The Medical Acupuncture Web Page

Chinese physicians working from the beginning of the Ming dynasty (1368-1644 C.E.) through the Qing dynasty (1644-1911 C.E.) developed what became known as the Pattern of Four Levels (wei-qi-ying-xue bian-zheng). Taking from the Nei Jing they described four sequential physiological entities/scenes, each one of them represents a different distinct depth of body’s pathology.

Level 1 is called the Wei Qi (wei-fen-zheng) Pattern. It occurs at the first depth of the body. In the skin, it is the Level above the epidermis (fur coat, flora of bacteria, fungi etc on the skin, sweat, sebum, IgA from animal’s saliva etc) and goes down through the epidermis, through different layers from outside to inside: stratum corneum, stratum granulosum, up to the upper part of stratum spinosum.

Level 2 is called the Qi (qi-fen-zheng) Pattern. It occurs at the second depth of the body. In the skin, it is the Level of epidermal basal layer (stratum basale) with some portion of lower part of stratum spinosum, both referred as stratum germinativum or Malpighian layer.

Level 3 is called the Ying (ying-fen-zheng) Pattern. It occurs at the uppermost layer of the dermis and extends down through its deeper layers, excluding the lower third of the dermis. The word ying describes the Nutritive aspect of Qi that is associated with Blood and mainly with the extra-cellular fluid.

Level 4 is called the Xue [Blood] (xue-fen-zheng) Pattern. It is the final and deepest of the Four Levels. In the skin, it is the lower part of the dermis, mainly in the lower blood plexuses, and in the hypodermis.

According to this specific concept, one should look on animal’s skin and ask: “At what Level is the lesion located?”

Acute moist dermatitis due to flea bites [“hot spot”] might be in the Wei Qi Level. In chronic ulcerative dermatitis due to immunological condition, like discoid lupus erythematosus, the lesion has entered deep into the Xue Level. In lichenification and hyperpigmentation, the lesion might be in the Ying Level.

Identification of the lesion’s Level can be found by a simple observation without any specific advanced tools. One may use histological preparations or other advanced methods to assist in making the determination of the lesion’s location.

Determination of the lesion’s Level in this way makes our diagnostic process easier. It allows us also to plan therapeutic goals. For example, one should nourish the Yin etc for lichenification and hyperpigmentation due to lesion at the Ying Level.

We will be able to give prognosis and realistic timetable for healing; healing time for Wei Qi Level problems will be a few days and prognosis is excellent. As the lesion goes deeper, healing time increases from weeks to months, and the prognosis for complete cure diminishes as the process goes deeper. Also one will have better understanding of the pathology & pathogenesis of the Pattern.

This new approach makes us consider acupoints other than those we used in the past (viz Blood-related points, like BL-17, LU-09, SP10 etc for Xue Level issues) and new herbal formulas (viz formulas to Clear Heat from Ying Level, Invigorate Blood etc for Ying & Xue Level issues).

One can adapt the Four Levels concept regarding skin diseases and work clinical cases successfully. We can expand our abilities by adding the Six Stages concept to work up schemes to treat skin conditions.

Zhang Zhong-jing, one of the greatest physicians in Chinese history, developed in his classic book Shang-han Lun (“Discussion of Cold-induced Disorders”, written around 220 C.E.) the idea of Six Stages Pattern (liu-jing bian-zheng). The ideological background is taken from the Nei Jing that describes Six Stages of disease. The Six Stages presented in his book comprise a series of Patterns that map out the course of diseases.    

Dr. Zhang suggests that disease begins with Stage 1 and proceeds in sequence to Stage 6; however, a disease can go straight to any Stage, skip Stages, or even move in a reverse way.

Stage 1 is called Taiyang (Small Intestine and Urinary Bladder) Stage, when the disease is still in the Exterior.

Stages 2 and 3 are when the disease enters either Yangming (Large Intestine and Stomach) or the Shaoyang (San Jiao and Gallbladder) Stages. Yangming marks the internal development of the disease. Shaoyang is known as a half-Exterior/half-Interior Pattern, and therefore should be before Yangming. However, based on the original Nei Jing concept it appears after Yangming.

Stages 1, 2 and 3 (Taiyang, Yangming and Shaoyang Stages) are Patterns of Excess. Stages 4, 5 and 6 are Patterns of Deficiency and Interiority.

Stages 4, 5 and 6 are Taiyin (Lung and Spleen), Shaoyin (Heart and Kidney) and Jueyin (Liver and Pericardium) Stages, in which the disease or Pathogenic Factor moves progressively deeper into the Interior.

It is common in dermatology to place the Four Levels and Six Stages one beside each other, thereby expanding our diagnostic and therapeutic abilities:

             4 Levels                                                                   6 Stages

This one step, classification of the case in terms of the Four Levels and Six Stages together, directs the clinician not only to a better understanding of the process involved, but allows a better selection of goals and accordingly set of acupoints and herbal remedies.

To improve our abilities to be successful in application of TCVM herbal remedies to skin conditions in animals, I would like to introduce to you to transdermal herbal gel or foam, the third and last concept in this lecture.

I urge you to put your Chinese herbal remedies for skin conditions into transdermal gel or foam. Application of herbs in this way dramatically increases clinical success rates in skin diseases.

Advantages of using transdermal gels or foam:

• No need to give pills, capsules, tincture etc and by that avoiding fights with the treated animal, or having a mental & physical trauma to the treated animal or the owner
• Good cosmetic qualities as no visibility, no smell and no residues on the skin, avoiding sticky or greasy feeling, and avoiding rubbing on carpets, furniture, clothes etc
• Potential for in-clinic manufacturing
• Ability to apply remedy to large surface area
• No lag time
• Cost effective
• Lack of irritancy associated with occlusion or response to adhesives
• Absorption is done within less than one minute – so no need for neck collars or other protective measures to avoid the animal from licking or rubbing the remedy
• Excellent skin tolerability and non-toxic
• Uniform absorption
• The remedy forms a reservoir in the epidermis and enables a once-a-day application
• The high water content has good moisturizing properties

Disadvantages of using transdermal gels or foam:

• Not appropriate if the remedy needs activation in the gut
• When applying foam, the owner needs to wear gloves, or use a topical syringe

Note – gel should be protected from sunlight and heat, and out of reach of children and animals.