Chapter45identificationofpatternsaccordingtothefourlevels卫气营血辩证
Clinicalnote Exampleof‘warmdiseases’include:
Influenza流感,
Measles麻疹(rubeola麻疹)
Germanmeasles德国麻疹(rubella德国麻疹)
Chickenpox水痘(varicella)
Mononucleosis(glandularfever传染性单核白细胞增)
Mumps流行性腮腺(parotitis)
SARS非典型性肺炎
Meningitis脑膜炎
Encephalitis[内科]脑
Whoopingcough[内科]百日(pertussis)
Scarletfever[内科]猩红(scarlatina) 温热病邪由卫入气，由气入营，由营入血，病邪步步深入，病情逐渐加重。就其病变部位来说：
卫分证主表，病在肺与皮毛
气分证主里，病在胸膈，肺，胃，肠，胆等脏腑
营分证是邪热入于心营，病在心与包络
血分证是热已深入于肝肾，重在动血，耗血
卫分 发热，微恶风寒，舌边尖红，舌苔薄白，脉浮数。头痛，口干微渴，咳嗽，咽喉肿痛，微汗 气分 发热，不恶寒反恶热，舌红苔黄，口苦，脉数，心烦，口渴饮冷水，尿赤，头身重，丘疹，大汗淋漓，
兼咳嗽喘，胸痛，咳吐黄痰：热壅于肺
兼心烦懊侬，坐卧不安：热扰胸膈
兼自汗喘息，烦闷，渴甚，脉数苔黄燥：热在肺胃
兼胸痞，烦渴，下利，谵语：热迫大肠 营分 身热夜甚，口渴不甚，心烦不寐，甚或神昏谵语，斑疹隐现，有便秘，口干不欲饮水。
此时诊断上最有力的最可靠的症象为舌质红绛无苔，脉细数 血分 血分实证：在营分的基础上更见烦热燥扰，昏狂，谵妄，斑疹透露，色紫或黑，吐衄，便血，尿血，舌质深绛或紫，脉细数或兼抽搐，颈项强直，角弓反张，举视，牙关紧闭，脉弦数。 血分虚证：持续低热，暮热朝凉，五心烦热，热退无汗，口干咽燥，神倦，耳聋，肢体干瘦，舌口少津，脉象虚细或见手足蠕动，瘈疭等。 Defensive-Qilevel(wei)
Thedefensive-Qilevelisthebeginningstageofinvasionsofwind-heat.Itistheonlyexteriorlevel,thatis,characterizedbythepresenceoftheexteriorwindontheexteriorofthebody,thedefensive-Qilevelcomprisesoffourdifferentpatternsaccordingtothenatureofthepathogenicfactor:
Wind-heat
Summer-heat
Damp-heat
Dry-heat
Ofthesefour,wind-heatisbyfarthemostcommon.
Comparisonofdefensive-qiandqilevelsinidentificationofpatternsaccordingtothefourlevels
Level Eightprinciples Organs UprightQi location DefensiveQi External-heat-full Notaffected strong Exterior(uprightQireactsinexterior,aversiontocold) Qi Interior-heat-full affected strong interior(uprightQireactsininterior,
noaversiontocold) Qilevel(Qi)
TheQilevelisinterior,thatis,thepathogenicfactorhaspenetratedintotheinteriorandishasalsotransformedintoheat.However,theQilevelisthemostsuperficialofthethreeinteriorlevels.ThereisasayingabouttheQilevelstaring“nobodydiesattheQilevel”,thismeansthat,inthecontextofacutefebrilediseases,contrarytotheNutritive-Qiandbloodlevels,theQilevelisneverlifethreatening.
TheQilevelischaracterizedbyinteriorfull-heatwithsymptomsoffever,thirst,afeelingofheat,mentalrestlessness,aredtonguewiththickyellowcoatingandarapid-fullpulse.thesearejustgeneralsymptomsasothermanifestationsdependonthepatterninvolved,ofwhichtherearefive:
Lung-heat(heatinchestanddiaphragm).
Stomach-heat
Intestinesdry-heat
Gallbladder-heatand
damp-heatinstomachandspleen.
ComparisonofheatandfireattheQilevel
Stomach-heat(heat) Intestinesdry-heat(fire) Commonmanifestations Fever,feelingofheat,thirst,redtonguewiththickyellowcoating,rapidpulse differences Profusesweating,overflowingpulse,tonguecoatingnottoodry Constipation,abdominalfullness/pain,mentalrestlessness,drymouth,deep-fullpulse,thick,drytonguecoating
Nutritive-Qilevel(Ying)
Atthenutritive-Qilevel,theheathaspenetratedtoadeeperenergeticlayerandithasbeguntoinjuretheYin.Atthislevel,heatisobstructingthemindandthepericardium.Causingdeliriumandevencoma.Feveratnightisadistinctivesignofthenutritive-Qilevel.
Thetongueappearanceatthenutritive-QilevelisanimportantsignthatdifferentiatesthislevelfortheQilevel:atthenutritive-Qilevelthetongueisdeep-redwithoutcoating,whereasattheQilevelitisredwithathickcoating.
Therearetwopatternsatthenutritive-Qilevel:
heatinnutritive-Qileveland
heatinthepericardium.
Bloodlevel(Xue)
Thebloodlevelisthedeepestenergeticlayerwithheataffectingtheblood.Thereareseveraldifferentpatternswithvaryingclinicalmanifestations,butthechiefclinicalfeaturesofthebloodlevelareasfollows:
ThereisYindeficiency
Heatisaffectingthebloodcausingbleeding
HeatisaffectingtheMindcausingdeliriumorcoma
Heatinthebloodcausingbleedingundertheskinwiththeappearanceofmacules
Internalwinddevelopscausingconvulsionsandtremors.
CollapseofYinorYangmayoccur. Maculesareadefinitesignthatheathasreachedthebloodlevel.Therearefivepatternsatthebloodlevel:
Heatvictoriousmovingblood
Heatvictoriousstirringwind
Empty-windagitatingintheinterior,
CollapseofYinand
collapseofYang
comparisonoffourlevels
Symptoms Defensive-Qi Qi Nutritive-Qi/blood Fever Slightlyfever,aversiontocold Highfever,feelingofheat Feveratnight Thirst Slightlythirst Intense,desiretodrinkcolddrinks Drymouth,desiretosipliquids Mentalstate unchanged Restlessness,maybedelirium,generallymindclear Delirium,fainting,mindconfused Sweating slight profuse Nightsweating Tongue Redsides/front,thinwhitecoating Redbody,thickyellowcoating Redbody,nocoating Pulse Floating-rapid Big-rapid,deep-full-rapidorslippery-rapid Fine-rapid summary Exteriorpattern Interiorpattern,uprightQistrong Interiorpattern,uprightQiweak Warmdiseasesandskinrashes
Manywarmdiseasesoftenmanifestwitharash.Examplesofexanthematous(thatis,manifestingwithrash)diseasesaremeasles麻疹，风疹.Germanmeasles德国麻疹，风疹andchickenpox水痘.Onemustdistinguishbetweenvesicles囊泡,papules丘疹andmacules斑疹
Vesiclesareblister-like水泡状spotsfilledwithaclearfluidandtheyalwaysindicatedampness.
Papulesarered,solidspots,theygenerallyindicateheatattheQilevel(andespeciallyinthelungsandstomach).
Maculesarespotsundertheskin,which,unlikevesiclesandpapules,cannotbefeltonpalpation:theyalwaysindicateheatatthenutritive-Qiorbloodlevel.
Thefourlevelspatternsincludethefollowing:
Defensive-Qilevel: wind-heat,summer-heat,damp-heat,dry-heat Qilevel:
lung-heat(heatinchestanddiaphragm),stomach-heat,intestinesdry-heat,gallbladder-heat,damp-heatinstomachandspleen Nutritive-Qilevel: heatinnutritive-Qi,heatinthepericardium Bloodlevel： heatvictoriousmovingbloodheatvictoriousstirringwind,Empty-windagitatingintheinterior,collapseofYin,collapseofYang.
Defensive-Qilevel Wind-heat Fever,aversiontocold,headache,sorethroat,slightsweating,runnynosewithyellowdischarge,swollentonsils,bodyaches,slightthirst,tongueredinthefrontorsideswithathinwhitecoating,floating-rapidpulse. Treatment
Releasetheexterior,expelwind-heat,andrestorethediffusinganddescendingofLung-Qi Summer-heat Fever,aversiontocold,sweating,headache,afeelingofheaviness,anuncomfortablesensationintheepigastrium,irritability,thirst,tongueredinthefrontorsideswithawhitestickcoating,soggyandrapidpulse Treatment
Releasetheexterior,expelsummer-heat,clearheat,andpromotefluids Damp-heat Feverthatisworseintheafternoon,bodythatishottotouch,aversiontocold,swollenglands,headache,afeelingofheaviness,afeelingofoppressionoftheepigastrium,stickytaste,thirstbutwithnodesiretodrink,stickwhitetonguecoating,soggypulse Treatment
Releasetheexterior,resolvedampness,andclearheat Dry-heat Fever,slightaversiontocold,slightsweating,dryskin,nosemouthandthroat,drycough,sorethroat,drytonguewiththinwhitecoating,floating-rapidpulse. Treatment
Releasetheexterior,clearheatandpromotefluids.
Qilevel Lung-heat Highfever,afeelingofheat,noaversiontocold,thirst,coughwiththinyellowsputum,shortnessofbreath,sweating,redtonguewithyellowcoating,slippery-rapidpulse Treatment：
ClearQi,clearLung-Qi,resolvephlegm,andrestorethedescendingofLung-Qi Stomach-heat Highfeverthatisworseintheafternoon,noaversiontocold,afeelingofheat,intensethirst,profusesweating,redtonguewithyellowcoating,overflowing-rapidpulse. Treatment:
ClearQiandclearStomach-Heat Intestines-heat Highfeverthatishigherintheafternoon,constipation,drystools,burningintheanus,abdominalfullnessandpain,irritability,delirium,redtonguewiththickyellowdrycoating,deep-full-rapidpulse.
Thisisfireinthestomachandintestines.Thispatternisthesameasthatforthebright-yangorganstageofthesixstages. Treatment:
Drainfire,clearthestomachandintestines,andmovedownward Gallbladder-heat Alternatinghotandcoldfeelingwithaprevalenceofheat,abittertaste,thirst,drythroat,hypochondrialpain,nausea,afeelingoffullnessintheepigastrium.Redtonguewithunilateralstickyyellowcoating,wiry-rapidpulse. Treatment:
HarmonizethelesserYang,andclearGallbladder-heat Damp-heatinstomachandspleen Continuousfeverthatdecreasesaftersweatingbutsoonincreasesagain,afeelingofheavinessofthebodyandhead,afeelingofoppressionofthechestandepigastrium,nausea,loosestools,redtonguewithstickyyellowtonguecoating,soggy-rapidpulse.
Treatment:
Clearheatinstomachandspleen,andresolvedampness. Nutritive-Qilevel Heatinnutritive-Qilevel Feveratnight,drymouthbutwithnodesiretodrink,mentalrestlessness,insomnia,delirium,incoherentspeechoraphasia,macules,redtonguewithoutcoating,fine-rapidpulse. Treatment:
ClearNutritive-Qiheat,andpromotefluids Heatinthepericardium Feveratnight,mentalconfusion,incoherentspeechoraphasia,delirium,bodyhot,coldhandsandfeet,macules,redtonguewithoutcoating,fine-rapidpulse Treatment:
Clearnutritive-Qiheat,clearpericardium-heat,restoreconsciousness,andpromotefluids. Bloodlevel Heatvictoriousmovingblood 热盛动血Highfever,mentalrestlessness,manicbehaviors,darkmacules,vomitingofblood,epistaxis,bloodinstools,bloodinurine,dark-redtonguewithoutcoating,wiry-rapidpulse. Treatment:
Clearblood-heat,andstopbleeding Heatvictoriousstirringwind 热极生风Highfever,fainting,twitchingoflimbs,convulsions,rigidityofneck,opisthotonos,eyeballsturningup,clenchingofteeth.Dark-redtonguewithoutcoating,wiry-rapidpulse. Treatment:
Clearblood-heat,andextinguishwind Empty-windagitatingintheinterior 虚风内动Low-gradefever,tremoroflimbs,twitching,lossofweight,malarflush,listlessness,dark-redtonguewithoutcoatinganddry,fine-rapidpulse Treatment:
Clearblood-heat,nourishLiver-YinandKidney-Yinandextinguishwind CollapseofYin
阴竭 Low-gradefever,nightsweating,mentalrestlessness,drymouthwithdesiretosipliquids,five-palmheat,malarflush,emaciation,dark-redanddrytonguewithoutcoating,fine-rapidpulse. Treatment:
Rescueyin,andrestoreconsciousness CollapseofYang
阳竭 Afeelingofcold,coldlimbs,bright-whitecomplexion,profusesweatingontheforehead,listlessness,pale-swollenandshorttongue,hidden,slow,scatteredpulse. Treatment:
RescueYang,andrestoreconsciousness.
Latentheat
Comparisonofinvasionofwind-heatandlatentheat
Wind-heat Latent-heat symptoms Aversiontocold,sweating,fever Noaversiontocold cough cough Nocough pulse Floating-rapid Rapid,alsowiryorintermittent tongue Thinwhitecoating Redtonguefromthebeginning pathology Easytohaveabnormaltransmissiontopericardium easytoconsumeyinanddryupfluids ComparisonofQiandBloodlevelinlatentheat
Heat Thirst Skinspots tongue pulse Qilevel apparent Thirst,desiretodrink papules Red Big Bloodlevel Notsoapparent Drymouth,nodesiretodrink macules Deep-red Fine-rapid
Relationshipsbetweenthefourlevels,sixstagesandthreeburners
3/10Chapter45identificationofpatternsaccordingtothefourlevels卫气营血辩证
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