Pathological Mechanism of Triple-Jiao
The triple-jiao pathomechanism was first stated by Wu Jutong in his book entitled
Treatise on Differentiation and Treatment of Warm Diseases. Based on the description of the location and function of triple-jiao in Internal Classic, the exposition of heat in the upper, middle, and lower-fiao in Synopsis of the Golden Chamber, and in light of the wei-qi-ying-xue pathomechanism of Ye Tianshi, Wu made conclusions regarding the regularities in the occurrence, development, and transmi'ssion of the triple-jiao discases, and founded the theory. This theory is used primarily to explain the pathological changes of viscera pertaining to the triple-fiao in the warm disease (including the damp-warm disease). It makes up for the defects of wei-qi-ying-xue pathomechanism in the explanation of the warm disease, particularly of the damp-warm disease.
The warm disease is a general term for the acute febrile disease caused by the intruding of various warm or heat-evils in the four seasons. They can be classified into two major categories according to their natures, namely warm-heat disease and damp-heat (or damp-warm) disease. There are commonalities between these two diseases, but there are also distinguishing features. For example, the damp-heat disease is caused mainly by the damp-evil. The dampness is a yin-evil. It tends to impair yang-qi. The water-dampness evil often stays between the wei-stage and qi-stage. It seldom hurts yin, but leads to a syndrome of heat in ying or xue. Another characteristic of dampness is its heaviness and turbidity. Because dampness flows downwards, the damp-heat disease often transmits from the upper to middle and then to the lower-jiao . This is the transmitting rule of damp-heat disease.
Diseases of damp-heat are caused by the invasion of exogenous dampness together
with warm or heat-evil. So their pathomechanisms include the pathological reaction of both heat-evil and damp-evil. The pathomechanism of damp-heat disease can be illustrated in the following aspects: First, the dampness and heat are entangled, dampness envelops the heat, and heat is in surrounding of dampness. When damp-evil still exists, it is hard to clear up heat-evil. Second, damp-evil is a yin evil, and it is characterized by heaviness, turbidity, stickiness and greasiness. It tends to obstruct the qi circulation, and checks and damages the yang. So the damp-heat diseases are often relatively protracted and refractory. Lastly, the damp-heat evils have a spreading nature. When heat-evil heats the dampness, the dampness will flow and spread over the whole body. So the damp-heat diseases often have their central location in spleen and stomach, and then spread over all parts of the body.
In clinical conditions, many cases are characterized by the fact that the upper, middle, and lower-jiao are filled with damp-heat evils, the qi is stagnated, and yang is damaged, which leads to a condition of general disturbance of water circulation and transformation. The location of disease often alters in the order of upper, middle and lower-jiao.The triple-jiao pathomechanism is suitable for exposition of the pathological changes in damp-heat disease, in which damp-heat evils intrude into the triple-jiao and involve the viscera. The upper-jiao damp-heat, middle-jiao damp-heat, and lower-jiao damp-heat compose the main pathological process.
1. Pathological Mechanism of Upper-Jiao Damp-Heat
Upper-jiao damp-heat is the initial stage of damp-heat disease. This condition is caused by a joint invasion of the damp-evil and warm or heat-evil. When damp evil invades the body and hinders qi circulation, the stagnated dampness will partially transform itself into heat-evil, which results in a disease of damp-heat.
The disease location of upper-jiao damp-heat is mainly the lung, defensive qi and pericardium. It causes a failure of the lung in its dispersing and depurative descending function. The evils also stagnate and check the defensive qi. This leads to the dysfunctioning of surface guarding. The hindering of damp-heat makes qi stagnated, and the dampness can not be dissolved or dispersed. Instead, it will begin spreading over skin and muscles, and hems in the lucid yang. Its main clinical manifestations include fever with aversion to cold, obscure fever, heaviness of the head, heavy limbs, choking sensation in the chest, stuffiness of epigastrium, sticky feeling in mouth, no thirst, white and greasy tongue coating, and a soggy pulse.
If the dampness encumbers the spleen and stomach, and impairs the receiving and
transforming function, there will be poor appetite and loose stool. If the stagnated damp heat produces phlegm, and the coves the heart orifice, this will result in a condition of obscure mind in heart. Its clinical characteristics are apathy, dullness, dementia, stupor,etc. If the damp-heat in upper-jiao is not eliminated, it will transmit to middle-jiao.
2. Pathological Mechanism of Middle-diao Damp-Heat
The middle-jiao damp-heat is the intermediate stage of damp-heat disease. This
because the remaining damp-heat evil in upper-jiao enters middle-jiao. If the dysfunctioning of spleen in its transportation and transformation functions leads to endogenous dampheat, and the spleen and stomach are further affected by summer-heat and damp-evil,damp-heat in middle-jiao will occur as well. It may also be caused by an improper diet,which leads to food retention, with the retained food being transformed into damp-heat.
The pathological change of middle-jiao damp-heat focuses on the spleen and st0m-
ach, and it is a primary condition of spleen and stomach impairment due to dampness.
The spleen dislikes dampness and is prone to be encumbered by dampness. If the spleen
and stomach are injured by damp evil, the transporting and transforming functions will obstructed. Because the muscles and limbs are dominated by spleen, middle-jiao dampheat condition results in the dysfunction of the muscles and limbs, as well as the digestive tract.
The damp evil has a nature of stickiness, and it arrives and departs slowly. When it adheres to something, it is difficult to remove. Because of these characteristics, the damp-heat in middle-jiao usually lasts for an extended period of time. Because of disparities in patients' constitutions, the major aspect of the evils may be either dampness or heat. If the patient is in a yang deficiency condition, or the dampness is prevalent, the pathomechanism will be more dampness and less heat, and the disease will locate in the spleen of Foot-Taiyin. When the patient's constitution is of abundant yang, or heat evil is prevalent, the pathomechanism will be more heat and less dampness, and the diseae will locate in the stomach of Foot-Yangming. As was stated by Ye Tianshi in his book Treatise on Warm and Heat: "In a yang exuberant body, the dampness is almost always in the stomach, while in a yin exorbitant constitution, the dampness is more often seen in the spleen. However, the process of the evils' transforming into heat is the same. " If, in one another alternative case, the spleen-dampness and stomach-heat are equivalent, this results in an equal dampness and heat condition.
The main pathomechanism of the condition of more dampness than heat in the middle-fiao is the internal retention of dampness and the dysfunction of the spleen in transporting. The clinical reaction is characterized mainly by the dampness, the heat nature is not obvious. There will be heavy and aching limbs, epigastric stuffiness, lack of appetite,tastelessness, lack of thirst, loose stool with difficulty in defecation, greasy tongue coating, and a soggy pulse.
The excess interior heat complicated by dampness is the main pathomechanism of more heat than dampness in the middle-jiao. The interior heat is characterized by high fever, vexation, and thirst. Since the damp-heat encumbers the spleen and stomach, the receiving and transporting functions are out of order, and there are also symptoms of abdominal distention and fullness, yellow and greasy tongue coating, and rapid soggy pulse. In the condition of more heat than dampness in the middle-jiao, the dampness is apt to transform into heat, and the disease then becomes warm disease.
The pathomechanism of equal dampness and heat is stagnated dampness combined with steaming heat, which are entangled and hardly separated. The symptoms include fever abated by sweating, which then becomes former fever, chokeing sensation in the chest,and abdominal distention,thirst but lack of desire to drink or just like to drink little.
There are three transmission directions of the middle-jiao damp-heat. The first, under the prevalent yang condition, the damp-heat becomes dryness, and then forms qistage syndrome of warm disease, or injuries the yin and enters ying or xue-stage. The second, with the prevalent yin condition, the evils can transmit into cold, and then become a cold-dampness disease. The third, the long staying damp-heat in the middle-jiao will go downwards into the lower, and the disease becomes a lower-jiao damp-heat disease.
3. The Pathological Mechanism of Lower-diao Damp-Heat
The disease location of lower-jiao damp-heat is in the urinary bladder, small intestine, and large intestine. Its occurrence is due to a direct attack on the urinary bladder or intestines by the damp-heat evil. It can also be caused by the downward transmission of the retained middle-jiao damp-heat. The main pathological reactions are the metabolic disturbance of body fluid and a disorder in the transporting of food waste. Abdominal
micturition and defecation are the main clinical characteristics.
If damp-heat obstructs the urinary bladder and leads to a disturbed transforming function of qi, and if it blocks water passage, there are symptoms such as anuria and dysuria. If it impedes the large intestine, qi cannot flow freely, and if the fu-viscera-qi is hampered, the resulting symptoms may include infero-lateral abdominal distention or constipation. If damp-heat flows downwards to the intestines, there will be loose and foul stools and unsmoothed defecation. If excess damp-heat stifles the intestines, qi can not flow freely, and qi and blood will be injured. This results in diarrhea, abdominal pain,blood and pus in the stool, tenesmus, and a burning feeling in anus. If damp-heat changes into dry-heat, enters ying or xue-stage and damages the yin-collateral, there will be hemafecia, restlessness, high fever, crimson tongue, and so on. If the hemafeeiais not stopped, and too much blood is lost, there will be a condition of qi collapse following massive bleeding, and the symptoms will include a pale complexion, cold limbs with sweating, and a faint pulse. Besides the conditions and symptoms listed above, the finalconsideration is when dampness changes into heat ,and it results in a situation where the evil will injure the liver and kidney, yin and blood are consumed, and the liver loses its nourishment, thus bringing about the syndrome of liver-wind stirring inward. The symptoms are twitching of limbs, convulsion, or spasm.
It should be pointed out that although there are a number of disparities of the triple jiao disease, they often combine with or are complicated by one another. For instance,the middle-jiao damp-heat can be complicated by upper-jiao damp-heat. The lower-jiao damp-heat, which mainly locates itself in the urinary bladder and intestines, can affect the upper or middle-jiao and lead to a pathological reaction of the spleen, stomach, heart or lung. This characteristic is due to the spreading nature of the damp-heat evil.
