Lurking Pathogens 2
Four Levels Review
Before we get into the specifics of Lurking Pathogens (LP), it might be helpful to have a quick and basic review of Warm Disease theory, for those who have forgotten or are new. For this purpose, I’m chopping and splicing from my class materials for the Shāng Hán / Wēn Bìng course I taught at ASAOM the last couple of years. Since the textbook was Maciocia’s Foundations (2015), the notes were geared toward that but also used material from Wen and Seifert (2000), Liu (2005), and Deng (1999), as well as a translation of Discussion of Warm Diseases (Wēn Rè Lùn) by Chace & Van Wart (2006).
Wēn Bìng / Warm Diseases
Warm Diseases have special characteristics that set them apart from Cold Damage (Shāng Hán):
· They have distinct natures and are closely correlated with seasonal qi (Spring Warmth, Autumn Dryness, Summerheat-Damp, etc)
· They manifest with fever/heat effusion from the onset, with more fever than chills
· Pathogens enter through the nose and mouth in addition to the surface
· Rapid development of pathology
· Strong tendency to injure Yīn
There are two major pathodynamic maps in the Warm Disease school, the Four Levels (Four Aspects, Four Divisions) and Three Burners. For now, we will be discussing the Four Levels.
Four Levels (Sì Fèn)
Devised by Yè Tiānshì in Discussion of Warm Diseases (Wēn Rè Lùn) (1746)
Location Of Pathology
Wèi Level – Exterior stage
Pathology is located in the Lung (upper respiratory), and the skin and body hair.
This is the level associated with Wind-Heat, though other pathogens also pass through this level, even if briefly.
Qì Level - Interior /Superficial Organs
Pathology is in the Lung, chest and diaphragm, Spleen and Stomach, Intestines, Gallbladder, Triple Burner, etc.
This is the level at which can be found the Yáng organs as well as the Yīn organs most closely associated with the production of the body’s Qì, namely Lung and Spleen.
This is an important level in both pathology and treatment. Diseases at this level are seldom fatal, even if symptoms are severe: Maciocia (2015) quotes a maxim, “no one dies at the Qì level.”
Though the level is considered interior (or half-interior half-exterior in the case of the Gallbladder), there are plenty of exit routes to expel the pathogenic factors.
Qì level patterns contain a lot of crossover with the Yáng portions of Six Stages, including Yáng Brightness channel syndrome with its “Four Greats”, Intestinal heat bind, Lesser Yáng disease, and so forth.
The Warm Disease school also made great advances in understanding and treating Damp pathogens (Damp Warmth and Summerheat-Damp), which target the Spleen and Stomach and thus have a strong impact on the Qì level.
Yíng Level – Yáng portion of blood; Heart/Pericardium
Pathology is in the Heart and Pericardium.
The Yīn and Blood take damage due to the heat of the pathogens and the correct qì’s response in the Qì level.
Symptoms show signs of injury to Yīn -- fever at night, peeled tongue coat on a crimson red tongue, and thin rapid pulse.
The presentations often include signs of Spirit disturbance – insomnia, vexation, delirium or clouding – that indicate heat entering the Pericardium.
Skin eruptions may occur from heat forcing blood from the collaterals.
Xuè level – Blood /Deeper Organs
Pathology is in the Liver and Kidney, as well as Heart. Blood and Yin are consumed rapidly.
This level is the deepest of the four, and the most serious in terms of pathology.
The symptoms of the previous stage may still be present and worsening: delirium, even coma.
Bleeding under the skin may turn to outright bleeding from body orifices.
Heat steaming off the Yin fluids leads to Liver wind, with spasms and convulsions.
Left unchecked, the process may lead to complete collapse of the Yìn (and/or Yáng ).
Tracking the Pathogen
When a warm disease evil invades the body, in general the pathogen moves from exterior to interior.
Beginning in the Wèi Level, it gradually, and in order, advances to the Qì Level, the Yíng Level and the Xuè Level.
Yè also describes an abnormal or counterflow transmission (nì chuán) from Lung to Pericardium (Wèi to Yíng), which may explain in Chinese traditional pathophysiology some of the hematologic effects of SARS-CoV2, but that is a discussion for another time.
Lurking Pathogens (LP) are somewhat different in that they are said to emerge from the interior and thrust out to the exterior. They are able to penetrate the Wèi Level without causing symptoms and lodge at the Qì, Yíng, or Xuè Levels; from there they may then move outward to the Qì or Wèi Level. More superficial levels reflect less severe conditions, thus if the pathogen thrusts out to the exterior from the interior, this indicates a more favorable prognosis.
Basic Treatment Principles
Wèi Level: Release exterior and promote sweating to expel the evil to the outside
Qì Level: Many treatment principles depending on type of pathogen and organ involvement, including:
Clear heat and generate fluids.
Harmonize
Dry dampness
Purge accumulation
It is extremely important at the Qì Level to keep the pathogen from falling inward to the Yíng or Xuè Level.
Yíng Level: clear Yíng Level heat and outthrust heat to kick it back to the Qì Level.
Xuè Level: Enrich Yin, cool blood, dispel blood stasis, extinguish wind, open orifices
Conclusion
Warm disease theory can get quite complicated and this is just a rough outline for purposes of review. We will circle back to all of these things in the series. Next time we’re going to look specifically at Lurking Pathogens.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Chace, C., & Van Wart, D. (2006). Ye Tian-Shi’s Wen Re Lun: Discourse on warm-heat disease. The Lantern, 3(1).
Deng, T. (1999) Practical diagnosis in traditional Chinese medicine (Marnae Ergil & Sumei Yi, trans.). Churchill Livingstone.
Liu, G. (2005). Warm pathogen diseases: A clinical guide. Eastland Press.
Maciocia, G. (2015). Foundations of Chinese medicine: A comprehensive text (3rd edition). Elsevier Health Sciences (US).
Wen, J. M., & Seifert, G. (2000). Warm disease theory: Wen bing xue. Paradigm Publications.