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August 2017

The Primary Pathological Triad
By William Maclean, M.Sc. Chin. Med.
Featured Article

There is a wide array of disharmony patterns that
describe diseases within the diagnostic parameters
of Chinese medicine. Recognition and identification
of these patterns is at the heart
of Chinese medicine. More often
than not, and almost always
in chronic conditions, patients
present with multiple patterns, and
the clinical picture can become
quite complicated. The job of the
clinician is to tease out the various
presentations and try to discern the
causal and pathological relationships between them. Even though
many syndromes and combinations are possible, some patterns
are so common as to be ubiquitous. One particular combination
of patterns is seen so frequently in clinic, and has such a diverse
range of effects and presentations that I have named it the
“primary pathological triad” (PPT).

The primary pathological triad is three patterns of pathology
that frequently occur simultaneously, are tightly interlinked
and mutually engendering. The triad comprises Spleen yang qi
deficiency, Liver qi stagnation, and Heat of some type, usually
Damp Heat or Heat derived from constrained qi. In addition to
the basic triad of pathology, there may be further complication by
Figure 1. Some of the pathological relationships of the primary
Blood and/or yin deficiency, Blood stagnation, shen disturbances, pathological triad
and Phlegm. The pathology can be quite complex, but can be
traced back to interaction of the three main players. the patterns, or have a bewildering array of symptoms. In
addition, the classical signs and symptoms of one pattern can
The manifestations and scope of the triad be modified by the presence of the other, for example the pale
The clinical manifestations of the PPT can be numerous and tongue of qi deficiency is less pale when subjected to Heat
varied depending on the balance of pathologies, the constitution and similarly the red tongue of Heat is not especially red
of the patient, and the etiological conditions. In essence, any when complicated by qi deficiency.
combination of qi constraint, qi deficiency and Heat signs and
symptoms are possible. Patients may tend to display more of one The pathological balance is not static, and changes
pattern than the others, be more or less equally balanced between depending on what is happening in the individual’s life. The

THE MAYWAY MAILER • August 2017

the PPT is seen at play in a wide variety of chronic problems characterized by varying mixtures of gastrointestinal and autonomic nervous system dysfunction1 and inflammation. and the increase in qi pressure behind an obstruction. sinus and ear infections. creates Damp Heat. deplete qi and in the long term aggravate the Dampness. Heat from qi constraint. of the afflicted individual. The social. bitter cold and sweet warm substances in varying proportions condition. Put simply. while the PPT is very common and always warranting consideration. It should be noted that. once present and applied to pre- The PPT is generated largely by internal organ system existing Dampness. certain skin diseases. each three main patterns of the PPT engender and reinforce with a different emphasis. In practice. the herbs used to regulate Liver with prevailing dietary and recreational habits. herbs are good at dissipating stagnant qi but their prolonged use all contribute to producing the PPT. to the more complex like chronic hepatic. only to have it return later down the track. leading to a gradual depletion combination of stress (in its many guises2). Harmonizing prescriptions combine herbs with pathology stands out and is dealt with therapeutically.manifestations seen depend on where in the triad map the balance of the pathology falls at the time of assessment. pancreatic disease and inflammatory conditions like ulcerative colitis and connective tissue disease (lupus. The sweet warm herbs used to strengthen and inappropriate or poor diet and eating habits3. Many chronic diseases may have the PPT as their underlying pathology. or be systemic. clear Heat and supplement qi. There is because of the self-perpetuating nature of the triad. and recurrent inflammatory conditions of the genitourinary Figure 2. Liver qi constraint pathological patterns requires that each pattern be addressed at impacts on the Spleen and Stomach. there are other pathological processes that can give rise to functions and encouraging the generation of Dampness. everyday qi and resolve constrained qi are pungent and dispersing. opposing actions. The are a number of formulas in the harmonizing group. Pathological triad formulas map (edited for FDA compliancy) system. The bitter cold herbs used to overuse of pharmaceuticals all play a part. Dampness on its own. utilizing pungent patients will experience some improvement in their hot. biliary. (See Fig. due dysfunction. a can also disperse healthy zheng qi. which in turn is disrupted by pressures to its sticky obstructing nature. and have a increasingly sedentary occupations and lifestyles and cloying and congesting effect on qi. skin or one or more joints. and the depths of the gastrointestinal system. tend to generate Why is the PPT so common? Heat. rheumatoid arthritis etc. the diet and the particular habits qi flow and so transform into Damp Heat.). For example. otherwise clinical results will be short term and THE MAYWAY MAILER • August 2017 . weakening their the same time. They are typically complex. Inflammation can be localized to a discreet region such as the reproductive system. If one noted above. 2). worry. can also generate Heat by blocking from the environment. Successful treatment of the triad of each other in the following way. supplement qi can aggravate Heat and Damp Heat. and not every case will be is heavy in nature and tends to sink downwards to the lower body associated with the PPT. Some endocrine problems (particularly thyroid and pancreatic) can also be traced to the PPT. in combination PPT. economic and environmental conditions found in modern societies When it comes to using herbs to treat complex phenomena like the (and presumably older ones as well). It can also be found in chronic or recurrent infections such as genital herpes. Constrained qi. alcohol. Pungent stresses and pressures and the rapid pace of change. Dampness the conditions noted above. This to disperse stagnation. clear Heat and Damp Heat weaken the Spleen. and qi deficiency. The problem – difficulties in treatment from complex pathology The solution – harmonizing as the main therapeutic strategy One of the characteristic features of conditions associated Harmonizing is the strategy employed to address the diverse with the PPT is the tendency of the main complaint to pathology of the PPT while avoiding or minimizing the conflicts recur when only one of the pathologies is tackled. from the relatively simple such as indigestion and gastro-esophageal reflux (GERD). conflicts arise.

The key feature giants of Chinese medicine. accumulation. with cultural variations. and its reputation as a ‘clearing’ clinic. manufactured in greater volume worldwide The PPT is a remarkably common phenomenon in the modern than any other formula. When used for ‘clearing’. but have a descending effect. and practitioners will recognize some of their patients prescription. and any complicating it is well balanced between the three major principles of factors that may be identified. da zao (chinese dates) and gan is treated. For qi dynamic4 (with pungent dispersing herbs). were at play. It does not specifically phenomena and the formulas he devised to deal with them are as address Liver qi constraint. for the use of this formula is a sense of blockage in the Without his genius. The main aim of the formula is to of classification and analysis of these and other common clinical get the qi dynamic working again. Med. The three primary principles are to strengthen the The major prescriptions for dealing with the pathological Spleen to bolster qi (with sweet and warm herbs). Another popular and effective formula. similar factors. Whether this is used for patients with numerous or contradictory signs triad of pathology is more or less common than it was in Zhang’s and symptoms. the weakened Spleen will balanced by the pungency and bitterness of the other herbs. Pungent herbs disperse qi and Damp 25 years of clinical experience in the field of Chinese medicine. sweet and warm. and the debt practitioners owe to the contains seven herbs in three groups. although the pungent herbs will fresh and relevant today as they were 2. and warm and hot respectively. if only the Spleen 3. regulate the triad can be assigned positions on the triad map Liver. and gets Spleen and Stomach qi moving again. and is applied in an attempt to ‘clear’ the day is anyone’s guess. the repeated insult by invasive Liver qi will cao (licorice). Xiao Chai Hu Tang immediately. like Zhang Zhong-Jing is immense. not only clear Heat. It strengthens above.the condition will tend to recur because the some of the causative factors still exist.000 years ago. It of Chinese medicine. in about equal proportions. M. In addition to his tendency and so encourage Spleen qi to ascend. teacher and author from Australia. symptom picture to allow the primary pathology to emerge. and to clear Heat example. and lectures to Pungent warm herbs also have an inherent lifting students and practitioners around the world. Their potentially cloying sweetness is If only Damp Heat is treated. Xiao Chai Hu Tang (Minor Bupleurum or Damp Heat (with bitter cold herbs). 2 2. the Clinical Manual of Chinese Herbal Patent Medicines. both bitter and 3. Heat. long years in practice. clear Heat and Damp Heat. dealing with each pathology adequately without a suitable guiding prescription can be selected from the diagram being too biased towards any particular one.Sc Chin. used to resolve renowned practitioner. This neatly balances the ascending action of the pungent herbs and drives the engine of the qi dynamic. Sydney and University of Technology Sydney. If only qi constraint is addressed the weak Spleen will continue to generate Dampness that will clog the qi. move qi to an extent. and supplement qi. is an internationally pungent. regulates Liver qi and clears Damp Heat. and cold. Bitter cold herbs and the Clinical Handbook of Chinese Herbs: Desk Reference. Based on the clinical assessment. both Bio: William Maclean. For example. but presumably humans being human. His methods dynamic dysfunction. with Phlegm Damp. and may see them in a different light. Will is the author (with Jane Lyttleton) of the Clinical Handbook of Internal Medicine series Volumes 1. invigorate qi and stimulate the correct functioning of the according to the weighting of their therapeutic action. and therefore ‘take the weight off the Will teaches in the Masters programs at the University of Spleen’ enabling its qi to rise as it naturally should. Selection of the appropriate guiding prescription is based on a clinical assessment of the relative importance and dominance of Harmonizing formulae any pathology. Huang qin (scute) and huang lian (coptis). This accounts for Conclusion: its popularity. strengthen the Spleen continue to weaken it and the Spleen will be damaged again. continue to produce Dampness and will likely be damaged and their warmth counteracts the coldness of the Heat by the bitter cold herbs or substances used to clear the Damp clearers. our therapeutic armory and way of seeing upper abdomen along with many other clear signs of qi certain complex problems would be much poorer. Ban Xia Xie Xin The formulas of the harmonizing group and the deep clinical Tang (Pinellia Decoction to Drain the Epigastrium) is insights that lead to their creation are among the finest aspects a good example of how harmonizing formulae work. treatment. Ren shen (ginseng). Ban xia (pinellia) and gan jiang (dry ginger). The above principles are Decoction) can be mapped in the centre of the triangle as prioritized depending on their balance. the Spleen and supplements qi. THE MAYWAY MAILER • August 2017 . It maps between Spleen qi deficiency and Damp Heat: 1.

specifically excessive noted above. by the body. thready etc. at the left middle position (Liver) and a quickly increase in anticipation of conception. a series of physiological stressful. global threats. The sum total of phenomena that lead sympathetic tone. i. the hormone secreted in response to lead to a failure of the body to adapt quickly or completely physiological and psychological stress. When the qi. any one of which causes no problem but which creates a situation that the body interprets as a persistent accumulate over time and alter the body’s ability to adapt. low-level threat. at the right middle position job is to adjust the internal environment accordingly to (Spleen/Stomach). Following ovulation. alcohol and system. The paradoxical pulse is so called because it is the opposite flow of qi. This is what is meant by maintaining the free 5. scope of this article. shutdown mode. When adaptation is poor. defined here as conditions leading to constrained Liver system. as nervous system dysfunction. Liver congestion and internal Heat. A good clinical example of the Liver’s role is seen of the pulse expected for the pattern it reflects. the Liver does not middle position. both external and internal. levels of progesterone pulse–wiry.. The Liver’s deficient pulse–weak. In many cases stress. being the areas most vulnerable to surprise activities that disrupt the internal clock and that run counter attack (your primitive midbrain thinks your enemies will to millions of years of evolutionary adaptation to the various try to sneak up behind you and knock you on the head) rhythms of the world – shift work and frequent crossing of time tense up in anticipation. epinephrine in the blood increase activity in the sympathetic Stress. the TV or staring at a computer) when the body is trying to go into level of epinephrine in the blood returns to normal levels. that stimulates correct movement of qi through the digestive tract. pulse is a very clear indicator of Liver invading Spleen and fluid retention. the parasympathetic nervous system kicks in. has passed. Simple activities that are not thought to be stressful at all switches off sympathetic response and autonomic equilibrium can produce measurable physiological stress. as it is popularly defined. muscle tone and spasm. These include is restored. especially upper back and neck. as interpreted Unfortunately. These include back and neck. The Liver is responsible vomiting. financial pressures and so on trivial activities. irritability–usually attributed to Liver Stomach patterns. and so on. This creates a dynamo disturbances. acting as a shield. Increased levels of enough to changing conditions. and by extension the internal organ systems reliant 2. physical manifestations of that failure. When the qi dynamic fails qi accumulates medicine) is to help the body adjust to change. beyond the nervous system never completely returns to resting level. repressed emotion that help escape the threat–heart and lungs. are seen.. In addition to the classical changes occur. sugar. and so on. In a broad sense the Liver’s job (as defined by Chinese on Spleen qi. Then we begin to see the long-term effects consumed relative to physical output and overabundance of of qi constraint.Endnotes 1. reflux. increase in blood pressure. Alertness. peripheral vascular tone to adapt to change is registered by the body as stress. supply and peristalsis in the intestines and increase in smooth food stagnation. 4.e. The qi dynamic is the movement of Spleen qi upwards and increase in alertness and inability to switch off causing sleep movement of Stomach qi downwards. The muscles of the upper a clear physiological result (outlined above). pain. The paradoxical in women with premenstrual symptoms–breast tenderness. dairy foods. increased tension in the musculoskeletal energy rich carbohydrates. and the large and so on). The paradoxical pulse presents as a large ensure a smooth transition to the new state and so maintain bulge at the right middle position and a clear dip at the left equilibrium. where the expected pulse is an replete qi constraint. any phenomena that impacts on the body’s ability muscles of the legs. constipation and so on. The result is a constant low-level secretion of epinephrine and elevated sympathetic tone–the sympathetic 3. In evolutionary terms threats of this type are staying up late at night processing information (ie. the modern world with its constant change. hatred. Suffice it to say that the particulars of the The longer this state persists the more it is perceived by the modern western diet with its emphasis on the volume of food body as normal. The issue of diet is a large and complex topic. with and blood pressure increase. frustration. Liver qi constraint can be seen in terms of autonomic do its job properly. THE MAYWAY MAILER • August 2017 . includes phenomena that may not be considered inherently body goes into fight and flight mode. strong etc. both or counter-flows causing abdominal bloating. watching relatively infrequent and after the threat has passed. is the accumulation of many small and seemingly deadlines. decreased blood processed or adulterated foods easily lead to Phlegm Damp. for the maintenance of homeostasis in response to changing conditions. setting off the ‘fight and flight’ response. It is mediated through the adrenal cortex to constrained Liver qi can be defined as those conditions that and epinephrine. fats. Once the threat zones (air crew and business travelers) are particular culprits. Blood is routed away from non-essential etiological stressors that lead to qi constraint as defined in systems (such as the digestive tract) and pumped into those Chinese medicine (anger. nausea and environmental and physiological. peripheral vasoconstriction and poor circulation to the extremities.

The text also includes: . The clinical notes section offers general prognoses to help elucidate Indications. treatment principle. Composition. In addition. this tome is a practical Clinical Handbook of Internal Medicine. by William Maclean. prescription. Jane Lyttleton The Clinical Manual of Chinese Herbal Patent Medicines- The second of a 3-volume TCM clinical guide. patent medicines. variations. formula name or TCM pattern.An intuitive 75 page index. are discussed with reference to etiology pathophysiology. Kidney. Blood. All disorders are discussed with reference to etiology herbs within a group. 3. and tiredness. phlegm disorders. Keys to diagnosis is an essential addition to the desk and bookshelf of all and pattern identification accompany major disorders. purpura. as well as make clear the and intuitive index makes it easy to search for topics by biomedical fine points of discrimination for the experienced practitioner. It TCM medical terms used in the text in clear language. numbness. prescription. hysteria. Spleen and assistant to the complex world of Chinese herbal prescription. and medicinals The tables and text in this book will facilitate efficient derived from endangered species and animals. applicable acupuncture points and clinical notes. Jane Lyttleton interactions laid out in table form. thin mucus syndromes. fainting. colds and flu. left margin to highlight useful information. Kidney. pathologies of the raw materials. Disorders practitioners and students interested in using patent medicines. treatment principle. clinical features. toxic substances. edema. acute fever. All disorders are discussed with reference to etiology. Biomedical actions. Vol. A comprehensive and intuitive index makes it easy to search for topics by biomedical application. incompatible and antagonistic herbs. nature. with in-depth analysis Channels of more than 20 common disorders affecting the Spleen and Stomach. Each table prescriptions are referenced. Kathryn Taylor Each pattern is discussed from the perspective of its presentation The extensively revised second edition (August 2003) of and treatment in a Western context. appendices contain describes the characteristics of a group of herbs.Potential herb drug by William Maclean. formula name or TCM pattern. Another treatment is applied. practical advice the Clinical Manual of Chinese Herbal Patent Medicines and clinical tips relevant to Western patients. focuses on diseases of qi. by William Maclean Liver. prescription. clinical One nice feature of the text is its use of small icons in the features. Combinations. original unmodified formulas. Stomach by William Maclean. Vol. and a deep understanding of the unique pathophysiology. Each formula is patent medicines. Heart by William Maclean. applicable acupuncture points charts is designed to aid the student or the busy practitioner in and clinical notes. Within each organ’s section. treatment principle. obesity. A comprehensive comparative study for the student. diabetes. including information on. and Cautions and Contraindications. covering Lung. application. Dose and Method of the kind of results that may be reasonably expected when correct Administration. depression. Qi. . Vol. Jane Lyttleton Proficiency in the prescription of Chinese herbs depends The first of a 3-volume TCM clinical guide. clinical features. as well as a general estimate of the length of feature that facilitates quick reference is the authors’ use of treatment required.Also by William Maclean: Clinical Handbook of Chinese Herbs Clinical Handbook of Internal Medicine. and contains chapters on abdominal masses. Fluid. extensive indications with relative strengths of action and delivery methods. headache. This volume of comparative modifications. Easy to use. characteristics of each herb. pattern indicated. Lung. pathophysiology. fits and funny turns. blood. neck lumps. applicable acupuncture points and clinical notes. Where applicable. TCM disorders. persistent and recurrent fever. . discussed in terms of its TCM Actions. and fluids. herbs contraindicated during pregnancy. . processing methods. with insights. blood stasis. sweating. function. patent medicines. 2. complete with listings for both biomedical and Clinical Handbook of Internal Medicine. 1. modifications. This in turn depends on being able to are organized by established TCM patterns within biomedical discriminate the fine points of difference between the similar categories. flavor.Tables of comparisons between similar Channels formulas designed to aid differentiation.A glossary describing the This is the final volume of a 3-volume TCM clinical guide. modifications. These are often expressive of the TCM patterns as well as a section on the properties and TCM actions emotional and psychological characteristics that match the of common foods. . and dosage guidelines. gallbladder disorders. not only on good diagnosis but on an intimate knowledge Liver and Heart disorders. the domain. with clear and accurate tables comparing all the main herbs used in a modern clinic. variations and additional selecting the optimal medicinals for their patients. As an added benefit the text includes a section on simple line drawings to illustrate the key symptoms and signs diet which includes information on what foods help treat common for each formula/pattern. painful obstruction (bi).