Traditional Chinese Medicine: Theory and Principles 9783110417661, 9783110417296, 9783110579925

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Hu Dongpei (Ed.) Traditional Chinese Medicine

Traditional Chinese Medicine  Theory and Principles

Edited by Hu Dongpei

This work is co-published by Tsinghua University Press and Walter de Gruyter GmbH. Contributors Committee Editor-in-Chief: Hu Dongpei Chinese Chief Reviewer: Li Qizhong English Chief Reviewer: Portia Barnblatt Assiociate Chief Editors: Zhang Ting, Xie Ning Editors (in alphabetical order of surnames): Cheng Liguo (Medical College of Ji’Nan University) Hu Dongpei (Shanghai University of Traditional Chinese Medicine) Ji Lijin (Fujian University of Traditional Chinese Medicine) Li Jing (Anhui College of Traditional Chinese Medicine) Li Qizhong (Shanghai University of Traditional Chinese Medicine) Li Xiaoqian (Shanghai University of Traditional Chinese Medicine) Liang He (Henan College of Traditional Chinese Medicine) Liu Xiaoyan (Changchun University of Traditional Chinese Medicine) Lü Zhiping (Southern Medical University) Ma Shuran (Beijing University of Traditional Chinese Medicine) Meng Jingyan (Tianjin University of Traditional Chinese Medicine) Ni Xianghui (Guiyang College of Traditional Chinese Medicine) Portia Barnblatt (America College of Traditional Chinese Medicine) Shi Jianmei (Shanxi College of Traditional Chinese Medicine) Wang Yingxiao (Shanghai University of Traditional Chinese Medicine) Xie Ning (Heilongjiang University of Traditional Chinese Medicine) Yu Ling (Shanghai University of Traditional Chinese Medicine) Zhang Qingxiang (Shandong University of Traditional Chinese Medicine) Zhang Ting (Shanghai University of Traditional Chinese Medicine) Zhu Manjia (Chengdu University of Traditional Chinese Medicine)

ISBN 978-3-11-041729-6 e-ISBN 978-3-11-041766-1 e-ISBN (EPUB) 978-3-11-041780-7 Library of Congress Cataloging-in-Publication data A CIP catalog record for this book has been applied for at the Library of Congress. Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.dnb.de. © 2016 Walter de Gruyter GmbH, Berlin/Boston and Tsinghua University Press, Beijing Cover image: Yi Lu/iStock/Thinkstock Typesetting: Lumina Datamatics Printing and binding: CPI books GmbH, Leck ♾ Printed on acid-free paper Printed in Germany www.degruyter.com

Preface Management of teaching materials is one of the basic requirements for high quality education in traditional Chinese medicine (TCM). This requirement applies to training of TCM practitioners as well. Since the establishment of the universities of traditional Chinese medicine, teaching materials have been developed by the state-unified TCM colleges and universities. They have played an important role in the application of TCM, systematically improving teaching quality as well as cultivating talents in the TCM field. With the rapid development of the TCM field and the need for globally expanding TCM education, comprehensive teaching material, incorporating digital features of the English language, has become important. With the help of such high quality teaching material, Chinese culture and knowledge of TCM may be spread worldwide without loss of its essence. The basic theory of TCM is an important part of the curriculum of TCM. The theory is not only a basic course for the Chinese-medicine profession but also a compulsory content for the license examination of domestic and international Chinesemedicine practitioners. It is the foundation for continual education in the field of TCM diagnosis, Chinese herbal medicine, Chinese herbal formula, TCM classics, and TCM clinical education. It includes the study of basic TCM philosophy, TCM visceral manifestation, TCM etiology and pathology, and the TCM treatment principle. This book is most suitable for TCM universities and western-medicine practitioners. It is also an important reference book for TCM clinical practice and research. As on date, there are about 50 kinds of teaching materials for topics in basic theory of TCM and TCM foundation. But none of those include the digital features in the English language. The existing materials are written in the traditional and classical form, without effectively using modern scientific means and methods to represent knowledge with regard to the simplicity of the ancient Chinese language, its profound concept, and the difficulties commonly encountered in the teaching of TCM theory. Current scholars in the TCM field concur that materials on TCM theory require significant improvement to enhance readability and understanding. This book is intended to break the inherent model and establish a culture that promotes independent learning ability. The basic theory of TCM supports multimedia digital teaching and changes the merely simple text mode effectively. The content is rich while the text is concise and focused. Using videos, pictures, and animation, the book creates a vivid, innovative, and lively learning mindset. It departs from the old and dull teaching models of the previous educational system, cultivating interest in the student to explore and learn TCM. The bilingual form of this material mitigates the language barrier often faced by international exchange students; it stimulates students’ interests in learning as well as activates a classroom atmosphere. By using the digital production for the entire material will lead the reform in the teaching textbooks.

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Preface

The content of this book is based on China’s TCM undergraduate educational syllabus. It covers all the materials for TCM licensing exams domestically and internationally as well as fully embodies the basic theory, knowledge, and skills related to TCM. It integrates every aspect of the basic TCM theory in accordance with the nature of the subject and the scope of the study. The book reflects the disease spectrum of today’s society and provides guidance to the modern clinical practice of TCM. The features of modern international education have been integrated into this book, which gives full consideration to beginners and foreign students, particularly focusing on the way they think and learn and the difficulties they face in learning TCM. To enhance readability and practicality for foreign students, this book reorganizes every concept concisely in a simple, correct, and orderly digital way in both Chinese and English. This book summarizes the essence of Chinese medicine and records the results of modern research; learn from the experience of textbook writings of the entire country in China, maintain and carry forward the characteristics of traditional Chinese medicine. This book is written under the guidance of the high starting point, high standard and high concept, as well as endowed with an innovative mode of thinking and the positive learning attitude. I believe this book will play a positive role in improving the quality of teaching of the basic theory of TCM, prospecting the Chinese medicine and spreading the TCM culture. I thank the office of academic affairs from the university and members of the department of fundamental medicine college, who gave me huge encouragement and support during the writing of this book. There might be flaws in this book despite my efforts to eliminate them. I welcome advice from experts in this field to make the book better. Hu Dongpei March 2013

Contents 1 1.1 1.1.1 1.1.2 1.1.3 1.1.4 1.2 1.2.1 1.2.2

Introduction  1 The discipline, nature, and properties of traditional Chinese medicine  1 TCM is characterized by its natural science nature  1 TCM has the characteristics of social science  1 The mutual influences of TCM and ancient Chinese philosophy  2 TCM is a product of multidisciplinary interactions  2 The main characteristics of TCM theory  3 Concept of holism  3 Differential diagnosis and treatment  5

2.2.4

The Philosophical Basis of Traditional Chinese Medicine  7 Theory of yin-yang  7 The basic concept of yin-yang  7 The basic contents of yin-yang theory  8 The applicable examples in traditional Chinese medicine of the yinyang theory  10 Five elements theory  14 Fundamental concepts and characters of the five elements  14 The classification of the five elements  16 The cycle of generation, restriction, over-restriction, and counterrestriction in five elements  18 The application of five elements theory in TCM  19

3 3.1 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.3.6

Visceral Manifestation  24 Summarization of visceral manifestations  24 Five zang-organs  25 Heart  25 Lung  27 Spleen  30 Liver  34 Kidney  38 Six fu-organs  43 Gallbladder  43 Stomach  44 Small intestine  45 Large intestine  45 Urinary bladder  46 Triple-jiao  47

2 2.1 2.1.1 2.1.2 2.1.3 2.2 2.2.1 2.2.2 2.2.3

VIII 

3.4 3.4.1 3.4.2 3.5 3.5.1 3.5.2

Contents

Extraordinary fu-organs  48 Brain  48 Uterus  49 The relationships among the zang-organs and fu-organs  50 The relationships among the six fu-organs  56 The relationship between the five zang-organs and six fuorgans  57

4 4.1 4.1.1 4.1.2 4.1.3 4.1.4 4.1.5 4.2 4.2.1 4.2.2 4.2.3 4.2.4 4.3 4.3.1 4.3.2 4.3.3 4.4 4.4.1 4.4.2 4.4.3

The Theory of Qi, Blood, and Body Fluids  59 Qi  59 Concept of qi  59 Production of qi  59 Movement of qi  60 Functions of qi  61 Classification of qi  62 Blood  65 Concept of blood  65 Production of blood  65 Functions of blood  66 Blood circulation  66 Body fluids  67 Concept of body fluids  67 Metabolism of body fluids  68 Function of body fluids  69 The relationships among qi, blood, and body fluids  69 The relationship between qi and blood  70 The relationship between qi and body fluids  71 The relationship between blood and body fluids  72

5 5.1 5.1.1 5.1.2 5.2 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.2.6 5.3 5.3.1

Theory of Meridians and Collaterals  73 Overview of the theory of the meridians and collaterals  73 The concept of the meridians and collaterals  73 Composition of the meridian  73 Twelve meridians  75 Nomination of 12 meridians  76 Route and connection of the 12 meridians  76 Distribution of the 12 meridians  77 Exterior–interior relationship  78 Circulating sequence of the 12 meridians  78 Travelling routes of the 12 meridians  79 Eight extra meridians  90 Concept and functions of eight extra meridians  91

Contents

5.3.2 5.4 5.4.1 5.4.2 6 6.1 6.1.1 6.1.2 6.2 6.2.1 6.2.2 6.3 6.3.1 6.3.2 6.3.3 6.4 6.4.1 6.4.2 6.4.3 6.4.4 6.4.5 6.4.6 7 7.1 7.2 7.2.1 7.2.2 7.2.3

8 8.1 8.1.1 8.1.2 8.2 8.2.1

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IX

Distribution and physiological functions of the eight extra meridians  91 Physiological functions and applications of the meridians  99 Physiological functions of the meridian  99 Application of the theory of the meridian  100 Constitutional Theory  101 Concept of constitutional theory  101 Basic concept of constitution  101 Signs and characteristics of constitution  102 Factors affecting constitution  102 Relationship of the constitution to viscera, meridians, essence, qi, blood, and body fluids  103 Factors which affect the constitution  103 Classification of constitution  106 Balance constitution  107 Yang-inclined constitution  107 Yin-inclined constitution  107 Application of the constitution theory  108 Explanation of the susceptibility of individual to certain pathogens  108 Illustrating the etiology  109 Explaining the pathological changes  109 Guiding syndrome differentiation  110 Guiding treatment  110 Guiding the health maintenance  111 Onset of Disease  112 Concepts of pathogenesis  112 Cardinal principle of disease onset  112 Deficiency of vital qi is the intrinsic factor for the pathogenesis  113 Pathogenic qi is an important factor to cause the disease  114 Struggle between pathogenic and vital qi determines the progress and prognosis of disease  115 Etiology  117 Exogenous pathogens  117 Six evils  117 Pestilential pathogens  125 Endogenous pathogens  127 Internal injury due to mental disorders  127

X 

8.2.2 8.2.3 8.3 8.3.1 8.3.2 8.3.3 8.4 8.4.1 8.4.2 9 9.1 9.1.1 9.1.2 9.1.3 9.2 9.2.1 9.2.2 9.3 9.3.1 9.3.2 9.3.3 9.3.4 9.3.5

Contents

Injury due to improper diet  129 Injury due to overstrain and over-idleness  131 Pathogens from pathological products  132 Water-dampness, phlegm, and retained fluid  133 Blood stasis  135 Calculus  137 Other pathogens  139 Medicine abuse  139 Iatrogenic pathogen  141 Pathogenesis  143 Exuberance and debilitation between vital and pathogen  143 Concept of pathogen, vital, exuberance, and debilitation  143 Changes of deficiency or excess  145 The relationships among pathogen, vital qi, excess, and deficiency as well as the outcome of disease  147 Imbalance of yin and yang  150 Concept of imbalance of yin and yang  150 Types of imbalance of yin and yang  150 Disorders of qi, blood, and body fluids  155 Disorders of qi  156 Disorder of blood  158 Disharmony between qi and blood  160 Metabolic disorders of body fluids  161 Disharmony among qi, blood, and body fluids  163

10 Principles of Prevention and Treatment of Diseases  165 10.1 Principles of disease prevention  165 10.1.1 Disease prevention prior to its outbreak  165 10.1.2 Controlling the development of an existing disease  165 10.2 Principles of treatment  166 10.2.1 Treating the root of a disease  166 10.2.2 Strengthening the vital and dispelling the pathogen  170 10.2.3 Regulating yin and yang  173 10.2.4 Regulating qi and blood  175 10.2.5 Regulating the viscera  175 10.2.6 Three optimal treatment administrations  175 References  179

1 Introduction 1.1 The discipline, nature, and properties of traditional Chinese medicine Key points – – – –

TCM belongs to the category of natural science. TCM has the characteristics of social science. TCM is profoundly influenced by ancient Chinese philosophy. TCM is the product of multidisciplinary interactions.

Traditional Chinese medicine (TCM) is a life science that originated from ancient China, focusing on researching human health, illness, and disease prevention. It has a close relationship with the geographic culture in China and belongs to the traditional-science category of the Orient. TCM is an important part of the world’s knowledge of medical science; its characteristics and properties are discussed in the following sections.

1.1.1 TCM is characterized by its natural science nature Natural science is a subject which studies the law or nature of material movement and change and development in nature. Medical science is a scientific system which studies the process of life and its fight against disease. It belongs to the category of natural science. The study of TCM is focused on human beings, especially on the basic law of birth, growth, aging, and death. TCM also emphasizes the mechanism of physiology, pathology, and disease prevention. It has the characteristics of medical science. Therefore, TCM belongs to the category of natural science.

1.1.2 TCM has the characteristics of social science Social science is a subject which studies the change of human society and its development. Human beings are not only the highest product of natural evolution but also have social attributes. TCM focuses on studying different physiological functions from different angles of the social background. It also studies the social roots and the personal relationship and how they affect the physical as well as the mental health of human beings. These features reflect distinctively the social and scientific characteristics of TCM.

2  1 Introduction

1.1.3 The mutual influences of TCM and ancient Chinese philosophy Philosophy is a science which studies the general rules of the common movement in nature, society, and thoughts. The development of any object is related to philosophy. The interactive relationship between TCM and philosophy is reflected in two aspects. Firstly, TCM was constantly receiving the development of philosophical research during its process of formation and development. Since its initiation, TCM has unceasingly absorbed research progress from ancient Chinese philosophy; a series of TCM phenomena may be explained through important philosophical concepts. For example, yin-yang, a philosophical concept in Huangdi Nei Jing, is used to explain the relative attributes and their relationships of the two opposite aspects of correlative things or two opposite aspects within one thing. Combining with the other terms, it formulates the special TCM terms which are used to explain the physiological functions and pathological changes of the human body. Therefore, yin-yang is a methodology which is used to direct the development of TCM theory and is also applied repeatedly in TCM research. The same concept is applied to the theories of yuan-qi and the five elements. Secondly, TCM enriched and developed ancient Chinese philosophy. For example, the relationships between yin and yang and the laws of promotion, restriction, counter-restriction, and over-restriction among the five elements were first put forward and fully discussed in the TCM literature. Many philosophers also used the TCM theory to do philosophical research. Therefore, TCM not only enriched ancient Chinese philosophy but also promoted the development of the ancient philosophy.

1.1.4 TCM is a product of multidisciplinary interactions To a certain extent, the development of TCM is also the medical application history of multidisciplinary knowledge. Besides ancient Chinese philosophy, our ancient astronomy, geography, meteorology, phenology, agronomy, biology, botany, mineralogy, specialties, mathematics, and metallurgy played an important role in the initiation and development of TCM. For example, meteorological knowledge is an important factor in the development of the initial theory of the six climatic pathogens. By comparing the four seasons, TCM recognized the differences in pulse according to the changes of the four seasons. With knowledge of geography, ancient TCM scholars developed the theory of treatment according to environmental changes. Therefore, TCM is a product of multidisciplinary interactions. Multidisciplinary knowledge promotes the development of TCM.

1.2 The main characteristics of TCM theory

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3

1.2 The main characteristics of TCM theory The theoretical system of TCM is influenced by ancient philosophical thought and developed over long-term clinical practice. TCM theory consists of two aspects: holism and differential diagnosis and treatment. Key points –

The main characteristics of the theoretical system of TCM: – Concept of holism – Differential diagnosis and treatment

1.2.1 Concept of holism Key points –

The concept of holism includes the following: – The human body as an organic whole – The unity between human and environment

Wholeness signifies the unity and integrity of an object. TCM holds that the human body is an organic whole in which all constituent parts are structurally inseparable, functionally coordinative and interactive as well as pathologically interinfluencing. The human body is closely related to the natural and social environments. Through the process of adaptation, it maintains its balanced activities. The concepts of unity between the internal and external environment, the connection, the integrity of the body itself as well as the balance represent the wholeness of TCM theory. The wholeness concept is an important thinking method permeating in various areas such as physiology, pathology, diagnosis, health care and treatment. 1. The human body as an organic whole The human body is composed of different viscera and tissues. Each of them has different functions which are the constituent part of the whole activity. A human’s normal physiological activity is affected by the whole activity. On the other hand, it also influences the functions of other viscera and tissues. This kind of function is the whole activity. From the viewpoint of TCM, integral unity is established by connecting the five zang-viscera, six fu-viscera, the five body constituents, the sensory organs, the nine orifices, the four limbs, and the bones through the meridian systems: The liver, gallbladder, tendon, and eye constitute the liver system; the heart, small intestine, vessel, and tongue constitute the heart system; the spleen, stomach, muscle, and mouth constitute the spleen system; the lung, large intestine, skin, and nose constitute the lung system; and

4  1 Introduction

2.

the kidney, urinary bladder, bone, ear, and anus constitute the kidney system. These constituents form the whole unity and accomplish its functional activities. Any local areas belong to the parts of the whole unity. Local illness, diagnosis, and treatment must be based on the concept of wholeness. Otherwise, whole pathological changes will affect local disorder. The unity between human being and external environment Human being is a by-product of natural evolution. From the TCM point of view, a human being is materially connected with the external environment. Human beings live in nature. Therefore, the external environment will directly or indirectly affect the functional activities of the human body. The body’s beneficial adaptations to environmental changes belong to the category of physiologically adaptive adjustments. Otherwise, they are called pathological reactions and will result in diseases. This idea is referred to as the unity between the human being and the external environment. A. The unity between human being and nature Human beings live in nature. Natural factors, for example, seasonal and climatic changes, day and night as well as the geographical differences, can directly or indirectly affect the body’s physiological functions and pathological changes. In general, it is warm in spring, hot in summer, damp in late summer, dry in autumn, and cold in winter. Under the influence of these climatic changes, there are many adaptation changes for living things: germination in spring, growth in summer, change in late summer, reap in autumn, and storage in winter. Just as any other living thing, human beings must also adapt themselves to climatic changes. For example, in spring and summer, yang-qi rises upward and flourishes whereas qi-blood of the body trends to circulate superficially, which often results in loose skin, profuse sweating, and less urination. During autumn and winter, yang-qi goes inward and becomes astringent whereas qi-blood of the body trends to go internally, which often results in tight skin, less sweating, and more urination. These adaptations indicate that seasonal climatic changes can influence the body’s physiological functions. Although daily temperature changes are not as obvious or regular as seasonal changes, long-term regular changes will result in the same rhythmic change as the day and night to adapt to the changes in the environment. Geographical differences in living environment are also an important factor, which can directly influence the physiological function of the human body. Regional climate and different cultures and customs are all geographical differences. They can affect the body’s physiological function and mental activities to a certain degree. For instance, the southern region of China is usually damp and hot, and the striae of the human body tends to be loose and body shape thin; the northern part of China is dry and cold, and the striae of the human body tends to be tight and the body shape is stronger.

1.2 The main characteristics of TCM theory

B.

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5

The close relation between human beings and society Human beings live in society. Different social environments also result in different physical and mental functions. The change of social status definitely brings differences to the individual’s spiritual life. Social development enriches humans, widens living room, elevates levels of health care and promotes human living conditions and lengthens life span. On the other hand, with a turbulent society or war occurring frequently, an individual’s physical and mental functions will be affected more. The progress that society makes will undoubtedly bring many benefits to human health. Due to the relationships of unity and opposition between the human being and the external environment, the principles of treatment according to time, different locations and each individual have become the important rules in the TCM treatment. Therefore, more attention should be paid to the organic relationships between the external environment and the overall functional activity during the treatment process.

1.2.2 Differential diagnosis and treatment Key points – –

– –

– – – –

– –

Syndrome A syndrome is a pathological summary during a stage of disease onset. It includes etiology, the location of the disease, the pathology as well as the relationship between right and evil pathogen. Differential diagnosis Differential diagnosis refers to the analysis, differentiation, recognition, and summarizing of the syndrome of a disease by the collection of medical history, symptoms and signs through the four traditional methods of inspection, olfaction, inquiry, and palpation. Treatment determination Treatment determination refers to the choice and formulation of the corresponding therapeutic principle as well as the method according to the result of the differential diagnosis. Same disease but different treatment This method refers to the different treatment principles due to different disease onsets, different disease locations, different body reactions or different stages of the disease originating from the same kind of a disease. In other words, treatments are based on the different syndromes. Different diseases but same treatment This method refers to the same treatment principle based on diseases with similar etiology, and pathology.

There are fundamental differences among the syndromes, symptoms, and diseases. Symptoms refer to the complaints by a patient, such as headache and abdominal pain. The same symptom may have different reasons. And its pathological mechanism

6  1 Introduction

can also be completely different. Disease refers to a complete morbid process, including the specific etiology, disease onset, typical clinical presentation, prognosis, and outcome. For example, common cold, stroke, and dysentery are all diseases. Therefore, compared to symptom and disease, syndrome reflects much profound pathological change than the disease itself and symptom. Differential diagnosis refers to the analysis, differentiation, recognition, and summarizing of the syndrome of a disease by the collection of medical history, symptoms, and signs through the four traditional methods of inspection, olfaction, inquiry, and palpation. Treatment determination refers to the choice and formulation of the corresponding therapeutic principle as well as the method according to the results of differential diagnosis. Differential diagnosis is the prerequisite and basis for treatment determination, whereas treatment determination is the means and method for treating disease based on the result of differential diagnosis as well as its execution. On the other hand, treatment result can test the precision of differential diagnosis and treatment determination. During clinical treatment, two different therapeutic methods – different treatments for the same disease and the same treatment for different diseases – can be applied separately according to the results of differential diagnosis. Same disease but different treatment refers to different treatment principles employed due to different disease onsets, different disease locations, different body reactions or different stages of the disease originating from the same kind of a disease. In other words, different treatments are based on different syndromes. Different diseases but same treatment refers to the use of the same treatment principle based on the different diseases with similar etiology and pathology. In other words, the syndromes are the same. On the whole, TCM treatment is based on the syndrome instead of different diseases. Because the same syndrome represents the same patho-mechanism, the same or similar treatment can be given; and different syndromes represent different patho-mechanisms, therefore, the treatment must be given differently. This reflects the true essence of differential diagnosis and treatment. Yin-yang and the five elements belong to ancient Chinese philosophy. It is the methodology by which our ancestors recognized and explained nature. The five elements permeate TCM and become an inseparable part of TCM. The yin-yang and five elements theory is applied in TCM and has become the theoretical tool and methodology of TCM. It determines the thinking mode of TCM and directs its clinical practice.

2 The Philosophical Basis of Traditional Chinese Medicine 2.1 Theory of yin-yang 2.1.1 The basic concept of yin-yang Key points – –

Yin and yang Yin and yang are the summarization of the attributes of two opposite aspects of correlative subjects or phenomena in universe.

Relativity: The original meaning of yin and yang was very simple and was from hieroglyphs. It mainly referred to the directions facing toward the sun and away from the sun. Facing toward the sun belongs to yang, while facing away from the sun belongs to yin. Based on the yin-yang theory, the ancient scholars made further inferences and extensions. Anything with the characteristics of facing toward the sun was classified as yang, while anything facing away from the sun was classified as yin. Generally speaking, the things that bear the properties of being active, external, ascending, warm, and bright pertain to yang, while the things that bear the properties of being static, internal, descending, cold, and dark pertain to yin. Separability: The ancient scholars realized that all kinds of things and phenomena had two opposite sides. The mutual actions of the two opposite sides promote the formation, development, and change of things. Therefore, yin-yang was used to explain all kinds of natural things that were inter-opposite and mutually wane or wax. The interactions between yin and yang exist intrinsically within all kinds of things. Thus, yin-yang is refined to a specific philosophical concept. It is the summarization of the attributes of the two opposite aspects of correlative things or phenomena in universe. Correlation: Yin-yang refers to the attributes of two opposite aspects of correlative things or phenomena. It can be used to distinguish all kinds of phenomena under the condition that yin-yang stands for two correlative things or two opposite aspects within one thing. The ancients realized that all things can be divided without limitation. Any correlative things or phenomena in the universe can be summarized as yin or yang. Any aspect of yin or yang within one thing can be further classified into yin or yang. This classification is called the infinite divisibility of yin-yang. Everything is in constant motion. Therefore, the attributes of things in yin-yang can change as well, which means that one side of yin-yang under a certain condition can

8  2 The Philosophical Basis of Traditional Chinese Medicine

transform itself into the other, that is, yin may change into yang and yang may change into yin. Obviously, the yin-yang attribute is in relative motion and changes constantly.

2.1.2 The basic contents of yin-yang theory The basic contents of yin-yang theory are mutual opposition and restriction, mutual rooting and dependence, waxing and waning, and balance as well as mutual conversion. Key points – – – – –

The basic contents of yin-yang theory Mutual opposition and restriction of yin and yang Mutual rooting and dependence of yin and yang Waxing – waning and balance of yin and yang Mutual conversion of yin and yang

1.

Mutual opposition and restriction of yin and yang The opposition and restriction of yin and yang include two aspects. One aspect refers to the opposition of yin and yang, while their properties are opposite in the universe, such as heaven and earth, day and night, cold and heat, active and static, internal and external, ascending and descending, and entering and exiting. The other aspect refers to the complicated relationships of mutual restriction and opposition between yin and yang, such as the four seasonal changes. It is warm and hot in spring and summer because ascending yang qi restricts the cold-cool qi, while it is cool and cold in autumn and winter because ascending yin qi restricts the warm-hot qi. These are results of mutual restriction between yang qi and yin qi in nature. Mutual rooting and dependence of yin and yang Yin and yang are rooted in each other. One cannot exist without the other. For example, upper belongs to yang and lower to yin, and without the lower there would be no upper, and vice versa. Left belongs to yang and right to yin, and without left there would be no right, and vice versa. Thus, it is obvious that yin and yang rely on each other. Interdependence of yin and yang refers to the mutual generation and promotion among certain categories of yin-yang relationships. Take, for example, heaven and earth and cloud and rain. The water on the earth can be carried up to the heaven to form cloud and mist by the ascending of earthly qi, while the cloud and mist in the sky can fall onto the surface of the earth in the form of rain by the descending of heavenly qi. This reciprocal process of cloud and rain and heavenly qi and earthly qi is called the interdependence of yin and yang.

2.

2.1 Theory of yin-yang

3.

4.

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9

The waxing – waning and balance of yin and yang The waxing and waning of yin-yang refers to the movement of yin and yang. The two opposite and interdependent forms are not in a state of stillness but constantly change. This change includes the following two types. In the first type, yin wanes while yang waxes or yang wanes while yin waxes. The mutual restriction of yin and yang leads to such a consequence. For example, considering the four seasonal changes, from winter to spring and summer, the weather becomes warmer gradually, which is called yin wanes and yang waxes, while from summer to fall and winter, the weather becomes colder gradually, which is called yang wanes and yin waxes. In the second type, yin wanes the yang also wanes or yin waxes the yang also waxes. Under the condition of reciprocity of yin and yang, any side of yin-yang becoming too deficient to promote its counterpart will make it weak, while any side of yin-yang becoming abundant will promote its counterpart, so yin-yang also gets abundant. For example, in qi and blood, qi belongs to yang and blood belongs to yin. Qi promotes blood production and its deficiency may further cause blood deficiency, resulting in manifestation of deficiency of both qi and blood. Tonifying qi can promote the generation of blood. Thus, qi and blood are both sufficient. The former is called waning of yin-yang and the latter is called waxing of yin-yang. The waxing and waning movement of yin-yang is absolute and endless. When waxing and waning of yin-yang can be kept within a certain range, degree, and period, it will not be recognized and things will be in a relatively stable state. On the contrary, when waxing and waning of yin-yang are not kept within a certain range, degree, and period, things will be in an abnormal state. Mutual conversion of yin and yang Mutual conversion of yin and yang refers to yin-yang conversation among themselves under certain circumstances. It is the change of the attribute of yin-yang. Anything has two aspects of yin-yang and is in the state of waxing and waning motion. When the motion is out of a certain range, one side of yin-yang can transform itself into the other. This change often occurs in the extreme phase during the changing cycle. The waxing and waning of yin-yang is a process of the quantitative change, while the transformation of yin-yang is a process of the qualitative change based on the quantitative change. The transformation of yin-yang can be a gradual process such as the alternation of cold and warm during the four seasons. It can also appear to be a sudden process such as the sudden shock or fainting as well as the cold extremities during the acute febrile disease symptoms change suddenly from yang to yin. No matter which kind of form it converses, it will always experience a process from quantitative change to qualitative change. Therefore, the mutual rooting and interdependence of yin-yang is the foundation for the transformation of yin-yang. And the waxing and waning of yinyang is an important prerequisite for the transformation of yin-yang.

10  2 The Philosophical Basis of Traditional Chinese Medicine

2.1.3 The applicable examples in traditional Chinese medicine of the yin-yang theory 1.

2.

3.

To interpret the structure of human body All the tissues and organs in the body are not only organically related to each other but are also categorized into two parts of yin and yang. Generally speaking, the upper part of the body pertains to yang, while the lower part to yin. The exterior of body belongs to yang, while the interior of the body to yin. The back pertains to yang, while the abdomen to yin. The lateral side of the four limbs pertain to yang, while the medial side to yin. When considering the functions of the viscera, the five zang-viscera pertain to yin because they store the essence but do not transport and transform food. The six fu-viscera pertain to yang because they transport and transform food but do not store essence. Among the five zang-viscera, the heart and lung are located in the upper (thorax), so they pertain to yang, while the liver, spleen, and kidney are located in the lower (abdomen), so they pertain to yin. Each viscera itself can be further divided into yin and yang aspects, such as heart-yin and heart-yang, kidney-yin, and kidney-yang. Overall speaking, every part of the human body, superior – inferior, internal – external, interior – exterior, and anterior – posterior as well as the inner organs may all be applied by yin-yang theory. To explain physiological functions The coordination and balance of yin-yang result in normal human life activity. In terms of substances and functional activities, their relationship embodies the unity of the opposite aspects of yin-yang. The physiological function of the human body is based on the substances of the body. Without the movement of the substances, there would be no physiological function. On the one hand, the physiological activities consume energy and substances, but on the other hand, they constantly promote metabolism as well as receive and store the energy. Once the physiological activities are blocked to function normally, it will affect the normal metabolism. Therefore, the relationship between the physiological activities and substances is the process of mutual restriction, production as well as waxing and waning of yin-yang. From the point of view of qi and blood, qi belongs to yang while blood belongs to yin, and qi can generate, move, and control blood. Therefore, the normal function of qi helps the blood to have the normal production and circulation. Blood can generate and hold qi. Therefore, the abundance of blood can promote qi’s normal function. The correlation between qi and blood reveals the mutual rooting and interdependence of yin-yang. To explain pathological changes The harmony and balance between yin and yang in Chinese medicine is considered as healthy symbol, whereas the imbalance of yin-yang is regarded as the basic reason of the occurrence, development, and change of the disease.

2.1 Theory of yin-yang

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11

The mutual rooting and restriction of yin-yang exist in the state of constant waxing and waning. The imbalance of yin-yang will result in the excess or deficiency that causes the diseases; which is called the disharmony of yin-yang. On further analysis, the occurrence and development of disease mainly involve the two aspects: vital qi and pathogenic qi. The vital qi is classified into yang qi and yin fluid, while the pathogenic qi is classified into yin and yang pathogens. For example in the six climatic pathogens, cold and damp belong to the yin pathogen, while wind, summer heat, and fire (heat) belong to yang pathogen. The process of the occurrence, development, and change of the disease is a process of conflict between the vital qi and the pathogenic qi. The conditions reflected by the interaction and mutual conflict between the vital qi and the pathogenic qi can all be explained by excess or deficiency of yin-yang, namely the imbalance as well as the waxing and waning of yin and yang. A. Excess of yin or yang Excess of yin or yang refers to the pathological change due to the excessive yin or yang. Generally speaking, the predominant part belongs to the pathogenic qi, while the deficient part belongs to the vital qi that includes yin fluid or yang qi. The pathological changes generally have the following categories. (a) Excess of yang: Excess of yang leads to heat and results in yin disease. It refers to the pathogen going beyond the physiological limit and reaching the absolute exuberance degree, all of which belongs to the excess of yang. Due to the nature and pathogenic character of yang pathogen, that is excessive heat, excessive yang results in heat. Predominance of yang often consumes yin-fluid within the body and leads to the pathological deficiency of yin-fluid. Therefore, there is a saying “predominance of yang makes yin suffer.” (b) Excess of yin: Excessive yin leads to cold and results in yang disease. It refers to the pathogen going beyond the physiological limit and reaching the absolute exuberance degree, all which belongs to excess of yin. Due to nature and pathogenic character of yin pathogen, that is excessive cold, the predominance of yin often damages yang-qi within the body and leads to the pathological deficiency of yang-qi. Therefore, there is a saying “predominance of yin makes yang suffer.” B. Deficiency of yin or yang Deficiency of yin or yang refers to the pathological change of either yin or yang going beyond the normal level. Generally speaking, deficiency refers to yang qi or yin fluid that is the same as the vital qi. The pathological changes generally have the following categories. (a) Deficiency of yang: Yang deficiency leads to cold. It refers to yang-qi deficiency and is characterized by its decreasing ability to move and warm the system. On the other hand, yang-qi deficiency causes the

12  2 The Philosophical Basis of Traditional Chinese Medicine

C.

D.

E.

body to be easily attacked by cold pathogen. Therefore, there is a saying “yang deficiency leads to cold.” (b) Deficiency of yin: Yin deficiency leads to heat. It refers to the fluid deficiency and is characterized by its decreasing ability to nourish and moisten the system. On the other hand, yin deficiency cannot restrict yang-qi and resists yang pathogen. Therefore, there is a saying “yin deficiency leads to heat.” Mutual damage of yin and yang It is the pathological manifestation of both damage of yin and yang. Yin and yang are mutually connected and rooted with each other. If one side is damaged, the other side will be affected. When yang-qi or yin fluid gets damaged, it will result in the deficiency of either side and cause a pathological change of the system. When yang deficiency reaches to a certain degree, it cannot transform or generate yin fluid, which results in symptoms of yin deficiency, which is called damage of yang affects yin. Vice versa, when yin deficiency reaches to a certain degree, it cannot nourish or moisten yang-qi, which results in deficiency of yang-qi; this is called damage of ying affects yang. Both types will lead to deficiency in both yin and yang eventually. To guide the diagnostic application Yin-yang diagnosis based on color and luster of the skin: A brighter color pertains to yang, while a darker and gloomy color to yin. Yin-yang diagnosis based on the sound of voice and breathing: Higher tone, talkativeness and restlessness pertain to yang, while a low and feeble voice, reticence, and speechlessness to yin. Rough breathing pertains to yang, while shallow breathing to yin. Yin-yang diagnosis based on pulse: From the position of the pulse, cun pertains to yang, while chi pertains to yin; from the pulse rates, rapid beats pertain to yang and slower ones pertain to yin; and from the shape of the pulse, the floating, rapid, excessive, slippery, and big pulses pertain to yang, while deep, slow, thin, small, and deficient pulses pertain to yin. In diagnosis, the accurate distinguishing of yin-yang is the key to master the root of the disease. Eight principles are the fundamental diagnostic method. Among the eight principles, external, excessive, and heat syndromes pertain to yang, while internal, deficient, and cold syndromes to yin. To guide the application to the treatment The basic therapeutic principles of traditional Chinese medicine (TCM) are to maintain the balance of yin-yang, reduce the excess and reinforce the deficiency. The application of yin-yang theory to guide treatment of disease is mainly to determine the therapeutic principle and to summarize the medicinal property.

2.1 Theory of yin-yang

B.



13

(a) To determine the therapeutic principle (i) The therapeutic principle for excess of yin and yang It refers to the excess of yin or yang. It is a case of surplus. When the excessive yin or yang has not caused the deficiency of the opposite party, it belongs to the simple excessive case. The therapeutic principle is to sedate the excess. For example, excessive yang causes heat, and the cooling or cold herbs should be applied to restrict the yang and expel the heat. Vice versa, the warm herbs should be applied to restrict the yin and expel the cold. (ii) The therapeutic principle for deficiency of yin or yang It refers to the deficiency of yin or yang. The therapeutic principle is to tonify the deficiency. Deficient yin often results in the inability of yang restriction that causes the yin-deficient syndromes. In this case, it is better not to use the cool-cold herbs to expel the heat directly. Instead, the principle of nourishing yin and replenishing water should be applied. By nourishing yin, heat due to the hyperactive yang will be restricted. In the case of a deficiency-cold pattern due to the excess of yin caused by the failure of deficient yang to check yin, no dispersing medicine of acrid and warm nature should be taken to dispel its coldness, but a method of yang-supporting and fire-supplementing to expel the excessive yin should be applied. According to the theory of interdependence of yin-yang, the methods of seeking yang from yin and seeking yin from yang may also be considered in the treatment of the deficiency of yin or yang. When using yang-warming herbs, by adding the yin-nourishing herbs as the subsidiary, it is called seeking yang from yin. When using yin-nourishing herbs, by adding the yang-supplementing herbs as the subsidiary, it is called seeking yin from yang. Summarization of the properties of the herbal medicine Generally speaking, when differentiating the nature and properties of the medicinal herbs, TCM focuses on the nature, the flavors, and the acting tendencies (namely ascending, descending, sinking, and floating). They can be summarized by the theory of yin-yang. The nature: It refers to cold, hot, warm, and cool natures of herbs, which is also called four natures. Among them, cold and cool belong to yin, while hot and warm pertain to yang. Generally speaking, the herbs that can reduce or eliminate the heat syndromes pertain mostly to cold-cool nature. Conversely, the herbs that can reduce or eliminate the cold syndromes pertain to warm-hot nature.

14  2 The Philosophical Basis of Traditional Chinese Medicine

The five flavors: The flavors refers to acrid, sweet, sour, bitter, and salty. Among them, acrid, and sweet flavors pertain to yin, while the sour, bitter, and salty flavors pertain to yin. Ascending, descending, floating, and sinking: These refer to the actions when herbs enter into the human body. Herbs with actions of yangelevating, exterior-relieving wind and cold-expelling, emesis, and orificeopening mostly have the ascending and outward-going properties. They are characterized by ascending and floating actions, so they belong to yang. While herbs with actions of purgation, heat-clearing, diuresis, mind-tranquilizing, yang-subduing, wind-quenching, digestion-promoting, vomitingstopping, and qi-astringing mostly have the descending and inward-going properties. They are characterized by sinking and descending, so they belong to yin.

2.2 Five elements theory Five elements theory belongs to the category of ancient philosophy. It believes that the world is made of five basic substances with the specific forms, namely wood, fire, earth, metal, and water. These five substances are in a state of mutual generation and restriction. Due to this fact, the world moves and changes constantly, and everything in this world is directly or indirectly related. When the theory of the five elements is applied in TCM, it helps the TCM doctors to recognize the internal relationships inside the body as well as its connection with its outside surroundings.

2.2.1 Fundamental concepts and characters of the five elements Key points – – – –

Fundamental concepts of the five elements It refers to the mutual connection and their change of movement among the five elements. The characters of the five elements Wood is characterized by bending and straightening, fire is the flaming upward, earth is the sowing and reaping, metal is the working of change, and water is the moistening and descending.

1.

Fundamental concepts of the five elements In Chinese, wu refers to five different subjects, namely wood, fire, earth, metal, and water. Xing has two meanings. One refers to order, while the other refers to movement and change. Therefore, wu xing, or the five elements, refers to the connections, movement, and changes among the five elements.

2.2 Five elements theory

2.

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15

The characters of the five elements The concept of five elements was once the abstract conceptualization of climatic feature and phenological characteristics for five time interval of the Yellow River basin. Respectively, wood indicates everything grows in warm spring; fire indicates everything thrives in hot summer; earth indicates everything transforms in moist late-summer; metal indicates everything restrains in cool and dry autumn and water indicates everything stores and hides in cold winter. The feature of five elements can be generalized by climatic characters of spring-warm, summer-hot, late summer-moist, autumndry, and winter-cold, as well as by phenological change characteristics of growing, thriving, transforming, restraining, and storing. Shang Shu Hong Fan wrote: “Wood bends and strengthens; Fire burns and flares up; Earth provides for sowing and reaping; Metal works for change; Water moistens and flows downward.” Hence, feature of five elements became wider and abstracter. With the practice of everyday life and production, characteristics of five elements were gradually developed and formed by ancient people through their life experience and recognition toward elements of wood, fire, earth, metal, and water. The characteristics were mainly used to analyze and generalize the attributes of various things in the five elements, and to study the connection among different subjects. Therefore, the characteristics of five elements have gone beyond their concept. Characteristics of wood: Wood bends and strengthens, which means stems and branches of a tree can bend, strengthen, and grow upward and outward. Thus, it is inferred that anything that has the function or property of growing, developing, and flourishing is attributed to wood. Characteristics of fire: Fire burns and flares up, which means that fire has the characters of warmth, heat, and ascending. Thus, it is inferred that anything that has the function or property of warmth, heat, and ascending is attributed to fire. Characteristics of earth: Earth provides for sowing and reaping, which means that earth can be used for sowing and reaping. Thus, it is inferred that anything that has the function or property of generating, holding, and receiving is attributed to earth. Characteristics of metal: Metal works for change, which means that metal has the characteristics of clearing and descending. Thus, it is inferred that anything that has the function or property of clearing, descending, and astringing is attributed to metal. Characteristics of water: Water moistens and flows downward, which means that water has the characteristics of moistening and descending. Thus, it is inferred that anything that has the function or property of cold and coolness, moistening, and descending is attributed to water.

16  2 The Philosophical Basis of Traditional Chinese Medicine

2.2.2 The classification of the five elements 1.

2.

Direct classification Direct classification is to compare some phenomenon directly with some characteristics of the five elements, so as to get the property of the thing or phenomenon in the five elements. Taking the directions and the five elements as example, the east with more vital power where the sun rises is similar to characters such as growing, developing, and flourishing of wood, so east pertains to wood. In the south where it is hot, plants are flourishing, which is similar to characters such as burning and flaring of fire, so the south pertains to fire. The west with a declining sign where the sun sets is similar to characters such as clearing and descending of metal, so west pertains to the metal. In the north where it is cold, pets are torpid, which is similar to characters such as cold and storage of water, so the north pertains to water. In the central region, the climate is mild and governs the four directions as well engenders the myriad things, so the central region pertains to earth. Indirect inferring When a thing or phenomenon with one of the characters of the five elements has been classified into one of the elements, some other things or phenomena that are closely related with it can also be brought into this element. This classification is called indirect inferring. Lots of dampness occur during the late-summer when it is humid; therefore, dampness pertains to earth. Lots of dryness occur during the fall; therefore, dryness pertains to metal. The theory of the five elements categorizes subjects or phenomena by direct classification or indirect inferring according to the characters of the five elements. Among the subjects or phenomena that are classified into the same element, there must be certain inner relationship of either one or another type. This type of connection is based on the similar characteristics among the same type of subjects. Table 2.1 shows the attribution of subjects in nature and human to the five elements.

 Flavors

Sour

Bitter

Sweet

Acrid

Salty

5 Notes

Jue

Zhi

Gong

Shang

Yu

Black

White

Yellow

Red

Green

 Colors

Storing

Transformation Reaping

Germination Growth

 Changes

Cold

Dryness

Dampness

Heat

Wind

 Climates

Nature

North

West

Center

South

East

 Directions

Winter

Latesummer Autumn

Summer

Spring

Seasons

Tab. .: The attribution of things in nature and human to the five elements

Water

Metal

Earth

Fire

Wood

5 Elements

Kidney

Lung

Spleen

Heart

Liver

 Zangviscera

Large intestine Urinary bladder

Gall bladder Small intestine Stomach

 Fuviscera

Ear

Nose

Mouth

Tongue

Eye

 Sense organs

Bone

Skin

Muscle

Vessel

Tendon

 Constituents

Human body

Fear

Sorrow

Thinking

Joy

Anger

 Emotions

Nasal discharge Spittle

Saliva

Sweat

Tear

 Secretions

2.2 Five elements theory 

17

18  2 The Philosophical Basis of Traditional Chinese Medicine

2.2.3 The cycle of generation, restriction, over-restriction, and counter-restriction in five elements 1.

2.

Generation and restriction among the five elements A. Generating cycles among the five elements Sheng refers to generation. Generation among the five elements means that one of the five elements generates and helps another element in the five elements. The order of generation among the five elements is as follows: wood generates fire, fire generates earth, earth generates metal, metal generates water, and water generates wood. In the generating relationships among the five elements, each element has two sides of being generated or generating. The generating one is considered to be mother, while the one being generated is considered as the child. Therefore, the generating relationships among the five elements are so-called mother – child relationship. Take wood as an example. Wood is generated by water, so water is the mother of wood and wood is the son of water. Wood generates fire, so wood is the mother of fire, while fire is the son of wood. B. Restriction among the five elements The Chinese character ke refers to restriction. Restriction among the five elements means that one of the five elements restricts and checks another element in the five elements. The order of restriction is as follows: wood restricts earth, earth restricts water, water restricts fire, fire restricts metal, and metal restricts wood. In the restricting relationships among the five elements, each element has two sides of being restricted and restricting. The one being restricted is the phase that is dominated by another, while the one restricting is the phase that dominates the other. Take wood for example. The one that restricts wood is metal and the one that is restricted by wood is earth. Thus, metal is called the dominator of wood and earth is called the subordinate of wood. Generation and restriction among the five elements are two inseparable aspects, which expresses concretely that there is restriction within generation and there is generation within restriction. For example, wood generates fire and also restricts earth; earth restricts water and also generates metal. The relationships of restriction within the generation and generation within restriction can be the key to maintain the coordination and balance of everything. Over-restriction and counter-restriction among the five elements These two cycles indicate the abnormal relationships among the five elements.

2.2 Five elements theory

A.

B.

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19

Over-restriction among the five elements Over-restriction means excessive restriction. In five elements, it refers to an abnormal condition in which one element of the five elements excessively restricts its restricting element, namely over-restriction. It has the same sequence as the restricting cycle. Counter-restriction among the five elements Counter-restriction means the reverse restraint. It refers to an abnormal condition in which one element of the five elements reversely restrains and bullies the element that restricts it. Its sequence is just the opposite of the restricting cycle. There are two causes that result in over-restriction and counter-restriction. One is due to the one element being overly powerful, which either excessively restrains the element that it normally restrains or reversely restricts the element that originally restricts it. For example, if wood is too powerful, it will excessively restrain earth, leading to the deficiency of earth which is called wood over-restricting earth. As another example, under the condition of too much power of wood, it is not only being restricted by metal but also reversely restricts metal. This cycle is called wood counter-restricts metal. The other is that one element among the five elements becomes too weak, which causes either the element that restricts it being relatively hyperactive or the element being originally restricted by it being relatively powerful. Hence, the cycle of over-restricting or counter-restricting occurs. For example, if the strength of earth itself gets weaker, then the strength of restriction of earth by wood becomes relatively enhanced and it will make earth more deficient. This cycle is called wood over-restricts earth. As another example, when the powerfulness of metal gets too weak, it cannot restrict wood anymore and it will be reversely restricted by wood. This cycle called wood counter-restricts metal. Both over-restriction and counter-restriction are abnormal restrictions and they both have differences and similarities. The difference is that overrestriction has the same sequences as the restricting cycle, except that one element is being overly restricted, while the counter-restriction follows the same sequence as the restricting cycle besides the abnormal restricting cycle. The similarities are that when the over-restriction occurs, the counter-restricting cycle can appear at the same time, and vice versa.

2.2.4 The application of five elements theory in TCM 1.

To explain the physiological functions of the five viscera and their relationships A. To explain characteristics of the physiological functions in five viscera The five elements theory classifies the five zang-viscera into the five elements to explain their physiological functions. For example, the liver

20  2 The Philosophical Basis of Traditional Chinese Medicine

2.

3.

prefers to free flow of qi and tends to be free from obstruction. So its characteristic of the physiological function is to smoothen qi dynamically. This is similar to the characteristics of wood of growing and flouring. Therefore, the liver pertains to wood. The rest can be explained in the same order. B. To explain the inner relationships among the five viscera Because five zang-viscera are attributed to the five elements, not only their physiological functions can be explained by this theory but also their inner relationships can be explained by the generating and restricting cycles. Generation among the five elements may be used to explain the generating relationships among the five zang-viscera. For instance, the liver stores blood to support the heart. Thus wood generates fire and liver promotes heart, and so on. The restricting relationships among the five zang-viscera can be explained in term of restriction among the five elements. For instance, the transformation and transportation by the spleen may prevent the disorder of kidney (water), which is referred to as earth restricting water. The kidney (water) yin goes up to prevent the hyperactivity of the heart (fire), which is referred to as fire restricting fire, and so on. To explain pathological change and their mutual influences A. The abnormal change of generating cycle means that disease occurs by following the order of generation or against the order of generation. It includes two conditions: involvement of the child by its mother and involvement of the mother by its child. (i) The involvement of the child by its mother means that disease occurs following the order of generation. It means that a disorder of a motherelement involves or affects its child-element, leading to both anomalies from mother to child. Because a mother-element is weak, its childelement also gets deficient. For example, if a kidney disease affects the liver, a mother disease involves its child. (ii) The involvement of the mother by its child means that disease occurs against the order of generation. It means that a disorder of a childelement involves or affects its mother-element, leading to both anomalies from child to mother. For example, if a heart disease affects the liver, a child disease involves its mother. B. Abnormal change of restriction is over-restriction and counter-restriction. It means that disease occurs following order of restriction or against the order of restriction. For example, if a liver disease affects the spleen, which is called wood over-restricting earth; if a liver disease involves the lung, which is called wood counter-restricting metal. To guide the clinical diagnosis The five zang-viscera have certain relationships in the attribution to the five elements according to the changes of five colors, five flavors, five emotions, and

2.2 Five elements theory

4.

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21

pulse condition. Therefore, the theory of the five elements can be used to diagnose disease. According to its attribution to the five elements, the diagnosis can be made according to the laws of generation and restriction. For example, a patient whose complexion is greenish with a preference for sour food and a wiry pulse may be diagnosed as having a liver disease; a patient with spleen deficiency accompanied with a greenish complexion implies that wood (liver) over-restricts earth (spleen) with deficiency. To guide the treatment of disease A. To prevent the changes of disease During the disease onset, one zang-viscera disease may affect other zangviscera. Therefore, when treating the pathological viscera, the other related zang-viscera should also be treated according to the laws of generation, restriction, over-restriction, and counter-restriction. Thus, the changes of disease can be prevented and the recovery can be promoted. B. To decide the therapeutic principle and method (i) The therapeutic principle and method to be decided according to the law of generation The therapeutic principles decided according to the law of generation include “tonifying the mother for deficiency and sedating the child for excess.” Tonifying the mother for deficiency: This principle is applied in the deficiency syndrome of both mother and child. For example, if kidney yin gets deficient and fails to nourish the liver-wood, it implies that water fails to nourish wood. The therapeutic principle is not only to deal with the liver but also to nourish kidney yin. Therefore, by nourishing the kidney, yin will nourish liver. Sedating the child for excess: This principle is applied in the excess syndrome of both mother and child. Take for example the liver fire that gets too hyperactive. The liver is the mother and the heart is its child. Therefore, sedating heart fire will help to restrict liver fire. There are other therapeutic methods applied according to the generating cycle that mainly include the following. The method of replenishing water to nourish wood: This method is also called replenishing the kidney to nourish the liver. It is a method to nourish the liver by supplementing the kidney so as to astringe liver yang and is mainly suitable for liver-kidney yin deficiency, or liver-yin deficiency and liver-yang uprising. The method of reinforcing earth to strengthen metal: It is also called invigorating the spleen to benefit the lung. It is a method to replenish lung qi by replenishing spleen qi and is mainly suitable

22  2 The Philosophical Basis of Traditional Chinese Medicine

during an insufficiency of both the spleen and lung due to the lung qi deficiency or spleen and stomach deficiency. The method of assisting fire and strengthening earth: It is also called warming the kidney and strengthening the spleen. It is a method to support spleen yang by warming and strengthening kidney yang and is suitable for a syndrome of yang deficiency of both the spleen and kidney or a part of patterns of spleen yang deficiency. It should be pointed out that in terms of generating law among the five elements, heart belongs to fire and spleen to earth. Fire failing to generate earth should be understood as the failure of heart fire to promote spleen-earth. However, since the time when the theory of life gate was established, there was a change in this concept. Clinically, the fire refers to the kidney yang (or life gate fire), and seldom means the heart fire anymore. The method of mutual generation of metal and water: a method of nourishing both lung and kidney yin. It is also called as the method of lung-nourishing and kidney-tonifying and is mainly suitable for the case when insufficient lung fails to distribute the fluid to nourish the kidney, or the case of yin deficiency of the lung and kidney due to the kidney-yin deficiency with failure of essence-qi to go up to nourish the lung. (ii) The therapeutic principles and methods according to the restriction law The therapeutic principles selected according to law of restriction include restricting the strong and strengthening the weak. Restricting the strong: This is a therapeutic principle to restrict the hyperactive viscera. For example, if the liver qi gets disordered, it can transversely affect the stomach or spleen and lead to disharmony of the liver and the stomach, or disharmony of the liver and spleen. The therapeutic method is to sooth or restrict the liver. Strengthening the weak: This is a therapeutic principle to support the functions of the viscera being either over-restricted or counterrestricted. For example, if the insufficient kidney yin (water) fails to restrict the heart fire, it is called disconnection between the kidney and the heart. The clinical manifestations are soreness and weakness of the lower back and knees, insomnia, spermatorrhea, and so on. The treatment should be nourishing kidney yin along with sedating heart fire. The therapeutic methods selected according to the law of restriction include the following. Inhibiting wood to assist earth: It is also called smoothing the liver and strengthening the spleen. This is a method to treat the case of failure of the insufficient spleen in transformation and transportation

2.2 Five elements theory

C.

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due to hyperactivity of liver qi by soothing the liver and strengthening the spleen. It is mainly suitable for the pattern of excessive depressed liver over-restricting spleen. Supporting earth to restrict water: This is a method to treat the case of accumulation of water-dampness by warming and strengthening spleen yang, or strengthening the spleen and warming the kidney. It is mainly suitable for the oedema due to the spleen deficiency failing to transport and transform the water-dampness. Earth here refers to spleen, while water means damp pathogen. The definition is a little different. Assisting metal to subdue wood: It is also called subduing the liver and clearing the lung. This is a method to inhibit the hyperactivity of liver fire by clearing and purifying lung qi. It is mainly suitable for the case of excessive liver fire affecting the clearing and descending of lung qi. Sedating the south and tonifying the north: It is also called a method of fire-sedating and yin-nourishing. South refers to fire (heart fire) and north to water (kidney yin). This method is to sedate heart-fire and nourish kidney-water. It is mainly suitable for the case of kidneyyin deficiency and heart-fire excess. This syndrome is called disconnection between heart and kidney. To guide treatment for mental disorder The emotions originate from the five zang-viscera, and among the latter there are relationships of generation and restriction. Therefore, there are the same generating and restricting relationships among the emotions. Clinically, by applying these restricting relationships, the emotional disorders can be regulated and the disease can be treated. This method is called the restricting and non-restricting laws of the five emotions. Sorrow is the emotion of the lung that belongs to metal, while anger is the emotion of the liver that belongs to wood. Therefore, metal can restrict wood and sorrow can restrict anger. Fear is the emotion of the kidney that belongs to water, while joy is the emotion of the heart that belongs to fire. Therefore, water can restrict fire and fear can restrict joy. Anger is the emotion of the liver that belongs to wood, while pensiveness is the emotion of the spleen that belongs to earth. Therefore, wood can restrict earth and anger can restrict pensiveness. Joy is the emotion of the heart that belongs to fire, while worry is the emotion of the lung that belongs to metal. Therefore, fire can restrict metal and joy can restrict worry. Pensiveness is the emotion of the spleen that belongs to earth, while fear is the emotion of the kidney that belongs to water. Therefore, earth can restrict water and pensiveness can restrict fear.

3 Visceral Manifestation 3.1 Summarization of visceral manifestations Key points –

The categories and common functions of zang-fu organs: – Five zang-organs include the heart, the liver, the spleen, the lungs, and the kidneys; the common function of the five zang-organs is to produce and store jing-qi (essence). – Six-fu organs include the gallbladder, the stomach, the small intestine, the large intestine, the urinary bladder, and the triple burners; the common function of the six-fu organs is to receive, transport, and transform food. – The extraordinary fu-organs, which are hollow and resemble the fu-organs in shape and store essence and resemble the zang-organs in function, include the brain, the marrow, the bones, the vessels, the gallbladder, and the uterus.

The term zangxiang first appeared in Suwen. Zang refers to internal organs inside the body. Xiang refers to external manifestations of physiological and pathological phenomenon. The theory of zangxiang (visceral manifestations) mainly focuses on the physiological functions, pathological changes and relationships of zang-fu organs, which is the core parts of traditional Chinese medicine (TCM). The theory of visceral manifestations is mainly based on the zang-organs and the fu-organs. Zang-fu is a collective term for internal organs, which can be divided into three categories, namely the zang-organs, the fu-organs, and the extraordinary fu-organs. Zang-organs include the heart, the liver, the spleen, the lungs, and the kidneys; collectively called the five zang-organs. The common function of the five zang-organs is to produce and store jing-qi (essence). Fu-organs include the gallbladder, the stomach, the small intestine, the large intestine, the urinary bladder, and the triple burners; collectively called the six-fu organs. The common function of the six-fu organs is to receive, transport, and transform food. The extraordinary fu-organs, which are hollow and resemble the fu organs in shape and store essence and resemble the zang-organs in function, include the brain, the marrow, the bones, the vessels, the gallbladder, and the uterus. The theory of visceral manifestations has already established a comparatively complete framework in Huangdi Neijing. Later, the doctors further explored and supplemented on the framework that was originated from the following aspects: knowledge of ancient anatomy, observation of physiological and pathological phenomenon, and accumulation and conclusion of clinical practice. On the whole, the theory of visceral manifestations that was formed based on the knowledge of ancient anatomy and through long-term accumulation of practical experiences then came into being through observation of various external manifestations caused by the internal organs utilizing generalization, abstraction, reasoning, analogy, and other methods.

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The theory of visceral manifestations is characterized by holism centered by five-zang organs which embodies as follows: firstly, one zang-organ and one fuorgan have exterior – interior relationship; secondly, the five-zang organs have close relationships with the body, organs, and orifices; thirdly, physiological functions of the five-zang organs are closely connected with mind. The theory of visceral manifestations emphasizes on five-zang organs, attributing six-fu organs, the body, organs, and orifices, and the mental activity to five-zang organs, and forming five physiological and pathological systems represented by the heart, the lung, the spleen, the liver, and the kidney. The five systems promote one another, restrain each other, and maintain harmony and balance of any circumstances inside the body, which represents the integrity and unity of human body.

3.2 Five zang-organs 3.2.1 Heart Key points –

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The physiological functions of the heart: – Governing blood and vessels – Storing the spirits The systemic relationships of the heart: – The heart is related to the vessels in body constituent, and shines in the face. – The heart opens into the tongue. – The heart corresponds to joy in emotion. – Sweat is the fluid of the heart.

The heart is located in the chest between the two lobes of lung, above the diaphragm, which is just like the stamen of lotus. It is surrounded by a protective membrane, the pericardium. The physiological functions of the heart mainly include two aspects: to govern blood circulation and to govern mental activities. The systemic relationships of the heart with the body are as follows: the heart has an exterior – interior relationship with small intestine and is associated with the vessels in constituent, reflects its brilliance in the face, is associated with joy in emotion, with tongue in orifice, and with sweat in secretion. 1. Functions of heart A. Governing blood and vessels The term heart governing blood and vessels was first seen in the Suwen theory of atrophy. Generally speaking, it means that the heart can push the blood streaming in the vessels naturally, which in turn means that the heart governs the blood of the whole body and it also governs all the

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B.

vessels in the body. Blood circulation and its moistening function depend on heart qi’s motivation. The vessels all around the body are connected to heart, forming a net in which blood flows. Therefore heart is named as the house of blood. The heart is linked with the blood vessels to form a closed system. Blood can flow within the vessels fluently throughout the body. The three conditions necessary for normal blood circulation are as follows: the heart qi must be sufficient, the blood must be plentiful, and the vessels must not be obstructed. If there is a disorder in any of the factors, disease will occur. Sufficient heart qi is the most important factor. The function of the heart governing blood and vessels is manifested as pulse, facial complexion, tongue color, and the feeling in the chest. If heart functions well, the pulse is normal, smooth, and harmonious; complexion is bright and lustrous; and tongue is red and bright. If insufficiency of heart qi or blood occurs, conditions of pulse, facial complexion, and tongue color will be abnormal. For instance, pale complexion, pale and enlarged tongue, fine and weak pulse, and palpitation indicate insufficiency of heart qi. If there is a blockage of heart vessels, cyanosed face, dark-purple tongue with petechiae and ecchymoses, rough or intermittent pulse, and pain in the middle or lateral part of the chest will be manifested. Storing the spirits The heart storing the spirits is recorded in Suwen, also named as heart controlling the mind. Shen (spirits) is an important concept in TCM. In a broad sense, spirit refers to manifestations of life activities, such as physical condition, expression, and complexion. In a narrow sense, spirit refers to mental activities, including spirit, consciousness, and thinking. All of spirit activities are controlled by the heart, which is an important function of the heart. The function of heart storing spirits can be manifested as spirit, consciousness, thought, and sleep. When the function of heart in storing spirit is normal, there will be high spirit, clear consciousness, acute thinking, and deep sleep. And when the function of heart in storing spirit is abnormal, there will be insomnia or dream-disturbed sleep; agitation; slow response; insanity from mental disturbance caused by phlegm-fire harassing the heart; loss of consciousness; apathia; amnesia; dementia due to phlegm clouding the heart spirit, or high fever or coma due to fire harassing pericardium. All these abnormalities can be treated according to the heart condition. The two functions of the heart are very closely related to each other. The heart governs blood circulation, and blood is a cardinal basis of substance for viscus functions. Mental activities are external reflections of the functions of viscus. So dysfunction of the heart in governing blood circulation often results in abnormality of the spirits, and vice versa.

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Systematic relations of the heart A. The heart is related to the vessels in body constituent, and shines in the face The vessels are governed by the heart. Because the vessels are connected with the heart all through the body, the heart is related to the vessels in body constituent. The most adorned tissue by the heart is the face, which means that the normality of the function of the heart may be reflected by color of the face or the changes of complexion may serve as a mirror to show whether the heart functions well. When the heart qi is vigorous, blood in the vessels is enough and the complexion will be ruddy and lustrous. If heart blood is deficient, complexion will be sallow. If the blood is stagnated, the complexion will be bluish purple. B. The heart opens into the tongue The function of the tongue is to taste and speak. If heart functions well, tongue will be red and bright, taste quickly, and speak fluently. If heart does not function well, taste will change and tongue rigidity and delirium may occur. Hence, the tongue can reflect physiological and pathological conditions of the heart. For example, if heart-yang is deficient, tongue will be pale, white, tender-soft or enlarged. If heart-yin is deficient, tongue will be crimson and thin. If heart fire is flaming upward, tongue will be red, and aphtha may occur. When there is a stagnation of the heart blood, the tongue will be dark purple or with petechiae and ecchymoses. When the heart does not function normally in governing mental activities, tongue rigidity, delirium or aphasia may occur. C. The heart corresponds to joy in emotion The function of the heart is related to joy in emotion. Generally speaking, joy is a reaction to an optimal stimulation from outside information and is beneficial to health. But overjoy may lead to heart disorder, making the heart-qi sluggish and the mind unable to concentrate. D. Sweat is the fluid of the heart The heart is related to sweat. When a person is nervous or scared, spontaneous sweating occurs. Because the heart is cardinal lord of five zangorgans and six fu-organs and governs mental activities, sweating caused by spirit is related to heart. Hence, sweat is named as the fluid of the heart.

3.2.2 Lung Key points –

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The physiological functions of the lung: – Dominating qi and controlling respiration – Free and regulate the waterways – The lung links with all the vessels

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The systemic relationships of the lung: – The lung is related to the skin in body constituent, and shines in body hair. – The lung opens into the nose and produces the discharge. – The lung corresponds to sorrow and worry in emotion. – Discharge is the fluid of the lung.

The lung, consisting of the two lobes, is located in the chest. It is compared to the canopy because of its uppermost position among all the viscus. The main physiological functions of the lung are to dominate qi, control respiration, smoothen water passage, and assemble vessels. The lung is a place for convergence of blood vessels and helps in charging coordinative activities of qi, blood, and body fluids. The systemic relationships of the lung with the body are as follows: the lung has an exterior – interior relationship with large intestine, and is associated with skin in constituent, reflects its brilliance in the hair, is associated with sorrow in emotion, with nose in orifice, and with nasal discharge in secretion. 1. The physiological functions of the lung A. Dominating qi and controlling respiration The lung dominating qi and controlling respiration is recorded in Suwen. Lung dominating qi means “taking charge of the qi in respiration and operating the qi of the whole body.” (a) Taking charge of the qi in respiration The lung taking charge of the qi in respiration is due to dispersing and descending of lung qi in breathing movement. The lung is the chief organ for exchanging air between the interior and the exterior of the body. Human body takes in fresh air and expels waste gas by the lung’s respiratory function, therefore, to keep the metabolism of the human body functioning smoothly. If the lung’s functions are abnormal due to being harmed by external pathogenic factors, respiratory disorders will occur, such as cough, asthma dyspnea. (b) Operating the qi of the whole body The lung operating the qi of the whole body can be divided into two aspects. The first is that the lung takes part in qi production, especially pectoral qi. The lung performs respiratory function and inhales fresh air from nature. The fresh air inhaled by the lung from nature forms an important source for the formation of qi in human body. The second is that the lung regulates qi movement of the whole body. The qi of the lung can be dispersing and descending through the lung qi of the whole body will be ascending or descending, entering or exiting. By activating the flow of qi, lung is able to govern diffusion, dispersion, purification and descent of qi, as well as regulate the qi of entire body.

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Free and regulate the waterways This theory was first recorded in Jingmaibielun of Suwen. It refers to the function of diffusion, dispersion, purification, and descent. The lung regulates and controls water passage. Through its dispersion, lung qi disperses body fluids and food essence upward to face and head as well as outward to skin and hair. It disperses defensive qi to ensure the closing and opening of the sweat pore to discharge sweat generated after the metabolism. Through descending function of lung qi, water and food essence are transported downward and inward to nourish the whole body while the turbid fluid generated after metabolism is transported downward to become urine through the urinary bladder. Since the lung is the highest position of viscera and participates in the water metabolism of the whole body, it is known as the upper source of water. If there is a disorder in the function of lung’s freeing and regulating the waterways, it will affect the water metabolism which is manifested as edema, phlegm, and fluid retention. C. The lung links with all the vessels Linking refers to gathering whereas all the vessels refer to all blood vessels in the body. Therefore, lung linking to all the vessels means all blood assembling into the lung through vessels. Through breathing and exchanging turbid qi with clear qi in the lung, abundant blood in clear qi is transported to the whole body. Linking with all the vessels is the manifestation of lung governing dispersing and descending in blood circulation. Through the lung’s dispersion, lung qi disperses blood outward. Through descending function of lung qi, blood is transported inward and backward to nourish lung. Therefore, lung qi is able to help blood circulation. The lung linking with all the vessels also means that the lung can promote blood circulation for heart. In clinical settings, the dysfunction of lung qi of dispersing and descending can result in blood stagnation. Therefore, the function of lung includes three aspects: firstly, it forms qi and regulates movement of qi; secondly, it regulates water metabolism; and thirdly, it promotes blood circulation. Qi, blood, and body fluids are the basic materials to form and sustain life activities of the human body. If qi, blood, and body fluids are in normal condition, a person will be in good health. In a broad sense, the regulation of qi, blood, and body fluids of the whole body all depends on the lung. Therefore, TCM believes that lung governs coordination and is considered the prime minister. The systemic relationships of the lung A. The lung is related to the skin in body constituent, and shines in body hair The skin and fine hair are on the surface of the human body. They rely on the lung’s dispersion of wei qi and nourishment of the body fluids. They are the first barrier against external pathogens. Through the lung qi’s dispersing function, the essence can be transported to nourish and warm the skin and fine hair. When functions of the lung are normal, the skin and fine hair are

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lustrous; the exogenous pathogenic factors are not be able to invade in the body. When functions of the lung are abnormal, lung qi is deficient and fails to diffuse defensive qi onto the skin and fine hair, resulting in polyhidrosis and common cold. When skin and fine hair are affected by exogenous pathogenic factors, there will be cough or asthma due to disorder of the lung. The lung opens into the nose The nose is the passage way for entrance and exit of respiration. It communicates with the lung. Therefore, the nose is the orifice of the lung. Lung has a close relationship with the nose. The normality of the nose in ventilation and smelling depends upon the function of the lung qi. When lung qi diffuses smoothly, the nose will be free from obstruction with keen smelling. If the lung qi fails in diffusion, it will lead to nasal obstruction and hyposmia. The diseases of lung are mostly caused by exogenous pathogens through mouth or nose. The lung corresponds to sorrow and worry in emotion Sorrow and worry are parallel in seven emotions. Due to the similarities between them, they are put together in five spirits. Excessive sorrow and worry are extremely harmful to health. In TCM, it is called qi consumption by overly sorrow and worry. When the lung qi is deficient, the tolerance of pessimistic stimulation by human body will decrease and will results in the mood swings and sadness. The deficiency of lung qi and sadness affects each other. It is easy to create this vicious cycle. Discharge is the fluid of the lung Snivel is the nasal discharge which nourishes the nose. When the essential qi in the lung is sufficient, the snivel moistens the nasal cavity and does not flow outward. If the lung is invaded by exogenous pathogens, it will affect the nasal secretion and discharge. It can cause the clear nasal discharge due to the cold pathogen as well as the yellow nasal discharge due to the heat pathogen. It will also cause dry nose due to dry pathogen.

3.2.3 Spleen Key points –

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The physiological functions of the spleen: – Governing transportation and transformation – Governing ascent of the clear – Spleen governs control of the blood The systemic relationships of the spleen: – The spleen is related to the muscle in body constituent and dominates the four limbs. – The spleen opens into the mouth and shines at the lips. – The spleen corresponds to thinking in emotion. – Saliva is the fluid of the spleen.

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The spleen is located under the diaphragm, in the upper abdomen and left upper corner of the stomach. There are three physiological functions of the spleen: governing transportation and transformation, raising the clear, and governing the blood. The systemic relationships of the spleen with the body are as follows: the spleen governs the muscles of the body and four limbs, and is associated with thinking in emotion, with mouth in orifice, and with saliva in secretion. 1. Physiological functions of the spleen A. Governing transportation and transformation The spleen is in charge of transforming food and water into essential substances and transporting essence to the viscera as well as to tissues all over the body. There are two aspects about this: transforming and transporting the food and body fluids. (a) Transforming and transporting the food: Spleen can digest the food and absorb its essential substances The spleen can take part in the different stages of food digestion. First, the spleen qi promotes the digestive function of stomach and small intestine. After entering the stomach and small intestine, the food is digested and absorbed. This process actually takes place in the stomach and small intestine, but it must depend on the promotion of the spleen qi. Second, spleen qi promotes the absorption of stomach and small intestine. Stomach and small intestine can digest food into the essence, and absorb the essence and transport them to the whole body. The absorption of essence by the stomach and small intestine must depend on the function of spleen qi. Lastly, the spleen qi sends up the essence to the whole body. Due to the fact that body fluid and food are not only the chief source of the nutrients which a human being needs to keep life activities but also the material basis for producing qi and blood, TCM believes that spleen provides the material basis for the acquired constitution and is the source of producing qi and blood. When spleen qi is abundant, so are the qi, blood, and body fluids. The functions of viscera and meridians will be normal. If the spleen loses its function in transformation and transportation, clinically there will appear the manifestations of abdominal distention, diarrhea, anorexia, lassitude, emaciation, and so on. (b) Transforming and transporting the body fluids Transforming and transporting the body fluids refers to the function of absorbing and transporting the body fluids to avoid fluid retention inside the body. During the process of fluid metabolism, spleen transports the body fluids to lung and kidney and excretes them out through sweat and urination. When the spleen functions properly in transforming and transporting the body fluids, the pathological stagnation of the fluids may be avoided and the equilibrium of water meta-

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bolism of the body will be maintained. On the contrary, if there is a dysfunction of the spleen in transforming and transporting the body fluids, it will lead to stagnation or accumulation of water in the body and result in the syndrome of damp phlegm or stagnant phlegm, and even edema. This is the mechanism of the development of damp-syndrome, phlegm-syndrome, fluid retention syndrome, and edema resulting from the deficiency of spleen. The two aspects of transforming and transporting the food as well body fluids by the spleen are interrelated and inter-influenced. The disorders between the two often appear at the same time pathologically. Governing ascent of the clear Ascent refers to the upgoing motion of spleen qi, while the clear means the essential substances, including qi and blood. There are two aspects of the spleen function of governing ascent of the clear. The spleen qi goes upward and transports the essence up to the heart, lung, head, and eyes, as well as to nourish the whole body. When the spleen functions soundly, its qi goes up normally and the essence is absorbed and distributed normally. Therefore, qi, blood, and body fluids will be abundant. If the spleen qi fails to ascend the clear and also fails to transform and transport the food, the essence cannot be absorbed or distributed, resulting in the deficiency of qi and blood. Therefore, symptoms of listlessness, dizziness, abdominal distension, and diarrhea may appear. On the other hand, the doctors often associate the theory of spleen’s function of ascending the clear with the viscera position. If spleen qi fails to ascend or conversely sinks down, symptoms of chronic diarrhea and prolapse of the anus, stomach, and kidney will appear. Spleen governs control of the blood The spleen can keep blood circulating within the vessels, preventing extravasation. Spleen qi plays an important role in this function. The main mechanism is actually the controlling action of qi. When the function of spleen is normal in transforming and transporting, qi and blood will be abundant. Qi will keep blood circulating within the vessels and prevent extravasation. On the contrary, when the function of spleen is abnormal in transforming and transporting, it will lead to shortage of the source for generating qi and blood. Qi deficiency can no longer control the blood circulation and the blood may extravasate from inside of the vessels, thus resulting in bleeding. This is called syndrome of spleen failing to control the blood. It may lead to various kinds of bleeding of the lower parts of the body such as bloody stool, uterine bleeding, and purpura. The spleen’s governing transportation and transformation is the most important among the three functions. If the spleen qi is abundant, transportation and transformation will be normal, qi and blood will be abundant,

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five zang-organs will be nourished, and the functions of ascending the clear and keeping blood circulating within the vessels will be in order. Systemic relationships of the spleen A. The spleen is related to the muscle in body constituent and dominates the four limbs The spleen and stomach are the sources of qi and blood. Only when nourished by the essence which is transformed and transported by spleen and stomach can the muscles be healthy. The strength of the muscles depends on the transforming and transporting functions of the spleen and stomach. When the digestive function of the spleen and stomach is normal, qi and blood will be abundant, and the muscles will be strong. If the spleen and stomach are weak, qi and blood are deficient, leading to thin, weak, and atrophic muscles. Four limbs are the major tissues for sports. The four limbs demand the nutrition of essence being transformed and transported by spleen and stomach. The transportation of essence also depends upon ascending the clear of spleen qi. Therefore, the four limbs are related to the functions of governing transportation and transformation as well as ascent of the clear. If there is dysfunction of spleen in transportation and transformation, there will be scarce supply of nutriment to the limbs and limbs will be tired and flaccid, resulting even in atrophy. In treating chronic spleenstomach disease, characterized by weight loss or fatigue, the spleen and stomach should be invigorated and qi and blood should be replenished. B. The spleen opens into the mouth and shines at the lips The spleen opens into the mouth means that diet and appetite are closely related to transforming and transporting functions of the spleen and stomach. If the spleen and stomach transport food normally, the appetite and diet will be normal. Otherwise, a tasteless, sweet or bitter taste may appear. The color of the mouth and lips indicates whether qi and blood are sufficient. As the spleen and stomach are the resources of qi and blood, whether the mouth and lips are red or moist not only reflects the state of qi and blood but also reflects the transporting and digesting functions of the spleen and stomach. C. The spleen corresponds to thinking in emotion Thinking is one kind of emotion related to spleen. The normal thinking is not harmful to the body, but over-thinking will influence the body’s normal activities and cause the qi stagnation. Ascending of the spleen and descending of the stomach is the pivot for qi movement. When qi is congested, the transportation and transformation gets upset and the action of sending up the clear is impaired, leading to anorexia, epigastric distention, and even dizziness and vertigo. D. Saliva is the fluid of the spleen Saliva is the thin and clear part of the natural liquid in the mouth. It plays the role of protecting the oral mucosa and moistening the oral cavity.

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Saliva is secreted when one is taking in food, making it easier to be swallowed and digested. Under normal conditions, saliva is secreted into the mouth without spillage. If the spleen qi is deficient and fails to control the fluid, spillage will occur. Thus, spleen must be treated.

3.2.4 Liver Key points –

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The physiological functions of the liver: – Governing free flow of qi – Storing blood The systemic relationships of the liver: – The liver is related to the tendons in body constituent and shines in the nail. – The liver opens into the eyes. – The liver corresponds to anger in emotion. – Tears are the fluids of the liver.

The liver is located in the abdominal cavity, beneath the diaphragm and at the inside of the right hypochondrium. The physiological function of the liver is to govern free qi flow and store blood. The systemic relationships of the liver with the body are as follows: the liver has an interior – exterior relationship with gallbladder and is associated with the tendon in body constituent and shines at the nail, with anger in emotion, with eyes in orifice, and with tear as the fluid of the body. 1. Physiological functions of the liver A. Governing free flow of qi The liver can ensure the free movement of qi, blood, and body fluid, as well as prevent them from stagnation. The function of liver qi’s governing free qi flow is mainly manifested in the following aspects: (a) Regulating qi movement When the liver functions normally in governing free flow of qi, the qi dynamic will be smooth. Qi, blood, and internal organs will be in a harmonious state of balance. If there is a disorder in qi flow, it will affect the functions of the liver. An under-smooth flow of qi will lead to a stagnation of the liver qi which can result in the pathological changes of stagnation of qi. It is often manifested as distending pain and discomfort of the chest, breast, or lateral parts of the lower abdomen. On the other hand, an overly smoothing flow of qi will give rise to a hyperactivity of the liver which will result in pathological changes of adverse rising of liver qi. It is manifested as distending pain of the head, red face, and eyes as well as irritability.

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(b) Promoting circulation of blood and body fluids Qi is the commander of blood and blood is the mother of qi. When the liver functions normally in governing qi flow, the circulation of blood and body fluids will be smooth. If the liver dysfunctions in governing free coursing, it will lead to disorder of qi dynamic with disturbance of blood circulation. An under-smoothing flow of liver qi will lead to stagnation of liver qi and blood stasis which manifests as mass in the abdomen with fixed shape, tumor, and amenorrhea. On the other hand, an overly smoothing flow of liver qi will give rise to a hyperactivity of liver qi. It will force blood to go upward and lead to bleeding, such as hematemesis and hemoptysis. Besides, the abnormality of the liver’s governing free flow of qi may also lead to disturbance of body fluid metabolism, causing pathological changes of body fluids, dampness, phlegm, and fluid retention. (c) Regulating the emotion The liver regulates emotion by regulating the movement of qi and blood. When the liver functions normally in governing free coursing, qi dynamic will be smooth as well as the blood circulation, and mood will be good. If the liver functions insufficiently in governing free flow of qi, emotions will be easily disturbed. The concrete performance consists of two aspects: on the one hand, if the liver functions insufficiently in governing free flow of qi, the liver qi will be congested and the mood will be easily depressed, and a little stimulation may cause refractory melancholy. On the other hand, if the liver hyper-functions in governing free flow of qi with hyperactive rise of qi, the mood is easily to be irritable and a minor stimulation will easily cause rage. On the contrary, the abnormal emotion can also affect the liver governing free coursing, resulting in pathological changes, such as liver qi depression or liver qi ascending counterflow. (d) Promoting transportation and transformation of spleen and stomach The function in governing transportation and transformation of spleen and stomach is closely related to the function of the liver governing free coursing. The normality of liver’s governing free flow of qi serves as an important condition for normal ascent and descent of qi of spleen and stomach The liver and spleen-stomach are located in the middle burner. Transportation and transformation of spleen and stomach are based on the coordination between the ascent of spleen and descent of stomach. It can promote the functions of transportation and transformation of spleen and stomach. As the liver functions abnormally in governing free flow of qi, it will not only affect the spleen in ascending the clear, which manifests as dizziness and diarrhea, but will also affect the stomach in descending the turbid, which manifests as hiccup and vomiting, epigastric distention and fullness, or constipation.

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(e) Smoothing and promoting the bile Secretion and excretion of bile is controlled by the liver’s function of governing free flow of qi. When the liver functions normally, the bile will be normally secreted and excreted. If the liver dysfunctions in governing free coursing, it will affect secretion and excretion of bile, resulting in pathological changes of bitter taste, jaundice, and pain in the hypochondriac region. When the symptoms of dyspepsia due the gallbladder disorder are presented in the clinical settings, the principle of coursing the liver and promoting the gallbladder is often applied. (f) Regulating the ejaculation in men and menstruation in women The normal function of ejaculation in men and regular menstrual cycle in women are related to coordination and balance between the function of liver governing free coursing and the function of kidney storing essence. When the liver courses flow of qi normally, sperm can be discharged smoothly and moderately in men and menstruation is normal in women. If the function of kidney storing essence is normal, there will be normal menses and ejaculation. When liver qi fails to regulate and becomes congested, in women it will result in delayed menstruation, dysmenorrheal, and even menopause. In men, it will result in low libido and difficulty in ejaculation. If the liver qi ascend upward too much, it will result in early menstruation or excessive menstrual bleeding in women and libido hyperactivity or spermatorrhea. Storing blood The liver storing blood is first seen in menstrual regulation of Suwen and Benshen of Lingshu. This function implies that the liver has capability to store blood and regulate blood volume in circulation. Storing blood includes two aspects: first, a certain amount of blood is stored in the liver. The blood nourishes the liver itself to prevent yang-qi of the liver from hyperactivity. On the one hand, dysfunction of liver in storing blood will lead to blood deficiency in the liver, and, on the other hand, it cannot void liver yang from rising too much and will lead to ascending hyperactivity of liver yang, liver fire flaming upward, or liver wind. Second, liver storing certain amount of blood can prevent bleeding. Dysfunction of liver in storing blood will lead to various bleeding disorders such as epistaxis, metrorrhagia, or vomiting of blood. The liver regulating volume of blood is first seen in the chapter of Wuzangshengchenglun in Suwen. It said: “when a person is in asleep, the blood will be back to the liver.” Wangbing, a famous doctor in Tang dynasty, explained it as follows: “liver stores blood while heart governs blood circulation. When a person is in active, the blood moves into the vessels; when a person is in quiet, the blood goes back to the liver.” Blood volume of different parts of the body can adjust itself based on emotion or surrounding. Peripheral blood volume increases when a person is in active

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state, and blood stored in the liver is transported to the exterior to support physical functions. The peripheral blood volume decreases when a person is in quiet state, and the peripheral blood goes to the liver and gets stored in the liver. The liver plays an important role in regulating the blood volume, especially peripheral blood volume. It must be pointed out that the liver regulating blood volume is based on the liver storing blood. Only when the liver blood is abundant, can the liver regulate the blood. Therefore, when the liver is deficient of blood, it will lead to the syndromes of blood deficiency in the whole body. For example, when liver cannot nourish the eyes, it will lead to dry eyes or night blindness. When liver cannot nourish the tendons, it will lead to contracture of muscles and numbness of limbs. When it cannot nourish chong and ren meridians, it will lead to scanty menstruation or even amenorrhea. Therefore, liver’s governing free coursing is closely related to the function of the liver storing blood volume. Liver can transport the blood to the exterior which is actually the manifestation of the liver governing free coursing in promoting blood circulation. Liver regulating blood volume is based on the function of the liver governing free coursing and storing blood. Systemic relationships of the liver A. The liver is related to the tendons in body constituent and shines in the nail The tendons, also known as the sinew-membranes, include the tendons and ligaments. They connect joints and control movement. This kind of movement depends on the nourishment of blood. Sufficient liver blood can make the human body endure hard work and recover quickly from exhaustion. If there is a disorder in liver, it can lead to various tendon diseases. If the liver blood is deficient, tendons cannot be nourished, which can result in trembling of hands and feet, numbness of limbs, and influent of joint movement. The nail, including hand and foot nails, is an extension of tendon. Therefore, there is a saying nail is the extension of tendon. Luster of the nail depends on the nourishment of liver blood. Sufficient liver blood ensures dense nail with luster, while insufficient liver blood would cause thin, frail or even deformed nail without luster due to malnutrition. So, the luster of nail can reflect the function of the liver. The physiological or pathological functions of the liver can be judged by the nail in clinical settings. B. The liver opens into the eyes The function of eyes is based on the free coursing of liver qi and nourishment of liver blood. The function of the liver is always manifested from the eyes and its function. If yin or blood of the liver is deficient, there would be dry eyes, blurred vision, and night blindness. Wind-heat in the liver meridian can lead to red eyes with pain and itching; liver fire flaming upward can lead to red, sore, and swollen eyes; ascending hyperactivity of liver yang can lead to dizziness and vertigo; and liver wind can lead to upward

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C.

D.

staring of the eyes. Because the liver is closely related to the eyes, the function of the eyes can reflect the function of the liver. Doctors often treat eye disease from the liver meridian. The liver corresponds to anger in emotion Anger is the reaction of the body to the outside information. Ancient Chinese believed that anger was a normal emotion. It is a normal reaction to be angry when something bad happens. It helps the liver to disperse, smooth, and regulate. However, sudden anger or constantly being in a bad mood is easily to damage liver. Therefore, there is a saying in Suwen yinyang yinxiang da lun, which means “rage injures the liver.” Tears are the fluids of the liver The tears come from the eyes, so they are the fluids of the liver. Tears moisten and safeguard the eyes. Wind-heat in the liver meridian or deficiency of the liver and kidney can lead to epiphora. The deficiency of liver blood or yin deficiency of the liver and kidney can lead to dry eyes.

3.2.5 Kidney Key points –

–

The physiological functions of the kidney: – Storing essence and being in charge of growth, development, and reproduction – Governing the water metabolism – Governing the qi reception The systemic relationships of the kidney: – The kidney is related to the bone and marrow in body constituent and shines in the hair. – The kidney opens into the ears and two lower yin parts. – The kidney corresponds to fear in emotion. – Sputum is the fluid of the kidney.

The kidneys are located in the lumbar region, one each along the spine. It stores the prenatal essence, which is the root of yin-yang for every organ and the origin of life. Therefore, it is called the root of the prenatal. The physiological function of the kidney is to store essence, dominate water metabolism and govern reception of qi. The systemic relationships of the kidney with the body are as follows: the kidney is related to the bone in body constituent and shines in the hair, and is associated with fear in emotion, with ears and two genital areas in orifice, and with sputum as the fluid of the kidney. 1. The physiological function of the kidney A. Storing essence, being in charge of growth, development, and reproduction Essence has different meanings in TCM. In a broad sense, essence refers to all basic substances, such as qi, blood, and body fluids; in a narrow sense,

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it refers to essence stored in the kidney, called simply as the kidney essence. Kidney essence includes two parts from origin. The first part is endowed by parents and comes from birth; so it is also called as prenatal essence. The second part is called acquired essence. It is formed by the nourishment substance of the body deriving from food and surplus part of visceral essence which is produced by physiological activities of zang-fu organs. The prenatal essence and the acquired essence depend on each other. The prenatal essence must rely on constant replenishment and nutrition of acquired essence for its physiological function, while constant generation of the acquired essence yet depends on support of vitality of prenatal essence. The two parts are combined to form the kidney essence to sustain life and reproduction. Physiological significance of kidney’s storing essence is to keep the kidney essence full and forbid it from flowing out. If the function of kidney’s storing essence is in disorder, it will lead to the pathological changes of kidney essence deficiency which is caused by kidney essence flowing outside. The physiological effect of the kidney essence is to promote the growth, development, and reproduction. The kidney essence has its own process from waxing to waning. There is a life law of birth, growth, mature, aging, and death in human body which is influenced by kidney essence-qi. As seen in the chapter of ShangGuTianZhenLun in Suwen, the growth and development of men and women are closely related to kidney essence. The natural law of birth, growth, mature, aging, and death is due to the kidney essence. After birth, the kidney essence begins to grow gradually because of the nourishment of prenatal and postnatal essence. There appear the phenomena of dental transition and growth of hair. When kidney essence gets abundant to a certain degree, one kind of essential substance known as tiangui is produced. Tiangui is a substance related to reproduction and promotes the development of sex organs and maintains normal sex function. As a result, woman has menarche and man has sperm generated. At middle age, the kidney essence starts to decline gradually. Subsequently the tiangui gets exhausted, and accordingly disappears in the end. Thereafter, reproductive function is lost completely and the person comes into his senile stage. The conditions for the growth and development of teeth, bone structures, and hair are the objective indications of the life process. They are the external manifestations of the kidney essence and are important guidelines in the clinical treatment. Loose teeth, teeth loss, gray hair, hair loss, weak bones, and infertility are all signs of premature aging, which indicate deficiency of kidney essence. These symptoms are also seen in the case of five delayed or five soft syndromes in infants. Tonifying kidney and supplementing essence are the therapeutic principles when treating premature aging problems, low libido, and infantile development issues. Kidney essence plays an important role in physiological

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B.

activities of the human body. TCM utilizes yin-yang theory to explain the effect of kidney essence. It can be divided into two parts: functions of moistening and nourishing pertain to kidney yin, while promoting and warming pertain to kidney yang. Kidney yin and kidney yang are also known as original yin and original yang, or genuine yin and genuine yang, which are the roots of yin and yang of the whole body. Kidney yin and kidney yang restrict and promote each other to maintain the dynamic balance of human body physiologically. If this balance is destroyed due to certain factors and cannot be recovered by itself, then there may occur deficiency of kidney yin or kidney yang with heat and cold disorder. For example, deficiency of kidney yang is clinically manifested as cold outlook with cold limbs, low spirit, coldness and pain in the lower back, clear urine with increased volume or dysuria, enuresis, incontinence, and edema. Deficiency of kidney yin is clinically manifested as vexing heat in the five centers, tidal fever and night sweat, dizziness, tinnitus, soreness and weakness in the lower back and knee joints, and spermatorrhea in males. Because kidney yin and kidney yang are the roots of zang-fu organs, their disorder will lead to disorder of other zang-fu organs, and vice versa. TCM believes that chronic illness involves the kidney. Due to the fact that kidney essence is the basis for kidney yin and kidney yang, the deficiencies of kidney yin or yang are the manifestations of the deficiency of kidney essence. Therefore, kidney yin and kidney yang can affect each other, which result in the deficiencies of both eventually. Governing the water metabolism Governing the water metabolism refers to the function of kidney’s governing and regulating the fluid metabolism. Therefore, kidney is also known as water organ. There are two aspects in this theory. First, every organ involved in water metabolism is based on the promotion of kidney essence. The receiving function of the stomach, the dispersing and descending actions of the lung, the transforming and transporting functions of the spleen, the regulating and promoting functions of triple burner, and the opening and closing functions of the urinary bladder are all based on the warming and qi-transforming functions of the kidney. If kidney is deficient, especially when kidney yang is deficient, the organs involved in the water metabolism will be abnormal, and there is disturbance in water metabolism. Second, the formation and excretion of the urine depends upon the warming and qi-transforming functions of the kidney. Excretion of urine plays a key role in water metabolism. It is the most important route in regulating the whole volume of the body. When fluid in the body increases or when there is no sweat during cold days, the kidney will transport the remaining water to the urinary bladder through the qi-transforming function to form urine and excrete it out. As a result, polyuria occurs and the

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2.

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color of urine is pale. But when fluid in the body decreases or when there is profuse sweating during summer, the kidney will control the excretion of the body fluid. As a result, oliguria occurs and the color of the urine is yellow. The kidney keeps the equilibrium of water metabolism by regulating the formation and excretion of urine. If there is dysfunction of warming and qi transformation, pathological symptoms such as oliguria and edema occur. When kidney qi is not stabilized, it will result in polyuria and frequent urination. C. Governing the qi reception Reception means taking in. This function refers to the kidney qi grasping or holding the clear qi inhaled by the lung from nature to maintain the depth of respiration to avoid superficial respiration. While the respiration of the body is controlled by the lung, it must rely on the accepting role of the kidney. Respiration must be maintained to certain depth so as to promote normal exchange of internal and external qi. The function of the kidney in governing qi reception is the concrete embodiment of the storing action of the kidney in respiration. It is based on the kidney essence. If kidney essence is deficient and it cannot govern qi reception, the clear qi inhaled by the lung floats upward and hypopnea occurs, prolonged expiration or shortness of breath induced only by a little exertion. This is known as the kidney failing to govern qi reception, and the therapeutic principle will be tonifying and stabilizing the kidney. Systemic relationships of the kidney A. The kidney is related to the bone and marrow in body constituent and shines in the hair Governing the bones and generating the marrow are an important component of the function of kidney essence in promoting growth and development. Marrow includes bone marrow, spinal cord, and brain which are derived from the kidney essence. The growth and development of bones depends upon the enrichment of the bone. Bone cavity is full of bone marrow if the kidney essence is sufficient. It is solid and strong if fully nourished by bone marrow. If the kidney essence is insufficient, the production of bone marrow will be reduced. Thus, insufficiency of bone marrow cannot nourish the bone fully and a malnourished and poor bone is developed which is soft and weak. In infants it is characterized by late closure of the fontanel and soft, weak bones; in adults, aching and weakness of the lower back, knees and lassitude, and in old people, fragile and weak bone. These symptoms are often treated clinically by tonifying the kidney and supplementing the essence. The strength and growth of teeth also depends on the kidney essence, which is known as the teeth being the surplus of the bone. If the kidney essence is sufficient, teeth will be solid

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B.

and strong. If the kidney essence is insufficient, teeth will be loose and will be lost in a younger age. The development and maintenance of the spinal cord and brain are also related to kidney essence. The brain is called the sea of marrow because the spinal cord is connected with the brain and forms the brain after it merges into the brain. The function of the brain is to govern the spirit which depends on the nourishment of the kidney essence. If the kidney essence is sufficient, so will be the brain which is characterized by good energy, better vision, and hearings, as well as quacking thinking ability. If the kidney essence is insufficient, the production of brain marrow will be reduced, leading to various pathological changes such as low spirit, lassitude, tinnitus, dizziness, retarded thinking, and pain in the lower back and knees. Hair is also called the extension of blood and it depends on blood for nourishment. Therefore, it is said that the hair is the extension of blood. Hair’s life mechanism originates from the kidney. The kidney stores essence and the essence can turn into blood. Therefore, it is said that the kidney reflects its brilliance on hair. The growth, loss, moistening, and withering of hair are related to kidney essence. In young and middle-aged people, kidney essence is sufficient and blood is plentiful, so hair will appear lustrous. In old age, kidney essence is insufficient, so hair will appear gray or white and begins to thin. Even for young and middle-aged people this may happen if kidney essence is insufficient. The kidney opens into the ears and two lower yin parts The hearing ability also relies on the kidney essence. If kidney essence is sufficient, the sea of marrow is nourished and the ears will have good hearing ability. If kidney essence is insufficient, the marrow will be deficient and the ears will become weak, leading to symptoms such as decreased hearing, tinnitus, and even deafness. Old people tend to be poor in hearing because the kidney essence declines naturally as they grow old. The two lower yin parts of the body refer to the anterior and posterior genital areas. The anterior genitalia govern the functions of urine excretion and birthgiving, while the posterior genitalia govern the function of stool-expelling. Although urine is discharged from the bladder, urination depends upon the steaming and transforming function of the kidney. Hence, urination disorders such as frequent urination, enuresis, oliguria or urodialysis are often related to the kidney dysfunction. As to the relationship between the kidney and the reproductive function, nothing will be added to what have been stated above. Although the removal of feces is controlled by the large intestine, spleen, and stomach, it is also related to the qi transformation of the kidney. The deficiency of kidney yin may cause the intestinal fluid to dry up, leading to constipation. The deficiency of kidney yang can lead to constipa-

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tion caused by yang deficiency, failing to produce yin. It can also lead to diarrhea due to the cold spleen as well as the accumulation of water and dampness. The weak kidney may also result in loose stools over a long period or incontinence. The kidney corresponds to fear in emotion Fear is an emotional reaction to a fearful situation. Kidney corresponds to fear in emotion. Excess fear may injure the kidney and make it weak which result in the incontinence of urine and feces, premature ejaculation, and miscarriage. Sputum is the fluid of the kidney Sputum in the mouth belongs to fluid. The thicker part of the sputum belongs to kidney, while and thinner part belongs to spleen. TCM believes that sputum is transformed from the kidney essence. Therefore, swallowing it without spitting out can nourish the kidney essence. If too much sputum is spitted out, it will damage the kidney essence. Ancient experts who practiced the Daoyin KungFu would prop the tip of the tongue against the palate till the saliva became full in the mouth, then swallow it to nourish the kidney essence. Patients with kidney deficiency or kidney coldness will often spit out the sputum.

3.3 Six fu-organs Six fu-organs refer to the gallbladder, stomach, small intestine, large intestine, urinary bladder, and triple burners. Most of them are hollow organs and their common functions are to receive, digest, transmit, and excrete the food. Therefore, they are characterized as sedating but not storing and solid but not full. The process of food digestion, absorption, and excretion are the results of connection and cooperation among the six fu-organs.

3.3.1 Gallbladder The gallbladder is located under the right hypochondriac region, attached to the liver. It is one of the six fu-organs and belongs to the extraordinary fu-organs. The gallbladder has exterior – interior relationship with liver. Key points –

Physiological functions: – Stores and excretes the bile – Governs the power of decision

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1.

2.

Stores and excretes the bile The main function of the gallbladder is to store and excrete the bile. The bile is transformed by the liver essence. After bile is produced by the liver, it is stored in the gallbladder and directed by the dredging and dispersing functions of the liver. Later the bile is excreted into the small intestine to participate in the process of digestion. Failure of the liver to dredge and disperse of the gallbladder itself will affect the excretion of the bile and disturb digestion and absorption, leading to distending pain in the hypochondriac region, poor appetite, abdominal distention, and loose stool. Governs the power of decision The gallbladder is related to psychological activities. It has the function to govern decision. If the gallbladder qi is deficient, the person might be fearful, indecisive, and sleepless.

3.3.2 Stomach The stomach is located below the diaphragm. It connects superiorly with the esophagus and inferiorly with the small intestine. Stomach is an important organ that helps in the absorption and digestion of food. The spleen is located on the left side of the stomach, and both are located in the middle-jiao. They form a relationship through mutual affiliation and connect with their meridians. Key points –

Physiological functions: – Governs intake and decomposition of food and drinks. – Stomach performs its function well when there is descent and free flow.

1.

Physiological functions A. Governs intake and decomposition of food and drinks Governing the intake simply means that stomach can accept and contain the food and drinks. Decomposing indicates the beginning stage of food digestion in the stomach and when food changes into chyme. The function of the stomach depends on the propelling of stomach-qi. Therefore, it is very important to protect the stomach-qi during any treatment. B. Stomach performs its function well when there is descent and free flow The food and drinks enter the stomach and transform into chyme. The chyme is then transmitted to the small intestine for further digestion and absorption. Therefore, the stomach dominates dredging and descending. Stomach dysfunction leads to poor appetite, bad breath, epigastric distention and pain, nausea, vomiting, and constipation.

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3.3.3 Small intestine The small intestine is located in the abdomen between the stomach and large intestine. It includes duodenum, jejunum, and ileum. The small intestine has the exterior – interior relationship with the heart. Key points –

Physiological functions: – Receives and digests the chyme – Separates the clear from the turbid

1.

Receives and digests the chyme The small intestine receives the chyme from the stomach and retains it for a certain period of time to further digestion. Dysfunction of the small intestine will lead to indigestion, abdominal distention and pain, diarrhea, and loose stool. Separates the clear from the turbid The clear refers to food nutrients and the turbid refers to the wastes of the food. After further digestion of the chyme, the small intestine separates the food essence from the wastes and absorbs the essence and transmits the wastes to the large intestine. Because the small intestine absorbs a great amount of water, there is a saying the small intestine dominates thick fluid. If the small intestine is abnormal in separating the clear from the turbid, the stool will be sloppy and the urine will become scanty, or it may lead to profuse urination and constipation. Therefore, the therapy for diarrhea in the clinical setting is often to promote urination.

2.

3.3.4 Large intestine The large intestine is connected with the small intestine at the ileocecal valve in the upper part and the anus in the lower part. It has the exterior – interior relationship with lung. Key points –

Physiological functions: – Transforms and conveys the waste – Reabsorbs the redundant water

1.

Transforms and conveys the waste The large intestine receives the waste of food transmitted down from the small intestine. After absorbing part of the water from the waste, the large intestine

46  3 Visceral Manifestation

2.

transmits the waste downward and transforms it into stool to be excreted from the anus. Dysfunction of large intestine may lead to diarrhea, purulent blood in stool, bad breath, abdominal distention or constipation. Reabsorbs the redundant water Since the large intestine reabsorbs the redundant water from the food residue, there is a saying the large intestine dominates thin fluid. If food residue remains in the large intestine for a minimal time, diarrhea may occur, eventually causing constipation.

3.3.5 Urinary bladder The urinary bladder’s upper outlet connect to the kidneys through the ureters while its lower outlet connects with the urethra. The urinary bladder has exterior – interior relationship with the kidney. Key points –

Physiological functions: – Stores urine – Discharges urine

1.

Physiological functions A. Stores urine The urine is produced by kidney-qi transformation and is stored in the urinary bladder. Therefore, the function of the urinary bladder depends on the functions of kidney. If kidney-yang is deficient, the bladder will close and open abnormally. It will result in profuse night urination, enuresis, and incontinence of urine. B. Discharges urine Urine can be excreted naturally out of the body through qi-transforming function of the kidney and the urinary bladder. If the kidney and the bladder lose their functions, it will lead to dripping urination, incontinence of urine, anuria, frequent urination, urgent urination, odynuria, and so on. Usually, acute micturition disorders are related to urinary bladder while chronic cases are related to the kidney.

3.3.6 Triple-jiao The triple-jiao refers to the upper-jiao, middle-jiao, and lower-jiao. It belongs to one of the fu-organs. No organ has close relationship with triple-jiao.

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Key points –

–

–

1.

2.

Concept: – The triple-jiao belongs to one of the fu-organs. It refers to the upper-jiao, middle-jiao and lower-jiao. Affiliation of the zang-fu organs: – The upper-jiao: heart, lung, above diaphragm – The middle-jiao: spleen, stomach, liver, gallbladder, below diaphragm and above naval – The lower-jiao: kidney, urinary bladder, small intestine, large intestine, below naval Total physiological functions: – The passage way for the transportation of primordial-qi and fluids. – Upper-jiao is like mist. – Middle-jiao is like foam. – Lower-jiao is like ditch.

Total physiological functions A. Opening the passage for primordial-qi The triple-jiao is the passage way for the primordial-qi, which is distributed to all parts of the body to nourish tissues and promote the physiological functions of viscera. Moreover, the function of the triple-jiao is to affect the whole body’s function of qi movement and qi transformation. Therefore, there is a saying, The triple-jiao governs the whole body qi as well as controls the qi movement and qi transformation. B. Transporting the body fluids The triple-jiao is a major passage way of fluid distribution and excretion. Obstruction of the triple-jiao may affect the functions of the lung, the spleen and the kidney, leading to phlegm and edema. Respective physiological functions of the triple-jiao A. The upper-jiao is like a mist The chest area above the diaphragm is the upper-jiao which includes the heart and lung. The upper-jiao distributes qi, blood, and body fluids to the heart, lungs, and head, just like fog permeating everywhere. B. The middle-jiao is like a foam The middle-jiao refers to the upper abdominal areas below the diaphragm and above the naval. It includes the spleen, stomach, liver, and gallbladder. The middle-jiao has the function of digestion, absorption, and distribution of food essence to produce qi and blood. C. The lower-jiao is like a ditch The lower-jiao refers to the lower abdominal areas below the naval. It includes the kidney, the urinary bladder, and intestines. The lower-jiao excretes wastes like drainage.

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3.4 Extraordinary fu-organs Key points –

The concept of extraordinary fu-organs: – Extra fu-organs include the brain, the marrow, the bones, the vessels, the gallbladder, and the uterus. – Extraordinary fu-organs are similar to the fu-organs in morphology and similar to the zangorgans in function. They have no exterior – interior relationships, except the gallbladder.

Extraordinary fu-organ includes the brain, the marrow, the bones, the vessels, the gallbladder, and the uterus. The gallbladder excrete promotes digestion and is similar to the functions of the fu-organ, and it also stores bile and is similar to the functions of zang-organ. Therefore, the gallbladder not only belongs to the six-fu viscera but also to the extraordinary fu-viscera. Extraordinary fu-organs have no exterior – interior relationships and the five elements attribution, except the gallbladder. Sections 3.4.1 and 3.4.2 will focus only on the functions of the brain and the uterus. The physiological functions of other extraordinary fu-organs have been discussed in other sections.

3.4.1 Brain The brain is located in the skull and is composed of marrow. Key points –

Physiological functions: – Dominate life activities. – Dominate mental activities. – Dominate sensation and movement.

1.

Physiological functions A. Dominate life activities The brain is the vital center which dominates important life activities, such as respiration and heartbeat. B. Dominate mental activities The functions of the brain attribute to the heart and belong to the five zangorgans. When the brain is normal in function, the person will have good energy and will be in full vigor with clear mind, quick thinking, good memory, fluent speech, and normal emotion. On the contrary, abnormal function of brain will lead to sag, retard thinking, amnesia, and even mental disorders.

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C.

2.

Dominate sensation and movement The eyes, ears, mouth, nose, and tongue are the external orifices of the five organs. They are located in the head and face and are connected with the brain. Therefore, the brain controls the five sensory functions as well as the movement. When the brain is in normal function, it provides good vision and audition, normal olfactory sense and speech, as well as powerful limbs. On the contrary, it will cause dim vision, deafness, anosmia, slow motion, dyskinesia, and speech problems. Physiological relations The function of the brain attributes to the five zang-organs and is closely associated with the twelve meridians as well as the eight extraordinary meridians. For example, the heart houses the mind, the lung houses the corporeal soul, the liver houses ethereal soul, the spleen houses thought, and the kidney houses the essence. Clinically, mental activities are mostly related to the heart, the liver, and the kidney. The heart governs the mind and all mental activities, the liver governs dredging and dispersing functions as well as regulates mental activities, and the kidney stores essence in order to produce marrow to nourish the brain. That is why mental diseases are usually treated by regulating the heart, the liver, and the kidney.

3.4.2 Uterus Key points –

Physiological functions: – Governs menses and pregnancy.

1.

Physiological functions A. Governs menses The uterus governs menses. The production of menstruation is a reflection of the viscera, qi, blood, fluid, and meridians acting on the uterus. Therefore, the developmental condition of the uterus influences the production of menstruation. B. Pregnancy Normal menstruation results in the normal fertile ability in women. Physiological relation The physiological functions of the uterus are related to the kidney, heart, liver, spleen, qi, blood, body fluids, and the chong and ren meridians. The level of essence storing in the kidney and the regulation of the chong and ren meridians is especially important. The essence stored in the kidney can promote genital growth. Tiangui produced by kidney essence is considered as the basic conditions of maintaining normal menstruation and conceiving fetus. The main component of the

2.

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menses is blood. The heart governs blood. The liver stores blood and promotes circulation of blood. The spleen serves as the source of qi and blood controls blood circulation inside the vessels. Therefore, the function of uterus is closely related to the heart, the liver, and the spleen. The chong and ren meridians originate from the uterus. They propel qi and blood to nourish the uterus and conceive fetus. If the functions of chong and ren meridians are abnormal, it will result in irregular menstruation and will result in metrorrhagia, amenorrhea, and infertility.

3.5 The relationships among the zang-organs and fu-organs 1.

The heart and the lung Key points – –

–

2.

The physiological relationships Pectoral qi: – The heart governs the blood and vessels while the lung dominates qi and governs respiration. Blood circulation: – The heart governs the blood circulation while the lung links with all the blood vessels.

The relationships between heart and lung include two aspects. On the one hand, the heart governs the blood while the lung governs the qi. On the other hand, the heart governs blood circulation while the lung governs respiration. Physiologically, blood circulation depends on the propelling of heart-qi and the assistance of lung-qi. Lung-qi also depends on heart blood because heart blood helps to distribute the lung-qi through the whole body. If the blood circulation is normal, respiration will be smooth and regular. Pathologically, deficiency or stagnation of lung-qi will lead to stasis of heart blood with the symptoms of palpitation, cyanosis of the lips, and a purplish tongue. Insufficiency of heart-qi or stagnation of heart blood will lead to deficiency of lung-qi or the rebellious lung qi which is characterized by cough, asthma, and chest oppression. The heart and the spleen Key points –

The physiological relationships: – Blood circulation: Heart governs blood vessels and spleen controls blood.

The relationships between heart and spleen are presented in the areas of blood generation, blood circulation, and emotional aspects. Physiologically, heart governs the blood and stores the spirits while spleen governs the blood and is

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the source of blood. Therefore, the heart and spleen has close relationship in regards to the generation and movement of the blood. When the functions of spleen qi are normal in transformation and transportation and the production of blood is abundant, it will support the heart and stabilize the emotion. When blood circulates in the vessel, it not only relies on the movement of heart-qi but also on the support of spleen qi so as not to let the blood spill outside the blood vessels. Pathologically, if the spleen loses its functions in transformation and transportation which leads to insufficiency of blood generation or blood loss, it will result in heart blood deficiency. On the other hand, over-pensiveness will lead to deficiency of heart blood and spleen qi which will eventually result in the deficiency in both heart and spleen. The heart and the liver Key points –

4.

The physiological relationships: – Blood circulation: Heart governs blood circulation and liver stores blood. – Mental activities: The heart is in charge of mental activities and the liver regulates emotional activities.

The relationships between the heart and liver are signified as circulation of blood and regulation of mental activities. Physiologically, blood is stored in the liver and distributed through the whole body by the heart. The normal blood-moving function of the heart relies on the dispersing and blood-regulating functions of the liver. On the other hand, the heart is in charge of the mental activities while the liver governs dredging, dispersing, and emotional regulating activities. The heart and liver are closely related to each other in regulating mental and emotional activities. Pathologically, it is often seen the patterns of heart and liver blood stasis, heart and liver blood deficiency, and exuberant fire of heart and liver, for example, deficiency of both liver and heart blood will lead to symptoms of pale complexion, palpitation, dizziness, dry and lusterless nails, and scanty and lightcolored menstruation. The heart and the kidney Key points –

The physiological relationships: – Heart-kidney interaction. – Heart-kidney noninteraction. – Heart-kidney fluids nourish each other.

The relationship between the heart and kidney is mainly manifested as coordination between water and fire as well as interdependence of essence and spirit.

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5.

According to the yin-yang theory, yin and yang must coordinate physiologically leading to the origination, development, and changes of things, and according to the theory of ascent-descent of yin-yang or water-fire, the one that is located superiorly should descend and the one situated inferiorly should ascend. The heart lies in the upper-jiao which belongs to fire in the five elements; therefore, the heart-fire should go down to warm the kidney-water. The kidney lies in the lower-jiao which belongs to water in the five elements theory; therefore, the kidney-water should go upward to assist the heart-yin for restricting heart yang. Such coordination between the upper fire and lower water is called coordination between heart and kidney. The heart governs mental activities while the kidney stores essence to produce marrow. Therefore, the heart and kidney maintain the mental activities simultaneously. Pathologically, if kidney-yin fails to nourish heart-yin due to insufficiency, or heart-fire fails to descend to warm kidney-water, it will lead to imbalance between the heart and kidney. Symptoms such as insomnia, irritability, tinnitus, lower back soreness and seminal emission appear. The lung and the spleen Key points –

The physiological relationships: – Generation of qi: The lung controls breathing and governs qi while spleen governs transportation and transformation of food essence. – Fluid metabolism: The lung regulates the water passage while the spleen governs the transportation and transformation of the fluids.

The relationships between lung and spleen are mainly reflected on the coordination between the generation of qi and water metabolism. Physiologically, the lung controls breathing and governs qi. The spleen is the source of nutrients for the growth and development of qi and blood. The generation of qi, especially the pectoral qi, depends upon the combination of the fresh air inhaled by the lung and the food essence transformed and transported by the spleen. As for the fluid metabolism, the lung regulates the water passage and belongs to the upper source of water, while the spleen transforms and transports water to guarantee generation and distribution of water. The lung distributes water to all parts of the body and the spleen absorbs and transports water as well as permeates water upward to lung. This harmonious balance between the lung and the spleen is needed for a smooth fluid metabolism. Deficiency of spleen and lung qi will lead to shortness of breath, no desire to speak, poor appetite, and loose stool. If it affects the metabolism of fluid, it may lead to edema, cough, asthma, and profuse phlegm.

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The lung and the liver Key points –

7.

The physiological relationships: – Regulation of qi movement: The liver governs the ascending of qi while the lung governs the descending of qi.

The relationships between the lung and the liver are signified by the interdependence and coordination of the qi movement. Physiologically, the lung governs purification and descent while the liver governs ascent and dispersion. The coordination between the ascent of liver qi and the descent of lung qi plays an important regulatory role in the whole body’s qi dynamic. Pathologically, too much fire in the liver or overly descent of liver qi will consume lung yin which leads to the symptoms of cough, chest pain, and hemoptysis. The lung and the kidney Key points –

The physiological relationships: – Respiratory movement: The lung governs respiration while the kidney governs qi reception. – Fluid metabolism: The lung regulates the water passage while the kidney governs the fluid. – Lung and kidney yin nourish each other.

The relationships between the lung and kidney are mainly manifested as mutual dependence in respiratory movement, water metabolism, and yin generation. Physiologically, the lung is the upper source of water and the kidney governs the water. On the one hand, the lung transmits the water downward to kidney by diffusion and descent of lung qi. On the other hand, the diffusion and descent functions of the lung qi depend upon the transforming and steaming functions of kidney yang. The lung and kidney act on each other to maintain the normal process of water metabolism. In regards to the respiratory movement, the lung controls respiration and governs the qi while the kidney stores essence and governs reception of qi. Respiratory movement is governed by the lung, but the lung’s function of controlling respiration needs assistance by the kidney’s function of reception of qi. Therefore, the body can keep the depth of inspiration and secure the harmony of respiratory movement. In addition, lung yin and kidney yin promote each other. Kidney-yin is the root of every organ; therefore, the lung-yin depends upon the nourishment of kidneyyin. The relationships between the lung and kidney are similar to the relationships of mother – son according to theory of the five elements. The lung fluid helps the kidney yin. They promote each other to keep the sufficiency and balance between them. According to TCM theory, it is also called mutual promo-

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8.

tion of metal and water. Pathologically, disorder of the lung and kidney functions, will cause disturbance in water metabolism, which will result in symptoms like oliguria, edema, cough, asthma, and phlegm. If both lung and kidney qi are deficient, it will disturb respiratory movement, resulting in shortness of breath and frequent dyspnea. Yin deficiency of both lung and kidney will cause symptoms of dry cough, tidal fever, and lower back soreness. The liver and the spleen Key points –

9.

The physiological relationships: – Digestion: The liver governs the free flow of qi while the spleen governs transportation and transformation. – Blood circulation: The liver stores blood while the spleen controls blood.

The relationships between the liver and the spleen are manifested in two aspects: one is the interdependence of qi free-flowing as well as the transformation and transportation and the other is coordination of blood-storing and blood-controlling. As for digestion, the liver governs free flow of qi while the spleen governs transportation and transformation. The liver governs free flow of qi, regulates qi dynamic, promotes the bile, and improves the transforming and transporting functions of spleen and stomach. Therefore, the liver governing the free flow of qi is the foundation of a healthy transporting function of the spleen. The liver stores the blood while the spleen is the source of qi and blood as well as controls the blood. When the spleen qi is abundant, the blood will be sufficient, and then the liver can store it. The liver and spleen cooperate with each other to prevent blood loss as well as to promote the movement of qi and blood. If the liver fails in governing flow of qi, it will lead to failure of the spleen in transportation and transformation; there will appear the syndromes of disharmony between liver and spleen with symptoms like chest fullness, poor appetite, abdominal distension, and diarrhea. If deficient spleen cannot produce or control the blood, it will cause bleeding which leads to the insufficiency of liver blood. If the liver cannot store the blood or the spleen cannot control the blood, the blood will escape from the vessels with symptoms like menorrhagia and uterine bleeding. The liver and the kidney Key points –

The physiological relationships: – Essence and blood originate from the same source. – Interdependence of storage and discharge. – The liver yin and the kidney yin nourish each other.

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The relationships between liver and kidney are mainly marked by mutual transformation between essence and blood, interdependence of storage and discharge, and mutual generation of yin essence. Physiologically, essence and blood come from the same source. The liver stores blood and the kidney stores essence. Both blood and essence come from the food essence transformed and transported by the spleen and the stomach. Sufficient blood in the liver makes it possible for the kidney to store essence and abundant kidney essence provides necessary nourishment for the liver. That is why the liver and kidney share the same origin and yi and gui share the same origin. The other is the interdependence of storage and discharge. The liver governs free flow of qi while the kidney dominates storage. Both are opposite and yet complementary to each other. The discharge of liver affects the function of the kidney, while the storage of kidney can prevent over-discharge of the liver qi. The two aspects support each other to coordinate the functions of menstruation and ejaculation. In addition, the liver yin and the kidney yin nourish each other. Kidney yin is the root source of every yin organ. Thus, the relationship between the kidney and liver is mother – son according to theory of the five elements. Therefore, liver yin and kidney yin invigorate each other so as to restrict liver-yang to maintain balance of yin-yang between kidney and liver. Pathologically, deficiency of kidney-essence may lead to insufficiency of liver blood, while insufficiency of liver blood can cause deficiency of kidneyessence. It eventually results in symptoms such as dizziness, tinnitus, deafness, lower back soreness, and lower sexual function. If the discharge of the liver and storage of the kidney are not in harmony, there may appear disorders of irregular menstruation, impotence, spermatorrhea, or erectile dysfunction. If the kidney yin is insufficient, it may lead to deficiency of liver yin and hyperactivity of liver yang, resulting in symptoms like dizziness, irritability, dry eyes, and lower back soreness. 10. The spleen and the kidney Key points –

The physiological relationships: – Prenatal versus postnatal: The spleen is the root of the postnatal essence and kidney is the root of the prenatal essence. – Fluid metabolism: The spleen governs the transportation and transformation of water while the kidney governs water metabolism.

The relationships between spleen and kidney are essentially reflected by the mutual promotion of prenatal and postnatal essence as well as their cooperation in water metabolism. The spleen is the root of prenatal essence and kidney is the root of postnatal essence. The transforming and transporting functions of spleen qi depend on the steaming function of kidney yang. The abundance of

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essence-qi in the kidney also depends on the nourishment of the postnatal essence by the spleen. The spleen and kidney promote each other, which is vital to life activities. The warming and qi-transforming functions of kidney yang are helpful to transform and transport water of spleen. Both organs coordinate with each other in the process of water metabolism. Pathologically, spleen and kidney, prenatal and postnatal essence affects each other, which can cause the syndrome of yang deficiency of both spleen and kidney with the manifestations of coldness and pain in the abdomen, diarrhea with undigested food, and edema.

3.5.1 The relationships among the six fu-organs 1.

2.

Coordination in the process of digesting, absorbing, and excreting food Although gallbladder, stomach, small intestine, large intestine, urinary bladder, and triple-jiao are different in functions, they are all organs for transmitting water and food. After the food enters the mouth, being accepted and digested in the stomach, it is transmitted to the small intestine where the chyme is further digested by separating the clear from the turbid. The clear is transported throughout the whole body by the function of the spleen. The turbid is transported down into the large intestine and becomes stool to be discharged out of the body through dryness and transformation functions of the large intestine. When the small intestine separates the clear from the turbid, it also absorbs body fluid which has something to do with the total amount of urine. The water stored in the urinary bladder will be excreted out of the body through the qi transformation of the kidney and triple-jiao. During the digestion process, the liver helps the gallbladder to excrete bile into the small intestine to promote digestion. The triple-jiao, the passage of water with its qi-transformation, is also involved in the digestion, absorption, and excretion of food. The six fu-organs affect one another pathologically. For example, disturbance of the large intestine in transmission and transformation not only leads to obstruction to cause constipation but also affects the regular descent of the stomach qi which can cause halitosis and belching. Six fu-organs function well when they are not obstructed Six fu-organs transport and transform food and water. They constantly perform the functions of receiving, transmitting, and excreting. Therefore, it is appropriate for them to be kept clear and free from obstruction. Clinically, the disease of six fu-organs is often presented as obstructive syndrome. As for the treatment, tonifying or sedating, the principle should be focused on unblocking the six fu-organs to promote the normal food transformation and transportation.

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3.5.2 The relationship between the five zang-organs and six fu-organs 1.

2.

3.

The heart and the small intestine The external and internal relationship between the heart and small intestine is formed by the connections between their meridians. Physiologically, the heart meridian of hand shaoyin affiliates to the heart and connects with the small intestine, while the small intestine meridian of hand taiyang affiliates to small intestine and connects with the heart. Pathologically, if heart fire gets hyperactive, the heat may be transported into the small intestine through the meridian, which will lead to the dysfunction of the small intestine with dysphoria, sores in the mouth, oliguria, and painful urination. The lung and the large intestine The external and internal relationship between the lung and large intestine is formed by the connections between their meridians. The lung meridian of hand taiyin affiliates to the lung and connects with the large intestine, while the large intestine meridian of hand yang ming affiliates to large intestine and connects with the lung. Physiologically, the purification and descent of lung qi help to normalize the transporting function of large intestine. The smooth conveyance by the large intestine is also beneficial to lung qi’s purification and descent. The large intestine governs the thin fluid, while the lung controls the water passage. They both coordinate with each other in the process of water metabolism. Pathologically, heat obstruction in the lung can affect the large intestine in conveyance of the waste which can cause constipation. On the contrary, constipation caused by heat obstruction in large intestine will lead to adverse rising of lung qi with manifestations as asthma, chest oppression, and cough. The spleen and the stomach The spleen and the stomach form an exterior – interior relation through their meridian’s connection and affiliation. The physiological relationship between the spleen and the stomach includes the following three aspects: first, coordination in reception and transportation. The spleen governs transportation and transformation while the stomach controls reception and digestion. They both cooperate with each other in digestion and absorption of food. Second, mutual influence of ascent and descent. Spleen qi governs the rise of the clear while stomach qi controls the descent of the turbid, both of which restrict and assist each other. The spleen and the stomach play the pivotal role in descending and ascending of qi activities. Third, mutual promotion between dryness and dampness. The spleen is a zangorgan pertaining to yin which prefers to dryness and dislikes dampness. The stomach is a fu-organ pertaining to yang which prefers to moisture and dislike dryness. The spleen is easily encumbered by dampness while the stomach is easily invaded by heat. Pathologically, the disorders between spleen and stomach tend to affect each other. Simultaneously, it can result in symptoms of anorexia, abdominal distension, vomiting, dizziness, and diarrhea. Symptoms such as abdominal

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4.

5.

distention and diarrhea are often seen in spleen disorder while poor appetite, easy hunger, and stomach are often seen in stomach disorder. The liver and the gallbladder The liver and the gallbladder form exterior – interior relationships through their meridian’s connection and affiliation. The secretion and excretion of the bile are regulated and controlled by liver’s function in governing free flow of qi. The smooth excretion of the bile is beneficial to liver’s function in governing free flow of qi. The liver is in charge of making strategy, but decision-making depends on the gallbladder. If the two organs cooperate closely, it will result in normal emotion and good decision-making. Pathologically, liver and gallbladder often affect each other. Symptoms such as bitter taste in the mouth and jaundice are often associated with liver qi congestion. The kidney and the urinary bladder The kidney and urinary bladder form an exterior – interior relationship through their meridian’s connection and affiliation. The turbid part of water in the body is transformed into urine by qi-transforming function of the kidney and transported down into the bladder, while the discharge of urine is the main function of the bladder. At the same time, it is adjusted by the function of qi-transforming and qi-controlling of the kidney. The relationship between the kidney and the urinary bladder lies in their interdependence and mutual coordination in the production, transformation, and excretion of urine. Pathologically, if kidney qi is deficient, it will affect excretion of urine with manifestations of lower back soreness, dysuria, and enuresis. If there is damp-heat in the urinary bladder, it will impair the kidney which can result in symptoms like frequent urination, urgent urination, and painful urination. Qi, blood, and body fluids are the basic substances which constitute the human body and maintain its life activity. Qi is a very active and refined substance while blood is a red liquid circulating within the vessels. Body fluids is a general term for all normal liquids in human body. Qi, blood, and body fluids constitute and sustain functions of organs, meridians, tissues, and orifices. They are metabolized by the functional activities of the viscera and meridians. Therefore, qi, blood, and body fluids are closely related to the organs, tissues, and meridians physiologically.

4 The Theory of Qi, Blood, and Body Fluids 4.1 Qi Key points –

– – – –

Concept of qi: – Qi is a kind of very active and refined substance that is in constant movement, which constitutes human body and maintains its life activity. Production of qi: – Congenital qi is related to kidney. Acquired qi is related to lung and spleen. Function of qi: – Propelling, warming, defending, controlling, and transforming. Movement of qi: – Ascending, descending, exiting, and entering. Classification of qi: – Primordial qi, pectoral qi, nutritive qi, and defensive qi.

4.1.1 Concept of qi Qi is one kind of simple understanding to natural phenomenon by the ancients. As early as the Dynasty of Spring-Autumn and Warring States, materialistic philosophers believed in qi as universal origin and the most basic substance forming the whole world. And everything in the universe was produced by motion and changes of qi. This kind of view was introduced into the medical domain to explain human activities and it was also widely applied to many aspects, such as physiology, pathology, diagnosis, treatment, and health maintenance. According to traditional Chinese medicine, qi is a very active and refined substance that constitutes human body and maintains its life activities. Qi produces everything in the universe, while humans are created by nature. Therefore, human body which includes zang-fu, meridians, five sense organs, and nine orifices is also created by the substances of qi. Meanwhile, the maintenance of life activities depends on the functions of qi. For example, after the clear qi and food enter the body, they turn into qi of various organs through the metabolic process. The sufficient qi make organs and tissues play their roles to maintain and promote life activities normally.

4.1.2 Production of qi The production of qi is divided into two aspects: congenital qi and acquired qi. The congenital qi is inherited from parents before birth, including the essence qi stored in parents’ kidney when embryo was created. It also includes food essence from mother. The acquired qi refers to nutritional substances (food and water essence)

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after birth as well as the fresh air from nature. Therefore, kidney essence, diet nutrients, and fresh air are the substantial basis to produce qi. Production of qi mainly depends on physiological functions of the viscera, especially the lung, spleen – stomach, and kidney. Among them, congenital essence-qi inherited from parents is stored in the kidney and is the most primitive basis to produce qi, the food essence-qi is acquired from diet and transformed by spleen, and the fresh air is inhaled by the lung. Hence, viscera qi throughout the whole body is produced by the combination and close coordination of the functions of the lung, spleen, and kidney. Production of qi is affected by many factors, such as poor constitution, deficiency of kidney essence, poor nutrition, decreased fresh air inhalation due to polluted environment, or dysfunctions of the lung, spleen, or kidney.

4.1.3 Movement of qi The motion of qi is called qi dynamic. The moving style of qi can be classified into four kinds, namely ascending, descending, exiting, and entering. Qi reaches all parts of the body, including zang – fu organs and meridians. All the viscera and tissues are areas for qi to ascend, descend, exit, and enter. Therefore, although qi is too fine to be measured, its motion can be embodied by all kinds of physiological activities of viscera and meridians. For example, lung controls dispersing and descending to regulate respiration. The process of dispersing and exhaling the turbid embodies qi’s ascending and exiting movement, while the process of descending and inhaling the lucid embodies qi’s descending and entering movement. For example, spleen and stomach are the main places for digestion. Spleen-qi is suitable for ascending the lucid while stomach-qi is suitable for descending the turbid. Interaction of ascending spleen-qi and descending stomach-qi completes the process of food digestion. As another example, the heart belongs to fire and is located in the upper part of the body, while the kidney belongs to water and is located in the lower part of the body. Heart and kidney need to coordinate well in order to maintain the balance of yin and yang (water and fire). Other life activities, such as the production and circulation of blood as well as the metabolism of body fluids, are all as a result of qi dynamic. In general, the generating, transforming, and essence-storing functions of five-zang organs are mainly ascending, while the receiving, transporting, and transforming functions of six-fu organs are mainly descending. It should be pointed out that each zang- or fu-organ may differ from each others in its moving style of qi. The liver and spleen qi tend to ascend, while the lung and stomach qi tend to descend. Overall speaking, the ascending, descending, exiting, and entering movements of qi are the basic characters of functional activities of viscera and tissues. The process of qi movement is the process of life activities. In fact, all functional activities of human body are embodied by qi movement. Thus, qi movement is the basic condition to maintain life activities. Only if the qi movement coordinates well, will there be normal physiological

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function of the organs. If the movement of qi is broken down, it will result in pathological changes and cause diseases. If the qi movement stops, the end of life occurs.

4.1.4 Functions of qi Qi is the basic substance to maintain the life activities. It plays an important role in the body. The physiological functions of qi are characterized in the following five aspects. 1. Propelling function The propelling function of qi refer to its strong movement. It can move and stimulate the physiological functions of all the organs as well as promote development and growth of human body. For instance, kidney-qi can promote human growth and reproduction; heart-qi can promote blood circulation; spleen-qi and stomach-qi can boost digestion and absorption of food; and qi of lung, spleen, and kidney can propel metabolism of body fluids. If qi is deficient or stagnated, it may result in hypofunction of the viscera, sluggish growth and development, indigestion, retarded blood circulation, abnormal metabolism of body fluids, and so on. 2. Warming function Qi is the source of thermal energy and can make the body warm. The warming function is characterized in three aspects: 1. To produce heat to maintain the normal body temperature. 2. To warm zang – fu organs and meridians to maintain their normal physiological function. 3. To maintain normal circulation of blood and body fluids.

2.

Disorder of qi-warming function will result in hypothermia, cold extremities, dysfunction of zang – fu organs, and poor circulation of essence, blood, and body fluids. Defending function A healthy qi can guard the body surface, resist invasion of exogenous pathogens, and fight against the pathogens and expel them out. The concrete performance is in two aspects: 1. Before the onset of disease, if the defensive qi is plentiful, it will safeguard the body surface as well as tighten the skin and striae enough to resist invasion of pathogens. 2. After the onset of disease, healthy qi will fight against the evil qi, expel them out of the body, and promote recovery as early as possible. Hence, when the defending function of qi is strong enough, not only is it hard for the evil qi to invade the body but also help the disease to be cured easily. If the defending function of qi gets weaker, the resistant ability will fall down gradually and the exogenous pathogens will attack the body easily. Moreover, the weakened qi may lead to long-term retention of the pathogens, resulting in deteriorated disease or even death.

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4.

5.

Controlling function This function refers to the ability of blood and fluid controlling so as to prevent them from losing unduly. For example, spleen-qi can control blood, make blood circulating inside the vessels, and prevent the blood from flowing outside the vessels; lung-qi or defensive qi can control sweat; spleen-qi or kidney-qi can control intestinal fluid; and kidney-qi can control urine or sperm as well as control its secretion and excretion to prevent excessive loss. If the controlling function of qi is weakened, it will lead to loss of fluid great quantities. For example, failure of qi to control blood may cause bleeding; failure of qi to control body fluids may lead to polyhidrosis, polyuria, or urinary incontinence; and failure of qi to control sperm may result in spermatorrhea or premature ejaculation. In addition, qi deficiency in intestines can cause chronic diarrhea or fecal incontinence. Qi transforming function Qi can produce and promote various changes through the motion of qi. Because qi is spread all over the body, production and maintenance of visceral functions as well as metabolism and inter-transformation among the essential substances are all dependent on the qi transformation. For example, functions of spleen and stomach depend on the movement of spleen – stomach qi. Digestion and absorption of foodstuff depend on heart qi and lung qi, wherein the food essence is transformed into qi, blood, and body fluids. Some body fluids become sweat and urine by lung’s dispersing function and kidney’s evaporating functions. Thus, series of material and energy metabolism are all manifestations of qi transforming function.

4.1.5 Classification of qi According to its origin, distribution, and function, qi is classified into the following categories: the primordial qi, pectoral qi, nutritive qi, defensive qi, visceral qi, and collateral qi. The latter two will be introduced in detail in other related chapters. 1. Primordial qi The primordial qi refers to the most fundamental and important qi of human body and is the motivating power of life activity. A. Production of the primordial qi The qi comes mainly from the innate essence and transformed from the kidney essence of the parents. It is nourished by the food essence after birth. Therefore, the production, prosperity, and declination of the primordial qi has direct relationship with constitution from prenatal essence as well as the absorbing function of the postnatal essence. The postnatal essence is especially important for production and vigor. Even if the prenatal essence is poor, as long as the postnatal essence is strong, it will still be able to supplement the primordial qi gradually. Thus, the function of spleen and stomach is very important to primordial qi.

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B.

2.

3.

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Distribution of the primordial qi The primordial qi is the prenatal qi. It is originated from kidney and distributed to all parts of the body through triple-jiao. It reaches everywhere to the zang-fu organs internally as well as to skin externally. C. Function of primordial qi The physiological functions of the primordial qi mainly manifest into two aspects: the primordial qi stored in the kidney can boost and regulate growth, development, and reproduction of the body, and the primordial qi spreading to the whole body can activate, promote, and regulate the physiological activities of the viscera, meridians, tissues, and organs. It is the power of the life activities. Plentiful primordial qi can strengthen the human constitutions as well as activate viscera and meridians. Pectoral qi The pectoral qi, also called daqi, is the qi accumulating in the thorax. Because the thorax is the part where the pectoral qi gathers, it is called the sea of qi or danzhong. A. Production of pectoral qi The pectoral qi is a combination of natural fresh air inhaled by the lung and the food essence transformed by spleen-stomach. Hence, prosperity and decline of pectoral qi are influenced directly by the respiratory function of lung and transportation and transformation functions of spleen. B. Distribution of pectoral qi Accumulating in the thorax, the pectoral qi permeates the heart and the lung as well as distributes in the area of Dan Tian (life gate) and reaches the point of (Qijie ST30). C. Function of pectoral qi The pectoral qi mainly has two functions: 1. It flows through the respiratory tract to promote the respiratory movement of the lung and it also governs the respiratory and vocal functions. 2. It permeates and warms the heart and vessels to promote circulation of blood and qi. Hence, the strength of the pectoral qi is closely related to the condition of respiration, the rhythm and strength of heart beats, and circulation of qi-blood. If the pectoral qi is sufficient, it will lead to harmonious breath, distinct speech, clear voice, and smooth pulse. Nutritive qi The nutritive qi, also called rongqi, refers to a kind of qi circulating within the vessels and having nutritive function. It is the important component of blood. Therefore, the name nutritive-blood is often mentioned. Compared to the defensive qi, the nutritive qi pertains to yin, so it is also called nutritive-yin. A. Production of nutritive qi The nutritive qi mainly comes from the food. It is the essence transformed and absorbed by spleen and stomach. The productive location of nutritive

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4.

qi is spleen and stomach in middle-jiao, and the food essence is the material basis of its production. B. Distribution of nutritive qi The nutritive qi flows inside the vessels to circulate throughout the body. Interiorly, it reaches the viscera while exteriorly it reaches the limbs and joints. This cycle is repeated without stopping. C. Function of nutritive qi The physiological functions of the nutritive qi show two aspects: to produce blood and to nourish the whole body. Containing rich nutrient, as the nutritive qi flows into the vessels, it becomes an important part of blood. Therefore, nutritive qi is the main material basis for the production of blood; it travels inside the vessels and provides essential nutritive materials for the physiological activities of all the viscera, meridians, tissues, and organs, as well as maintains its normal physiological function. Defensive qi The defensive qi refers to the qi circulating outside the vessels and having protective function to the body. Compared with the nutritive qi, it belongs to yang; therefore, it is also called defensive-yang. A. Production of defensive qi The defensive qi comes from the food essence of the spleen and stomach. B. Distribution of defensive qi The defensive qi has very strong vitality. Therefore, it is not restricted by the vessel passages and travels outside the vessels. It distributes through the whole body as well as the body surface. C. Function of defensive qi The physiological functions of defensive qi can be generalized by the following three aspects: (a) Protecting the body surface and resisting the invasion of the exogenous pathogens: Skin and muscles are the most important barrier to resist exogenous pathogens. Lung spreads the defensive qi to the body surface and strengthens the striae to increase the resistant ability. Insufficient defensive qi may lead to decreased resistant ability and apt to be invaded by exogenous pathogens. (b) Warming muscle, skin, and viscera: The defensive qi is the origin of energy. It spreads all over the body to warm muscle, skin, and viscera as well as make them strong and lustrous. (c) Regulating the opening and closing of the striae, controlling the excretion of the sweat, and maintaining the normal body temperature. Although both nutritive qi and defensive qi come from the same food essence, they differ in property, distribution, and physiological function. The nutritive qi comes from the most essential part of the food essence,

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flowing inside the vessels and having the function of producing blood and nourishing the whole body; so it belongs to yin. The defensive qi comes from the most active and powerful part of food essence, flowing outside the vessels and having the function of defending the body surface and warming the body; so it belongs to yang. Only when the nutritive qi and the defensive qi coordinate with each other, can they exert their own physiological function, respectively.

4.2 Blood Key points –

– –

Concept of blood: – The blood is a red liquid material circulating within the vessels and possessing nourishing and moistening functions. Production of blood: – Food essence and kidney essence. Functions of blood: – Nourishing and moistening function. – Material foundation for mental activities.

4.2.1 Concept of blood The blood is a red liquid material circulating within the vessels and has the nourishing and moistening functions. It is one of the basic substances which constitutes the human body and maintain its life activity. Comparing with qi, blood belongs to yin. So blood is also called yin-blood.

4.2.2 Production of blood Blood is produced from the two origins. The first origin is the transformation from the food essence. Food is converted into the essence through the decomposition by stomach as well as the transformation and transportation by spleen, where the pure and refined part is being transformed into the nutritive qi. The nutritive qi permeates the vessels and combines with body fluid to become blood. The second origin comes from the transformation of kidney essence. Kidney essence is the source of life. Essence is stored in the kidney and transformed into marrow, which can be changed into blood. Because food essence transformed and transported by spleen-stomach is the most important and basic material of the blood production, the prenatal kidney essence also depends on the postnatal

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food essence to replenish. Therefore, the transforming and transporting function of the spleen and stomach play an important role in the production of blood. Hence, there is a saying the spleen and stomach are the source for the production of qi and blood.

4.2.3 Functions of blood 1.

3.

Nourishing and moistening function Blood consists of nutritive qi and body fluids. Nutritive qi is produced from food essence. Body fluids can moisten the whole body. Hence, the main function of blood is to nourish and moisten the whole body. Blood circulates in the vessels from internal organs to external skin and orifices throughout the whole body. It nourishes and moistens all the organs and tissues to guarantee their normal physiological functions. Therefore, if the blood is sufficient and all the organs are nourished by it, it will manifested by healthy facial complexion, well-developed and strong muscles, lustrous skin and hair, and nimble movements. Material foundation for mental activities Although the mental activities are dominated by heart, they are also closely related with the other internal organs. Blood nourishes and strengthens the internal organs. Therefore, it can produce and maintain the normal mental activities. It is the main material foundation for the mental activities. Sufficient blood can nourish and harmonize the internal organs. It is manifested as good spirit, clear mind, and smart thinking. Blood deficiency may lead to malnourishment of the internal organs and the inability to make the right decision. It is manifested as palpitation, insomnia, lots of dreams, irritability, and somnolence.

4.2.4 Blood circulation Vessels house the blood. Relatively closed-flow vessels are the prerequisites for normal blood circulation. Blood flows inside the vessels and is restricted by it. It recycles endlessly to irrigate the whole body. Normal blood circulation depends on the promoting and controlling functions of the visceral qi. Movement of qi ensures constant blood circulation, while the controlling of qi restrict the blood to circulate within the vessels. These two functions cooperate harmoniously to keep blood circulation normal. Abundant heart-qi can maintain the normal beats and promote constant circulation. Hence, heart-qi is the basic power for blood circulation. Lung dominates qi, links with all the vessels, and helps heart to circulate the blood. Liver dominates the free flow of qi and regulate the qi dynamic. Hence, the dispersing

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and descending action of lung and soothing action of liver are important auxiliary factors for normal circulation. Spleen govern the blood. The blood circulation inside the whole body depends on the governing and controlling functions of the spleen to prevent it from spilling outside the vessels. In addition, liver can store blood and regulate the blood volume to prevent bleeding. Therefore, functions of liver and spleen are also important factors to maintain normal blood circulation. Overall speaking, the normal blood circulation depends on the coordination of the heart, lung, spleen, and liver, as well as the moving and controlling function of qi. Deficient qi can lead to slow movement and congestion of blood which will result in blood stasis. On the other hand, if the controlling function of qi is weak, blood will spill outside of the vessels, which will lead to various hemorrhaging conditions. In addition, the blood circulation is also influenced by the flow of the vessels and body temperature. For example, phlegm and blood stasis can oppress vessels and lead to impediment of blood circulation and local obstruction. Injuries from falls and other external force may burst vessels and cause bleeding. Blood has a likewarm-and-aversion-to-cold character. Hence, cold may slow down the blood circulation and cause stasis, while heat may accelerate the blood circulation and cause hemorrhage.

4.3 Body fluids Key points – –

Concept of body fluids: – Body fluid is a general term for the entire normal liquids in the body. Metabolism of body fluids: – The metabolism of body fluids is related to lung, spleen and kidney, among which kidney is the most important.

4.3.1 Concept of body fluids Body fluids is a general term for the entire normal liquids in the body. It is also the basic material constituting the human body and maintaining the life activities. Body fluids are mainly the fluid in or metabolized by viscera and tissues, including secretory liquids (such as the nasal discharge, tears, and saliva) and excretory liquids (such as sweat, urine). Comparing with qi, body fluids pertain to yin. Therefore, it is often called yinjin or yinye, which means the “yin fluid.” Body fluids can be subdivided into two parts of jin (thin fluid) and ye (thick fluid). They differ in character, distribution, and function. Generally speaking, the lucid and thin type is jin. It has more fluidity, moves more freely, and distributes onto the skin, muscles, and orifices. Its main function is to moisten the organs, surface, and orifices. The

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dense and thick type is called ye. It has with less fluidity and mainly distribute into the skeleton, joints, viscera, and brain-marrow to play the nourishing and lubricating function. Although jin and ye are different to some degree, they all come from food essence, transformed by the spleen-stomach and distributed inside as well as outside the vessels along with qi and blood. They supplement and transform to each other and have no specific differences. However, ye exhaustion is more severe than jin impairment pathologically.

4.3.2 Metabolism of body fluids 1.

2.

4.

Production of body fluids Body fluids come from the food essence, mainly produced by spleen, stomach, and intestines. After entering into the stomach, the food is decomposed by stomach and transformed by spleen. The function of separating the clear from the turbid by the small intestine produces the body fluids. Large intestine can also absorb parts of liquids to dry the feces during the process of transporting the wastes. It is thus clear that production of body fluids is influenced by the two factors: one is the sufficient liquid intake and the other is the dominant function of spleen coordinating with stomach and small and large intestines. Distribution of body fluids After production, body fluids is distributed in the whole body through the coordination of spleen, lung, kidney, and triple-jiao. First, spleen-qi ascends body fluids to the lung; then, lung is the upper source of water, regulating the waterways. By diffusing action, the lung further disseminates body fluids upward and outward; by descending action, it further sends body fluids inward and downward. After metabolism, body fluids is transported to the kidney. The kidney governs water. Through the steaming action and qi transformation by the kidney yang, the clear part of the fluid is sent up to the lung and the spleen to be used again and throughout the whole body. Smoothness of the water passage in triple-jiao and free flow of the liver qi also help the distribution of the body fluids. In addition, liver dominates the governing and smoothing function of free flow of qi. Distribution of body fluids also depends on the movement of qi. Therefore, liver plays a coordinating function in the fluid metabolism. Excretion of body fluids After body fluids is utilized by human body, its surplus and the metabolized wastes should be discharged outside of the body timely. It is mainly the result of functional collaboration of lung, kidney, large intestine, and urinary bladder. Lung dominates dispersing and associates skin and hair as well as the body fluids excreted as sweats from the skin or steam from the respiratory tract; kidney governs water and changes the turbid into urine and being excreted by

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bladder; large intestine dominates the transmission and the feces inside is being mixed with some water. Hence, there are four ways to excrete the surplus water and metabolized wastes: sweat, exhaled breath, urination, and defecation. Among them, urination is the key link regulating the dynamic balance of the body fluids metabolism. Overall speaking, the metabolism of body fluids is a complicated process. It is affected by the functions of the different organs, among which the lung, spleen, and kidney are the most important, especially, the function of the kidney. If there is a disorder in viscera’s function, the metabolic process of the body fluids will be influenced, which will result in deficiency or disorder of the body fluids. It will lead to the pathological changes of damp-phlegm and edema.

4.3.3 Function of body fluids 1.

2.

3.

4.

Moistening and nourishing There is a large amount of water and nutrients in the body fluids which are extensively distributed in the viscera, sense organs, orifices, body constituents, and limbs. They play an important role in moistening the whole body. For example, jin is distributed into the body surface to moist skin, muscle, and orifices. It smoothes the skin and muscle as well as make the hair luscious and orifices nourished and clear; ye spreads into the joints and marrow to make the movement free and flexible as well as strengthens the bone and consolidates the brain marrow. Components of the blood The body fluids from the food essence combine with the nutritive qi to transform into blood. Therefore, it is one of the important components of the blood and the basic liquid substances in the blood. Participation in the regulation of yin-yang balance Fluid metabolism plays an important role in regulation the yin-yang balance. Body fluids pertains to yin. Plentiful body fluids may restrain excessive heatyang to maintain harmonious balance of yin-yang and cold-heat of the body. In addition, body fluids can change into sweat. Sweating disperses body heat, weakens yang-pathogen, and regulates the body temperature. Fluid metabolism often adapt to the changes of life activities and environment, through which it can regulate yin-yang and maintain the normal body temperature. Assisting in waste excretion Through the metabolic process, body fluids carry various metabolic wastes to the related parts or excretory organs. By visceral qi-transformation, the wastes are excreted outside the body in time to guarantee the normal physiological function of different organs.

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4.4 The relationships among qi, blood, and body fluids Key points –

– –

Relationship between qi and blood: – Qi is the commander of blood (qi produces, circulates, and controls blood) and blood is the mother of qi (blood nourishes and carries qi). Relationship between qi and body fluids: – Qi generates, circulates, and controls body fluids, while body fluids carry qi. Relationship between blood and body fluids: – They come from the same origin and can change from each other.

Qi, blood, and body fluids are the basic substances constituting and maintaining the human body. They differ in property, function, and distribution. However, they connect and promote each other physiologically. During the onset of disease, they affect each other.

4.4.1 The relationship between qi and blood Qi belongs to yang, being invisible and active. It governs warming and moving function. Blood belongs to yin which is visible and quiet. It has the function of nourishing and moistening. They both originate from food essence produced by spleenstomach and kidney essence. They connect and produce each other to maintain the life activities together. The relationship between qi and blood can be generalized as qi is the commander of blood and blood is the mother of qi. 1. Qi is the commander of blood A. Qi produces blood Qi produces blood refers to qi participating and promoting in the process of blood formation. It is characterized by two aspects: nutritive qi can transform and generate blood. It is main foundation for blood production. The qi dynamic of spleen, stomach, heart, lung, and kidney is the power house for blood formation. Good diet, sufficient source of nutritive-qi, and strong qi of zang-fu organs will generate sufficient blood. On the other hand, deficient nutritive-qi and weak zang-fu qi can weaken the qi dynamic, which will result in blood deficiency syndromes due to the weakened blood source. B. Qi moves blood Qi moves blood refers to the power which moves the blood to circulate inside the vessel. In general, the heart qi promotes and strengthens the heart beat to move the blood circulation; lung qi disperses, descends, and helps blood movement; the liver qi regulates the qi dynamic as well as maintains the blood movement. Therefore, blood depends on the qi movement to circulate

4.4 The relationships among qi, blood, and body fluids

2.

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71

and reach to various parts of the body. If qi gets deficient and fails in propelling or qi gets congested, it will result in blood stagnation. The disorder of qi dynamic can also cause the disturbances of blood circulation, such as bleeding superiorly caused by adverse rise of qi. C. Qi controls blood Qi controls blood refers to qi having the function to keep blood circulating within the vessels and preventing it from extravasation. This is a specific embodiment of controlling function of qi and is mainly related with the blood-controlling function of the spleen qi. If deficiency of the spleen qi fails to control blood within the vessels, it will cause various kinds of hemorrhage. Blood is the mother of qi A. Blood nourishes qi Blood contains abundant nourishment. It can provide material foundation for generation and functional activity of qi so as to make qi replenished timely and appropriately. The abundant blood provides qi with nourishment. If blood gets deficient and fails to nourish qi, it may cause qi deficiency. B. Blood carries qi Qi circulates only when it attaches to blood. This is to prevent it from escaping due to its dispersing nature. Blood is the carrier for qi. Due to its invigorating power of movement, especially the defensive qi, it has to attach to a body for the blood to circulate normally. Clinically speaking, the hemorrhaging patients are often presented with the dangerous signs of qi collapsing followed by blood loss.

4.4.2 The relationship between qi and body fluids 1.

2.

Qi generates body fluids Qi generates body fluids refers to qi having the effect of promoting the production of body fluids, which is produced by absorption and digestion of the food essence by spleen-stomach qi. If the spleen-stomach qi is sufficient along with the good digestive and absorptive function, the production of body fluids will be prosperous. On the contrary, if the spleen-stomach qi is deficient along with the decreasing function of digestion and absorption, the generation of body fluids will be short. Qi moves body fluids Qi moves body fluids refers to qi having the ability to move the distribution and excretion of the body fluids. The movement of qi is the power of distribution and excretion of the body fluids. The qi of lung, spleen, kidney, and triplejiao moves and distributes the body fluids through the entire body. Through the qi transforming function of lung, intestines, kidney, and urinary bladder,

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it can turn the remaining fluid and the metabolic wastes into the sweats and urination. They can be discharged out of the body timely. The distribution and excretion of body fluids depend on qi transformation and coordination of the viscera such as the lung, spleen, kidney, and triple-jiao. If qi of the above-mentioned viscera are deficient or congested, it will hinder the fluid distribution and excretion which can result in damp congestion and phlegm retention. A. Qi controls body fluids Qi controls body fluids refers to qi having the effect to astringe the body fluid and preventing it from losing unduly. For example, lung and defensive qi can control sweat; spleen and kidney qi can control saliva; kidney and urinary bladder qi can control urine; and so on. If qi is deficient and fails to control, it will lead to abnormal loss of body fluids which is manifested as polyhidrosis, polyuria, and drooling. B. Body fluids conveys qi Fluid conveys qi refers to body fluids having the function of carrying qi. Qi has to attach to the body fluids so as to exist inside the body and spread to the whole body. In clinical setting, severe vomiting, diarrhea, and sweating can cause fluid loss in a great quantity which will result in qi collapse and death. 4.4.3 The relationship between blood and body fluids Physiologically, blood and body fluids originate from the same source. Both are produced from food essence and depend on the transforming and transporting function of the spleen and stomach. Meanwhile, fluid is also the component of blood. After being absorbed by the spleen and stomach, body fluids are transported upward to heart and lung to combine with the nutritive qi to become blood. Also, fluid and blood can convert to each other. When the outside fluid permeates into vessels, it becomes part of the blood, but when the blood inside the vessels gets out, it melts with the body fluids. This reflects the interdependent and interchangeable relationship between them. Due to the close relationship between the body and the body fluids physiologically, they also affect each other pathologically. If too much blood loss happens, large amount of the body fluids outside the vessels will permeate into the vessels. Along with the blood deficient signs, fluid-injuring symptoms such as dry mouth, throat, or skin and oliguria may appear. Hence, for patients with blood loss, diaphoretic therapy is prohibited. On the contrary, massive loss of body fluids may cause the liquid part of blood to leak outside the vessels, which will result in empty blood vessels, blood and fluid dryness, and blood stasis. Therefore, strong purgative and blood-breaking medicine should be used with great caution in patients with fluid loss due to diaphoresis.

5 Theory of Meridians and Collaterals 5.1 Overview of the theory of the meridians and collaterals Key points – – –

The concept It is a passage of transporting qi and blood, connecting zang-fu, tissues, and limbs as well as combining the body into an organic whole. The composition of the meridian and collateral system: – Meridians: – Twelve regular meridians – Eight extra meridians – Twelve divergent channels – Collaterals: – Fifteen divergent collaterals – Superficial collaterals – Minute collaterals – The affiliated portions: – Twelve meridian musculatures – Twelve cutaneous areas – Zang-fu organs

5.1.1 The concept of the meridians and collaterals The system of meridians and collaterals consists of meridians, collaterals, and its affiliated portions. It is the passages transporting qi and blood, connecting the viscera with other tissues and limbs, and combining the body into an organic whole (Table 5.1). Tab. .: The difference between meridians and collaterals Meaning

Distribution

Shape

Routes

Meridians

Trunk Branch

Thick and big Thin and small

Vertical

Collaterals

Run through deeper layer of the body Run through the superficial parts of the body

Crisscross

5.1.2 Composition of the meridian The meridian is a system consisting of meridians, collaterals, and its affiliated portions.

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1.

2.

3.

Meridians Meridians consist of three categories: (a) Regular meridians (b) Extra meridians (c) Divergent meridians There are 12 regular meridians, including three yin meridians of hand, three yang meridians of hand, three yin meridians of foot, and three yang meridians of foot, which are collectively called 12 meridians or 12 regular meridians. They are the main passages for the qi-blood circulation. The 12 meridians have their own starting and terminating points, running regions, connecting orders, certain regularities in distribution, and trend in the limbs. They have direct relationship of affiliation with viscera in the body. There are eight extra meridians, namely, du, ren, chong, dai, yinqiao, yangqiao, yinwei, and yangwei meridians, collectively called eight extra meridians. They play the role of governing, communicating, and regulating the qi and blood of the 12 meridians. Twelve divergent meridians are the meridians branching out from the 12 meridians. They run through the chest, the abdomen, and the head. Their main function of the 12 divergent meridians is to strengthen the communication between the two externally–internally related meridians inside the body. Collaterals Collaterals are the smaller branches of meridians. They run through the superficial parts of the body without regular circulating routes. Collaterals are divided into divergent collaterals, superficial collaterals, and minute collaterals. The divergent collaterals are the larger and major collaterals. They include each of the 12 meridians, du and ren meridians as well as other large collaterals of the spleen meridian, which is collectively known as the 15 divergent collaterals. These are the main parts of the collaterals which strengthen the qi and blood movement. Their major functions are to strengthen communication in the exterior of the body between the two externally–internally related meridians in the 12 meridians. The superficial collaterals run superficially of the body and often appear in the surface. The minute collaterals are the smallest collaterals. They branch from the larger collaterals, then gradually become thinner and smaller, and eventually distribute throughout body. They can strengthen the communication among the tissues and the circulation of qi-blood. Interior relationship Twelve meridians connect with its affiliated viscera. The fu-viscera pertain to yang, while the zang-viscera pertain to yin. The three yin meridians of hand relate to lung, heart, and pericardium in thorax; the three yin meridians of foot relate to spleen, liver, and kidney in the abdomen; the three yang meridians of foot relate to stomach, gallbladder, and urinary bladder; and the three yang meridians of hand relate to large intestine, triple-jiao, and small intestine. The

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12 regular meridians connect with their respective viscus. For example, the lung meridian of hand taiyin belongs to lung and connects with large intestine, while the large intestine meridian of hand yangming belongs to large intestine and connects with lung. The two internally and externally correlated meridians affect each other physiologically and pathologically. Exterior relationship Exterior relationship refers to the connection between the meridians and the superficial portions of the body through the 12 meridian musculatures and the 12 skin areas. The 12 meridian musculatures connect with the limbs and bones as well as dominate joint movement. The movement of the 12 meridians reflects the superficial location which is called the 12 skin portions. The above four parts consist of the meridian systems. The relationships among them are shown in Figure 5.1. Twelve regular meridians Meridians

Eight extra meridians: they govern, communicate, and regulate qi-blood in the 12 meridians Twelve meridian divergence: strengthen the communication in the interior of the body between the two externally-internally related meridians Fifteen divergent collaterals: strengthen the communication in the exterior of the body between the

Collaterals

two externally-internally related meridians Superficial collaterals: run and appear in the surface Minute collaterals: the thinnest and the smallest collaterals Interior relationship: The five zang-viscera and the six fu-viscera

The affiliated portions

The 12 meridian musculatures Exterior relationship The 12 skin areas

Fig. 5.1: Exterior relationship

5.2 Twelve meridians Key points –

–

The name of 12 meridians: – The lung meridian of hand taiyin–the large intestine meridian of hand yangming. – The pericardium meridian of hand jueyin–the triple-jiao meridian of hand shaoyang. – The heart meridian of hand shaoyin–the small intestine meridian of hand taiyang. – The spleen meridian of foot taiyin–the stomach meridian of foot yangming. – The liver meridian of foot jueyin–the gallbladder meridian of foot shaoyang. – The kidney meridian of foot shaoyin–the bladder meridian of foot taiyang. The travelling route of the 12 meridians: – The three yin meridians of hand–start from the thoracic cavity to the ends of fingers. – The three yang meridians of hand–run from the ends of fingers to the head and face. – The three yang meridians of foot–run from the head and face to the end of toes. – The three yin meridians of foot–run from the end of toes to the abdomen and thorax.

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–

Distribution of the 12 meridians: – The taiyin and yangming meridians are distributed over the anterior border. – The jueyin and shaoyang meridians are distributed along the midline. – The shaoyin and taiyang meridians are distributed over the posterior border. – The connecting route of the 12 meridians (detailed in the text).

5.2.1 Nomination of 12 meridians The 12 meridians distribute symmetrically along the right and left sides of the body and respectively run along the medial or lateral side of the upper or lower limbs. Each meridian belongs to an individual zang- or fu-organ. The hand meridians run along the upper limbs, while the foot meridians run along the lower limbs. The yin meridians run along the medial side of the limbs affiliated with the zang-viscera, while the yang meridians run along the lateral side of the limbs affiliated with the fu-viscera. Generally speaking, the taiyin and yangming meridians are distributed over the anterior border, the shaoyin and taiyang meridians are distributed over the posterior border, and the jueyin and shaoyang meridians are distributed along the midline. The name of the 12 meridians is demonstrated in Figure 5.2. Yin meridians

Yang meridians

the lung meridian of hand taiyin – anterior border – the large intestine meridian of hand yangming the pericardium meridian of hand jueyin – midline Upper limbs – medial

– the triple-jiao meridian of hand shaoyang

Lateral

the heart meridian of hand shaoyin – posterior border – the small intestine meridian of hand taiyang the spleen meridian of foot taiyin – anterior border – the stomach meridian of foot yangming Lower limbs – medial

the liver meridian of foot jueyin – midline – the gallbladder meridian of foot shaoyang

Lateral

the kidney meridian of foot shaoyin – posterior border – the bladder meridian of foot taiyang

Fig. 5.2: Nomination of 12 meridians

5.2.2 Route and connection of the 12 meridians The three yin meridians of hand all start from the thoracic cavity to the ends of fingers, and connect with three yang meridians of hand related exteriorly and interiorly. The three yang meridians of hand run from the ends of fingers to the head and face, and connect with the three yang meridians of foot sharing the same name. The three yang

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meridians of foot run from the head and face to the ends of toes, and connect with the three yin meridians of foot related exteriorly and interiorly. The three yin meridians of foot run from the ends of toes to the abdomen and thorax, extend to the head, and connect with the three yin meridians of the hand in the thoracic cavity. Thus, the 12 meridians connect with each other and travel through the entire body. A. The travelling route of the 12 meridians: (a) The three yin meridians of hand–start from the thoracic cavity to the ends of fingers (b) The three yang meridians of hand–run from the ends of fingers to the head and face (c) The three yang meridians of foot–run from the head and face to the ends of toes (d) The three yin meridians of foot–run from the ends of toes to the abdomen and thorax B. The connection of the 12 meridians: (a) The three yin meridians of hand → the three yang meridians of hand: the exteriorly and interiorly related meridians connect at the ends of fingers. (b) The three yang meridians of hand → the three yang meridians of foot: the same name meridians connect at the head and face. (c) The three yang meridians of foot → the three yin meridians of foot: the exteriorly and interiorly related meridians connect at the ends of toes. (d) The three yin meridians of foot → the three yin meridians of hand: they connect in the thorax.

5.2.3 Distribution of the 12 meridians The distribution of the 12 meridians on the body surface has certain laws. 1. The four limbs Yin meridians all run in the medial sides of the limbs while yang meridians in the lateral side of the limbs. There are three yin meridians in the medial side, so are the yang meridians in the lateral side. In the medial side of the upper limbs, taiyin meridian run in the anterior border, jueyin meridian in the midline, and shaoyin in the posterior border. In the medial side of lower limbs, in the region 8 cun above the medial malleolus, taiyin meridians in the anterior border, jueyin meridian in the midline, and shaoyin in the posterior border; while at the region 8 cun below the medial malleolus, jueyin meridians in the anterior border, taiyin meridian in the midline, and shaoyin in the posterior border. In the lateral side of the upper and lower limbs, yangming run in the anterior border, shaoyang meridian in the midline, and taiyang meridian in the posterior border.

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2.

3.

Head and face Yangming meridians run over the face and the forehead, taiyang meridians run over the nape, shaoyang meridians run along the lateral sides of the head, and jueyin meridians run on the vertex. The trunk The three yang meridians of the hand run over the scapula. The three yin meridians of the hand all emerge from the armpit. Among the three yang meridians of the foot, the yangming meridian runs over the front (the chest and abdomen), the taiyang meridian runs along the back, and shaoyang meridian runs along the side of the body. The three yin meridians of the foot run over the chest and abdomen. The meridians running on the chest and abdomen from the medial to the lateral are the kidney meridian of foot shaoyin, the stomach meridian of foot yangming, the spleen meridian of foot taiyin, and the liver meridian of foot jueyin.

5.2.4 Exterior–interior relationship The 12 meridians form six pairs of exterior–interior relationships through the communication of their divergent meridians and collaterals. The taiyang and the shaoyin meridians exteriorly–interiorly relate to each other, so do the shaoyang and the jueyin meridians and the yangming and the taiyin meridians.

5.2.5 Circulating sequence of the 12 meridians The 12 meridians are the main passageways for the circulation of qi-blood. Qi-blood of the whole body is produced from food essence through transformation by the spleen and stomach in the middle-jiao. The 12 meridians distribute inside and outside the human body. Qi-blood circulation in the meridians follows a certain flow and infuse order. Figure 5.3 shows the sequence of circulation. Lung meridian of hand taiyin

Large intestine meridian of hand yangming

Spleen meridian of foot taiyin

Stomach meridian of foot yangming

Heart meridian of hand shaoyin

Small intestine meridian of hand taiyang

Kidney meridian of foot shaoyin

Urinary bladder meridian of foot taiyang

Pericardium meridian of hand jueyin

Tri-jiao meridian of hand shaoyang

Gallbladder meridian of foot shaoyang

Liver meridian of foot jueyin

Fig. 5.3: Circulating sequence of the 12 meridians

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5.2.6 Travelling routes of the 12 meridians 1.

The lung meridian of hand taiyin The lung meridian originates from the middle-jiao, running downward to connect the large intestine; returning upward, it runs along the openings of the stomach (the lower opening is pylorus and the upper one is cardia), passes through the diaphragm, and enters the lung, its belonging organ. It then ascends to the throat, and transversely runs to the superolateral aspect of the chest (Zhongfu, LU1). It comes out from the axilla, descends along the anterior border in the flexor aspect of the upper limb, passes through the cubital fossa, and enters the cunkou (the radial artery at the wrist for pulse feeling); then it arrives at the thenar eminence and reaches the radial side of the tip of the thumb (Shaoshang, LU11). The branch: emerges from the proximal part of the wrist (Lieque, LU7) and runs along the dorsal side of the palm to the radial side of the tip of the index finger (Shangyang, LI1) where it links to the large intestine meridian of hand Yangming (Figure 5.4).

1. Zhongfu 2. Yunmen 3. Tianfu Yunmen Zhongfu

4. Xiabai 2 1

Tianfu 3 4

Xiabai

5. Chize 6. Kongzui 7. Lieque 8. Jingqu 9. Taiyuan

Chize 5

10. Yuji 11. Shaoshang

Kongzui

6

Lieque Yuji

7 8 9 10 11

Jingqu Taiyuan Shaoshang

Fig. 5.4: Lung meridian of hand taiyin

2.

The large intestine meridian of hand yangming The large intestine meridian of hand yangming originates from the radial side of the tip of the index finger (Shangyang, LI1). Passing through the dorsum of the hand, it runs upward along the anterior border in the extensor aspect of the upper limb and arrives at the anterior aspect of the shoulder joint. Then it runs backward to the site

80  5 Theory of Meridians and Collaterals

beneath the spinous process of the seventh cervical vertebra (Dazhui, GV14), and runs forward and downward to the supraclavicular fossa (Quepen, ST12). There it enters the thoracic cavity to connect with the lung, and further passes through the diaphragm, terminating at the large intestine, its belonging organ. The branch: Emerging from (Quepen, ST12), it runs upward through the neck to the cheek and enters the gums of the lower teeth. Then returning and running by the mouth, it crosses the opposite meridian at the philtrum and runs further to the site beside the opposite wing of the nose (Yingxiang, LI20), where it connects the stomach meridian of foot Yangming (Figure 5.5).

Dazhui

Futu Tianding Jugu 9 8

Jianyu

7

Binao

6

Zhouliao

5 4

Quchi

Pianli Hegu

12 13 11 10

3

Yingxiang Heliao

1. Shangyang 2. Hegu 3. Pianli 4. Quchi 5. Zhouliao 6. Binao 7. Jianyu 8. Jugu 9. Dazhui 10. Tianding 11. Futu 12. Heliao 13. Yingxiang

2

1

Shangyang

Fig. 5.5: Large intestine meridian of hand yangming

3.

The stomach meridian of foot yangming The stomach meridian of foot yangming originates from the site beside the wings of the nose (Yingxiang, LI20), and ascends along the bridge of the nose to the root of the nose where the left and the right meridians meet. It then runs laterally to the inner canthus where it meets the bladder meridian of foot taiyang. It then runs downward along the lateral side of the bridge of the nose and enters the upper gums of the teeth. Returning to the corner of the mouth and curving around the lips, it meets the opposite meridian at the mentolabial groove (Chengjiang, GV24). Turning back, it runs along the posterior–inferior border of the mandible to the site of the anterior angle of the mandible (Daying, ST5); then it ascends in front of the ear, passing through (Shangguan, GB3), and runs along the anterior hairline and reaches the forehead. Branch in the face: Emerging in front of (Daying, ST5), it runs downward to Renying (ST9). Along the throat it runs backward and downward to (Dazhui,

5.2 Twelve meridians



81

GV14). Turning back, it runs forward to (Quepen, ST12); then it runs deep into the thoracic cavity, descends through the diaphragm, enters the stomach, its belonging organ, and connects with the spleen. The straight portion: Starting from (Quepen, ST12), it runs downward along the midclavicular line and by the umbilicus all the way to (Qijie, ST30), superior to the inguinal groove. Branch in the lower opening of the stomach: Coming out from the lower opening of the stomach (pylorus), it descends along the inside of the abdomen to (Qijie, ST30), where it joins the straight portion. Then it runs downward along the anterior aspect of the thigh to the knee. Descending along the anterior border of the lateral aspect of the tibia, it arrives at the dorsum of the foot, then enters the lateral side of the tip of the second toe (Lidui, ST45). Branch in the leg: Emerging from the site 3 cun below the knee (Zusanli, ST36), it descends and enters the lateral side of the tip of the middle toe. Branch in the dorsum of foot: Arising from (Chongyang, ST42), it runs forward to the medial side of the tip of the big toe (Yinbai, SP1), where it links the spleen meridian of foot taiyin (Figure 5.6).

Touwei 8

Chengqi

9

Renying

10

Quepen Ruzhong

7 1 Sibai 2 Juliao 6 3 4 Dicang Jiache 5

Xiaguan

11

12

Burong

Rugen

Daying

13

1. Chengqi

15. Qichong

Tianshu

14

2. Sibai

16. Piguan

Qichong Piguan 16

15

3. Juliao

17. Futu

4. Dicang

18. Liangqiu

5. Daying

19. Dubi

6. Jiache

20. Zusanli

7. Xiaguan

21. Lanweixue

8. Touwei

22. Shangjuxu

9. Renying

23. Fenglong

10. Quepen

24. Xiajuxu

11. Ruzhong

25. Jiexi

Futu

17

Liangqiu 18 Dubi 19 Zusanli 20 Lanweixue 21 22 Shangjuxu Fenglong 23 24 Xiajuxu Jiexi 25 26

Lidui

Chongyang

27

12. Rugen

26. Chongyang

13. Burong

27. Lidui

14. Tianshu Fig. 5.6: Stomach meridian of foot yanming

82  5 Theory of Meridians and Collaterals

4.

The spleen meridian of foot taiyin The spleen meridian of foot taiyin originates from the medial side of the tip of the big toe (Yinbai, SP1). Running along the junction of the red and the white skin in the medial aspect of the foot, it ascends by the anterior border of the medial malleolus and along the midline of the medial aspect of the leg to the site 8 cun above the medial malleolus, where it crosses over and further runs in front of the liver meridian of foot Jueyin. It ascends along the anterior border of the medial aspect of the thigh, enters the abdomen, arrives at the spleen, its belonging organ, and connects with the stomach. Running upward through the diaphragm, it runs alongside the esophagus, reaches the root of the tongue, and scatters its collaterals over the lower surface of the tongue. The branch: Arising from the stomach, it ascends through the diaphragm and enters the heart, linking the heart meridian of hand Shaoyin (Figure 5.7).

Zhourong

11

Shidou

10

12

Daheng

Dabao

9

Chongmen 8

Xuehai 7

1. Yinbai

7. Xuehai

2. Gongsun

8. Chongmen

Diji

3. Shangqiu

9. Daheng

Sanyinjiao

4. Sanyinjiao

10. Shidou

5. Diji

11. Zhourong

6. Yinlingquan

12. Dabao

Yinlingquan

6 5

4

Shangqiu Gongsun

3 2 1

Yinbai

Fig. 5.7 Spleen meridian of foot taiyin

5.

The heart meridian of hand shaoyin The heart meridian of hand shaoyin starts from the heart and emerges and spreads over the heart system. It then goes downward through the diaphragm

5.2 Twelve meridians



83

to link the small intestine. The branch from the heart system runs alongside the esophagus to join the eye system. The straight branch from the heart system ascends through the lung and then turns downwards, emerging from the axillary fossa (Jiquan, HT1). From there, it runs along the posterior border of the medial aspects of the upper line and passes through the cubital fossa to the pisiform bone proximal to the palm, and finally enters the palm, where it reaches the radial tip of the litter finger (Shaochong, HT9) to link with the small intestine of hand taiyang (Figure 5.8).

Jiquan 1

1. Jiquan 2. Shaohai 3. Tongli

Shaohai

2

4. Shenmen

Shenmen 4

Shaochong

5. Shaofu

Tongli

6. Shaochong

3

4

Shenmen

6

Shaofu

5

Shaochong

6

Fig. 5.8: Heart meridian of hand shaoyin

6.

The small intestine meridian of hand taiyang The small intestine of hand taiyang starts from the ulnar side of the tip of the little finger (Shaoze, SI1). Running along the dorsum of hand and the posterior border of the lateral aspect of the upper arm and passing the elbow, it reaches the shoulder joint region. Circling around the scapular region, it converges over the shoulder (Dazhui, GV14) and then turns downwards to link with the heart. From there, it descends along the esophagus, passes through the diaphragm, reaches the stomach, and finally enters the small intestine to which it pertains (Figure 5.9).

84  5 Theory of Meridians and Collaterals

Jianzhongshu

1. Shaoze

12

Jianwaishu

Tinggong

11 10

Quyuan Tianzong

Quanliao 15 16

8 9

Tianrong

Naoshu

7

Jianzhen

Tianchuang

14 13

2. Houxi 3. Yanggu 4. Yanglao 5. Zhizheng 6. Xiaohai 7. Jianzhen

Xiaobai

8. Naoshu

6

9. Tianzong 10. Quyuan

Zhizheng

5

Yanggu Houxi Shaoze

4 3

Yanglao

11. Jianwaishu 12. Jianzhongshu 13. Tianchuang

2

14. Tianrong

1

15. Tinggong 16. Quanliao

Fig. 5.9: Small intestine meridian of hand taiyang

7.

Its branch from the supraclavicular fossa (Quepen, ST12) ascends along the lateral neck to the cheek. Then it reaches the outer canthus and enters the ear (Tinggong, SI19). Another branch separating from the cheek ascends through the infraorbital region to the inner canthus (Jingming, BL1), and connects with the bladder meridian of foot taiyang. The bladder meridian of foot taiyang The bladder meridian of foot taiyang starts from the inner canthus (Jingming, BL1), ascends to the forehead, and joins the opposite meridian at the vertex (Baihui, GV20). The branch emerging from the vertex reaches to the upper area of the ear. The straight branch of the meridian leaving from the vertex turns back to the occipital bone and enters the cranial cavity to connect with the brain. Then it reemerges and descends to the nape (Tianqzhu, BL10) and joins at (Dazhui, GV14). Along the medial side of the scapula and parallel to the vertebral column (1.55 cun lateral to the dorsal midline), it descends to the lumbar region (Shenshu, BL23) and enters the abdominal cavity from the deeper layer of the muscles along the lumbar region to link with the kidney and pertains to the urinary bladder. The branch stemming from the lumbar region runs downward parallel to the spine. Passing through the buttocks, it descends along the posterior border of the lateral side of the thigh into the popliteal fossa (Weizhong, BL40). The branch emerging from the neck runs downward along the medial border of the scapula. From (Fufen, BL41), it runs along the region 3 cun lateral to the spine and reaches the hip joint. From there, it goes downward along

5.2 Twelve meridians



85

the lateral aspect of the thigh and meets the previous branch from the loin in the popliteal fossa. Then it descends through the gastrocnemius, reaching the posterior aspect of the external malleolus (Kunlun, BL60), where it runs along the lateral side of the foot dorsum to the lateral side of the tip of the little toe (Zhiyin, BL67) to connect with the kidney meridian of foot shaoyin (Figure 5.10).

5

Tongtian Chengguang Zanzhu

6

Tianzhu

15

Ganshu

Quchai Jingming

Dazhu Feishu

8 9 10 11

Pishu

3 2 1

7

Fufen

4

Xinshu Shenshu

12

Shangliao

13

Zhibian

16 17

Huiyang

14

Chengfu

Weiyang

Feiyang

19

21

Shenmai Zhiyin

18

20 22

17. Chengfu 1. Jingming

9. Xinshu

2. Zanzhu

10. Ganshu

19. Weiyang

3. Quchai

11. Pishu

20. Chengshan

4. Chengguang

12. Shenshu

21. Feiyang

5. Tongtian

13. Shangliao

22. Kunlun

Chengshan

6. Tianzhu

14. Huiyang

23. Pushen

Kunlun

7. Dazhu

15. Fufen

24. Shenmai

8. Feishu

16. Zhibian

25. Zhiyin

Weizhong

25 24 23 Pushen

18. Weizhong

Fig. 5.10: Urinary bladder meridian of foot taiyang

8.

The kidney meridian of foot shaoyin The kidney meridian of foot shaoyin starts from the plantar surface of the little toe and runs obliquely toward the center of the sole (Yongquan, KI1). Emerging from the lower aspect of the tuberosity of the navicular bone (Rangu, KI2), it runs behind the medial malleolus where one of its branches enters the heel. Then it ascends along the posterior border of the medial side of the lower leg to the medial side of the popliteal fossa and goes further upward along the posteromedial aspects of the thigh to the coccygeal region (Changqiang, GV1), where it runs through the vertebral column, enter the kidney, and links with urinary bladder. The branch emerging from the thigh root runs alongside the perineum to the lower abdomen. Then it goes upward along the region 0–5 cun lateral to the abdominal midline to the subclavian

86  5 Theory of Meridians and Collaterals

region (Shufu, KI27). The branch stemming from the lung joins the heart and runs into the chest to meet with the pericardium meridian of hand jueyin (Figure 5.11).

12

Shufu Bukuo 11 Huangshu

1

9

Henggu

8

Yingu

7

Zhaohai Rangu 3 Yongquan 2

Youmen

10

6 5 4

1. Yongquan

7. Yingu

2. Rangu

8. Henggu

3. Zhaohai

9. Huangshu

Taixi

4. Shuiquan

10. Youmen

Dazhong

5. Dazhong

11. Bukuo

Shuiquan

6. Taixi

12. Shufu

Fig. 5.11 Kidney meridian of foot shaoyin

9.

The pericardium meridian of hand jueyin The pericardium meridian of hand jueyin originates from the chest and pertains to the pericardium. Then it descends through the diaphragm and successively links with the upper, middle, and lower jiao. Its branch from the chest runs inside the chest, emerges from the coastal region, and ascends to the subaxillary region from the point 3 cun below the axilla (Tianchi, PC1). Then it runs along the medial line of the upper arm to the cubital fossa and passes through the wrist, entering the palm (Laogong, PC8). Then along the radial side of the middle finger, it comes out at its radial tip (Zhongchong, PC9). Another branch from the palm runs along the ulnar side of the ring finger to its tip (Guanchong, TE1), where it connects with the triple-jiao meridian of hand shaoyang (Figure 5.12).

5.2 Twelve meridians



87

1. Tianquan 2. Tianchi 3. Quze 4. Ximen 5. Jianshi

Tianchi

6. Neiguan

2 1

Tianquan

7. Daling 8. Laogong

Quze

9. Zhongchong

3

4 5 6

Laogong

Ximen Jianshi Neiguan 7 Daling 8

Zhongchong 9

Fig. 5.12: Pericardium meridian of hand jeuyin

10. The triple-jiao meridian of hand shaoyang The triple-jiao meridian of hand shaoyang originates from the ulnar side of the tip of the ring finger (Guanchong, TE1) and runs upward along the dorsum of the wrist to (Yangchi, TE4). Running upward between the ulna and the radius, it passes through the olecranon and runs along the lateral side of the upper arm to the shoulder region where it moves into the supraclavicular fossa (Quepen, ST12) and spreads in the chest to link with the pericardium. Then it descends through the diaphragm to successively distribute into the upper, middle, and lower jiao. One branch from (Danzhong, CV17) runs upward and emerges from the supraclavicular fossa (Quepen, ST12). It reaches the shoulder and the back of the neck (Dazhui, CV14) where it crosses and meets its opposite branch. Then it ascends to the neck and runs along the posterior border of the ear (Yifeng, TE17), reaching the region superior to the apex of the ear. From there, it turns downward to the cheek and terminates in the infraorbital region. Another branch separating from the retro auricular region enters the ear. Then emerging along the anterior aspect of the ear in front of (Shangguan, GB3), it crosses the previous branch at the cheek and reaches the outer canthus (Tongziliao, GB1) to connect with the gallbaldder meridian of foot shaoyang (Figure 5.13).

88  5 Theory of Meridians and Collaterals

9

Tianliao

Sizhukong

8

Jiaosun

Jianliao

15 12

14 13

Tianjing

Yifeng Tianyou

11

Heliao Ermen

10

7

6

Yangchi Zhonghzu

Zhigou Huizong Waiguan

5 4 3 2

Guanchong 1

1. Guanchong 2. Zhongzhu 3. Yangchi 4. Waiguan 5. Huizong 6. Zhigou 7. Tianjing 8. Jianliao

9. Tianliao 10. Tianyou 11. Yifeng 12. Jiaosun 13. Ermen 14. Heliao 15. Sizhukong

Fig. 5.13: Tri-jiao meridian of hand shaoyang

11. The gallbladder meridian of foot shaoyang The gallbladder meridian of foot shaoyang originates from the outer canthus (Tongziliao, GB1) and ascends to the forehead (Hanyan, GB4) and runs downward to the retro auricular region (Wangu, GB12) where it turns upward along the forehead to the area above the eyebrow (Yangbai, GB12). Curving back to (Fengchi, GB20), it runs along the neck to the shoulder and meets the opposite branch at (Dazhui, GV14) where it runs forward into the supraclavicular fossa (Quepen, ST12). The branch originating from the retro auricular region enters the ear, emerges in front of the ear, and then reaches the posterior part of the outer canthus. Another branch from the outer canthus descends to (Daying, ST5) where it meets the branch of hand shaoyang running at the neck. After meeting the previous branch at the supraclavicular fossa (Quepen, ST12), it enters the chest, passes through the diaphragm to connect with the liver, and pertains to gallbladder. Emerging from qichong, it runs along the margin of the pubic hair and goes transversely to the hip region (Huantiao, GB30). The straight branch descends from the supraclavicular fossa (Quepen, ST12) to the axilla. Along the lateral side of the chest and through the hypochondrium, it continuously descends to meet with the previous branch at (Huantiao, GB30) where it descends along the lateral side of the thigh and knee. Descending along the lateral aspect of the fibula to its lower end, it reaches the anterior aspects of the external malleolus. Then it runs along the dorsum of the foot and reaches the lateral side of the tip of the fourth toe (Zuqiaoyin, GB44). Another

5.2 Twelve meridians



89

branch separating from the dorsum of the foot (Zulinqi, GB41) runs forward and emerges from the lateral side of the great toe. Turning back, it passes through the nail and ends at its hairy region to connect with the liver meridian of foot jueyin (Figure 5.14).

Toulinqi Yangbai

32

Wangu

1 4 5

Fengchi

Tongziliao

6

Jianjing 7

Yuanye

8

Jingmen

9

Riyue Weidao

10

Juliao

11 12

Huantiao Fengshi Zhongdu Yanglingquan

13 14

15

Waiqiu 16 17 Guangming 18 Xuanzhong 19 Qiuxu 2021 22 Zulinqi

Yangjiao

1. Tongziliao

12. Huantiao

2. Yangbai

13. Fengshi

3. Toulinqi

14. Zhongdu

4. Wangu

15. Yanglingquan

5. Fengchi

16. Waiqiu

6. Jianjing

17. Yangjiao

7. Yuanye

18. Guangming

8. Riyue

19. Xuanzhong

9. Jingmen

20. Qiuxu

10. Weidao

21. Zulinqi

11. Juliao

22. Zuqiaoyin

Zuqiaoyin

Fig. 5.14: Gallbladder meridian of foot shaoyang

12. The liver meridian of foot jueyin The liver meridian of foot jueyin starts from the dorsal hairy region of the great toe where it goes upward along the dorsum to (Zhongfeng, LR4), 1 cun in front of the medial malleolus. From there, it continuously ascends along the anterior border of the medial side of the knee, it runs along the medial aspect of the thigh into the pubic region where it curves around the external genitalia, and goes up to the lower abdomen. Ascending through (Zhangmen, LR13) and (Qimen, LR14), it enters the abdomen, runs along the stomach, and distributes in the costal and the hypochondriac regions. Ascending along the posterior aspect of the throat to the nasopharynx, it connects with the eye system and emerges from the forehead where it goes up to the vertex (Baihui, CV20) to connect with the governor vessel. One branch from the eye system descends inside the cheek and curves around the inner surface of the lips. Another branch starting from the liver

90  5 Theory of Meridians and Collaterals

ascends through the diaphragm and enters into the lung, where it connects with the lung meridian of hand taiyin (Figure 5.15).

Qimen Zhangmen

8 7

Jimai Yinlian

6

1. Dadun

5

2. Zhongfeng 3. Ligou Ququan

4. Ququan

4

5. Yinlian 6. Jimai 7. Zhangmen Ligou 3 2 1

8. Qimen

Zhongfeng Dadun

Fig. 5.15: Liver meridian of foot jueyin

5.3 Eight extra meridians The concept of eight extra meridians: du, ren, chong, dai, yinqiao and yangqiao, and yinwei and yangwei meridians. Extra means “different.” Their distributions are not as regular as the 12 meridians. They also do not have exterior–interior relationship among themselves. Key points –

The physiological functions of eight extra meridians: – Strengthen the connection with 12 meridians. – Regulate qi-blood in 12 meridians. – Closely related with some viscera.

There are eight extra meridians, namely du, ren, chong, dai, yinqiao, yangqiao, yinwei, and yangwei meridians, collectively called eight extra meridians. They can govern, communicate, and regulate qi-blood in the 12 meridians.

5.3 Eight extra meridians



91

5.3.1 Concept and functions of eight extra meridians As we know, extra means “different.” Their distribution and relationship with the viscera are not regular like 12 meridians. They also do not have direct connection with the viscera and exterior–interior relationship among themselves. The physiological functions of eight extra meridians mainly present with the following three aspects. 1. Strengthen the connection with the 12 meridians In the running and distributing process, eight extra meridians crisscross with other meridians to strengthen the connection with the 12 meridians. 2. Regulate qi-blood of the 12 meridians Eight extra meridians run vertically, transversely, and crosswise among the 12 meridians. When qi-blood of the 12 meridians gets overabundant, it will flow into the eight extra meridians for storage. As qi-blood of the 12 meridians gets deficient, the qi-blood stored in extra meridians will flow out for compensation so as to irrigate and supply for the tissues. 3. Be closely related with some viscera The eight extra meridians are relatively communicated closely with some viscera, such as the liver, kidney, uterus, brain, and marrow. Among them, the uterus, brain, and marrow directly communicate with the eight extra meridians. They affect each other physiologically and pathologically.

5.3.2 Distribution and physiological functions of the eight extra meridians 1.

Du meridian A. Circulating routes The du vessel starts from the uterus, exits downward at the perineum, and moves upward along the spinal column to (Fengfu, GV16) at the nape, entering the brain. Then it ascends to the vertex and winds along the forehead, nose, and upper lip to the frenulum of the upper lip. One branch from the coccyx and sacrum region pertains to the kidney. Another branch from the lower abdomen ascends through the umbilicus and passes the heart to the throat where it reaches the mandible. Curving round the lips, it goes up and ends below the eyes (Figure 5.16).

92  5 Theory of Meridians and Collaterals

Shenting Yintang 12 Suliao 13 Renzhong

14

15

Baihui

11

10 9

Yinjiao

Fengfu Yamen Dazhui 8 Taodao 7

6

Shenzhu

5

Zhiyang

Mingmen Yaoyangguan

4 3 2 1

Yaoshu Changqiang

1. Changqiang

9. Yamen

2. Yaoshu

10. Fengfu

3. Yaoyangguan

11. Baihui

4. Mingmen

12. Shenting

5. Zhiyang

13. Yintang

6. Shenzhu

14. Suliao

7. Taodao

15. Renzhong

8. Dazhui

16. Yinjiao

Fig. 5.16: Du meridian

A.

2.

Basic function Du meridian in Chinese means controlling or governing. (a) Governing all the yang meridians The du meridian runs along the midline on the back and meets many times with three meridians of hand and foot as well as the yang meridian. With the function of regulating qi and blood in yang meridians and commanding all yang meridians of the body, it is considered as the sea of yang meridians. (b) Linking with the brain and pertaining to the kidney The du meridian enters the skull to link with the brain and goes into the abdomen to pertain to the kidney. The kidney, known as the sea of marrow, can produce marrow and brain which indicates that they are closely related to the du meridian. (c) Controlling reproduction The du meridian controls the reproductive function, especially for male. Ren meridian A. Circulating routes Ren meridian starts form the uterus and descends downward at the perineum. It ascends along the anterior medial line to the throat where it reaches the mandible, curves round the lips, and moves along the face to the infraorbital region. One branch from the uterus runs upward along the spinal column with the chong meridian (Figure 5.17).

5.3 Eight extra meridians



93

1. Huiyin 14 13

Chenjiang

2. Qugu

Tiantu

3. Zhongji 4. Guanyuan 5. Shimen

Shanzhong

12

Jiuwei

6. Qihai

11 10

Zhongwan

8. Xiawan

8

Shenque

Shimen Zhongji

7. Shenque

Shangwan

9

Xiawan

9. Zhongwan

Qihai Guanyuan Qugu

11. Jiuwei

10. Shangwan

7 6 5 3

4 2

12. Shanzhong 13. Tiantu 1

14. Chengjiang

Huiyin

Fig. 5.17: Ren meridian

B.

3.

Basic function Ren in Chinese means “take charge, or be responsible.” (a) Governing all the yin meridians Ren meridian runs along the abdominal midline and frequently meets with the three yin meridians of hand or foot. With the functions of regulating qi and blood in the all yin meridians and governing all the yin meridians in the body, it is also called the sea of yin meridian. (b) Governing uterus and pregnancy Ren in Chinese means pregnancy. Ren meridian, originating from the uterus, is in charge of regulating menses and promoting the female reproductive function. It is closely related to pregnancy. Therefore, there goes the saying ren meridian is in charge of the uterus and pregnancy. Chong meridian A. Circulating routes Chong meridian starts from the uterus, descends at the perineum, and passes through the (Qichong, ST30) where it runs along both the sides of the umbilicus with the kidney meridian of foot shaoyin to spread over the chest. Then it ascends to the throat and goes around the lips, and finally reaches the infraorbital region. One branch originates from the kidney, descends to the (Qichong, ST30), and enters the popliteal fossa along the medial side of the leg. It reaches the bottom of the foot along the medial side of the tibia. With another branch out of the posterior region of the

94  5 Theory of Meridians and Collaterals

B.

medial malleolus, it runs to the dorsum of the foot and finally enters the great toe. Another branch out of the uterus moves backward to connect with the du meridian and ascends along the spinal column. Basic function Chong in Chinese means “communication center.” With the regulation of qi and blood in all meridians, Chong is considered as the communication center of qi and blood. (a) Regulating qi and blood in the 12 main meridians Chong meridian, which ascends to the head and descends to the foot along the spinal column, is in charge of regulating qi and blood in the 12 main meridians and serves as the linchpin for the circulation of qi and blood. Therefore, it is known as the sea of 12 main meridians. (b) Regulating menstruation Chong meridian, also known as the sea of blood, originated from the uterus and is in charge of regulating menstruation and promoting reproduction (Figure 5.18).

1. Guanyuan 2. Hengu 3. Dahe 4. Qixue 5. Siman

Youmen Futonggu Yindu Shiguan

12 11 10

6. Zhongzhu

Shangqu

9

7. Huangshu

Huangshu Zhongzhu Siman Qixue

7

8. Shangqu 9. Shiguan 10. Yindu 11. Futonggu

Dahe Hengu

12. Youmen

Fig. 5.18: Chong meridian

5 3 2

8 6 4

1

Guanyuan

5.3 Eight extra meridians

4.



95

Dai meridian A. Circulating routes Dai meridian starts from the hypochondrium and obliquely descends to (Daimai, GB26) where it transversely runs around waist. The parts of dai meridian below the abdomen directly falls to the lower abdomen. B. Basic function (a) Constricting all meridians Dai meridian, the only meridian running transversely around the waist, acts as a belt to control all the longitudinally running meridians. (b) Protecting the fetus and regulating leucorrhea The damage of dai meridian may lead to miscarriage and abnormal vaginal discharge (Figure 5.19).

1. Daimai 2. Weidao

Daimai

3. Wushu

1 2 3

Wushu

Weidao

Fig. 5.19: Dai meridian

5.

Yinqiao and yangqiao meridians A. Circulating routes Qiao meridians appear in pairs and consist of yinqiao meridian and yangqiao meridian, both of which originate from below the ankle and runs separately along the right and left sides of body. Yinqiao meridian starts from (Zhaohai, KI6), below the inner malleolus, and runs along the medial side of the lower leg of the external genitalia. Then through the abdomen and chest, it enters the supraclavicular fossa (Quepen, ST12) and emerges in front of (Renying, ST9). Passing through the side of nose, it reaches the inner canthus where it meets with the yangqiao meridians (Figure 5.20).

96  5 Theory of Meridians and Collaterals

3

Jingming

1. Zhaohai 2. jiaoxin 3. Jingming

Jiaoxin Zhaohai

2 1

Fig. 5.20: Yinqiao meridian

Yangqiao meridian starts from (Shenmai, BL62) below the external malleolus and ascends along the posterior of the external malleolus. Along the abdomen, the posterior and lateral sides of the chest, through the scapular regions, lateral side of the neck, along the mouth corner, it finally reaches the inner canthus where it meets the taiyang meridians of hand and foot as well as yinqiao meridian. It then goes upward to the hairline and curves down to the back of the ear where it meets the gallbaldder meridian of foot shaoyang at the nape (Figure 5.21). Jingming Chengqi 1011 Juliao 9 8 Dicang Jianshu

Fengchi

1. Pushen

Jugu

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3. Fuyang 4. Juliao 5. Naoshu 6. Jianshu

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9. Juliao 10. Chengqi 11. Jingming 12. Fengchi

Fuyang Shenmai

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Fig. 5.21: Yangqiao meridian

5.3 Eight extra meridians

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Basic function Qiao in Chinese means “agile and nimble movement.” (a) Controlling the movements of the extremities Both yinqiao and yangqiao meridian have the function of regulating the muscular movements and communicating yin-yang in the body, which makes the movements of the extremities more vigorous and nimble. (b) Governing the opening and closing of the eyes Since yinqiao and yangqiao meridians meet with each other at the inner canthus, they are believed to provide the nourishment for the eyes and control the opening and closing of the eyelids. (c) Governing yin-yang of the right and left of the whole body, respectively Ancient people held that yinqiao and yangqiao meridians govern yinyang of the right and left of the whole body, respectively, that is to say, yinqiao meridian control the yin of the right and left side of the whole body, while yangqiao meridian controls the yang of the right and left side of the whole body. Yinwei and yangwei meridians A. Circulating routes Yinwei meridian starts from the medial aspect of the lower leg and runs upward along the medial side of the lower limb to the abdomen. From there, it runs along with the spleen meridian of foot taiyin to the hypochondriac region where it meets with the liver meridian of foot jueyin. It then further ascends to the throat to meet the ren meridian at the neck (Figure 5.22).

1. Zhubin 8 7

2. Chongmen 3. Fushe

Lianquan Tiantu

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Fig. 5.22: Yinwei meridian

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Yangwei meridian starts from below the external malleolus and ascends along with the gallbaldder meridian of foot shaoyang. It goes upward along the lateral side of the lower limb and passes through the posterolateral side of trunk to the axilla from where it reaches the shoulder. Through the neck, retro auricular region, it arrives at the forehead to distribute over the side of the head and nape, where it meets the du meridian neck (Figure 5.23).

1. Jinmen

Muchuang Benshen Toulinqi

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Fig. 5.23: Yangwei meridian

B.

Basic function Yinwen and yangwei meridians serve to connect with the whole yang and yin meridians in the body. They also play an important role in regulating the strength of qi and blood.

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5.4 Physiological functions and applications of the meridians Key points –

Physiological functions of the meridian: – Communicate exterior–interior and superior–inferior relationships. – Connect viscera and joints. – Convey qi-blood in the whole body. – Nourish the viscera and tissue. – React and conduct the life information. – Regulate the functional balance for the body.

5.4.1 Physiological functions of the meridian 1.

Communicate and connect viscera and organs The meridian communicates and connects viscera, tissue, and organs by the following four ways. A. Connection between the viscera and extremities The viscera and extremities connect each other with 12 meridians. Twelve meridians affiliate interiorly with the viscera. Qi in the meridian communicates with the 12 meridian musculatures and distributes over the 12 skin areas. Thus, the 12 meridians link the peripheral tissues of skin, tendons, muscles, and joints with the internal organs. B. Connections among the viscera, the five sense organs, and the nine orifices Eyes, ears, nose, mouth, tongue, inguinal, and coccygeal regions are the areas where all meridians pass through. Moreover, 12 meridians internally belong to the viscera. Therefore, the sense organs and orifices connect with the inner organ through the meridian. Some of them are the sprout and opening of the five zang-viscera. For example, the liver meridian of foot jueyin belongs to the liver and connects with the gallbladder, and runs up to link the eye connector. So the liver opens in the eyes. C. Connections among the viscera Each of 12 meridians affiliates and connects with a zang-viscus and a fuviscus. Therefore, it can strengthen the communication between the two externally–internally related zang- and fu-viscera. Meanwhile, some of the meridians communicate with several viscera, while some viscera will have several meridians to reach to. For example, the kidney meridian of foot shaoyin not only affiliates with the kidney and connects with the bladder but also passes through the liver, enters the lung, and connects with the heart. Thus, it forms multiple communications among zang-organs and fu-organs. D. Connections among the meridians There are certain linking and flowing orders among the connections of the 12 meridians. There are also many crosses and intersections which add the

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relations among the meridians and the divergent collaterals, forming an annular system preliminarily. The 12 meridians and the eight extra meridians communicate with each other in a crisscross manner. The eight extra meridians communicate with each other among themselves as well. They become a complete regulating system. Convey qi-blood in the whole body and nourish the viscera and tissue Every organ and tissue of the human body needs nourishment by qi-blood in order to maintain and play their normal physiological function. As the passage way for the movement of qi-blood, the meridians transport qi-blood to the whole body, nourish all the organs, fight against the external pathogens, and defend the body system. Conduct life information and regulate functional balance for the body The meridian system acts like a net to sense and transfer different information from both inside and outside of the body. It then conveys the information to zangfu organs, sense organs, orifices, and extremities according to its nature, characteristics, and measurement. It can reflect and regulate the functional status of the body. The meridian system can circulate qi-blood and link up the whole body. Twelve meridians can coordinate yin-yang. Eight extra meridians can regulate qi-blood. Therefore, the meridian system can regulate functional balance for the body. When disease occurs due to the disharmony of qi-blood and yin-yang, acupuncture, moxibustion, or massage treatment as well as breathing exercise can regulate and trigger the self-adjusting function of the body.

5.4.2 Application of the theory of the meridian 1.

2.

3.

Explanations of the pathological changes (a) Become the passageway for transmitting the pathogens (b) Reflect interior pathological changes Guidance for the diagnosis of disease (a) Differential diagnosis according to the belonging which meridian (b) Acupoints pressing Guidance for the clinical treatment (a) Elect the acupoints along the meridians (b) Select the herbal according to different meridians Constitutional theory was first discussed in Neijing and became a theory of Chinese medicine during the Ming and Qing Dynasties. The theory is a combination of biology, anthropology, psychology, and medicine science. It mainly discusses human constitution’s forming process, feature, type, diversity, and the relationship with the occurrence and development of the disease. Constitutional theory is a part of Chinese medicine and has an important significance in guiding health maintenance, prevention, and rehabilitation.

6 Constitutional Theory 6.1 Concept of constitutional theory Key points –

Basic concept of constitution: – Constitution means the relatively stable comprehensive characteristics in morphological structure, physiological function, and mental activities, which is determined by hereditary and acquired factors in the life process of human individual.

6.1.1 Basic concept of constitution Constitution refers to the relatively stable and comprehensive characteristics in morphological structure, physiological function, and mental activities, which is determined by hereditary and acquired factors of a human being. In other words, the constitution is physiologically manifested in the individual’s differences upon function, metabolism, and reaction toward the external stimulus; while pathologically, it is manifested in the susceptibility to some pathogenic factors and the tendency of the onset as well as the changes of certain diseases. Constitution is actually the individual’s physiological activity based on the common characteristics of the human physiology. Constitution affects body’s resistance against disease as well as the adaptability toward nature and social environments. It also influences disease patterns and individual’s reaction toward treatment. In this case, it will present the distinct individuality in the process of birth, death, illness, and aging. The offspring’s constitution is directly affected by their parents’, which is the foremost factor of one’s constitution. The constitution based on the genetic factors plays an important role on the entire life time. Everybody has his or her own relatively stable and specific living habits. These postnatal living environments promote the formation of the constitution as well as the stability, transformation, and change of the constitution. The constitutional theory is based on the traditional Chinese medicine theory. It studies the concept, formation, characteristics, patterns, and differences of the normal constitution as well as its influences upon the onset, development, and evolution of the disease. It guides the clinical diagnosis, prevention, and treatment of disease. Therefore, this theory pertains to the normal constitutional study in Chinese medicine. Emphasis of the research on the constitution can not only help to grasp the individual’s biological but also analyze the law of occurrence, development, and transmission of the disease. It plays an important role in diagnosis, treatment, health maintenance, disease prevention, and rehabilitation.

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6.1.2 Signs and characteristics of constitution The evaluation index of constitution involves morphological structure, body’s functional level, level of physical fitness, level of exercise, psychological development level, and adaptability, and so on. The healthy constitution refers to the relatively harmonious state between body and spirit, which is a whole for morphological structure, physiological function, psychological character, and adaptability to environments. It is based on the genetic factors and the active postnatal cultivation. Harmonies, as well as the unity of the body and mind, are the signs of the healthy constitution. The detailed signs are mainly as follows: 1. Good physical development, healthy and strong body shape, well-proportioned body type, and normal body weight. 2. Rosy and lustrous facial complexion with bright eyes, shining hair, and elastic skin and muscle tone. 3. Power voice, clean and strong teeth, good hearing, moderate pulse, good sleep, and normal urination and defecation. 4. Flexible movement, with good physical performance in sports and work. 5. Good energy, optimistic mood, sensitive feeling, and strong will. 6. Good attitude, calm, rational, creative, and independent. 7. Strong adaptability, strong resistance to interference, negative stimulation, and diseases. In general, every individual has his or her own constitution. As a unity of body and mind, everyone has his or her unique characteristic which is reflected in the differences of morphology, function, and psychology. The diversity is complicated and differs from person to person. Constitution is originated from the prenatal essence and nourished from the postnatal essence. The prenatal essence determines the relative stability and individual’s specificity, while the postnatal essence determines the variability. Constitution also has characteristic of continuity and predictability.

6.2 Factors affecting constitution Key points –

Factors affecting constitution are: – Natural endowment, age, gender, diet, work, rest, and emotional and geographical factors.

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6.2.1 Relationship of the constitution to viscera, meridians, essence, qi, blood, and body fluids Viscera, meridians, essence, qi, blood, and body fluids are the basic substances of constitution. Structural and functional varieties of the viscera and meridians and the abundance and distribution of essence, qi, blood, and body fluids are all the important factors to determine the constitution. The constitution reflects the deviant condition of the essence, qi, yin, and yang of viscera through the differences in morphology, function, and mental state. Actually, it is the comprehensive embodiment of intrinsic characters of the viscera, meridians, sensory organs, and orifices. It is also the actual reflection of deviant conditions of viscera, meridians, essence, qi, blood, yin, and yang. Therefore, the research in constitution lies in the study of differentiation of the visceral manifestation. The difference in formation and function of visceral manifestation is the important basis for different constitutions. The waxing and waning state of viscera decides the diversity of constitution. The morphological and functional characteristics of the viscera are the most basic factor composing and determining the differences upon the constitution. Under the interaction between the hereditary factor of the individual and the environmental factor, different individuals often show comparatively advantageous or disadvantageous tendency of a certain visceral manifestation system. The meridians are the passages of qi-blood circulation, as well as the structural foundation which communicate and coordinate the functions of the viscera. The constitution is mainly manifested through the exterior morphological characteristic, while the meridians transmit essence, qi, blood, and body fluids to the body. Different individuals show different external appearances due to differences in the waxing and waning of yin-yang of the viscera, as well as the condition of qi-blood in the meridians. The essence, qi, blood, and body fluids are the important material foundations which determine the characteristics of constitution. The waxing and waning of essence-qi, the amount of meridians-qi, and blood determine the strength of constitution and influence its type. Therefore, the essence, qi, blood, and body fluids are the important substances to determine the individual’s physiological and constitutional characteristics. Besides, the abundance or deficiency of essence also links to the age. The constitution of the old is generally characterized by essence deficiency.

6.2.2 Factors which affect the constitution Any factors that affect the functional activities of viscera, meridians, essence, qi, blood, and body fluids can influence the constitution. Constitution is determined by the prenatal essence and influenced by the postnatal factors. The internal and external environments are composed from the many factors of prenatal and postnatal essences. They form different constitutions under different affecting factors.

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The prenatal essence The prenatal essence is the basis and precondition of constitution. Everything that is received inside the uterus is generally called the prenatal condition. The quality of the reproductive essence from parents determines the condition and type of constitution of their offsprings. Generally speaking, if the constitutions of the parents are strong, so will be the offsprings, and vice versa. Therefore, the prenatal condition is the key and foundation to the formation of one’s constitution. However, the development and the types of the constitution are also affected by the other factors. Some hereditary diseases can be transmitted to the offspring by the parents. The specific constitution is not a true disease until it is induced by a certain acquired factor. This kind of disease usually does not outbreak until they are triggered by certain postnatal factors. It is found from the modern research that many diseases has the obvious trend of family heredity, such as hypertension, diabetes, asthma, dyslipidemia, breast cancer, stomach cancer, colorectal cancer, lung cancer, depression, and Alzheimer’s disease. Factor of age In the changing process of birth, growth, prime, aging, and death, with the change of essence of the viscera, and mind and physiological activities, individual’s constitution varies. The constitution gradually gets stable and matured at the end of adolescence. From adolescence to age 35, there are often obvious constitutional changes among women, while not so much in men. There is not much constitutional changes from age 35 to 49. Constitution often changes obviously after menopause. And the constitution of the old gradually declines. There is more deficient constitution among the senior populations. In this group of people, it is often the deficient syndromes combined with the damp-phlegm. Difference of gender The male and female constitutions are the most basic types among human beings. Male pertains to yang and female to yin. Therefore, male is often characterized by being masculine, tall, strong, good for heavy work, being extroverted, and broad minded. The female is mostly characterized by being gentle and quiet, small and slender, good for some gentle and detailed work, being introverted sentimental, and subtle. In addition, because women have the special physiological conditions of menstruation, leucorrhea, and pregnancy, their constitution changes through these periods. For male, kidney is the prenatal condition, while essence and qi are the root. For female, liver is the prenatal condition, while blood is the root. Therefore, male is often qi-deficient and female is often blood-deficient pathologically, and compared to female, male is more sensitive to pathogens. It is found in the study that female’s tolerance and immunity are stronger than male, so is the life expectancy. Dietary factor Diet is nutritional source after birth, which is very important for the life activity. The dietary structure and nutritional condition have a deep effect on constitution.

6.2 Factors affecting constitution

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Long-term dietary habit and the quality of the food will affect the change of body components. Generally speaking, sufficient and high-quality food intake will produce better physical figure and good constitution, while insufficient or poor quality food intake will result in smaller body shape and weaker constitution. However, overeating and overindulgence in heavy and greasy food, even though the body shape is bigger, often leads to qi deficiency and damp congestion with weaker constitution. On the other hand, simple food with sufficient nutrition, as long as not starving, often leads to better constitution and good qi-blood circulation without damp-phlegm congestion. Factor of work and rest Work and rest are other important factors affecting the constitution. The proper manual labor or exercise can make bones and muscles stronger, the movement of joint more flexible, qi dynamic smoother, qi-blood more coordinative, and the visceral function more powerful. The appropriate rest is helpful to maintain the physical and psychological health, as well as to keep a good constitution. Long-term over-ease with less exercise will make the muscles flabby, the circulation of qi-blood unsmooth, and the spleen-stomach hypo function which result in the constitution of phlegm congestion. Emotional factor Emotion refers to the psychological activities including joy, anger, worry, pensiveness, sorrow, fear, and frighten. The harmonious emotion results in good constitution, while a drastic or prolonged emotional stimulus will result in negative influence on the constitution. It will form certain type of constitution. When that happens, the same emotional stimuli will be triggered and cause impairment of the viscera. Therefore, a vicious circle develops. The qi-depressed constitution is commonly seen in clinic. Qi depression can accumulate heat to cause fire, as well as impair yin and consume the body fluids which lead to the constitution of yang heat and yin deficiency. Qi stagnation can produce bloodstasis constitution. The changes of constitution caused by emotional changes also have a particular relationship with the onset of certain diseases. For example, a person with liver depression constitution who easily gets persistent anxiety and depression will be predisposed to cancer diseases. Therefore, by keeping a good mental state is very beneficial to the constitutional health. Geographical factors By living in a certain region for a long period of time, one’s constitution can be affected by its water, soil, climate, habits, and customs. Generally speaking, people in the north are mostly strong in physique, with tight muscles. They tend to suffer from yang-deficient syndromes with the cold viscera. Comparatively, people in the southeast are mostly thin in physique, with loose muscles. They tend to suffer from yin-deficient syndromes with damp-heat. People live near the oceans often have dampness or phlegm in constitution. Severe climatic environment cultivates people with strong body and bold personality, and

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easeful climatic environment fosters delicate physique and gentle character. In Chinese medicine, treatment according to the local condition is always a treatment principle, namely, considering that the constitution is different in population of different regions. Overall speaking, a specific constitution formed by the prenatal condition is usually deeply rooted. Under the equal postnatal condition of cultivation, whether the constitution is strong or weak is mainly determined by the prenatal essence. However, the postnatal cultivation is also of importance to constitution. If one pays attention to health maintenance, follows proper diet and scientific principles in diet along with balanced work and rest, emotions, as well as the normal sexual activity, his or her constitution will get better, and better based on the prenatal essence. Or the weaker constitution will turn into the stronger constitution. It then will serve the purpose of aging-slowing, diseaseresolving, and longevity.

6.3 Classification of constitution Key points –

Constitution can be classified as: – Yin-yang balanced constitution. – Yang-inclined constitution. – Yin-inclined constitution.

The classification of constitution is an important method of understanding and mastering the constitutional differentiation. In Chinese medicine, the classification of constitution is mainly guided by the holism concept. It is based on the basic theory of Chinese medicine which includes the theories of yin-yang, five elements, viscera, essence, qi, blood, and body fluids. These theories are used to ascertain different constitutions of different individuals. The concrete methods include yin-yang classification, five elements classification, viscera classification, body shape classification, and natural disposition classification. In the “Research on criterion of constitutional classification and foundation of methodology system in Chinese Medicine” presided by professor WangQi from Beijing University of Chinese Medicine, the constitution is classified into nine categories. It includes the types of qi deficiency, dampness-heat, yin deficiency, qi depression, blood stasis, yang deficiency, phlegm dampness, and specially gifted constitution. It has been confirmed as a criterion of The Chinese Association of Chinese Medicine, and has gotten the comprehensive application as a standardized approach to identify the constitutional type in Chinese medicine. Generally speaking, human constitution is divided into three categories according to its function, that is, the yin-yang balanced constitution, yang-inclined constitution, and yin-inclined constitution.

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6.3.1 Balance constitution The yin-yang-balanced constitution is a more harmonious constitution. Typical constitutional features are as follows: strong physique, normal body shape, bright and ruddy complexion, bright and piercing light in eyes, optimistic personality, openmindedness and tolerant attitude, moderate intake of food, smooth urination and defecation, pink and moist tongue, even and moderate pulse with vitality, good sleep, good energy, agile strong self-adjustment, and good adaptability. People with this type of constitution are not easily affected by the exogenous pathogenic factors, and seldom become ill. Even if suffering from an illness, they may mostly present with an exterior and excessive syndrome which are easily cured. If they get proper cultivation after birth, they will mostly live longer.

6.3.2 Yang-inclined constitution The yang-inclined constitution means a constitutional type which has the characteristics of being more excited, inclined to heat, and excessive movement. The constitutional features are as follows: thin body shape but strong, slightly red complexion, or greasy skin, extroverted personality, hyperactive, easily being irritable, poorly self-controlled, large intake of food, good digestion and absorption, aversion to heat and preference to cold, or higher body temperature, easily sweating while moving, thirsty, red lips and tongue, slightly rapid pulse, energetic and fast-moving, and stronger libido. On the onset of disease, this type of people tend to present with the heat and excessive syndromes which often develop into the constitutional type of yang-hyperactive, yin deficiency, or phlegm fire.

6.3.3 Yin-inclined constitution Yin-inclined constitution often refers to the constitutional type which has the characteristics of being more inhibited, inclined to cold, and stillness. The constitutional features are as follows: bigger body shape but weak, easily to get tired, slightly white but little lustrous complexion, introverted personality, being fond of stillness and little movement, scared and being easily frightened, poor appetite, average digestion and absorption, aversion to cold and prefer to heat, or lower body temperature, low energy, slower reaction, and weaker libido. On the onset of disease, this type of people tend to present with cold and deficient syndromes which often develop into constitutional type of yang deficiency, phlegm-dampness, or phlegm stasis. It should be pointed out that the terms used in classifying the constitution, that is, yin deficiency, yang deficiency, hyperactive yang, phlegm and fluid retention, and blood stasis are different from the names of syndrome used in syndrome differentiation. The syndrome is an analysis to

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the nature of a disease, while the constitution reflects one kind of individual particularities existing under the non-disease state. The constitution is the foundation of the disease. The fundamental basis of many chronic illnesses is the result of their own constitution. Under this circumstance, the name of the syndrome might be the same as the original type of constitution, which shows the intrinsic relationship between the constitution and the syndrome.

6.4 Application of the constitution theory The differences manifested in the process of a disease depend on the constitution. The constitutional differentiation plays an important role in determining the onset, the changes, and the prognosis of the disease, as well as on the reaction to the treatment. Therefore, constitution has a close relationship to the etiology, pathogen, pathogenesis, syndrome differentiation, treatment, prevention, and life maintenance. The constitutional theory has an important value in the clinical setting. The principle of suiting treatment to the individual, which is emphasized in Chinese medicine, is the reflection of constitutional theory applied in the clinic, as well as the reflection of the individualized treatment principle.

6.4.1 Explanation of the susceptibility of individual to certain pathogens Constitutional factor determines the individual’s susceptibility and tolerance toward certain pathogens, as well as the tendency of disease onset. The constitution reflects the physiological waxing and waning of yin, yang, cold, or heat inside the body, which determines the differences of its function. Therefore, it has a different reaction toward the external stimuli and tolerance. Generally speaking, people inclining to yang constitution tend to be easily invaded by wind, summer-heat, heat pathogen, and tolerant to cold. Lung is easily damaged by the wind evil, while yin-qi of lungstomach or liver-kidney is impaired after being invaded by summer-heat pathogen. People inclining to yin constitution tend to be easily invaded by cold and dampness pathogen and tolerant to heat. Also, it make disease move toward inward more easily which often damages yang-qi of spleen and kidney. The spleen-yang always gets depressed by dampness, and discharge and swelling will occur due to the internal dampness induced by the external dampness. And children always have diseases due to the external pathogen or improper diet since they are deficient in qi and blood. In addition, an overweight person often has problems related to dampphlegm which causes stroke. A thin person often has more fire inside the body and often develops whooping cough. Kidney is often deficient among older people and they tend to develop phlegm pathogen and cough. All these show that the constitutional differences are the main causes for developing different diseases. Besides,

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the hereditary and congenital diseases, as well as the allergic body type are all closely related to the individual’s constitution.

6.4.2 Illustrating the etiology The constitutional condition determines the onset and development of the disease. Constitution is the reflection of waxing and waning of healthy qi. A person with strong constitution will have enough healthy qi to resist invasion of pathogen, while a person with weaker constitution will have weaker healthy qi and poor resistance as well as being invaded by the pathogens. Individual’s specific constitution or the defect is also the key factor to cause emotional disorder.

6.4.3 Explaining the pathological changes 1.

2.

Constitutional factor determines the transformation of pathogenesis Transformation of disease means that disease changes according to constitution. The general rule is: person with yin deficiency and excess of yang has a hyperfunctional activity, whose disease is easily turning to heat after the invasion of pathogen; person with yang deficiency and excess of yin tends to have a hypofunctional activity, whose disease is easily turning to cold after the invasion of pathogen; person with the fluid deficiency and blood exhaustion tends to present with the dryness after the invasion of pathogen; person with the qi deficiency and excess of damp often suffer from the dampness after the invasion of pathogen. Constitutional factor determines the prognosis of the disease The prognosis of disease refers to transmission of disease stage in the viscera and meridians, as well as transformation and changes of disease nature. Constitution mainly affects the prognosis of disease through two aspects. One aspect is that the condition of healthy qi determines onset and prognosis of disease. People with stronger constitution always have sufficient healthy qi and stronger ability to resist the exogenous pathogen. This group of people does not get easily sick. Even if they are sick, they are not deficient and always present with excess syndrome along with shorter course of disease. On the other hand, people with weaker constitution not only easily suffer from diseases but the disease also migrates into deeper location. It can cause constant change of disease onset as well as impose critical and dangerous condition. This group of people also has a lingering disease course and becomes difficult for them to recover in the later stage of disease. Sometimes, it results in some chronic illness. The other aspect is that constitution affects the prognosis of the disease by determining transformation of pathogens. For example, individual with yang-excess and yin deficiency always develops heat disease after being invaded, while person with yin-excess and yang deficiency mostly develops cold disease.

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6.4.4 Guiding syndrome differentiation The specificity of the constitution determines the tendency of clinical type after the onset of disease. Constitution is the basis of differential diagnosis. It determines the types of syndrome. First of all, when attracting a same type of disease, different manifestations of the syndromes will be different due to different constitutions, which is called the same disease with different syndromes, determined by the constitution. The other condition is different diseases with the same syndrome, that is, people present with the same type of syndrome when invaded by different pathogens or suffer from different diseases due to the same or similar constitution. Therefore, the constitutional differences are the physiological basis of the two conditions. And the constitution is the intrinsic basis of the formation of the syndrome.

6.4.5 Guiding treatment Differential diagnosis is the basic principle and character of the Chinese medicine treatment. The differences among the individual constitution determine the diversity of syndrome, treatment method, and medicine. Due to the fact that constitution is affected by prenatal condition, age, gender, living environment, and emotional distress, the treatment principle is based on each individual’s constitution. 1. Applying treatment according to different constitutions Constitutions are different in yin, yang, strong, weak, cold, or heat aspects. In clinic, treatment principle is always made according to the patient’s constitution. This type of principle is to regulate the imbalance of constitution, which is to treat the root of the disease. For example, for patients with constitution of yang deficiency, when suffering from a cold-damp illness, medicine of hot nature should be prescribed, while, for patients with constitution of yin deficiency, medicine of cooling and moist nature should be prescribed. Therefore, the principle of the same syndrome with different diseases and different syndromes with the same disease should be applied in the treatment. 2. Cautions and contraindications when applying acupuncture and Chinese herbal medicine according to constitutional characteristics In treatment, application of acupuncture and medicine should be based on the individual’s constitution. Treatment should end once the illness is resolved to protect the healthy qi. A. Nature and flavor of Chinese herbal medicine Generally speaking, people with yang-inclined constitution should be treated with medicine of sweet-cold, acid-cold, salty-cold, and mild nature. Try to avoid the pungent, hot, warm, or dispersed herbs. People with yininclined constitution should be treated with warming and tonifying herbs and avoid the bitter-cold or fire-sedating herbs.

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Dosage In general, people with strong constitution also have stronger drug tolerance and can be given larger doses of medicine. People with weak constitution should be treated with mild and low dose of medicine. C. Indication and contraindication of acupuncture People with the different constitutions will react differently toward the pain tolerance and needling sensation. Paying attention to the posttreatment care maintenance Posttreatment care involves many measures and balances, including medicine, diet, emotional comforts, and living habits. The care should be applied carefully according to the individual’s constitution. For patient with yang-inclined constitution, at the beginning stage of recovery, warm and pungent food such as dog meat, lamb, and longan should be avoided. And for those with yin-inclined constitution, medicine and food with stickiness and sourness, such as GuiBan, BieJia, and WuMei, should be avoided.

6.4.6 Guiding the health maintenance A good health maintenance plan is to select different methods according to different constitutions. Methods of health maintenance in Chinese medicine permeate throughout all the daily life. It includes principles of seasonal health, emotional balance, regular daily activity, normal resting and exercising schedule, and proper diet, all of which should be considered according to the constitution. For example, in dietary aspect, person with yang-inclined constitution should consume more cooling food and avoid the hot; person with yin-inclined constitution should consume warm food and avoid the cold; and person who is overweight should consume more plain food and avoid the greasy ones. In emotional aspect, different emotional balances should be applied according to individual’s constitution in order to keep balance of mind and improve mental health. For people with qi depression constitution, psychological counseling should be focused on removing emotional stagnation and eliminating bad mood. For people with yang-deficient type of constitution, they tend to have less energy and courage, are indifferent, and less confident. Treatment should focus on helping them to build confidence toward life. Music therapy should also be based on the individual’s psychological state. These methods play an important role in protecting health and reinforcing constitution. Pathogenesis refers to the onset of a disease. Any etiological factor acting on the body can cause occurrence of disease. Pathogenesis is a theory studying the mechanism of the onset of disease, namely, studying the law and influential factors how the body turns to disease from health or subhealth.

7 Onset of Disease In this chapter, the basic mechanism of disease onset will be mainly discussed. It is based on the relationship between vital qi and pathogenic factors. In Chinese medicine, the occurrence of disease involves two aspects: vital qi and pathogenic factors. The invasion of pathogenic factors is an important factor causing disease, while deficiency of vital qi is an intrinsic factor. When pathogenic factors defeat vital qi, disease occurs.

7.1 Concepts of pathogenesis Pathogenesis refers to the course of the onset of a disease. When human body is disturbed by certain disease-induced factors such as vital qi interacting with pathogenic factors, imbalance inside the body or imbalance between the external environment and inside of the body leads to disharmony in qi, blood, yin, and yang, abnormal metabolism of viscera and meridians, or pathological change of morphostructure. Thus, a series of clinical symptoms and signs (including various abnormal clinical changes detected in modern medicine) occur, and the human body deviates from normal condition (namely, health). The course of disease onset is, namely, the struggle between the pathogenic qi and the vital qi.

7.2 Cardinal principle of disease onset Key points –

Basic mechanism of disease onset: – Deficiency of vital qi plays a leading role. – Pathogenic qi is an important condition. – Struggle between the vital qi and the pathogenic qi determines the onset of the disease.

Generally speaking, despite the complication of disease onset, it mainly contains two aspects: vital qi and pathogenic qi. Disease onset is the contradictory struggle between the pathogenic qi and the vital qi. Struggle is the key to the occurrence and development of a disease. Specifically speaking, deficiency of vital qi is the intrinsic factor the pathogenic qi is an important condition. Struggle between the vital qi and the pathogenic qi determines whether disease occurs. In Chinese medicine, vital qi is emphasized for its leading role, but pathogenic qi is not ruled out in disease onset. Besides, under certain circumstances, pathogenic qi can play a leading role in disease onset.

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7.2.1 Deficiency of vital qi is the intrinsic factor for the pathogenesis 1.

2.

3.

Concept of vital qi Vital qi, usually abbreviated as “the vital,” exists in contrast with pathogenic qi. Vital qi is a general term for normal physiological function of human body as well as the ability to maintain the health. It includes the abilities of self-regulation, environmental adaptation, disease prevention, and persistence, as well as selfrecovery vital qi is closely related to essence, qi, blood, and body fluids as well as to the structure and function of viscera, meridians, and collaterals. In addition, it is concerned with one’s mind, spirit, cognitive level, and life style. Essence, qi, blood, and body fluids are the basic material to sustain functional activities of viscera and meridians. When human body has abundant essence, qi, blood, and body fluids along with normal structure and function of viscera and meridians, vital qi will be sufficient. Therefore, essence, qi, blood, and body fluids are the determining factors for vital qi. Manifestation of vigorous vital qi Whether vital qi is vigorous can be seen from the following points: (a) The ability of self-regulation to accommodate oneself to external and internal environment, to keep yin and yang in balance, and to maintain one’s health. (b) The ability of self-defense to prevent invasion of exogenous pathogenic factors from entering the body. (c) The ability of resisting pathogenic factors to drive it out during disease occurrence. (d) The ability of self-recovery to restore health after the onset of disease or from weakness. The function of vital qi during disease onset A. Deficiency of vital qi is the intrinsic factor of exogenous pathogen invading and disease occurring In Chinese medicine, vital qi is very important in the onset of disease. Generally speaking, when vital qi is vigorous or pathogenic qi is not very strong, pathogenic factors can hardly invade the body, or though invading, unlikely to causing disease. Under this condition, the functions of yin, yang, qi, blood, viscera, and meridians are normal; the vital qi can defend pathogenic qi; and no disease occurs. When vital qi becomes too weak to resist pathogenic qi or pathogenic qi is stronger than vital qi, the pathogenic factors invade the body and disturb the normal physiological activities and functions of viscera, resulting in disease. Deficiency of vital qi can be manifested in two aspects: first, the weak ability of disease prevention and resistance as well as recovery; second, the pathogenic factor is too strong to overcome the defending ability of vital qi. Both aspects can lead to invasion of pathogenic factors, making the functions of viscera abnormal

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B.

and cause disease. Although disease onset is concerned with both vital and pathogenic qi, the decisive factor is vital qi. In most cases, pathogenic factors cause disease followed by deficiency of vital qi. Therefore, the strength of vital qi is the intrinsic factor of whether disease can be induced. Generally, pathogenic factors cannot injure the body alone without deficiency of vital qi. For example, in the same living environment of influenza outbreak, someone with vital qi deficiency will more likely get infected, whereas someone without vital qi deficiency will not get infected. The degree of deficiency of vital qi is related to the course and severity of disease In general, when pathogens are invading, the person with vigorous vital qi has more superficial diseased location and short-diseased course because vital qi is vigorous enough to expel pathogens sooner; while the one with deficiency of vital qi, will always have deeper diseased location and cannot recover easily because vital qi cannot be exited until pathogens invade the interior. There is also exceptional case that when invasion is serious, the struggle between vigorous vital qi and pathogens is so severe that serious illness occurs.

7.2.2 Pathogenic qi is an important factor to cause the disease 1.

2.

Concept of pathogenic qi Pathogenic qi is a general term for various pathogenesis, usually abbreviated as “pathogen.” It includes six exogenous pathogens, pestilential qi, internal injury due to mental disorders, improper diet, injury from overstrain and idleness, traumatic injuries, parasites, drug abuse, doctor’s faults, phlegm-fluid retention, and blood stasis. The role of pathogenic qi in pathogenesis A. Pathogenic qi is an important factor to cause disease In disease onset, vital qi is emphasized for its leading role, but pathogenic qi should not be ignored. The invasion of pathogenic factors plays a significant role in the disease onset. In certain conditions, even if vital qi is not deficient, it is hard to avoid invasion of some pathogenic qi, such as high temperature, gunshot wound, and injuries by insects and animals. In addition, during prevalence of pestilential qi, almost everyone fall ill because of severe pathogenic qi. So under certain circumstances, pathogenic qi can play a leading role in disease onset, and avoiding poisonous factors is important in health maintenance to prevent the occurrence of disease. B. Pathogenic qi influences the nature, location, syndrome, course and severity of a disease

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The property of pathogenic can decide the nature of disease. Generally speaking, invasion by yang pathogen tends to cause excess-heat syndrome, while yin pathogen is likely to cause excess-cold syndrome. Different pathogenic factors invading the body can cause different diseases in organs or viscera and meridians, which is decided by the feature of pathogenic qi. Furthermore, pathogenic qi is closely related to the syndrome of disease. For example, dysenteric pathogen causes dysentery and malarious pathogen causes malaria. Besides the constitutional factors, the pathogenic qi also determines the severity of a disease. When the pathogenic qi is mild, the disease condition tends to be mild, but when the attack is serious, the condition is severe. Some pathogenic qi also decides the course of a disease. For example, diseases caused by dampness usually have long duration and are difficult to heal. Impairment of pathogenic qi to vital qi Pathogenic qi impairing vital qi is mainly manifested in three aspects: (1) causing loss of essence, qi, blood, and body fluids, which leads to dysfunctions; (2) causing injury of organs, which leads to abnormal change of tissue structure; and (3) altering one’s constitution or characteristic.

7.2.3 Struggle between pathogenic and vital qi determines the progress and prognosis of disease The struggle between the pathogenic and the vital qi runs through the course of a disease. It not only determines whether there would be the onset but also affects its development and final sequelae. Chinese medicine holds that vital qi is very important in the struggle. The intensity of vital qi determines the disease onset, deficiency or excess nature of pathological change, and the prognosis. Insufficient vital qi with pathogenic qi lingering causes many chronic diseases. In the occurrence and development of a disease, both deficiency of vital qi and invasion of pathogenic qi are essential factors. Comparatively speaking, the leading role of vital qi is more important in the course of a disease. Under normal circumstances, when vital qi is vigorous, qi and blood are abundant, the functions of viscera are normal, and pathogenic qi can hardly invade the body. When vital qi becomes weaker, failing to resist pathogenic qi, pathogenic qi invades the body and leads to disease. Therefore, deficiency of vital qi is the intrinsic factor causing disease, and interference of pathogenic qi is the extrinsic factor causing disease. Nowadays, this sagacious view of Chinese medicine still has important practical significance for people to maintain health and prevent diseases. Etiology refers to cause of disease. It is also called pathogenic factors. Etiology is an important component of theoretical system of Chinese medicine. It expounds properties and pathogenic characteristics of various pathogenic factors. It also discusses influ-

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ences of pathogenic factors acting on human body’s structure and physiological functions. Etiology is very important to treatment based on syndrome differentiation. There are three methods to seek causes of disease in Chinese medicine. First, some causes can be found by analyzing the conditions of disease onset. For example, by observing changes in human body after experiencing the alteration of environment. Some can be understood by observing emotional disorder caused by exterior stimulation. Second, invisible pathogenesis can be speculated by analogy method. For instance, nature of wind is characterized by constant movement and rapid change. It can make trees shake. When symptoms like headache, aversion to wind, sweating, migratory arthralgia, or pruritus occur, which are similar to the characters of wind, the body may be invaded by wind-evil. As another example, dampness belongs to water with nature of yin and is characterized by being heavy, turbid, viscous, and stagnant. When symptom like heavy sensation in head and body, turbid excretion, or edema in legs occurs, the body may be invaded by dampness-evil. Third, and the main method, is to seek cause by syndrome differentiation. It is a way to differentiate causes according to the clinical manifestations of disease and through analysis of symptoms and signs. For example, when the symptom is similar to the characters of cold-evil such as aversion to cold, spasm of limbs, or sweat pore closing, it is considered being attacked by cold. To some extent, the way of seeking causes uses analogy method for reference. Etiology is not only the result of syndrome differentiation but also the basis of treatment. Seeking the correct cause of disease can gain decisive treatment effect. So seeking the causes by syndrome differentiation plays an important role in mastering the essence of etiology in Chinese medicine. Causes of Chinese medicine are relative. Under normal conditions, wind, cold, summer-heat, dampness, dryness, and fire are normal climatic changes in nature. Joy, anger, worry, anxiety, sadness, fear, and surprise are human’s normal emotional activities. However, under exceptional conditions, they will cause disease and become pathogens. Moreover, in the course of a disease, cause and effect are often interactive. An effect in one pathological stage may be a cause in another stage. Examples are as follows: phlegm, stagnant fluid, blood stasis, and calculus are pathological outcomes of a disturbance of the functions of viscera, qi, and blood which also may become new pathological factors causing other diseases. In this chapter, the causes are classified into four categories: exogenous pathogens (including six pathogenic factors and pestilential qi), endogenous pathogens (including internal injury due to mental activities, improper diet, and injury from overstrain idleness), pathogens from pathological products (including phlegm, stagnant fluid, blood stasis, and calculus), as well as other pathogens (including traumatic injuries, medicine pathogens, and iatrogenic disease).

8 Etiology 8.1 Exogenous pathogens Exogenous pathogens invade the human body from the outside via the surface of the body, mouth, or nose and cause diseases. Diseases caused by exogenous pathogens are called exogenous diseases.

8.1.1 Six evils Key points – –

1.

2.

Concept of six evils: – Pathogenic wind, cold, summer-heat, dampness, dryness, and fire-heat. Common pathogenic characteristics: – Exogenous, seasonal, regional, concurrent, and transformational.

Concept of six evils Six qi refers to the six normal climatic changes in nature, including wind, cold, summer heat, dampness, dryness, and fire heat. As human beings have adapted to the climatic changes through their long-term life activities, normal climatic changes will not cause diseases. Six evils is a collective term used for the six kinds of exogenous pathogens including wind, cold, summer heat, dampness, dryness, and fire heat. When climate changes abnormally, such as abnormal cold in spring or abnormal heat in autumn, six qi changes sharply, or the body resistance becomes weak due to a deficiency of vital qi; then the six qi turns into six evils and causes diseases. Whether the six qi turns into six evils or not depends on an individual’s vital qi. Any change in weather conditions can trigger illness. The key component depends on an individual’s adaptive and defensive abilities. Common characteristics of six evils A. Exogenous character The six evils usually invade the body through the surface, mouth, or nose. At an early stage, diseases caused by exterior pathogens are manifested as aversion to cold, fever, and floating pulse. The disease will progress deeper and become more severe if the exterior syndrome is not cured. B. Seasonal character Diseases caused by six evils often show obvious seasonality. For example, more diseases are caused by the wind in spring, more heat in summer, more dampness in late summer, more dryness in autumn, and more cold in winter.

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C.

D.

E.

3.

Regional character Diseases caused by six evils are closely related to the living and working environments. Generally speaking, more diseases are caused by cold or dryness in northwest highland because of higher altitude and colder weather, and by dampness or heat in southeast coastal areas because of lower altitude and more hot and humid weather. More people suffer from damp diseases in damp environment, and people working at high temperatures are vulnerable to diseases caused by fire heat. Concurrent character Each of the six evils can not only cause disease alone but can also combine with each other, such as exterior syndrome caused by wind cold or wind heat invading the lung and dampness heat hindering middle jiao. Moreover, there are cases when three of them combine to cause a disease, such as arthralgia syndrome, caused by wind, cold and dampness, or wind, dampness and heat. Transformational character Transformational character refers to the nature of a syndrome caused when the six evils may exchange under certain conditions. For example, external wind cold syndrome may turn into interior heat syndrome when the body is invaded by wind cold pathogens. The transformation is related to constitution. In general, those with a constitution of yin deficiency and yang excess tend to transform into heat or dryness syndrome and those with yang deficiency and yin excess tend to transform into cold or dampness syndrome.

Respective pathogenic characteristics of six evils A. Wind pathogen Key points –

Pathogenic characteristics of wind pathogen: – Wind is a yang pathogen, characterized by dispersion, and tends to attack yang portion of the body. – It is characterized by constant movement and rapid change. – It is the most important factor that triggers a disease. – It is characterized by mobility.

(a) Concept of wind pathogen Wind pathogen refers to exogenous pathogenic factors characterized by mobile, light, upward, and outward movement. Wind prevails in spring, but it may occur in any season. So invasion by wind pathogen may often occur in spring, but it is not limited to spring only. When weather is abnormal or the resistance of the body becomes weak, wind pathogen invades the human body and cause illness.

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(b) Nature and pathogenic characteristics of wind pathogen – Wind is a yang pathogen, characterized by dispersion and tends to attack yang portion of the body Wind pathogen, being mobile and having upward and outward movement, is a yang pathogen. It is apt to invade the upper portion of the body (head and face), yang meridians, and body surface. It results in headache, dizziness, aversion to wind and cold, as well as fever. – Wind is characterized by constant movement and rapid change Constant movement implies that diseases caused by wind pathogen possess the feature of migration. For example, in migratory arthralgia invaded by wind pathogen, there is migratory pain in joints, which reflects the character of wind. Rapid change denotes that wind pathogen can cause many diseases, and these diseases are characterized by quick and diverse change. For instance, urticaria, which is caused by wind pathogen, is characterized by pruritus shifting in different locations and rising one after another. – Wind is characterized by mobility Diseases caused by wind pathogen are manifested as vertigo, trismus, rigid neck, convulsion of the limbs, and opisthotonus. Tetanus is an example. – Wind is the most important factor that triggers a disease Wind pathogen, a leading exogenous pathogenic factor, is the precursor of exogenous pathogens. Other pathogens such as cold, summer heat, dampness, dryness, and fire heat usually follow the wind to invade the human body. Wind cold, wind heat, and wind dampness attacking exogenously are examples. Therefore, the ancients used the general term wind pathogen for exogenous pathogens. B.

Cold pathogen Key points –

Pathogenic characteristics of cold pathogen: – Cold is a yin pathogen, which tends to damage yang qi. – Cold is characterized by condensation and stagnation. – It is also characterized by contraction.

(a) Concept of cold pathogen Cold pathogen refers to the exogenous pathogen characterized by cold, coagulation, and contraction. Cold is prevalent in winter. So more diseases are caused by cold in winter. Diseases caused by cold can also occur in other seasons due to exposure to rain or a sudden drop in air

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temperature. There is a difference between cold attack and cold stroke according to the different locations invaded by the cold pathogen. The case when cold pathogen attacks the body surface and suppresses the defensive yang is called a cold attack, while the case when cold pathogen directly invades the interior of the body and damages the visceral yang qi is known as a cold stroke. (b) Nature and pathogenic characteristics of cold pathogen – Cold is a yin pathogen, which tends to damage yang qi Cold pertains to yin. When cold pathogen invades the body, internal yang qi is not powerful enough to expel cold and may be damaged by yin cold. For example, as cold pathogen attacks the exterior, defensive yang will get suppressed and will be marked by aversion to cold and fever. If cold directly invades the spleen and stomach, it can damage the spleen yang and result in epigastric pain with a feeling of cold, vomiting, and diarrhea. If cold attacks the lung and spleen, it can damage the functions of dispersion, transportation, and transformation, which result in cough, tachypnea, thin sputum, or edema. – Cold is characterized by condensation and stagnation The circulation of qi, blood, and body fluids depends on the warming and promoting of yang qi. Invasion of the body by cold pathogen may block the movement of yang qi and cause stagnation of qi and blood in meridians. In that case, pain occurs, which can be relieved by warming and aggravated by cold. Symptoms vary with the parts attacked by cold. If cold invades the body surface, pain in the head and limbs will occur. If cold directly invades the interior, cold or colic pain in chest, stomach, and abdomen will occur. Moreover, if cold pathogen invades the skin, chilblain will occur due to the stagnation of qi and blood. – Cold is characterized by contraction Contraction means traction and constriction. When cold pathogen invades the body, it may block the qi activity, tighten the striae, and constrict the tendons. If cold pathogen attacks the body surface, it may close striae and result in aversion to cold, fever, and anhidrosis. If it invades meridians and the blood vessel, it will result in pain in the head and body, difficulty in stretching, and pale or black skin. If it invades the joints, symptoms of spasm and pain in limbs and joints will occur. Moreover, cold pathogen may invade viscera, causing cramping pain in the belly.

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Summer-heat pathogen Key points –

Pathogenic characteristics of summer-heat pathogen: – Summer-heat is a yang pathogen characterized by burning heat. – Summer-heat is characterized by rising and dispersion, and is apt to consume qi and body fluids. – Summer-heat tends to disturb the heart – mind balance, and causes liver-wind stirring. – Summer-heat is likely to be combined with dampness.

(a) Concept of summer-heat pathogen Summer-heat pathogen refers to exogenous pathogen characterized by burning heat, qi consuming, fluid damaging, as well as causing thirst and drowsiness. Summer heat prevails only in summer. There is yin summer heat and yang summer heat in Chinese medicine. Sunstroke due to exposure to hot summer for a long time pertains to yang summer heat, while diseases in summer caused by cold pertains to yin summer heat. Moreover, summer heat is a pure exogenous pathogen and there is no such thing as endogenous summer heat. (b) Nature and pathogenic characteristics of summer-heat pathogen – Summer heat is a yang pathogen characterized by burning heat Summer heat is transformed from fire-heat qi of summer. As fiery hotness belongs to yang, summer heat is a typical yang pathogen. People affected by summer heat often show various symptoms of yang heat, such as high fever, restlessness, flushed face, and a surging pulse. Both summer heat and heart belong to fire in the five element theory. Therefore, summer heat invading the human body tends to disturb the heart and the mind, results in dysphoria, and even cause sudden unconsciousness. Besides, because liver belongs to wood, just as fire is likely to ignite wood, summer heat tends to cause liver wind stirring and spasm in limbs, stiff neck, and even opisthotonus, which is called summer wind or summer epilepsy in ancient medical books. – Summer heat is characterized by rising and dispersion and is apt to consume qi and body fluids Rising refers to the ascending summer heat. It tends to invade the head and disturb the heart and the mind. Dispersion may cause excessive sweating; qi and fluid damage, which can lead to thirst; and scanty and brownish urine. Meanwhile, qi exits the body along with sweat, which results in qi deficiency with the symptoms of shortness of breath, weakness, and tiredness. Therefore, if summer heat invades the body, deficiency syndrome of qi and body fluids (yin) will occur.

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–

D.

Summer heat is likely to be combined with dampness It is often rainy and wet in summer. So summer heat tends to combine with dampness to cause diseases, especially in those who have inner damp constitution. Besides fever and polydipsia, diseases caused by summer heat combined with dampness are often manifested as lassitude of limbs, chest distress, nausea and vomiting, loose stool, and yellowish and greasy tongue fur.

Dampness pathogen Key points –

Pathogenic characteristics of dampness pathogen: – Dampness is a yin pathogen, apt to block qi movement and damage yang-qi. – It is characterized by heaviness and turbidity. – It is characterized by stickiness and stagnation. – It is characterized by descending and is apt to attack yin locations.

(a) Concept of dampness pathogen Dampness means presence of excess water or humidity. Dampness pathogen refers to exogenous pathogen characterized by heavy turbidity, stickiness, stagnation, and descending. Dampness is the predominant qi in late summer. The period when the season is changing from summer to autumn is the dampest time of a year. More diseases are caused by dampness in late summer. In addition, diseases can also be caused due to overexposure to rain, or living or working in humid places. Therefore, diseases caused by dampness are common in all seasons. Moreover, endogenous dampness can be caused by failure of the spleen in transportation. Though diseases caused by exogenous dampness are different from those caused by endogenous dampness, that is, spleen insufficiency, they often influence each other in the disease process. The invasion of dampness can affect the transportation and transformation function of the spleen, thus leading to intergeneration of dampness. On the other hand, patients with water-dampness retention due to the deficiency of spleen are vulnerable to invasion of exogenous dampness. (b) Nature and pathogenic characteristics of dampness pathogen – Dampness is a kind of yin pathogen, apt to block qi movement and damage yang qi The nature of dampness is similar to that of water, and thus it is a yin pathogen. The spleen is susceptible to dampness pathogen because it has aversion to dampness. When dampness pathogen invades the human body, it causes the disorder of the spleen,

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makes spleen yang unable to work, as well as causes retention of water and dampness. Thus, symptoms like anorexia, abdominal distension, diarrhea, tiredness, or edema may occur. Dampness pathogen is apt to block the qi dynamic, which can lead to disharmony of qi in ascending and descending. Thus, symptoms such as chest distress, epigastric distention, loose stool, and scanty urine may occur. Dampness is characterized by heaviness and turbidity Because dampness pertains to water, which has certain weight, diseases caused by dampness are characterized by heaviness. For example, when dampness pathogen invades the body surface, symptoms like heaviness of the head and body or severe pain of limbs will occur. If it invades meridians and joints, it will prevent the yang qi from spreading and symptoms like numbness of skin or severe joint pain will occur. Moreover, diseases caused by dampness are usually marked by turbid excretion and secretion. When dampness pathogen stays on the upper part of the body, patients’ face looks dusky and more eye secretion appears. If it stays in the large intestine, there will be symptoms of loose stool or diarrhea, purulent, and bloody dysentery with mucus. When it goes downward, there is turbid urine or excessive yellow vaginal discharge in the case of women. If it spreads over the skin, symptoms like sores and ulcers, eczema, or filthy pus will occur. Dampness is characterized by stickiness and stagnation This is mainly reflected in two aspects. The first is the sticky symptom, which means invasion by damp pathogen mostly leads to sticky and greasy discharges and secretions, as well as thick and greasy tongue fur, among other symptoms. The second is lingering course, which means diseases caused by damp pathogen usually have a prolonged course, relapse repeatedly, and are difficult to be cured, such as eczema or fixed arthralgia. Dampness is characterized by descending and is apt to attack yin locations Dampness is similar to water and is characterized by downward flow. So invasion by damp pathogen mostly leads to symptoms of lower part of the body, such as edema in legs, diarrhea, vaginal discharge, among other symptoms. Moreover, invasion by dampness pathogen can directly disturb the spleen and stomach, leading to dyspepsia.

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E.

Dryness pathogen Key points –

Pathogenic characteristics of dryness pathogen: – Dryness is characterized by aridity and is apt to consume body fluids. – Dryness has the tendency to impair the lung.

(a) Concept of dryness pathogen Dryness prevails in autumn. It is an exogenous pathogen that damages the body fluids. Besides, dryness pathogen often invades the lung, liver, and large intestine, and especially has the tendency to impair the lung. (b) Nature and pathogenic characteristics of dryness pathogen – Dryness is characterized by aridity and is apt to consume body fluids Dryness pathogen invading the body is most likely to consume body fluids because it is characterized by aridity, thus resulting in various symptoms such as dry mouth, nose, or throat; dry or even chapped skin; lusterless hair; scanty urine; and constipation. This kind of disease prevails in autumn or in northwest regions of China. – Dryness has the tendency to impair the lung The lung is a tender organ and requires moisture for its functioning, and shows aversion to dryness. It governs qi and controls respiration as well as is connected externally to the skin and hair. It is also associated with the nose orifice. Dryness pathogen invading the body through the mouth or nose is most likely to consume lung fluid and result in failure of the lung in diffusing and descending. The symptoms are characterized as dry cough with little sputum or sticky sputum that is difficult to be expectorate, bloodstained sputum, asthma, and chest pain. The lung and large intestine are in an exterior and interior relationship, so the exhaustion of body fluids in the lung will result in lack of moistening of the large intestine and will be manifested as dry stool. F.

Fire-heat pathogen Key points –

Pathogenic characteristics of fire-heat pathogen: – Fire heat is a yang pathogen characterized by burning upward. – Fire heat is likely to consume body fluids and damage qi. – Fire heat is apt to stir up wind and cause bleeding. – Fire heat is likely to disturb the heart – mind balance. – Fire heat is likely to cause sores and abscesses.

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(a) Concept of fire-heat pathogen Fire-heat pathogen refers to exogenous pathogen characterized by burning upward, being likely to consume body fluids, exhausting qi, stirring up wind, and causing bleeding, sores. or abscesses. Heat prevails in summer. But fire-heat diseases can be seen in all four seasons. (b) Nature and pathogenic characteristics of fire-heat pathogen – Fire heat is a yang pathogen characterized by burning upward Both fire and heat are yang in nature, so fire-heat pathogen is a yang pathogen. Invasions lead to heat symptoms such as high fever, flushed face, and surging and rapid pulse. Besides, due to the characteristic of flaring upward, fire-heat pathogen often invades the upper part of the body and is manifested as headache, tinnitus, sore throat or toothache, thirst, sweating, swollen gums, and aptha, among other symptoms. – Fire heat is likely to consume body fluids and qi Fire heat is likely to force body fluids to dry up and consumes yin fluid. Thus, it is characterized by thirst, dry throat and tongue, yellow and scanty urine, as well as dry stool. Moreover, qi will be exhausted as a result of body fluids consumption, causing symptoms of qi deficiency such as fatigue and short breath. – Fire heat is apt to stir up wind and cause bleeding Fire-heat pathogen is apt to burn liver meridians and cause internal stirring up of liver wind. So it is also called extreme heat causing wind. It is characterized by high fever, spasm of the limbs, upward staring of the eyes, and opisthotonos. Moreover, fire-heat pathogen invading the blood vessels may accelerate blood circulation, even burn the vessels and force blood to flow outside of vessels, thus leading to bleeding symptoms such as hematemesis, epistaxis, hematochezia and hematuria, echymosis, as well as uterine bleeding. – Fire heat is likely to disturb the heart and mind Fire heat corresponds with heart. So diseases caused by fire pathogen are usually manifested as distraction of the heart and mind, such as restlessness, insomnia, even mania, unconsciousness, and delirium, among others. – Fire heat is likely to cause sores and abscesses Fire-heat pathogen invades into the blood and may accumulate in a local area, causing ulceration of muscles. It can result in sores and abscesses marked by redness, swelling, and burning pain. Clinically, it is often accompanied by heat symptoms such as fever, restlessness, or thirst.

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8.1.2 Pestilential pathogens Key points –

Pathogenic characteristics of pestilential pathogens: – Strong infectivity and epidemicity. – Abrupt onset and serious condition. – Diseases vary with pestilential pathogens while the same disease has similar symptoms.

1.

Concept of pestilential pathogens Pestilential pathogens are the kind of exogenous pathogens with strong infectivity. They are also called pestilential qi, toxic qi, poisonous qi, epidemic qi, and special pathogens. The species of pestilential pathogens, their pathogenic characters, and treatments have been discussed in Treatise on Pestilence written by Wu Youxing 200 years earlier than the discovery of bacteria and other microorganisms. The writer attributed the cause of surgical infection to pestilential pathogen instead of fire pathogen, which made great contribution to the theory of epidemic febrile disease. Due to the earlier formation of the pestilential theory foundation, there were many inventions on preventing pestilential pathogens in Chinese medicine. Variolation is one of them. The ancients found that wearing clothes of infected patients or inoculation via nose could prevent epidemic diseases effectively, which was later learned by E. Jenner, who invented the smallpox vaccine in the early nineteenth century. Disease syndromes vary with different pestilential pathogens, which include many contagious diseases in modern medicine such as smallpox, cholera, plague, SARS, dengue fever, erysipelas of the face, mumps, bacillary dysentery, scarlet fever, and diphtheritis. Causes for the occurrence and epidemic of pestilential pathogens A. Abnormal climates Prolonged drought, heat, flood, damp fog, and malaria can all breed and spread pestilential pathogens that cause contagious diseases. For example, parasitic diseases are related to the flood, and miasma or malaria is related to climatic conditions in south of the Five Ridges. A. Environmental and food pollution Unsanitary environments such as polluted water or air can help the pestilential pathogens to multiply. Polluted or unclean food can also cause the onset of pestilences. For instance, pestilent dysentery and acute infectious hepatitis are caused by unclean diet. C. Lack of strict preventive measures Pestilential pathogens are strongly infective. If there is a lack of strict preventive measures, pestilences will occur or be epidemic. D. Social factors The occurrence and epidemic of pestilential diseases are closely related to social conditions. War chaos and famine can cause pestilences to spread

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widely. If effective preventive and treatment measures are taken to maintain social stability, good working and living conditions, as well as economic prosperity, pestilences can be controlled effectively. Pathogenic characteristics of pestilential pathogens A. Strong infectivity and epidemicity Pestilential pathogens can be transmitted in crowds through air or food. In epidemic regions, few can avoid getting infected. With strong infectivity and epidemicity, pestilential pathogens can cause diseases to spread to large areas. B. Acute onset and serious condition Pestilential pathogens have strong toxicity and often invade the body in combination with heat, poisonous fog, and malaria. So diseases caused by them are more sudden and severe than others caused by internal injury or the six evils. These epidemic invasions are most likely to consume body fluids, disturb the mind, cause bleeding, stir up wind, and impair important viscera such as the heart, kidney, and liver. So the mortality rate of some pestilent diseases is very high. C. Same pestilential qi lead to similar symptoms There are many different types of pestilential qi. One pestilential qi can induce one pestilential disease, and every pestilent disease can have similar symptoms. Different pestilential qi will present different symptoms. Take mumps for example; it is often manifested as swelling in the cheeks or behind the ear for every patient. It is also pointed out in Treatise on Pestilence that some pestilential pathogens invade animals only while other invade humans only, which is determined by their specificity.

8.2 Endogenous pathogens Endogenous pathogens cause diseases that are generated internally and directly impair viscera. They mainly include the internal injury due to seven emotions, improper diet, overstrain, and over-idleness.

8.2.1 Internal injury due to mental disorders Key points –

Pathogenic character of internal injury due to mental disorders: – Impair the viscera, mainly the heart organ. – Affect the viscera qi movement first (rage causes qi to go upward, excessive joy causes qi to relax, grief causes qi to be consumed, great fear causes qi to sink, overthinking causes qi to depress, and oversurprise causes qi to be disordered). – Disease condition will be aggravated by emotional disturbance.

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Concept of internal injury due to mental disorders Mental disorders refer to joy, anger, worry, thinking, sorrow, fear, and surprise. They are the normal physiological reactions to external stimulations. Under normal conditions, they do not cause diseases. Only when the emotional stimulations are too abrupt, violent, prolonged, and beyond one’s adaptability, they may cause disturbances of qi movement and impairment of viscera, and diseases then occur. This is what is called internal injury due to seven emotions. Moreover, whether the seven emotions will turn into pathogenic factors or not depends on an individual’s tolerance. For example, if two people are experiencing the same emotional stimulation, one with weak tolerance is more likely to fall ill and have difficulty in recovering than the stronger person. Pathogenic character of internal injury due to mental disorders A. Impair the viscera, injure the heart first Internal injury due to mental disorders can directly impair the corresponding viscera. For example, rage hurts the liver, leading to upward adverse flow of liver qi or liver fire flaming, both of which can consume yin blood of the liver. Overjoy hurts the heart, leading to slackened heart qi, and the spirit will be unable to rest. Excessive sorrow hurts the lung, leading to consumption of lung qi. Great fear hurts the kidney, causing loss of kidney qi. Overthinking hurts the spleen, causing stagnation of qi movement, and leading the spleen to fail in transformation and transportation. Oversurprise hurts the heart or the gallbladder, causing the heart to fail to control the mind, the gallbladder to fail in making decisions, and leading to palpitation. It is a general rule that mental disorders impair the corresponding viscera. But because the heart holds the spirit and is the master of five zang viscera and six fu viscera, it plays a decisive role in emotional activities. When mental disorders cause diseases, they impair the heart first, and then affect the other viscera. B. Affect the viscera qi movement first Internal injury due to seven emotions is most likely to cause disorder of the viscera qi movement. Because of different stimulating factors, different emotional changes may cause various changes of the viscera qi movement. That is, rage causes qi to go upward, excessive joy causes qi to be relaxed, grief causes qi to be consumed, great fear causes qi to sink, overthinking causes qi to be depressed, and oversurprise causes qi to be disordered. Rage causes qi to go upward. Rage may cause liver qi to go adversely upward, and blood follows the adverse qi movement and also goes upward. Symptoms such as flushed face with congested eyes, restlessness, insomnia, and even hematemesis and sudden coma may occur. Liver qi perversion may affect the spleen and stomach, resulting in their dysfunction. Liver fire due to stagnated liver qi may impair the lung. Excessive joy

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causes qi to be relaxed. Normally, joy can smooth the circulation of qi and blood as well as put the mind at ease. However, overjoy will make heart qi slacked and the spirit will be unable to rest. It is manifested as absent mindedness and mental confusion. Grief causes qi to be consumed. Excessive sorrow will result in depression and consumption of lung qi. It is characterized by low spirit, chest distress, shortness of breath, fatigue, and lassitude. Great fear causes qi to sink. Syndromes such as pale face, dizziness, and even coma may occur. Excessive fear will make kidney qi unconsolidated and make it sink downward. It is characterized by incontinence of urine and feces, spermatorrhea, miscarriage, and weakness of knees. Oversurprise causes qi to be disordered. Sudden surprise may cause disorder of the heart qi and make heart spirit uncontrollable. It is characterized by panic attacks and palpitation. Overthinking causes qi to be depressed. It may make spleen qi stagnant and cause it to fail in transformation and transportation. It is characterized by loss of appetite, abdominal distention, and loose stool. Besides, overthinking may cause consumption of heart blood, which is manifested as palpitation, insomnia, and amnesia. This is the heart spleen deficiency syndrome induced by overthinking. Disease condition will be aggravated by mood swings Normally, positive emotions can benefit the recovery of diseases. However, negative emotions may aggravate the disease condition or make it deteriorate rapidly. For example, if a patient with hypertension becomes enraged, liver yang and blood will suddenly rise, leading to sudden coma or hemiplegia. If a patient with heart disease experiences sudden emotional upset, it can aggravate conditions such as stenocardia and myocardial infarction. Sudden death might even occur.

8.2.2 Injury due to improper diet Key points –

Causes for injury due to improper diet: – Improper eating habit. – Insanitary diet. – Imbalanced diet.

1.

Concept of injury due to improper diet Proper diet is essential for the human body to maintain life activities. It is the main source of qi, blood, yin, and yang. However, improper eating habit and unhealthy and imbalanced diet are the important factors leading to disease.

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Causes for injury due to improper diet A. Improper eating habit Food should be taken on time and the food quantity should be moderate. The quantity of food should differ according to age, constitution, and physical condition. Both starvation and overeating can result in disease. Starvation means obvious insufficient ingestion of food. It may lead to a reduction of the source of production of qi and blood due to shortage of food. Prolonged shortage of diet may cause deficiency of qi and blood and result in lusterless complexion, shortage of breath, fatigue, dizziness, or spontaneous sweating. Overeating means excessive ingestion of food. It may impair the spleen and stomach and result in epigastric or abdominal distention with pain, foul belching and acid regurgitation, vomiting, as well as diarrhea. It even causes reverse flow of qi and leads to sudden coma, which is called coma due to improper diet. Infants are prone to be impaired by overeating because their spleen and stomach are weak. Prolonged food accumulation can cause infantile malnutrition, and then vexing heat in hands and feet, emaciation with sallow complexion, abdominal fullness, and distention, making the children prone to crying. Overeating can also affect circulation of qi and blood, causing stagnation of meridians, and lead to hemorrhoids, carbuncle, and abscess. Moreover, during earlier stage in recovering from a disease, overeating may cause the disease to reoccur. Improper order of eating is also harmful to health. For example, it is wrong to have meals first and then drink soup or eat dessert and fruits. B. Insanitary diet Insanitary diet refers to eating unclean food, such as deteriorated or poisonous food. Insanitary diet can cause dysfunctions of intestines and stomach such as abdominal pain, vomiting, and diarrhea. It also can lead to infectious diseases such as cholera, ileotyphus, and hepatitis. Consuming food polluted by parasites can cause verminosises. It is characterized by occasional abdominal pain, addiction of singular things, and emaciation with sallow complexion. If deteriorated or poisonous food is consumed, food poisoning will occur. It is manifested as severe abdominal pain, vomiting and diarrhea, even coma or death. Ancient physicians had paid great attention to food poisoning. We should emphasize on this condition more in modern times. C. Imbalanced diet Diet should be reasonably arranged and only then can it supply the nutrition to the human body. Diet predilection easily results in deficiency of some nutrients and then causes diseases. (a) Predilection for cold or hot food Excessive intake of cold food can impair yang qi of the spleen and stomach. Cold dampness thus occurs internally, which is characterized

8.2 Endogenous pathogens

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by abdominal cold pain and diarrhea. Predilection for spicy hot food can cause heat accumulation in the stomach and intestines, leading to thirst, abdominal distention and pain, constipation, or hemorrhoids. Predilection for the five tastes Acid, bitter, sweet, pungent, and salty tastes correspond to five viscera. Preference for food with a certain taste for a long time can cause preponderance of its corresponding viscera and lead to diseases. Patients should especially pay attention to suitable food tastes, or else the disease will be aggravated. Predilection for greasy or sweet food Predilection for greasy or sweet food may cause abdominal fullness and distention, or furunculosis, diabetes, hyperlipemia, or hypertension. Predilection for alcohol Wine is the essence of food and is hot in nature. Proper drinking can promote blood circulation and relax joints. Overdrinking, however, will impair the spleen and stomach and produce internal dampness heat. Internal fire heat can burn stomach meridian and force blood to go upward, marked by hematemesis and bleeding from teeth or nose. If there is heat stagnation in the intestines, kidney, or bladder, hematochezia and hematuria may occur. Parorexia Parorexia refers to intake of inedible food, such as raw tea, rice or paper, or even soil, stone, and insects. The causes for this kind of predilection are phlegms or stagnation. For patients with predilection who have normal diet and no thirst, parasitosis may be the cause.

8.2.3 Injury due to overstrain and over-idleness Key points –

Pathogenic character of injury due to overstrain and over-idleness: – Physical overstrain consumes qi. – Mental overstrain impairs the heart and spleen. – Sexual overstrain consumes kidney essence.

1.

Concept of injury due to overstrain and over-idleness It refers to disease caused by imbalance of work and rest. Classification and pathogenic character of injury due to overstrain and overease A. Overstrain It refers to body injury due to overstrain. It includes physical overstrain, mental overstrain, and sexual overstrain.

2.

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B.

(a) Physical overstrain It mainly refers to prolonged physical overwork leading to disease. Overexertion can cause consumption of qi at first and then impairment of the spleen. It can even affect the liver, which is characterized by fatigue and tiredness, shortness of breath, spontaneous sweating, and poor appetite. Long-term overexertion can also injure muscles, tendons, and bones. (b) Mental overstrain It refers to long-term intense mental work, continuous emotional upset, or great mental trauma. Mental overstrain is the characteristic of consuming yin and blood, impairing the heart, liver, spleen, and stomach. Thus, symptoms such as palpitation, insomnia, dizziness, amnesia, poor appetite, abdominal distension, vomiting, and diarrhea will occur. (c) Sexual overstrain It refers to excessive sexual activities, masturbation, or early pregnancy or too many births, which consume kidney essence. Clinical manifestations include ache and weakness in waist and knees, vertigo, tinnitus, spermatorrhea, abnormal vaginal discharge, hot flash, impotence, and emaciation. Overease It refers to lack of labor and exercise, including physical and mental overidleness. (a) Physical over-idleness No physical exercise over a long period can cause stagnation of qi and blood, dysfunction of the spleen and stomach, as well as deficiency of vital qi. Diseases caused by it are often marked by abdominal distension, poor appetite, fatigue, palpitation, shortness of breath, and sweating. And these symptoms can be alleviated by suitable physical exercise. (b) Mental over-idleness Mental over-idleness may exist with physical over-idleness. Lack of brainwork for a long period can cause reduced brain function, which is called use it or lose it. Then it will lead to indifferent expression, low spirit, reluctance to eat, fatigue, dullness, amnesia, dementia, or psychopathy. Furthermore, depression due to mental over-idleness can cause stagnation of qi and result in various emotional diseases.

8.3 Pathogens from pathological products A disease is a complicated pathological process with specific manifestations caused by pathogens. In the process, there is particular pathological change and manifestation

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at every stage. Phlegm, retained fluid, stagnant blood, and calculus are pathological products in the course of a disease due to dysfunction of viscera. For the whole course of a disease, they are pathological products in the former stage, and may become new pathogens in the latter stage. It means that pathological products stagnated in the body may cause new disorders and lead to new diseases. Pathogens from pathological products include phlegm, retained fluid, blood stasis, and calculus.

8.3.1 Water-dampness, phlegm, and retained fluid Key points – –

–

1.

2.

Concept of water-dampness, phlegm, and retained fluid Causes for water-dampness, phlegm, and retained fluid: Exogenous six evils, internal injury due to seven emotions, and improper diet cause dysfunctions of viscera and metabolic disorders of fluid. Pathogenic characters of water-dampness, phlegm, and retained fluid: – Flowing with qi throughout the body. – Variability and complexity. – Lingering pathological condition and prolonged duration. – Blocking circulation of qi and blood, affecting visceral functions. – Blocking the orifices and disturbing the spirit.

Concept of water-dampness, phlegm, and retained fluid Water dampness, phlegm, and retained fluid are the pathological products of water metabolism disorder. They are also the secondary pathogens. Water-dampness means edema due to failure of spleen in transporting and transforming water. Generally, phlegm is thick and turbid, while retained fluid is thin and clear. There are broad and narrow senses of the concept of phlegm. In a narrow sense, it refers to the respiratory secretion called visible phlegm. In a general sense, it is invisible and changing phlegm resulting from metabolism disorder of body fluids. It can flow with qi movement throughout the body and cause different diseases according to its accumulative locations. For example, if it runs in the intestine, it will cause intestinal gurgling sounds. If it flows into the hypochondrium, it can cause cough with referred pain. It stagnates in the limbs to cause body pain. It invades the lung to cause asthma. It invades the heart to cause dizziness. Phlegm accumulated in the heart can lead to palpitation, coma, and demented diseases. It can cause vomiting due to accumulation in stomach as well as result in crewels, hemiplegia, and deep multiple abscesses due to its flow throughout meridians, tendons, and bones. In a nutshell, diseases caused by phlegm are diverse. Formation of phlegm and retained fluid Causes for phlegm and retained fluid are exogenous six evils, pestilent pathogens, and internal injury due to seven emotions, improper diet, as well as

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3.

overstrain and over-idleness. All of the above-mentioned pathogens can cause water metabolism disturbances and fluid stagnation due to dysfunctions of viscera. The formation of phlegm and retained fluid is mainly related to the lung, spleen, kidney, liver, triple burners, and bladder. A. Improper diet Too much intake of greasy food can impair the spleen and stomach in failing to transform water and dampness, causing phlegm and retained fluid. Indulgence in drinking may also lead to phlegm disease due to accumulation of damp heat. B. Internal injury due to seven emotions Excessive grief, rage, fright, or joy can lead to disorder of the qi movement, stagnation of meridians, obstruction of nutritive qi and defensive qi, as well as interior water-dampness accumulation; thus phlegm and turbidity occur. Phlegm disease, which is caused by dysfunction of the spleen affected by liver due to emotional depression, is the most common in this kind of diseases. C. Exogenous six excesses The lung may fail to distribute body fluids due to wind cold pathogen attacking the body. The spleen will be impaired due to invasion of dampness pathogen. Besides, fire heat can condense the body fluids leading in phlegm and dampness to occur internally. D. Dysfunctions of viscera Formation of phlegm and dampness is mainly related to the lung, spleen, kidney, liver, triple burners, and bladder. The lung, which are in charge of qi, regulate waterways. If it fails to disperse body fluids, phlegm and turbidity will occur. The function of the spleen is transportation and transformation of water-dampness. Disharmony of the spleen and stomach will cause phlegm. Kidney also plays a leading role in water metabolism, and deficiency of kidney yang can also lead to stagnation of water-dampness. Triple burners offer the pathway for circulation of water fluids, and the bladder controls discharge of water. Their dysfunctions will cause water retention, which will cause phlegm to form. Phlegm caused by liver dysfunction results from qi stagnation and water accumulation. Besides, depression of heart yang or deficiency of heart qi also causes phlegm. Pathogenic characters of water-dampness, phlegm, and retained fluid A. Flowing with qi throughout the body Phlegm and retained fluid can flow with qi and go everywhere, internally to viscera and meridians while externally to skin. Qi movement will be obstructed where phlegm is retained. If it stays in the meridians, it will cause the channels to be obstructed. It also can lead to stagnation of lung qi due to its accumulation in the upper burner, dysfunction of the spleen and stomach due to accumulation in the middle burner, as well as difficulty in urinating due to flow into the lower jiao.

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Variability and complexity Diseases caused by water-dampness can vary depending on the constitutions of patients. Manifestations of this kind of disease are also changeable with disease progress. Phlegm and retained fluid are caused due to different reasons and they change all the time. There is an old saying, “Diseases are mainly haunted by phlegm,” or “Rare diseases are usually caused by phlegm.” Lingering pathological condition and prolonged duration Water-dampness, phlegm, and retained fluid are a result of accumulation of body fluids and are characterized by heaviness, turbidity, stickiness, and stagnancy. Diseases caused by them often have longer courses and cannot be healed in a short time. Water-dampness, phlegm, and retained fluid are often caused by deficiency of yin, yang, qi, and blood in the body. It is more difficult to expel them due to the weak resistance and dysfunction of viscera. Moreover, phlegm and retained fluid can lead to other diseases or aggravate disease conditions. Vital qi has been consumed to a certain extent when these pathological products occur. So it is also very difficult to treat the combination of deficiency excess syndromes. Blocking the circulation of qi and blood, affecting the visceral functions Water-dampness, phlegm, and retained fluid are substantial pathogens. They will inevitably block the circulation of qi movement, causing chest distress and abdominal distension. When they block the meridians, scrofula, and subcutaneous nodule, numbness will occur. When they stagnate in the lung, cough and asthma will occur. When the stagnation is in the heart, angina, and even coma, will occur. Being prone to disturbance of the spirit When phlegm turbid disturbing internally, it tends to cause lucid yang failing to rise and lead to dizziness and low spirit. Phlegm heat will disturb the heart, causing coma and dementia.

8.3.2 Blood stasis Key points – –

1.

Causes for blood stasis: qi deficiency, qi stagnation, blood cold, blood heat, consumption of body fluids, and traumatic injury. Pathogenic character of blood stasis: pain, swelling, bleeding, cyanosis, intermittent pulse.

Concept of blood stasis Blood stasis refers to a pathological product resulting from the stagnation of blood within the body. It includes both blood flowing out of meridians and sluggish blood inside the meridians. In ancient literature, it is also termed as

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blood clotting, blood accumulation, sluggish blood, and so on. Blood stasis can block circulation of qi and blood and affect normal functions of viscera, which leads to new diseases. It is a secondary pathogen just like phlegm and retained fluid. Causes of blood stasis There are two main aspects involved in the formation of blood stasis. One type of blood stasis is due to abnormal flow of blood caused by traumatic injuries. The other is due to unsmooth flow of blood due to qi deficiency, qi stagnation, blood cold, or blood heat resulting from various pathogenic factors. A. Qi deficiency leading to stagnant blood Qi is the commander of blood, and deficient qi cannot promote circulation of blood, which causes blood stagnation. Qi deficiency can also induce weak resistance to exogenous pathogens, affecting functions of viscera and blocking qi movement, thus leading to blood stasis. Moreover, if bleeding caused by qi deficiency cannot be eliminated promptly, it will also cause blood stasis. Causes for qi deficiency include inherent shortage, lack of health maintenance, aeipathia, or improper diet. Therefore, when treating blood stasis, it is essential to tonify qi followed by promoting blood circulation and removing blood stasis. B. Qi stagnation leading to blood stasis Emotional distress, phlegm dampness, and food retention can block qi movement and cause unsmooth flow of blood leading to blood stasis. C. Blood cold leading to blood stasis Exogenous cold pathogen or interior exuberance of yin cold can impair yang qi and cause it to fail in promoting blood circulation, thus leading to blood stasis. Besides, blood vessels will become constricted due to invasion of cold pathogen and aggravate the blood stagnation. This condition is described as follows: blood will get congealed due to cold. Clinically, treatment of warming yang to dispel cold is often used in blood stagnation syndrome. D. Blood heat leading to blood stasis Exogenous warm heat pathogen or endogenous fire heat can make blood concentrated and lead to blood stagnation. Moreover, blood mixed up with fire heat will burn blood vessels and abnormal flow of blood occurs, which leads to blood stagnation. Clinically, treatment method of clearing heat and cooling blood is often used in diseases caused by blood stagnation. E. Consumption of body fluids leading to blood stasis Heat pathogen, excessive sweating, vomiting and diarrhea, or mistaken use of diuretic can consume body fluids. Deficiency of the spleen and lung, or stagnation of phlegm dampness, can also cause shortage of body fluid sources. If blood is compared to a boat, body fluids can be compared to water, which can carry the boat. So the consumption of body fluids can cause unsmooth circulation of blood and lead to blood stasis.

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F.

3.

Traumatic injury leading to blood stasis Tumbling, injury by swords or beasts, and overloading can all lead to bleeding and abnormal flow of blood. If this kind of bleeding cannot be expelled timely, it will become stagnant blood. Abnormal flow of blood caused by internal injury left inside the body can also cause unsmooth circulation of blood, leading to blood stagnation. Furthermore, both stagnant blood and phlegm turbidity are pathological products in the course of diseases. They can affect each other. Their basic mechanism is to cause the stagnation of qi and blood as well as the blockage in the collaterals. Pathological character of blood stasis Stagnant blood can affect circulation of qi and blood, causing pain, bleeding, blockage of meridians, tumor in the viscera, as well as bruises on the body surface. Their clinical features are as follows: (a) Pain. Pain caused by blood stasis is usually manifested as fixed and stabbing. It will be aggravated by pressure or become worse at night. Distension pain can be caused by blood stasis resulting from qi stagnation. (b) Swelling. Swelling caused by blood stasis is manifested as a fixed hard lump. Local bruise on the body surface or abdominal mass can be palpated. (c) Bleeding. Stagnant blood staying in the body can affect circulation of qi and blood, leading to bleeding. It is often characterized by purplish blood with clots. (d) Cyanosis. It is often marked by purplish lip and nails, dark purplish tongue, purpura, phlebeurysma under the tongue, dark complexion, scaly dry skin, spider angioma, or blue veins in the abdominal wall. (e) Intermittent pulse. Diseases caused by blood stagnation are often manifested as thin, wiry, deep, or intermittent pulse.

8.3.3 Calculus Key points – –

– – – –

Concept of calculus Causes for calculus: improper diet, internal injury of seven emotions, deficiency of kidney essence, parasitic infection, improper use of medicine, foreign body deposits, and traumatic injury. Pathological character of calculus: usually stays in the liver, gallbladder, stomach, kidney, and urinary bladder. Prolonged clinical courses with mild or severe conditions. Blocking the qi movement and impairing the vessels. Pain.

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Concept of calculus Calculus refers to a mineral-like pathological product located in certain parts of the body. It can obstruct many locations of the body and mainly the gallbladder and kidney. Besides, it can occur in the nose, eyes (including corneal, atria, and tear gland), ears, or pulmonary alveoli. And tophi caused by abnormal metabolism can be seen in any part of the body except for the central nervous system. Calculus is also a secondary pathogen. It can cause new diseases such as stranguria, and jaundice. Causes of calculus A. Improper diet Indulgence in spicy or greasy foods can cause the formation of damp heat internally, which will affect the liver and gallbladder and lead to bile stagnation, hence, biliary calculus. If damp heat goes downward and affects the kidney and bladder, then renal or vesical calculus will occur. B. Internal injury due to seven emotions Emotional distress can cause stagnation of qi movement, which leads to calculus. Excessive emotional changes may impair the liver and kidney, causing retention of bile or urine as well as resulting in calculus. C. Deficiency of kidney essence Constitutional deficiency, chronic illness, aging, or weakness will cause deficiency of kidney essence, which leads to deficient fever consuming the body fluids and results in calculus. D. Parasitic infection Roundworm invading the biliary tract can lead to local infection and obstruction as well as cause biliary calculus. E. Improper use of medicine Long-term use and overdose of certain kinds of medicine will cause dysfunction of viscera or medicine remaining in the body, leading to calculus. F. Foreign body deposits If some foreign bodies stay in a certain cavity of the body for a long time, some metabolic materials will deposit and surround it to cause calculus. It often occurs in the nose, kidney, gallbladder, and bladder. G. Traumatic injury If traumatic injuries (including operation) impair the biliary tract, they can cause stenosis or obstruction, leading to bile stagnation and calculus. Moreover, calculus is related to one’s age, gender, physical quality, and living habits. It can also be caused by other diseases. Pathological characters of calculus Manifestations of diseases caused by calculus differ greatly because of the different locations where the calculus stays. Generally, calculus can cause stagnation of qi and blood as well as impair the viscera. The basic mechanism of calculus is qi stagnation while pain is the main symptom.

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Calculus usually stays in the liver, gallbladder, stomach, kidney, and urinary bladder Smooth flow of liver qi governs the production and excretion of bile; the steaming function of kidney qi affects the formation and discharge of urine. So dysfunction of the liver and kidney can lead to calculus. Calculus is prone to staying in the liver, gallbladder, kidney, bladder, and stomach. Prolonged clinical course with mild or severe conditions The formation of calculus usually results from accumulation of dampness and heat, which is hard to expel, causing a long course of disease. Its clinical manifestations differ greatly due to the difference in calculus size and location. Generally speaking, patients with small calculus show milder disease condition and even without clinical symptom. Too large calculus may be manifested as severer condition, obvious symptoms, and frequent onset. Tending to block qi movement and impair the vessels As a substantial excess pathogen, calculus staying in the body will block qi movement and affect the circulation of qi, blood, as well as body fluids. It can cause local distending pain. In a severer condition, calculus can impair the blood vessels and cause bleeding. Pain Pain caused by calculus is marked by paroxysmal dull pain, distending pain, and even colic pain. It is the characteristic of intermittency. The extreme pain caused by calculus can disappear immediately when calculus is dissolved.

8.4 Other pathogens Besides exogenous pathogens, endogenous pathogens, and pathogenic products, there are other reasons for occurrence of diseases. It includes unexpected injuries (including traumatic injury and toxicosis), iatrogenic pathogens (including medicine abuse, therapist fault, and needle infection), and congenital factors (including fetal transmission and inheritance). Medicine abuse and iatrogenic pathogens will be mainly discussed in this chapter.

8.4.1 Medicine abuse Key points –

Pathogenic characters of medicine abuse: – Usually manifested as toxic symptoms. – Acute onset with severe disease conditions. – Aggravating the condition and causing new disease.

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Concept of medicine abuse Medicine abuse refers to a pathogenic factor caused by improper administration of medicine. This is called drug-induced disease. Medicine is used for treating disease, but overdose or mistaken use of it can cause disease. Causes for medicine abuse A. Toxic reaction due to poisonous medicine Medicine itself is poisonous, which is common in herb, animal, and mineral drugs. For example, monkshood with hot nature is extremely poisonous. If it is not processed or boiled properly, it will cause toxicosis. Misuse of centipede with histamine and alpha hemolysin will cause hemolytic reaction. Overuse of cinnabar can lead to chronic mercury poisoning. Manifestations of drug poisoning vary according to the different medicines taken. Generally speaking, mild poisoning can cause dizziness, palpitation, nausea, vomiting, numb tongue, diarrhea, or constipation. Severe poisoning will lead to muscle vibration, restlessness, aggravated jaundice, shortness of breath, salivation, dysuresia, drop in blood pressure, bleeding, cyanosis, or even death. B. Misuse of medicine Every medicine has its own indication. Treatment should be done in accordance with the proper indication. For example, normally, for patients with deficiency, tonifying treatment should be done, but some patients cannot endure the tonifying therapy, including those with stagnation of dampness hot pathogen, blockage of spleen and stomach qi, and retained lochia in women. Another example is, for patients with excess pathogens, purgative medicine should be used commonly. But if there is deficiency of vital qi, purgative medicine will become a pathogenic factor and lead to disease. Pathogenic character of medicine abuse A. Usually manifested as toxic symptoms Mistaken or overuse of poisonous medicine will cause dizziness, palpitation, nausea, vomiting, numb tongue, diarrhea or constipation, muscle vibration, restlessness, jaundice, cyanosis, bleeding, coma, and even death. B. Acute onset with severe disease conditions Abuse of extreme poisonous medicine often causes acute poisoning with severe conditions, impairing important viscera, and even leading to death. C. Aggravates disease condition and causes new diseases Improper use of medicine will cause aggravation of disease and lead to new diseases. For example, unsuitable medicine used by pregnant women can cause miscarriage, defect fetus, or fetal death.

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8.4.2 Iatrogenic pathogen Key points –

Causes for iatrogenic pathogens: – Improper speech. – Illegible writing. – Misdiagnosis. – Improper treatment.

1.

Concept of iatrogenic pathogen It refers to a pathogenic factor resulting in disease aggravation or onset of other diseases caused by a doctor’s faults. Causes for iatrogenic pathogen A. Improper speech Rude or inappropriate words spoken by a doctor can cause patient’s aversion to treatment. If the doctor tells about the disease conditions that should not be known by patients, patients will become overloaded in thought, which can cause disease aggravation or onset of new diseases. B. Illegible writing Illegible writing or using rare medicinal name in prescriptions can cause mistakes. It will delay treatment and cause disease aggravation. C. Misdiagnosis Misdiagnosis or delayed treatment will lead to mistakes in treatment or onset of new disease. For example, if a deficiency syndrome is misdiagnosed as excess with many purgative medicines being prescribed, or an excess syndrome is misdiagnosed as deficiency with tonifying medicine being used, disease condition will be aggravated even to the stage of being dangerous. D. Improper treatment Medical accidents can be caused by ignorance or roughness during the treatment. For example, improper needling in the chest or back can cause pneumothorax; overexertion in medical massage may cause fracture. In Suwen, it is discussed about acupuncture therapy that doctors should concentrate on treatment, which is called feel like standing upon the edge of an abyss, holding needles like holding a tiger. E. Pathogenic character of iatrogenic pathogen Different iatrogenic factors can cause different diseases or syndromes. Improper words are similar to internal injury due to emotional activities in pathogenic character. Pathogenic character of illegible writing is similar to medicine abuse while improper treatment is similar to traumatic injury. They are discussed in other relevant chapters. Pathogenesis refers to mechanism of occurrence, development, and change of a disease. It reveals characteristics and principles of disease

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onset and progress. Therefore, analysis of pathogenesis is the internal evidence and the theoretical guidance of the clinical treatment based on syndrome differentiation. Pathogenesis includes general pathogenesis, systematic pathogenesis, symptom pathogenesis, and the progress of the diseases. General pathogenesis includes exuberance and debilitation between vital and pathogen pathogens, imbalance of yin and yang, disorders of qi and blood, as well as the disorders of fluids metabolism. Systematic pathogenesis includes pathogenesis of viscera, body, and orifices as well as five endogenous pathogens. Exogenous pathogenesis includes patho mechanism of six phases, defense qi nutrient blood, as well as triple burners. Meridians pathogenesis includes 12 meridians and 8 extra channels. Progress of disease refers to transmission and changes among viscera, meridians, and tissues. It is significant to clinical treatment based on syndrome differentiation, early treatment, and control of the disease advancement. Pathogenesis is a theory of discussing and clarifying principles of pathological changes. It elaborates interrelationship between parts and the whole, viscera and its accessories, internal and external environments. It is based on the functional changes resulting from combined actions as well as taking into account individuality and diversity. Pathogenesis of Chinese medicine implies profound recognition of life activities and contributes to enrichment of life science.

9 Pathogenesis 9.1 Exuberance and debilitation between vital and pathogen Key points – –

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Concepts of pathogen, vital qi, deficiency, and excess Deficient or excessive changes: – Mixture of deficiency and excess. – Inter-transformation between deficiency and excess. – True – false of deficiency and excess. Prognosis of disease: – Domination of vital qi with decline of pathogen. – Struggle between pathogen and vital qi. – Domination of pathogen with decline of vital qi. – Withdrawal of pathogen with decline of vital qi. – Deficiency of vital qi with pathogen lingering.

9.1.1 Concept of pathogen, vital, exuberance, and debilitation This concept refers to the exuberant and debilitating changes in the struggle between body resistance and pathogenic qi in the course of disease. The struggle not only determines the onset, development, and final prognosis of disease but also affects changes of deficient or excessive syndromes. The course of diseases is a process of struggling between the vital and the pathogen as well as its exuberance and debilitation changes. In the course of disease development, the struggle between the vital and pathogen always varies. In the struggle, the pathogen declines as the vital grows, and vice versa. With the growth and decline of the vital and pathogen, disease is marked by two different essences, namely, the changes of deficiency and excess. 1. Pathogen Pathogen refers to all kinds of pathogenic factors in general. 2. The vital Vital refers to vital qi, a summarization of normal body functions including defensive ability, disease-resistance ability, and recovery ability. 3. Deficiency syndrome A. Concept Concept refers to deficiency of vital qi and weak resistance to disease. It is a pathological manifestation with deficiency of vital qi as dominant aspect of the contradiction mainly marked by insufficiency of essence, qi, blood, and body fluids; hypo-function of viscera and meridians; and low body resistance. Drastic pathological reaction is difficult to appear in the struggle of vital qi and pathogens due to deficiency syndrome.

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B.

4.

Etiology Causes for deficiency of vital qi involve two aspects. One aspect is from the deficiency in pre-natal qi which is often due to weak essence, or imbalance of post-natal qi which is due to weak constitutions. This aspect belongs to the category of pure deficiency without any pathogen. The other is from sequel of a disease or chronic case which results from the damaged vital qi unable to fight against pathogen. The long-term or serious diseases cause consumption of qi, blood, body fluids, and essence. Besides, invasion of pathogens can lead to over-consumption of refined nutrient substances. C. Pathological manifestations Deficiency of vital qi is often manifested as emaciated body, fatigue, palpitation, sweating, weak voice (caused by qi deficiency), sallow complexion, dizziness (caused by blood deficiency), urinary and fecal incontinence, pressure-relieved dull pain (caused by viscera deficiency), feverish feelings in five centers (caused by yin deficiency), weakness and soreness in lower back and knees, aversion to cold with cold limbs (caused by yang deficiency), and feeble pulse. Excess syndrome A. Concept Concept refers to the exuberant pathogen with sufficient vital qi, or a pathological manifestation with super-activity of pathological qi as the dominant aspect of the contradiction. In such cases, pathogens are excessive and vital qi is strong enough to fight against pathogens. Thus, the struggle between the vital and pathological qi is severe. It is clinically indicated by a series of excessive symptoms. B. Etiology Causes for the excessive pathogens include invasions of six exogenous evils or pestilential qi, stagnations of pathological products or visible pathogens (such as phlegm, retained fluids, water-dampness, blood stasis, food retention, and parasites), as well as internal injury due to emotional distress. All of them can cause dysfunctions of viscera, meridians, qi, blood, and body fluid. C. Pathological manifestations Excessive syndrome usually occurs at the early or middle stage of the disease. The struggle between vital and pathogenic qi is violent because even though the pathogenic qi is strong, the vital qi is not weak enough. Clinically, it is often manifested by the syndromes of excessive syndromes such as blockage of the skin and meridians, hypo-activity of internal organs, as well as qi and blood stagnation. It is characterized by stagnation of pathogenic heat, obstruction of phlegm-turbid and water-dampness, dyspepsia, and constipation. It is often manifested as high fever, mania,

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loud and hoarse voice, impalpable abdominal pain, constipation and food stagnation, and full and forceful pulse. The concept of deficiency or excess pathogenesis in endogenous miscellaneous diseases is different from that of exogenous diseases. In endogenous miscellaneous syndromes such as phlegm, fluid retention, blood stasis, parasites, and food stagnation, excessive syndromes refer to syndrome with invasion of pathogens and deficient syndromes refers to syndrome with deficiency of vital qi. But in exogenous diseases, excess syndrome refers to syndrome with severe struggle between vital and pathogenic qi and deficiency syndrome is the syndrome with low disease-resistance. Generally speaking, when pathogenic qi invades the body, pathogens impair the vital qi while the vital qi also resists against and expel pathogens. Therefore, the struggle between vital and pathogenic qi not only determines development and prognosis of disease but also affects the changes of deficiency or excess syndrome. In fact, in the process of disease development, balance between the vital and pathogen is altered. If the vital qi is sufficient, it is apt to expel pathogens and disease may get better or get cured. If pathogenic qi is exuberant, it will impair and consume the vital qi, and disease can be aggravated.

9.1.2 Changes of deficiency or excess Excess and deficiency between the pathogen or the vital qi can not only result in the simple pathological changes but can also lead to various changes in the prolonged and complicated courses of disease, including mixture of deficiency and excess, inter-transformation between deficiency and excess, and true-false of deficiency and excess. 1. Mixture of deficiency and excess Mixture of deficiency and excess refers to a pathological condition in which the struggle between vital and pathogenic qi leads to coexistence of exuberant pathogens and declined vital qi in the course of a disease. It involves two aspects: deficiency syndrome mixed with excess and excess syndrome mixed with deficiency. It may be caused by stagnant pathogens impairing vital qi due to improper treatment of a disease or by blockages of water-dampness, phlegm, and fluid retention, as well as blood stasis resulting from deficient vital qi failing to expel pathogens. A. Deficiency syndrome mixed with excess This syndrome refers to a pathological condition in which predominance of deficient vital qi mixes with excessive pathogens. For example, in a case of edema caused by spleen yang deficiency which fails to transport and transform water pertains to deficiency syndrome, and the retention of

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2.

water pertains to excess syndrome. This kind of pattern is mainly due to deficiency with excess as the secondary syndrome. B. Excessive syndrome mixed with deficiency This syndrome refers to a pathological change in which predominance of excessive pathogenic qi mixes with deficient vital qi. For example, in exogenous febrile disease, invasion of exuberant heat pathogen causes excess heat syndrome marked by high fever, sweating, constipation, red tongue, and rapid pulse. At the same time, heat pathogen causes consumption of body fluids, leading to qi deficiency syndrome marked by thirst, wanting to drink water, scanty urine, fatigue, and shortness of breath. This kind of syndrome is characterized by primary excessive syndrome with secondary deficient syndrome. The primary and secondary for deficiency or excess syndrome, respectively, should be determined by analyzing the stage and amounts of pathogens and vital qi. In clinic, there are also other mixture of deficiency and excess syndromes such as exterior excess mixed with interior deficiency, exterior deficiency with interior excess, deficiency in the lower and excess in the upper, and deficiency in the upper and excess in the lower. Inter-transformation between deficiency and excess Inter-transformation between deficiency and excess refers to pathological conversion between deficiency and excess in the course of disease, including the transformation of excessive syndrome into deficiency and excessive syndrome resulted from deficiency. A. Transformation of excess into deficiency In the process of a disease, conversion of the pathological nature from excess to deficiency may occur from impairment of vital qi and viscera due to delayed or improper treatment. For example, exterior cold or exterior heat syndrome which pertains to excessive syndrome at the early stage will transform into the deficient lung and spleen syndromes manifested as emaciation, poor appetite, lusterless complexion, shortness of breath, and fatigue as a result of improper treatment of the exogenous disease. B. Excessive syndrome resulted from deficiency Excessive syndrome resulted from deficiency means that vital qi is originally deficient or viscera function become declined, which leads to dysfunction of qi, blood, and body fluids, thus resulting in stagnation of excessive pathogens such as blood stasis, phlegm, fluid retention, and water-dampness. It is a syndrome of obvious excessive pathogenic qi with declined vital qi. For example, edema caused by kidney-yang deficiency is manifested as symptoms of both deficient kidney-yang and water retention. This pathological change is similar to that of a mixture of deficiency and excess.

9.1 Exuberance and debilitation between vital and pathogen

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True – false syndrome between excess and deficiency This syndrome refers to a pathological condition that the nature of a disease is not in accordance with its clinical manifestations under some particular circumstances. Generally speaking, the symptoms in the clinical setting often match the root issues. However, under certain specific circumstances, some false symptoms might appear. Therefore, in the clinical setting, we must make differential diagnosis in order to identify the real disease pattern. Due to the opposite manifestations between true and false, it often results in the true deficient syndrome with false excessive symptoms and true excessive syndrome with false deficient symptoms. A. True deficient syndrome with false excessive symptoms (symptoms of excess in extreme deficiency) This symptom is often caused by deficiency of qi and blood as well as the weakened viscera. For example, symptoms of abdominal distension and pain can be caused by spleen dysfunction. But the abdominal distension is not acute, and the pain can be alleviated by pressure. It is different from that of excessive syndrome. Moreover, when there is extreme deficiency of yang qi in the body, false excessive symptoms such as mental excitement, flushed face, and restlessness will occur. B. True excessive syndrome with false deficient symptoms (deficiency manifesting with extreme excess) It refers to some syndromes with extreme exuberance of pathogens in nature. Clinically, it may be manifested as deficiency symptoms. It is often caused by stagnations of heat, phlegm, food, damp-heat constipation, abdominal pain aggravated by pressure, tidal fever, and delirium. On the other hand, it might be presented with the false deficient symptoms such as pale complexion, cold limbs, and fatigue symptoms. Overall speaking, in the course of a disease, deficiency or excess is relative in pathogenesis. Clinically, we need to keep an objective and relative view when analyzing the changes of pathogenesis.

9.1.3 The relationships among pathogen, vital qi, excess, and deficiency as well as the outcome of disease During the early and middle stage of the disease, struggle between vital and pathogenic qi is violent along with the pathological reaction. And the changes of growth and decline between vital qi and pathogens can lead to the different prognosis. It includes the following types. 1. Domination of vital qi with decline of pathogen – recovery Domination of vital qi with decline of pathogen refers to the best result of a disease that vital qi defeats pathogenic qi, pathogens being declined or expelled

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2.

3.

and the disease recovers. It is the common ending to many diseases. Recovery attributes to sufficient vital qi of the body, strong resistance to pathogens, or proper treatment. It indicates that the damage of pathogens to the body is coming to an end or disappearing; the visceral functions along with the balance of yin and yang are resumed. Apart from the patient’s own health condition and resistance against diseases, timely and proper treatment are essential to the recovery of a disease. Confrontation between pathogen and vital qi – the lingering stage of the disease Confrontation between pathogen and vital qi refers to a pathological course in which vital and pathogenic qi are in a very close condition and cannot defeat each other, leading to a lingering phase. In this stage, pathogens are stagnated at certain locations and cannot be expelled or move inward. No matter where the pathogens stagnate, treatment of strengthening the vital qi and eliminating pathogens should be taken simultaneously. Exuberance of pathogen with decline of vital qi – disease aggravation or even to death Exuberance of pathogen with decline of vital qi refers to a pathological course in which the vital qi becomes weaker and fails to resist against exuberant pathogenic qi, and the disease is aggravated. It involves two pathological conditions: for an ordinary patient with a relatively stable vital qi, the more exuberant the pathogens are, the more serious the disease condition will be; and for the same invasions of the pathogens, the weaker the body is, the more serious the disease condition will be. An example is the six exogenous evil syndromes. Its common pathological change is the impairment of the defensive-yang with more superficial disease location and milder condition. However, if the vital qi is very deficient or the invasion of pathogenic qi is too strong, special transmissions of disease such as double contraction, direct attack, or direct penetration into nutrient-blood may occur. Double contraction refers to both exterior and interior meridians being invaded by exogenous pathogens. The extensive and serious damage to the vital qi is often seen in exterior – interior concurrent disease such as cold or heat in both exterior and interior. Direct attack refers to the attack of exogenous pathogens directly to three yin meridians rather than transmitting from the three yang meridians. It indicates more serious disease conditions. If cold pathogen directly attacks taiyin meridian and impairs the spleen yang, abdominal pain and diarrhea may occur. If cold pathogen directly attacks shaoyin meridian and impairs the heart and kidney, cold limbs and feeble and impalpable pulse may occur. Direct penetration into nutrient-blood refers to a process of the warm-heat disease, attacks of the pathogens rapidly penetrate into the nutrient-blood stage rather than being expelled at the defensive or qi stage. It indicates a critical stage of disease in which nutrient-yin is impaired and blood is consumed. This

9.1 Exuberance and debilitation between vital and pathogen

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condition can be caused by misuse of purgative drugs for disease invaded by exogenous cold pathogen. It may occur at the later stage of exogenous heat disease with syndrome of yin or yang depletion. If prompt treatments are not taken, there will be exhaustion of essence, qi, blood, and body fluids as well as the feebleness of viscera functions. It can even cause death. Death refers to the end of life activity, yin-yang dissociation, and permanent end of the whole physiological function of the body. There are two types of deaths: physiological and pathological. The former refers to a natural death without disease. The later refers to death due to a disease or an accident. Pathological death is an undesirable end resulting from an aggravated disease with pathogenic qi defeating declined vital qi. Withdrawal of pathogen with decline of vital qi – recovery period Withdrawal of pathogen with decline of vital qi is often seen in recovery stage of a serious disease. It refers to a pathological course in which the pathogenic qi have been expelled and the damaged vital qi is waiting to be restored. It is usually caused by severe impairment of vital qi due to excessive pathogenic qi, or overtreatment by diaphoresis, vomiting, or purgation which results in elimination of pathogens followed by severe damage to vital qi. It can also be seen in patients with deficient vital qi. Deficiency of vital qi with pathogen lingering – lingering stage Deficiency of vital qi with pathogen lingering refers to a pathological stage of a disease in which the vital qi has been weakened and pathogenic qi has not been expelled thoroughly. It is a disease condition with pathogenesis of the deficient vital qi with pathogen lingering. Under this condition, the vital qi has been impaired by pathogens but not been defeated, and the pathological qi has declined after resistance of vital qi. The weakened vital qi fails to drive pathogens outside which causes residual pathogens lingering inside. If disease condition is relatively stable, disease can be cured. However, if the disease lingers with unstable condition, it may frequently occur and account for disease turning from acute to chronic, prolonged disease, or existence of some prognosis even to death. Therefore, measures should be taken to break the lingering pathological deadlock and to gain the recovery. Sequelae refers to the end of a pathogenic course of the disease or the disappearance of the symptoms during the recovery which only leaves malfunctions and malformations of the body, such as tremor of limbs, physical abnormality, aphasia, dementia, and hemiplegia. Sequelae are different from disease lingering. The former is an end of a disease and the latter is a lingering stage or the chronic course of disease. Moreover, there is a form of a disability that results from traumatic injuries such as gunshot, swords, falling, and beasts, leading to permanent damage or deformation of the body. Both the sequelae and disability involve semipermanent end of a disease.

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9.2 Imbalance of yin and yang Key points –

Types of imbalance of yin and yang: – Preponderance of yin or yang. – Abnormal debilitation of yin and yang. – Mutual impairment of yin and yang (yin impairment affecting yang, vice versa). – Mutual repelling of yin or yang (preponderant yin repels yang, preponderant yang repels yin). – Transformation of yin and yang (yin syndrome transforming into yang syndrome, yang syndrome transforming into yin syndrome). – Depletion of yin or yang (yin depletion, yang depletion).

9.2.1 Concept of imbalance of yin and yang Imbalance of yin and yang is a series of pathological changes marked by imbalance of growth and decline of yin and yang in the process of a disease occurrence and development. It includes the exuberance of yin or yang, debilitation of yin or yang, mutual impairment of yin and yang, mutual repelling of yin and yang, transformation of yin and yang, and depletion of yin or yang. Among them, exuberance and debilitation of yin or yang are the most basic pathological changes. Being healthy refers to balance and harmony between yin and yang of the human body. It is marked by moderate body temperature, being mobile or stillness freely, and normal qi movement and physiological activities. Imbalance of yin-yang is the most basic pathomechanism for various diseases. Various pathogenic factors acting on the body, such as exogenous six excesses, mental disturbance, improper diet, injuries from overstrain, or idleness, may lead to an imbalance of yin and yang which can cause diseases. So the imbalance of yin and yang is the inner basis of the onset and development of diseases.

9.2.2 Types of imbalance of yin and yang 1.

Exuberance of yin or yang Exuberance of yin or yang refers to a pathological change in which excessive pathogenic qi is the primary aspect of contradiction. Yang excess is characterized by an excessive heat syndrome resulting from exuberant yang without yin deficiency. Yin excess is characterized by excessive cold syndrome resulting from exuberant yin without yang deficiency. Growth of yang results in decline of yin and growth of yin leads to decline of yang. They are called preponderance of yang makes yin suffer, and preponderance of yin makes yang suffer. They are inevitable trend in the progress of exuberance of yin or yang.

9.2 Imbalance of yin and yang

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Exuberance of yang Exuberance of yang refers to a pathological change marked by exuberance of yang, hyperfunction of viscera and meridians, as well as the excessive heat pathogen. It is usually caused by invasion of exogenous warm-heat pathogens, interior transformation of heat from cold pathogen, internal injury due to mental activities, transformation of five emotions into fire, or fire-heat transformed by qi stagnation, blood stasis, phlegm-turbid, and food retention. Generally, an excess of yang leads to heat syndrome. Yang is characterized by hotness, motion, and dryness. So syndromes caused by excessive yang may manifest as fever, restlessness, red tongue with yellow fur, and rapid pulse. In addition, excess of yang may impair yin marked by thirst, oliguria, and constipation. This situation is called preponderance of yang makes yin suffer. B. Preponderance of yin Preponderance of yin refers to a pathological change marked by exuberance of yin, hypofunction of viscera, meridians, and accumulation of pathologically metabolic products. It is usually caused by invasion of cold-dampness pathogens or over-intake of cold food, leading to inner stagnation of colddampness. An excess of yin will cause cold syndrome. Generally speaking, yin is characterized by cold, stillness, and dampness. So syndrome caused by excessive yin may manifest as cold body, fond of warmth, being not thirsty, white-furred tongue, and tight or slow pulse. Moreover, excessive yin usually causes consumption of yang qi, leading to cold symptoms such as aversion to cold, abdominal pain, clear urine, and loose stool, which is called preponderance of yin makes yang suffer. Debilitation of yin or yang It is a pathological change caused by deficiency of yin essence or yang qi of human body. When deficient yang cannot restrain yin, deficient cold syndrome will occur, or vice versa. A. Debilitation of yang Debilitation of yang refers to a pathological change of a decreased body functions caused by deficiency of yang qi and shortage of thermogenesis. The reasons for this condition are various, including congenital deficiency, postnatal malnutrition, internal injury due to overstrain or idleness, or impairment of yang qi due to prolonged disease. Generally, it is marked by cold symptoms such as pale complexion, intolerance of cold and cold limbs, pale tongue, slow pulse, deficient symptoms of listlessness, clear abundant urine, and diarrhea with undigested food. Deficient yang qi mainly relates to the spleen and kidney, especially kidney. Kidney-yang takes charge of all the yang qi in the whole body. The decline of kidney yang (deficiency of vital gate fire) is very important in the pathogenesis of yang decline. Mechanism of yang deficiency leading to cold is that deficient

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3.

yang qi cannot restrict yin and is lack of warming function, causing hypofunctions of meridians and viscera, slow blood circulation and body fluids, stagnation of water fluid, thus inner exuberance of yin-cold occurs. B. Debilitation of yin Debilitation of yin is a pathological change in which yin is deficient due to consumption of essence, blood, and body fluids, and is a condition when yin fails to restrict yang. It results in relative excess of yang and asthenic body hyperfunction. The reasons include injury due to excessive mental activities transforming into fire and impairing yin, or consumption of yin fluid due to prolonged diseases. In clinical manifestations, the deficientheat syndrome due to insufficient yin fluid failing to restrict yang qi occurs, which is marked by vexing heat in chest, palms and soles, bone-steaming tidal fever, flushed face with hot eyes, emaciation, night sweating, dry mouth and throat, red tongue with thin coating, and thin and rapid pulse. Yin deficiency may occur in five viscera, but mainly involves the liver and kidney. Prolonged yin deficiency of other viscera will ultimately affect the liver and kidney. In clinic, syndromes of yin deficiency in the lung and kidney along with yin deficiency in the liver and kidney usually occur. Deficiency of kidney yin is of vital importance due to kidney yin being the leader of yin in the body. Mutual impairment of yin and yang Mutual impairment of yin and yang means that the deficiency of either yin or yang may involve in opposite aspect, thus resulting in deficiency of both yin and yang. It includes yin impairment involving yang and yang impairment involving yin. Because the kidney stores vital essence, it is the foundation of yang qi and yin fluid all over the body. Mutual impairment of yin and yang is apt to occur under the circumstance of which kidney yin or yang is impaired. A. Yin impairment affecting yang Yin impairment affecting yang means that consumption of yin fluid affects yang qi and causes inadequate production or exhaustion of yang qi due to shortage of what it depends on. It results in deficient syndrome of both yin and yang with a predominance of yin deficiency. For example, chronic consumptive diseases such as spermatorrhea, night sweating, and loss of blood, which badly impair yin essence of human body, can cause inadequate resources of producing yang qi. It can gradually lead to syndrome of yang deficiency marked by spontaneous sweating, intolerance to cold, and diarrhea with undigested food in the stool. B. Yang impairment affecting yin Yang impairment affecting yin means that deficiency of yang qi affects yin fluid and causes inadequate production of yin fluid, resulting in deficiency syndrome of both yin and yang with a predominance of yang deficiency. For instance, edema caused by deficient yang qi fails to promote water

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fluid and causes water-dampness retention. But with its development, yin is consumed due to the deficient yang, and syndrome of yin deficiency will occur marked by emaciation, vexation, and thirst, and even spasms. Repelling of yin and yang Repelling of yin and yang refers to a pathological change in which either yin or yang is of extreme excess inside and rejects its opposite aspect outside. It is a kind of special pathogenesis in the imbalance of yin and yang, including preponderant yin repelling yang and preponderant yang repelling yin. Its mechanism is that yin or yang is extremely exuberant or weak, and the excessive one blocks internally rejecting the other aspect externally which leads to breakdown of interdependence of yin and yang. Repelling of yin and yang can be manifested as disease of true cold syndrome with false heat symptoms and true heat syndrome with false cold symptoms. A. Preponderant yin repelling yang (true cold and false heat) Preponderant yin repelling yang, also called as the repelling yang syndrome, refers to a pathological state of true cold syndrome with false heat symptoms caused by exuberant yin pathogens or with yang deficiency forcing extremely declined yang to go outside. For example, patients with extremely declined yang qi and extremely exuberant deficient cold can show symptoms such as pale complexion, severe cold limbs, listlessness, chillness, cowered lying, and feeble and impalpable pulse. If the disease is aggravated, false heat symptoms will occur, such as floating red complexion, mutter, restlessness with dysphoric heat, sudden increase of appetite, and huge but unrooted pulse. In ancient medicine books, sudden flushed zygomatic region like being putting on the make-up is called as floating yang, while sudden increase of appetite is called as sudden spurt of appetite prior to collapse. Both of them are sudden spurts of activities before collapsing, which pertain to false manifestation of vitality in Chinese medicine inspection. B. Preponderant yang repelling yin (true heat syndrome with false cold symptoms) Preponderant yang repelling yin, also called as repelling yin syndrome, refers to a pathological state of true heat syndrome with false cold symptoms, in which extreme heat pathogens is deep inside the body. It causes stagnant yang-heat failing to reach the limbs. It is a serious syndrome characterized by excess heat in essence. For example, at extremely exuberant stage of exogenous heat disease, heat symptoms occur, such as continual strong fever, dysphoria, thirst, and red tongue with yellow fur, and rapid and strong pulse. If the disease is aggravated, false cold symptoms such as cold limbs and deep pulse will occur. Cold limbs are also called as yang faint or heat faint. In Treatise on Febrile Diseases, this syndrome is called as “more exuberant the heat is, the more serious the faint is; the weaker the heat is, the milder the faint is.”

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5.

6.

Transformation between yin and yang In the process of disease, imbalance of yin and yang can also be manifested as transformation between yin and yang, including yin syndrome transforming into yang syndrome and yang syndrome transforming into yin syndrome. A. Yang syndrome transforming into yin syndrome This transformation means that heat-natured diseases with preponderance of yang qi in essence can be turned into cold-natured diseases when the excessive yang aggravates to certain extent. For instance, at the early stage of some acute exogenous diseases, manifestations of excessive heat pathogens can occur, such as high fever, thirst, chest pain, cough, red tongue, and yellow fur. But improper treatment or too excessive invasion of pathogens may cause acute yin-cold manifestations such as sudden declined body temperature, cold limbs, cold sweating, and feeble and impalpable pulse. B. Yang syndrome transforming into yang syndrome This transformation refers to cold-natured diseases with preponderance of yin qi in essence which can be turned into heat-natured diseases when the excessive yin aggravates to a certain extent. For example, at the early stage of cold, yin syndrome manifested as wind-cold pathogens invading body surface is marked by serious aversion to cold, mild fever, headache and bodily pain, joint pain, running nose with nasal congestion, no sweating, cough, thin and white furred tongue, and floating tense pulse. Improper treatment or being with heat constitution can cause yang syndrome manifested as high fever, sweating, being vexed, thirst, red tongue, yellow fur, and rapid pulse. Depletion of yin or yang Depletion of yin or yang refers to a pathological state of dying illness caused by sudden massive loss of yin fluid or yang qi of the body. Depletion of yin or yang is a severe syndrome of the disease which can be caused by high fever, profuse sweating, infections, poisoning, excessive vomiting, diarrhea, loss of blood, and untreatable prolonged diseases. Among them, profuse perspiration and excessive loss of blood are most apt to cause exhaustion of yin or yang because sweat and blood pertain to yin fluid. Yin fluid will be exhausted following the loss of sweat and blood, while yang qi will also be depleted due to its failing to be attached to yin fluid. Therefore, depletion of yin or yang will cause decline of the opposite aspect. The differential diagnosis and treatment should be taken into considerations. A. Yang depletion Yang depletion is a critical collapsing state due to the sudden and massive loss of yang qi of the body. Generally speaking, it is caused by a sudden massive loss of yang qi due to failure of vital qi to fight against excessive exogenous pathogens, deficiency of vital qi and overstrain, or overuse of diaphoresis. In addition, yang depletion due to chronic consumptive disease usually results from collapse due to serious depletion of yang qi along with

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deficient yang going outward. Yang depletion is often manifested as pale complexion, cold limbs, listlessness, even coma, chillness, profuse sweating, cold sweat, and feeble and impalpable pulse. Yang depletion indicates critical condition of diseases. Because of interdependence of yin and yang, yang exhaustion will cause depletion of yin. Therefore, exhaustion of yin and depletion of yang occur in succession, leading to death. Yin depletion Yin depletion is a critical collapse state due to the sudden and massive loss of yin fluid of the body. Yin depletion is usually caused by excessive heat pathogen or prolonged stagnation of heat pathogen which greatly consumes yin fluid, or the massive consumption of yin fluid due to chronic consumptive diseases. Yin exhaustion is manifested as flushed complexion, dysphoria, even coma and deliration, thirst, dyspnea, warm limbs but hyperhidrosis with a tendency to collapse, or continual sweating, hot and sticky sweat, deep red and mirror tongue without fur, and rapid but feeble pulse. Due to interdependence of yin and yang, yin depletion will make yang to lose its attachment and escape outward, and finally lead to the end of life. In conclusion, pathogenesis of imbalance of yin and yang is a mechanism for illustrating, analyzing, and synthesizing all pathogenic phenomena of the body. It is based on the theories of restriction, growth, and decline; interdependence; and complementation as well as inter-transformation between yin and yang. Therefore, preponderance of yin or yang is closely related to decline of yin or yang, and yin depletion is closely related to yang depletion. Therefore, the kinds of pathogenic imbalance of yin and yang are not unfixed and will change along with the disease conditions.

9.3 Disorders of qi, blood, and body fluids Key points – – – – – – – – – –

Disorders of qi Qi deficiency, disorder of qi movement (qi stagnation, qi sinking, reversed flow of qi, qi blockage, and qi exhaustion). Disorders of blood Blood deficiency, blood stasis, blood heat, and blood cold. Disharmony between qi and blood Qi stagnation with blood stasis, qi deficiency with blood stasis, failure of qi to control blood, qi exhaustion following blood damage, and deficiency of both qi and blood. Disorders of body fluids Deficiency of body fluids and retention of water-dampness. Disharmony among qi, blood, and body fluids Water retention with qi stagnation, qi exhaustion following fluid damage, fluid exhaustion with blood dryness, fluid shortage with blood stasis, and blood stasis with fluid retention.

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9.3.1 Disorders of qi Disorders of qi refer to the various pathological changes due to qi deficiency resulting from inadequate production or excessive consumption, abnormal qi movement, and hypofunction of qi which include qi deficiency and disorder of qi movement. Disorder of qi movement includes qi stagnation, qi sinking, reversed flow of qi, qi blockage, and qi exhaustion. 1. Qi deficiency A. Concept Qi deficiency refers to the pathological changes in which original qi is deficient with loss of normal functions, causing hypofunction of viscera and weak resistance to diseases. B. Causes for qi deficiency Many factors may lead to qi deficiency. It includes congenital deficiency, postnatal malnutrition, inadequate production of qi due to dysfunctions of the lung, spleen, and kidney, excessive qi exhaustion due to overstrain and prolonged diseases, or hypofunction of qi due to being weak with age. It is often seen in chronic diseases, aged or weak patients, deficient diseases, and recovery phase of diseases. C. Clinical manifestations Qi deficiency is characterized by shortage of qi, no desire to speak, fatigue, dizziness, spontaneous sweating, frequent cold, thin body, and weak pulse. Fatigue and lack of strength are typical cases among them. Besides, qi deficiency of different viscera manifests different symptoms. For examples, qi deficiency of lung is characterized by hypofunctions of its dominating qi and respiration as well as convergence of vessels. Qi deficiency of heart is characterized by hypofunctions of governing blood and housing spirits. Hypofunctions of digesting food and transforming food essence occur due to qi deficiency of spleen and stomach. Qi deficiency of liver is characteristic by hypofunction of governing regulation and storage of blood. Kidney qi deficiency is characterized by hypofunction of storing essence, generating marrow, sealing and storing as well as inspiration. Since the lung is in charge of qi in the body, and the spleen is the source for the production and transformation of qi and blood, primordial qi depends on the cultivation of lung and spleen qi. So qi deficiency of spleen and lung directly affects the generation of original qi. In clinic, syndromes of qi deficiency mainly refer to spleen qi deficiency and/or lung qi deficiency. Original qi is the basis of all kinds of qi. Due to the close relationships between qi and blood as well as body fluids, deficient original qi can not only cause qi stagnation but also affect blood and body fluids which lead to relevant diseases. For example, qi deficiency can cause blood deficiency, blood stasis and bleeding, as well as dysbolism of body fluids. For

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instance, deficiency of spleen qi failing to transform food essence may cause shortage of generating blood which leads to blood deficiency. Besides, phlegm and fluid retention result from deficiency of spleen qi failing to transform water-dampness normally. Failing to control blood or saliva may cause bleeding or drooling. Disorder of qi movement Disorder of qi movement refers to the pathological changes characterized by qi stagnation, reversed flow of qi, qi sinking, qi blockage, and qi exhaustion due to disturbance of qi in its ascending, descending, exiting, and entering movement. A. Qi stagnation Qi stagnation refers to a pathological state of hindered flow of qi in some viscera or meridians. It mainly results from emotional depression, retention of phlegm, dampness, foodstuff accumulation, or stagnant blood and invasions due to traumatic injury or overstrains. Qi stagnation may cause dysfunctions of some viscera and meridians and is characterized by stuffy sensation, swelling, or distended pain. Qi stagnation is closely related to dysfunctions of the liver, lung, spleen, and stomach because these viscera are of great importance in regulating qi movement. So in clinic, qi stagnation syndrome often manifests as qi blockage of lung, liver, spleen, and stomach. Generally speaking, qi stagnation pertains to excess syndrome, but it can also be caused by a deficiency syndrome. For example, qi stagnation in middle-jiao can result from qi deficiency of the spleen and stomach failing to transform and transmit. The same condition may occur in the liver. B. Reversed flow of qi Reversed flow of qi is a pathological change in which the excessive upward flow of qi or failure of qi to descend results from disorders of visceral qi. It is often caused by emotional injury, improper diet, or retention of phlegmturbidity. This disorder of qi movement mostly occurs in the lung, stomach, and liver. For example, the adverse flow of lung qi can cause cough with dyspnea while the adverse rising of stomach qi leads to nausea, vomiting, belching, or hiccups. The adverse flow of liver qi brings about distending pain of head, red complexion and eyes, and susceptibility to anger. Besides, because the liver stores blood, serious adverse rising of liver qi can lead to reversed flow of blood manifested as hemoptysis, hematemesis, or coma due to blockage of the clear orifices. Adverse rising of qi usually pertains to excess syndrome, but it can also cause deficiency syndromes. For example, deficiency of the lung causes failure to descend, and lung qi rises adversely; deficiency of kidney qi failing to control respiring qi can cause reverse flow of qi; and adverse rising of stomach qi may result from deficient stomach failing to make qi descend.

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C.

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Qi sinking Qi sinking refers to a pathological change characterized by powerless lifting of qi with failure to ascend due to qi deficiency. Qi sinking develops from qi deficiency and is closely related to the spleen. Deficiency of spleen qi is apt to cause qi sinking which is usually called as sinking of the middle qi. If the spleen qi is deficient failing to lift viscera of the body, prolapses of some viscera will occur such as gastroptosis, nephroptosis, metroptosis, and rectocele followed by abdominal distension, lower back sinking sensation, repeated desire to defecate, shortness of breath, fatigue, low voice, and feeble pulse. Qi blockage Qi blockage refers to a pathological change caused by depression and blockage of qi movement in viscera and meridians. It often results from obstructions of phlegm-turbidity or dampness-heat along with the symptoms of sudden unconsciousness. Qi exhaustion Qi exhaustion refers to a pathological state of extreme qi deficiency with a critical tendency of collapse. It is caused by escaping of vital qi due to massive consumption of qi, blood, and body fluids in the body, and extremely declined functions of viscera. It is closely related to the exhaustion of yin and yang, and they often interact as both cause and effect.

9.3.2 Disorder of blood Disorder of blood is a pathological state caused by declined blood nourishing functions or abnormal blood circulation due to inadequate generation or excessive consumption of blood which includes blood deficiency, blood stasis, blood heat, and blood cold. 1. Blood deficiency A. Concept Blood deficiency refers to a pathological change in insufficiency of blood and its declined nourishing function. B. Causes Blood deficiency may result from five reasons. First is massive loss of blood such as hematemesis, epistaxis, menorrhagia, or bleeding due to traumatic injury and no new blood can be promptly replenished. The second reason is the shortage of blood production due to deficient spleen and stomach failing in transformation and transportation, or declined functions of the heart, liver, and lung. The third one is consumption of nutritive-blood due to prolonged diseases, chronic consumption, or overstrains. The forth one is blood stasis which hinders generation of new blood. The last reason is declined blood nourishing function due to aging or weak body.

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Clinical manifestations Blood deficiency failing to nourish viscera causes declined visceral functions which is characterized by dizziness, sallow complexion, and pale lips, tongue, and nails. Moreover, deficiency of blood is closely related to dysfunction of the heart, liver, spleen, and kidney due to the fact that heart is in charge of blood and vessels, liver stores blood, the spleen is the source for production and transformation of qi and blood, and kidney essence can be turned into blood. Blood stasis A. Concept Blood stasis refers to a pathological state of slow or unsmooth circulation of blood, or blood escaping outside from the vessels. Bleeding which pertains to blood stasis often results from fire-heat pathogens forcing blood circulation in a disorder, excessive heat with yin deficiency burning vessels, qi deficiency, blood stagnation, or traumatic injury. Massive bleeding can not only cause deficiency of both qi and blood which leads to hypofunction of viscera but also result in qi escaping with blood exhaustion, even leading to yin-yang dissociation and death. B. Causes Blood stasis usually results from unsmooth blood circulation due to qi stagnation, slow circulation due to qi deficiency, phlegm-turbid stagnating vessels, and coagulation of blood due to invasion of cold pathogen, boiled down of blood due to invasion of heat pathogen, or traumatic injuries. Moreover, stagnant blood which is a pathological product of blood stasis can block vessels and then lead to blood stasis. C. Clinical manifestations When blood stasis blocks in certain locations of viscera or meridians, symptoms of slow and unsmooth blood circulation may occur. It is often manifested by fixed pain even with the formation of swelling which is accompanied by dark complexion, scaly skin, cyanotic lips and nails, as well as ecchymosis. Pathologically, blood stasis often affects qi deficiency, qi stagnation, blood cold, and blood heat. Therefore, apart from blood cold and blood heat patterns, it is often accompanied by the pathological changes such as qi deficiency, qi stagnation, and blood deficiency. Blood heat A. Concept Blood heat refers to a pathological change caused by accelerated circulation or bleeding resulting from heat in the blood. B. Causes Blood heat often results from impairment in blood due to invasions of exogenous heat pathogen or fire-heat transformed by cold pathogen or emotional depression.

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Clinical manifestations Blood heat can cause accelerated blood circulation or abnormal blood flow, disturbed mind, as well as concentration of blood and body fluids. It is characterized by blood loss, bleeding, disturbed mind, and damage of yin. Blood cold A. Concept Blood cold is a pathological change in slow or sluggish blood circulation caused by cold in the blood. B. Causes It is often due to invasion of cold pathogen or yang deficiency. C. Clinical manifestations Due to blood coagulation resulting from cold, blood cold is mainly characterized by slow and unsmooth blood circulation, manifested as numbness with cold pains in limbs, hands, and feet, or cold pain in the heart and abdomen, and abnormal menstruation in women.

9.3.3 Disharmony between qi and blood Qi is closely related to blood, manifested as the interdependence in physiology and interplay in pathogenesis. Since qi can promote, warm, generate, and control blood, disorder of qi will inevitably affect blood. Disharmonies between qi and blood include qi stagnation with blood stasis, qi deficiency with blood stasis, failure of qi to control blood, qi exhaustion following blood, and deficiency of both qi and blood. 1. Qi stagnation with blood stasis Qi stagnation with blood stasis refers to a pathological change in which depressed qi movement makes sluggish flow of blood which leads to the concurrence of qi stagnation and blood stasis. It may result from obstruction of blood circulation due to stagnant flow of qi, or from traumatic injuries. It is characterized by distending pain, ecchymosis, and abdominal mass. Moreover, it is closely related to the liver and the heart. Being able to govern regulating qi, the liver is critical in qi movement. The heart is in charge of blood vessels with function of promoting blood circulation, so dysfunction of the heart can cause blood stasis leading to qi stagnation. 2. Qi deficiency with blood stasis Qi deficiency with blood stasis refers to a pathological state in which sluggish flow of blood results from qi deficiency leading to the concurrence of qi deficiency and blood stasis. Qi deficiency in a milder condition may cause slow flow of blood. If more serious deficiency of qi occurs in some location of the body, it will fail to promote blood flow and result in blood stasis. It is manifested by symptoms due to the malnourishment in the meridians such as feeble limbs even with amyotrophy, dry or scaly skin, or pruritus.

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Failure of qi to control blood Failure of qi to control blood is a pathological state in which deficient qi fails to keep blood flow inside the vessels and leads to various bleeding symptoms such as hemoptysis, hematemesis, hemorrhinia, ecchymosis, hematochezia, hematuria, and uterine bleeding. It also includes sinking of spleen qi causing hematochezia and uterine bleeding. Qi exhaustion following blood damage Qi exhaustion following blood damage refers to a pathological state of deficiency or exhaustion of both qi and blood caused by massive qi exhaustion following heavy bleeding. It often results from traumatic bleeding, uterine bleeding, or postpartum hemorrhage. Deficiency of both qi and blood Deficiency of both qi and blood is a pathological state of concurrence of deficient qi and blood which is usually caused by consumption due to prolonged disease, loss of blood followed by depletion of qi, or inadequate production of blood due to deficient qi or bleeding. It is characterized by pale or sallow complexion, shortness of breath, fatigue, thin body, palpitation, insomnia, dry skin, or numbness of limbs. Qi and blood is the material basis for physiological activities of viscera and meridians in the body. Production and circulation of qi and blood depend on the normal functions of viscera. Therefore, there is an interplay relationship between viscera and qi and blood in pathogenesis.

9.3.4 Metabolic disorders of body fluids Metabolic disorders of body fluids refer to the pathological conditions in which imbalance between generation and excretion of body fluids causes disturbance of body fluids in producing, transporting, distributing, and excreting. It leads to stagnation and overflow of water fluid. Metabolism of body fluids, being a complicated physiological course, is closely related to the lung, spleen, and kidney. Abnormal function of any viscera can cause metabolic disorder of body fluids which results in syndromes of consumption of fluid, fluid exhaustion, endogenous dryness, or retention of water-dampness or phlegm. 1. Deficiency of body fluids Deficiency of body fluids is a pathological condition with a series of dry symptoms caused by scanty body fluids failing to nourish and moisten the viscera, orifices, skin, and hair. It often results from excessive consumption of body fluids due to dry-heat pathogen, pathogenic fire caused by excessive mental activities, fever, burning, too much sweating, vomiting, diarrhea and urine, loss of blood, or overuse of hot medicines. It can be caused occasionally by inadequate intake of water fluid.

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Deficiency of body fluids can be divided into consumption of jin (essence) and exhaustion of ye (fluid) according to different degree of the consumption. There are differences between jin and ye in quality, distribution, and physiological function. So, deficiency of jin is different from deficiency of ye in pathogenesis and clinical manifestations. Jin is thin and watery with more fluidity which can moisten blood vessels and nourish viscera as well as moisten skin and orifices externally. It is easy to be consumed and to escape; however, it is also easily replenished. So, consumption of jin is often manifested as excessive sweating in hot summer, thirst due to high fever, dry mouth, nose, and skin in dry climate, deep sunken eyes, shriveled muscles, and even spasm caused by excessive sweating, diarrhea, and urination. Ye is thicker with less fluidity which nourishes the viscera, replenishes the marrow in the bone, brain, and spine, and lubricates the joints. It is not likely to be consumed, but once consumed, it cannot be rapidly replenished. Exhaustion of ye is often manifested as symptoms of yin fluid depletion such as light-red tongue without fur or with little fur caused by prolonged disease impairing yin, dry lip and tongue, emaciation, withered skin and hair, and even tremors of hands and feet. Consumption of jin and exhaustion of ye are different in pathogenesis and manifestations, but they depend on each other in physiology and interplay in pathogenesis because they are originally as integrity whole. Generally speaking, consumption of jin (which is milder) is definitely not accompanied by exhaustion of ye, but the consumption of the latter (which is more serious) is definitely accompanied by the former. Both of them can be manifested as symptoms of endogenous dryness. As body fluids and blood share the same source, deficiency of body fluids definitely causes deficiency of yin blood which leads to endogenous deficient heat and wind due to blood dryness. Besides, deficiency of body fluids can reduce blood and cause unsmooth flow of blood which leads to blood stasis. The existence of qi depends on the body fluids while metabolism of body fluids depends on qi movement. So, massive loss of body fluids may lead to exhaustions of qi, yin, or yang. Retention of water-dampness Fluid distribution and excretion are the two important links in the metabolism of body fluids. Even though different, they both can result in abnormal stagnations which can be the basic causes for the pathological products such as endogenous water-dampness, phlegm, and retained fluid. Disorder of distribution of body fluids refers to a kind of pathological state in which body fluids cannot be normally distributed, leading to slow flow or stagnation, and resulting in endogenous water-dampness and phlegm. It mainly involves the lung in diffusing and ascending, the spleen in transforming and transporting, the liver in regulating, the kidney in transforming, and triple burners in water passage. In addition, the dysfunction of spleen is mostly apt to cause disorder in distribution of body fluids. Disorders in excretion of body fluids is a pathological state of

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edema caused by retention of water fluid due to hypofunction of body fluids in transformation into sweat and urine. Transformation of body fluids into sweat mainly depends on the diffusing and dispersing actions of the lung. Transformation of body fluids into urine mainly depends on the steaming and qi transforming actions of the kidney, and also relies on the descending action of the lung. Declined functions of both lung and kidney can cause retention of water fluid and lead to edema. In addition, the steaming and qi transforming of kidney play a dominating role in the excretion of body fluids. Although there are differences between distribution and excretion of body fluids, they also interplay and interact as both cause and effect, resulting in endogenous waterdampness, phlegm, and retained fluid. Moreover, metabolic disorders of body fluids can also lead to pathological changes in stagnation of qi movement.

9.3.5 Disharmony among qi, blood, and body fluids Disharmony among qi, blood, and body fluids mainly includes water retention with qi stagnation, qi exhaustion following fluid, fluid exhaustion with blood dryness, fluid deficiency with blood stasis, and blood stasis with fluid retention. 1. Water retention with qi stagnation Water retention with qi stagnation is a pathological state of stagnation of water, qi, or phlegm caused by disorders of metabolism of body fluids due to qi deficiency or qi stagnation. Movement of visceral qi can promote circulation of water and body fluids. Qi deficiency in the lung, spleen, kidney, or liver and qi stagnation in the liver, spleen, or lung definitely causes disorders of distribution and excretion of body fluids, leading to stagnations of water-dampness which is characterized by subcutaneous nodule, numb limbs, goiter, difficult urination, edema, and tympanites. Conversely, water-dampness or phlegm can hinder circulation of qi movement. For example, if retained fluid stagnates in the lung, causing qi blockage of lung, symptoms as cough with dyspnea may occur. If retained fluid represses yang qi in the heart, it may cause palpitation and heartache. When it stagnates in the middle-jiao, depressing qi movement of spleen and stomach, it will lead to sleep, abdominal fullness and distention, poor appetite, nausea, and vomiting. If retained fluid stays in limbs, blocking circulation of qi and blood in the meridians, edema with distending pain in limbs will occur. So in clinic, treatment should be taken based on pathological changes caused by water, qi, and phlegm. 2. Qi exhaustion following fluid damage Qi exhaustion following fluid damage is a pathological state of exhaustion of both qi and yin caused by qi exhaustion due to massive loss of body fluids. It usually results from too much consumption of body fluids due to high fever, excessive sweating, or vomiting and diarrhea.

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Fluid exhaustion with blood dryness Fluid exhaustion with blood dryness refers to a pathological state of endogenous heat and wind due to blood dryness resulting from deficiency or even exhaustion of the body fluids. Body fluids are an important component of the blood, while both come from essence of water and food. Fluid exhaustion with blood dryness may be caused by consumption of fluid due to high fever or empyrosis, massive loss of blood, or by tuberculosis. It is characterized by vexation, dry nose and throat, emaciation, or dysphoria fever in chest, palms, and soles, dry skin or even pruritus with exfoliation, red tongue with little fluid, and thin and rapid pulse. Fluid deficiency with blood stasis Fluid deficiency with blood stasis is a pathological state of unsmooth flow of blood with deficiency of body fluids. Sufficient body fluids is an important condition for blood to circulate smoothly. Deficiency of body fluids may cause deficiency of blood and lead to blood stasis. Fluid deficiency with blood stasis often results from high fever, empyrosis, vomiting, diarrhea, massive sweating, or prolonged disease. It is characterized by deep red tongue or petechia, dry skin or exfoliation, or macula. Blood stasis with fluid retention Blood stasis with fluid retention refers to a pathological state in which unsmooth blood circulation leads to stagnation of body fluids which later on causes retention of blood, water, phlegm, and blood stasis. Body fluids inside the vessels can promote blood circulation, and effused blood can become body fluids. Fluids and blood come from the same origin. Stagnation of blood definitely affects circulation of body fluids which can cause blood stasis and fluid retention. If body fluids accumulate and lead to phlegm and fluid retention or edema which hinder circulation of blood and cause blood stasis, stagnations between blood and water, and retention of phlegm, stagnant blood will finally occur. The clinical manifestations for stagnation of water and blood stasis are amenorrhoea with dropsy, edema, or swelling, dark tongue, or uneven pulse. Phlegm and blood stasis retained in the body is characterized by abdominal mass, accumulation, dysphagia, dysmenorrheal, amenorrhea, sterility, goiter, and gangrene of fingers or toes. So, for these stubborn syndromes, treatments should be taken to invigorate blood circulation, clear water-dampness, expel blood stasis, and reduce phlegm at the same time.

10 Principles of Prevention and Treatment of Diseases 10.1 Principles of disease prevention Key points –

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Principles of prevention: – The criteria of preventing the occurrence, development, and transmission of diseases according to the etiology and mechanism. Preventive treatment of diseases: – The criteria of measurements taken prior to the onset of a disease.

Disease prevention means taking certain actions in advance to prevent a disease from occurring and progressing. Prevention has always played an important role in Chinese medicine. Treating disease before it arises is an idea put forward in Huangdi Neijing (Huangdi’s Inner Classic of Medicine) long time ago. It has great influence on the formation and development of preventive medicine. Preventive principles refer to the criteria of preventing a disease from occurrence and progress according to its etiology and mechanism.

10.1.1 Disease prevention prior to its outbreak Disease prevention means taking certain actions in advance to prevent occurrence of a disease. It was also known as cultivating life or preserving health in ancient times.

10.1.2 Controlling the development of an existing disease Once a disease has already occurred, early diagnosis and treatment are essential to prevent the disease from worsening. 1. Early diagnosis and treatment Early diagnosis and treatment are the key to disease recovery. Treatment is also necessary for the prevention of the disease aggravation. 2. Controlling the progress of a disease The progress of any disease follows its own unique patterns. Hindering the progress of a disease is a major measure to prevent its aggravation. For example, since liver disease is most likely to influence spleen, measures should be taken to strengthen the spleen in order to prevent the influence in treatment of liver disease. It is an effective way to control the progress of the disease.

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10.2 Principles of treatment Key points –

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Routine treatment: – Routine treatment refers to the treatment of a disease adverse to its manifestations, also known as allopathic treatment. It includes the following: – Treat cold with heat, treat heat with cold, treat deficiency by tonifying, and treat excess by drainage. Contrary treatment: – Contrary treatment refers to the treatment of a disease agreeable to its false manifestations, also being named coactions treatment. It includes the following: – Treat coldness with cold, treat heat with heat, treat the flowing by promoting its flow, and treat obstruction with tonics.

The treatment principles are the rules to be followed in all treatments. They are formulated under the guidance of holism and treatments based on syndrome differentiation. They are the universal guiding principles for the determination of treatment methods, formulas, and medicinals in the clinic settings. A treatment principle is different from a treatment method. Guided by the former, the latter refers to detailed therapeutic rules and methods in accordance with various syndromes. They include major therapeutic methods of diaphoresis, emesis, purgation, harmonizing, warming, clearing, eliminating, and reinforcing. There are a lot of treatment principles and methods in Chinese medicine. The treatment principles are discussed in this chapter.

10.2.1 Treating the root of a disease Treating the root refers to seeking the fundamental cause of a disease and focusing the treatment on it. This is the cardinal principle for differential diagnosis and treatment in Chinese medicine. According to the principle, traditional Chinese medicine (TCM) formulates the basic treatment principles based on the severity and the clinical manifestation. 1. Routine treatment versus contrary treatment A. Routine treatment Routine treatment refers to the treatment of disease adverse to its manifestation, also known as allopathic treatment. It uses the formulas and herbs which act against its syndromes to treat. It is applicable to a disease with its nature in conformity with its manifestations. For example, a heat syndrome is marked by heat signs, a cold syndrome by cold signs, a deficient syndrome by deficient signs, and an excess syndrome by excess signs.

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Routine treatment includes methods of heating what is cold, cooling what is hot, tonifying what is deficient, and reducing what is excessive. (a) Treat cold with heat: A cold syndrome with cold manifestations should be treated with warm or hot recipes. For example, relieving an external syndrome with warm drugs is used to treat a wind-cold syndrome of external type, and warming interior with hot drugs is used to treat a cold syndrome of internal type. (b) Treat heat with cold: A heat syndrome with heat manifestations should be treated with cool or cold recipes. For example, relieving an external syndrome with cool drugs is used to treat a wind-heat syndrome of external type, and relieving interior with bitter-cold drugs is used to treat heat accumulation in the stomach and intestines. (c) Treat deficiency by tonifying: A deficiency of vital qi with deficiency signs should be treated with tonifying recipes. It includes methods of tonifying yang, and qi, nourishing yin, and enriching the blood. (d) Treat excess by purging: Excess of pathogenic qi with excess signs should be treated with purgative recipes. It includes methods of dispersing and removing indigestion, dispelling retained water, promoting blood circulation by removing blood stasis, and expelling parasites. Contrary treatment Contrary treatment refers to the treatment of a disease agreeable to its false manifestations, also being named coactions treatment. It is applicable to complicated morbid states in which the nature of a disease is not completely in conformity with its manifestations. Although the treatment is going on with the false manifestations of the disease, it is aiming at the root of the disease. Contrary treatment mainly includes treating cold with cold, treating heat with heat, treating obstruction with tonics, and treating flow by promoting its flow. (a) Treat cold with cold: Diseases of true heat syndrome with false cold symptoms should be treated with cold or cool medicinals. For example, in the stage of extreme internal heat of some exogenous diseases, there may appear false cold signs of extremely cold limbs, with true heat signs of hyperpyrexia, restlessness, thirst, red tongue, and full and rapid pulse due to predominant yang rejecting yin. So it still needs cold or cool medicinals such as Baihu decoction for treatment. When the pathogenic qi of yang heat is cleared away, false cold disappears subsequently. (b) Treat heat with heat: Diseases of true cold syndrome with false heat symptoms should be treated with warm or hot medicinals. In treatment of this kind of diseases, aiming the root, warm or hot medicinals should be used. When the pathogenic qi of cold yin is cleared away, false heat disappears subsequently.

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(c) Treat obstruction with tonics: Obstructive diseases with true deficiency syndromes and false excess symptoms are treated with tonifying medicinals, also known as relieving obstruction with tonics. It is suitable for syndromes of obstruction and stagnation caused by deficiency. For example, abdominal distension and fullness caused by deficiency of spleen and qi stagnation should be treated by tonifying spleen and replenishing qi. When the spleen and stomach function normally in transportation, distension and fullness disappear spontaneously as well as constipation due to deficiency of qi, dysuria due to deficiency of kidney function, and amenorrhea due to blood exhaustion. (d) Treat the flowing by promoting its flow: Diseases with true excess syndromes and false deficiency symptoms should be treated with purgative medicinals. It is applicable to syndromes of diseases caused by stagnation of excess pathogens, for example, dysentery caused by stagnation of damp-heat in the large intestine. Treatment is focused on clearing heat, promoting dampness, moving qi, and relieving the stagnation. Once damp and heat are cleared away, diarrhea ceases spontaneously. Other examples are diarrhea due to food stagnation and metrorrhagia due to blood stasis. They can be treated with stagnationrelieving, blood-invigorating, and stasis-resolving herbs. Thus, this treatment principle is called treating flowing by promoting its flow.

2.

Routine treatment is the general treatment criteria which go against the manifestations of diseases while contrary treatment is a method which goes with the false manifestations of diseases. Besides, both of them focus on the root of a disease, so they embody the basic treatment principle of treating the root. Treating root or branch aspect of diseases A. Concept of root or branch aspect The root and the branch treatments are relative concepts with multiple meanings. They are used to explain the primary and the secondary relationships among various contradictions in the course of a disease. In the course of a disease, its root and branch aspects are determined by the development of the disease. For instance, viewing the two sides of the vital and pathogenic qi, vital qi is the root and pathogenic qi is the branch. In terms of etiology and manifestation, etiology is the root and manifestation is the branch. According to the order of diseases, an old or a primary disease is the root while a new or a secondary disease is the branch. B. Applications of root and branch treatment In the complicated cases, there will be different treatment aspects of root and branch with regard to the onset and severity of the diseases. Generally speaking, the root is the primary contradiction or the primary aspect of a contradiction, while the branch is the secondary contradiction or the

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secondary aspect of a contradiction. However, under some exceptional circumstances, the primary and secondary relationships of a contradiction can be changed. Namely, the branch becomes the primary aspect of the contradiction, while the root becomes the secondary aspect temporarily. Only by resolving the primary contradiction of a disease, after distinguishing the root from the branch, can the essence of a treatment be grasped. Therefore, the treatment principles should be as follows: “in urgent conditions, treat the branch; in moderate conditions, treat the root and treat both root and branch.” (a) Treating the branch in urgent conditions: During disease onset, if the branch is acute and severe, then it should be treated first to increase the life expectancy of the patient. For example, bleeding should be stopped to avoid massive blood loss and relief should be provided when a patient is suffering from dyspnea to avoid apnea, which might otherwise lead to death. After the bleeding has been stopped and the breathing has been stabilized, further diagnosis and treatment aiming the root of disease should be done. As another example, for patients with hyperpyrexia, intense pain, unconsciousness, or hyperspasmia, regardless of the reason behind the cause, emergency measures should be taken first to bring down the fever and to relieve the pain and spasm. Moreover, for those who suffer from a chronic disease and newly contract other pathogens, the old disease is the root aspect and the new contradiction is the branch aspect. In routine treatment, the exogenous contraction will be treated first, and then the old disease will be treated after the new disease is cured. It can, thus, be concluded that treatment of the branch in an emergency situation is an expedient measure to create a favorable condition for treating the root. The final goal will be to focus on a better treatment for curing the root of the disease. (b) Treating the root in moderate conditions: For a chronic disease or during the recovery stage of an acute disease, treatment should be focused on the root aspect. The branch aspect of a disease will be cured subsequently when the root issue is resolved, because it usually originates from the root aspect. In general, if the branch aspect of a disease does not affect the treatment of the root aspect or does not endanger a patient’s life, then in such moderate conditions the treatment should be based on the principle of treating the root. For example, consider coughing due to tuberculosis, where the lung and kidney yin deficiency is the root aspect, while cough is the branch aspect. Therefore, the treatment should focus on nourishing yin of the lung and kidney, which is the root. Moistening the yin fluid of the lung and kidney will relieve the cough naturally. As another example, at a

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later stage of an acute disease, the pathogenic qi is eliminated, while the vital qi is still deficient. In such a condition, the treatment should be focused on the root to tonify the vital qi, which will cure the branch aspect of the disease simultaneously. (c) Treating the branch and the root simultaneously: When the branch and root aspects of a disease are both severe, treatment should be focused on both. For a complicated disease, where the branch and root aspects are of equal importance as they interlace with each other, treatment should be aiming at both the branch and the root simultaneously because the disease will not be cured if only one aspect is considered. For example, consider cold caused by qi deficiency. Qi deficiency is the root aspect, and cold is the branch aspect. In such conditions, simply tonifying qi will cause stagnation of pathogenic qi and cold cannot be cured, and simply relieving external syndrome will impair the vital qi. Therefore, only by tonifying qi and relieving external syndrome simultaneously, or by treating both root and branch aspects, the cold can be cured.

10.2.2 Strengthening the vital and dispelling the pathogen Strengthening the vital and dispelling the pathogen are an important principle in clinical treatment. The struggle between the vital and the pathogenic qi determines the progress of a disease. When the pathogen gains the upper hand, the disease progresses, and when the vital gains the upper hand, the disease subdues. Thus, the treatment should be carried out to change the ratio of strength between the two sides, improve the vital qi, eliminate the pathogenic qi, and speed up the recovery process. 1. Concepts of strengthening the vital and dispelling the pathogen A. Strengthening the vital Strengthening the vital refers to tonifying the vital qi, strengthening the constitutions, and improving the body’s resistance against the disease and the ability to recover. The specific measures to replenish the qi, blood, and body fluids are diverse, including drugs, acupuncture and moxibustion, qigong, regulation of emotions and diet, and physical exercise. Tonifying the deficiency is the specific application of this principle. B. Dispelling the pathogen Dispelling a pathogen refers to the elimination of the pathogenic qi, relieving the invasion, and impairment of pathogenic qi. The specific measures to remove the pathogens include drugs, acupuncture and moxibustion, and massage. Treating excess with drainage is the specific application of this principle.

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Application of strengthening the vital and dispelling the pathogen In general, strengthening the vital is used for a deficient syndrome, while dispelling the pathogen is used for an excessive syndrome. If a syndrome is mixed with deficiency of vital qi and excess of pathogenic qi, it should be treated by both strengthening the vital and dispelling the pathogen. During the treatment, attention should be paid to differentiate the primary from secondary and degree of urgency, so that strengthening the vital and dispelling the pathogen can be taken up in the order of importance and priority. A. Strengthening the vital Strengthening the vital is applicable to a deficiency syndrome in which deficiency of vital qi is the primary contradiction and pathogenic qi is not exuberant. It is realized by tonifying and replenishing. For instance, qi deficiency is treated by tonifying qi, blood deficiency by enriching the blood, yang deficiency by strengthening the yang, and yin deficiency by nourishing the yin. B. Dispelling the pathogen Dispelling the pathogen is applicable to an excess syndrome in which exuberance of pathogenic qi is the primary contradiction and meanwhile vital qi does not decline. It is enforced by purgation. Treatment methods such as diaphoresis, emesis, purgation, heat-clearing, and stagnation-resolving are all guided by this principle. For example, diaphoresis is used to relieve excessive external syndrome, phlegm and retained food due to pathogens retained in the chest are treated by emesis, heat accumulation in the stomach and intestines are treated by purgation with bitter cold drugs, and accumulation of heat and fire are treated by clearing heat and purging fire. C. Combining strengthening the vital with dispelling the pathogen The combined method is applied to complicated diseases mixed with deficiency of vital qi and excess of pathogenic qi. For such syndromes, if vital qi is not reinforced, pathogenic qi will increase, whereas if pathogenic qi is not eliminated, vital qi will be impaired further. Therefore, in such conditions, strengthening the vital combined with dispelling the pathogen should be used. According to the degree of deficiency of vital and excess of pathogen, this principle can be applied as follows: (a) Strengthening the vital prior to dispelling the pathogen: This method is applied to the syndromes of deficiency of vital qi with excess of pathogenic qi, in which vital qi cannot withstand attack. Though there is excess of pathogenic qi, vital qi should be first reinforced by tonifying as it is too weak to withstand the attack. When vital qi becomes vigorous enough to withstand the attack, treatment should be given to eliminate the pathogen. For instance, for patients with parasite accumulation, since the spleen qi has already declined to extremes and cannot withstand pesticides, vital qi should be first strengthened by tonify-

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ing the spleen and benefiting the qi. When deficiency of the spleen qi is gradually relieved, treatment measures should be taken to dispel the parasites. (b) Dispelling the pathogen prior to strengthening the vital: This method is applied to the syndromes of excess of pathogenic qi with deficiency of vital qi, where the pathogens should be eliminated urgently but the vital qi can still withstand the attack. Under this circumstance, pathogens should be eliminated first by purgation, followed by regulation and tonification. For example, consider blood deficiency caused by blood stasis, metrorrhagia, and metrostaxis. If blood stasis continues, metrorrhagia and metrostaxis cannot be stopped and blood deficiency will worsen. So, blood stasis should be dispelled by invigorating the blood and tonifying the blood afterward. (c) Strengthening the vital as the main focus while dispelling the pathogen: This method applies the principle of strengthening the vital as the main focus of treatment while dispelling the pathogen at the mean time. It is suitable for syndromes with deficiency of vital qi as the primary contradiction and exuberance of pathogenic qi as the secondary contradiction. For such syndromes, if vital qi is not reinforced, pathogenic qi will become more exuberant, whereas if pathogenic qi is not eliminated, vital qi will be impaired further. In treating this kind of diseases, the principle should be strengthening the vital and dispelling the pathogen simultaneously. For instance, for the syndrome of blood stasis in the heart vessels caused by heart qi deficiency, treatment should focus on tonifying heart qi along with invigorating blood and removing blood stasis. Because qi serves as the commander of the blood, vigorous qi of heart can promote circulation of blood, and then the blood stasis will be removed. Blood, the mother of qi, can carry qi in its circulation. So, after blood stasis is eliminated, the qi stagnation can be relieved. The two aspects are dependent upon and supplementary to each other. (d) Dispelling the pathogen as the main focus while strengthening the vital: This treatment principle emphasizes on dispelling the pathogen as the main focus and strengthening the vital is secondary. It is applied to the syndromes with exuberance of pathogenic qi as the primary contradiction and deficiency of vital qi as the secondary. For such syndromes, if pathogenic qi is not eliminated, vital qi will be impaired further, whereas if vital qi is not reinforced, pathogenic qi will become more exuberant. Therefore, treatment should be focused on dispelling the pathogen and simultaneously be combined with strengthening the vital. For example, damage of yin by heat should mainly focus on clearing the heat first and then nourishing the yin.

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The specific methods of application of strengthening the vital and dispelling the pathogen are as follows: A. Single (a) Application – Strengthening the vital – applicable to a deficiency syndrome. – Dispelling the pathogen – applicable to an excess syndrome. B. Combined (a) Application – Applicable to complicated diseases mixed with deficiency of vital qi and excess of pathogenic qi. – Strengthening the vital combined with dispelling the pathogen – applicable to syndromes mixed with deficiency and excess in which deficiency of vital qi is the primary contradiction. – Dispelling the pathogen combined with strengthening the vital – applicable to syndromes mixed with deficiency and excess, in which excess of pathogenic qi is the primary contradiction. C. Alternate (a) Application – Applicable to complicated diseases mixed with deficiency of vital qi and excess of pathogenic qi. – Dispelling the pathogen prior to strengthening the vital – applicable to syndromes with excess of pathogenic qi in which vital qi can still withstand attack though deficient. – Strengthening the vital prior to dispelling the pathogen – applicable to syndromes with deficiency of vital qi which cannot withstand attack.

10.2.3 Regulating yin and yang According to the TCM, the fundamental mechanism behind the occurrence of a disease is the disharmony of yin and yang. Different syndromes of cold, heat, deficiency, and excess occur due to the deficient or excessive change in yin or yang. Therefore, regulating yin-yang and restoring their relative balance and coordination is the fundamental treatment principle. This principle includes two aspects: eliminating the surplus and supplementing the deficiency. 1. Eliminating the surplus This principle is to treat syndromes with an excess of yin or yang by reducing it in order to restore the balance and harmony. An excess of yin or yang is often due to the invasion of yin or yang pathogens. Therefore, the principle of eliminating the surplus should be applied, that is, cooling what is hot, or clearing away yang heat with cold-natured remedy is used for an excess-heat syndrome

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due to exuberance of yang heat, and heating what is cold, or dispelling yin cold with heat-natured remedy for an excess-cold syndrome due to exuberance of internal yin cold. Due to the mutual restriction between yin and yang, the exuberance from either will affect the other as well as result in deficiency and will lead to difficulty in recovery. Supplementing the deficiency This principle is applied to treat syndromes with the debilitation of yin or yang by supplementing insufficient yin or yang and restoring the balance between them. Debilitation of yin or yang includes deficiency of yin, deficiency of yang, and deficiency of both yin and yang. Therefore, treatment principles should be applied accordingly. A. Nourishing yin to restrict yang This therapeutic principle nourishes yin to restrict relatively excessive yang. It is applied for yin deficiency. Yin cannot restrict yang due to its deficiency and yang becomes preponderant. As a result, the syndrome of deficiency-heat occurs, which should be treated by nourishing yin so as to restrict yang, that is, nourishing yin to restrict hyperactivity of yang. B. Tonifying yang to restrict yin This therapeutic principle tonifies yang to check preponderant yin. It is applied to yang deficiency. Yang cannot restrict yin due to its deficiency and yin becomes preponderant. As a result, the syndrome of deficiencycold occurs, which should be treated by tonifying yang so as to restrict yin, that is, supporting yang to eliminate preponderance of yin. C. Supplementing both yin and yang This principle is to treat the syndromes of both yin and yang deficiency. Yin deficiency should be treated by nourishing yin, yang deficiency by tonifying yang, and deficiency of both yin and yang by supplementing both yin and yang. In clinical application, attention should be paid to differentiate which side is more predominant so that nourishing yin and tonifying yang can be taken up in the order of importance. (a) Seek yang in yin: This principle involves adding yang-tonifying herbs in the yin-nourishing formula. It is applied to the syndromes of yin deficiency or deficiency of both yin and yang with yin deficiency as the primary contradiction. Based on the theory of interdependence between yin and yang, inferiority of either yin or yang may affect each other. Therefore, when treating the syndrome of yin deficiency, nourishing yin only cannot reinforce deficient yin, and tonifying yang only will damage yin further. So, if nourishment of yin is supplemented by tonifying yang, the source of yin will last continuously. This syndrome of deficiency of both yin and yang always manifests in the cases of severe deficiency of yin, which can hardly produce yang.

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(b) Seek yin in yang: This principle involves adding yin-tonifying herbs to the yang-nourishing formula. It is applicable to yang deficiency or deficiency of both yin and yang with yang deficiency as the primary contradiction. Based on the theory of interdependence between yin and yang, treating the syndrome of yang deficiency by tonifying yang alone will impair yin while nourishing yin alone will make yang escape. So, if tonifying yang supplemented by nourishing yin, the source of yang will last infinitely. This syndrome of deficiency of both yin and yang is always caused by long-term deficiency of yang.

10.2.4 Regulating qi and blood Qi and blood are the essential substances for the maintenance of life activities and also the material basis of functional activities of organs and tissues. Therefore, regulating qi and blood is not only a therapeutic principle aiming at disorders of qi and blood but also an important principle of treating diseases.

10.2.5 Regulating the viscera Guided by the holism concept, the rule of regulating the viscera is stipulated according to the disorder of visceral function. The detailed methods are made according to the theory of five elements, the relationship among the viscus, and the characteristics of the viscus.

10.2.6 Three optimal treatment administrations 1.

Treatment in accordance with chronological conditions This treatment principle is applied according to the time, person, and place which are affected by many internal and external factors. Therefore, in clinical treatment, seasonal climates, geographic environments, and individual differences should all be taken into account, and appropriate methods should be selected according to the specific conditions. The treatment principles are based on the features of the seasonal climates. Since the seasonal variations of the weather affect the human body to a large extent physiologically and pathologically, treatment and prescription should be selected accordingly. For example, in spring and summer, when weather changes from warm to hot and yang qi ascends, the striae of body become looser. During this period, even for external contraction of wind-cold, pungent-warm dispersing herbs, such as Ma Huang and Gui Zhi, should be used

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3.

cautiously so as not to impair qi and yin due to excessive dispersion. In autumn and winter, when weather turns cold from cool and yin becomes preponderant with decline of yang, the striae become tighter and yang qi retreats interiorly. So, herbs with cool or cold nature, such as Shi Gao and Bo He, should be used cautiously to avoid impairment of yang qi. Therefore, for different seasons and climates, the herbal dosage as well as the nature of the herbs (cold or hot) should be selected accordingly, which means the use of Xiang Ru in summer is like the use of Ma Huang in winter, and Ma Huang should not be used in summer and Shi Gao should not be used in winter. Treatment in accordance with geographic conditions This treatment principle is based on the different features of geographic environments. In different regions and geographic environments, there are different climatic conditions and customs. Therefore, patient’s constitutions and physiological conditions vary as well. The treatment principle should be selected accordingly. For example, in the northwestern highlands of China, it is cold and dry with little rainfall. So, disease of wind-cold and dryness are commonly seen and usually treated by pungent-moistening formula, while cold-cool and dry remedy should be used cautiously. In the southeastern coastal regions of China, it is hot and damp with plentiful rainfall. So, disease of damp-heat is commonly seen and should be treated by heat-clearing and damp-resolving herbs, while damp-inducing herbs with warm or hot nature should be used with great care. Treatment in accordance with individuality This treatment principle is based on different age groups, genders, constitutions, living habits, and occupations. A. Age Different age groups often present with different physiological conditions and pathological changes. Aged people often suffer from deficiency syndrome or syndrome of deficiency-excess in complexity due to deficient qi and blood as well as decline of physiological functions. They should be mainly treated by tonifying methods. Even when there are excess pathogens, drastic medicine, large dosage, and long-term treatment are not advisable. As to children, they are vigorous in physiological functions, but their qi and blood are not sufficient enough and their viscera are tender and delicate. For them, drastically purgative remedies should be avoided, tonics should be carefully used, and dosages should be smaller. B. Gender Women differ from men physiologically. Women have special conditions such as menstruation, leucorrhea, pregnancy, and delivery, which all need to be considered when prescribing. For example, during pregnancy, drugs of drastic purgation and blood stasis-breaking, water-promoting, moving, and toxic herbs should be forbidden or used cautiously. After childbirth, in

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case of deficiency of qi and blood, breast-feeding and lochia should be taken into account. Constitutions Different types of constitutions not only produce direct effect on the occurrence of a disease but also result in different responses to the medicinal treatment. Therefore, constitutional factors must be taken into consideration in treatment. For instance, for the same disease, individuals with constitution of yin deficiency and yang excess should be treated cautiously by herbs of warm, hot, pungent, and dry nature, while those with constitution of yang deficiency and yin excess should contraindicate herbs of cold, cool, and raw and cold food. The ones with strong constitution and high tolerance can be treated by large dosages of drastic herbs, while those of weak constitution and low tolerance should be treated by small dosages of mild herbs. In addition, attention should also be paid to the individual’s psychological state, occupational features, working conditions, and living environments, for they are all related to the occurrence of a disease.

In conclusion, patient’s individual characteristics and physical environment should all be taken into consideration when it comes to treatment. The three considerations of time, person, and place fully embody the holism and syndrome differentiation of the Chinese medicine. It is well applied in clinical practice. Only by comprehensively observing the conditions and concretely analyzing the specific circumstance can one gain a better treatment.

References 1. 2. 3. 4. 5. 6. 7. 8.

HE YM. 2004. Introduction to Traditional Chinese Medicine. Beijing: China Union Medical University Press. ZHANG YF. 2004. Visceral Manifestations Theory of Tradtional Chinese Medicine. Beijing: China Union Medical University Press. HU DP. 2004. Etiology and Pathogenesis Theory of Traditional Chinese Medicine. Beijing: China Union Medical University Press. ZHANG DB. 2007. Fundamentals of Traditional Chinese Medicine. 2nd Version. Beijing: Chinese Press of Traditional Chinese Medicine. GAO SH, WANG J. 2012. Basic Theories of Traditional Chinese Medicine. 2nd Version. Beijing: People’s Medical Publishing House. GUO XZ. 2012. Basic Theories of Traditional Chinese Medicine. 2nd Version. Shanghai: Shanghai Science and Technology Press. HE JC. 2012. Fundamentals of Traditional Chinese Medicine. Beijing: People’s Medical Publishing House. XIE N. 2012. Fundamentals of Traditional Chinese Medicine. Beijing: Higher Education Press.