The Three Treasures Newsletters
WINTER 2005
AVIAN INFLUENZA AND CHINESE MEDICINE
Before discussing avian influenza, I will discuss influenza
in general from the view point of Western medicine first and
then from that of Chinese medicine
1. WESTERN MEDICINE VIEW
a) Influenza
Epidemiologists predict a new influenza pandemic during the
current winter. In fact, whether there will be a new
pandemic or not, influenza spreads every winter and accounts
for a substantial mortality every year.
Influenza viruses are characterized by a high variability and
high infection rate. The so-called "Spanish Flu" of
1918 killed an estimated 40-50 million people world-wide, more
than did the First World War.i Two
other pandemics occurred in 1957 with 2 million deaths and
1968 with 1 million deaths ("Asian" and "Hong Kong" Flu
respectively).ii The
most recent large epidemic in the United Kingdom was in 1989-1990,
when an estimated 26,000 people died in association with influenza.iii
There are three types of influenza virus, A, B and C. Influenza
A viruses are found in humans and animals, whereas B and C
are found only in human beings. Infection with influenza
produces an immune response with the production of antibodies
in the blood which neutralise the virus. If the person encounters
the same influenza virus again while the antibodies are still
present, the body is protected and the person should not develop
the infection.
It is a characteristic of influenza viruses, and especially
of the A virus, that they frequently mutate into sub-types
so that the virus is "one step ahead" of the natural immunity
created by the body. It is usually when sub-types develop
that epidemics occur because the antibodies produced will not
protect individuals against an influenza virus in which the
surface proteins have undergone a significant change since
the previous infection.
The latest example of an emerging new subtype is the H5N1 Aavian
influenza@ virus, first isolated in Hong Kong in May 1997,
which previously had only been found in birds and was not associated
with disease in humans.
Influenza viruses spread from person to person by tiny droplets
produced by coughing and sneezing. The initial site of infection
is the lining of the respiratory tract, and the infection has
a short incubation period of up to five days. The virus is
shed in respiratory secretions starting about one day before
the onset of the illness and lasting for about three to five
days.iv
The classic symptoms of influenza include fever, malaise, headache,
aches and pains in the muscles and joints, and a characteristic
dry cough and sore throat. The acute illness usually lasts
for three to five days but recovery may be slow, and cough
and tiredness may persist for two to four weeks post infection.
Complications may occur in groups of patients who are particularly
at risk (e.g. those with underlying lung disease or those with
defective immune systems), and usually affect the lungs and
the heart. Upper and lower respiratory tract infections are
common and subsequent invasion of the lungs by bacteria may
result in the development of pneumonia.v
b) Avian Influenza
An unprecedented epizootic avian influenza A (H5N1) virus that
is highly pathogenic has crossed the species barrier in Asia
to cause many human fatalities and poses an increasing pandemic
threat. The occurrence of human influenza A (H5N1)
in Southeast Asia has paralleled large outbreaks of avian
influenza A (H5N1), although the avian epidemics in 2004
and 2005 have only rarely led to disease in humans. The largest
number of cases has occurred in Vietnam, particularly during
the third, ongoing wave, and the first human death was recently
reported in Indonesia. The frequencies of human infection
have not been determined.vi
Human influenza is transmitted by inhalation of infectious
droplets by direct contact, and perhaps, by indirect
(fomite) contact, with self-inoculation onto the upper respiratory
tract or conjunctival mucosa.
In 1997, exposure to live poultry within a week before the
onset of illness was associated with disease in humans, whereas
there was no significant risk related to eating or preparing
poultry products or exposure to persons with influenza A (H5N1)
disease. Recently, most patients have had a history of
direct contact with poultry, although not those who were involved
in mass culling of poultry. Plucking and preparing of diseased
birds; handling fighting cocks; playing with poultry, particularly
asymptomatic infected ducks; and consumption of duck's blood
or possibly undercooked poultry have all been implicated.vii
Most patients have initial symptoms of high fever (typically
a temperature of more than 38°C) and an influenza-like
illness with lower respiratory tract symptoms. Upper respiratory
tract symptoms are present only sometimes. Unlike patients
with infections caused by avian influenza A (H7) viruses, 23
patients with avian influenza A (H5N1) rarely have conjunctivitis.
Diarrhea, vomiting, abdominal pain, pleuritic pain, and bleeding
from the nose and gums have also been reported early
in the course of illness in some patients. Watery diarrhea
without blood or inflammatory changes appears to be more common
than in influenza due to human viruses and may precede respiratory
manifestations by up to one week. One report described two
patients who presented with an encephalopathic illness and
diarrhea without apparent respiratory symptoms.
Lower respiratory tract manifestations develop early in the
course of illness and are usually found at presentation. In
one series, dyspnea developed a median of 5 days after the
onset of illness. Respiratory distress, tachypnea, and
inspiratory crackles are common. Sputum production is
variable and sometimes bloody. Almost all patients have
clinically apparent pneumonia; radiographic changes include
diffuse, multifocal, or patchy infiltrates; interstitial infiltrates;
and segmental or lobular consolidation with air bronchograms.
Radiographic abnormalities were present a median of 7 days
after the onset of fever in one study In Ho Chi Minh
City, Vietnam, multifocal consolidation involving at least
two zones was the most common abnormality among patients at
the time of admission. Pleural effusions are uncommon. Limited
microbiologic data indicate that this process is a primary
viral pneumonia, usually without bacterial suprainfection at
the time of hospitalization. Progression to respiratory failure
has been associated with diffuse, bilateral, ground-glass infiltrates
and manifestations of the acute respiratory distress syndrome
(ARDS).viii
In Thailand, the median time from the onset of illness to ARDS
was 6 days (range, 4 to 13). Multiorgan failure with signs
of renal dysfunction and sometimes cardiac compromise, including
cardiac dilatation and supraventricular tachyarrhythmias, has
been common. Other complications have included ventilator-associated
pneumonia, pulmonary hemorrhage, pneumothorax, pancytopenia,
Reye's syndrome, and sepsis syndrome without documented bacteremia.ix
2. CHINESE MEDICINE VIEW
Acute respiratory infections such as influenza cannot be diagnosed
and treated properly without a thorough understanding of
the theory of the 6 Stages and particularly that of the 4
Levels. The beginning stages of an acute respiratory
infection usually manifest with symptoms of invasions of
exterior Wind from the Chinese medicine point of view.
The "Discussion of Cold-induced Diseases" by Zhang
Zhong Jing provided the earliest framework for the diagnosis
and treatment of diseases from exterior Wind-Cold. Although
this famous classic does also discuss invasions of Wind-Heat
and their treatment, a comprehensive theory of exterior diseases
from Wind-Heat was not developed until the late 1600s by the
School of Warm Diseases (Wen
Bing). Thus, the
two schools of thought which form the pillars for the diagnosis
and treatment of exterior diseases in Chinese medicine are
separated by about 15 centuries: they are the School of Cold-induced
Diseases (School of Shang
Han) based on the "Discussion
of Cold-induced Diseases" ("Shang
Han Lun")
by Zhang Zhong Jing (c. AD 220) and the School of Warm Diseases
(Wen Bing School) which started in the late 1600s and
early 1700s. The main advocates of this school were Wu
You Ke (1582-1652), Ye Tian Shi (1667-1746) and Wu Ju Tong
(1758-1836).
Shang Han Lun - The Six Stages
The symptomatology of Wind-Cold was discussed by Zhang
Zhong Jing in the "Discussion of Cold-induced Diseases" (c.
AD 220) where he first elaborated the theory of the 6 Stages.
The Six Stages are:
| • |
Greater Yang |
| |
| |
Wind-Cold with prevalence
of Cold |
| |
Wind-Cold with prevalence
of Wind |
|
| • |
Bright Yang |
| |
| |
Channel pattern (Stomach-Heat) |
| |
Organ pattern (Stomach-Fire) |
|
| • |
Lesser Yang |
| • |
Greater Yin |
| • |
Lesser Yin |
| • |
Terminal Yin |
The first stage, Greater Yang, is the only Exterior one.
At this stage Wind-Cold is on the Exterior and only the Lung's
Defensive-Qi portion is affected, not the Interior. The
Lung's diffusing and descending of Qi is impaired and the
external Wind is lodged in the space between skin and muscles
impairing the circulation of Defensive-Qi.
The essential symptoms of the Greater Yang stage are:
| • |
aversion to cold or shivering |
| • |
occipital headache and/or stiff neck |
| • |
Floating pulse |
"Aversion to cold" indicates the typical cold
feeling and shivering which comes on as a wave in the beginning
stages of a cold or influenza. It is characteristic
in so far as it is not relieved by covering oneself. Most
people who experience a bad cold or flu shiver even in bed
under the blankets.
The occipital headache or stiffness is due to the obstruction
of Defensive-Qi circulation in the Greater-Yang channels
(Small Intestine and Bladder) which flow in that area.
The Floating pulse reflects the rushing of Defensive Qi towards
the Exterior to fight the pathogenic factor.
Besides these three cardinal symptoms there are many others
such as a runny nose, sneezing, possibly a fever, a cough,
body aches, itchy throat, etc. All these are due to
the impairment of the diffusing and descending of Qi by the
Lungs and by the obstruction to the circulation of Defensive-Qi
in the muscles.
In particular, the aversion to cold occurs simultaneously
with "emission of heat" (fa
re), i.e. the
patient's body emits heat and it feels hot to the touch:
please note that the patient may or may not have an actual
fever. Therefore "aversion to cold" is a subjective cold
feeling of the patient while "fever" (or rather "emission
of heat") is an objective hot feeling of the patient's body
to the touch.
Aversion to cold is caused by the obstruction of the space
between skin and muscles by exterior Wind: as the Defensive
Qi circulates in this space and warms the muscles, when it
is obstructed by exterior Wind, the patient feels cold. The
emission of heat is an expression of the fight between the
body's Upright Qi and the exterior Wind.
Warm Diseases (Wen Bing) - The 4
Levels
What does "Warm disease" mean? This is my
own translation of the Chinese term Wen
Bing. The
above-mentioned doctors from this school of thought introduced
important innovations to the theory of Wind in Chinese medicine. The
School of Warm Diseases postulates that some exterior pathogenic
factors go beyond the natural characters of "Wind";
they are so virulent and strong that, no matter how strong
a person's body's Qi may be, men, women and children fall
ill by the dozen. More importantly, for the first time
in the history of Chinese medicine, these doctors recognized
that some external pathogenic factors are infectious.
A further innovative idea stemming from this school was that
the pathogenic factors causing Warm diseases, all of them
falling under the category of Wind-Heat, enter via the nose
and mouth, rather than via the skin as happens for Wind-Cold.
The essential characteristics of Warm diseases therefore
are:
| 1) |
They manifest with the general
symptoms and signs of Wind-Heat in the early stages
(Wind-Heat is intended here in a broad sense as it
may also manifest as Damp-Heat, Summer-Heat, Winter-Heat,
Spring-Heat and Dry-Heat) |
| 2) |
There is always a fever |
| 3) |
They are infectious |
| 4) |
The Wind-Heat penetrates via the nose
and mouth |
| 5) |
The pathogenic factor is particularly
strong |
| 6) |
The Wind-Heat has a strong tendency
to become interior Heat |
| 7) |
Once in the Interior, the
Heat has a strong tendency to dry up body fluids. |
Thus, although all pathogenic factors contemplated by
the School of Warm Diseases fall under the broad definition
of Wind-Heat, not all diseases caused by Wind-Heat are
Warm diseases. Some of the exterior diseases that
start with symptoms of Wind-Heat are Warm diseases (with
all the above-mentioned characteristics) and some are not.
Examples
of Warm diseases are influenza, measles, chicken-pox, German
measles, poliomyelitis, smallpox, scarlet fever, whooping
cough or meningitis. Examples of Wind-Heat diseases
which are not Warm diseases are common cold (of the Wind-Heat
type), some types of influenza, glandular fever (mononucleosis)
and any non-specific upper-respiratory infection manifesting
with symptoms of Wind-Heat. An influenza epidemic
that sweeps the world is always a Wen
Bing disease. This
is because it is very virulent and has a strong tendency
to enter the Qi level (causing chest infections) very quickly.
The distinction between "simple" invasions of Wind-Heat
and invasions of Wind-Heat that are a Wen
Bing disease
is a very important consideration in practice: it is possible
to stop diseases from "simple" Wind-Heat at the
early stages, but although true Warm diseases may always
be alleviated in the initial stages, they may not always
be entirely stopped at the initial stages. In particular,
in the case of Warm diseases, even though it may not stop
them at the Exterior level, Chinese medicine can certainly
achieve the following aims:
| • |
Alleviate the symptoms |
| • |
Shorten the course of the disease |
| • |
Prevent transmission to the Ying and Blood levels
(see below) |
| • |
Prevent complications |
| • |
Prevent the formation of residual pathogenic factors |
The treatment of exterior invasions is important because
they can have very serious consequences in children and
the elderly. In children, many serious diseases start
with symptoms of invasion of Wind-Heat: in the initial
stages one does not know what disease it might be and it
is therefore important to treat the manifestations early. For
example, measles, diphtheria, whooping cough, poliomyelitis,
acute nephritis, scarlet fever and meningitis may all manifest
with symptoms of Wind-Heat in the beginning stage. In
the elderly, exterior Wind may easily penetrate the Interior
causing bronchitis and pneumonia which is often fatal in
old age.
a) THE FOUR LEVELS
The 4 Levels are:
| • |
Defensive-Qi (Wei) Level |
| |
| |
Wind-Heat |
| |
Damp-Heat |
| |
Summer-Heat |
| |
Wind-Dry-Heat |
|
| • |
Qi Level |
| |
| |
Lung-Heat |
| |
Stomach-Heat |
| |
Stomach and Intestines Dry-Heat |
| |
Gall-Bladder Heat |
| |
Stomach and Spleen
Damp-Heat |
|
| • |
Nutritive-Qi (Ying) Level |
| |
| |
Heat in Pericardium |
| |
Heat in Nutritive
Qi |
|
| • |
Blood Level |
| |
| |
Heat Victorious agitates Blood |
| |
Heat Victorious stirs Wind |
| |
Empty-Wind agitates in the
Interior |
| |
Collapse of Yin |
| |
Collapse of Yang |
|
The Wei Level concerns the exterior stage of an invasion
of Wind-Heat, the other three Levels describe pathological
conditions which arise when the pathogenic factor penetrates
the Interior and turns into Heat. The four Levels
represent different levels of energetic depth, the first
being the Exterior and the other three being the Interior.
The interesting part of this theory is the distinction,
within the Interior, of three different levels, the Qi
Level being the most superficial (within the Interior)
and the Blood Level the deepest.
The Wei Level of the 4 Levels broadly corresponds to
the Greater Yang Stage of the 6 Stages. The former
deals with Wind-Heat and the latter with Wind-Cold.
The main symptoms of invasion of Wind-Heat are aversion
to cold, shivering, "fever", sore throat, swollen tonsils,
headache and body-aches, sneezing, cough, runny nose
with yellow discharge, slightly dark urine, slightly
Red sides of the tongue and a Floating-Rapid pulse. It
is worth noting that in Wind-Heat too there is aversion
to cold as this is due to Wind-Heat obstructing the Defensive
Qi which therefore fails to warm the muscles.
i. Aetiology and pathology
An invasion of an exterior pathogenic factor is due to a temporary
and relative imbalance between it and the body's Qi. This imbalance
may occur either because the body's Qi is temporarily and
relatively weak
or because the pathogenic factor is very strong. The body's
Qi may be temporarily and relatively weak due to overwork,
excessive sexual activity, irregular diet and emotional stress
or a combination of these. When the body is thus weakened,
even a mild pathogenic factor may cause an external invasion
of Wind.
"Wind" indicates both an aetiological factor and a pathological condition.
As an aetiological factor, it literally refers to climatic influences and especially
sudden changes of weather to which the body cannot adapt.
As a pathological condition, "Wind" refers to a complex
of symptoms and signs manifesting as Wind-Cold or Wind-Heat.
In clinical practice, this is the most important aspect of the concept
of Wind. Thus, the diagnosis of "Wind" invasion
is made not on the basis of the history (no need to ask the patient
whether he or she has been exposed to wind), but on the basis
of the symptoms and signs. If a person has all the symptoms
and signs of "Wind" (aversion to cold, shivering, "fever",
sneezing, runny nose, headache and a Floating pulse), then the
condition is one of exterior Wind, no matter what climate that
person has been exposed to in the previous days or hours.
Indeed, there are also chronic conditions which manifest with
symptoms of "Wind" and are treated as such even though
they have no relation to climatic factors. For example,
allergic rhinitis (due to house-dust mites or pollen) manifests
with symptoms and signs of "Wind" and is treated as
such.
Influenza manifests primarily with symptoms of Wind-Heat.
ii. Simultaneous cold feeling and fever
The simultaneous fever and shivers is the most characteristic
symptom of the beginning stages of an invasion of Wind: they
indicate that there is an invasion of an exterior pathogenic
factor and that this factor is still at the Exterior level.
A long as there are shivers the pathogenic factor is on the Exterior.
I shall now discuss in detail the pathology and clinical significance
of the "aversion to cold" and "fever" in the beginning stage
of invasion of exterior Wind.
Aversion to cold
In Exterior patterns, the aversion to cold and cold feeling is
due to the fact that the external Wind obstructs the space
between skin and muscles where the Defensive Qi circulates;
as Defensive-Qi warms the muscles, its obstruction by Wind
causes the patient to feel cold and shiver (even if the pathogenic
factor is Wind-Heat). Thus, Defensive-Qi is not necessarily
weak but only obstructed in
the space between skin and muscles.
In Exterior patterns, both Wind-Cold and Wind-Heat cause a cold
feeling and shivering: it is a common misconception that this
is not the case with Wind-Heat. Since the cold feeling is caused
by the obstruction of Defensive Qi by Wind (whether it is Wind-Cold
or Wind-Heat) in the space between skin and muscles, the cold
feeling and shivering is present also in invasions of Wind-Heat,
albeit to a lesser degree than in Wind-Cold.
Generally speaking, there are three aspects to the "cold feeling"
in invasions of exterior Wind: the patients feels cold, he or
she has "waves" of shivers, and he or she is reluctant to go
out and wants to stay indoors. Except in mild cases, the cold
feeling is not relieved by covering oneself.
In conclusion, a feeling of cold in exterior invasions is due
to the obstruction of Defensive-Qi in the space between skin
and muscles and it indicates that the pathogenic factor is on
the Exterior: as soon as the feeling of cold goes, the pathogenic
factor is in the Interior.
"Fever"
As for "Fever" it is
important to understand that the Chinese terms fa
shao or fa
re do not necessarily indicate
"Fever". "Fever" is
a sign in modern Western medicine, not in old Chinese medicine.
In old China, there were obviously no thermometers and the
symptomsfa shao or fa
redescribed in the old texts do not necessarily mean that
the patient has an actual fever. It literally means "emitting
heat" and it indicates that the patient's body feels hot, almost
burning to the touch: the areas touched were usually the forehead
and especially the dorsum of
the hands (as opposed to the palms which tend to reflect more
Empty Heat).
In fact, it is a characteristic of fa
re (so-called "Fever")
in the exterior stage of invasions of Wind that the dorsum of
the hands feel hot compared to the palms and the upper back feels
hot compared to the chest. This objective hot feeling of the
patient's body may or may not be accompanied by an actual fever.
When the symptoms of shivers and feeling cold occurs simultaneously with
the objective sign of the patient's body feeling hot to the touch
(or having an actual fever), it indicates an acute invasion of
external Wind and it denotes that the pathogenic factor is still
on the Exterior. In particular, it is the symptoms of shivering
and feeling cold that indicate that the pathogenic factor is
on the Exterior: the moment the patient does not feel cold any
longer but feels hot and, if in bed, he or she throws off the
blankets, it means that the pathogenic factor is in the Interior
and it has turned into Heat.
The "Fever", or hot feeling
of the body in external invasions of Wind is due to the struggle
between the body's Qi (Upright Qi) and the external pathogenic
factor. Thus, the strength
of the fever (or hot feeling of the body) reflects the intensity
of this struggle: this depends on the relative strength of the
external pathogenic factor and the strength of the Upright Qi.
The stronger the external pathogenic factor, the higher the fever
(or hot feeling of the body); likewise, the stronger the Upright
Qi, the higher the fever (or hot feeling of the body). Thus
the fever will be highest when both the external pathogenic factor
and the Upright Qi are strong. Therefore, there are three
possible situations:
| • |
Strong pathogenic factor and strong Upright Qi: high
"fever" (or hot feeling of the body) |
| • |
Strong pathogenic factor with weak Upright Qi or
vice versa: medium "fever" (or hot feeling of the body) |
| • |
Weak pathogenic factor and weak Upright Qi: low "fever"
(or hot feeling of the body) or no "fever" |
However, the relative strength of the pathogenic factor and
the Upright Qi is only one factor which determines the intensity
of the fever (or hot feeling of the body). Another factor
is simply the constitution of a person: a person with a Yang
constitution (i.e. with predominance of Yang) will be more
prone to invasions of Wind-Heat rather than Wind-Cold and will
be more prone to have a higher fever (or hot feeling of the
body). Indeed, it could be said that the constitution
of a person is the main factor which determines whether a person
who falls prey to an invasion of Wind develops Wind-Cold or
Wind-Heat. Were it not so, in cold, Northern countries
nobody should fall prey to invasions of Wind-Heat which is
not the case. This is also the reason why, in children,
invasions of Wind-Heat are far more prevalent than Wind-Cold:
this is because children are naturally Yang in nature compared
to adults. There are, however, also new, artificial factors
which may predispose a person to invasions of Wind-Heat when
succumbing to Wind and these are very dry, centrally-heated
places, hot working conditions (e.g. cooks, metal workers),
etc.
The differentiation between Wind-Heat and Wind-Cold is not
made only on the basis of the intensity of shivers and fever
(or hot feeling of the body), although it is true to say that
a high fever is more likely to occur with invasions of Wind-Heat. Other
factors, such as tongue and other symptoms help us to differentiate
Wind-Cold from Wind-Heat. This is illustrated in Table 1. An
influenza epidemic definitely manifests with symptoms of Wind-Heat
in all cases.
The most important thing to establish when we see a patient
suffering from an acute respiratory infection is whether the
stage of the condition is external or internal, i.e. whether
the pathogenic factor is still on the Exterior or is in the
Interior. In terms of levels, this means distinguishing
whether the patient is still at the Wei level or at the Qi
level. The differentiation between the Wei and the Qi
level is relatively easy: if the patient suffers from aversion
to cold, he or she is still at the Wei level; if he or she
does not suffer from aversion to cold but, on the contrary,
from aversion to heat, the patient is at the Qi level.
Thus, influenza will always start with manifestations similar
to the Wei-Qi level of the 4 Levels. If the pathogenic
factor is not expelled at the beginning stages, it will change
into Heat and penetrate into the Interior.
Once the pathogenic factor penetrates into the Interior, the
body's Qi carries on its fight against it in the Interior:
this causes a high fever and a feeling of heat, in marked contrast
to the aversion to cold and the shivering which occur when
the body's Qi fights the pathogenic factor on the Exterior. At
the exterior level, the internal organs are not affected and
it is only the Lung's Wei-Qi portion which is involved. When
the pathogenic factor becomes interior, the organs are affected
and especially the Lungs and/or Stomach (see below).
This stage of development in the pathology of these diseases
is crucial as, if the pathogenic factor is not cleared, it
may either penetrate more deeply and cause serious problems
(at the Ying-Qi or Blood Level) or give rise to residual Heat
which is often the cause of chronic post-viral fatigue syndrome.
In the Interior, the main patterns appearing will be either
the Bright-Yang pattern of the 6 Stages or, more commonly,
one of the Qi-Level patterns within the 4 Levels. In
general, at the Qi Level, either the Stomach or Lung or both
are affected.
b) WEI LEVEL
The Wei level is the beginning stage of invasions of Wind-Heat:
it is the only exterior level, i.e. characterized by the presence
of the exterior Wind on the Exterior of the body. The
Wei level comprises of four different patterns according to
the nature of the pathogenic factor, i.e. Wind-Heat, Summer-Heat,
Damp-Heat and Dry-Heat. Of these four, Wind-Heat is by
far the most common one.
The clinical manifestations of invasion of Wind-Heat at the Wei
Level are "fever", aversion to cold, headache, sore throat, slight
sweating, runny nose with yellow discharge, swollen tonsils,
body aches, slight thirst, tongue Red in the front or sides with
a thin-white coating, Floating-Rapid pulse.
The pathology of aversion to cold and "fever" has already been
discussed. The headache is caused by the obstruction of
the channels of the head by exterior Wind in the same way as
for the Greater Yang Stage. The body aches, which may be
very pronounced, are caused by the obstruction of the muscles
by exterior Wind. The tongue coating is white because the pathogenic
factor is on the Exterior.
A sore throat is due to invasion of the Wind in the Lung channel
in the throat: a sore and red throat is a distinctive sign of invasion
of Wind-Heat as compared to Wind-Cold.
Table 1. Comparison of Wind-Cold and Wind-Heat.
| |
WIND-COLD |
WIND-HEAT |
| PATHOLOGY |
Wind-Cold obstructing Defensive Qi |
Wind-Heat injuring Defensive Qi and impairing
the descending of Lung-Qi |
| PENETRATION OF PATHOGENIC
FACTOR |
Via skin |
Via nose and mouth |
| FEVER |
Light |
High |
| AVERSION TO COLD |
Pronounced |
Slight |
| BODY ACHES |
Severe |
Slight |
| THIRST |
None |
Slight |
| URINE |
Pale |
Slightly dark |
| HEADACHE |
Occipital |
Whole head |
| SWEATING |
No sweating or slight sweating on head |
Slight sweating |
| TONGUE |
No change |
Slightly Red on the sides and/or front |
| PULSE |
Floating-Tight |
Floating-Rapid |
| TREATMENT |
Pungent-warm herbs to cause sweating |
Pungent-cool herbs to release the Exterior |
|
Three Treasures remedies
Expel Wind-Heat
For invasions of Wind-Heat at the Wei Level. The dosage
is at least 9 tablets a day but if the symptoms are severe,
an adult can use up to 12-15 tablets per day. Expel
Wind-Heat should be a stand-by remedy in any household
with children.
Acupuncture
LU-7 Lieque, L.I.-4 Hegu, T.B.-5 Waiguan, Du-14 Dazhui, L.I.-11
Quchi, LU-11 Shaoshang (in case of tonsillitis), BL-12 Fengmen
with cupping, BL-13 Feishu.
c) QI LEVEL
If the external Wind is not expelled, it will usually turn
into Heat and enter the Interior and most frequently the
Lungs. The main symptoms at this stage are aversion
to heat, a feeling of heat, possibly fever, cough (which
may be dry or productive), slight breathlessness, restlessness,
disturbed sleep, thirst, a feeling of oppression of the chest,
Red tongue with yellow coating, Deep-Full-Slippery pulse.
These are manifestations of the Qi level.
It is a characteristic of avian influenza that it affects the
Qi level very quickly and very early on.
The main patterns appearing at the Qi level are:
| • |
Lung Phlegm-Heat |
| • |
Damp-Phlegm in the Lungs |
| • |
Dry-Phlegm in the Lungs |
Three Treasures remedies
Clear Metal
Clear Metal is a
new addition to the Three
Treasures range. This
remedy clears Lung-Heat, clears Ying,
benefits fluids. It is used for invasions of Wind-Heat progressing
rapidly into the Interior, with Lung- and Stomach-Heat. The
location of Heat is at the Qi and Ying/Blood
level simultaneously.
This remedy has been formulated specifically for the later
stage of influenza when the pathogenic factor has entered the
Qi Level and even possibly the Ying level; it may also be used
when the pathogenic factor is just beginning to pass from the
Wei to the Qi level.
At the first signs of the beginning of influenza (feeling chills,
fever, sore throat) take Expel
Wind-Heat. If one is
in doubt whether the symptoms are those of a "simple" influenza
or of those of a more serious type (such as avian influenza),
then Expel Wind-Heat and
Clear Metal can be
taken simultaneously for a couple of days until the clinical
manifestations reveal what type of virus it is. If the symptoms
persist and progress rapidly to the lower respiratory tract
causing high fever, cough, breathlessness, respiratory distress
and inspiration crackles, the patient should stop taking Expel
Wind-Heat and take Clear
Metal immediately.
Please note that this remedy can be administered concurrently
with any Western anti-viral medication.
Dosage: for adults, take 12-15 tablets
a day, i.e. 3 tablets 4-5 times a day in between meals. Reduce
the dosage for children according to age.
Ingredients of Clear Metal
Huang Qin Radix Scutellariae
Huang Lian Rhizoma Coptidis
Jin Yin Hua Flos Lonicerae japonicae
Lian Qiao Fructus Forsythiae
Da Qing Ye Folium Daqingye
Ban Lan Gen Radix Isatis seu Baphicacanthis
Shi Gao Gypsum Fibrosum
Zhu Ye Folium Phyllostachys nigrae
Yu Xing Cao Herba Houttuniae
Chuan Bei Mu Bulbus Fritillariae cirrhosae
Zhi Mu Radix Anemarrhaenae
Sheng Di Huang Radix Rehmanniae
Bai He Bulbus Lilii
Mao Dong Qing Radix Ilicis pubescentis
Mu Dan Pi Cortex Moutan
Clear the Soul
Clear the Soul can
be used for acute chest infections following an invasion
of Wind, i.e. when the pathogenic factor is Phlegm-Heat at
the Qi level. The main manifestations calling for this remedy
in this context are: a cough following a cold or flu, expectoration
of profuse sticky-yellow sputum, slight breathlessness, a
feeling of oppression of the chest, possibly fever, thirst,
disturbed sleep, a Full-Slippery pulse, a red tongue with
sticky-yellow coating. The dosage is at least 9 tablets per
day.
Clear the Soul can be used also for residual pathogenic
factor with Phlegm-Heat when the patient suffers from a chronic
cough with catarrh and some breathlessness (see below).
Acupuncture
LU-5 Chize, LU-7 Lieque, Ren-12 Zhongwan, L.I.-11 Quchi, BL-13
Feishu, Du-14 Dazhui, ST-40 Fenglong.
Other prescriptions
There are two prescriptions that I can highly recommend for
acute chest infections to be used as a decoction: the first
is Qing Qi Hua Tan Tang Clearing
Qi and Resolving Phlegm Decoction (Bensky p. 437)
for Phlegm-Heat in the Lungs and the second is Qing Zao Jiu
Fei Tang Clearing Dryness
and Rescuing the Lungs Decoction (Bensky p. 160) for
Dry-Phlegm in the Lungs. Both are specific for Heat
in the Lungs at the Qi level following an invasion of Wind:
the former is for Phlegm-Heat and the latter for Phlegm-Heat
combined with dryness.
The clinical manifestations calling for the first formula,
Qing Qi Hua Tan Tang, are: a cough with expectoration of profuse,
sticky-yellow sputum, slight breathlessness, a feeling of oppression
of the chest, possibly fever, thirst, disturbed sleep, a Full-Slippery
pulse, a red tongue with sticky-yellow coating. If cough
is the main symptom add Kuan Dong Hua and Zi Wan.
The clinical manifestations calling for the second formula,
Qing Zao Jiu Fei Tang, are: a cough that is mainly dry but
the patient feels some phlegm in the chest which is expectorated
occasionally and with difficulty, a slight breathlessness,
a raw feeling in the chest and trachea, a dry mouth. From
the point of view of Western medicine this can correspond to
tracheitis.
d) YING LEVEL
At the Ying Level, the Heat has penetrated to a deeper energetic
layer and it has begun to injure the Yin. At this level,
Heat is obstructing the Mind and the Pericardium causing delirium
and even coma. Fever at night is a distinctive sign of
the Ying Level.
The tongue appearance at the Ying Level is an important
sign that differentiates this level from the Qi Level: at the
Ying Level, the tongue is Deep-Red without coating (while
at the Qi Level, it is Red with a thick coating).
e) BLOOD LEVEL
The Blood Level is the deepest energetic layer with Heat affecting
the Blood. There are several different patterns with
varying clinical manifestations but the chief clinical features
of the Blood Level are as follows:
| • |
There is Yin deficiency |
| • |
Heat is affecting the Blood causing bleeding |
| • |
Heat is affecting the Mind causing delirium or coma |
| • |
Heat in the Blood causes bleeding under the skin with the appearance of macules |
| • |
Internal Wind may develop causing convulsions and tremors |
| • |
Collapse of Yin or Yang may occur |
Macules are a definite sign that Heat has reached the Blood
Level. There are five patterns at the Blood Level, i.e.
Heat victorious moving Blood, Heat victorious stirring Wind,
Empty Wind agitating in the Interior, Collapse of Yin and Collapse
of Yang.
"Blood" here should be intended as a description of the deepest energetic
level of the body. When Heat penetrates this level in the context of
a Wen Bing disease, the person may die. The chief sign of invasion of
the Blood Level by Heat is in fact bleeding, which may be in the stools, in
the vomit and under the skin. Indeed, the presence of maculae under the
skin always indicate that the Heat has reached the Blood level and the situation
is potentially serious.
Table 2 compares the clinical manifestations of the Four Levels
while Table 3 differentiates the Four Levels according to tongue
appearance.
Table 2. Comparison of Four levels.
| Symptoms |
WEI |
QI |
YING/BLOOD |
| Fever |
Slight fever, aversion to cold |
High fever, feeling of heat |
Fever at night |
| Thirst |
Slight |
Intense, desire to drink cold drinks |
Dry mouth, desire to sip liquids |
| Mental state |
Unchanged |
Maybe delirium, generally mind clear |
Delirium, fainting, mind confused |
| Sweating |
Slight |
Profuse |
Night-sweating |
| Tongue |
Red sides/front, thin-white coatingRed sides/front,
thin-white coating |
Red body, thick-yellow coating |
Red body, no coating |
| Pulse |
Floating-Rapid |
Big-Rapid, Deep-Full-Rapid or Slippery-Rapid |
Fine-Rapid |
| Summary |
Exterior pattern |
Interior pattern, Upright Qi strong |
Interior pattern, Upright Qi weak |
|
Table 3. Comparison of tongue appearance in
Four Levels.
| Tongue |
WEI |
QI |
YING |
BLOOD |
Wind-
Heat |
Summer Heat |
Dry Heat |
Damp-
Heat |
| Body |
Red sides or front |
Red |
Dry |
Red |
Red |
Deep-Red |
Deep-Red |
| Coating |
Thin-white or yellow |
Thin-white |
Thin-white, dry |
White, sticky |
Thick, dry, yellow or brown (sticky in Stomach
and Spleen Damp-Heat) |
No coating |
No coating |
| Remark |
|
Coating more important |
Body more important |
Body more important |
|
f) THE FOUR LEVELS AND AVIAN INFLUENZA
The Four Levels are crucial to understand the pathology of
avian influenza. As mentioned above, in the beginning
stages of an invasion of Wind during an attack of influenza,
the clinical manifestations are those of attack of Wind-Heat
at the Wei Level. As indicated above, the essential symptom
is the simultaneous occurrence of aversion to cold and "fever".
Influenza, and especially avian influenza, is a type of Warm
disease (Wen Bing) and Warm diseases are characterized
by the fact that they are infectious and also that the pathogenic
factor tends to move into the Interior rather quickly; the
Heat or a Warm disease has also the tendency to injure Yin
rather quickly.
When the pathogenic factor penetrates into the Interior, it
becomes interior Heat and it may affect primarily the Lungs,
Stomach and Intestines. As mentioned above, it is a brilliant
aspect of the theory of the Four Levels, that, when Heat is
in the Interior, it distinguishes between three different levels
of Heat, i.e. Qi, Ying and Blood levels. The Qi Level
is never serious enough to cause death and there is saying
that states "nobody can
die at the Qi Level".
The Qi level is characterized by Full-Interior-Heat with symptoms
of fever, thirst, feeling of heat, mental restlessness, Red
tongue with thick-yellow coating and a Rapid-Full pulse.
The Ying and Blood levels are more serious and can potentially
lead to death. The main characteristic of the Ying
and Blood levels is that the Yin is severely damaged and dried
up by the Heat, the Mind is affected (delirium or coma) and
the Blood is affected.
If we analyze the clinical manifestations of avian influenza,
we can see clearly that it is a type of Wen Bing disease that
progresses to the Qi Level very quickly affecting both the
Lungs and the Large Intestine. We can also see that some
clinical manifestations indicate that the Ying and Blood levels
are also affected rapidly during the course of the infection.
I will report below the clinical manifestations listed above
with their interpretation in terms of the Four Levels:
| • |
Upper respiratory
tract symptoms are present only sometimes: the pathogenic factor leaves the Wei Level rapidly |
| • |
High fever
(typically a temperature of more than 38°C) and an influenza-like illness with lower respiratory tract symptoms: Qi Level with Lung-Heat |
| • |
Lower respiratory
tract manifestations develop early in the course of illness
and are usually found at presentation: pathogenic factor progresses very rapidly to the Qi Level and hardly stays any time at all at the Wei Level |
| • |
Diarrhea,
vomiting, abdominal pain: Qi Level with Heat in Stomach and Intestines |
| • |
Pleuritic
pain: Qi Level with Lung-Heat |
| • |
Dyspnea,
respiratory distress, tachypnea, and inspiratory crackles: Qi Level with Lung-Heat |
| • |
Almost all
patients have clinically apparent pneumonia: Qi Level with Lung-Heat |
| • |
Watery diarrhea
without blood or inflammatory changes: Qi Level with Heat in the Stomach and Spleen |
| • |
Sputum: Qi Level with Phlegm-Heat in Lungs |
| • |
Bleeding
from the nose and gums: Blood Level with Heat in the Lungs and Stomach |
| • |
Pulmonary
hemorrhage: Blood Level with Lung-Heat |
| • |
Sepsis syndrome: Toxic Heat at the Blood Level |
| • |
Multi-organ
failure with signs of renal dysfunction and sometimes cardiac
compromise: Collapse of Yin or of Yang |
END NOTES
| i |
WHO website. |
| ii |
Ibid. |
| iii |
Association of Microbiologists
(UK) website, 1998. |
| iv |
Ibid. |
| v |
Ibid. |
| vi |
New England Journal
of Medicine, Vol. 353, No. 13, 2005, pp. 1374-1385. |
| vii |
Ibid. |
| viii |
Ibid. |
| ix |
Ibid. |
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