu ling zhi 6g, xiang fu 3g, chuan niu xi 9g, di long 6g, gan cao 6g
Sheng Mai San

Ren shen 9g, mai men dong 15g, wu wei zi 6g
Shi Hui San

Da ji 9g, xiao ji 9g, he ye 9g, ce bai ye 9g, bai mao gen 9g, qian cao gen 9g, zhi zi 9g, da
huang 9g, mu dan pi 9g, zong lu pi 9g
Shi Wei San

Shi wei 6g, che qian zi 9g, qu mai 6g, hua shi 9g, dong kui zi 6g, jin qian cao 60g, hai
jin sha 30g, ji nei jin 15g
Si Miao San
Huang bai 12g, yi yi ren 12g, cang zhu 6g, huai niu xi 6g
Si Ni Tang
Fu zi 9g, gan jiang 4.5g, zhi gan cao 6g
Si Sheng Wan
He ye 9g, ai ye 9g, ce bai ye 12g, sheng di huang 15g
Si Wu Tang
Dang gui 9g, shu di huang 12g, bai shao 12g, chuan xiong 6g
Su Zi Jiang Qi Tang
Zi su zi 9g, ban xia 9g, dang gui 6g, qian hu 6g, hou po 6g, rou gui 3g, zhi gan cao 6g,
zi su ye 2g, sheng jiang 2 slices, da zao 1pc
Suo Quan Wan

Wu yao 12g, yi zhi ren 12g, shan yao 15g
Tao He Cheng Qi Tang

Tao ren 15g, da huang 12g, mang xiao 6g, gui zhi 6g, zhi gan cao 6g
Tao Hong Si Wu Tang

Shu di huang 15g, dang gui 12g, bai shao 9g, chuan xiong 9g, tao ren 6g, hong hua 6g
Tian Ma Gou Teng Yin

Tian ma 9g, gou teng 12g, shi jue ming 18g, zhi zi 9g, huang qin 9g, niu xi 9g, du zhong
12g, yi mu cao 9g, sang ji sheng 9g, ye jiao teng 9g, fu shen 9g
764
Tian Tai Wu Yao San

Wu yao 12g, mu xiang 6g, xiao hui xiang 6g, qing pi 6g, gao liang jiang 9g, bing lang
9g, chuan lian zi 12g, ba dou 70 pcs
Tian Wang Bu Xin Dan

Sheng di huang 24g, mai men dong 12g, tian men dong 12g, dang gui 12g, dan shen
3g, xuan shen 3g, suan zao ren 12g, bai zi ren 12g, ren shen 3g, fu ling 3g, yuan zhi 3g,
wu wei zi 3g, jie geng 3g
Wei Ling Tang

Ze xie 12g, fu ling 9g, zhu ling 9g, bai zhu 9g, gui zhi 9g, cang zhu 6g, hou po 12g, chen
pi 9g, gan cao 4.5g, sheng jiang 3 slices, da zao 2 pcs
Wen Dan Tang

Ban xia 6g, zhu ru 6g, zhi shi 6g, chen pi 6g, fu ling 9g, sheng jiang 4.5g, da zao 1pc,
zhi gan cao 3g
Wen Jing Tang

Dang gui 9g, wu zhu yu 9g, bai shao 6g, chuan xiong 6g, ren shen 6g, gui zhi 6g, e jiao
6g, mu dan pi 6g, ban xia 6g, mai men dong 9g, sheng jiang 6g, gan cao 6g
Wu Ling San
Fu ling 9g, zhu ling 9g, ze xie 15g, bai zhu 9g, gui zhi 6g
Wu Mei Wan
Wu mei 9g, xi xin 3g, gan jiang 6g, huang lian 9g, dang gui 3g, fu zi 3g, hua jiao 2g, gui
zhi 3g, ren shen 3g, huang bai 3g
Wu Pi San
Sheng jiang pi 9g, sheng bai pi 9g, chen pi 9g, da fu pi 9g, fu ling pi 9g
Wu Zhu Yu Tang
Wu zhu yu 12g, ren shen 9g, da zao 12 pcs, sheng jiang 18g
Xi Jiao Di Huang Tang

Xi jiao 3g, sheng di huang 24g, chi shao 12g, mu dan pi 9g
Xiao Chai Hu Tang

Chai hu 12g, huang qin 9g, ren shen 6g, ban xia 6g, zhi gan cao 4.5g, sheng jiang 9g,
da zao 4 pcs
Xiao Feng San

Dang gui 3g, sheng di huang 3g, fang feng 3g, chan tui 3g, zhi mu 3g, ku shen 3g, hei
zhi ma 3g, jing jie 3g, cang zhu 3g, niu bang zi 3g, shi gao 3g, mu tong 1.5g, gan cao
1.5g
765
Xiao Qing Long Tang

Ma huang 9g, gui zhi 6g, bai shao 9g, gan jiang 9g, xi xin 3g, wu wei zi 3g, ban xia 9g,
zhi gan cao 6g
Xiao Yao San

Chai hu 9g, dang gui 9g, bai shao 12g, bai zhu 12g, fu ling 15g, bo he 3g, wei jiang 6g,
zhi gan cao 6g
Xie Bai San

Di gu pi 15g, sang bai pi 15g, zhi gan cao 3g, geng mi 9g
Xie Xin Tang

Huang lian 3g, huang qin 9g, da huang 6g
Xing Su San
Zi su ye 6g, xing ren 6g, ban xia 6g, fu ling 6g, chen pi 6g, qian hu 6g, jie geng 6g, zhi
ke 6g, sheng jiang 6g, da zao 2pcs, gan cao 3g
Xue Fu Zhu Yu Tang

Tao ren 12g, hong hua 9g, dang gui 9g, sheng di huang 9g, chuan xiong 4.5g, chi shao
6g, chuan niu xi 9g, jie geng 4.5g, chai hu 3g, zhi ke 6g, gan cao 3g
Yi Pi Tang
Tai zi shen 12g, fu ling 9g, bai zhu 9g, jie geng 3g, shan yao 9g, lian zi rou 9g, yi yi ren
9g, qian shi 6g, bai bian dou 9g, shi hu 12g, gu ya 9g, zhi gan cao 3g
Yin Chen Zhu Fu Yu Tang

Yin chen hao 12g, bai zhu 9g, fu zi 6g, gan jiang 6g, rou gui 3g, zhi gan cao 6g
Yin Qiao San

Jin yin hua 9g, lian qiao 9g, jie geng 6g, bo he 6g, dan zhu ye 4.5g, gan cao 4.5g, jing
jie 4.5g, dan dou chi 4.5g, niu bang zi 9g, lu gen 6g
You Gui Wan

Shu di huang 24g, shan zhu yu 9g, shan yao 12g, gou qi zi 12g, tu si zi 12g, lu jiao jiao
12g, du zhong 12g, dang gui 12g, rou gui 9g, fu zi 9g
Zhen Gan Xi Feng Tang

Niu xi 30g, dai zhe shi 30g, long gu 15g, mu li 15g, gui ba 15g, bai shao 15g, xuan shen
15g, tian men dong 15g, chuan lian zi 6g, mai ya 6g, yin chen hao 6g, gan cao 4.5g
Zhen Ren Yang Zang Tang

Ren shen 6g, dang gui 9g, bai zhu 12g, rou dou kou 12g, rou gui 3g, bai shao 15g, mu
xiang 9g, he zi 12g, ying su ke 21g, zhi gan cao 6g
Zhen Wu Tang Tang

Fu zi 9g, bai zhu 6g, fu ling 9g, bai shao 9g, sheng jiang 9g
766
Zhi Bai Di Huang Tang

Shu di huang 24g, shan zhu yu 12g, shan yao 12g, fu ling 9g, ze xie 9g, mu dan pi 9g,
zhi mu 6g, huang bai 6g
Zhi Zi Dou Chi Tang

Zhi zi 9g, dan dou chi 9g
Zou Gui Wan

Shu di huang 24g, shan zhu yu 12g, shan yao 12g, gou qi zi 12g, tu si zi 12g, chuan niu
xi 9g, lu jiao jiao 12g, gui ban jiao 12g
767
GLOSSARY
A-shi points Spots on the body that are sore on palpation or are reactive.
Back-shu points Back transport points. Category of acupuncture points, all of which are located on the
Urinary Bladder channel. These acupuncture points can transport qi directly to their
same name internal organ.
Bao Envelope, wrapping. The Uterus; the place where the semen is stored; the space between
the Kidneys.
Bao luo The channel that connects the Kidneys and the Uterus.
Bao mai The channel that connects Heart and the Uterus.
Bei Sorrow, sadness, melancholy.
Ben Root or cause.
Bi Painful blockage of channel qi.
Biao Branch or manifestation.
Cou li The space between the skin and muscles; spaces in the tissue.
Cun Chinese body measurement unit.
Da qi ‘Big’ qi or air qi.
Fu Hollow organ.
Gao Fatty tissues.
Gu qi Food or basis qi. Gu qi is an antecedent and the foundation of xue and zong qi.
Huang Membranes.
Hui-gathering Hui can be translated as ‘meeting’, ‘collecting’ or ‘gathering’. It is a place where certain
points energies gather or meet.
Hun The ethereal spirit. The shen aspect of the Liver.
Jiao Space or burner. There are three jiao – san jiao. Some people define the three jiao as
being the organs that are located in that part of the body. Others define the three jiao as
being the cavity around these organs. A third definition is that san jiao is all the spaces
in the body, i.e. that san jiao can be defined as being the following: the space between
the organs; the spaces between connective tissue and the skin; the spaces in the tissue
itself and between the individual cells.
Jin Tendons.
Jin Thin, light body fluids.
Jing Essence or the innate qi inherited from the parents. The form of qi in the body that is
the most yin.
Jing Shock, fright, terror.
Jing luo Channels and collaterals.
Jinye Body fluids.
Jueyin Terminal yin. Liver and Pericardium.
Kong Fear.
Le Joy.
Luo-connecting The place on a channel where the luo-connecting vessel branches away from the primary
points channel.
Mingmen Gate of fire. The source of all yang qi in the body.
Mu-collecting Category of acupuncture points that are almost exclusively located on the front of the
points body. A mu-collecting point is the place where an organ’s qi collects.
Nu Anger.
Po Corporeal spirit. Shen aspect of the Lung.
Qi Qi is often translated as energy or bio-energy, but this is a very narrow definition of
something that is very encompassing and vast. Qi is the fundamental substance or
energetic matter of the universe. At the same time, qi is the energy or the potential that
creates all the movement and all change in the universe. In the body qi is the sum of all
768
Glossary
the vital substances and of all physiological activity in the body. At the same time, there
are specific forms of qi in the body that are further differentiated from each other.
Qi ji Qi mechanism, qi dynamic.
Rou Muscle, meat, flesh.
Shan Shan can have three definitions. It can be an organ or tissue that protrudes or has
sunk from its position, for example a hernia in Western medicine. It can be extreme
abdominal pain when there is concurrent urinary difficulty or constipation. Finally, it
may be disorders that relate to the external genitalia.
Shaoyang Lesser yang. San jiao and Gall Bladder.
Shaoyin Lesser yin. Heart and Kidneys.
Shen Shen encompasses concepts such as mind, awareness, consciousness, vitality and spirit.
Shen is the sum of all the five organs’ shen aspects, whilst being the specific shen aspect
of the Heart. Shen is the form of qi in the body that is most yang.
Shi Full, excess or surplus.
Shu transport Category of five points on each channel. The five shu-transport points are jing-well,
points ying-spring, shu-stream, jing-river and he-sea.
Si Worry, speculation, pensiveness.
Taiyang Greater yang. Urinary Bladder and Small Intestine.
Taiyin Greater yin. Spleen and Lung.
TCM Traditional Chinese Medicine.
Tian gui Heavenly or celestial water. Menstrual blood; semen. Created when jing is transformed
by Heart fire.
Wei qi Defensive or protective qi. The aspect of zhen qi that flows under the skin. Wei qi
moistens and warms the skin whilst protecting the body against invasions of xie qi.
Wu xing Five Phases, Five Movements or Five Elements.
Xi Happiness, joy, ecstasy.
Xi-cleft points Category of acupuncture points. Xi-cleft points are the place where qi gathers before
plunging deeper into channel.
Xie qi Evil, perverse or pathogenic qi. It is a pathological form of qi.
Xu Emptiness, vacuum, a lack of. Often translated as deficiency.
Xue Blood. Xue is a more physical form of qi. Xue is more than just blood in Western
physiology. Xue nourishes and moisturises the body. Xue also nourishes and anchors
shen.
Yang One of the two opposing but at the same time complementary forces in the universe.
Yangming Yang Brightness. Stomach and Large Intestine.
Ye The denser and more turbid aspect of the body fluids.
Yi Shen aspect of the Spleen. Yi can be defined as our mental faculties, our intellectual
focus and intention.
Yin One of the two opposing but at the same time complementary forces in the universe.
Ying qi Nourishing qi. Nourishes both zangfu organs and the whole body. Ying qi flows together
with xue in the channels.
You Oppression, anguish, restraint.
Yuan qi Original qi. Jing that has been transformed into qi.
Yuan-source The place on a channel where yuan qi enters the channel and the place where yuan qi
points can be accessed.
Yun hua Transportation and transformation.
Zang Solid organ.
Zangfu Internal organs.
Zhen qi True qi, formed when zong qi is transformed by yuan qi. Zhen qi has a yin and a yang
aspect that are wei qi and ying qi respectively.
Zheng qi Correct, upright or healthy qi. The sum of the body’s anti-pathogenic qi. The term is
normally only used as a contrast to xie qi.
Zhi Shen aspect of the Kidneys. Determination, will power.
Zong qi Basis, ancestral, inherited or gathering qi. Zong qi is generated when air inhaled by the
Lung is combined with gu qi.
769
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772
ENDNOTES
Part 1
1. Dao De Jing – Lao Zi.
2. Traditional Chinese Medicine (TCM) is a modern version of acupuncture, created in the second half
of the 20th century. It is based on classical Chinese acupuncture but is also heavily influenced by
modern Western medicine. TCM is the primary acupuncture style practised in mainland China today.
3. In Chinese medicine physiology, the Lung is a singular organ.
4. Qing is a green/blue colour and is described as the colour that a dragon has. A more domestic
comparison is the colour of peacock feathers or the colour on the head of a mallard duck.
5. In humans and most other mammals, cutaneous respiration accounts for one to two per cent of
respiration.
6. Western medicine differentiates between macules that are larger or smaller than one centimetre in
diameter. Chinese medicine does not have this differentiation.
7. ECIWO (Embryo Containing Information of the Whole Organism) is a modern acupuncture system.
8. Pain will always indicate that there is some form off stagnation. This is summarised in the saying ‘Bu
ze tong tong, tong ze bu tong’ which translates as ‘Where there is stagnation, there is pain. Where there
is free circulation, there is no pain.’
9. I have capitalised the names of specific Chinese medicine pulse qualities.
10. Older texts refer to only five zang organs – the Heart, Lung, Liver, Spleen and Kidneys.
11. For example, the Shen/Hammer pulse system,
12. The left side is considered to be yang. This is because when the Emperor sat on his throne facing south,
the Sun rose on the left side of his body and sank on the right side.
13. This is why it is unfortunate that arthritis patients and others with joint pain are encouraged to swim.
Exercise is good to move the stagnant qi and thereby relieve pain, but if they have Cold or Damp bi
syndrome, swimming can aggravate the cause of their qi stagnation.
Part 2
14. Although there is wei qi xu, it will never be a pure xu condition, because the moment the body is
invaded by xie qi there is a relatively shi condition due to the presence of xie qi in the body.
15. In ‘cross channel’ theory, acupuncture points are selected on the opposite side and in the opposite limb
to where the pain is. These acupuncture points must be located in a similar area, for example if the pain
is in the lateral side of the right ankle, you will select an equivalent point on the lateral side of the left
wrist, or on the equivalent spot on the same great channel, such as St 36 on the left side to treat the area
corresponding to LI 10 on the right side, because they are both yangming channel points.
16. An exception is shaoyang patterns. In shaoyang patterns xie qi is ‘locked’, the energetic ‘hinge’ between
the interior and the exterior.
17. Often it is only the hands that feel warm. It is rare for Western patients to report that they have a warm
sensation in the centre of the chest.
18. It is important that the liver is organic. This is because the Western function of the liver is to clean and
break down chemicals and drugs from the blood. This means that there will be a higher concentration
of toxins and chemicals in the liver than in other meat.
19. It is important to be aware of the seriousness of this situation, and the patient should be investigated
by a Western medicine doctor.
20. It is important to be aware of the seriousness of this situation, and the patient should be investigated
by a Western medicine doctor.
21. In Chinese medicine, fever is defined by the patient’s subjective sensation of heat in the body or
by the practitioner’s observation, i.e. palpation of the skin and visual observation, rather than via a
thermometer.
773
22. Another explanation is that Dryness is the climatic influence that resonates with the Metal Phase. The
Gobi desert, where the air is extremely dry, is located in the west of China.
23. For a more thorough discussion of Spleen yin xu, the reader is referred to Steve Clavey’s excellent article
on the subject in the Journal of Chinese Medicine (Clavey 1995).
24. It is the bitter taste that is traditionally associated with Fire conditions. My own experience is that
many of the patients whom I would expect to have a bitter taste in the mouth report that they have a
metallic taste instead. I therefore perceive the bitter taste as encompassing the metallic taste.
25. It is important that the liver is organic. This is due to the liver’s function of cleansing chemicals and
drugs from the blood, which means that there will be a higher concentration of toxins and chemicals
in liver than in other meat.
26. It is important that the liver is organic. This is due to the liver’s function of cleansing chemicals and
drugs from the blood, which means that there will be a higher concentration of toxins and chemicals
in liver than in other meat.
27. ‘Running piglet qi’ is a sensation that arises when rebellious qi ascends uncontrolled up through chong
mai. It can feel like ‘butterflies’ in the Stomach and chest, but it can also feel like a panic attack. There
are often palpitations, chest oppression, a choking sensation in the throat and an inner turmoil.
Appendices
28. Unfortunately, supermarkets and the food industry are aware that consumers consciously and
unconsciously choose such wares. This means that we are often deceived into believing that the
products are fresher and more vibrant than they really are. This is done using all sorts of practices and
substances that we would probably rather not know too much about.
29. Millet is classified in some texts as being neutral, whilst in others it is either slightly warm or slightly
cool.
774
INDEX
Page references to figures and tabular Large Intestine imbalances 430, headaches 239
summaries will be in italics and 431–2, 433, 434–5, 436 jinye imbalances
followed by the letters ‘f ’ or ‘t’, as Liver imbalances 599–600, fluids, accumulation of 382–3
appropriate. Names of herbs are 602, 604, 607, 609, 612, internally generated Dampness
in italics. 614, 616–17, 618–19, 620, 385
622–3, 625, 628, 631, 633, jinye xu 381
636, 639 Phlegm 391
abdomen Lung imbalances 400, 402, 404, mu-collecting points 191, 192–3
lumps 184–5 406, 408, 411, 412, 415, palpation of points 191–3
pain 184 417, 419, 421, 424, 426 patterns of imbalance 19–20
palpation of 183–7 Pericardium imbalances 579 pulse diagnosis 159
sounds 141–3, 185 Small Intestine imbalances 526, qi imbalances
temperature 183 528, 530 qi sinking 360–1
tension and hardness 183–4 Spleen imbalances 466–7, 469, qi xu 290, 358–9
zones 186–7 472, 477, 478–9, 481, 483, rebellious qi 365
acupressure 752 485 ren mai imbalances 724
acupuncture Stomach imbalances 441, 443, San Jiao theory
back-shu points 191, 192–3 445, 448, 449–50, 452, 456, lower jiao 707–8, 709, 711
chong mai imbalances 725 458 middle jiao 704, 705
dai mai imbalances 726 Urinary Bladder imbalances 536, upper jiao 697, 701, 702
diagnosis according to Eight 538, 540, 541, 543, 545 a-shi points 191
Principles model diagnosis according to the twelve Six Stages model
exterior imbalances 266, 267–8 regular channels jueyin stage 669
qi xu 290 Gall Bladder channel imbalances shaoyang stage 660
shi Cold 284 720 shaoyin stage 665, 667
shi Heat 274, 278 Heart channel imbalances 717 taiyang stage 648, 650, 652, 653
xue xu 293 Kidney channel imbalances 719 taiyin stage 662
yang xu 298 Large Intestine imbalances 716 yangming stage 656, 657–8
yin xu 296 Liver channel imbalances 721 xu Cold 287
diagnosis according to xie qi Lung channel imbalances 715 xue imbalances
Cold 318 Pericardium channel imbalances xue loss 379
exogenous Dampness 323 719 xue stagnation 193, 350, 373
exogenous Dryness 338 San Jiao channel imbalances 720 xue xu 293, 369
food stagnation 353–4 Small Intestine channel yang wei mai imbalances 728
internally generated Dampness imbalances 718 yin qiao mai imbalances 727
326 Spleen channel imbalances 717 yin wei mai imbalances 728
internally generated Dryness 340 Stomach channel imbalances 717 acupuncture channels
internally generated Wind 315 Urinary Bladder channel abdominal palpation 187
invasion of Exogenous Wind imbalances 719 diagnosis according to the 12
312–13 diagnostic approach 15, 18, 26, 27 regular channels 712–21
Phlegm 345 du mai imbalances 724 Gall Bladder channel imbalances
shi Heat and Fire 334–5 Five Element acupuncture system 720
Summer-Heat 330 37, 46 Heart channel imbalances 717
xu Heat 337 Five Phase diagnosis Kidney channel imbalances 719
xue stagnation 350 Ke phase dominating patterns Large Intestine channel imbalances
diagnosis according to zangfu 733, 734, 735 715–16
organ patterns Ke phase ‘insulting’ patterns Liver channel imbalances 720–1
Gall Bladder imbalances 583, 736, 737 Lung channel imbalances 715
585, 587, 589–90 Sheng phase patterns 730, 731, observation 112
Heart imbalances 496, 500, 502, 732 palpation 191–2
505, 508, 511, 513, 515–16, Four Levels model Pericardium channel imbalances
518, 519–20, 522 qi level 678, 679–80, 681, 683, 719
Kidney imbalances 551, 555, 685, 686–7 San Jiao channel imbalances
560, 562, 564, 566–7, 570, wei level 672, 674 719–20
572, 574, 576 xue level 691, 692, 694, 695 Small Intestine channel imbalances
Ying level 689 718
775
acupuncture channels cont. bian zheng lun zhi (differentiation gums 121
Spleen channel imbalances 717 of symptoms and signs by index finger vein 119
Stomach channel imbalances imbalance patterns) 17, 18–19, lips 120
716–17 20, 27, 33 mouth 72
Urinary Bladder channel Bin Hu Mai Xue (The Study of movement 117–18
imbalances 718–19 the Pulse by the Bin Hu Lake muscle tone 118
see also twelve regular channels, Master) 156 shen 117
diagnosis according to Birch, Stephen 186 skin colours 118
age/gender of patient 200–1 black hue, skin 59, 65, 106 sleeping position 122
aggressive voice 137 black macules 109 throat 120–1
An Gong Niu Huang Wan 330, 689, bleeding tongue 120
703, 758 disease history 204 veins 119
antibiotics 79 and dizziness 229 Chinese Medical Palmistry (Xiao and
appetite 215–16 menstrual 146, 204, 240, 241–4, Liscum) 103
Applied Channel Theory in Chinese 243, 244–5t Chinese medicine see Traditional
Medicine (Robertson) 193 spontaneous 33, 114 Chinese Medicine (TCM)
artificial lighting 41 visual observation 68, 73 chong mai imbalances 725
ascending Liver yang 605–8 vomit, blood in 218 abdominal symptoms 217
asthma sprays 79 xue loss 377–9 Eight Extraordinary Vessels,
auditory diagnosis 124, 125–38 blocked Heart vessels 498–501 diagnosis according to 725
focus areas 125–6 blue tinge, skin 59, 106 visual observation 70, 71
signs to look for 126 body hair 96, 97t Choppy pulse 160, 176
sounds from the abdominal cavity body language 29 Chuan Xiong Cha Tiao Tang 266,
141–3 body movements, visual observation 268, 284, 400, 759
sounds from the mouth, nose and 40, 42, 49–51, 117–18 Clinical Medicine Guide, The
chest 138–40, 141t body odour 144–5 (Gascoigne) 203
sounds of person in the clinic body shape and posture 44–9, 46t clothing
142–3 Five Phase body shapes 46–9 advice to patient 750
voice 126–38 general 44–5 colour choices 53–4
auricular acupuncture 113 body temperature 206–8 drabness 53–4
Auriculotherapy Manual (Oleson) bones, shen, observation of 42 harmony, dressing in 52–3
194 borborygmi 141 observation of 43, 52–4
breath, olfactory analysis 146 shen 43
breathing patterns clumsiness 51
Ba Hu Jia Gui Zhi Tang 758 auditory diagnosis 139–40 Cold
Ba Zhen Tang 294, 369, 513, 758 diagnostic approach 23 acupuncture 318
Ba Zheng San 758 visual observation 42 aetiology 316
Ba Zheng Tang 276, 294, 335, 536 Bu Fei Tang 291, 359, 415, 759 in children 117
Ba Zheng Wan 323, 708 Bu Gan Tang 294, 625, 759 clothing, observation of 52
Ba Zheng Wan Yu Dai Wan 327 Bu Zhong Yi Qi Tang 291, 361, 366, combined Hot and Cold imbalance
back muscles, visual observation 415, 424, 426, 472, 477, 759 patterns 288–9
98–9 bulla 110 diagnosis according to Eight
Bai He Gu Jin Tang 420, 422, 758 Principles model 270–1, 280–9
Bai Hu Jia Gui Zhi Tang 268 ‘false’ 57
Bai Hu Tang 330, 656, 678, 758 cardiac pain 225 herbal formulas 318–19
Bai Tou Weng Tang 276, 323, 327, caricatures 52 shi Cold 280–4
708, 758 cereals 754–5 stagnation 236
Bai Tou Weng Wan 430 Chai Hu Shu Gan Tang 363, 366, and Stomach qi xu 457–9
Ban Xia Hou Po Tang 366, 443, 496, 529, 600, 602, 759 symptoms and signs 317
634, 758 Cheng Zhong Ling 261 abdomen 185, 218
Bao He Wan 354, 446, 758 chest body movements 49, 50
barley 754 interviewing of patients in relation face 57, 58, 59
beans 756 to 224–8 menstrual problems 244
beef, consumption of 755 pain in 225 skin 105, 188
Bei Xie Fen Qing Yin I 538, 758 palpation of 187, 188t visual observation
Bei Xie Fen Qing Yin II 536, 758 visual observation 98 body movements 49, 50
Bei Xie Shen Shi Tang 323, 327, 759 chicken, consumption of 755 clothing 52
belching 142 children face 57, 58, 59
bi syndrome 101, 105, 188, 316 food stagnation 201 lips 70–1
bian bing lun zhi (differentiation of visual observation skin 105
symptoms and signs by disease ears 120 tongue diagnosis 83, 87, 88
category) 17–18, 27, 32 eyes 119–20 xie qi, diagnosis according to
see also Western diagnosis forehead/root of nose 67, 121 315–19
776
Index
yin nature 70–1, 105, 315–16 visual observation 59, 92 itch 230
see also Heat; Wind-Cold see also Urinary Bladder Damp- skin 107, 229
colours Cold sperm quality 249
clothing choices 53–4 Damp-Heat urinary disturbances 224
ears 120 acupuncture 430 vaginal discharge 245–6
energetic resonance 53 aetiology 429 visual observation
eyes 63–4 diagnosis according to xie qi acupuncture channels 112
area around 65–6 319–20 back 98
facial skin see facial colours diagnosis according to zangfu body movements 51
fingernails 103 organ patterns 428–31 clothing 54
gums 73 disease history 205 eyes 65
hair 95–6 Four Levels model nails 103
hands 101, 103 qi level 683–5 skin 107
nose 68 wei level 673–4 tongue diagnosis 79, 85, 86, 93
shi conditions 282 hand and foot palpation 190 xie qi 319–28
skin lesions 109 herbal formulas 430 see also Damp-Heat
tongue 22, 81–4, 84–5t invading the Large Intestine Damp-Phlegm
coating 92–3 428–31 acupuncture 406
vaginal discharge 115 invading the Spleen 468–70 aetiology 405
complaining/moaning 130, 139 invading the Stomach 450–2 herbal formulas 406
complex patients, treating 34 olfactory diagnosis 146 Lung imbalances 397, 404–7
‘difficult to treat, knotty diseases’ symptoms and signs 429–30 symptoms and signs 218, 227,
29 abdominal 221–2 405–6
concentration problems 253 genitalia, in men 250 visual observation 45, 59, 121
Confined pulse 172 hair/scalp 95, 98, 230 voice, auditory diagnosis of 134
conformism, clothes choices 52–3, impotence, in men 249 Dan Shen Yin 500, 759
54 skin 104, 107, 110, 111, 229, dandruff 111
constipation 220 230 Dao Chi San 276, 335, 527, 759
constitution 44 sperm quality 249 deafness 232
corn 754 sweating 214 Deep pulse group 170–2
Cosmological Five Phases see Five urinary disturbances 224 delirium 137
Phases visual observation Di Tan Tang 391, 760
coughing ears 69 Diagnosis in Chinese Medicine
auditory diagnosis 126, 140, 141t eyes 64, 65 (Maciocia) 103
chronic cough 226 face 59 diagnosis/diagnostic process 14
interviewing of patients 226–7 forehead/root of nose 67 approaches according to disease
Lung imbalances 397 hair/scalp 95, 98 category or imbalance patterns
cracking of skin 111 lips 71 17–19
cracks on tongue 88 nails 103 checklist approach, limitations
crusting of skin 111 secretions and exudations 114 of 30
crying 130, 139 skin 104, 107, 110, 111 combining of approaches 18–19
cystitis 223 stools 115 complex patients, treating 29, 34
tongue diagnosis 77, 83 diagnostic journal, correct use
see also Dampness; Gall Bladder of 30
Da Bu Yin 694, 695, 709 Damp-Heat; Heat; Intestines different processes/strategies 32–3
Da Bu Yin Wan 279, 303, 555, 759 Damp-Heat; Liver Damp- information gathering 21, 28,
Da Chai Hu Tang 678, 687, 759 Heat; Urinary Bladder Damp- 31–2
Da Cheng Qi Tang 658, 683, 704, Heat investigation 30
759 Damp-Heat in the Liver 619–21 lack of standard treatments for
Da Cheng Tang 678 Damp-Heat in the lower jiao 706–8 specific diseases 19–20
Da Ding Feng Zhu 617, 693, 711, Damp-Heat in the upper jiao linear approach 17, 18
759 698–700 process starting at first contact 28
Da Jian Zhong Tang 448, 759 Dampness skills 14–15
dai mai imbalances 725–6 abdominal palpation 184 structured approach 29–30, 40
dairy products 755 disease history 204 telescope metaphor 19
Damp-Cold emotional problems 252 time constraints 32
acupuncture 433 Exogenous 319, 320, 321–2t, in Traditional Chinese Medicine
aetiology 432 323–4 17, 31
herbal formulas 433 fatigue 211–12 Western see Western diagnosis
invading the Large Intestine 432–4 hair 230 see also diagnostic pillars;
invading the Spleen 465–7 headaches 239 diagnostic perquisites
symptoms and signs 246, 433 internally generated 319, 324–8
777
diagnostic models 33–4, 258–60 Lung imbalances 397 elasticity, skin 108
diagnosis according to Eight seasonal pattern 337 elderly people, body movements 50
Principles model see Eight visual observation 71, 111 emotions
Principles model xie qi 337–40 interviewing of patients 251–3
diagnosis according the Eight yang nature 338 mental and emotional approach to
Extraordinary Vessels 722–37 dryness, hair 95 life 748–9
diagnosis according to qi, xue and Du Huo Ji Sheng Tang 268, 760 and the voice 131–2
jinye imbalances 355–92 du mai 68, 70 Empty pulse 168
diagnosis according to the 12 du mai imbalances 723–4 energy levels 209–12
regular channels 712–21 duck, consumption of 755 environment, response to 43
diagnosis according to the Four Duo Huo Ji Sheng Tang 284 Er Chen Tang 327, 345, 391, 406,
Levels 669–96 760
diagnosis according to the san jiao erosion, skin 111
theory 696–711 E Jiao Ji Zi Huang Tang 619, 760 excoriation of skin 111
diagnosis according to the Six ear acupuncture 113 exercise 254, 299, 750
Stages 642–9 ears Exogenous Dampness 323–4
diagnosis according to xie qi children 120 acupuncture 322–3
305–54 discharges/exudations from 69–70, aetiology 320
diagnosis according to zangfu 114 herbal formulas 323
organ patterns 393–640 interviewing of patients in relation symptoms and signs 321–2t
outline of 259 to 231 Exogenous Dryness 338–9
diagnostic pillars shape 69 exterior imbalances 263–8
auditory and olfactory 124–46 visual diagnosis 69–70, 120 acupuncture 266, 267–8
interviewing of patients 195–255 Earth dominates Water 733 acute 264–5
palpation 148–94 Earth not generating Metal 730 chronic 267–8
questions to ask 37 Earth type, Five Phase system 48, herbal formulas 266, 268
symptoms and signs 37–8 130, 131 symptoms and signs 265–6, 267
use of all four 31 eating 254, 745–8 exudations 114–15
visual see visual observation Eight Extraordinary Vessels, eyes
diagnostic perquisites diagnosis according to 722–37 area around the eyes 65–6
experience 14, 25 chong mai imbalances 725 ‘bags’ under the eyes 66
imbalance patterns, identifying dai mai imbalances 725–6 in children 119–20
17, 24–5 du mai imbalances 723–4 colours 63–4
intuition 25–6 and Five Phases, diagnosis exudations 114
‘norm’, recognising deviations from according to 729–37 inflammation 64
15, 22–3, 36, 52 Ke phase dominating patterns interviewing of patients in relation
techniques, knowledge and skill 732–5 to 231
23–4 Ke phase ‘insulting’ patterns 735–7 puffiness 66
understanding of Chinese medicine ren mai imbalances 724 shen 42, 62
physiology and pathology 21–2 Sheng phase patterns 729–32 styes 64
diarrhoea 77, 221–2 yang qiao mai imbalances 727 tears and mucous 64–5, 233
diet 254–5 yang wei mai imbalances 728 visual observation 61–6
difficulty adhering to dietary yin qiao mai imbalances 726–7 zones 63
recommendations 739–41 yin wei mai imbalances 727–8
lack of familiarity with/access to Eight Principles model 34
certain foods 741 benefits of use 262 face
Ding Chuan Tang 366, 760 clothing, observation of 52 areas of face 60
Ding Zhi Wan 516, 760 Cold 270–1, 280–8 colours see facial colours
disease history 204–6 combined Hot and Cold imbalance moistness 57, 58
dizziness 18, 228–9, 342 patterns 288–9 observation of 55–60
drabness, clothing 53–4 diagnosis according to 261–304 radiance 57
drinks, affecting tongue diagnosis 79 diagnostic approach 20 shen 42
drooling from mouth 72 exterior imbalances 263–8 tics 60
Drumskin pulse 167 facial colours 56–7 wrinkles 67
dry voice 136 Heat 271–80 zangfu organs 61f
Dry-Heat 674–6 interior imbalances 263, 268–70 facial colours
Dryness pulse diagnosis 148 area around the eyes 65–6
coughing 226–7 Shi conditions 289, 300–1 Eight Principles model 56–7
Exogenous 338–9 tongue diagnosis 78f, 91t intensity and depth 57
internal 339–40 Xu conditions 289–300 normal 42, 58
itch 230 yin and yang 261, 301–4 pathological 58–60
Large Intestine imbalances 434–5 ejaculation, uncontrolled 249 in relation to Five Phases 55
see also face
778
Index
faeces see stools diagnosis according to zangfu Gan Mai Da Zao Tang 590, 760
Faint pulse 180 organ patterns 444–7 Gascoigne, Stephen 203, 204
false Heat and Cold 57 herbal formulas 354, 446 gasping 139
false shen 43–4 insomnia 234 gates, index finger 119
Fang Ji Huang Qi Tang 383, 760 symptoms and signs 353, 444–5 Ge Gan Tang 760
fatigue visual observation 91 Ge Gen Tang 648
Dampness 211–12 foods Ge Xia Fu Zhu Yu Tang 450, 760
Phlegm 211–12 affecting tongue diagnosis 79 Ge Xia Zhu Yu Wan 604
qi stagnation 211 cereals 754–5 genitalia, in men 250
qi xu 209–10 dairy products 755 gravelly voice 136
xue xu 210 energetic properties 754–7 green macules 112
yang xu 210 fish 755 green skin 58, 106
yin xu 211 fruit 755 green vegetables 756
feet 190–1, 208 meat 755–6 grey hair 95–6
fertility problems 242 nuts and seeds 756 grey skin, face 58
Fine pulse 180 seaweed 756 Gui Pi Tang 294, 479, 486, 513,
fingernails 103, 104t vegetables 756–7 522, 639, 760
fingers 101–3 forehead/root of nose, visual Gui Zhi Fu Ling Tang 351, 373, 760
Fire not generating Earth 730 observation 66–8 Gui Zhi Tang 266, 400, 650, 761
Fire type, Five Phase system 47, Four Levels model 212 gums, visual observation 73, 121
129–30 diagnosis according to 669–96
first impressions 28, 39 qi level 676–87
fish 755 wei level 670–6 hair
Five Element acupuncture system xue level 690–6 body hair 96, 97t
37, 46, 55, 144–5 Ying level 687–96 colour 95–6
Five Element Constitutional fruit 755 dryness 95
Acupuncture (Hicks and Mole) Fu Zi Li Zhong Tang 436, 760 hair loss 95–6
144 Full pulse 152, 181 head 94–6
Five Elements and Ten Stems Fundamentals of Acupuncture, The interviewing of patients in relation
(Matsumoto and Birch) 186 (Ching) 251, 254 to 230
‘five palm Heat’ 207 scalp 96
Five Phase diagnosis 729–37 halogen lighting 79, 80
body shapes 46–9 Gall Bladder Damp-Cold 582–4 hands
Earth type 48, 130, 131 Gall Bladder Damp-Heat palpation of 190–1
Fire type 47, 129–30 aetiology 584 temperature 208
Hara diagnosis 185 diagnosis according to zangfu visual observation 101–3, 104t
Ke phase dominating patterns organ patterns 584–6 Hara diagnosis 185–7
732–5 symptoms and signs 232, 584–5 headaches 18, 239–40, 241t
Ke phase ‘insulting’ patterns 735–7 visual observation 59, 69–70, 71 exterior imbalances 264–5
Metal type 48–9, 130, 131 Gall Bladder Heat 69, 686–7 hearing, diagnosis using see auditory
Sheng phase patterns 729–32 Gall Bladder imbalances diagnosis
visual observation 46–9, 55 abdominal palpation 184 hearing difficulties 232
voice 129–35, 135–6t chest palpation 187 Heart and Gall Bladder qi xu
Water type 49, 130, 131 combined patterns 588–90
Wood type 47, 130–1 Heart and Gall Bladder qi xu Heart Fire
flaccidity, tongue 87 588–90 acupuncture 508
flatulence 142, 146, 222 Liver and Gall Bladder Damp- aetiology 506
Flaws, Bob 32, 198 Heat 586–8 auditory diagnosis 127
Flooding pulse 169–70 diagnosis according to zangfu diagnosis according to zangfu
flowcharts 34 organ patterns 580–90 organ patterns 506–9
fluids, accumulation of 381–4 Gall Bladder channel imbalances herbal formulas 508
acupuncture 382–3 720 symptoms and signs 506–7
aetiology 382 Gall Bladder Damp-Cold 582–4 Heart imbalances
herbal formulas 383 Gall Bladder Damp-Heat see Gall aetiology 488–90
symptoms and signs 382 Bladder Damp-Heat appetite 216
food stagnation general symptoms and signs 581 combined patterns, Heart xue su
acupuncture 445–6 see also Gall Bladder Damp-Heat; and Spleen qi xu 520–4
aetiology 352–3, 444–5 Gall Bladder qi xu; Gall diagnosis according to zangfu
appetite 217 Bladder Wind-Heat organ patterns 487–524
in children 201 Gall Bladder qi xu 142 general symptoms and signs 494–5
diagnosis according to xie qi 352–4 Gall Bladder Wind-Heat 69 Heart channel imbalances 717
Gan Jiang Ling Zhu Tang 418 Heat 196
779
Heart imbalances cont. combined Hot and Cold imbalance Bai Hu Jia Gui Zhi Tang 268
pathology 490–4 patterns 288–9 Bai Hu Tang 330, 656, 678, 758
shi patterns 495–509 diagnosis according to Eight Bai Tou Weng Tang 276, 323, 327,
blocked Heart vessels 498–501 Principles model 270–80 708, 758
Heart Fire 506–9 excessive 45 Bai Tou Weng Wan 430
Heart qi stagnation see Heart qi exterior and interior imbalances Ban Xia Hou Po Tang 366, 443,
stagnation 264 496, 634, 758
Heart xue stagnation see Heart ‘false’ 57 Bao He Wan 354, 446, 758
xue stagnation ‘five palm Heat’ 207 Bei Xie Fen Qing Yin I 538, 758
Phlegm obscuring the shen 501–3 in Heart 196 Bei Xie Fen Qing Yin II 536, 758
Phlegm-Heat agitating the Heart herbal formulas 432 Bei Xie Shen Shi Tang 323, 327,
503–6 insomnia 234 759
voice, auditory diagnosis of 126–7, in Large Intestine 431–2 Bu Fei Tang 291, 359, 415, 759
133 pulse diagnosis 178 Bu Gan Tang 294, 625, 759
xu patterns 509–20 symptoms and signs 431 Bu Zhong Yi Qi Tang 291, 361,
Heart qi xu see Heart qi xu abdominal 218, 222 366, 415, 424, 426, 472, 477,
Heart xue xu 512–14 skin 188 759
Heart yang collapse 519–20 urinary disturbances 223 Chai Hu Shu Gan Tang 363, 366,
Heart yang xu 517–19 vaginal discharge 246 529, 600, 602, 759
Heart yin xu see Heart yin xu temporary state 71 Chuan Xiong Cha Tiao Tang 266,
Heart qi stagnation tongue diagnosis 82, 83, 85, 86, 268, 284, 400, 759
acupuncture 496 88, 92 Da Bu Yin 694, 695, 709
aetiology 495 visual observation Da Bu Yin Wan 279, 303, 555, 759
auditory diagnosis 127 body movements 49, 50 Da Chai Hu Tang 678, 687, 759
diagnosis according to zangfu clothes 52 Da Cheng Qi Tang 658, 683, 704,
organ patterns 495–7 eyes 63 759
herbal formulas 496 face 56 Da Cheng Tang 678
palpitations 225 forehead/root of nose 67 Da Ding Feng Zhu 617, 693, 711,
symptoms and signs 495–6 joints 100 759
visual observation 62 skin 109 Da Jian Zhong Tang 448, 759
Heart qi xu veins 102 Dan Shen Yin 500, 759
acupuncture 515–16 voice, auditory diagnosis of 126, Dao Chi San 276, 335, 527, 759
aetiology 515 133, 135, 136, 137 Di Tan Tang 391, 760
auditory diagnosis 127 yang nature 82, 87, 105, 232–3 Ding Chuan Tang 366, 760
diagnosis according to zangfu see also Cold; Gall Bladder Heat; Ding Zhi Wan 516, 760
organ patterns 514–17 Intestines Heat; Kidney Heat; Du Huo Ji Sheng Tang 268, 760
herbal formulas 516 Kidney yin xu Heat; Liver Duo Huo Ji Sheng Tang 284
palpitations 225 Heat; Lung Heat; Pathogenic E Jiao Ji Zi Huang Tang 619, 760
symptoms and signs 515 Heat; Phlegm-Heat; Spleen Er Chen Tang 327, 345, 391, 406,
visual observation 62 Heat; Stomach Heat; Systemic 760
Heart xue stagnation Heat; Toxic-Heat; Urinary Fang Ji Huang Qi Tang 383, 760
aetiology 497 Bladder Heat; Wind-Heat; xue Fu Zi Li Zhong Tang 436, 760
diagnosis according to zangfu Heat Gan Jiang Ling Zhu Tang 418
organ patterns 497–8 Heat and Fire 331–3 Gan Mai Da Zao Tang 590, 760
symptoms and signs 58, 225, Heat blocking the Pericardium Ge Gan Tang 760
497–8 578–80 Ge Gen Tang 648
visual observation 58 Heat in the chest and diaphragm Ge Xia Fu Zhu Yu Tang 450, 760
Heart xue xu 512–14 680–2 Ge Xia Zhu Yu Wan 604
Heart yang collapse 519–20 Heat in the Stomach and Intestines Gui Pi Tang 294, 479, 486, 513,
Heart yang xu 517–19 682–3 522, 639, 760
Heart yin xu heat loss 45 Gui Zhi Fu Ling Tang 351, 373,
acupuncture 511 Heat qi xu, auditory diagnosis 142 760
aetiology 509 herbal formulas Gui Zhi Tang 266, 400, 650, 761
diagnosis according to zangfu An Gong Niu Huang Wan 330, Hou Po Wen Zhong Tang 467, 761
organ patterns 509–12 689, 703, 758 Huang Lian E Jiao Tang 667, 761
herbal formulas 511 Ba Hu Jia Gui Zhi Tang 758 Huang Lian Jie Du Pian 441
insomnia 235 Ba Zhen Tang 294, 369, 513, 758 Huang Lian Jie Du Tang 276, 430,
symptoms and signs 509–11 Ba Zheng San 758 452, 761
visual observation 97 Ba Zheng Tang 276, 335, 536 Huang Lian Tang 335
Heat Ba Zheng Wan 323, 708 Huang Qin Tang 323, 327, 335,
acupuncture 431–2 Ba Zheng Wan Yu Dai Wan 327 761
aetiology 431 Bai He Gu Jin Tang 420, 422, 758 Huang Tu Tang 761
780
Index
Huo Po Xia Ling Tang 674, 699, Shen Tong Zhu Yu Tang 351, 373, hiccupping 141
761 764 Hicks, John and Angela 144
Huo Xiang Zheng Qi Tang 266, Sheng Mai San 426, 516, 764 Hidden pulse 171
268, 284, 313, 318, 323, 327, Shi Hui San 764 hoarse voice 136
433, 761 Shi Wei San 764 Hollow pulse 168
Ji Sheng Qi Wan 761 Si Miao San 327, 764 Hou Po Wen Zhong Tang 467, 761
Ji Sheng Shen Qi Wan 383 Si Ni Tang 665, 764 Huang Di Nei Jing – Ling Shu
Jia Wei Xiao Yao Wan 602 Si Sheng Wan 376, 764 (The Yellow Emperor Classic –
Jian Pi Wan 354, 446, 761 Si Wu Tang 294, 764 Spiritual Axis) 46–7, 58, 60
Jin Gui Shen Qi Tang 287, 291, Su Zi Jiang Qi Tang 366, 409, 418, Huang Di Nei Jing – Su Wen (The
299, 557, 560, 576, 761 562, 764 Yellow Emperor’s Classic –
Ju Pi Zhu Ru Tang 366, 761 Suo Quan Wan 543, 764 Simple Questions) 60, 151
Juan Bi Tang 313, 318, 323, 761 Tao He Cheng Qi Tang 350, 373, Huang Lian E Jiao Tang 667, 761
Li Zhong An Hui Tang 532, 762 653, 764 Huang Lian Jie Du Pian 441
Li Zhong Tang 284, 287, 318, 418, Tao Hong Si Wu Tang 350, 373, Huang Lian Jie Du Tang 276, 430,
458, 475, 576, 662, 762 764 452, 761
Ling Gan Wu Wei Jiang Xin Tang Tian Ma Gou Teng Yin 315, 607, Huang Lian Tang 335
406, 762 764 Huang Qin Tang 323, 327, 335, 761
Ling Jiao Gou Teng Yin 612, 614, Tian Tai Wu Yao San 531, 545, Huang Tu Tang 761
762 623, 765 hun 62, 234, 292, 591
Liu Jun Zi Tang 291, 359, 456, Tian Wang Bu Xin Dan 279, 511, Huo Po Xia Ling Tang 674, 699, 761
472, 483, 762 572, 765 Huo Xiang Zheng Qi Tang 266, 268,
Liu Wei Di Huang Tang 296, 552, Wei Ling Tang 327, 765 284, 313, 318, 323, 327, 433,
570, 628, 762 Wen Dan Tang 391, 505, 765 761
Long Dan Xie Gan Tang 276, 323, Wen Jing Tang 284, 319, 765 husky voice 136
327, 335, 376, 585, 588, 609, Wu Ling San 383, 652, 765 hypochondria 238
621, 762 Wu Mei Wan 532, 669, 765
Long Dan Xie Gan Wan 636 Wu Pi San 383, 765
Ma Huang Tang 266, 284, 313, Wu Zhu Yu Tang 669, 765 imbalance patterns, identifying
318, 400, 648, 762 Xe Bai San 678 17–20
Ma Zi Ren Wan 432, 762 Xi Bai San 413 acupuncture points, choice of
Mai Men Dong Tang 340, 381, 762 Xi Jiao Di Huang Tang 376, 691, 19–20
Mai Wei Di Huang Tang 574 765 difficulty complying with
Ping Wei San 327, 385, 762 Xiao Chai Hu Tang 660, 765 recommendation 742
and pulse diagnosis 159 Xiao Feng San 327, 376, 765 exterior imbalances 263–8
Qi Ju Di Huang Tang 570, 762 Xiao Qing Long Tang 266, 313, mistakes with relation to 33–4
Qiang Huo Sheng Shi Tang 268, 383, 404, 409, 766 multiple patterns 34
762 Xiao Yao San 600, 766 own patterns, consciousness of
Qin Qi Hua Tan Tang 391, 678, Xiao Yao Wan 631 29–30
680, 701 Xie Bai San 276, 335, 680, 701, studying 24–5
Qing Luo Yin 330, 762 766 see also bian zheng lun zhi
Qing Qi Hua Tan Tang 681, 763 Xie Xin Tang 508, 766 (differentiation of symptoms
Qing Wei San 276, 335, 441, 763 Xing Su San 313, 339, 766 and signs by imbalance
Qing Ying Tang 376, 579, 689, Xue Fu Zhu Yu Tang 351, 373, patterns); diagnostic models
703, 763 498, 766 Imperial fire 246
Run Chang Wan 435, 763 Yan Hu Suo San 604 impotence, in men 248–9
San Ren Tang 323, 327, 452, 470, Yi Pi Tang 481, 766 infants 201
685, 706, 763 Yin Chen Zhu Fu Yu Tang 583, 766 inflammation 64, 69
San Shi Tang 330, 763 Yin Qiao San 266, 275, 313, 335, information gathering 21, 28, 126
San Wu Bei Ji Wan 319, 433, 763 672, 698, 766 conflicting information, managing
San Zi Yang Qin Tang 406, 763 You Gui Wan 287, 299, 557, 560, 31–2
Sang Ju Yin 672, 763 766 insomnia 234
Sang Xing Tang 313, 339, 676, 763 Zhen Fu Tang 520 interior imbalances 263, 268–70
Sha Shen Mai Men Dong Tang 420, Zhen Gan Xi Feng Tang 617, 766 Intermittent pulse 173
454, 763 Zhen Ren Yang Zang Tang 436, 766 Internal Heat 207, 217
Shao Fu Shu Yu Tang 540 Zhen Wu Tang Tang 518, 565, 766 internally generated Dampness
Shao Fu Zhu Yu Tang 351, 373, Zhi Bai Di Huang Tang 279, 337, acupuncture 326, 385
763 555, 628, 767 aetiology 324, 384
Shao Yao Tang 430, 763 Zhi Zi Dou Chi Tang 678, 681, diagnosis according to xie qi 324–8
Shen Fu Tang 304, 764 767 herbal formulas 327, 385
Shen Ling Bai Zhu Tang 456, 483 Zou Gui Wan 296, 552, 567, 570, jinye imbalances 384–92
Shen Ling Bai Zhu Wan 454 767 symptoms and signs 324–5,
herpes simplex 71 325–6t
781
internally generated Wind jing xu, visual observation 69, 95, Kidney yang xu, overflowing
skin 230 96, 98 water 563–5
visual observation 72, 100 Jing Yue Quan Shu (Jing Yue Kidney yin xu see Kidney yin xu
xie qi, diagnosis according to Complete Book) 156 Kidney yin xu Heat 553–5
314–15 jinge, visual observation 100, 101 Kidney jing, visual observation 69
interviewing of patients 29–30, 31 jinye imbalances 380–92 Kidney jing xu
current medication 203–4 fluids, accumulation of 381–4 aetiology 566
as diagnostic pillar 195–255 internally generated Dampness diagnosis according to zangfu
disease history 204–6 384–92 organ patterns 565–7
ears and eyes 231 jinye xu 380–1 ears 231, 232
emotions and mental state 251–3 Phlegm 386–92 herbal formulas 567
employment 202 joints, visual observation 100–1 symptoms and signs 566
energy levels 209–12 joy and laughter, voice 129–30, 131 Kidney qi not grasping Lung qi
enquiry specific to men 248–50 Ju Pi Zhu Ru Tang 366, 761 561–2
enquiry specific to women 241–8 Juan Bi Tang 313, 318, 323, 761 Kidney qi xu
family situation 202–3 jueyin energetic stage 643, 668–9 aetiology 559
general questions 200–4 Ju-Yi, Wang 193 diagnosis according to zangfu
habitation 202 organ patterns 559–62
housing 202 symptoms and signs 559–60
lifestyle and diet 254–5 ke cycle 55 Kidney xu 53, 59
medical history 203 Ke phase dominating patterns 732–5 Kidney yang xu
sleep patterns 234–5 Earth dominates Water 733 acupuncture 557
stools 220–2, 222–3t Fire dominates Metal 734 aetiology 556
sweating 212–14 Water dominates Fire 733–4 diagnosis according to zangfu
techniques 196–9 Wood dominates Earth 732–3 organ patterns 556–9
temperature 206–8 Ke phase ‘insulting’ patterns 735–7 herbal formulas 557
ten questions 199–200 Earth insults Wood 737 symptoms and signs 556–7
thirst, appetite and taste 214–20 Fire insults Water 736 visual observation 61, 65, 66, 69,
see also questioning of patient Metal insults Fire 735–6 100
Intestines Damp-Heat, forehead/root Water insults Earth 736 Kidney yang xu, overflowing water
of nose 67 Wind insults Metal 735 563–5
Intestines Heat, forehead/root of Kidney Heat 708–10 Kidney yin, pulse diagnosis 153
nose 67 Kidney imbalances Kidney yin xu
intuition 25–6, 40 aetiology 546–7 acupuncture 551
invasion of Cold in the Stomach auditory diagnosis 131 aetiology 550
447–9 combined patterns 567–77 diagnosis according to zangfu
invasion of exogenous Wind 311–14 Kidney yang xu and Spleen yang organ patterns 550–3
acupuncture 312 xu 575–7 dryness in mucous membranes 247
aetiology 311 Kidney yin xu and Heart yin xu ears 231, 232
herbal formulas 313 570–2 herbal formulas 552
symptoms and signs 311 Kidney yin xu and Kidney yang impotence, in men 248, 249
see also Wind xu 568 insomnia 235
invasion of Wind-Cold Kidney yin xu and Liver yin xu symptoms and signs 550–1
auditory diagnosis 140 568–70 urinary disturbances 223
Lung imbalances 398–401 Kidney yin xu and Lung yin xu visual observation 61, 65, 70, 88,
Six Stages model 646–9 573–4 99, 101
visual observation 20, 24, 72, 97 diagnosis according to zangfu Kidney yin xu and Heart yin xu
invasion of Wind-Heat 401–3 organ patterns 546–77 570–2
invasion of Wind-Water 403–4 general symptoms and signs Kidney yin xu and Kidney yang xu
invasion of xie qi 91 549–50 568
inventory boxes 34 Kidney channel imbalances 719 Kidney yin xu and Liver yin xu
irregular pulse group 172–4 pathology 547–9 568–70
itch 230, 232, 233 urinary disturbances 223 Knotted pulse 172–3
visual observation 77
xu patterns 550–67
Ji Sheng Qi Wan 761 Kidney jing xu see Kidney jing xu lamb, consumption of 756
Ji Sheng Shen Qi Wan 383 Kidney qi not grasping Lung qi Large Intestine imbalances
Jia Wei Xiao Yao Wan 602 561–2 diagnosis according to zangfu
Jian Pi Wan 354, 446, 761 Kidney qi xu 559–62 organ patterns 427–37
jiao, tongue 76, 77 Kidney yang xu see Kidney yang Large Intestine channel imbalances
Jin Gui Shen Qi Tang 287, 291, 299, xu 715–16
557, 560, 576, 761 shi patterns 428–34
782
Index
Damp-Cold 432–4 diagnosis according to zangfu extreme Heat generating 611–13

Damp-Heat 428–31 organ patterns 590–640 herbal formulas 612, 614, 617,
Heat 431–2 dizziness 229 619
visual observation 68, 77 general symptoms and signs 597 Liver Fire generating 613–14
xu patterns 434–7 Liver channel imbalances 720–1 Liver xue xu generating 617–19
Large pulse 180 pathology 594–7 symptoms and signs 611–12,
length of tongue 87–8 shi patterns 613–14, 615–16, 617–18
Li Shi Zhen (Ming dynasty doctor) ascending Liver yang 605–8 visual observation 64, 118
153, 156 Damp-Heat in the Liver 619–21 Liver Wind-Heat, visual observation
Li Zhong An Hui Tang 532, 762 Liver Fire see Liver Fire 69
Li Zhong Tang 284, 287, 318, 418, Liver qi stagnation see Liver qi Liver xue stagnation
458, 475, 576, 662, 762 stagnation acupuncture 604
libido 246–7 Liver qi stagnation Heat 601–3 aetiology 603
lichenification of skin 111 Liver Wind see Liver Wind diagnosis according to zangfu
Life Gate, index finger 119 Liver xue stagnation see Liver xue organ patterns 603–5
lifestyle and diet 254–5 stagnation herbal formulas 604
see also Yangshen, supporting stagnation of Cold in the Liver symptoms and signs 230, 603–4
treatment through channel 622–3 visual observation 67, 68
lighting, visual observation 39, visual observation 60, 62 Liver xue xu
40–1, 55 voice, auditory diagnosis of 137 acupuncture 625
tongue diagnosis 79–80 xu patterns 623–9 aetiology 624
limbs, visual observation 99–100 Liver xue xu see Liver xue xu diagnosis according to zangfu
Ling Gan Wu Wei Jiang Xin Tang Liver yin xu see Liver yin xu organ patterns 623–6
406, 762 see also Liver Damp-Heat; Liver diagnostic approach 20
Ling Jiao Gou Teng Yin 612, 614, Fire; Liver qi stagnation; Liver herbal formulas 625
762 Wind; Liver Wind-Heat; Liver symptoms and signs 624–5
lips 70–1, 72ti, 120 xue stagnation; Liver yin xu eyes 233
Liu Jun Zi Tang 291, 359, 456, 472, Liver qi invading the Spleen 629–32 menstrual problems 244
483, 762 Liver qi invading the Stomach 632–4 numbness and tingling 237
Liu Wei Di Huang Tang 296, 552, Liver qi stagnation visual observation 68, 103
570, 628, 762 aetiology 598 Liver yang 45
Liver and Gall Bladder Damp-Heat diagnosis according to zangfu Liver yin 153
586–8 organ patterns 598–601 Liver yin xu
Liver and Heart xue xu 637–40 diagnostic approach 18, 20, 30 acupuncture 628
Liver Damp-Heat 59, 69–70, 71, hand and foot palpation 190, 191 aetiology 627
232 stress 205 diagnosis according to zangfu
Liver Fire symptoms and signs 598–9 organ patterns 626–9
abdominal symptoms 217–18 cold and hot hands and feet 208 disease history 204
acupuncture 609 constipation 221 eyes 233
aetiology 608 emotional problems 252 herbal formulas 628
diagnosis according to zangfu hypochondria 238 numbness and tingling 237
organ patterns 608–10 insomnia 234 symptoms and signs 627–8
diagnostic approach 30 libido, lack of 247 visual observation 97, 99, 103
eyes 233 menstrual problems 243, 244 Long Dan Xie Gan Tang 276, 323,
herbal formulas 609 sexual problems 247 327, 335, 376, 585, 588, 609,
symptoms and signs 608–9 visual observation 621, 762
visual observation 64, 97, 103 back 98 Long Dan Xie Gan Wan 636
Liver Fire invading the Lung 634–7 body movements 50 Long pulse 179–80
Liver Heat 69 eyes 62 lower jiao
Liver Heat generating Wind 710–11 forehead/root of nose 67 Damp-Heat in the lower jiao
Liver imbalances posture 45 706–8
abdominal palpation 184 skin 58 Kidney Heat 708–10
aetiology 591–4 stools 116 Liver Heat generating Wind
chest palpation 187 throat 97 710–11
combined patterns tongue diagnosis 84 Lung and Heart qi xu 425–7
Liver and Heart xue xu 637–40 Liver qi stagnation Heat 601–3 Lung and Spleen qi xu 422–5
Liver Fire invading the Lung Liver Wind 610–19 aetiology 422–3
634–7 acupuncture 612, 614, 616, symptoms and signs 423
Liver qi invading the Spleen 618–19 Lung Dryness 421–2
629–32 aetiology 611, 613, 615, 617 Lung Heat
Liver qi invading the Stomach ascending Liver yang generating aetiology 412
632–4 615–17 qi level 679–80
783
Lung Heat cont. Ma Huang Tang 266, 284, 313, 318, ‘norm’, recognising deviations from
symptoms and signs 412 400, 648, 762 15, 22–3, 36, 52
upper jiao 700–3 Ma Zi Ren Wan 432, 762 nose 68, 69t, 114
visual observation 68 Maciocia, G. 93, 169, 170, 577, 723 numbness 237–8
Lung imbalances macules 67, 109 nuts and seeds 756
aetiology 393–4 Mai Jing (The Pulse Classic) 155
air pollution 394 Mai Men Dong Tang 340, 381, 762
auditory diagnosis 127–8, 140 Mai Wei Di Huang Tang 574 oats 754
combined patterns maize 754 observation see visual observation
Lung and Heart qi xu 425–7 mania 253 oedema 100, 382
Lung and Spleen qi xu 422–5 Matsumoto, Kiiko 186 Oleson, Terry 194
Damp-Phlegm 397 meat, consumption of 755–6 olfactory diagnosis 124, 125, 143–6
diagnosis according to zangfu mediation 753 onions 757
organ patterns 393–427 medical history 203 orgasm 247
Dryness 397 medication 203–4 Overflowing pulse 170
emotions 252, 395 menarche (first menstruation) 242
Lung channel imbalances 715 menopause 241
pathology 395–8 menstruation 146, 204, 348
shi Heat 397 interviewing of patients 240, pain 184, 225, 235–8
shi patterns 398–413 241–4, 244–5t pale and wan skin 106
Damp-Phlegm see Damp-Phlegm mental illness 43 pale tongue 82
invasion of Wind-Cold 398–401 mental restlessness 253 palpation 31, 148–94
invasion of Wind-Heat 401–3 Metal type, Five Phase system 48–9, of abdomen 183–8
invasion of Wind-Water 403–4 130, 131 Hara diagnosis 185–7
Lung Heat see Lung Heat micro-systems of chest 187, 188t
Phlegm-Fluids blocking the Lung palpation 194 relative strengths and weaknesses
407–9 visual diagnosis 75, 113–16 149
Phlegm-Heat see Phlegm-Heat middle jiao see also pulse diagnosis
skin 229 Spleen Damp-Heat 705–6 palpitations 224–5
visual observation 104 Yangming Heat 703–5 papillae, tongue 83
xu patterns 413–22 millet 754 papules 109–10
Lung Dryness 421–2 mindfulness 753 partially swollen tongue body 86
Lung qi xu see Lung qi xu Ministerial fire 246 Pathogenic Heat, visual observation
Lung yang su 416–18 moaning 130, 139 93
Lung yin xu see Lung yin xu moistness patterns of imbalance see imbalance
Lung qi face 57, 58 patterns, identifying
employment patterns 202 hands 102 Pericardium Heat 701–3
sneezing 227 skin 107, 108t, 189 Pericardium imbalances
visual observation 23, 66 tongue coating 93 diagnosis according to zangfu
Lung qi xu Mole, Peter 144 organ patterns 577–80
acupuncture 415 mood swings 252 Pericardium channel imbalances
aetiology 414 mouth, visual diagnosis 72, 114 719
auditory diagnosis 128 moxa 752–3 shi patterns 578–80
breathing problems 226 mucous, eyes 64–5 voice, auditory diagnosis of 137
diagnosis according to zangfu muscles, visual observation pharmaceutical medicines, effect 79
organ patterns 413–16 back muscles 98–9 pharynx, visual observation 97
herbal formulas 415 in children 118 Phlegm
sneezing 227 muscle tone 98–9, 118 acupuncture 345, 391
symptoms and signs 414–15 shen 42 aetiology 343–4, 389
visual observation 68, 72, 86 tension 45 blocking action of 45, 58, 108,
Lung yang su 416–18 mushrooms 757 124, 137, 139, 190, 194, 225,
Lung yin xu 229, 341–2, 490, 493, 713
acupuncture 419–20 shen 134, 490, 493, 501–3
aetiology 418–19 diagnosis according to xie qi 340–6
Nan Jing (The Classic of Difficulties) diagnostic approach 18–19
diagnosis according to zangfu 21, 151, 155, 185, 186
organ patterns 418–20 herbal formulas 345–6, 391
nasal mucus, olfactory analysis 146 jinye imbalances 386–92
herbal formulas 420 nasal voice 137
symptoms and signs 419 skin 107, 108, 229, 230
nausea and vomiting 18–19, 217–18 substantial or insubstantial 341,
visual observation 88, 101 neck, observation of 97 386
nightmares 234 symptoms and signs 341–5,
nodules 110 386–90
784
Index
breathing patterns 139 diagnostic parameters 161–2 qi stagnation 361–4

coughing 227 disturbing factors and natural abdominal palpation 183, 184
eyes 62, 64, 233 differences 158–60, 161t aetiology 362
fatigue 211–12 group types 166 auditory diagnosis 141, 142
hair 230 guan position 152, 154, 160 coughing 227
headaches 239 hands-on training requirement 74 diagnostic approach 24
heaviness 342, 387 having root 158 fatigue 211
numbness and tingling 237 history 151 pain 235, 237
visual observation horizontal plane 152, 155 Small Intestine 527–9
body movements 51 interfering factors 159t symptoms and signs 361–3
in children 121 length of pulse 165 see also Heart qi stagnation; Liver
clothing 54 natural variations 161t qi stagnation; Stomach qi
eyes 62, 64, 65 normal pulse 158 stagnation
face 58 physiology 151 qi xu 356–60
nails 103 practice, need for 150–1 acupuncture 290, 358–9
posture 45 in pregnancy 160 aetiology 290, 357–8
skin 107, 108 qualities of pulse 162–6, 181–2t diagnosis according to Eight
throat 97 questions to ask 24 Principles model 289–91
tongue diagnosis 79, 86, 87, 93 rate 163–4 dizziness 228–9
voice, auditory diagnosis of 134, rhythm and regularity of pulse 165 fatigue 209–10
137, 138 six parameters 150 herbal formulas 291, 359
see also Wind-Phlegm strength of pulse 74, 150, 164–5 sweating 214
Phlegm-Cold 101 structure of pulse 151–2 symptoms and signs 290, 358
Phlegm-Dampness taking the pulse 156–8, 159 visual observation 50, 56, 58, 72,
auditory diagnosis 140 three levels 152–3 86, 87, 106
headaches 240 three positions 154–6 voice, auditory diagnosis of 135
visual observation 86, 95, 97, 101, time of day taken 159 Qiang Huo Sheng Shi Tang 268
116 two-dimensional structure of pulse Qiang Huo Sheng Shi Tang 268, 762
Phlegm-Fluids blocking the Lung 152 Qin Qi Hua Tan Tang 391, 678,
407–9 vertical plane 152 680, 701
Phlegm-Heat width of pulse 165 Qing (green/blue colour) 58
aetiology 410 see also specific pulse groups and types Qing Luo Yin 330, 762
agitating the Heart 503–6 purple macules 109 Qing Qi Hua Tan Tang 681, 763
diagnosis according to zangfu purple papules 110 Qing Wei San 276, 335, 441, 763
organ patterns 409–12 purple skin 59–60, 106 Qing Ying Tang 376, 579, 689, 703,
herbal formulas 411 purple tongue 83–4 763
symptoms and signs 410 pustules 110 questioning of patient
visual observation 30, 92, 101, 114 general questions 199–200
pigmentation, skin 112 pulse diagnosis 24
pillars, diagnostic see diagnostic qi (cosmic energy) ten questions 199–200
pillars distribution in body 44–5 quinoa 754
ping mai (healthy pulse) 158 imbalances see qi imbalances
Ping Wei San 327, 385, 762 qi-producing organs 160–1
pork, consumption of 756 rebellious 364–6, 397 Rapid pulse 177–9
posture 44, 45 stagnation see qi stagnation rebellious qi 364–6
pregnancy qi Gate, index finger 119 red macules 109, 112
fertility problems 242 qi imbalances 356–66 red papules 110
nausea and vomiting 217 qi sinking 360–1 red skin, face 58, 59, 65
pulse diagnosis 160 qi stagnation see qi stagnation red spots, tongue 83
premature ejaculation 249 qi xu see qi xu red tongue 82–3
Prescribed Drug Guide, The rebellious qi 364–6, 397 referral to Western doctors, where
(Gascoigne) 204 Qi Ju Di Huang Tang 570, 762 necessary 16
prostate gland 249–50 qi level 676–87 ren mai 70, 71, 247, 724
pulmonary mucus, olfactory analysis Damp-Heat 683–5 respiration see breathing patterns
146 Gall Bladder Heat 686–7 rice 754
pulse diagnosis 150–82 Heat in the chest and diaphragm Robertson, Jason D. 193
challenges/difficulties 23, 74, 150 680–2 root vegetables 757
Choppy pulse 160 Heat in the Stomach and Intestines rumbling, abdominal 141
compared to tongue diagnosis 682–3 Run Chang Wan 435, 763
73–4 Lung Heat 679–80 rye 754
depth 162–3 see also Four Levels model
diagnostic images 166–81 qi sinking 360–1
785
salad vegetables 756 Fire not generating Earth 730 visual observation 49–50, 56
San Jiao channel imbalances 719–20 Metal not generating Water 731 shi Heat and Fire 333–6
San Jiao theory, diagnosis according Water not generating Wood 731–2 acupuncture 334–5
to 696–711 Wood not generating Fire 729–30 aetiology 333
and diagnosis according to zangfu shi Cold herbal formulas 335
organ patterns 577–80 acupuncture 284 symptoms and signs 333, 334t
lower jiao 706–11 compared to xu Cold 285t shi Heat in the Small Intestine
middle jiao 703–6 differences between exterior and 525–7
upper jiao 696–703 interior patterns 283t Shi Hui San 764
San Ren Tang 323, 327, 452, 470, exterior pattern 280–1, 285t Shi Wei San 764
685, 706, 763 herbal formulas 284 Short pulse 179
San Shi Tang 330, 763 interior pattern 281–4, 285t shouting 130–1
San Wu Bei Ji Wan 319, 433, 763 symptoms and signs 283 Si Miao San 327, 764
San Zi Yang Qin Tang 406, 763 thirst 215 Si Ni Tang 665, 764
Sang Ju Yin 672, 763 vaginal discharge 246 Si Sheng Wan 376, 764
Sang Xing Tang 313, 339, 676, 763 shi conditions Si Wu Tang 294, 764
scalp 96 abdominal symptoms 141, 220, sighing 138–9
Scattered pulse 169 222 signs and symptoms see symptoms
screaming 139 acute 222 and signs
seaweed 756 aetiology 301 singing 130
secretions 114–15 in channel 713t Six Stages model 212
sexuality/sexual desire 246–7 colours 282 diagnosis according to 642–9
Sha Shen Mai Men Dong Tang 420, compared to xu conditions 220, energetic stages
454, 763 299t jueyin 643, 668–9
Shao Fu Shu Yu Tang 540 diagnosis according to Eight shaoyang 642, 659–61
Shao Fu Zhu Yu Tang 351, 373, 763 Principles model 262–3, 300–1 shaoyin 643, 663–7
Shao Yao Tang 430, 763 disease history 204 taiyang 642, 643, 644–54
shaoyang energetic stage 642, 659–61 dizziness 228 taiyin 643, 661–3
xie qi locked in 213–14 emotions 251 yangming 642, 654–8
shaoyin energetic stage 44, 663–7 exterior and interior imbalances location of disease 643–4
shaoyin Cold stage 663–6 265t, 269, 282 skin
shaoyin Heat stage 666–7 fatigue 209 colours 58–60, 105–7, 118
shaoyin Stage Cold, diagnostic headaches 240 elasticity 108
approach 18 Lung imbalances 187 facial 42, 58–60
shen (spirit, mind and consciousness, pain 236, 238t humidity, effects on 189
or vitality) 43 palpation 186, 188t interviewing of patients in relation
blocked 45, 54, 62, 134, 490, 493 symptoms and signs 301 to 229–30
in children 117 visual observation lesions see skin lesions, visual
concept 42–3, 62 skin 105 diagnosis
false 43–4 tongue diagnosis 86 moistness 107, 108t, 189
formation 42 veins 119 palpation of 188–90
insomnia 234 see also shi Cold; shi Heat; xu rough or flaky 189
observation 42 conditions shen, observation of 42
in pulse 158 shi Heat sticky/oily 189
strong or weak 42 acupuncture 275, 279 suppleness 189–90
visual diagnosis 41–4 aetiology 274, 278 temperature 188
breathing patterns 42 age/gender of patient 200–1 visual diagnosis 42, 58–60,
clothing 43 auditory diagnosis 128, 142 104–12, 118
eyes 42, 62 compared to xu Heat 276t, 277, skin lesions, visual diagnosis 109–12
hair 95 332t primary 109–12
muscles and bones 42 diagnosis according to Eight secondary 111–12
skin, facial 42 Principles model 271–2 Skipping pulse 173
tongue 81 exterior 273 sleep, talking in 137
Shen Fu Tang 304, 764 hand and foot palpation 190 sleep patterns 234–5, 750–1
Shen Ling Bai Zhu Tang 456, 483 herbal formulas 275–6, 279 sleeping position, children 122
Shen Ling Bai Zhu Wan 454 insomnia 234 Slippery pulse 160, 175, 176
Shen Tong Zhu Yu Tang 351, 373, interior 272–3 Slow pulse 177
764 Lung imbalances 397 slumped posture 45
sheng cycle 55 pulse diagnosis 159 slurred voice 137
Sheng Mai San 426, 516, 764 symptoms and signs 274–5, 278–9 Small Intestine imbalances
Sheng phase patterns 729–32 temperature 207 diagnosis according to zangfu
Earth not generating Metal 730 thirst 215 organ patterns 524–32
786
Index
general symptoms and signs 525 diagnosis according to zangfu visual observation 59, 67, 72, 93,
shi patterns 525–32 organ patterns 470–3 120
shi Heat in the Small Intestine emotional problems 252, 253 Stomach imbalances
525–7 herbal formulas 472 combined patterns 459
Small Intestine qi bound 529–31 olfactory diagnosis 146 diagnosis according to zangfu
Small Intestine qi stagnation symptoms and signs 471–2 organ patterns 437–59
527–9 visual observation general symptoms and signs
worms 531–2 back 98 439–40
Small Intestine channel imbalances fingers 101 shi patterns 440–52
718 gums 73 Damp-Heat 450–2
visual observation 77 mouth 72 food stagnation see food
Small Intestine qi bound 529–31 nose 68 stagnation
smell, diagnosis using 124, 125, stools 116 invasion of Cold 447–9
143–6 tongue diagnosis 86 Stomach Fire see Stomach Fire
sneezing 140, 227 urine 115 Stomach qi stagnation 442–4
snoring 139 Spleen qi xu and Liver xue xu 484–6 xue stagnation 449–50
soft voice 137 Spleen yang xu Stomach channel imbalances
Soggy pulse 169, 180 aetiology 473–4 716–17
spelt 755 diagnosis according to zangfu xu patterns 453–9
sperm count, low 249 organ patterns 473–6 Stomach qi xu see Stomach qi xu
spine, abnormal curvature 98 herbal formulas 475 Stomach yin xu see Stomach
Spleen symptoms and signs 222, 474–5 yin xu
appetite, influence on 216 visual observation 66, 69, 100 Stomach qi
central role 745 Spleen yin xu diagnostic approach 19
development 201 acupuncture 481 rebellious movement of 21–2
imbalances see Spleen imbalances aetiology 480 visual observation 57, 99
weak 352–3 diagnosis according to zangfu Stomach qi stagnation 442–4
Spleen Damp-Heat 705–6 organ patterns 479–81 Stomach qi xu
Spleen Heat, visual observation 59 herbal formulas 481 acupuncture 456, 458
Spleen imbalances symptoms and signs 480 aetiology 455
aetiology 460–2 visual observation 88 appetite 216
combined patterns 482–7 sputum 226, 227 and Cold 457–9
Spleen qi xu and Liver xue xu staccato voice 137 diagnosis according to zangfu
484–6 stagnation organ patterns 455–7
Stomach and Spleen qi xu 482–4 Cold 236 herbal formulas 456, 458
diagnosis according to zangfu food see food stagnation symptoms and signs 455–6, 458
organ patterns 457–87 Heart qi 62 visual observation 68, 101
pathology 462–5 Heart xue 58 Stomach yin xu
shi patterns 465–70 Liver qi see Liver qi stagnation acupuncture 454
Damp-Cold 465–70 Liver xue 67, 68 aetiology 453
Damp-Heat 468–70 stagnation of Cold in the Liver diagnosis according to zangfu
Spleen channel imbalances 717 channel 622–3 organ patterns 453–5
xu patterns 470–81 xue see xue stagnation herbal formulas 454
Spleen qi not holding xue inside see also qi stagnation symptoms and signs 453–4
the vessels 477–9 Stirring pulse 177 visual observation 73, 88
Spleen qi sinking 476–7 Stomach stools 115–16, 123
Spleen qi xu see Spleen qi xu appetite, influence on 216 constipation 220
Spleen yang xu see Spleen yang xu central role 745 interviewing of patients in relation
Spleen yin xu see Spleen yin xu development 201 to 220–2, 222–3t
see also Spleen Heat; Spleen qi xu; imbalances see Stomach imbalances loose 221–2
Spleen yang xu; Spleen yin xu weak 352–3 olfactory diagnosis 145
Spleen qi 27, 68, 88, 99, 202 Stomach and Spleen qi xu 482–4 structured approach 29–30, 40
Spleen qi not holding xue inside the Stomach Fire styes 64
vessels 477–9 acupuncture 441 Su Zi Jiang Qi Tang 366, 409, 418,
Spleen qi sinking 476–7 diagnosis according to zangfu 562, 764
Spleen qi xu organ patterns 440–2 Summer-Heat
abdominal symptoms 221, 222 herbal formulas 441 abdominal symptoms 218
acupuncture 472 symptoms and signs 216, 217–18, acupuncture 330
aetiology 471 440–1 aetiology 329
appetite 215, 216 visual observation 64, 93, 97 diagnosis according to xie qi
auditory diagnosis 141 Stomach Heat 328–31
breathing problems 226 headaches 240 herbal formulas 330
787
symptoms and signs 329, 330t Pericardium imbalances 579 shaoyang stage 659–60
sunken areas, tongue 87 Small Intestine imbalances 526, shaoyin stage 664–5, 666–7
Suo Quan Wan 543, 764 528, 530, 531 taiyang stage 647–8, 649, 651,
Superficial pulse group 152, 153, Spleen imbalances 466, 468–9, 653
157, 163, 166–70 474–5, 476–7, 478, 480, taiyin stage 661–2
sweating 114, 212–14 482–3, 484–5 yangming stage 655–6, 657
olfactory diagnosis of sweat 146 Spleen qi xu 471–2 tongue diagnosis 80
swollen tongue body 86, 88 Stomach imbalances 440–1, visual observation 39–41
symptoms and signs 442–3, 447–8, 449, 451, weighting of 37–8
chong mai imbalances 725 455–6, 458 xue imbalances
dai mai imbalances 725–6 Urinary Bladder imbalances 535, xue loss 378
diagnosis according to Eight 537–8, 539, 541, 542–3, 544 xue stagnation 347–50, 370–3
Principles model diagnosis according to the twelve xue xu 292–3, 368–9
exterior imbalances 265–6 regular channels yang qiao mai imbalances 727
interior imbalances 270 Gall Bladder channel imbalances yang wei mai imbalances 728
qi xu 290 720 yin qiao mai imbalances 726–7
shi Cold 283 Kidney channel imbalances 719 yin wei mai imbalances 727–8
shi conditions 300–1 Large Intestine channel see also bian bing lun zhi
shi Heat 274–5, 278–9 imbalances 715–16 (differentiation of symptoms
xu Cold 286–7 Liver channel imbalances 720–1 and signs by disease
xue xu 292–3 Lung channel imbalances 715 category); bian zheng lun zhi
yang xu 297–8 san jiao channel imbalances (differentiation of symptoms
yin xu 295 719–20 and signs by imbalance
diagnosis according to xie qi Small Intestine channel patterns); visual observation
Cold 317 imbalances 718 Systemic Heat, eyes 63
Exogenous Dryness 338 Spleen channel imbalances 717
food stagnation 353 Stomach channel imbalances
internally generated Dampness 716–17 taiyang energetic stage 44, 642, 643,
324–5, 325–6t Urinary Bladder channel 644–54
internally generated Dryness imbalances 718–19 accumulation of Water 651–2
339–40 du mai imbalances 723–4 invasion of Wind-Cold
internally generated Wind Five Phase diagnosis Cold is dominant 646–9
314–15 Ke phase dominating patterns Wind is dominant 649–51
invasion of Exogenous Wind 732–4 Taiyang fu – accumulation of xue
311, 312t Ke phase ‘insulting’ patterns 652–5
Phlegm 341–5 735–6, 737 see also Six Stages model
shi Heat and Fire 333, 334t Sheng phase patterns 729–30, taiyin body type 44
xu Heat 336 731, 732 taiyin energetic stage 643, 661–3
xue stagnation 347–50 Four Levels model Tao He Cheng Qi Tang 350, 373,
diagnosis according to zangfu qi level 677–8, 679, 680–1, 653, 764
organ patterns 682–3, 684–5, 686 Tao Hong Si Wu Tang 350, 373, 764
Gall Bladder imbalances 582–3, wei level 671–2, 673, 675 taste 219–20
584–5, 586–7, 589 xue level 690–1, 692, 693–4, 695 tears, eyes 64–5, 233
Heart imbalances 495–6, 497–8, Ying level 688–9 temperature
499, 501–2, 504–5, 506–7, jinye imbalances abdomen 183
509–11, 513, 515, 517–18, fluids, accumulation of 382 interviewing of patients 206–8
519, 521–2 internally generated Dampness skin 188
Kidney imbalances 550–1, 384–5 theoretical foundations 40
553–4, 556–7, 559–60, 561, jinye xu 380–1 thin skin 111
563–4, 566, 568–9, 571–2, mistakes with relation to 33 thin tongue body 85–6
573–4, 575–6 qi imbalances thirst 215
Large Intestine imbalances 430, qi sinking 360 thorax 98 188t
431, 433, 434, 435–6 qi stagnation 361–3 three treasures (shen, qi and jing) 158
Liver imbalances 598–9, 602, qi xu 290, 358 throat
603–4, 606, 608–9, 611–12, rebellious qi 364–5 sensation of something being stuck
613–14, 615–16, 617–18, ren mai imbalances 724 in 238
619–20, 622, 624–5, 627–8, san jiao theory visual observation 97, 120–1
630–1, 633, 635–6, 637–8 lower jiao 707, 708–9, 710 Tian Ma Gou Teng Yin 315, 607,
Lung imbalances 399, 401–2, middle jiao 703–4, 705 764
403–4, 407–8, 410, 412, upper jiao 697, 698–9, 700, 702 Tian Tai Wu Yao San 531, 545, 623,
414–15, 416–17, 419, 421, Six Stages model 765
423, 425–6 jueyin stage 668
788
Index
Tian Wang Bu Xin Dan 279, 511, Toxic-Heat, visual observation 64 diagnosis according to zangfu
572, 765 Traditional Acupuncture Volume II – organ patterns 532–45
tics 60 Traditional Diagnosis (Worsley) general symptoms and signs 534
Tight pulse 162, 167, 174, 175t, 213 144 shi patterns
time constraints 32 Traditional Chinese Medicine Urinary Bladder Damp-Cold
tingling sensations 237–8 (TCM) 537–9
tinnitus 231 compared to Western diagnosis 18, Urinary Bladder Damp-Heat
tongue coating 90–3, 94t 19, 36 534–7
causes 75 diagnostic prerequisites 21–6 Urinary Bladder stones 540–2
colour 92–3 facial colours, observation 56 Urinary Bladder xue stagnation
Eight Principles model 91t linear approach 17 539–40
moistness 93 patterns of imbalance, identifying Urinary Bladder channel
normal tongue 22 see imbalance patterns, imbalances 718–19
rootless 91–2 identifying urinary disturbances 223
tongue diagnosis shamanistic past 305 visual observation 77
body colour 84–5t treatment of patient, supporting see xu patterns 542–3
body shape 85–8, 89–90t Yangshen, supporting treatment Urinary Bladder stones 540–2
brushing tongue 79 through 17 Urinary Bladder xu Cold 542–3
in children 120 tremors 102 Urinary Bladder xue stagnation
coating see tongue coating turquoise skin, face 58 539–40
colours 22, 81–4, 84–5t, 92–3 twelve regular channels, diagnosis urine 115, 123
compared to pulse diagnosis 73–4 according to 712–21 interviewing of patients in relation
cracks 88 Gall Bladder channel imbalances to 223–4
effective tool 74 720 olfactory diagnosis 145
Eight Principles model 78f Heart channel imbalances 717
flaccidity 87 Kidney channel imbalances 719
foods and drink affecting tongue Large Intestine channel imbalances vagina 247–8
79 715–16 vaginal discharge 115, 241
general condition of patient 74 Liver channel imbalances 720–1 varicose veins 100
length of tongue 87–8 Lung channel imbalances 715 vegetables 756–7
lighting conditions 79–80 Pericardium channel imbalances veins
normal tongue 22 719 hands 102
optimal conditions 78–81 san jiao channel imbalances index finger vein, children 119
pale tongue 82 719–20 on underside of tongue 84, 88
partially swollen body 86 Small Intestine channel imbalances varicose veins 100
pharmaceutical medicines, effect 718 visual observation 84, 88, 102, 108
79 Spleen channel imbalances 717 venison, consumption of 756
red tongue 82 Stomach channel imbalances vertigo 229
reflecting body as a whole 81 716–17 Very Rapid pulse 179
relaxed tongue 80 treatment of channel problems vesicles 110
root 77 714–15 visual observation 39–123
shen 81 Urinary Bladder channel acupuncture channels 112
sunken areas 87 imbalances 718–19 back 98–9
swollen body 86, 88 see also acupuncture channels body movements 40, 42, 49–51,
thin body 85–6 117–18
topography of tongue 76–7, 78f body shape and posture 44–9
uncontrolled movement and ulcers 111 chest 98
stillness 87 uncontrolled movement and children 67, 117–23, 122t
veins on underside 84, 88 stillness, tongue 87 clothing 43, 52–4
zones 77 upper jiao 696–703 ears 69–70
tonsils, swollen 97 Damp-Heat in the upper jiao eyes 42, 61–6
Tourette’s syndrome 138 698–700 face 55–60, 61f
Toxic-Fire Lung Heat 700–3 forehead/root of nose 66–8
ears 232 Pericardium Heat 701–3 gums 73
olfactory diagnosis 146 Wind-Heat invasion in the upper hair 94–6, 97t
visual observation jiao 697–8 hands 101–3, 104t
in children 120, 121 Urinary Bladder Damp-Cold 537–9 intuition, limitations of 40
secretions and exudations 113, Urinary Bladder Damp-Heat 534–7 joints 100–1
114, 115 Urinary Bladder Heat, forehead/root lighting conditions 39, 40–1, 55,
skin 110, 111 of nose 67 79–80
throat 97 Urinary Bladder imbalances limbs 99–100
tongue diagnosis 93 combined patterns 544–5 lips 70–1, 72t
789
visual observation cont. Western diagnosis see also Gall Bladder Wind-Heat;
micro-systems 75, 113–16 based on Western medicine Liver Wind-Heat
mouth 72 physiological and pathological Wind-Heat invasion in the upper
nose 68, 69t model 26–7 jiao 697–8
pharynx 97 compared to Chinese approach 18, Wind-Phlegm 72, 137
shen 41–4, 62, 81 19, 36 Wiry pulse 152, 174
skin see skin correct use of 27–8 Wood dominates Earth 732–3
symptoms and signs to be aware incorrect, where 26 Wood not generating Fire 729–30
of 39–41 linear approach 18 Wood type, Five Phase system 47,
thorax 98 multiple causes of disorder, 130–1
throat 97 recognising 27 worms in the Small Intestine 531–2
tongue see tongue problems with using as a starting Worsley, J. R. 40, 144
veins 84, 88, 102, 108 point 26–8 wrinkles 67, 71, 108
when patient unaware of being similarities to bian bing lun zhi Wu Ling San 383, 652, 765
observed 40 17–18 Wu Mei Wan 532, 669, 765
yuan-source points 113 see also bian bing lun zhi Wu Pi San 383, 765
see also symptoms and signs (differentiation of symptoms Wu Zhu Yu Tang 669, 765
voice, auditory diagnosis of 126–38 and signs by disease category)
complaining/moaning 130 wheat 755
crying 130 white macules 109 Xe Bai San 678
emotions 131–2 white skin, face 58 Xi Bai San 413
engagement of patient in Wind Xi Jiao Di Huang Tang 376, 691, 765
conversation 132–3 internally generated Wind 314–15 Xiao Chai Hu Tang 660, 765
Five Phases in voice 129–35, invasion of Exogenous Wind Xiao Feng San 327, 376, 765
135–6t 311–14 Xiao Qing Long Tang 266, 313, 383,
flow and structure of speech pain 237 404, 409, 766
133–5, 135–6t visual observation 60, 85, 111 Xiao Yao San 600, 766
joy and laughter 129–30, 131 xie qi 310–15 Xiao Yao Wan 631
normal voice 129 yang nature 310 Xie Bai San 276, 335, 680, 701, 766
quality of voice 136–8 see also Wind Gate, index finger; xie qi (pathogen) 24
shouting 130–1 Wind-Cold; Wind-Damp; abdominal symptoms 218, 220,
singing 130 Wind-Heat; Wind-Phlegm 221
strength and quality 128 Wind Gate, index finger 119 Cold 315–19
vomiting 141, 142 Wind-Cold coughing 226
auditory diagnosis 140 Damp-Heat 319–20
diagnostic approach 18, 20 Dampness 319–20
Water dominates Fire 733–4 exterior imbalances 263 exogenous 320, 321–2t, 323–4
water retention 185 exterior shi Cold 281 internally generated 324–8
Water type, Five Phase system 49, headaches 239 diagnosis according to 305–54
130, 131 invasion of the Wind-Cold 20, 24, and Eight Principles model 309
watering eyes 64–5 72, 140 Dryness 337–40
Weak pulse 171 Lung imbalances 396 exogenous 338–9
weals 110 pulse diagnosis 154 internally generated 339–40
wei level 670–6 sneezing 227 exogenous 320, 321–2t, 323–4,
Damp-Heat 673–4 temperature 207 338–9, 645
Dry-Heat 674–6 visual observation 66, 72, 74, 96, food stagnation 352–4
Wind-Heat 671–2 114, 115 Heat and Fire 331–3
see also Four Levels model Wind-Damp 18, 239 interior imbalances 269
Wei Ling Tang 327, 765 Wind-Heat invasion of xie qi 91
wei qi ears 232 locked in shaoyang aspect 213–14
diagnostic approach 24 exterior imbalances 263 Phlegm 340–6
Lung imbalances 396 hair 230 prolonged exposure to 308
pulse diagnosis 154 headaches 239 pulse diagnosis 166
sweating 212, 213 invasion of 97, 136 shi Heat and Fire 333–6
temperature 206, 207 sneezing 227 strong 308
visual observation 96 sweating 213 sudden exposure to 308
Wind 310 temperature 207 Summer-Heat 328–31
Wen Bing Tiao Bian (The Text on visual observation 68, 97, 110, 121 susceptibility to 308
Differentiation and Treatment of in children 119, 120 sweating 213–14
Heat Disorders) 642 eyes 64, 66 temperature 207
Wen Dan Tang 391, 505, 765 voice, auditory diagnosis of 136 urinary disturbances 223
Wen Jing Tang 284, 319, 765 wei level 671–2 visual observation 76, 115, 119
790
Index
eyes 64, 66 xue Heat generating Wind 691–3 yang xu

tongue diagnosis 91, 92 xue Heat injuring yin 693–4 acupuncture 298
voice, auditory diagnosis of 137 yin expiring and extreme aetiology 298
Wind 310–15 dehydration 694–5 diagnosis according to Eight
internally generated Wind xue loss 377–9 Principles model 297–9
314–15 xue stagnation 370–4 fatigue 210
invasion of Exogenous Wind abdominal palpation 184 herbal formulas 299
311–14 acupuncture 193, 350, 373 sweating 214
xu Heat 336–7 aetiology 349, 372 symptoms and signs 298
xue stagnation 347–51 diagnosis according to xie qi temperature 206
and zheng qi 207, 307–8 347–51 visual observation 50, 58, 73, 106
Xie Xin Tang 508, 766 disease history 206 voice, auditory diagnosis of 135
Xing Su San 313, 339, 766 ears 231 yang xu Cold 215
xu Cold 285–8 in elderly patients 347 yangming energetic stage 642, 654–8
acupuncture 287 headaches 239 Yangming channel syndrome
aetiology 286 herbal formulas 350–1, 373 655–6
compared to shi Cold 285t itch 230 Yangming organ stage 656–8
herbal formulas 287 menstrual problems 243 Yangming Heat 703–5
in Large Intestine 435–7 pain 236, 237 Yangshen, supporting treatment
symptoms and signs 286–7 palpitations 225 through 738–53
xu conditions 357, 397, 494, 595 in Stomach 449–50 altering diet when living with
abdominal symptoms 141, 142, symptoms and signs 347–50, others 742
220 370–3 central role of Stomach and Spleen
auditory diagnosis 127 visual observation 745
in channel 713t acupuncture channels 112 clothing 750–1
compared to shi conditions 220, body movements 50 conflicting advice 741
299t eyes 64 cooperation with patient 738–42
diagnosis according to Eight face 56, 59 dietary recommendations 748
Principles model 289–300 limbs 99, 100 encouraging compliance with
disease history 204 nails 103 advice 743–4
dizziness 228 skin 107, 108, 110, 111 enjoyment 742
headaches 239 stools 115 ethical aspects 742
menstrual blood 243 throat 97 exercise 750
pain 235–6 tongue diagnosis 83, 84 following natural rhythm of life
palpation 186, 187, 192t see also Heart xue stagnation; Liver 751–2
pulse diagnosis 173, 265 xue stagnation; Urinary Bladder golden rules of eating 745–8
sweating 212, 214 xue stagnation lack of familiarity with/access to
visual observation xue xu 367–9 certain foods 741
body shape and posture 44 acupuncture 293, 369 lack of time and energy 739
movement 117 aetiology 292, 368 mental and emotional approach to
nose 68 auditory diagnosis 128, 136 life 748–9
skin 105, 106, 118 bleeding 229 patient having difficulty adhering
veins 119 diagnosis according to Eight to dietary recommendations
see also shi conditions Principles model 291–4 739–41
Xue Fu Zhu Yu Tang 351, 373, 498, disease history 204 patient having difficulty complying
766 dizziness 228–9 with recommendations 742
xue Heat 374–7 fatigue 210 resistance to giving things up
aetiology 375 herbal formulas 294, 369 744–5
herbal formulas 376 insomnia 234 rest 750–1
symptoms and signs 375–8 numbness and tingling 237 see also lifestyle and diet
visual observation 120 symptoms and signs 293, 368–9 yawning 138–9
xue Heat agitating xue 690–1 visual observation 58, 64, 70, 73, Ye Tian Shi 642
xue Heat generating Wind 691–3 86, 104 yellow skin 106
xue Heat injuring yin 693–4 yellow skin, face 59
xue imbalances 367–79 Yi Pi Tang 481, 766
xue Heat 120, 374–7 Yan Hu Suo San 604 yin and yang 301–4
xue loss 377–9 yang qi 24, 114, 115 Yin Chen Zhu Fu Yu Tang 583, 766
xue stagnation see xue stagnation yang qi xu, 107 yin expiring and extreme dehydration
xue xu see xue xu yang qiao mai imbalances 727 694–5
xue level 690–6 yang wei mai imbalances 728 yin qiao mai imbalances 726–7
xue Heat agitating xue 690–1 Yin Qiao San 266, 275, 313, 335,
672, 698, 766
791
yin wei mai imbalances 727–8 zangfu organs visual observation

yin xu diagnosis according to patterns face 58, 60, 61f
acupuncture 296 148, 393–640 tongue diagnosis 75, 77, 78f
aetiology 295 emotions 251 Zhang Jie-Bin 156
auditory diagnosis 128, 136 Gall Bladder imbalances 580–90 Zhang Zhong Jing 641, 642
diagnosis according to Eight Heart imbalances 487–524 Zhen Fu Tang 520
Principles model 294–7 Kidney imbalances 546–77 Zhen Gan Xi Feng Tang 617, 766
fatigue 211 Large Intestine imbalances 427–37 Zhen Ren Yang Zang Tang 436, 766
herbal formulas 296 Liver imbalances 590–640 Zhen Wu Tang Tang 518, 565n, 766
insomnia 234 Lung imbalances 393–427 zheng qi 207, 213, 307–8
sweating 214 palpation of acupuncture points Zhi Bai Di Huang Tang 279, 337,
symptoms and signs 295–6 191 555, 628, 767
visual observation 86 Pericardium imbalances 577–80 Zhi Zi Dou Chi Tang 678, 681, 767
voice, auditory diagnosis of 136 and pulse diagnosis 148 zong qi
Ying level 687–96 San Jiao imbalances 577–80 auditory diagnosis 127–8, 138
You Gui Wan 287, 299, 557, 560, Small Intestine imbalances 524–32 chest palpation 187
766 Spleen imbalances 459–87 pulse diagnosis 153
yuan-source points, visual observation Stomach imbalances 437–59 visual observation 98
113 taste 219 Zou Gui Wan 296, 552, 567, 570,
Urinary Bladder imbalances 767
532–45
792

The Art and Practice of Diagnosis in Chinese Medicine. NIGEL CHING

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The Art and Practice of Diagnosis in Chinese Medicine. NIGEL CHING

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‘What Nigel Ching has achieved in this thorough and detailed study of

traditional Chinese diagnosis is to outline and explain clearly both the

DIAGNOSIS IN Chinese Medicine

The Art and Practice OF

Nigel Ching is a lecturer in Chinese Medicine and course director at the

The Fundamentals of Acupuncture

Acupuncture and Chinese Medicine

The Acupuncture Points Functions Colouring Book

The Spark in the Machine

The Acupuncturist’s Guide to Conventional Medicine

LONDON AND PHILADELPHIA

Foreword by Jeremy Halpin . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Part 1: The Diagnostic Pillars

Part 2: The Diagnostic Models

Appendix 1: Supporting the Treatment of the Patient through Yangshen . . 738

Another way of seeing things

The Dao that can be named is not the Dao1

Before we even start to look at how to diagnose in Chinese medicine, it is appropriate

Patient with a problem Diagnostic techniques to reveal the

By diagnosing and identifying the underlying pattern or patterns of imbalance, we

To be able to detect which patterns of imbalance are present requires a

Observe and analyse deviations from the ‘norm’

the relevance of diagnostic signs and symptoms, by thinking of qi dynamics and

Study and become adept at using the various diagnostic techniques

to keep on practising. It is often easier, when diagnosing, if you deconstruct the

Study the various patterns of imbalance

it can nevertheless recognise a pattern when it is presented with a particular group

pattern of imbalance in Chinese medicine. We need to translate diagnoses

In what way can we then use a Western medicine diagnosis?

The diagnostic process

The diagnostic process starts at the first contact

Have a structured approach

might be involved in us having difficulty in controlling the interview. If it is not our

A structured approach is more than just a checklist

Use all four of the diagnostic pillars

Different processes, different strategies

Treating complex patients with many

Make inventory boxes and flowcharts

THE DIAGNOSTIC PILLAR:

Relative weaknesses of visual diagnosis

Visual diagnosis of a person’s shen

Visual diagnosis of the body shape and posture

Body shape and posture

Five Phase body shapes

• Quiet and calm, but solid

Visual diagnosis of a person’s movements

Visual diagnosis of a person’s clothing

Drab colours and clothing

Visual diagnosis of the face

The colours of the face

The colours of faces in relation to the Five Phases

Conforming and contradictory colours in relation to the Five Phases

Facial colours in relation to the Eight Principles

Intensity and depth of the colours

Face colour in relation to the Eight Principles

The skin should be slightly moist and the

Qing4 (green/blue), green

Figure 1.1 Positions of the zangfu organs in the face according

Visual diagnosis of the eyes

Observation of the eyes

The zones in the eyes

The zones in the eyes

The colours in the eyes

Colours in the eyes