Pathogenic Factors

General
In the view of TCM , health is a state in which the relations
of the components of the human body and the unity
between man and nature are kept in harmony. When this
harmony is destroyed by certain factors and the body cannot
maintain its normal state , disease occurs. So , any factors
that destroy the relative balance of the human body are
known as causes of disease in TCM.
Etiology in TCM is characterized by three points : First,
recognizing etiologic factors under the guidance of the
Concept of Holism. Unlike Western medicine, TCM does not
emphasize the identification of the specific etiologic factors
such as viruses and bacteria of diseases. Instead, it stresses
the significance of the environmental or internal conditions
of the human body in the occurrence of disease. For
example, man depends on the supply of both Heaven Yang
and Earth Yin, which affect the human body through
different climatic conditions and food and drink. Therefore ,
abnormal changes of the weather or climatic conditions are
regarded as one of the major groups of pathogenic factors
that invade the body from the outside; and improper diet ,
such as excessive or inadequate intake of food, or
preference for food of certain tastes , are pathogenic factors
that directly disturb the functional activities of the Zang and
Fu Organs.
In addition, emotional stress, if in excess, may also become
a pathogenic factor as it will lead to dysfunction of the Zang
and Fu Organs.
Second, stressing the relativity of pathogenic factors.
Whether or not abnormal changes of any factors, such as
climatic conditions or emotional changes, can transform into
pathogenic factors depends not only on the changes

themselves , but also the reaction of the human body to

these changes. For example, a sudden and violent climatic
change may become one of the Six External Pathogens , but
if its effect is limited for some reason, or the resistance of
the body is strong enough to defend the body, it will not
cause diseases. In such conditions ,it cannot be regarded as
one of the Six External Pathogens. Abnormal changes of
weather provide the possibility for climatic conditions to
become pathogens, but it is the mutual action of the climatic
conditions and Vital Qi that determines whether the
abnormal weather transforms into a pathogen or not.
Third, identifying pathogenic factors by analyzing the
manifestations of a disease. TCM believes that any
syndrome is a morbid reflection of the human body under
the action and influence of pathogenic factors. There is a
correspondence
between
the
pathogens
and
the
manifestations of disease. Therefore, when analyzing causes
of a disease, apart from possible objective considera- tions ,
TCM deduces the nature of the pathogens mainly on the
basis of the manifestations. For example, when a patient has
fever and chills, lack of sweat, stuffy and running nose and a
floating tense pulse, he can be diagnosed as having an
Exterior Syndrome due to Wind Cold. Whether or not it is
very cold during the occurrence of the disease is not very
important in the determination of the pathogens.
I. The Six External Pathogens
This is a general term for Wind, Cold, Summer Heat, Damp,
Dryness and Fire. The six kinds of climatic changes in
excess, which usually invade from outsidethe body to cause
diseases. They are transformed from the six kinds of climatic
changes, which, in normal conditions, are the basic
conditions for the survival of the human being. In the long
period of evolution, man has gradually developed the ability
to adapt himself to the changes of weather. However, when
these changes are excessive and go beyond the adaptability

of the human body, they may disturb the functional

activities of the human body, turning into pathogenic
factors. As they invade the human body from the outside,
diseases caused by them are referred to as External
diseases. Generally speaking , the Six External Pathogens
have the following common characteristics:
First , invasion of the Six External Pathogens into the human
body is closely related to the climatic conditions in different
seasons and the environment one lives in. Diseases related
to Wind occur more frequently in spring because Wind is
prevalent in this season. Summer Heat attacks the body
only in the summer because it exists only in this season.
Living for a long time in a damp place, one is likely to suffer
from arthritis. And working in a hot environment, one is
liable
to
be
invaded
by
Heat
and
Fire.
Second, each of these pathogens can cause disease alone or
in combination with other pathogens. For example, Wind
may attack the body alone, causing an Exterior Syndrome
due to Wind, or in combination with Cold or Heat, causing
Exterior Syn- dromes due to Wind Cold or Wind Heat, or in
combination with both Cold and Damp to cause arthralgia.
Third, because they originate in the external environment,
the Six External Pathogens invade the body mainly through
the skin, or the nose and mouth, the Organs and tissues
exposed to the environment.
Fourth, the Six External Pathogens can act not only on one
another in the occurrence of diseases, but can transform
into each other in accordance with the constitution of an
individual. As a result, the nature of the disease's
pathogenesis and Syndrome changes accordingly. For
example, Cold may transform into Heat due to the Yang
Excess constitution of a patient when it invades from the
Exterior to the Interior; while Damp, in the case of
interlocking in the interior of the body and obstructing the
3

distribution
Dryness.

of Body Fluids, may be

transformed into

1. Pathogenic Wind
Wind prevails in spring, but it also exists all the year round.
So diseases caused by Wind can be seen in all four seasons.
Wind in excess is known as pathogenic Wind, which serves
as the most important External pathogen and usually
invades the human body by attacking the superficial muscles
and skin first. Pathogenic Wind possesses the following
features: First, wind is air in motion. Being a pathogen of
Yang nature, Wind tends to cause loose striae of muscles,
and disease caused by Wind usually occurs in the upper
body. As Wind is mobile, going upwardand outward, it is a
yang pathogen. When it attacks the body, it tends to attack
the superficial muscles, the Yang Channels and the upper
part of the body. So, Wind often causes such symptoms as
sweating and hesdache.
Second, wind has the property of moving and changing. This
means that Wind is mobile in nature and it may cause
shaking of trees. So diseases caused by Wind are
characterized by their migratory symptoms, sudden onset,
and rapid progression. For example, rheumatic arthralgia
caused mainly by pathogenic Wind is marked by migratory
pain of the joints, and urticaria, which is due to invasion of
pathogenic Witid, is marked by migratory itching of the skin
and its intermittent occurrence. Third , wind is the
predominant pathogen. As Wind exists all year round, it can
cause diseases whenever the defensive ability of the body
declines. Therefore, a great variety of diseases are related to
the invasion of Wind. Furthermore, as Wind is in a state of
constant motion and tends to cause loose striae of muscles,
other pathogens usually attack the human body following
the invasion of pathogenic Wind. So external diseases are
usually ascribed to pathogenic Wind or Wind in combination
with other pathogenic factors.

2. Pathogenic Cold
Cold is prevalent in winter. It usually attacks the body when
the temperature is low and man fails to adapt himself to the
change by dressing properly. Pathogenic Cold may attack
the Exterior of the body or invade the interior of the body
directly. Diseases in the former case are called affliction pf
pathogenic Cold, and those in the latter case, direct attack
of Cold on the interior.
Pathogenic Cold has the following features:
First, being a Yin pathogen, Cold tends to impair Yang Qi.
Cold is the prevalent climate in winter, in which Yin Qi of
nature is flourishing, so it is a Yin pathogen. Like attracts
like. So Yin of the body will become hyperactive in the case
of invasion of Cold and Yang Qi is overrestricted. For
example, Cold attacking the Exterior often obstructs
Defensive Qi (one kind of Yang Qi), leading to failure of the
Exterior to be warmed and resultant chills. Direct attack of
Cold on the Spleen and Stomach usually cause Cold pain in
the abdomen, watery diarrhea, etc. , meaning that Spleen
Yang is impaired and its transforming and transporting
actions are disturbed.
Second, cold is liable to cause coagulation of Blood and
retention of Body Fluids. Blood and body fluids depend on
the propelling effect of Yang Qi and a moderate temperature
for their free circulation. If Cold invades the body, Yang Qi
will be impaired and body temperature will be lowered. So
the flow of Blood and Body Fluids will become sluggish, or
even coagulated, which is clinically marked by pain. For
example, rheumatic arthralgia mainly due to pathogenic
Cold is marked by Cold pain of the joints, which is usually
severe and fixed.
Third, contracting nature of Cold. This means that
pathogenic Cold often leads to ingoing of Qi , contraction of

the muscular striae and convulsion of tendons and vessels.

If attacked by pathogenic Cold, the muscular striae and the
sweat pores will be closed, so Defensive Qi will be
obstructed, and fever or chills and absence of sweating will
occur as a result. Invasion of patbogenic Cold into the
vessels will cause coagulation of Qi and Blood and
contraction of the vessels, leading to headache, pantalgia,
tense pulse, etc. Inability of the limbs to flex and extend
freely or Cold and numbness of the limbs will follow if the
Cold attacks the Channels and joints and results in
contraction of the tendons and Channels.
3. Pathogenic Summer Heat
Summer Heat is a pathogen existing only in summer. So
diseases caused by it are also seen only in summer and are
obviously seasonal. Summer Heat results from the hot
climate in this season dueto the exuberance of Yang Qi in
nature.
Summer Heat has the following characteristics:
First, as a Yang pathogen, Summer Heat has a scorching
nature. Summer Heat derives from overabundant Yang Heat
in summer, so when it attacks the body, Yang Qi of the body
will be extremely exuberant. For this reason, diseases
caused by Summer Heat are usually manifested as excessive
Heat symptoms such as high fever, dysphoria, a red face,
full and large pulse.
Second, going upward and dispersing, Summer Heat tends
to consume Qi and Body Fluids. When Summer Heat invades
the body, it often leads to opening of the sweat pores,
therefore profuse sweating results. Meanwhile, excessive
Yang due to attack of Summer Heat will also consume Yin
Fluids. So Deficiency of Body Fluids occurs. Because of the
excessive discharge of Body Fluids, Qi will escape at the
same time, which is known as escape of Qi following

discharge of Body Fluids. Besides, hyperactivity of the body,

with Qi as the motive force of the activities, will also cause
Deficiency of Qi. Therefore, invasion of Summer Heat is also
marked by the symptoms of Deficiency of both Qi and Yin,
such as thirst with desire for drinks, scanty and dark urine,
shortness of breath, lassitude, or even sudden syncope and
coma.
Third, summer Heat often invades the body in combination
with Damp. Summer is both hot and rainy, and people
usually take more cold food and beverages; tberefore, Damp
is also a common factor contributing to diseases in summer.
In such cases, there is latent moderate fever, latent
sweating, thirst with little fluid intake, dusky and greasy
face, heaviness of body, lassitude, depressed feeling over
the chest, nausea, vomiting, and loose stools.
4. Pathogenic Damp
Damp prevails in long summer, a season in which Yang Qi
begins to decline and Yin Cold begins to rise. So water and
Damp exist everywhere. Diseases caused by Damp can be
divided into two types, Internal Damp and External Damp.
The former is mostly caused by a wet climate, living in a
damp place or being caught by rain, the latter by retention
of water in the interior due to dysfunction of the Spleen, or
excessive intake of cheese , alcohol, and raw and cold food.
Pathogenic Damp has the following features:
First, being a Yin pathogen, Damp tends to obstruct the flow
of Qi and to impair Yang Qi. Damp, heavy and turbid in
nature, is similar to water, so it belongs to Yin. As a
substantial Yin pathogen, Damp is most likely to obstruct the
flow of Qi when it stays in Zangfu Organs or Channels,
giving rise to disturbance of the ascent and descent of Qi, or
blockage of the Channels. Clinically this is mainly marked by
chest fullness, an oppressed feeling in the epigastric region,

scanty and difficult urination, sticky stools, abdominal pain,

tenesmus, etc. Damp depends on Yang Qi for movement;
when it invades the body, it will impair Yang Qi, especially
Spleen Yang, leading to Kiarrhea, oliguria, edema, etc.
Second, Damp has a turbid and heavy nature. Damp tends
to lead to a heavy feeling of the head as if being bound,
soreness and aching of the whole body, and lassitude and
heaviness of the limbs. This is because Damp is a Yin
pathogen that is apt to lodge in the Channels and obstruct
the flow of Qi. For example, an attack of pathogenic Damp
on the superficial muscles will be manifested by heaviness of
the head due to obstructed lucid Yang being unable to reach
the head; obstruction of Yang Qi in the joints and Channels
by Damp often gives rise to numbness of the muscles and
skin and pain and heaviness of the joints, which is also
referred to as Damp arthralgia. By the turbid nature of
Damp is meant that pathogenic Damp often brings about
dirty and turbid excretions, a dirty face, loose and mucous
stools, bloody and purnlent stools, turbid urine. leukorrhea,
eczema with excessive exudate.
Third, Damp is marked by viscosity and stagnation. Damp is
thickened water, so it is sticky in nature. For this reason,
diseases caused by Damp are characterized by their
lingering course and are difficult to cure. Even when they
are temporarily relieved, they are liable to reattack, as
usually seen in eczema and arthralgia due to Damp. Besides,
diseases due to Damp often exhibit sticky symptoms such as
slimy and greasy stools and urine, and greasy fur of the
tongue.
Fourth, Damp tends to flow downward and to attack the
lower portion of the body. As Damp is similar to water in
nature, it has a tendency to go downward. So diseases
caused by Damp are often marked by symptoms in the
lower portion of the body, such as edema, which occurs

mostly in the legs, strangury, leukorrhea, diarrhea and

dysentery.
5. Pathogenic Dryness
Dryness is prevalent in autumn, a season caused by decline
of Yang Qi in nature in which everything becomes
astringent. If it is excessive, it will cause diseases. In eariy
autumn, Dryness often attacks the human body in
combination with Heat, because summer Heat has still not
abated completely. In such cases, it is called warm Dryness,
while in the autumn, it usually attacks the body together
with Cold, because winter cold is coming. In such cases, it is
known as Cold Dryness.
Pathogenic Dryness has the following features:
First, pathogenic Dryness, which is dry in nature, tends to
impair Body Fluids. As Dryness is the opposite of moisture, it
is liable to injure Body Fluids, leading to dry symptoms as a
result of loss of moisture in organs and tissues, such as a
dry nose and mouth, a dry throat accompanied by thirst,
lusterless hair, dry or even cracked skin, scanty urine and
dry stools.
Second, pathogenic Dryness impairs the Lung first. The Lung
is a delicate organ which means it is easily impaired by
pathogens. Under normal conditions, the Lung desires
moistening and is disgusted at Dryness, so Dryness tends to
impair the Lung. In addi- tion, the Lung corresponds to
autumn according to the Five Elements theory, so Dryness
affects the Lung more frequently at that time. Furthermore,
the Lung commumcates with the environment directly
through the nose, and Dryness usually enters the body
through the nose, thus the Lung is the first organ to be
affected in the case of invasion of pathogenic Dryness.
Impaired by pathogenic Dryness, Lung Yin or Body Fluids in
the Lung will become deficient and ascent-descent of Lung

Qi will be disturbed, giving rise to a dry cough with little

sputum, or thick sputum which is very difficult to
expectorate, dry nose and skin, or even sputum mixed with
blood, and chest pain associated with shortness of breath.
6. Psthogenic Fire (Heat)
Pathogenic Heat, Fire and warmth all arise from
overabundance of Yang Qi. They are of the same nature but
their degree is different. Fire is advanced Heat, while Heat is
advanced warmth. Pathogenic Heat and warmth are usually
caused by External pathogens such as External pathogenic
Wind Heat and pathogenic Warm Heat while Fire can be
caused by either an attack of External pathogens or
excessive Yang Qi of the body, such as Fire transformed
from extreme External pathogenic Heat or from stagnant
Damp, Heart Fire and Liver Fire.
Fire as one of the Six External Pathogens actually refers to
External Heat. The term "Fire" is often used to refer to
External pathogenic Heat. Pathogenic Fire (Heat) is clinically
characterized as follows
First, being a Yang pathogen, it tends to flare up. Fire
results from excessive Yang, so it is a Yang pathogen.
Besides, Fire has the properties of going upward and of
being hot. Therefore, Syndromes due to an attack of Fire are
marked by high fever, aversion to heat, severe thirst,
profuse sweating, full and rapid pulse, red face and eyes,
redness on the tongue tip or edges, oral ulcers, swollen and
painful gums, etc.
Second, fire is liable to consume both Qi and Yin Fluids.
Being the result of Excess Yang, Fire often forces Body Fluids
to be discharged profusely and directly impairs Yin Fluids, so
impairment of Yin is frequently seen in diseases caused by
Fire. Fire can consume Qi in two ways: first, Qi may be
discharged together with sweat; secondly, Fire often leads to

10

hyperactivity of the body which then must be supported by

more Qi. For these reasons, Syndromes due to pathogenic
Fire are not only manifested by Heat symptoms, but also
manifested by symptoms of Deficiency of both Yin Fluids and
Qi, such as thirst with preference for Cold drinks, dry throat
and tongue, scanty and dark urine, constipation, and
lassitude.
Third , fire tends to accelerate circulation of Blood and to
cause Internal Wind. The Heart belongs to Fire in the Five
Elements and controls Blood vessels, so pathogenic Fire has
an affinity for Blood and tends to enter the Blood vessels to
cause the accelerated flow of Blood or even bleeding.
Clinically, this is marked by various kinds of bleeding such
as hematemesis, epistaxis, uremia, hemafecia, and
metrorrhagia. Also Fire tends to consume Yin Fluids and to
lead to malnourishment of the tendons, giving rise to
convulsion, upward staring of the eyes, a stiff neck or
opisthotonos, the symptoms of internal Wind.
Fourth, fire is responsible for skin ulcers and swelling. Fire
entering the Blood vessels may collect in certain areas,
leading to abscesses or skin ulcers. This is why such
diseases are manifested as redness, swelling, heat and pain
in the affected part.
Fifth, fire often disturbs Heart Spirit. According to the Five
Elements theory, Fire is closely related to the Heart, which
controls the spirit. So disturbance of Heart Spirit is often
present in the case of pathogenic Fire attacking the body,
manifested as dys- phoria, insomnia, mania, coma, delirium,
etc.
2. Epidemic Pathogens
This refers to a group of pathogens responsible for infectious
diseases. They also bear names such as Li Qi, which means
they are strenuous and liable to cause severe diseases, Du

11

Qi, which also means that they often impair the body
severely, or Yi Qi, which indicates that they are different
from the common External pathogenic factors.
It was in the Ming Dynasty that epidemic pathogens were
included in TCM. As infectious diseases spread widely and
failed to respond to treatment based on the theory of the Six
External Pathogens, the ancients summarized the features of
epidemic or infectious diseases, and concluded that these
diseases were caused by some external pathogens with
features different from the Six External Pathogens. So they
put forward the concept of epidemic pathogens to explain
the mechanism of infectious or epidemic diseases. The
special features of epidemic pathogens are:
First, they are obviously epidemic and infectious. Spreading
through the air or by contact and entering the body through
the nose and mouth, they may cause epidemic diseases that
spread rapidly in the community.
Secorrd, the diseases caused by epidemic pathogens usually
have a sudden onset, are relatively severe, and have similar
manifestations in different individuals.
Third, epidemic pathogens are mostly Warm Heat in nature,
so they tend to cause diseases marked by Yang Excess
symptoms.
Fourth, the spread and generation of epidemic pathogens
are related to seasonal conditions and abnormal changes of
climate, extreme Heat, long term draught, and dew or fog.
Fifth, the pathogens often invade the body by polluted air,
food and water supply.
3. Internal impairment by the Seven Emotions
A. Concept of the Seven Emotions

12

Joy, anger, worry, anxiety, sorrow, terror and fright are

collectively known as the Seven Emotions, which, under
normal conditions, are the physiological responses of the
human body to enviropmental stimuli. Therefore, they are
not pathogenic factors. However, if the emotional stimuli are
too sudden or too strong or last a long time, they will disturb
the functional activities of Zang-fu Organs, cause
disharmony of Qi in its ascent, descent, entry and exit
movements, and eventually result in diseases. They cause
internal disorders of the body, so they are also called the
Seven Emotional states as pathogens responsible for internal
diseases.
In the light of TCM theory, the Seven Emotions are closely
related to the Five Zang Organs and the circulation of Qi and
Blood. On the one hand, they are dependent upon the
functional activities of different Zang-fu Organs for their
generation; on the other, they affect the functional states of
these organs. Therefore, diseases of Zang-fu Organs may be
manifested as abnormal changes of the emotions, and
emotional changes in excess, in turn, impair these organs.
For exainple, stagnation of Liver Qi often presents as
emotional depression or irritability, while excessive anger
often stagnates the flow of Liver Qi or induces Liver Qi to
rise excessively.
B. Characteristics of the Seven Emotions as pathogenic
factors
Different fromthe Six External Pathogens,which usually
invade the human body by attacking the Exterior of the body
first, the Seven Emotions in EXcess often impair the
corresponding organs directly, leading to adverse flow of Qi
and disharmony of Qi and Blood of Zangfu Organs with the
ensuing occurrence of disease.
B-1. Impairing the internal organs

13

The Seven Emotions often impair the internai organs

directly, and first of all, the Heart. Emotion, as one kind of
mental activity, is controlled by the Heart. However, each of
the Seven Emotions is ascribed to a different Zang-Fu Organ
in TCM, because emotions take Essence Qi for their material
basis. TCM believes that the Heart is related to joy, the Liver
to anger, the Lung to worry and sorrow, the Spleen to
anxiety, and the Kidney to both terror and fright. Therefore,
excessive joy impairs the Heart; excessive anger impairs the
Liver, excessive worry or sorrow impairs the Lung, excessive
anxiety impairs the Spleen; and excessive terror or fright
impairs the Kidney.
Of course, the correspondence of Zangfu Organs with
emotional activities by no means indicates that a specific
emotion only impairs its corresponding organ, in fact, as the
Heart controls spirit, any emotional change in Excess will
impair the Heart. In addition, one emotion may impair
several organs, for the disturbance of one organ may cause
disorders of other organs closely related to it. For example,
emotional depression will cause disharmony between the
Liver and Stomach or the Liver and Spleen as a result of the
impairment of the Liver and the transverse attack of Liver Qi
on the Stomach and Spleen.
Emotions are produced based on the flow of Qi and Blood.
As the Heart governs Blood and spirit, the Spleen, situated
in the Middle Jiao and serving as the hub of the ascent and
descent of Qi, dominates transformation and transportation,
and the Liver stores Blood and dominates dispersion and
discharging, diseases caused by emotional disorders are
mostly manifested as disorders of Qi and Blood of these
organs. For example, worry often impairs both the Heart and
the Spleen, leading to mental disorders and dysfunction of
the Spleen. Injured by emotional depression, Liver Qi will go
up excessively and Blood will follow the rise of Liver Qi to go
upward, leading to distending pain in the hypochndriac

14

region, sighing, dysmenorrhea, amenorrhea, or abdominal

masses.
B-2. Disturbing flow of Qi
When emotional states are abnormal, they will affect the
ascent, descent, entry and exit of Qi. This is because
emotional activities depend on the free flow of Qi.
Anger induces Qi to flow upward. This indicates that
excessive anger can induce Liver Qi to go up excessively and
give rise to the subsequent upward adverse flow of Blood.
As Liver Qi tends to go up and anger corresponds to the
Liver, excessive anger injures the Liver and disturbs the
nornial descent and ascent of Liver Qi. In such cases, it is
often manifested as a red face and eyes, dizziness and
vertigo, distending pain of the head, or even sudden coma
or syncope. Sometimes, hematemesis and diarrhea may also
be seen as a result of Blood following the adverse Qi to rise
excessively or due to Liver Qi attacking the Spleen.
Joy relaxes Qi. This includes two aspects. In normal
conditions, joy can promote the flow of Qi and Blood, thus it
can relax mental strain. However, excessive Joy may cause
Qi to flow too fast to be controlled, so there are such
manifestations as poor concentration of the Mind, or even
mania.
Sorrow consumes Qi. This means that deep sorrow is likeiy
to consume Lung Qi, leading to chest depression and
demoralization. Voice is produced by the flow of Lung Qi
through the throat, and depends on sufficient Lung Qi for its
material basis. In a state of sorrow, one is liable to cry or
weep for a long time, so Lung Qi is consumed and lassitude,
a depressed feeling in the chest, as well as demoralization
occur as a result of deficient Lung Qi failing to perform the
functional activities of the Lung.

15

Anxiety stagnates the flow of Qi. When thinking, one must

concentrate and Vital Qi will remain in place to support the
thinking. Therefore, excessive lengthy or intense thinking
will lead to stagnation of Qi, especially Spleen Qi, which
tends to accumulate. Manifestations of such a morbid state
include poor appetite, abdominal distention, constipation,
etc., due to.the stagnation of Spleen Qi.
Fright causes disturbed flow of Qi. When one is suddenly
frightened, his or her circulation of Qi will be disturbed,
leading to palpitations, a distressed mind, inability to
concentrate the mind, etc. Terror induces Qi to flow
downward.
The
Kidney
is
related
to
terror and also controls defecation and urination. These
mainly depend on the controlling effect of Kidney Qi, which
is produced by Kidney Essence. Excessive terror often leads
to incontinence feces and urine, as well as weakness of the
legs, as a result of the impairment of Kidney Qi and Kidney
Essence, which in turn fail to control defecation and
urination and to nourish the bones.
B-3. Worsening or deterioration of a disease
As emotional changes often exert an unfavorable influence
on the functional activities of Zangfu Organs and the flow of
Qi and Blood, they may worsen or cause a disease to
deteriorate. For example, patients with hypertension, a
disease caused by excessive rising of Liver Yang due to
Deficiency of both Kidney Yin and Liver Yin, may suffer from
sudden coma or syncope, or even paralysis in the case of
being stimulated by sudden and violent rage. This is because
the Liver is related to anger, and sudden anger will induce
further excessive rising of Liver Yang.
Of the etiologic factors TCM has identified, External diseases
are usually caused by the Six External Pathogens, and
infernal diseases by the Seven Emotionai changes in excess

16

4. Improper Diet and. Imbalance Between Work and

Rest
Proper diet, workand rest are imperative for the survival of
human beings and preservation of their health. Improper
diet as well as imbalance between work and rest, however,
will disturb the physiological functions of the body, leading
to disease.
A. lmproper diet leading to disease
Inadequate intake of food, eating too much, intake of
decayed, or toxic food as well as an unbalanced diet can all
cause disease.
A-1. Underfeeding or overeating
Proper amounts of food should be taken regularly so that
they can be digested and generate Qi and Blood. If one eats
too much at one meal or has insufficient food to eat over
along period, one is susceptible to disease. Usually,
insufficient intake of food will cause Deficiency of Qi and
Blood as they are lacking in a source, leading to diseases of
Deficiency type. In addition, when Qi and Blood are deficient
because of underfeeding, the body's resistance to invasion
of pathogens will be lowered; therefore, diseases secondary
to Deficiency of Qi and Blood will occur.
Excessive intake of food, as a result of the amount of food
exceeding the capacity of the digesting function of Spleen
and Stomach, tends to impair the Spleen and Stomach.
Sudden indigestion often presents with the symptoms of
impairment of the Spleen and Stomach, such as epigastric
and abdominal fullness, abdominal pain, acid regurgitation
and eructation, disgust at the smell of food, or vomiting and
diarrhea. As their Spleen and Stomach are not fully
developed, children are more likely to suffer from diseases
caused by indigestion. In the case of long term food
retention, malnutrition will ensue, which is mainly
17

manifested as Heat in the palms and soles of the feet,

restlessness, epigastric and abdominal distention, a sallow
face and emaciation, restless sleep, etc. Retained food often
obstructs the flow of Qi and Blood and causes blockage of
the vessels, causing hemorrhoids. Moreover, excessive
intake of fatty and greasy food is apt to induce the
generation of Heat in the interior, which may in turn lead to
skin infectfons.
A-2. Intake of unclean food
Unclean food may cause a number of diseases of the
digestive tract, with abdominal pain, vomiting with diarrhea,
or dysentery as the most commonly seen manifestations.
Contaminated food may also cause parasitic diseases, which
are marked by abdominal pain, preference for unusual food,
a sallow appearance and emaciation.If decayed or poisonous
food is taken, symptoms of poisoning, including severe
abdominal pain, vomiting and diarrbea, or even coma and
death, will occur as a consequence.
A-3. Food preference
Physiologically,Yin and Yang of the bodyare kept balanced by
eating food which nourishes Yin and supports Yang evenly. If
cold foods or foods Cold in nature are taken excessively,
they will strengthen Yin and restrict Yang, causing imbalance
of yin and Yang and subsequent disease. In a similar way,
excessive intake of hot food or food hot in nature will
increase Yang of the body, leading to its overrestraint over
Yin and the ensuing imbalance of Yin and Yang, thereby
causing diseases. For example, excessive intake of raw and
cold food and drinks in summer often leads to diarrhea and
abdominal pain, indicating that Spleen Yang is impaired by
excessive Yin.
According to TCM, the Five Zang Organs require food of
different tastes to be nourished so as to maintain the

18

coordination among them. Thus, preference for food of

certain tastes will strengthen the organ it corresponds to,
leading to disturbance of the organ and disharmony among
the five Zang Organs. In such cases, disease will follow. For
example, excessive intake of bitter tasting food will lead to
hyperactivity of the Heart, which may overrestrict the Lung
and lead to withered hair and dry skin. Therefore, TCM
stresses that food of different tastes should be eaten in
combination, so that relations among the five Zang Organs
can be maintained and health preserved.
B. Imbalance between work and rest
Appropriate work or exercise can promote circulation of Qi
and Blood and strengthen the constitution, while proper rest
can help to relieve fatigue, and restore physical and mental
strength; therefore both of them are conducive to health.
However, overstrain or undue leisure may be transformed
into pathogenic factors and cause diseases.
B-1. Overfatigue
In TCM overfatigue can be classified as excessive physical
exercise, excessive mental exertion, or intemperance in
sexual life. Excessive physical exercise. Long term overwork
may consume too much Qi and Blood and lead to Deficiency
of Qi and Blood, from which disease results. Exercise mainly
depends on the support of Qi. So overexertion consumes Qi,
which may become deficient because it cannot be reinforced
quickly enough.
Excessive mental activity. This mainly refers to worry
impairing both the Heart and Spleen. As the Heart controls
both Blood and mental activity and the Spleen is related to
thinking in emotions, excessive mental activity is most likely
to impair the heart and Spleen, causing Deficiency of both
Heart Blood and Spleen, whicb is usually manifested as

19

palpitations, forgetfulness, insomnia, dream disturbed sleep,

loss of appetite, abdominal distention and loose stools.
Intemperance in sexual life will impair the Essence stored in
the Kidney. In accordance with TCM theory, Kidney Essence
is the most important substance fo rlife; it should be stored
more than discharged. Thus, intemperance in sexual life
often leads to soreness and weakness of the loins and
knees, dizziness and tinnitus, listlessness, decline of sexual
capacity, or nocturnal emission, premature ejaculation, or
even impotence.
B-2. Inactivity
This refers to excessive ease and comfort without
participation in labor or other physical activities. Man must
have a certain amount of physical exercise every day;
otherwise, his Qi and Blood will fail to flow freely. If he is not
engaged in physical labor or exercise for a long time, his Qi
and Blood will flow sluggishly, and hypofunctioning of the
Spleen and Stomach will occur, so there will be poor
appetite, lack of strength, lassitude, weakness of limbs,
obesity, palpitation, sweating on exertion and shortness of
breath. Obese patients often have constitutions marked by
deficiency of Qi and Excess of Damp, because they lack
sufficient exercise to metabolize the Yin substance, which
then accumulates in the body to cause obesity.

5. Traumatic injuries
Traumatic injuries include gunshot injuries, incised wounds,
contusions, sprains, scalds and burns, hypothermia, and
injuries inflicted by animal stings or bites. Gunshot injuries,
incised wounds, contusions, and sprains directly injure the
skin, muscles, bones, joints, tendons, Blood Vessels or
Zangfu Organs, leading to Blood Stasis, painful swelling of
the skin and muscles, bleeding or laceration of muscles and
20

tendons, fracture and dislocation, or even coma, tics, Yang

depletion or prostration Syndrome as a result of massive
hemorrhage.
Burns and scalds are caused by high temperature objects,
boiling water, scorching oil or fire and so on. Mild burns and
scalds may injury only the skin, manifested as redness,
swelling, heat and pain in the affected area. In cases of
severe wounds, where the surface area is large, there may
be complications such as dysphoria,fever, thirst or oliguria.
In the case of severe pain or inward attack of Fire toxin,
with accompanying evaporation or exudation of Body Fluids,
death may occur.
Hypothetmia .refers togeneral or local traumatic wounds due
to low temperature.The former results from failure of the
deficient Yang Qi to warm the body and to promote
circulation of Blood due to its impairment by Cold
pathogens, which is usually accompanied by a gradual
lowering of the body temperature, pale face, bluish purple
lips, tongue and finger nails, shallow breathing, slow and
faint pulse, etc. If not treated promptly, it may even cause
death. The latter is often seen on the hands, feet, auricullae,
etc., and is marked by local pale skin and Cold numbness,
followed by swelling and itching pain and scorching heat or
blisters of varying sizes. Insect or animal stings and bites
include bites by poisonous snakes, wild beasts or rabid dogs,
or stings by scorpions and bees. The symptoms in mild
cases are usually a local wound accompanied by painful
swelling and bleeding. In the case of massive hemorrhage,
the internal organs maybe involved and death may occur as
a result.
6. Phlegm Retention and Coagulated Blood
Both Phlegm Retention and Coagulated Blood are the
pathologic products of the process of diseases due to the
action of pathogenic factots. When they are formed,

21

however, they may affect directly or indirectly the functional

activities of Zangfu Organs, leading to various kinds of
diseases; therefore, they are also pathogenic factors.
1. Phlegm Retention
This is the combined name of Phlegm and Phlegm Fluids, are
both pathologic products of disturbed water metabolism.
Generally speaking, Phlegm is the thicker product that will
flow throughout the whole body following the ascent and
descent of Qi, while phlegm Fluids is the thinner one that
tends to stay in a local areas. In TCM, Phlegm is divided into
two types: the visible and the invisible. The visible Phlegm
usually refers to the sputum that often occurs with coughs,
while the invisible Phlegm refers to the thicker retained
water existing in Zangfu Organs, Channels, or skin and
muscles. They can be seen only by the manifestations of
Phlegm, such as greasy and thick tongue coating, obesity,
full sensations in the affected parts, or sputum-like pus.
According to the manifestations, a diagnosis of Phlegm can
be made and the treatment should be aimed at eliminating
Phlegm.
1-1. Formation of Phlegm Retention
Water metabolism is a process concerning a number of
ZangFu Organs, especially the dispersing and descending
actions of the Lung, the transforming and transporting
actions of the Spleen and the controlling effect of the
Kidney. Therefore, disturbance of any of these organs, if
involving water metabolism, will lead to disturbance of the
distribution and discharge of water and ensuing Phlegm
Fluids. For example, when External pathogens attack the
Lung, Body Fluids in the Lung will not be able to be
distributed through the dispersing and descending actions of
Lung Qi, from which Phlegm results. Thus, Lung disorders
are usually marked by expectoration of sputum. After
formation, Phlegm will flow to Zangfu Organs internally and

22

the skin and muscles externaily, giving rise to various

diseases with various manifestations. As the Phlegm may
exist in multiple parts of the human body, there are the
sayings that "hundreds of diseases are caused by Phlegm"
and that "Phlegm contributes to unusual diseases". Phlegm
Fluids often stays in certain areas of the body such as the
pleurae, the gastrointestinal tract, the subcutaneous regions
and the diaphragm.
1-2. Pathologic characteristics of Phlegm Retention
The manifestations of Phlegm Retention vary with the areas
they affects after their formation. But they are most likely to
obstruct the flow of Qi and disturb the ascent and descent of
Qi of Zangfu Organs.
The commonly seen symptoms caused by Phlegm include:
cough with sputum and asthma due to uneven ascent and
descent of Lung Qi arising from Phlegm obstructing the
respiratory tract and blocking the way for Lung Qi to flow;
chest fullness and palpitations due to blockage of the Heart
vessel by Phlegm; coma or dementia due to Phlegm
confusing the Mind; mania due to Phlegm disturbing the
Heart in combination with Fire; nausea, vomiting and
epigastric distention due to Phlegm disturbing the descent of
Stomach Qi; scrofula and numbness of the limbs or
hemiplegia due to obstruction of Phlegm in the channels,
bones and tendons; dizziness with blurring of vision due to
an attack of Phlegm in tbe head; and globus hystericus,
marked by the feeling of a foreign body obstructing the
throat that cannot be swallowed or vomited, due to Phlegm
interlocking with Qi in the throat, etc.
Generally speaking, Phlegm, as a substantial pathogen, has
four characteristics when causing diseases. First, it tends to
obstruct circulation of Qi and Blood, leading to distention
and Blood Stasis. Secondly, it prevents Qi from ascending,
descending, en- tering or exiting, leading to disturbance of

23

Zangfu Organs. Thirdly, it affects water metabolism, leading

to new retention of water in the body; and fourthly, it tends
to disturb mental activities, as stagnation of Phlegm in the
Heart often brings about disorders of mentality.
2. Coagulated Blood
This refers to either impeded Blood in the vessels or
extravasated Blood incZangfu Organs or Channels, which is
not dissipated promptly. Coagulated Blood is itself a
pathofogic product, but after its formation, it may cause new
pathologic changes, therefore, it is also a pathogenic factor.
Bloodmust flow smoothly in the vessels so that it can reach
the required areas, as the free flow of Blood in the vessels is
imperative for it to perform its nourishing effect. In the case
of extravasation or impeded flow of Blood, it will lose its
nourishing function, so Coagulated Blood is also known as
Dead Blood, or Dry Blood in TCM.
2-1. Formation of Coagulated Blood
Circulation of Blood is concerned with the propelling and
controlling actions of Qi, the temperature of Blood, and
maintaining vessel integrity. Generally speaking, Coagulated
Blood in the vessel is caused by Deficiency of Qi which
hasn't enough power to propel the circulation of Qi, Blood
Cold, leading to the contraction of vessels and coagulation of
Blood, and Blood Heat which consumes Body Fluids in the
Blood, leading to the sluggish flow of Blood. Extravasated
Blood is mostly caused by direct injury to the vessels,
Deficiency of Qi which fails to keep the Blood flowing in the
vessels, or Blood Heat which forces Blood to flow too swiftly.
When the extravasated Blood cannot be dissipated promptly,
it will coogulate.
2-2. Pathologic characteristics of Coagulated Blood

24

After formation, Coagulated Blood will not only lose its

normal nourishing function, but will also obstruct the free
flow of Blood in the whole body or in a local area, causing
pain, bleeding or accumulation of Coagulated Blood in the
internal organs or in the skin and muscles. The
manifestations of Coagulated Blood are rather different,
depending on its positions and causes. Coagulated Blood in
the Heart is marked by palpitations, chest fullness and
precordial pain, bluish purplish lips and nails, or even coma,
and accompanied by sweating and cold limbs; that in the
Lung is manifested as chest pain, hemoptysis, or coughing
with purulent and bloody sputum that in the gastrointestinal
tract often presents with epigastric and abdominal pain,
hematemesis, and tarry stools that in the Liver may lead to
hypochndriac pain with abdominal masses; that which
attacks the Heart often causes mania; that in the Uterus
may give rise to pain in the lower abdomen, irregular
menstruation, dysmenorrhea, amenorrhea, dark menses
with blood clots, or metrostaxis and metrorrhagia; and that
in a local area of the skin and muscles will cause pain and
swelling with a purple skin color in the affected area.
Diseases due to Coagulated Blood have some common
features, which are as follow:
Pain
There is usually stabbing pain, which is localized, aggravated
by pressure, and more severe at night. This is becaued
Coagulated Blood is a substantial pathogen, tending to cause
severe obstruction. Besides, Blood is of Yin nature; at night,
Yin in nature prevails, thus the coagulation of Blood is more
severe.
Lumps
Coagulated Blood of the skin and muscles often leads to
purple swelling or lumps. If it is in the internal organs, there
will be hard abdominal masses which are fixed.

25

Bleeding
Bleeding, which is usually dark with blood clots, is caused by
the obstruction of Blood flow by Coagulated Blood.
Fever
Fever is mostly seen at night, accompanied by a dry mouth
with a desire to gargle water but not to swallow it, because
the fever affects the Blood instead of Qi.
Dark
reddish-purple
tongue,
lips,
nails
and
skin
On observation, there is a dark and dim complexion, dry and
thickened skin with desquamation, purplish lips and nails,
varicose sublingual veins, and the tongue may be dark
purple or dotted with ecchymosis.
Pulse
The pulse is usually thready, hesitant, deep and wiry, or
intermittent and knotted, as a result of Coagulated Blood
blocking the outgoing of Qi and Blood.

7. Discussion of Difficult Points

1. What is a toxic pathogen?
In TCM, we often read such phrases as toxic Damp, toxic
Fire, toxic Heat or toxic pathogen. What does the "toxic"
mean here? Is toxic Damp another kind of pathogen that is
different from Damp?
The word "toxic" means all the things that may do severe
harm to the body, including the toxic substances produced
by a snake, or those originating from further developed
common pathogens. Toxic Damp, for example, is not an
isolated pathogen from the pathogenic Damp mentioned
above. It only refers to the Damp or retained water seen in
severe diseases, like the edema in patients with nephrotic
26

Syndrome. Take toxic Heat or Fire for another example. In

most cases. the causative factors of a localized diseases
marked by swelling, pain, hotness and redness are called so,
the manifestations of Heat or Fire in the diseased part are
more obvious or severe than those we usually mention in
other common diseases caused by Heat or Fire, such as
Excess of Stomach Heat which is marked by dry stools,
thirst and red tongue.
2. Why is the theory of epidemic factors not well developed
in TCM?
Epidemic factors, which were suggested by a famous doctor
during the Ming Dynasty of China, are a group of pathogenic
factors different from the Six External Pathogens which have
their own characteristics. To a great extent, they are similar
to the specific pathogens mentioned in Western medicine,
because they are believed to be specific to different
infectious diseases. The question is, however, why the
theory of the epidemic factors was not well developed in
later times, which seems to be very strange.
It is true that infectious diseases are different from the
diseases caused by the Six External Pathogens, because
their clinical manifestations are very different, and infectious
diseases seem to be more severe than the diseases caused
by the Six External Pathogens. However, as infectious
diseases present mostly Heat symptoms in accordance with
TCM theory, they should be caused by the pathogens Hot in
nature. And, since pathogenicHeat or Fire.is one of the Six
External Pathogens, it is impossible fot epidemic factors to
be isolated from them, although their differences are
stressed in TCM. These differences lie mainly in the degree
of the pathogens instead of their nature. So epidemic factors
are in fact a group of Heat pathogens with a strong capacity
for causing diseases.

27

Another reasonis that the way of thinking stiggested by the

theory of epidemic factors is opposite to that adopted in
TCM. If the epidemic factors were analyzed and understood
in the same way as Western medicine, it could not be used
to guide the treatment of infectious diseases with Chinese
traditional methods. This is because the differentiation of
Syndromes and the resultant corresponding treatments in
TCM are carried out on the basis of the patients' systemic
manifestations rather than on the local structural changes or
pathologic changes which are the basis for the
understanding of the epidemic factors from the viewpoint of
Western medicine. For these reasons, the theory of epidemic
factors compared with that of the Six External pathogens, is
not well clarified, but it is, in fact, included in the External
pathogens theory in TCM.
3. What is the dlffereuce between Damp, Phlegm Fluids and
Water?
All three of these concepts refer to the products of the
disturbance of water metabolism in the human body, which
after being produced will cause furtber pathologic changes,
and thus are regarded as pathogenic factors in TCM. They
are often used interchangeably, but they really have some
differences and should, therefore, be used differently.
Damp is both a physiological and a pathologic concept in
TCM. As a physiological concept it refers to the water
received by the Stomach and digested and absorbed by the
Spleen, so it is also called Water Damp. As a pathologic
concept, it refers to the re- tained water caused by
disturbance of the Spleen, so it is mainly used in the case of
water retention due to Spleen diseases. Phlegm retention,
on the one hand, is a general term for all disturbed water in
the human body. On the other band, it mainly indicates
retained water not directly related to the Spleen. For
example, we may ascribe the cause of diarrhea to the
downward flow of excess Water Damp from the Middle Jiao,

28

or the cause of edema to the outward flow of Water Damp

as a result of the hypofunctioning of the Spleen. But we
usually say the causative factor of goiter is accumulation of
Phlegm Fluids, because this is a disease mainly secondary to
stagnation of Liver Qi, which futher disturbs water
metabolism, instead of being secondary to Spleen disorders.
As for Water, it is mainly used to describe the water that
accumulates in a cavity of the body, such as pleural effusion,
ascites or edema.

29