Three Kinds Of Depletion, Three Kinds Of Repletion:
A Simpler Understanding Of The
Complex Forty-Eighth Difficult Issue In Nan-Ching
Holmes Keikobad, MD

ABSTRACT
The Forty-Eighth Difficult Issue in the Nan-Ching Classic states, "A person may have three kinds of depletion, and three kinds of repletion." Chi Po postulates that a depletion or repletion can be recognized by a distinct symptom profile in 3 well-marked areas: movement in the vessels, course of an illness, and patient examination. This article explores these symptom profiles and highlights the depletion or repletion diagnoses.
KEY WORDS
Depletion, Repletion, Nan-Ching, Qi

INTRODUCTION
The Forty-Eighth Difficult Issue in the Nan-Ching Classic states: "A person may have three kinds of depletion, and three kinds of repletion."¹ What does that mean?

Chi Po, the sage of Nan-Ching, explains this difficulty in 10 clauses or so,² and scores of scholars over the centuries have followed this with their own commentaries. For students of this ever-enduring classic, this can lead to brilliant clarity or something less.

This article works with the adage "a picture speaks a thousand words." It combines expressive imagery and easy line drawings with relevant commentaries from healers through the ages in original text, as well as this author's observations, to further clarify the issue in contemporary light, so that one can integrate the information, stand in proper awe, and apply it in the clinic.

Chi Po postulates that a depletion or repletion can be recognized by a distinct symptom profile in 3 well-marked areas (Figure 1).

Hsu Ta-chun,³ circa 1727, quoting in part from the Shang-han lun:⁴ "A soft movement only at times in the vessels indicates loss of blood." He states further, "A soft movement in the vessels indicates diminished protective influences... A stringy and stiff movement in the vessels is called 'tight'; a hard and replete movement is called 'firm.'"

The sage states 2 reasons for the soft pulse: blood loss and a compromised protective Wei Qi. Note, though, that the meaning is actual blood loss and not a Blood Deficient state.
When one thinks of blood loss, we are reminded of the hollow pulse. Li Shi Zhen, circa 1518, writes in his Pulse Diagnosis,⁵ "The hollow pulse usually appears after bleeding." He describes it as "a pulse which feels like floating, big and soft under slight pressure, but without substance at the center under heavier pressure...".

He further explains the soft pulse as "in depth floating, in strength is weak, in width thin, in meaning symbolizing various types of severe deficiency or trapped dampness."

The latter attributes one did not perceive, and in paraphrasing Zhen, floating would mean a pulse that feels strong under light pressure, but losing its strength when pressure is increased; big would mean wider than the norm; weak would be very soft under deep pressure and not felt at a superficial level; and thin, a pulse that feels like a thread even though it is soft, weak, and without strength.

Alternatively, if one is dealing not with blood loss but with a compromised Wei protective Qi , the pulse will be weak, i.e., "a pulse which is felt to be very soft and thin under pressure, but cannot be felt at the superficial level."

According to Zhen, (a tight, firm pulse) is "a pulse which rises and falls with strength and vibrates to the left and right." Further, "it is like a tightly stretched rope and feels twisted, whether light or heavy pressure is applied."

A firm pulse is a pulse "which is very deep, almost hidden, and not only strong and long, but wiry and impatient."

Lastly, how do you differentiate the soft pulse of trapped dampness? Zhen writes, "When dampness is trapped inside the spleen and the Qi mechanism is blocked, the pulse becomes leisurely." He describes the leisurely pulse as "a pulse which is slightly faster than a slow pulse, with exactly 4 beats per respiration."⁵ As this pulse is also seen in health, one can differentiate from the dampness-trapped pulse by the fact that the latter will tend to be deep, thin out, and become slow.

Figure 1. Symptom profiles for recognizing depletion and repletion DEPLETION Any condition of Xu, Empty nature 1. Movement in the vessels (pulses) Soft and constrained 2. Course of an illness (a) From center to periphery (b) Patient vocal and talkative (c) Patient relaxed 3. Examination of a patient (a) Area soft to touch (b) Patient reports itching (c) External pain, internal comfort (d) Internal pain, external comfort REPLETION Any condition of Shi, Full nature 1. Movement in the vessels (pulses) Tight and firm, overflowing 2. Course of an illness (a) From periphery to center (b) Patient quiet (c) Patient tense 3. Examination of a patient (a) Area firm to touch (b) Patient reports pain (c) Internal pain, external comfort (d) External pain, internal comfort

THE COURSE OF AN ILLNESS TAKES 3 ROUTES
Chang Shih-hsien,⁶ circa 1510, states that "Move towards the outside" means that the 5 depots in the interior section of the organism have fallen ill by themselves and are depleted. "Move towards the interior, on the other hand, means that the exterior sections of the organ-ism have been harmed by evil influences and suffer from repletion."

Yin lives inside and Yang lives outside. If Yin moves externally to usurp Yang, the 5 solid organs, the repository of Yin, have lost something; hence, the state of depletion. Conversely, when the Yin and Yang are in place inside and outside, but an external factor invades, e.g., Heat, Wind, Cold, or Damp, and it tracks from outside to inside and there is no place to accommodate it, a state of repletion results. If the patient speaks, this indicates depletion. If he/she does not speak, this indicates repletion.

Yang K'ang-hou,⁷ circa 1098, said, "When the influences of the depots are depleted, the essential influences are lost, resulting in the respective person speaking freely. When the influences of the depots are replete, evil influences are present in abundance. Hence, one is not willing to speak."

 The terms "speaks" or "does not speak" do not mean the way people usually talk or keep silent, but instead signifies an aberrant form of speech in which a person continues to talk even when words are superfluous, or does not respond to interaction and is silent and withdrawn. An interesting corroboration appears in Diagnostic Methods in Chinese Acupuncture and Moxibustion:⁸ "Repeated speech in a feeble voice accompanied by listlessness suggests a syndrome of the deficiency type of the heart, resulting from severe damage of Heart Qi." One is also reminded of the Empty Laughter of the HT Qi Deficient syndrome.

A soft pulse which: (a) Feels soft to touch on either wrist and on any of the positions of cun, guan, and Qi; and (b) Falls short of the natural length of the pulse. A firm and tight pulse which: (a) Feels firm and tight on either wrist and on any of the positions of cun, guan, and Qi; and (b) Extends well beyond the natural length of the pulse.

If the patient is relaxed, this indicates depletion; if tense, this indicates repletion. Tin Te-yung,⁹ circa 1062, stated, "Yang influences are responsible for haste; Yin influences are responsible for calmness. Thus, if Yin influences are present in abundance, the patient is relaxed. If Yang influences are present in abundance, the patient is tense. Hence, one knows that a relaxed state of the patient indicates a depletion; a tense state of the patient indicates a repletion."
However, one may not take the words "relaxed" and "tense" too literally; they may as easily mean lethargic, slowed down for relaxed; on-edge and jittery for tense. An interpretation by sage Hua Shou, circa 1361,¹⁰ relates the words Qi and Pu-Qi: speedy and not speedy, i.e., relaxed and tense; in the Difficulty, to denote the quickness or natural progression of the illness; in the relaxed patient, moving slowly; in the tense patient, moving rapidly.

EXAMINATION FOR PATTERNS
The examination can reveal 4 patterns of depletion or repletion. If, on touching the patient, one gets a sense of softness, this is depletion; if, instead, a firmness is felt, this is repletion.
Yang said,¹¹ "In case of depletion, the skin is soft and relaxed. In case of repletion, the skin is firm and vigorous." Po clearly says," If by touching the patient, one perceives firmness, that marks a repletion."

Between Po and the sage Yang, it is established that one touches somewhere on the skin, but it is uncertain where. Does this mean the pulse? Or, the abdominal Hara, which figures so greatly in the Japanese school of acupuncture where the findings are co-opted from the inferences of the Blind Healers, great diagnosticians whose refined sense of touch provided a method greatly valid today. This is difficult to determine and even in the Nan-Ching, there are only 3 commentaries.

Figure 4. External Movement, Depletion Figure 5. Inward Movement, Repletion (a) If the illness moves externally, it causes Emptiness within and a resulting depletion. (a) If the illness, which could be pathogenic factors, is trekking inward, Fullness arrives, resulting in repletion.

Kiiko Matsumoto and Stephen Birch¹² describe a method of feeling the skin of the forearm and correlating findings to the pulse profile. The skin of the forearm is brushed very lightly with the fingertips in a slow and regular motion. If the fingers move faster than they should, i.e., slip away over the skin, this correlates to a slippery pulse. If the fingers seem to come to a halt or slow down, this denotes a rough quality.

If the patient reports itching, it is depletion; if pain, there is repletion. Hsu Ta-chun,¹³ circa 1727, states," If blood and protective influences are depleted and cannot fill skin and flesh, itching results. If evil influences gather together and if, as a result, constructive and protective influences cannot proceed in harmony, pain results."

Why does a lack of Wei Qi, Ta-chun's protective influences in the skin and subcutaneous tissue, result in the sensation of itching? One aspect of Wei Qi is that it runs outside the channels. The other is that it actively influences the opening and closure of pores.

The Pulse Classic¹⁴ ascribes exhalation, monitored by HT and LU, to be Yang in nature; inhalation, monitored by KI and LV, is considered Yin in character. Thus, the pores are ruled by the LU Qi, which is Yang in nature from the point of view of respiration, and actively causes these to remain patent or constricted, depending on the requirement at the moment.

As Ta-chun implies, when the protective influences of Wei Qi are depleted, the pores will not open with facility. This will cause a build-up of moistness under the skin, which cannot exit as perspiration and creates a sensation of backpressure in all the tiny pores and presents as a sensation of itching. In the author's experience,¹⁵ patients with a chronic LU Qi-Deficient pattern often report 1 or more of the following:

• Sensation of multiple tiny pricks, especially on the Yang surfaces of the body.
• History of rarely noticing perspiration.
• History of developing a headache when out in the sun.
• Perennially dry skin; LU ruling dryness.

As to the pain factor, Ta-chun designates evil influences as interrupting the continuity of the interface between the protective and constructive influence.

The Thirtieth Difficult Issue in the Nan-Ching16 states: "In general, the constructive influences and the protective influences follow each other proceeding through the organism." Again, the same Issue continues to state, "The constructive influences proceed inside the vessels; the protective influences proceed outside the vessels. They circulate through the organism without a break; after fifty passages, they have a great meeting. The Yin and the Yang conduits are tied to each other like a ring without end. Hence, one knows that the constructive and protecting influences are following each other."

When a tertiary factor of evil influences intrudes in this continuity, pain results. Such a pain, almost a space-occupying factor, displaces the 2 legitimate forces and ends up causing repletion.

If the patient feels pain externally but is comfortable internally, this indicates a repletion in the exterior and a depletion in the interior. If the patient feels pain internally but is comfortable externally, this indicates a repletion in the interior and a depletion in the exterior.

Commentary by Yang¹⁴ says, "If light pressure with one's hand causes pain, this indicates an external repletion. The reason is that the illness is near the surface. If heavy pressure with one's hand makes a patient comfortable, this indicates an internal depletion. The illness is located in the depth." (Figures 6 & 7).

CONCLUSIONS
Almost all chronic cases one encounters in practice have an element of Deficiency, even when there are symptoms of apparent excess. Chi Po, who remains unknown to this day, provided us with the simplest methods to identify this condition and all that remains is to narrow the element to be toned. Qi is then restored.



REFERENCES

1. Unsschuld PU. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
2. Po C. The legendary physician who provides answers for the Eighty-One Difficult Issues posed by Huang DI, the famous Yellow Emperor, in the Nan-Ching, the Classic of Difficult Issues. Regents of the University of California: University of California Press; 1986.
3. Ta-chun H. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
4. Zhang ZJ. Shang Han Lun, The Classic: A Treatise on Cold Damage. Brookline, MA: Paradigm Publications; 1999.
5. Zhen LS. Pulse Diagnosis. Sydney, Australia: Paradigm Publications; 1981.
6. Shih-hsien C. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
7. K'ang-hou Y. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
8. Diagnostic methods, auscultation, and olfaction; Chapter 12, p.274.
9. Te-yung T. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
10. Shao H. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
11. Yang. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
12. Matsumoto K, Birch S. Five Elements and Ten Stems: Nan-Ching Theory, Diagnosis, and Practice. Brookline, MA: Paradigm Publications; 1983.
13. Ta-chun H. On illness: the forty-eighth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II, Chapter Four. Regents of the University of California: University of California Press; 1986.
14. Yang SZ. The Pulse Classic; A Translation of the Mai Jing [originally translated by Wang-Shu he]. Boulder, CO: Blue Poppy Press; 1997.
15. Keikobad H. On the Mechanism of Itching in Lung Yin Deficiency Illness. Scottsdale, AZ: Tru Self Inc.
16. Unsschuld PU. The depots and palaces: the thirtieth difficult issue. In: Nan-Ching: The Classic of Difficult Issues, Part II. Regents of the University of California: University of California Press; 1986.

AUTHOR INFORMATION
Dr Holmes Keikobad is semi-retired as a practitioner, and his current practice is solely comprised of traditional acupuncture in the Nan-Ching Classical School. During 4 decades of practice covering 3 continents, he worked in family and community care. Dr Keikobad set up healthcare systems for large cities and was responsible for the creation of the Port Health and Wellness Health Care System in Muscat, in the Sultanate of Oman. Dr Keikobad was on the team of physicians that originally eradicated smallpox in the field, and has worked as a Senior Medical Officer with epidemics under emergency situations. He is an expert in the field epidemiology of smallpox, cholera, and botulism.

Holmes Keikobad, MD, DPH Ret, DIP AC, NCCAOM, LIC ACUP CO, AZ*
Community Acupuncture Clinic
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