Section 4 Pathological Mechanisms of the Zang-Viscera and Fu-Viscera
The pathological mechanism of the viscera is the mechanism through which normal
physiological functions of the viscera are disturbed in the process of the occurrence, development, and change of a disease. The disease, whether caused by external pathogenic factors or internal impairment, leads to disturbances in the physiological functioning of the viscera, as well as disorders of the viscera's yin-yang, qi, and blood,so it forms the foundation for TCM's pathological mechanisms and treatment, which are based upon differential diagnosis, a method of analyzing and summarizing the occurrence and development of the viscera's pathological state according to the different physiological functions of each viscera.
The theory of the visceral pathological mechanism is first stated in the "Nineteen Items of Pathological Mechanism," Chapter 74 in Plain Questions: "Syndromes characterized by shaking, dizziness and vertigo are related to the liver; cold syndromes characterized by contraction are related to the kidney; qi disorders characterized by respiratory distress and chest depression are related to the lung; dampness syndromes characterized by edema and fullness are related to the spleen; various disorders characterized by abscess or ulcer with pain and itching are related to the heart. "
Within this theory, there is also an explanation as to the normal and contrary development of the visceral diseases according to the theory of generation, restraint, over-restraint and counter-restaint of the five elements. This theory was applied by Zhang Zhongjin in the prevention and treatment of visceral diseases. He stated what became a famous theory in the book Synopsis of the Golden Chamber: "One should reinforce the spleen when there is a disorder in the liver, for the latter will affect the former. " Derived mostly from clinical observation, Zang Zhongjing also put forward the theory, "To determine the therapy order according to the syndromes and pulse condition of the viscera and meridians. " This stresses the idea of treating diseases according to the pathological mechanism of the viscera, and it formed the foundation of the theory of the visceral pathological mechanism.
In the book the Treasured Classic, Hua Tuo further sums up the pulse condition and symptoms of the viscera which are described in the book the Yellow Emperor's Internal Classic. He also wrote the article entitled "The Normal and Contrary Development of both Deficient and Excess Syndromes of the Five Zang and Six Fu-visera. " This has greatly influenced later generations in their research of the visceral pathological mechanism. Later, the theory of viscera pathological mechanism can be seen in the books Pre.scriptions Worth a Thousand Gold for Emergencies, by Sun Simiao, and Key to Therapeutics of Children's Diseases, as well as the List of the Drugs for the Cold, Heat, Deficiency and Excess of the Viscera, written by Zhang Yuansu. Other works include the Treatise on the Spleen and Stomach by Li Gao; On Inquiring the Properties of Things by Zhu Danxi; Through Knowledge of Medicine by Zhao Xianke, and the book Complete Works of Zhang Jingyue written by Zhang Jiebin, Treatise on Viscera Pathological Mechanism, a Chapter of Treatise on Blood Syndromes by Tang Rongchuan in the Qing Dynasty. These books discuss not only the visceral influence on blood, but also each visceral pathological mechanism according to characteristics of the viscus. These documents and theories are important reference values for the research of visceral pathological mechanlsms.
The visceral pathological mechanism is the disorder of the visceral yin-yang, qi and blood, which leads to the excessiveness or weakness of the physiological functions of the viscera, or the disturbance in the coordinated relationship between the physiological functions of the viscera. These will be discussed separately.
I. Pathological Mechanism of the Five Zang-Viscera
The pathological mechanisms of the five zang-viscera refers to the disturbance in yin, yang, qi, and blood of the five zang-viscera. The yin-yang, qi, and blood of the five zang-viscera are the components of the body. The relationship between each visceral yin-yang, qi, and blood is comprised of the following: qi and yang function in the warming and promoting of the physiological activities of the viscera, and are called "yang-qi";while blood and yin function in nourishing viscera and the tissues, creating the viscera,and in calming the mental emotions, and are called "yin-blood". Differences exist between yin, yang, qi, and blood in the physiological activities of various visceral organs.
Generally the yin or yang of the viscera represent the functional state of the physiological activities in each viscera, such as exciting, inhibiting, ascending and dispersing, or descending, and storing. While qi and blood of the viscera comprise the material basis for the physiological activities of the viscera, qi also functions in not only promoting and warming, but also consolidating. Blood has the important function of nourishing. Mean while, since the root of yin-yang of each viscera is the kidney-yin and kidney-yang, an enduring imbalance of the visceral yin and yang will injury the kidney. The qi and blood in each viscera are derived from the essential substances of drink and food, therefore the deficiency of qi and blood is closely related to the deficiency of the kidney and stomach.
It should be pointed out that since there are differences in the physiological functions of each viscus, there will exist differences between the imbalances of the yin, yang, qi, and blood of each viscus. These are discussed in the following :
1. Pathological Mechanism of the Heart
The pathological mechanism of the heart refers to the pathological state of dysfunction among the yin, yang, qi and blood of the heart.
The heart is the most vital organ among the viscera. It is referred to as "the monarch of all organs. " It is composed of the heart, heart system (the large vessels connecting with the heart), and pericardium. Its meridian connects with the small intestine's meridian and it shares an exterior-interior relation with the small intestine. Moreover, there is a close relation between the heart and the vessels and tongue.
The physiological functions of the heart are to control the blood circulation and govern the mental activities. This is the result of the joint functions of heart-yin, heart-yang, heart-qi and heart-blood. Heart-yang and heart-qi control the blood circulation,and promote the circulation of blood; when they govern the mental activities, they maintain the normal activities of the spirit, and of consciousness and thought process of the human being; they also control other viscera, in regards to coordinating the physiological activities. Heart-yang functions in warming the vessels, so as to maintain blood flow.The heart-yin and heart-blood perform the functions of replenishing the vessels to nourish the heart and astrict heart-yang which prevents an excess of it either. Together they also maintain the functioning of the mind, so that the mind may be calm and free to expand.Due to this reasoning, TCM believes that the heart dominates the five zang-viscera and six fu-viscera. It is the basis for all the life activities.
Any pathological changes of the heart manifest as a morbid disorder in the heart and blood vessels, the changes of the mind and the emotions. These pathological phenomena are caused by imbalances of yin and yang, and disorders of qi and blood in the heart.Therefore, the imbalance of yin and yang, qi and blood are an internal factor which cause the pathological changes of the heart. The so-called imbalance refers to the excess and deficiency of functions. Generally speaking, the excess of a function comes about through pathogenic factors, while the deficiency function results from an insufficiency in itself.
1) Disorder of Heart-Yang and Heart-Qi
The disorder of heart-yang and heart-qi is mainly manifested through two aspects of excess and deficiency of yang-qi in the heart.
a. Excess of the yang-qi in the heart
Excess of the heart yang-qi manifests as heart-fire. The fire caused by the internal stasis of the pathogenic heat and phlegm-fire belongs to excessive-fire. However, the fire caused by excess of heart-yang due to overstrain of the heart which exhausts heart-yin and heart-blood belongs to deficiency fire. The heart-fire caused by the impairment of the emotions or five extreme emotions may be both excess or deficiency fire. But both types of fire can change into the other. The excess fire exhausts yin and blood, and leads to a flaming of fire due to yin deficiency; the deficiency fire may also combine with the phlegm-heat or pathogenic-heat. Though the causes and pathological manifestations of both excessive and deficient fire are different, they are similar in their ability to influence the physiological functions of the heart in controlling blood circulation and mental activities.
The main influence of excess heart yang-qi (absolutely or relatively) on the heart functions are: Disturbance in the mind; rapid flow of blood due to blood heat; and the heart-fire flaring up or moving down. These will be discussed in greater detail below.
Disturbance in the Mind : Yang-qi is in charge of ascending and movement. The exwhich control the mind lose invigoration by yang-qi, resulting in the decline of the functions of spirit, consciousness and thought, and resulting in inhibition with difficulty being excited. This is caused by a congenital deficiency or malnourishment of the mind due to the prolonged illness impairing heart-qi and heart-blood. Clinical manifestations are mental fatigue and weakness, depression, weakened mental state, slow response, unwilling to talk or low voice.
Stagnation in the blood vessels due to cold: Blood flows when it is warm, and stagnates when it meets cold. Insufficient heart yang-qi weakens both dynamic forces of blood circulation and yang-qi in the chest, and results in the dysfunction of the heart governing the blood circulation. The blood flows feebly, leading to the stagnation of blood, then further to the obstruction of the heart vessels. Insufficiency of warmth due to yang deftciency will induce internal cold, marked by such clinical symptoms as chills and cold extremities, pale or cyanotic complexion, palpitation, oppressive sensation on chest, vague pain or twinge in the chest, soft or feeble pulse, slow or rapid pulse, however the pulse may at times be knotted, slow, regular or intermittent.
Deficiency of heart qi: This refers to the weakness of the physiological functions of the heart, which is caused by a body deficiency due to protracted illness, or by the weakened visceral qi due to aging, or by a congenital insufficiency. The pathological mechanism of insufficiency of heart-qi mainly manifests as a heart deficiency caused by the weakness of motive power for blood circulation, with a feeble heart beat, and a failure in replenishing the heart vessels. Deficiency of heart-qi affects the functions of the lung which causes the instability of defence-yang and an abnormal interstitial space; Deficiency of qi leads to the malnourishment of the heart-mind. Clinical symptoms are palpitation and shortness of breath, fatigue both in the mind and body, spontaneous sweating, deep but weak pulse. If the sudden illness impairs yang and qi, it may result in the sudden collapse of yang, marked by yang depletion symptoms of cold limbs, profuse sweating,shortness of breath, faint, and an indistinct pulse.
Moreover there is a mutual influential relationship between the heart yang-qi deftciency and the pathological changes of the lung and kidney. For example, heart yang-qi deficiency may be caused by a lung insufficiency. Insufficiency of heart-yang may affect the functions of the lung to cause a respiration disorder. The pathological change resulting in an insufficient yang-qi is generally accompanied by symptoms of cough with dyspnea.In severe cases, a patient may only breath when sitting, not lying down. This is caused from dysfunctions of the pectoral qi that runs through the heart and blood vessels and controls the respiration. Kidney-yang is the basis of all yang. In clinical practice, the deficiency of both the kidney and heart-yang will affect each other, and occur at the same time. For example, edema due to the kidney deficiency may cause the deficiency of heart-yang, while deficiency of heart-yang may injury kidney-yang to cause oliguria and edema.
2) Disturbance in Heart-Yin and Heart-Blood
The disturbance in heart-yin and heart-blood mainly is manifested through an insufficiency of heart-yin, an impairment of heart-blood and the stagnation of heart-blood.
a. Insufficiency of heart-yin
Insufficiency of heart-yin is a synonym of heart-yin deficiency. It is caused by the exhaustion of heart-yin due to an overstrain of the mind, improper care after a chronic illness, consumption of heart-yin due to the internal impairing of emotion, or the excess of heart fire and liver fire resulting from the stagnation of heart-qi. Heart-yin deficiency fails to restrain yang, leading to hyperactivity of heart yang, and excessive heart-fire due to heart-yin deficiency. Because the calming action of yin is weak, it cannot astrict the floating of yang-qi, thus affects the functions of the heart in controlling the mind. This is marked by restlessness of the mind, insomnia due to deficiency and fidgets. Excess of yang that is caused by a yin deficiency will give rise to deficiency fire. This is marked by the pathological reaction of feverish sensation in the five centers, night sweating, the ready rapid pulse and red tongue.
b. Impairment of heart-blood
Impairment of heart-blood is caused by the loss of blood, insufficient generation of blood, or consumption of yin-blood due to an internal injury of the seven emotions. It usually manifests as the following: An insufficiency of heart-blood due to failure of vessel replenishment, leading to hollow vessels, and to a small weak pulse; A deficiency of blood which leads to a failure to nourish the mind, causing neurosis, and to the dysfunction of the heart's ability to govern mental activities, manifested by a difficulty to concentrate one's mind, amnesia, or even metal derangement in severe cases; Another manifestanon is an impairment of blood and yin that fails to store heart-yang, leading to mental derangement marked by the symptoms of insomnia, and dreaming; A blood deficiency causes general malnourishment of the heart, manifesting in palpitation, even panic; Lastly, blood deficiency which causes malnourishment of the meridian, marked by the numbness of extremities and fingers.
c. Stagnation of heart-blood
Stagnation of heart-blood refers to the pathological state arising in the obstruction of blood circulation. It is caused mostly by a deficiency of heart-yang and heart-qi or the stasis of blood due to cold, or obstruction of the vessels due to phlegm accumulation. It can also be induced by overstrain, catching cold, and emotional depression. The stagnation of heart-blood leads to the obstruction of qi and blood in the heart vessels, which results in oppression and pain in the chest. However sudden stagnation in the heart vessels will lead to the symptoms of stuffy pain in the perieardial region, palpitation or severe palpitation,terror, or even cold extremities, deep pulse, and syncope after profuse sweating in severe
cases.
2. Pathological Mechanism of the Lung
The lung pathological mechanism refers to the pathological state of imbalance of yin-yang, and disturbance of qi and blood in the lung.
The lung is the organ which has direct contact with the external air. It is composed of the lung proper, the pulmonary system (including the air passages connecting with the lung, throat and other tissue linking and appending to the lung), and the meridian etc.Its meridian connects with the Large Intestine Meridian of Hand Yangming and it has an exterior-interior relationship with the large intestine. In addition, there are some other tissues or organs closely related to the lung such as the skin, hair, nose ,etc.
The lung is the organ where the respiring air is internally and externally exchanged.It's main pathological functions are dominating qi and performing respiration, dominating the dispersion and depurative descending of qi, the convergence of the vessels in order to help the heart promote the circulating of blood, dredging and regulating water passage to promote the water metabolism, dispersing defensive qi to the body's surface to warm the skin and to defend the body.
The pathological changes of the lung are caused by invasion of the evil-qi, which is related to its physiological properties of respiration, contacting with the external world,and controlling the skin and hair. It can be also affected by other visceral pathological changes. The disturbance of yin, yang, qi and blood in the lung mainly manifests through a dysfunction of dispersion and depurative descending of lung-qi This influences the ascending, descending, exiting and entering of qi, leading to abnormal respiration and dysfunctions of water metabolism and body defense, and dysfunctions of the heart in controlling the circulation of blood and in the abnormality of blood circulation.
It should be pointed out that the lung is the organ which controls the qi. The ascending and spreading functions of lung-yang are summarized in the dispersing function of lung-qi. Therefore when discussing the disorder of lung yang-qi, it may involve the deficiency of lung-qi instead of the deficiency of lung-yang. Since all vessels meet in the lung,the deficiency of lung-blood seldom happens. Therefore, the imbalance of yin and yang and disorders of qi and blood in the lung is mainly manifests through the disorder of lung-qi and lung-yin.
1) Abnormality of Lung-Qi
Since the lung's func.tions are in dominating the qi of the whole body and performing the respiration, the dispersing, the depurative descending of lung-qi, and the regulating qi activity, as well as the metabolism of body fluid, the disorder of qi is mainly manifested through an abnormality of lung-qi dispersing and through the depurative descending and deficiency of lung-qi.
a. Disorders of lung-qi dispersing and depurative descending
Dispersing and depurative descending are two aspects of the ascending, descending,exiting and entering of lung-qi. Though they are different, they affect each other. The dysfunctions of the two are usually caused by the invasion of pathogenic factor or by the stagnation of phlegm in the Lung Meridian, and by the fire traveling reversely upward to disturb the lung due to an over ascending of liver-qi. They may also be induced by an insufficient lung-qi, leading to a failure in dispersing or in depurative descending of lung-qi.The deficiency of lung-yin to produce the dryness-heat in the interior, and disturb the dispersing and depurative descending may also result in disorder.
When the dispersing of the lung-qi is abnormal, it may lead to the dysfunction of qi activities or the accumulation of lung-qi followed by a disturbance in the lungs ability to function in respiration. This is marked by feeble breathing, cough or even asthma, nasal obstruction, nasal discharge, itching of the throat, and chest distress. The impairment of the lungs dispersing function also results in the stagnation of defense qi, causing the body to suppress its sweating ability. If lung-qi is insufficient and results in a dysfunction of dispersion, it may lead to the deficiency of defense yang-qi, thus causing a failure of warming and strengthening of the interstitial space, skin and hair, marked by spontaneous sweating and susceptibility to cold. This is due to the failure of superficies to protect the body, and a dysfunction of controlling the opening and closing of the pores.
The abnormality of lung-qi depurative descending refers to the weakened physiological functions in the descending of lung-qi and the clearing of the respiratory tract. This will manifest in the pathological reaction of cough with dyspnea and abundant expectoration.
The impairment of lung-qi's ascending or depurative descending can lead to the abnormal rising of lung-qi, marked by a cough with dyspnea, asthma etc.. This may also affect the lungs' physiological function of water passage regulation, leading to disorders of water metabolism with such symptoms as oliguria, and edema. Further development of the dysfunctions may impair lung-qi and lung-yin, resulting in the deficiency of lung-qi or lung-yin.
b. Insufficiency of lung-qi
This morbid state is mostly caused by consumption of lung-qi due to overstrain, or by the deficiency of lung-qi due to protracted illness or chronic cough. Insufficiency of lung-qi causes weakness in the respiration function, leading to an insufficiency air exchange, marked by shortness of breath. It also influences the distribution and metabolism of body fluid, and results in an upset of normal fluid dispersion leading to phlegm retention or even edema. Insufficiency of lung-qi results in the deficiency of the defense yang-qi, weakness of the interstital space and body superficies, and a dysfunction of defense.These are manifested as spontaneous sweating due to deficient superficies.
2) Disorder of Lung-Yin
This is the morbid state of the impairment of lungs' yin fluid and the flaring of fire due to yin deficiency, which leads to the malnourishment of the lungs and their related organs (such as the nose, skin, hair etc. ), resulting in the internal producing of deficiency heat, and deficiency fire to consume the lung. This morbid state is mainly induced by the pathogenic heat, the chronic cough, phlegm-fire interior depressed impairing the lung, by the impairment of yin due to consumptive disease, or the fire produced by overaction of the five emotions to disturb lung-yin.
Insufficiency of lung-yin affects the lung's physiological function of controlling the respiration and manifests as dryness of the lung, failure of dispersion and depurative descending of lung-qi, internal producing of fever due to yin deficiency, to the extent of damaging the lung collateral. A series of symptoms will occur. Those being of dryness,deficient heat or fire will appear such as dry cough without sputum, or with little sticky sputum, shortness of breath, thirst, dryness of the throat, tidal fever, night sweating, molar flush and dysphoria with feverish sensation in the five centers. In severe cases,there will be cough with bloody sputum or hemoptysis etc. Continuous consumption of body fluid usually damages the kidney and causes the deficiency of yin-fluid both in the lungs and kidney.
3. Pathological Mechanism of the Spleen
Pathological mechanism of the spleen refers to the pathological state of imbalance of yin and yang and disorders of qi and blood in the spleen.
The spleen is an organ system which transports and transforms the essential sub- stance. It is composed of the spleen and its meridian. It has an exterior-interior relation ship with the stomach due to its meridian connecting to the stomachs meridian. It is also closely related to the muscles (The spleen dominates the muscles), the lips (The spleen has its outward manifestation on the lips), the mouth (The spleen opens into the mouth), and the eyelids.
The physiological functions of the spleen are as follows: the spleen-yang and spleen-qi warm, transport and transform the essential substances of drink and food, and help the stomach to decompose food; the spleen-qi is in charge of sending up essential substance and conicrolling the blood; the spleen-yang and spleen-qi warm and nourish the muscles and four limbs spleen-yin nourishes the spleen itself and helps the spleen-yang and spleen-qi to perform their functions as well.
The pathological mechanism of the spleen is mainly reflected as a disturbance in the functioning of transportation and transformation of the essential substance and water; as disorder in the ascending and descending of qi; and in failure to control blood etc. It mainly manifests as a dysfunction of spleen yang-qi and of spleen-yin.
1) Disorder of Spleen-Yang and Spleen-Qi
Disturbances in spleen-yang and spleen-qi is that impairment of spleen yang-qi which leads to the failure of the production qi and blood due to dysfunctions of transportation, or leads to the deficiency of the spleen and kidney-yang due to the impairment of kidney-yang by the damp evil in the interior. Insufficiency of the spleen- qi results in the sinking of the middle-jiao qi which impedes the lifting function of the spleen, or even causes prolapse. A dysfunction of governing the blood brings about hemorrhage. They are manifested as a deficiency of spleen-qi and spleen-yang, and accumulation of water in the middle-jiao.
a. Deficiency of spleen-qi
Deficiency of spleen-qi is an insufficiency of qi in the middle-jiao, and is caused by improper diet and dysfunction of transportation of the spleen. It may also be caused by the deficiency of acquired essence, or exhaustion by protracted illness or overstrain. Insufficiency of spleen-qi leads to the dysfunction of transportation and transformation, appearing in symptoms of anorexia, indigestion, and tastelessness. The weakness of the spleen ascending function must influence the stomach descending digested food, thus cause the dysfunction of ascending the essential substance and descending the digested food, marked by the symptoms of vertigo, abdominal distension and loose stool.
Dysfunction of the spleen's transportation leads to a weakness in the ability of food digestion and transportation of the essential substances and in the functions of producing qi and blood, which will cause a general shortage of qi and blood. Deficiency of spleen-qi will fail to control the blood and lead to blood flow outside the vessels. Impairment of the spleen-qi leads to the inability of lifting or sinking of qi in the middle-jiao, marked by proctoptosis, chronic diarrhea, fecal incontinence, and prolapse of the viscera.
b. Deficiency of spleen-yang
Deficiency of spleen-yang is caused by the deficiency of spleen-qi, or by the deficiency of congenital weak constitution, through a lack of the proper care due to long-standing illness, or by the spleen failing to be warmed due to the kidney deficiency and decline of the vital gate fire. Spleen-yang deficiency leads to the production of cold in the middle-jiao, and is manifested by pathological changes such as cold pain in the epigastrium and abdomen, and loose stool and diarrhea before dawn. Deficiency of spleen-yang also leads to dysfunctions of transportationand transformation, thus causing water accumulation inside the body and retention of phlegm or edema.
c. Water accumulating in middle-jiao
This is caused by the accumulation of water within the body due to dysbolism of water. This results from the dysfunction of transportation and transformation of the spleen due to an insufficiency of spleen yang-qi. When the spleen is deficient, the damp evil will be produced internally, and leads to the retention of phlegm or edema.
In addition, insufficiency of the spleen-yang leaves the spleen vulnerable to attack by the exogenous damp evil. This is due to the dysfunction of water transportation and transformation. On the other hand, an over consumption of raw and cold fruits or an over consumption of alcohol leads to the accumulation of water within the body. When the interior damp evil combines with that of the exterior and stagnates in the middle-jiao it may give rise of syndromes in both deficiency and excess type.
When the water stagnates in the middle-jiao, it may be transformed to cold due to the constitution of the yin type or it may also be transformed to heat due to the constitution of the yang type. If it combines with the pathogenic cold, it will further impair the spleen-yang, leading to weakness of spleen-yang due to dampness, and marked as c01ddamp syndrome. If it combines with the pathogenic heat, it may lead to the disturbance in yang due to the stagnation of dampness, and result in the damp-heat syndrome. If the damp-heat stagnates in the middle-jiao, it may steam the liver and gall bladder, impair the liver and gall bladder's function of dominating the conducting, and dispersing of qi leading to bile over-flow to the skin and the occurrence of jaundice.
2) Disorder of Spleen-Yin
Disorder of spleen-yin refers to the pathological state of insufficiency of spleen-yin fluid. It is caused through the consumption of body fluid by the febrile disease, or by chronic diarrhea, or hemorrhage. The spleen and stomach are the acquired foundation of the body. The nourishment of all viscera, tissues and organs of the body depends on the distribution and transportation of essential substance by spleen-qi. If spleen-yin is insufficient, the essential qi will be impaired, leading to lassitude. The spleen helps the stomach to transport the body fluid. Deficiency of spleen-yin may lead to the failure of the water transporting upward, marked by thirst. Impairment of spleen-yin fluid results in the dysfunction of transportation and transformation. With the stomach losing the help of the spleen, an adverse rising of the stomach-qi instead of descending is manifested as poor appetite, retching, hiccup etc. Deficiency of spleen-yin fails to restrain the yang and leads to the syndrome of deficient heat, marked by the symptoms of dryness in the tongue and mouth, and red tongue with little coating.
4. Pathological Mechanism of the Liver
The pathological mechanism of the liver is the pathological state of dysfunction of yin and yang, qi and blood of the liver. The liver is an important organ which stores the blood and regulates the blood volume. It is composed of the liver proper and its meridian.Its meridian connects with the Gallbladder Meridian. The liver has an exterior-interior relationship with the gall bladder. It is also closely related to the tendons, ( the liver controlling the tendons of the body) ,the eyes, ( opening into the eyes), and the nails (manifesting in the nails).
The physiological functions of the liver are as follows: The liver-yang and liver-qi are responsible for conducting and dispersing, and regulating the emotions and helping the stomach and spleen to ascend the essential substance and descend the digested food. Liver-qi also controls the flexing and extending of the tendons and the regulation of blood in the body. It should be pointed out that under the pathological condition, liver-yang and liver-qi are characterized by aptness to hyperactivity, inversion, stagnation and depression. Besides nourishing the liver itself, liver-yin and liver-blood are able to astrict liver-yang to prevent it from hyperactivity; to nourish liver-qi and conduct and disperse of it,so as to prevent qi from stagnation; to nourish the eyes, so the eyes will be able to see clearly; to nourish the tendons to keep them tenacious and strong. Therefore, the physiological functions of the liver involve in the qi, blood, body fluid and tendons, which are mainly related to the normal or abnormal function of conducting and dispersing of the liver.
The pathological mechanism of the liver mainly manifests as hyperactivity, weakness or obstruction of the conducting and dispersing function; dysfunctions of nourishment of the liver blood; and the disturbance in the restriction between the yin and yang of the liver. The property of the pathological change of the dysfunction of yin and yang, qi and blood in the liver are characterized as: excess of liver-yang and liver-qi and insufficiency of liver-yin and liver-yang. They are discussed as follows:
1) Disorders of Liver-Yang and Liver-Qi
Disorder of liver-yang qi is characterized by pathological changes of hyperactivity of the liver yang and liver-qi. The symptoms of deficiency of liver-yang or liver-qi seldom happen. In addition, the excessiveness of liver-yang will be discussed in the disturbance of liver-yin and liver-blood because it is caused by the shortage of liver-yin. Therefore,the pathological mechanism of the disturbance of liver-yang and liver-qi mainly manifests as stagnation of liver-qi, traverse invasion of tiver-qi, flaming-up of the liver-fire etc. It may also influence the digestion of the spleen and stomach, leading to dysfunctions of
stomach-qi descending, and transportation and transformation.
a. Stagnation of liver-qi
This unhealthy state is brought about through emotional depression or through an impairment of the liver caused from excessive anger. Both impairments may lead to a dysfunction of the conducting and dispersing of liver-qi and result in the stagnation of qi;Therefore, in the affected area of the body, there will appear distending pain. If the stagnation of qi combines with the stagnation of phlegm or blood, it will appear a mass in the affected area. If qi stagnates in the liver itself, there will be distension in the hypochondrium or pain in the right hypochondrium. If the stagnation of liver-qi combines with the stagnation of phlegm-qi or with the stasis of blood in the Liver Meridian, it will appear as a goiter and as globs hysterious in the upper throat region, or as lumps with distending pain in the breasts, and as lower abdominal pain, with a bearing down and distending pain in the testis, and dysmenorrhea, even causing anemia in cases regarding women.While the stagnation of liver-qi results in the dysfunctions of the conducting and dispersing abilities of the liver, it also affects the functions of the spleen and stomach in decomposing of food, transportation and transformation, and descending of qi. This is manifested as distending pain in the chest and hypochondrium, fullness of the stomach, hiccups and acid regurgitation, poor appetite etc..
b. Transverse inversion of liver-qi
This is caused by a qi transverse invasion of the spleen and stomach, due to the stagnation of liver-qi and dysfunction of the conducting and dispersing abilities. If liver-qi transversely invades the stomach, it will lead to dysfunctions of the descending of stornach-qi, and induce the adverse rising of stomach-qi. This is marked by the symptoms of belching, acid regurgitation vomiting, even epigastralgia. If the hyperactive liver-qi at tacks the spleen and induces the dysfunction of transportation and transformation, it may lead to the symptoms of diarrhea with pain, which will begin or stop with the changes of emotion. The reverse flow of liver-qi due to rage, or sudden excessiveness of liver-fire may affect the blood, and the blood will reversely flow as qi does, marked by the symptoms of restlessness, irritability, sudden onset of hemorrhage, hematemesis, and epistaxis.
c. Flaming up of the liver-fire
The flaming up of liver-fire is mainly caused by liver-fire resulting from the depress and stagnation of liver-qi; by the rising of liver-fire due to the excessiveness of liver-qi induced through violent rage, or by the exuberance of heart-fire due to the injury of emotion. Flaming up of the liver-fire may lead to an over ascending of liver-yang, manifested as symptoms of distension of the head, headache, flushed face, congested eyes, restlessness, irritability, sudden attack of tinnitus and deafness. Over-rising of liver-yang consumes yin blood and easily causes the excessive fire due to yin deficiency. It also affects the liver's function of storing blood easily, and the symptoms of hematemesis, and epistaxis will occur. When qi and fire rises upward to the extreme point, yang-qi will be suddenly excessive, and the fire will flare up following the qi, and attack the tendons and meridian, which will cause the up-stirring of liver wind which will disturb the head arid
four limbs. This is marked by qi syncope and spasm.
2) Disturbance of Liver-Yin and Liver-Blood
The pathological mechanism of this morbid condition is characterized by an impairment and insufficiency of yin and blood. Yang will be exuberant when yin is deficient. So the upstirring of liver-wind caused by the unrestricted ascending of liver yang-qi is related to the shortage of liver-yin-blood. Therefore disorders of liver yin and blood mainly manifest as an insufficiency of liver blood, hyperactive liver-yang, and up-stirring of liverwind.
a. Insufficiency of liver-blood
Deficiency of liver-blood is due to over-bleeding, the exhaustion of blood from chronic illness, or the deficiency of the spleen and stomach, which brings about the dysfunction of blood generation. This dysfunction leads to a deficiency of blood, an insufficiency of liver-blood and a disorder of the regulation of blood volume. An insufficiency of liverblood may lead to the malnourishment of tendons and vessels, manifested as difficulty in flexing and extending of the joints, or numbness. Deficiency of blood brings about the malnutrition of the eyes marked by dryness of the eyes, dizziness and hypopsia. It also easily induces pathogenic dryness and wind, and causes a stirring up of deficient wind in severe cases, leading to the symptoms of itching, and muscle spasms.
b. Hyperactivity of liver-yang
This is an unhealthful condition caused by an abnormal ascending of floating and an adverse flow of liver yang-qi, resulting from the insufficiency of liver-yin, and a failure in restricting of yang. It may also be caused by excessive yang due to a yin deficiency,which is brought about by emotional disturbance and an upward adverse flow of qi and fire which consumes liver-yang, and emotional disturbance. Since the liver-yin and kidney-yin come from a common source, when the kidney-yin is insufficient, water (the kidney) fails to nourish wood (the liver), and this also causes the pathological change of excessiveness of liver-yang, marked by dizziness, tinnitus, flushed face, irritability, and a tact and rapid pulse. Meanwhile, the lower part of the body will be accompanied by the symptoms of a deficient type of condition, such as lassitude in the loins and legs.
c. Stirring of the liver-wind
Stirring of the liver-wind is the pathological reaction of the liver-yin and liver-blood disorder, the malnourishment of fascia. As it is said in Chapter 44 in Plain Question,"The liver is in charge of the fascia of the body. " The tendons and fascia's functions depend on the nourishment of the yin-fluid and blood. When the tendon and fascia appears as pathological changes, it is manifested as spasms in large tendons such as convulsion and contraction, and flaccidity in the small tendons, such the symptoms as paralysis and atrophic debilities.
A stirring of the liver-wind can be caused by various factors, such as excessive
pathogenic heat injuries of the Liver Meridian and yin-fluid, leading to the wind-syndromes; deficiencies of liver-yin and kidney-yin which lead to uncontrollable liver-yang,resulting in the wind syndromes due to yang excessiveness; and consumption of liverblood which causes the malnourishment of tendons and vessels, bringing about the wind syndromes in deficient types. The common wind syndromes viewed in clinical practice are the wind syndromes caused by hyperactivity of liver-yang due to deficiency of both the liver and kidney. The pathological manifestations of wind syndromes are tremor of the limbs, convulsion or muscular twitching and cramps or involuntary movements of the limbs, and even convulsion, sudden fainting, unconsciousness, facial hemi-paralysis and hemiplegia in severe cases.
5. Pathological Mechanism of the Kidney
Pathological mechanism of the kidney is morbid state caused by the disturbance of yin, yang, qi, and blood of the kidney.
The kidney is one of the most important organs involved in the life activities of the body. It is composed of the kidney proper and its meridian. The Kidney Meridian connects with the Urinary Bladder Meridian and it is exterior-interiorly related to the urinary bladder. The kidney also relates closely with the bones and marrow (as it controls the bones and produces the marrow), the ears (as it opens into the ears), the external genitalia, anus, and the loins (which are the house of the kidney).
The physiological functions of the kidney mainly manifest as the kidney-yang, kidney-qi, kidney-yin, and kidney-essence. Kidney-yang is the basis of all visceral yang-qi in the body. It governs the evaporating and ascending of the body fluid, and helps the spleen and stomach yang-qi to produce the food-essence and fluid. The main functions of kidney-qi are: to store the essence, to dominate growth, development and reproduction,to store and consolidate, and to receive the qi necessary in respiration.
Kidney-yin is the basis of the visceral yin-qi. Its functions include inhibiting the kidney-yang, including the ministerial fire from the vital gate, so as to prevent hyperactivity, and nourishing the kidney-qi. The kidney-essence can produce marrow and nourish the bones, "replenish the brain marrow and promote the development of the body's skeletal structure and is important in reproduction. Meanwhile, the kidney essence also cooperates with other organs in creating and healing the viscera and tissue to ensure proper functioning of their metabolic activities.
The disturbance of yin, yang, qi, and blood of the kidney mainly manifests through a dysfunction of the storing of the essence, or of controlling the fluid metabolism. Dysfunctions of storing the essence lead to an insufficiency of vital essence, which may result in a underdevelopment or hypofunction of reproduction. Dysfunction of governing waterfluid leads to the dysmetabolism of water, marked by oliguria, edema, or polyuria, clear urine in large amounts, or incontinence of urine in severe cases.
It should be pointed out that the pathological mechanism of the kidney has its own characteristics. Since the kidney-essence is the basis of kidney-yin and kidney-yang,which comprise the body's source of yin and yang, a pathological change of the kidney is seldom involved in the disturbance of qi and blood. However, it plays a large part in insufficiency of vital essence-qi. So the pathological mechanism of the kidney mainly manifests as an insufficiency of the kidney-essence and a disturbance of kidney-yang and kidney-yin.
1) Insufficiency of the Essence-Qi of the Kidney
The essence and qi of the kidney are related through their mutual production and transformation of one another. The two form the material basis for the physiological activities of the kidney. Insufficiency of the kidney essence-qi induces deficiency of the kidney-essence and insufficiency of kidney-qi.
a. Deficiency of the kidney-essence
This morbid condition is caused from congenital deficiency, essence reduced with
age, essence consumed by protracted illness, or lack of proper care after birth.Insufficiency of the kidney-essence may retard the growth and development of maturity or delay the arrival of menstruation and impede the maturation of "tiangui" at a younger age. It also may lead to senility, or hypofunction of the sexual function in middle age, marked by spermatorrhoea and impotence. The kidney dominates the bones and produces marrow.Insufficiency of the kidney-essence leads to the deficiency of marrow, and malnourishment of the bones, marked by flaccidity and softness of the bones and skeleton, and weakness of the feet. The brain can not be replenished due to the deficiency of marrow,thus the brain becomes hollow, leading to mental retardation due to the weakness of vitality. Generally, deficiency of the kidney-essence manifests as underdevelopment in children, and debility due to senility in adults.
b. Unconsolidation of kidney-qi
This morbid state is caused by insufficiency of kidney-qi in children, or by the de cline of kidney-qi due to debility of the aged, by consumption of kidney-qi due to early marriage and intemperance in sexual intercourse, or by deficiency of the kidney due to protracted illness. Deficiency of kidney-qi leads to the dysfunction of the storing of essence by the kidney. As a result, the essence-qi of the kidney is easily lost, a condition marked by seminal emission and spermatorrhoea. Unconsolidation of kidney-qi affects the qi-receiving function, which is manifested as up-floating of the qi, prolonged expiration, and shortness of breath even on slight movement. The dysfunction of essence-storing and consolidation due to the kidney deficiency brings about incontinence of defecation and urination, marked by fecal incontinence, diluted urine, dripping urine, and enuresis.
2) Disturbance of Kidney-Yin and Kidney-Yang
Kidney-yin and kidney-yang are the basis of yin-yang in the body. By inhibiting and coordinating each other, they maintain the normal physiological activities of the kidney, and stimulate and promote all visceral yin and yang in the body. This is why the disturbance of yin and yang of kidney affects the physiological functions of all viscera and tissues in the body. The pathological mechanism of the disturbance of yin and yang of kidney primarily manifests as deficiency of the kidney-qi, impairment of kidney-yang, and hyperactivity of the ministerial fire of the vital gate.
a. Deficiency of kidney-yin
This is caused by the impairment of kidney-yin due to protracted illness, or by the consumption of the yin of each viscera due to the fire produced by an excess of the five emotions or by a prolonged stay of pathogenic heat. It can also be brought about by the loss of blood and fluid, the over-intake of warm, dry herbs to invigorate the kidney-yang, or the impairment of kidney-yin due to intemperance of sexual intercourse. Insufficiency of kidney-yin leads to a failure in controlling kidney-yang (fire of the vital gate), hyperactivity of ministerial fire, and internal production of deficiency heat, thus causing the interior heat-syndromes and hyperactivity of fire due to yin deficiency. Its pathological manifestations are emaciation, lassitude in the loins and knees, dysphoria with a feverish sensation in five centers, hectic fever, flushed cheeks, night sweat, red tongue with little coating, and a rapid thready pulse.
b. Deficiency of kidney-yang
Deficiency of kidnty-yang actually is the decline of the vital gate fire. But in the clinical differentiation of syndromes, they are different in the level of the diseases.
Deficiency of kidney-yang is brought about by the impairment of the kidney due to the deficiency of the heart and spleen yang-qi, or by excessive sex which consumes kidney-yang. Deficient kidney-yang fails to nourish the mind and tendons, and gives rise to yin-cold in the interior, leading to the hypofunction of all viscera and tissues, with manifestations in underdevelopment, dysfunction in the production of food-essence, decline of the sexual function, impediment of reproductive function, and the syndrome of cold of deficiency type. The symptoms include impotency, cold sperm, and sterility.
Deficiency of kidney-yang leads to the hypofunctioning of evaporation and a failure in the kidney's functions of discharge and retention, resulting in the hypofunction of water metabolism, which brings about the retention of water and pathogenic water flooding in the interstitial space. This is marked by edema and anuresis. Deficiency of kidney-yang may also leads to the dysfunctioning of the kidney's functions of discharge and retention,producing prolonged discharge, frequent micturition or urinary incontinence.
Moreover, deficient kidney-yang is unable to warm the spleen-yang, and the defi-
ciency of the kidney and spleen-yang lead to the dysfunction of transportation and transformation, marked by diarrhea with undigested food in the stool, diarrhea before dawn,and so on.
c. Hyperactivity of ministerial fire
This refers to the inability of deficient kidney-yin to astrict the ministerial fire of the vital gate, which leads to hyperactivity of the ministerial fire, resulting in the loss of fluid due to the fire. The hyperactivity of the ministerial fire from the vital gate is caused by the impairment of kidney-yin due to protracted illness, intemperance of sexual intercourse, or by over-intake of herbs with warm-dry nature which consume kidney-yin.Clinical manifestations are dysphoria with a feverish sensation in the five centers, dizziness, tinnitus, insomnia, dreaminess, hypersexuality, spermatorrhea, and premature ejaculation.

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