Cats TCM Notes

a resource for students of chinese medicine

The Four Levels

Wen Bing, or the Four Levels theory, is one of the ways in which you can diagnose and treat diseases in TCM. The Four Levels is designed for identification and treatment of invasions of wind-heat or warm febrile and epidemic diseases (acute externally contracted diseases that are hot in nature). Onset for these diseases is generally rapid, with fevers and predominant heat signs, diseases are exogenous in nature, are generally associated with specific seasons of the year and can be found grouped in specific locations. The mobile nature of our society, however, can spread a contagious disease further and wider (i.e., H1N1/Swine flu and avian flu epidemics) than was possible when the Warm Disease school of TCM doctors was treating when the theory was first developed during the late Ming and early Qing Dynasty (A.D., 16th C.).

Infection is acquired in warm diseases via respiratory contact, through ingestion of food and in rare cases through skin contact. The respiratory and food-borne routes are by far the most common. Food ingestion will most often lead to a damp heat condition and gastrointestinal problems.

Onset, as previously stated is acute and rapid, but is further broken down into new and hidden onset. New onset warm diseases will often progress through the four stages of the disease. The body's defenses are stimulated by the invasion and a set of reactions (symptoms and signs) appear. Hidden onset warm disease, however, is the result of previous contact and invasion of the pathogen. Rather than being expelled, the pathogen hides quietly inside the body and waits until conditions are ripe for it to emerge, rather like a terrorist sleeper cell. In these cases, the early stages are skipped and you will see sudden severe symptoms such as high fevers, strong pulse, severe thirst, scanty urine, red tongue, etc. very quickly. One example of this is getting a wind-heat infection in a warmer-than-normal winter, or almost any winter in my current town, Austin Texas, then getting a sudden outbreak monster heat signs in the Spring when the warm becomes active with the seasonal rising of Yang qi. (Hint for treatment: don't use exterior formulas because the pathogen is already inside - use clear interior heat formulas instead.)

Regardless of whether the invasion is new or hidden, the exogenous heat associated with warm febrile diseases damages yin and body fluids, so in later stages of Wen Bing deficient heat joins with the excessive heat. Eventually there will be damage to the Zangfu and to their functions.

What follows is by no means a comprehensive look at the Four Levels (Wen Bing), but is a simplified version of the principles of the theory and some treating suggestions. Whole volumes have been written on it and I can't hope to organize it all here. However, you can find more detail about this method of diagnosing and treating by reading Wen Bing Xue. Dr. Ye Tian Shi also discussed this theory in his work, Wen Re Lun in 1644 A.D. Stuff in red is required knowledge for the Herbal Classics 2 exam.

Wei/Defensive Level

The Wei or Defensive level of qi flows on the outer layers of the body and is yang in relation to the deeper layers. Wei qi protects the body from pathogens, circulating outside the channels in the skin and muscles. It also warms, moistens and partially nourishes skin and muscle. It adjusts the opening and closing of the pores, regulating sweating and body temperature. The Lung, with it's ability to disperse and mist, controls Wei qi. If the Lung qi is weak, the Wei qi may also be weak. If the Wei qi is weak, the body's defenses will be weakened, may catch cold easily, and may feel colder more easily than someone with strong Wei qi.

The Wei stage is usually the initial stage of many infectious and epidemic diseases that are warm in nature. You might think of it as early wind/heat. The initial attack of this type of disease is an attack upon the exterior or surface where the Wei or Defensive Qi guards the body. The skin at the surface and the Wei qi are closely tied to the Lungs which is why symptoms of wind heat start with Lung related symptoms.

Development of the wei stage can begin with a mild pathogen and undamaged vital qi which then pushes the pathogen out of the body. With correct treatment and/or a bit of time, the body will recover. If however the pathogen is severe and/or the vital qi is weak, improper, non-existent, or delayed treatment can result in the pathogen pushing deeper into the Qi, Ying (Nutritive) and even Xue (Blood) levels. This is a dangerous situation.

Symptoms
Symptoms in blue are hallmark symptoms for this level.

  • Fever
  • Chills, with fever greater than the chills.
  • Aversion to cold and possibly to wind.
  • Headache coming from the wind-heat attack
  • Cough with thick and yellow sputum
  • Sore throat due to heat in the throat
  • Possible sneezing, nasal congestion, sinus drainage
  • Very little or no sweating
  • Possibly slight thirst
  • Tongue: Red body with a thin white or yellow coating.
    Some sources say red tongue tip and edges. The edges indicate the exterior nature of the pathogenic invasion.
  • Pulse: Floating, rapid.

Treatment of the Wei Stage
Obviously, your treatment will need to be modified to fit the patient's condition. Some suggestions for acupuncture are as follows: LI 4, LI 11, LU 7, GB 20, SJ 5, Du 14, BL 12. You might cup and bleed at Du 14 to release the heat. Other modalities might include sliding cupping along the bladder lines between T1 and T7 and you might also do Gua Sha on the upper back and throat. Maciocia also suggests LU 11 with bleeding for more intense heat.

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Qi Level

When a pathogen is at the Qi level it has reached the interior of the body (even if it is the most external of the 3 interior levels). This stage is usually the longest, the broadest, and can have the most severe symptoms, depending on the strength of a person's vital qi. If the pathogen is strong and the vital qi is strong, the symptoms can be severe. If the vital qi is weak, the symptoms may not have such a strong presentation. The Qi level is not considered a life-threatening stage. There is a saying that "Nobody dies at the Qi level." However, if a pathogen penetrates this far it has reached the interior portion of the body. The warm/heat evil will attach the Zangfu organs and will manifest as an internal heat excess. The Upright or Zheng Qi will come under attack as well. This level includes half-in and half-out symptoms such as you find described in the Shaoyang stage of the Six Channel Theory.

Please be aware that pathogens and diseases do not read textbooks or websites and are likely to do unpredictable things. Pathogens might move from Wei to Qi levels, but are just as likely to jump over the Wei stage entirely and get right down to business at the Qi stage. This is particularly true for hidden pathogens also. They tend to manifest quickly at the Qi stage. You might also be treating a person who is in the Ying stage and notice that their symptoms have moved to the Qi stage, which is actually a good thing and shows that the disease is getting more superficial in the body and is on it's way out.

Symptoms
Look for the Four Bigs below. This looks a lot like the Yangming level in the Six Channel Theory. Symptoms for the Qi Level will vary depending on which of the organs is attacked. The most commonly affected are the Lungs, Stomach, Large Intestine, Gallbladder and Spleen. Symptoms in blue are hallmark symptoms for this level.

  • High fever/excessive heat
    Maciocia differentiates heat from fire, saying that Qi level heat causing dry heat in the Intestines is called fire while heat at the Qi level manifesting at the Lung, Stomach, Gallbladder, Stomach or Spleen is just 'heat.' And by the way, Stomach heat in this case equates to the Yangming channel pattern in the Six Channel theory while Large Intestine dry heat corresponds to the Yangming organ pattern.
  • Profuse sweating
  • No chills, no aversion to cold
    This is indicative of the interior progression of the pathogen.
  • Aversion to heat
  • Big thirst with a desire for cold drinks
  • Cough with yellow and sticky sputum, maybe with chest pain
  • Possible asthma due to Lung Qi deficiency
  • Irritability and restlessness (discomfort in any position)
  • Concentrated urine
    Urine is very yellow and may have a strong smell. This indicates damage to fluids by interior heat.
  • Constipation or watery diarrhea
    The stool will be dry because of the internal heat and this hard or impossible to pass.
    Intestinal fluids may be passed, hence the watery diarrhea.
  • Stomach discomfort or ache with distention and aversion to pressure
  • Tongue: Red with yellow dry coating, possibly black if there is big heat.
  • Pulse: Rapid, full (indicating heat). Can also be deep (indicating interior).

Notes:

Treatment of Qi Level

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Ying/Nutritive Level

When a pathogen reaches the Ying Level it has penetrated to a deeper energetic layer, a depth at which it begins to damage the Yin and affects the Shen. This level normally follows the Wei and Qi levels. Ying is viewed as the Qi of Blood and the precursor of blood. It circulates through the the blood vessels and Heart. As a result, most of the symptoms affect the Pericardium/Heart and produce interior deficient heat due to the depletion of the Yin.

Symptoms in blue below are hallmark symptoms of this level.

Symptoms

  • High fever, worse at night
  • Mental restlessness, irritability and insomnia
    Heat is progressing to the Blood level. As blood belongs to the Heart, the Shen is affected producing mental restlessness and insomnia.
  • Delirous or illogical speech, plus muddled consciousness. Possibly coma.
  • Thirst/dry mouth, but little desire to drink. Will take small sips to rinse the mouth.
    This is a symptom of Stomach deficiency.
  • Red rash or maculopapular lesions on the skin - small red dots on some or all of the body due to the heat affecting the blood
  • Tongue: Deeper red body than in previous stages, yellow coat that could be peeling or no coat
  • Pulse: Thin/fine and rapid

Treatment of Ying Level

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Xue/Blood Level

The pathogen has entered into the Blood at this stage, the deepest energetic layer. Because the Heart controls the blood and the Liver stores the blood, both organs are affected. Kidneys are also involved now, probably because of the Heart/Fire and Kidney/Water balance relationship. Blood heat is prominent and bleeding signs are evident as a result throughout the body at the skin and organ levels. The blood is disturbed and exhausted. This is a terminal stage of febrile illness and death is usually quick. Symptoms are of both excess heat and deficient yin (because the heat has burned up the yin resources).

And again, diseases don't know they have rules, so a disease may jump over the Ying stage and skip to the blood stage, can be a hidden pathogen and spring up in the Xue stage, etc.

Symptoms

Note that children progress to blood heat very rapidly. You might see red bumps or rashes on their faces when they have fevers. This does not mean they have a febrile disease nor that they have a Blood stage syndrome. You may also see drugs that mimick the rash symptoms. Look for the signs above and for the symptom history to confirm Xue/Blood stage.

Treatment of Xue Level

Resources:

A number of my professors have lectured on the Four Levels theory. The materials above are largely a compilation of notes I gathered in the classes they taught during my studies at the AOMA Graduate Institute of Integrative Studies (formerly Academy of Oriental Medicine at Austin). I am privileged to have studied with them. Other resources are noted below as well.

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