Section 2 The Pathological Mechanism of Exogenous Febrile Diseases
The exogenous febrile diseases (EFDs) are the diseases caused by the attack of exogenous evils, such as the six climatic evils and pestilential evils. Because fever often is the main symptom, they are named exogenous febrile diseases. The pathomechanism of EFDs refers to the pathologic process that follows the invasion of the exogenous evils. It he general regularity of the occurring, developing, and transforming of EFDs. EFDs are different from endogenous diseases in the following aspects: In EFDs, the main cause is exogenous evils, and the pathologic processes can be divided into different stages. The special feature of each stage is shown when EFDs develop from the exterior to the inter or, from the superficial to the deep, and from excess to deficiency.
There are two theories about the pathomechanism of EFDs: the theory of cold-ai
tack disease, and the theory of warm disease. The two theories deal with the some subject. The theory of cold-attack disease places more emphasis on the exogenous cold evils It holds that the cold evils invade the human body from the skin and cause EFDs. The disease transmits along the six meridians and can be differentiated with the six meridian syndrome differentiation. The theory of warm disease holds that most EFDs are cause by an invasion of warm or heat evils through the mouth and nose, and the disease transmits in the sequence of wei, qi, ying and xue, or the uppermid- and lower-jiao, an can be classified with either the wei,qi, ying, xue syndrome differentiation or triple-jiao syndrome differentiation.
Though the two theories differ in their approach to the pathomechanism of EFDs
common points do exist. As regards the changes of EFDs, both theories hold that the
spreading of pathologic factors are from exterior to interior, upper to lower, superficial to deep, and mild to severe. When pathologic factors enter the interior they transform mainly into the heat evil, and lead to excessive heat in stomach and intestines, regardless of what kind of evils they are. So the Yangming disease of cold attack in six meridian syndrome has common point with the qi-stage disease (in wei-qi-ying-xue diseases) and middle-jiao disease (in triple-jiao diseases) of warm disease.
The differences between two theories are that cold evil is apt to hurt yang, and can attack the three yang meridians directly, while warm and heat evils are prone to injure yin, and in some cases heat can hide in the interior of body. The yang deficiency predom inates in three yin meridian syndromes of cold-attack, while yin and body-fluid deficiency can be seen in the ying and xue stages, or lower-jiao syndrome of the warm disease. The two theories are discussed below.
I. The Pathological Mechanism of the Six Meridians
The six meridians refer to the three yang and three yin. Three yang are Taiyang,
Yangming, and Shaoyang, and the three yin are Taiyang, Shoyin, and Jueyin. The
pathomechanism of six meridians is the general regularity of EFD's occurring and developing in the cold-attack diseases.
The development of six meridian diseases is the result of combat between the genuine-qi and evil-gi after the invasion of exogenous factors. This fight leads to a functioa disorder of viscera and meridians, which is followed by a series of pathologic changes.
Generally speaking,in the initial and middle stage ,the genuine-qi is exuberant and has a strong resistance. The evil-qi is exorbitant as well. The nature of the disease is manifested as heat and excess. Then,the genuine-qi and body resistance become weaker and the evil-qi is still in action. The genuine-qi can not match the evil-qi, and the body reaction lowers. At this point ,the nature of disease is manifested as cold and deficiency.
The exogenous evils develop from exterior to interior step by step. The Taiyang disease is the initial stage of cold-attack. In this stage ,tbe evil-qi is in the exterior. The Yangming disease is the extreme stage. The evil-qi enters the interior and transforms into heat in this stage. The Shaoyang disease is the transition stage of half-exterior and halfinterior. Disease in this stage is characterized by the deeper position of the evil-qi and insufficient genuine-qi The evil-qi is easily able to enter the three yin meridians and causes three yin diseases. Taiyin disease is a stage of spleen deficiency with exorbitant dampness. Shaoyin disease is a stage of both heart and kidney deficiency. Jueyin disease is a stage of complicated cold and heat and alternation of yin and yang.
1. Pathological Mechanism of Taiyang Disease
Taiyang dominates the exterior part of the body and commands the nutritive qi and defensive qi. Under normal conditions, it is firm and tight on the body surface, and serves a defensive function while the nutritive and defensive qi are in harmony. The skin and hair are on the body surface and components of the body fence. Their normal funclions rely on the lung's function of dispersing defensive-qi and body-fluid. Because of this,the function of Taiyang to dominate the exterior is actually a summarization of the lung and defensive qi.
The meridian of Taiyang goes upwards to the top of the head and enters into the
brain, and then goes downwards along the medial side of the arm. The fu-viscus of Taiyang is the urinary bladder which is in a exterior-interior relationship with the kidney. So the disease of Taiyang often relates closely to urination and sweating.
Taiyang diseases are the initial stage of EFDs. They can be classified into meridian syndrome and fu-viscus syndrome as follows:
(1) The pathological mechanism of Taiyang meridian syndrome: When the wind-
cold evil attacks the body surface ,the Taiyang meridian,the lung,and the defensive qi,the firstly affected parts. The genuine-qi fights with the evil-qi. The nutritive qi and ensive qi are in disharmony. The exterior loses its control and regulation. Lung also is etted, and it fails to disperse and descend. The symptoms of fever and aversion to cold are caused by the evil's attack on the exterior. Because the evil-qi invades the Taiyang
Meridian,obstruction of meridian-qi, headache,stiff neck,and general pain can occur.
If the nutritive qi and yin are insufficient in ordinary times,the interstitial space becomes loose and infirm, and wind attacks the exterior, causing disharmony between nutrient and defensive qi. In this case, the defensive qi fails to control the opening and closing of the body surface, and the Taiyang wind-stroke syndrome is often seen. If, however, cold attacks the exterior and blood does not circulate freely, the Taiyang cold-attack syndrome is then the main problem. The Taiyang wind-stroke syndrome is a relative deficiency condition of the exterior syndrome, manifested by sweating and a floating mild pulse. The Taiyang cold-attack syndrome is a relative excessive condition of the exterior syndrome, characterized by a lack of perspiration and a floating tight pulse. Both of these syndromes belong to the category of meridian syndromes of Taiyang, though some disparity exists between them.
(2) The Mechanism of Taiyang visceral syndrome: Most cases of this syndrome occur after a prolonged Taiyang meridian syndrome. This is because the pathogenic factor
enters into the bladder or small intestine. The position of this disease is in two different stages, namely the qi-stage and blood-stage. The syndrome also can be divided into two sub-syndromes: the water accumulation syndrome and the blood accumulation syndrome.
The occurrence of water accumulation syndrome is due to a prolonged of Taiyang exterior syndrome (meridian syndrome). The heat evil enters into the urinary bladder along the meridian. The qi transformation function of the bladder is disturbed. Qi is in stagnation and water is retained, thus forming the water accumulation syndrome. Clinical symptoms include lower abdominal pain, distention, and oliguria.
The blood accumulation syndrome is caused when the heat evil enters into the lowerjiao along the meridian. The heat evil invades the blood and accumulates in the lower-jiao with the blood. Heat combined with blood stasis forms the blood accumulation syndrome.A contraction of inferolateral abdomen, normal urination, and mental disorder are the clinical symptoms. According to some studies, the blood stasis does not stay in urinary bladder, but rather in the small intestine with the heat evil. The main difference of the clinical manifestation between this syndrome and water accumulation syndrome is their effect on the urination and the patient's mental state.
There is a maxim that "excess is in Taiyang while deficiency is in Shaoyin. " In the process of Taiyang disease, if the exterior syndrome is not relieved or is improperly treated, the evil-qi will enter the deeper part of body from fu-viscera to zang-viscera. The heart or kidney (Shaoyin) also is involved, and the yang deficiency of heart and kidney will appear.
2. The Mechanism of Yangming Disease
The Yangming disease is a stage in which the heat evil is at its most exorbitant state in the process of EFDs.
Yangming refers to the stomach and large intestine. The stomach has a exterior-interior relationship with the spleen, and the large intestine has the same relationship with the lung. They are very closely related in both physiological and pathological conditions.The stomach is the sea of food. It dominates food receiving and dissolving. The stomach and large intestine are the place where the qi, blood, and body fluid are generated. They are fu-viscera that are rich of qi and blood. Stomach is a yang fu-viscus, and belongs to the earth in the five elements theory. It requires to be moisturized and is hurt by dryness.When pathogenic factors invade the stomach, they often are transformed into dryness.The syndromes of Yangming have a character of heat, dryness, and excess. Most of the Yangming diseases belong to the excess syndrome of the stomach and large intestine. So there is a saying of excessive syndromes of gastrointestinal tract".
Yangming disease has a number of possible causes. It may be the result of improper
treatment of Taiyang disease, which would cause that condition to be transformed into Yangming disease. Likewise, it also can be transformed from Shaoyang disease, due to the improper applications of some therapeutic methods such as sweating (diaphoresis),vomiting (emetic therapy), purgation, and inducing diuresis, all of which can cause the exhaustion of the body fluid. A third possible cause is that some dry-heat evils can attack Yangming directly and cause Yangming disease.
In this stage, the yang-qi of the body is in their most exuberant state. When yang-qi is overwhelming, heat will be produced. The heat evil is also in its most exorbitant state. Like Taiyang disease, the patho-mechanism of Yangming disease can be classified into meridian syndrome and fu-viscera syndrome.
(1) The pathological mechanism of Yangming meridian syndrome. In this condi-
tion, the evil-qi enters the interior and transforms into heat. The exorbitant heat and dryness consume body fluid. They can also go up and disturb the mind in heart. At this point, though heat and dryness occupy the entire body from outside to inside, they are still shapeless evils and there is no dry-stool obstructed in intestines. The clinical characteristics are high fever, profuse sweating, thirst, surging pulse and restlessness.
(2) The pathological mechanism of Yangming fu-viscera syndrome. In this condi-
ti0n, the evil enters the interior and forms dry-heat. The dry-heat evil meets the food waste in the intestine. After the body fluid is consumed, the food waste becomes hard and firm stools, or the dry-stool in the body. Then the dry-stool obstructs the intestines nd inhibits the descending of the intestine-qi. The dry-heat evil and the turbid-qi of the intestlnes attack the upper part of the body, and the mind in heart will be impaired. The syndrome can manifest by tidal fever, delirium, constipation, abdominal pain and fullness with guarding, and excessive or forceful pulse.
Besides the two syndromes mentioned above, there is another condition of the Yang ruing disease. It is caused by heat-evil's inability to diverge to the outside. The heat-evil combines with blood, and forms heat-blood-stasis. This blocks the bile flow, and does not allow the bile to flow into the intestine. So the bile flows instead reversely into the blood, creating the symptom of jaundice. This condition is called Yang ruing jaundice.
"Excess in Yangming while deficiency in Taiyin," implies that if the Yangming disease is treated by purgation too early or in an overly drastic manner, the spleen (Tai-yin)-yang will be hurt. That will make the strong resistance become weak. The nature of disease will convert from heat to cold and from excess to deficiency. Then the Yangming disease will transform into the Taiyin disease, which is characterized by the spleen deficient cold.
3. The Pathological Mechanism of Shaoyang Disease
The Shaoyang disease is a disease with a situation that is neither in the exterior nor the interior. It is a transition stage between the exterior and interior, and so it is named half-exterior and half-interior syndrome.
The Shaoyang refers to the gall bladder and triple-jiao. They have exterior-interior relationships with the liver and pericardium. The gall bladder is located in the interior to the liver. It stores bile and dominates the functions of conveyance and dispersion. When the gallbladder is smooth and free, the liver will function well. The bile being dredged into the intestines helps in the digestion and absorption of food. The normal functions of the gallbladder, spleen, and stomach are a reflection of the state of harmony between the liver and gallbladder.
The physiological function of triple-jiao is to coordinate all of the qi and dredge the water passage. The function of Shaoyang is comprehensive the functions of the gallbladder and triple-jiao. In a pathologic condition, changes of Shaoyang often affect the gallbladder, triple-jiao, liver, and stomach.
Shaoyang disease is mainly caused by a prolonged Taiyang disease which transmits to inner part of the body. It can also be caused by the direct attack of evil, when the genuine-qi and evil-qi wrestle between the exterior and interior.
The main pathomechanism of Shaoyang disease is that evil in Shaoyang makes the
liver and gallbladder qi flow reversely, Or makes liver and gallbladder-fire flame up. The evil could also cause qi stagnation in the liver and gall bladder, or in the Shaoyang Meridian. The stagnated qi will impact the spleen or stomach and lead to a syndrome of disharmony between the liver and spleen or stomach. The main symptoms are alternative fever and chill, fullness of chest or hypochondrium, apathy, poor appetite, vexation, nausea or vomiting, bitter taste in mouth, dry throat, and a taut pulse.
Because there are two developing tendencies of Shaoyang disease causing exterior
syndrome or causing interior syndrome, the Shaoyang is considered to be a pivot. In clinical practice, the tendencies of this condition to develop to the exterior or the interior syndrome are embodied in complicated diseases. Shaoyang disease complicated by Taiyang disease and Shaoyang disease complicated by Yangming disease are examples.
4. Pathological Mechanism of Taiyin Disease
Taiyin is the first one of the three yin. The spleen and lung are its inner correspondents, which have exterior-interior relationships with the stomach and large intestine.The main manifestation of Taiyin disease happens in the spleen and stomach.
The onset of Taiyin disease occurs because of the improper treatment on the three
yang disease that impairs the spleen-yang. It may also be caused by a cold-dampness
which attacks the middle-jiao directly. If the spleen and stomach are in deficient condiions, the cold and dampness will grow in the body and lead to Taiyin disease. The spleen dominates the transportation and transformation of food- essence and water-dampness. In pathological conditions of the spleen, the transporting and transforming functions are weakened. The spleen can not transport water-dampness normally. The water-dampness is retained.
The Taiyin disease of spleen and Yangming disease of stomach are both related to diesti0n. But one is related to deficiency and another to excess. The deficiency condition is the Taiyin disease while the excess condition is the Yangming disease. Taiyin disease is characterized by spleen deficiency and exorbitant dampness. Because the deficient spleen fails to transport drink and food, and the cold-dampness obstructs internally, the spleenqi can not ascend and the stomach-qi can not descend. Both the receiving function of the stornach and the transforming function of the spleen are impaired. The clinical characteristlcs are abdominal fullness, vomiting, poor appetite, diarrhea, paroxysmal abdominal pain, and a weak or mild pulse.
There are three possible directions of further development of a Taiyin disease: The first possibiyity is that it becomes Yangming disease. This is due to the overreacted yangci of the stomach and intestines, which makes the disease convert to a dry-heat synme. The second one is that it changes into a yin-jaundice syndrome. Because long-retained dampness obstructs the drainage of bile, the bile is kept in the body and jaundice appears. The third one is that the disease alters into a Shaoyin disease. In prolonged cases
Taiyin disease, the deficiency of middle-yang implicates the kidney-yang and leads to Shaoyin disease.
5. Pathological Mechanism of Shaoyin Disease
The Shaoyin refers to the heart and kidney, which have exterior-interior relationships with the small intestine and urinary bladder. The heart dominates blood-vessels and stores the mind. The kidney is in charge of water metabolism and tranformative function of qi. The primordial yin and yang stay in the kidney, so the kidney is considered the life root. In normal conditions, the Shaoyin-qi controls mental activity and the circulationi qi and blood. It also manages the metabolism of water and body fluid of the entire body
Shaoyin disease is the critical stage in the process of cold-attack disease. The main patho-mechanism is the deficiency of qi, blood and yang. The yang deficiency of both heart and the kidney is the major aspect of all deficiency. The body resistance become weak, and the disease manifests itself by a general deficient condition.
Most cases of Shaoyin disease are due to a direct attack on Shaoyin by the evils
When other diseases were treated incorrectly, the heart and kidney may be impaired,
Shaoyin disease will occur.
In Shaoyin disease condition, the heart and kidney-yang is weak, and yin and blood are insufficient. So a faint or thready pulse, and drowsiness are the common clinca symptoms. Because of the disparity of constitutions between patients with this condition the disease can be classified into Shaoyin-cold syndrome and Shaoyin-heat syndrome.
The Shaoyin-cold syndrome occurs in patients who are generally yang insufficien
and yin exorbitant. Their heart and kidney functions are weakened. When the evils ente the Shaoyin, they will comply with the predominant yin and convert into cold evil. The clinical manifestation is a reflection of the deficient cold due to heart, spleen, and kidneyyang deficiency. The symptoms include aversion to cold, lateral recumbent position with flexion, listlessness, cold limbs, diarrhea with undigested food, lack of thirst or thirst only for hot drinks, clear urine, pale tongue with white coating, and a deep and fain pulse.
If the yin-cold evil is too powerful, it will force the deficient yang to float to thee terior. This is a severe case. It is named cold syndrome with pseudo-heat. The pathomechanism of this syndrome is that the excessive yin keeps yang outside.
If the patients generally are yin deficient and yang exuberant, the heart and kidne yin is insufficient, and the function of body is in a pseudo-excited state. This makes patient particularly susceptible to Shaoyin heat syndrome. When evils enter Shaoyin they will comply with the predominant yang and convert to heat. The genuine-yin will further consumed. The kidney-water will be too weak to go up to assist heart-yin, That leads to heart-fire overwhelming in the upper part. The harmony between the water an fire is broken, and yin fails to restrict yang. The body reacts with deficient heat,clinical symptoms include vexation, insomnia, dryness in mouth and throat, dark urine red tongue tip or crimson tongue with little coating, and a thready and rapid pulse.
In some cases, genuine-qi or yang can be restored, in which case Shaoyin disease may become Taiyin or Yangming disease.
6. The Pathological Mechanism of Jueyin Disease
Jueyin pertains to the liver and pericardium, which have exteriory-interior relationships with the gallbladder and triple-jiao. The liver dominates the regulation function and stores blood. The pericardium can perform some functions of heart. The pericardium-fire can reach lower-jiao to warm the kidney water and liver through the triple-heaters. If it does so, the upper- jao will be clear and harmonious, and the lower-jiao will be warm.That is the normal condition which keeps body in full health.
Jueyin is the end of three yin and the beginning of yang. There is yang in yin. The Jueyin disease is the last stage of cold-attack disease, and is quite complicated. The genuine-qi is feeble, and the regulation of yin and yang is out of order. The patho-mechanism of Jueyin disease is characterized by miscellaneous heat and cold (mainly, heat is in the upper, and cold in the lower), alternation of cold limbs and fever (alternation of yin and yang), cold limbs, and stomach and intestinal disorders associated with liver problems.
The intermingled heat and cold: In Jueyin disease, evils exist in the liver and pericardium. The regulation function of the liver is abnormal, and qi and blood circulate disorderly. Yin and yang are out of control, and heat and cold coexist in the body intermingledly. The yang-heat is in the upper, and is mainly the flamed liver-fire, while the yinco1d is in the lower, and is due to the failing of heart-fire to reach the lower part. In this condition, there will be symptoms such as thirst, gas bumps against the heart, burning pain in the epigastrium, hunger without appetite, and diarrhea.
Alternation of cold limbs and fever: In this condition, genuine-qi struggles against the evils. When yang-qi (genuine) is predominant, there will be fever. While yin-qi (evil) is predominant, there will be cold limbs. Because the genuine-qi and evil-qi are predominant alternatively, the cold limbs and fever also appears alternately. If yang and yin tie in their struggle, the patient's experience of cold limbs will equal that of fever.
This reflects the fact that the genuine-qi and evil-qi are both exuberant. When yang is exuberant and yin is weak, yang predominates over yin, and the time of having cold limbs will be less than that of having fever. The patient's condition will improve, and vice versa. When yang recovers, there will be only fever without cold limbs. If the yin is extremely exorbitant and yang is feeble, it will be a critical case.
Cold limbs: Since evils enter the Jueyin, the function of viscera is in disorder, qi and blood circulate irregularly, and yin and yang can not connect closely. That is the pathomechanism of cold limbs syndrdme. There are many causes for cold limbs syndrome,such as exorbitant cold, deep heat evil, ascariasis, genuine-yang declining, heart being affected by water, and abundant phlegm. Among these, cold evil, heat evil, and ascariasis are the most commonly seen.
Besides the three conditions discussed above, reversed qi flowing of liver and stomach, downward damp-heat, blocked excessive heat, and deficient cold in spleen and stomach can cause symptoms of vomiting and diarrhea in Jueyin disease.
In some conditions, Jueyin disease and Shaoyang disease can convert to one another,since Jueyin and Shaoyang are exterior-interior related. Generally speaking, it is an unfavorable development when Shaoyang disease converts into Jueyin disease, and a favorable development when Jueyin disease converts outwardly to Shaoyang disease.

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