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 anywinter 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 or Defensive Level
• Qi Level
• Ying or Nutritive Level
• Xue or Blood Level

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.

• Wind Heat invading the Lung (no cough)
  • Yin Qiao San (Honeysuckle and Forsythia Powder)
    Indication: Early stage of warm-febrile disease
    Function: Disperses wind-heat, clears heat and relieves toxicity.
  • LI 4, LI 11, TB 5, DU 14, BL 12 (cupping or gua sha), LU 11 (with severe heat)
• Wind Heat invading the Lung (with cough)
  • Sang Ju Yin (Mulberry Leaf and Chrysanthemum Decoction)
    Indication: Wind warmth invading the Lung with cough
    Function: Expels wind-heat, opens Lung qi, stops coughing
• Summer heat
  Includes the above symptoms plus more sweating, feelings of heaviness, discomfort in the epigastrium, irritability, thirst. The tongue will have a sticky white coat and the pulse can be soggy, rapid. Note that this only occurs in the summer! Often combines with dampness. Release the exterior, expel summer-heat, clear heat and drain damp.
  • Qing Luo Yin (Clearing the Connecting Channels Decoction)
    Indication: Summer heat injuring the Lung - can be used in the the Qi stage also
    Function: Clears summer heat.
  • LI 4, LI 11, TB 5, Du 13, Du 26, BL 40, PC 9 (because damp heat tends to affect the Pericardium), SP 9.
• Damp heat
  Fever more in the afternoon, body is hot to the touch, aversion to cold, swollen glands, headache (usually frontal), heaviness, oppression in the epigastrium, sticky taste in the mouth, thirst without desire to drink. Sticky white tongue coat, soggy pulse. This is dampness in the exterior. More likely to happen at the Qi level, but happens at Wei also. Release the exterior, resolve damp, and clear heat.
  • Huo Xiang Zheng Qi Tang (Agastache Powder to Rectify the Qi)
    Indication: External wind-cold with internal damp stagnation
    Function: Release exterior, transform damp, regulate qi and harmonize the middle jiao
  • Hou Po Xia Ling Tang
    Damp heat obstructing at the Wei qi level with obvious exterior damp
  • San Ren Tang
    Damp heat obstructing with obvious interior damp
  • Da Yuan Yin, Lei Shi Xuan Tou Mo Yuan Fa
    Pathogen obstructed in Mo Yuan
  • Gan Lu Xiao Du Dan (modified)
    Damp heat with toxins
• Dry heat
  All of the main symptoms plus dryness at the skin, nose, mouth, throat. Dry cough and a sore throat. Even the tongue is dry. Pulse is superficial and rapid. This pattern injuries body fluids. Release the exterior, clear the heat and promote fluids
  • Xing Su San (Apricot Kernel and Perilla Leaf Powder)
    Indication: External invasion of cool dryness
    Function: Disperses cool dryness, opens Lung qi and transforms phlegm
  • Sang Xing Tang (Mulberry Leaf and Apricot Kernel)
    Indication: External invasion of warm dryness
    Function: Disperse warm dryness.
  • Sha Shen Mai Men Dong Tang (Glehnia and Ophiopognis Decoction)
    Use when remaining pathogenic heat has injured the Yin of the Stomach and Lung. 

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.

SymptomsLook 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 heatMaciocia 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 coldThis 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:

• Lungs attacked: probably cough with yellow phlegm and/or asthma and probably chest pain.
• Heat in the chest: irritability will be present.
• Heat in the Stomach: profuse sweating, fever, strong thirst for cold liquids, possible black tongue coating.
• Heat in Large Intestines: constipation, abdominal ache and "diarrhea" (which is more likely to be intestinal fluids passing through without absorption of nutrients.

Treatment of Qi Level

• Excessive Heat in the Lung: 
  Also called heat in the chest and diaphragm. Heat impairs the descending ability of Lung qi causing shortness of breath and coughing.
  • Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction)
    Indication: Exterior wind-heat (or wind-cold transforming to heat) invading the Lungs
    Function: Restore flow of Lung qi, clear heat, disperse wind-heat, calm wheezing
  • Xuan Bai Cheng Qi Tang
    This is for excess heat in the Lung and Large Intestine
  • Ge Gen Huang Qin Huang Lian Tang
    This is for Lung heat transferring the the Large Intestine
  • Yin Qiao San (minus dan dou chi and adding sheng di, dan pi, and da qing ye)
    Treats eruptions due to Lung heat
  • Xie Bai San (Drain the White Powder)
    Originally designed for children. Very mild formula. Also recommend that patient eliminates dairy as well as other cold foods and drinks (which create phlegm) and sugary sweet foods (which create more heat).
    Indication: Lung heat excess, cough due to Lung heat
    Function: Clear Lung heat, stop cough and wheeze (asthma)
  • Qing Qi Hua Tan Tang (Clearing Qi and Resolving Phlegm Decoction)
    Indication: Interior phlegm-heat retention in the Lung
    Function: Clears phlegm heat, regulates qi, relieves coughing.
  • Wu Hu Tang (Five Tiger Decoction)
    Indication: Lung heat with coughing and wheezing
    Function: Clears Lung heat, disseminates Lung qi, stops coughing and wheezing
• Stomach Heat
  High fever is worse in the afternoon. Look for an overflowing rapid pulse. Same pattern as Yangming channel pattern in the Six Channel theory. Clear the qi and the Stomach heat.
  • Bai Hu Tang (White Tiger Decoction)
    Indication: Yangming/Qi heat with the 4 Bigs
    Function: Clears heat and generates fluids
  • Zhu Ye Shi Gao Tang
    Treats Stomach heat with injury to the yin.
  • ST 44, ST 34, ST 21, ST 43, LI 11, ST 25
• Dry-Heat in the Large Intestine
  Fever is higher in the afternoon, constipation, dry stools, burning in the anus, abdominal fullness/pain, irritability, possibly delirium. Tongue will have a thick dry yellow coating, Pulse is deep, full and rapid. Drain the fire, clear the stomach and intestines and promote downward movement.
  
  • Tiao Wei Cheng Qi Tang (Regulating the Stomach Conducting Qi Decoction)
  • LI 11, ST 25, SP 15, ST 37, ST 39
• Gallbladder Heat
  Alternating hot and cold feeling with heat prevalence (like Shaoyang stage), bitter taste in the mouth, thirst, dry thorat, hypochondriac pain, nausea, full feeling in stomach/epigastrium. Tongue will be red with sticky yellow that may be just on one side. Pulse will feel wiry and rapid. Harmonize the shaoyang and clear gallbladder heat.
  • Hao Qin Qing Dan Tang (Artemisia Scutellaria Clearing the Gallbladder Decoction)
• Damp Heat in the Stomach and Spleen
  Constant fever which goes down after sweating but increases again. Heaviness in the head and body, oppression in the chest and epigastrium, nausea, loose stools. Tongue is red with sticky yellow coating. Pulse is soggy and rapid. Clear the heat in the Stomach and Spleen and resolve damp.
  • Wang Shi Lian Po Yin (Coptis-Magnolia Decoction)
    Damp heat obstructions in the Middle Jiao. Modify as needed.
  • Bai Hu Jia Ren Shen Tang
    Summer heat/warm in the Qi stage with summer heat invading the Yangming
  • Qing Shu Yi Qi Tang
    Summer heat injuring fluids and qi
  • Sheng Mai San
    Body fluids and qi collapse
  • Bai Hu Jia Cang Zhu Tang
    Summer heat damp obstructing the Middle Jiao. Also treats heat in the Yangming with damp in Taiyin.
  • San Shi Tang
    Summer damp heat diffuse across all 3 jiaos.
  • Si Jia Jian Zheng Qi San and Wu Jia Jian Zheng Qi San
    Treat dampness generating cold.
• Autumn Dryness in the Qi Stage
  • Qiao He Tang
    Dryness disturbs the orifices
  • Qing Zao Jiu Fei Tang
    Dry heat injury to the Lung
  • Sha Shen Mai Men Dong Tang
    Lung and Stomach yin injury due to dryness. You saw this in the Wei stage above also.
  • Wu Zhi Yin
    Also for Lung and Stomach yin injury.
  • E Jiao Huang Qin Tang
    Lung dryness and Large Intestine heat with bleeding
  • Wu Ren Ju Pi Tang
    For dryness in the Lung with constipation in the Large Intestine.

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

• Heat in the Ying Level
  See symptoms above.
  • Qing Ying Tang (Clearing the Nutritive Qi Heat Decoction)
    Indication: Heat in the Ying stage
    Function: Clears heat from Ying, nourishes yin, moves blood
  • PC 9, PC 8, HT 9, KI 6 and the ten spreading points (shixuan).
• Heat in the PericardiumBasically the same as above, but there are more Shen signs because the Pericardium has been invaded by heat. Patient may have cold hands and feet, but these are false cold signs and are caused when the heat is so intense that the circulation of Qi is blocked to the lower extremities. Clear the nutritive qi heat, clear the Pericardium heat, restore consciousness and generate fluids in the body.
  • Qing Gong Tang (Clear the Palace Decoction)
    For heat sinking into the Pericardium
  • Niu Huang Cheng Qi Tang (Calm the Palace with Cattle Gallstone)
    Treats heat in the Pericardium with excessive Yangming heat. Purges the Fu heat downward and out of the body.
  • Chang Pu Yu Jin Tang
    Damp heat transforming to phlegm and covering the Pericardium.
• Autumn Dryness in the Ying Stage
  • Bai Hu Jia Di Huang Tang
    Autumn dry in the ying or xue stages.
• Summer Heat entering the Ying Stage
  • Qing Ying Tang + An Gong Niu Huang Wan

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

• All Ying Level symptoms above in addition to those below...
• Spasms, shaking (internal Liver Wind due to the internal heat)
• Bleeding signs and loss of blood including:
  • Vomiting of blood
  • Nasal bleeding
  • Blood in stools
  • Blood in urine
  • Bleeding under the skin layers showing as maculopapular rashes over the whole body and larger bleed-outs under the skin. This happens in all epithelial tissues both on the surface of the body as well as on the surface of the organs. Other organ bleeding also.
  • Tongue: deep red/crimson or purple body
  • Pulse: thin and fast or choppy.

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

• Heat affecting the blood
  All symptoms above. Heat is causing the reckless movement of blood so that it spills out of the vessels. You will see this most notably in the skin, but be aware that it is also happening in the organs as well. The mind is severely disturbed by heat, causing the restlessness and mania. Clear the blood heat and stop the bleeding.
  • Xi Jiao Di Huang Tang (Rhinocerous Rehmannia Decoction)
    Obviously, at this stage of our own planetary destruction, rhinocerous horn is no longer an option. Substitute a whole bunch (30 grams or so) of shui niu jiao. 
    Indication:
    Function:
  • BL17, SP 10, LV 5, SP 4, LI 11, LV 2, KI 6, HT 9, ten spreading points (shixuan).
• Excessive heat stirring inner wind
  Same signs as above with fainting, twitching of limbs, convulsions, neck rigidity and stiffness, opisthotonos, upward staring eyes, clenched teeth. Qi is collapsing. There's a whole forest fire of heat inside causing these signs. Clear blood heat and extinguish the wind.
  • Ling Jiao Gou Teng Tang (Antelope Horn and Uncaria Decoction)
    Indication: Extreme heat in the Liver channel causing inner wind. Also for Summer heat stirring wind.
    Function: Clear Liver heat, extinguish wind, tonify fluids
  • SP 10, LI 11, LV 2, KI 6, HT 9, LV 3, Du 16, GB 20, SI 3 + BL 62 and the Shixuan extra points (ten spreading points)
• Empty (deficient) heat stirring inner wind
  Low grade fever, tremors, twitching, weight loss, yin deficiency signs. Tongue will be dark red with no coat or peeled coat and will look dry. Pulse is fine and rapid. This is due to heat at the blood level injuring the yin of the Liver and Kidneys. Clear the blood heat, nourish Liver and Kidney yin, and extinguish wind.
  • Zhen Gan Xi Feng Tang (Pacify Liver and Extinguish the Wind Decoction)
    Indication: Liver and Kidney yin xu, Liver yang rising, disturbance of qi and blood.
    Function: Sedate Liver, extinguish wind, nourish yin, anchor yang
  • Lian Mei Tang
    Excessive Heart fire with Liver and Kidney deficiency
  • LV 3, Du 16, GB 20, SI 3+BL 62 combined, LV 8, KI 6, KI 3, SP 6
• Autumn Dryness in the Ying Stage
  • Bai Hu Jia Di Huang Tang
    Autumn dry in the ying or xue stages.
• Summer Heat entering Blood stage
  • Shen Xi Dan
• Yin Collapse
  Typical yin deficiency heat signs: low grade fever, night sweats, mental restlessness, dry mouth with only a desire to sip, five palm heat, malar flush, emaciation. Dark red dry tongue with no coat and a fine/rapid pulse. You must rescue the Yin and restore consciousness.
  • Da Bu Yin Wan (Great Tonify the Yin Pill)
    Indication: Liver and Kidney yin deficiency with empty heat or deficient fire flaring upward.
    Function: Tonifies yin and descends fire
  • ST 36, KI 3, SP 6, KI 6, Ren 4
• Yang Collapse
  Feelings of cold, cold limbs, warming does not help, bright white complexion, profuse sweating on the forehead, listlessness. The tongue is pale and swollen. The pulse is hidden, slow, and scattered. You just rescue the yang and restore the consciousness.
  • Shen Fu Tang (Ginseng Aconitum Decoction)
  • ST 36, Ren 6, Ren 4, Ren 8. Moxa is applicable upon Ren points. Du 4 as well.

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.

• Dr. Song Luo, Ph.D, MD (China), L.Ac.
  Dr. Song Luo is currently a professor at the AOMA Graduate Institute of Integrative Studies.
• Dr. Yuxing Liu, PhD, MD (China), L.Ac.
  Dr. Yuxing Liu is currently a professor at the AOMA Graduate Institute of Integrative Studies.
• Dr. Yaoping Song, PhD
  Dr. Yaoping Song is currently a professor at the AOMA Graduate Institute of Integrative Studies.
• Maciocia, Giovanni. The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturist and Herbalists, 2nd ed. Churchill-Livingstone, London. 2006. pp 721-748.

http://catstcmnotes.com/pages/Clinic/Diagnosis/Four%20Level%20Theory.html#xue