Overview of Chinese medicine and autoimmune diseases, and the role of Yin deficiency

CHAPTER 2 Overview of Chinese medicine and autoimmune diseases, and the role of Yin deficiency



Contents


1. Yin deficiency in autoimmune diseases 14

2. Yin deficiency in non-autoimmune diseases 20

3. Blood stasis is both a pathological product and an aetiological agent that may aggravate an illness 21

4. The phenomenon of Fire manifests as inflammation within the body 22
(1) Acute inflammation is equivalent to Fire flaring up with Heat-Toxins 23

(2) Chronic inflammation is equivalent to Fire flaring up due to Yin deficiency 23

(3) Qi and Yang deficiency may occur later in the disease process 23

5. Phlegm-Dampness and Fluid retention are pathological products in autoimmune disease 24

6. Yin grows when Yang generates 24
(1) Treatment of immune-related diseases, such as type I hypersensitivity 25

(2) Treating autoimmune diseases 28

7. Chinese medicine treatment of autoimmune diseases 32
(1) Protecting or ‘masking’ antigens that are the body’s own tissues and cells, and that may have a high risk of being damaged by disordered immunity 32

(2) Removing Blood stasis may improve the cellular environment 35

(3) Clearing Heat can help protect Yin and prevent further damage to Yin 37

(4) Tonyfying Qi helps Yin to grow 38

(5) Eliminating Dampness is one of the treatments in autoimmune disorders 39

(6) Treatment may be based on differentiation of symptoms and signs or on differentiation of diseases, or a combination of the two 40

8. Keeping Yin and Yang balanced is the key to preventing and treating autoimmune diseases 43

Summary 43
(1) Preventing invasion by the six external pathogens 43

(2) Yin and Yang balance 44

(3) Vitalizing or removing Blood stasis 44

(4) Eliminating Phlegm and Dampness 44

(5) Clearing Heat 45

9. Treatment 45
(1) Treatment of type I hypersensitivity 45

(2) Treatment of autoimmune diseases 48

10. Chinese medical treatment is based on symptoms and signs 51

To clarify the view of autoimmune diseases in both Chinese and Western medicine, this chapter briefly highlights several Western diagnoses of autoimmune diseases within the context of Chinese medicine. As further illustration, these diagnoses are juxtaposed with diseases that are not the result of an autoimmune process, but still have a component of Yin deficiency.



1 Yin deficiency in autoimmune diseases


Yin deficiency plays a central role in autoimmune diseases (Figure 2.1). Specifically, a deficiency of Yin affects cells negatively and may lead to tissue degeneration, apoptosis (programmed cell death), and Qi and Yang deficiency, as well as stasis of Blood and the body’s greater susceptibility to pathogens.


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Figure 2.1 Yin deficiency is a cause and a result of autoimmune disease.


To maintain effective immunity, good health and normal physiological function, a person must have healthy reserves of Yin, which must be in harmony with Yang, as Yin and Yang are always in a state of dynamic flux. Yin refers to formed substances, such as organs, tissues, cells and body fluids, that is, visible and measurable things. Yang refers to the physiological function of visible things, such as the ability of hydrochloric acid and enzymes to digest food in the stomach or the function of thyroxine in regulating metabolism. Physiological function is based on substance. Without substance, there would be no source for function. Without physiological function, substance exists as nothing more than an inanimate entity. If Yin and Yang separate from each other within the body and become incapable of aiding or assisting one another, life ends.


Zheng Qi, or vital Qi, represents the energy of the body and the function of the organs. As Yin is the foundation from which it is formed and is the basic substance of life, if Yin becomes damaged for any reason, vital Qi will become deficient. For instance, should thyroid cells be destroyed they will be unable to produce thyroxine and the person will present with feelings of cold, fatigue and oedema. Chinese medicine would differentiate these symptoms and signs as Qi and Yang deficiency, although they result from an underlying Yin deficiency. Using another example, should brain cells be destroyed, a patient may experience insomnia, emotional disorders, seizures or amnesia. Chinese medicine would diagnose these symptoms and signs as Kidney Yin is insufficient to nourish the Sea of Marrow.


Yin can be damaged by both excess and deficient Heat. Both can cause symptoms and signs of Heat and Fire flaring. This Fire can burn the Blood, causing Blood stasis. If the Qi is damaged and becomes stagnant, it cannot perform its function of promoting Blood circulation in the vessels, which can also cause Blood stasis. Or, if Qi is deficient, it can neither warm nor pump the Blood, nor govern the Blood in the vessels very well, leading the Blood to extravasate, which can also cause Blood stasis. Therefore, any pathology that affects the otherwise smooth and normal movement of Blood in the vessels will cause Blood stasis.


The crucial point is that Yin deficiency may eventually develop into Damp-Heat or Blood stasis, or lead to internal Wind. This is referred to as ‘excess pathogenesis caused by deficiency’. Yin deficiency can also cause other physiological changes, leading to Qi, Blood and even Yang deficiency. Pathological change is at the cellular level, but as different cells, tissues and organs may be damaged, different pathologies will present with different symptoms and signs. Our forefathers tell us to ‘treat tenacious disease by removing Blood stasis; treat stubborn illness by eliminating Phlegm’. Here Blood stasis and Phlegm are pathological products resulting from cellular damage and/or pathological change.


In some instances, there are close similarities between the theories of Chinese and Western medicine. In other cases, only some components of the theories are similar. After all, Chinese medicine is quite complicated and often difficult to explain using the language of Western medicine. We will try to explain this issue based on modern research in China, coupled with our clinical experience.


Zhu Danxi, who practised around 1347 CE during the Jin-Yuan Dynasty, said: ‘Yin is ever deficient and Yang is ever excess in the human body’. How does one understand this? As explained above, Yin includes cells, tissues, organs, fluid and the body itself; it includes all visible substances. As Yin declines with age, a person’s skin becomes thinner and wrinkles develop; their stature becomes shorter; they may develop blurry vision, tinnitus and insomnia, and even a short temper. These changes can also be explained by Western medicine’s concept of cellular apoptosis. Apoptosis releases cytokines that trigger immune cells to engulf fragments of the apoptotic cells, causing inflammation and a heat sensation, which Chinese medicine calls Heat. Such Heat caused by cell apoptosis arises from Yin deficiency, and is called deficient Heat due to Yin deficiency.


Here, let us define the word apoptosis, or programmed cell death – a form of cell lysis. This Western medical term may be able to explain Chinese medicine’s description of Yin deficiency, because Yin includes cells.1


‘A major mechanism of cellular destruction is apoptosis, a highly organized form of cell death that is critical for maintaining homeostatic function in a variety of tissues in normal condition.’2 This modern theory mirrors Zhu Danxi’s idea that ‘Yin is even deficient’ in the normal process of life.


Although apoptosis is an intrinsic process present in all cells, it can be regulated by extrinsic factors, including growth factors, cell surface receptors, cellular stress, hormones, etc. In normal conditions, apoptosis plays a central role in regulating not only the development of lymphocytes but also their homeostasis. In fact, there is evidence of apoptosis in normal tissue probably as part of homeostatic regulation of cell number and differentiation.3


This process, which maintains the tissues in their normal size and function, sounds like the way in which Chinese medicine describes how the body maintains the balance of Yin and Yang. Apoptosis is a physiological mechanism that occurs continuously at impressive rates. Dedicated phagocytes, such as monocytes and macrophages, remove apoptotic cells very effectively via phagocytosis, in which foreign particulate matter is engulfed and destroyed. Rapid elimination of apoptotic cells is important as it prevents the release of toxic cell constituents such as cytolytic enzymes. When the numbers of apoptotic tissues are in homeostasis with the number of naturally growing tissues, everything is balanced and the body is healthy. However, if the frequency of apoptosis is greater than normal cell growth, the body begins to degenerate, but may still be within tolerance. If apoptosis progresses beyond body tolerance levels, the process may trigger the development of autoimmune diseases. This is because numerous antigens are newly exposed in the cell membranes of apoptotic cells. To maintain health, the prevention of excessive autoantigenic exposure requires the removal of apoptotic cells.


A breakdown in apoptosis-related signalling mechanisms can result in the development of autoimmune disorders by causing apoptosis to exceed tolerance. There is increasing evidence that the presence and accumulation of these apoptotic cells can result in autoimmunity. We illustrate cellular apoptosis in several autoimmune and degenerative diseases using the Chinese medicine concept of Yin deficiency (Figure 2.2).


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Figure 2.2 Diseases with Yin deficiency.




A Yin deficiency and systemic lupus erythematosus


In systemic lupus erythematosus (SLE), immune tolerance can be destroyed by an increased number of apoptotic cells. Should immune tolerance be compromised, the body produces autoantibodies that will bind to antigens whenever they become exposed on the cell membrane. The presence of these autoantibodies allows interaction with Fcγ receptor-binding cells. This will result in Fc receptor-mediated phagocytosis, which induces the release of pro-inflammatory cytokines. This cascade of events leads to the development of the inflammation characteristic of many autoimmune diseases.


In Chinese medical theory, we liken this process to the impairment of Yin, specifically as results in Yin deficiency. We describe the inflammation caused by apoptosis as Fire flaring up as a result of Yin deficiency. This deficiency Fire, in turn, further impairs Yin; that is, inflammation also causes apoptosis, resulting in still more tissue damage, exacerbating the disease process. Once one understands these apoptotic and inflammatory processes, one can apply Chinese medical theory to intervene and treat autoimmune-mediated disorders, thus reducing the morbidity and mortality of patients suffering from these diseases.



B Yin deficiency and Hashimoto’s thyroiditis


Apoptosis plays an important role in all autoimmune diseases, including Hashimoto’s thyroiditis. In Hashimoto’s thyroiditis, Fas-mediated apoptosis of thyrocytes in thyroid tissue is due to at least two separate mechanisms. The first mechanism is the infiltration of activated T cells that destroy thyroid cells, and the second is that FasL-positive thyrocytes induce cellular suicide.


Evidence is accumulating that modifications of autoantigens during apoptosis lead to the development of autoantibodies by bypassing the normal mechanisms of tolerance. As explained above, tissue homeostasis is maintained through a balance between cell proliferation and apoptotic cell death. This theory explains why treating Hashimoto’s thyroiditis with thyroxine replacement does not resolve a hypofunctioning thyroid, because it does not resolve the autoimmune reaction.



C Yin deficiency and autoimmune hepatitis


Autoimmune hepatitis (AIH) is classified as either type I or II, type I being the most common form. Type I commonly combines with other autoimmune disorders, such as type 1 diabetes, proliferative glomerulonephritis, Hashimoto’s thyroiditis, Graves’ disease, Sjögren’s syndrome, autoimmune anaemia and ulcerative colitis. Type II AIH is less common, typically affecting girls aged 2–14 years, although adults can have it, too. Regardless of the type, the basic pathogenic change in AIH is due to hepatocyte apoptosis.4 Chinese medical theory describes this process as hyperactive Fire due to Liver Yin deficiency.



D Yin deficiency and Sjögren’s syndrome


Sjögren’s syndrome is an autoimmune disorder in which immune cells attack and destroy the glands that produce tears and saliva. Sjögren’s syndrome is also associated with rheumatic disorders such as rheumatoid arthritis. The hallmark symptoms of the disorder are dry mouth and dry eyes resulting from the destruction of salivary acinar cells, even though ductal cells are frequently spared. In addition, Sjögren’s syndrome may cause skin, nose and vaginal dryness, and may affect other organs of the body including the kidneys, blood vessels, lungs, liver, pancreas and brain. Beyond all doubt, these symptoms, signs and pathogenesis belong to the Chinese medicine description of Lung, Stomach, Liver and Kidney Yin deficiency.



E Yin deficiency and scleroderma


Yamamoto and Nishioka5 of the Department of Dermatology, Tokyo Medical and Dental University School of Medicine, have elucidated the role of apoptosis in cutaneous sclerosis. Using animal models, they examined the induction of apoptosis and expression of Fas, Fas ligand and caspase-3 in a murine model of bleomycin-induced scleroderma. Dermal sclerosis was induced by local injections of bleomycin (1 mg/mL) in C3H/HeJ mice. Induction of apoptosis was examined by TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labelling) assay and DNA gel electrophoresis. There is no question that apoptosis is the causal factor in an autoimmune attack of local cells leading to fibrosis proliferation. The essential pathological change in Chinese medical theory is that Yin deficiency induces deficiency Fire to flare up (chronic inflammation), which singes the Blood and becomes Blood stasis (scleroderma).



F Yin deficiency and multiple sclerosis


Several recent studies have provided evidence that apoptosis is an important feature in the pathogenesis of multiple sclerosis (MS), an autoimmune disease of the central nervous system. Apoptosis presumably plays a role in the immunoregulation via activation-induced T-cell death and in local processes of tissue damage.6 In MS the central nervous system is impaired when the myelin coating of neurons is damaged in a process called demyelination. Myelin is damaged and replaced by scar tissue that lacks the insulating function of healthy myelin. This essentially results in bioelectricity leakage, resulting in improper stimulation of cells, tissues and organs, and causing MS symptoms. Myelin is a kind of fatty tissue that is visible and is also considered Yin. This process of remyelination is the treatment for degenerating protein and fibrosis. In Chinese medicine, we call remyelination nourishing Yin and removing Blood stasis (degeneration and fibrosis). Chinese medical theory says that the causes of MS relate to internal and external pathogenic factors, for example six external pathogens encroach on the human body and over a long period of time destroy Yin and create Blood stasis.



G Yin deficiency and rheumatoid arthritis


Rheumatoid arthritis (RA) is characterized by pronounced hyperplasia of the synovial tissue, cell infiltration and periarticular osteoporosis. Enhanced Bcl-2 expression and NF-κB nuclear translocation of synovial cells are induced by inflammatory cytokines and/or growth factors. These synovial cells become resistant to apoptosis triggered by various stimuli. The infiltrated cells that are defective in activation-induced cell death can cause autoimmunity by allowing the survival of autoreactive T and B cells. The proliferative synovial cells secrete more and more fluid. If the condition exists mainly with inflammation, we call it Damp-Heat Bi syndrome; if it exists mainly with exudation, we call it Cold-Damp Bi syndrome; and when the disease progresses and results in deformity of the joint coupled with osteoporosis, we say that there is Yin deficiency with Blood stasis. However, Yin deficiency always exists throughout the progression of the illness. Yet when there are pathogens such as Damp-Heat or Cold-Damp, we are prohibited from nourishing the Yin, because we will exacerbate the effect of the pathogens.


These examples suggest that apoptosis might be implicated in the pathogenesis of autoimmunity, although the mechanisms may be distinct in each autoimmune disease.


In the authors’ clinical experience, patients with autoimmune diseases almost always present with Yin deficiency symptoms and signs. This clinical observation mirrors clinical studies on treating autoimmune diseases with Chinese medicine, such as discussed by Zhou & Zhou.7


Western medicine also describes specific pathogeneses that result in autoimmune diseases. Excessive apoptosis and cell fragments trigger the immune system to attack tissues and organs, producing chronic inflammation locally or systemically. Although Western medicine names each disease based on its unique signs and symptoms and its pathological changes, the Chinese medicine concept of Yin and Yang observes the commonality of the different autoimmune diseases. Therefore, regardless of the specific disease, Chinese medicine can treat them all with similar prescriptions and methods.


Yin deficiency is not unique to autoimmune diseases. However, according to Chinese medicine, the pathogenesis is often the same. Thus, the treatment of Yin deficiency should be the same regardless of the disease. In Chinese medicine we call this Tong Bing Yi Zhi image, Yi Bing Tong Zhi image, or treating similar diseases with different methods, but treating different diseases with the same method. For instance, one finds that in treating Sjögren’s syndrome there are two distinct presentations. In the first, a patient has dry mouth. The prescription will be to nourish Stomach Yin, because the Stomach opens on the mouth. In the second presentation there is the symptom of dry eyes. The prescription for this manifestation is to nourish Liver Yin, because the Liver opens on the eyes. Therefore, even for the same disease, the treatment and prescription may differ. Yet, consider two different diseases, such as hyperthyroidism with symptoms of tachycardia, anxiety and insomnia, and infertility with raised levels of follicle stimulating hormone (FSH). In Western medicine, these two diseases have different causes, but according to Chinese medicine the first one is due to Liver and Kidney Yin deficiency with Liver Fire rising. The second condition is caused by degeneration of ovaries possibly consistent with perimenopause, with symptoms of insomnia, night sweats, increased basal body temperature and hot flushes. These result from deficient Fire due to Liver and Kidney Yin deficiency. Although two different diseases, they both result from Yin deficiency. Therefore the treatment method is the same: to nourish Yin. To reiterate, Yin deficiency is not unique to autoimmune diseases; it also exists in other diseases.



2 Yin deficiency in non-autoimmune diseases


In Western medicine, the terminology of apoptosis includes morphological changes such as cellular shrinkage, nuclear condensation, DNA fragmentation, membrane blebbing and the generation of apoptotic vesicles. In comparing the two medical theories, one can say that Yin deficiency is equivalent to Western medicine’s description of the activity of apoptotic cells. In general, the phagocytes of the immune system remove apoptotic cells rapidly so as to avoid the major inflammatory tissue reactions that may result in necrosis. As apoptosis is an active process of self-destruction, it requires the activation of a genetic programme that may lead to changes in cell morphology and DNA fragmentation. Apoptosis can be triggered in several ways and affect many cellular functions. The mechanism provides protection from the possible consequences of uncontrolled cell proliferation, which could lead to neoplasia. Cell death is a factor in the pathogenesis of several diseases besides autoimmune disorders, such as cancer, acquired immune deficiency syndrome (AIDS), Alzheimer’s disease, Parkinson’s disease and neurodegenerative diseases.


Cellular senescence, or age-related degeneration, is caused by DNA damage. As cells age and mature, they either senesce or self-destruct (apoptosis). If numerous damaged cells become irreparable, the result is degenerative diseases or illnesses related to ageing and the elderly.


Chinese medical theory explains that people age and degenerate as the result of Kidney deficiency and Yin deficiency.8 Generally speaking, Yin deficiency is the primary cause of any number of common diseases. In fact, there is evidence of degeneration and apoptosis in normal tissue and organs, probably as part of homeostatic regulation of cell number and differentiation.


The crucial point here is that the basic pathogenesis of many degenerative diseases is similar to the pathogenesis of autoimmune diseases. Therefore, it makes sense to apply theory related to the treatment of Yin deficiency for both autoimmune and degenerative diseases.


For example, let us look at Alzheimer’s disease. Researchers have discovered that the brains of people with Alzheimer’s disease contain dying neurons that display some characteristic signs of apoptosis, such as DNA breaks and activation of enzymes called caspases that carry out the predetermined cellular death process.9 Many neurons in Alzheimer’s disease exhibit terminal deoxynucleotidyl transferase (TdT) labelling for DNA strand breaks with a distribution suggestive of apoptosis.10 Chinese medicine would describe this process as the Kidney Yin being insufficient to nourish the Sea of Marrow, resulting in symptoms including amnesia, poor memory and compromised cognition.


Consider also Parkinson’s disease, which is different from Alzheimer’s disease in clinical symptoms and signs. However, there are similarities, because they both result from the degeneration of brain cells. Various evidence supports the idea of an apoptotic contribution to the neuronal loss associated with Parkinson’s disease, particularly in the area of the substantia nigra. Recent findings suggest that the multiple caspase-dependent or caspase-independent signalling pathways that mediate apoptotic nuclear degradation determine the morphological features of apoptotic nuclear degradation.11 Chinese medicine would describe this process as a result of Liver Yin deficiency. Yin insufficiency cannot nourish the Jing, leading to the recognised symptoms such as shaking limbs and head.


Should cells proliferate sufficiently to recover from apoptosis, a patient can continue in good health or recover from an illness. On the other hand, if apoptosis exceeds cellular proliferation, it may lead to autoimmune or degenerative diseases. Or, if proliferation exceeds apoptosis, benign or malignant cancer may result. Of course, this dynamic state of apoptosis versus proliferation depends on multiple factors. Additionally, excess cell apoptosis causes different symptoms based on the tissue in which it occurs.


Western medicine has realized that T-cell activation plays a pivotal role in immunopathogenesis. Lymphocyte processes are tightly controlled by molecules that activate either proliferation or apoptosis. An imbalance in apoptotic function and increasing autoreactive cells may lead to persistent autoreactive phenomena.12



3 Blood stasis is both a pathological product and an aetiological agent that may aggravate an illness


Blood circulates continuously in the vessels throughout the body. Normal circulation results from the mutual action of the Heart, Lung, Spleen and Liver. If a pathogen compromises the function of these organs, Blood stasis results. Blood stasis means that Blood does not circulate smoothly through the vessels. In extreme cases, it blocks the vessels or leaves the vessels entirely.


Blood is a formed, visible substance belonging to Yin. Blood stasis can be caused by numerous pathologies: excess or deficient Heat burns the Blood, causing it to congeal and become Blood stasis; Qi stagnation leads to Blood stasis; deficiency of Qi makes Qi too weak to push the Blood through the vessels, causing Blood stasis; accumulation of pathogenic Cold or Qi and Yang deficiency cannot warm the vessels, causing Blood stasis. Once formed, the Blood stasis aggravates the underlying disease’s condition aetiologically. First, the formed Blood stasis blocks the vessels, so Qi and Blood cannot flow smoothly, further aggravating Blood stasis; with the vessels blocked, the four limbs cannot be nourished, resulting in cold limbs and, in extreme cases, purple fingers and toes. Additionally, Blood stasis can compromise the formation of new Blood, resulting in Blood deficiency.


Theories of Chinese and Western medicine have a homologous meaning for circulation, which is blood flowing smoothly through the vessels, and for Blood stasis. However, Chinese medicine also includes the Western medical concepts of inflammation, fibrosis, deposition of collagen (a protein normally found in tendons, bones, connective tissue and scar tissue) and proliferation of other tissues and complexes.


With regard to Chinese medicine and autoimmune diseases, Blood stasis may be (1) the result of an autoimmune reaction, or (2) the cause of an autoimmune disease process. To treat Blood stasis, one can do any of the following: (1) clean out complex to protect cells that may be at risk; (2) reduce fibrosis by interrupting or cutting short the deposition of fibrotic protein; or (3) improve microcirculation to help reduce inflammation and the number of apoptotic cells, in order to reverse the process or recover cellular function.


Fibrosis is a condition that causes irreversible scarring of damaged tissue. The replacement of normal tissue by scar tissue hampers Blood flow through the damaged tissue. This decreased Blood flow makes it increasingly difficult for affected organs and tissues to perform essential functions. Blood stasis rarely causes signs and symptoms in its early stages, but becomes apparent once tissues and organs lose normal function. Examples of diseases resulting from fibrosis include pulmonary fibrosis, also called idiopathic pulmonary fibrosis, and liver cirrhosis.



4 The phenomenon of Fire manifests as inflammation within the body


Fire, a manifestation of Yang, is of two types in Chinese medicine: excess and deficient. Excess Fire results from any of six exopathic factors. It is characterized by sudden onset, superficial location, mild symptoms and short course. If vital Qi is not strong enough to fight them, then the exopathic factors cause febrile disease and transmit the pathogen deeper into the body. When this happens, the result is acute Fire and Heat-Toxin diseases. If the body must fight the febrile disease for an extended period, the pathogenic Fire destroys Yin and the illness may evolve into a chronic disease. One will then observe Yin deficiency symptoms. Should the disease become chronic, Fire will eventually become deficient and, with Yin too damaged to suppress it, it will worsen.


One way to understand more about excess and deficient Fire is by observing the dynamic changes that take place in pathological inflammation from a Chinese medicine perspective. Inflammation is a complex biological response of vascular tissue to a harmful stimulus, such as pathogens, damaged cells and/or irritants. Inflammation can be classified as either acute or chronic.



(1) Acute inflammation is equivalent to Fire flaring up with Heat-Toxins


Acute inflammation is the initial response of the body to harmful stimuli and is achieved by the increased movement and infiltration of plasma and leukocytes from the blood into the injured tissues. It is a short-term process characterized by the classical signs of inflammation: swelling, redness, pain, heat and loss of function. The cascade of biochemical events that propagates and ends in the inflammatory response involves the local vascular system, the immune system and various cells within the injured tissue.


It becomes clear that these separately described phenomena are actually identical. This redness and heat sensation are symptoms of what Chinese medicine refers to as excess Fire and Heat-Toxin.



(2) Chronic inflammation is equivalent to Fire flaring up due to Yin deficiency


Chronic inflammation is a prolonged condition that leads to a progressive shift in the types of cell that are present at the site of inflammation. It is characterized by simultaneous destruction and healing of the local tissue from the inflammatory process. The presence of destroyed tissue and apoptotic cells triggers an immune response, specifically the mobilization of monocytes, macrophages, lymphocytes and plasma cells to clean up the fragments caused by injury, resulting in chronic inflammation. In chronic inflammation, tissue destruction occurs faster than cellular regeneration, causing pathological fibrosis to replace physiological apoptotic cells. Eventually, the tissue’s function will be reduced or even lost. In chronically inflamed tissue, the stimulus of the immune system is persistent. Therefore, recruitment of monocytes is maintained, existing macrophages are tethered in place, and proliferation of macrophages is stimulated continuously. In this chronic process, the local redness and heat sensation are less severe than in the acute process and are characterized as empty Fire and Yin deficiency.



(3) Qi and Yang deficiency may occur later in the disease process


In autoimmune diseases, sometimes a self-antigen is closely mimicked by an extrinsic molecule. Despite the similarities, it differs sufficiently from the self that the immune system still recognizes it as foreign. Mimicking antigens may enter the body initially as invading pathogens, or even by alteration of endogenous antigens due to infection, environmental chemicals or drugs.


Obviously, different cells, tissues and organs have unique functions. Should any of these be damaged, their functions would be affected and clinical symptoms would materialize. For example, if heart tissue were damaged, it would affect the heart’s vascular ability to pump and circulate blood. We call this Heart Yang deficiency due to Heart Yin deficiency. Damaged thyroid tissue would result in reduced metabolism and a colder body. We call this Spleen Qi and Yang or Kidney Qi and Yang deficiency due to Yin deficiency. In these examples, specific body substances have been damaged, causing reductions in corresponding function. Therefore, we refer to these conditions as a deficiency of Yin affecting Yang.


Excess Yang can be due to ageing, as bodily substances are often impaired by injury or simply the act of living, so that the tissue simply repairs more slowly than it is damaged or from six pathogens invasion Empty Fire (Yang) always results from Yin deficiency; excess Fire always impairs Yin. The Western concept of inflammation is clearly explained by Chinese medical theory of the transformation between Yin and Yang, specifically the waning and waxing of Yin and Yang. An understanding both theories aids clinical practice.



5 Phlegm-Dampness and Fluid retention are pathological products in autoimmune disease


Phlegm-Dampness and Fluid retention are pathological products that result from metabolic disorders occurring in the course of some illnesses. Retention of Phlegm-Dampness and Fluid is characterized by accumulation of Dampness resulting from disturbed distribution of water metabolism. In describing fluid physiology, Chinese medicine identifies thick, turbid Dampness as Phlegm and the thinner, clearer Dampness as Fluid.


How does the theory of Chinese medicine compare with that of Western medicine with regard to retention of Phlegm-Dampness and Fluid? During an autoimmune reaction there are two different sources producing Phlegm-Dampness and Fluid. Both come from tissue exudation. Exudation is the slow escape of liquids and serous fluid from blood vessels through pores or breaks in the cell membrane.


1. In fluid exudation due to acute inflammation, the pressure in postcapillary venules may overcome the osmotic pressure of plasma proteins, thereby forcing fluid and low molecular substances to penetrate into the surrounding area. From the venules, this fluid infiltrate can include any or all components of plasma, such as metabolized administered drugs and herbal medicines. This fluid exudate is a visible substance and belongs to the category of Fluid in Chinese medicine.

2. Cellular exudation is formed during the second and third phases of inflammation – acute and chronic cellular responses. If tissue (antigen) damage is slight, an adequate supply of neutrophils is derived from those naturally circulating in the blood. If tissue damage is extensive, stores of neutrophils, including some immature forms, are released from bone marrow to increase their absolute count in the blood. Thus, a number of different cell types are recruited into the area where damage has occurred, and these are responsible for inactivating and removing invading infectious agents, removing damaged tissues, inducing the formation of new tissue and reconstructing the damaged cell matrix, including basement membranes and connective tissue. This process mirrors the concept of Phlegm-Dampness.


6 Yin grows when Yang generates


This is a very important concept in Chinese medicine. It suggests that tonifying Qi and Yang can help promulgate Yin. However, as will be described in later chapters, one must be careful in tonifying Qi and Yang in autoimmune diseases, because doing so can also engender Heat, which can exacerbate an autoimmune disease.


What are Qi and Yang? Qi and Yang are metaphors for naturally occurring phenomena. Although invisible, they reflect basic substances in the world and their effect can be experienced. There are two distinct concepts describing Qi and Yang. The first refers to the vital energies coursing through the human body and maintaining its activities, drawn from such substances as the Qi of water and food, the Qi of breathing and the Qi of other sources of life. The other refers to the physiological functions of the viscera and bowels and channels and collaterals, such as the Qi of the Heart, Lung, Spleen, Kidney, Stomach, etc. This latter Qi refers specifically to the physiological function of the organs. Qi is a function of Yang, so we often refer to Yang Qi together.


Research into the function of Yang and Qi has shown that tonifying Qi and warming Yang also have the effect of strengthening immunity, especially increasing the number of T cells. For example, in clinic we treat human immunodeficiency virus (HIV)-positive patients with the tonifying method with the result being an increase in patients’ CD4/CD8 ratio. Following this improvement in laboratory results, patients’ symptoms also often improve. This immune enhancement effect is found both in clinic and in the laboratory, as reported in China using tonification in animal models. Research shows that herbs such as Bai Bian Dou Lablab Semen album, Dang Shen Codonopsis Radix, Huang Qi Astragali Radix, Lu Rong Cervi Cornu Pantotrichum and Zi He Che Hominis Placenta increase the number of T cells.


How are tonifying methods used to treat diseases caused by immune disorder? To understand this treatment more easily, let us first look at the treatment of diseases arising from an external antigen – asthma and allergies. Following that, we will look at an example explaining how to treat autoimmune diseases that arise from an autoantigen.



(1) Treatment of immune-related diseases, such as type I hypersensitivity


Asthma and allergies are not autoimmune diseases, but disorders of immune function, although there is some overlap between patients with autoimmune disorders and patients with type I hypersensitivity. Patients with these diseases almost always have a high level of immunoglobulin (Ig) E level in their blood. This raised IgE concentration makes the patients sensitive to antigens in the air, food or many other factors external to the body, causing symptoms of asthma and/or allergy.


Tonifying Qi and warming Yang to raise the T-cell count can help inhibit B cells and reduce IgE levels. Although one must take care not to tonify Qi and warm Yang during an acute flair, as this would have the side-effect of astringing an acute pathogen, making the illness difficult to treat or aggravating it.


Allergic rhinitis, commonly called hay fever, and asthma are both diseases of a malfunctioning immune system. The common symptoms are sneezing, stuffy or runny nose, itchy eyes, nose and throat, a nasal-sounding voice, difficulty breathing, poor appetite, snoring during sleep and coughing with or without phlegm. These symptoms may occur seasonally or during the entire year. Sometimes the condition is simply diagnosed as allergy. However, some more severely affected patients receive a diagnosis of bronchial asthma.


An elevated level of IgE is the essential pathogenic change that occurs in type 1 hypersensitivity. It can result in bronchial asthma occurring when patients inhale or come into contact with allergens such as pollen, dust, insects, germs, seafood, nuts, etc. While different people may react to different allergens, the process of the antigen–antibody reaction is the same for everyone. Should treatment focus exclusively on the antibody (IgE) or histamine, symptoms will be relieved, but treatment must be repeated year in and year out. On the other hand, using Chinese medicine, if we are able to affect suppressor T cells in order to control B cells, we may also be able to control the hyperactive production of IgE and prevent the need for continual treatment for symptom relief.


With regard to treatment there are two important aspects: (1) resolve the immediate symptoms when a patient is experiencing an allergy or asthma attack; and (2) resolve the underlying problem, which is disordered immune function. Figure 2.3 helps us to understand this more easily. When an antigen is present, for instance during the allergy season when there is a high density of pollen, if we promote Qi and/or Yang the patient’s condition may get worse. The reason for this is that promotion of Qi or Yang while antigens and antibodies are in high concentration or during an autoimmune disease flare will cause the antibodies to attack the antigens. In these circumstances, both suppressor and helper T-cell counts will increase. Helper T cells will stimulate more B-cell growth in order to eliminate the antigens and clear them out. In this case, an increase in the number of antibodies fighting the antigens will aggravate the inflammation, making the illness worse.


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Figure 2.3 Promoting Qi and Yang to support immune function.


However, a high level of antigens would reduce the number of suppressor T cells and increase helper T cells, thereby increasing the B-cell concentration. The presence of antibodies coupled with antigens increases the ability to stimulate the circulation of helper T cells. This process of ever-increasing T-cell numbers responding to increased antibodies and antigen is like a circle – never ending.


To break down this circular situation, Chinese medicine has a way of assessing acute symptoms and treating the problem. Acute symptoms are external phenomena, and once external symptoms are under control the underlying problem can be treated by finding a way to increase suppressor T cells and prevent B cells from producing antibodies. When there is a low level of, or no, antigens is treatment by replenishing Qi and warming Yang to raise the T-cell count, including both suppressor and helper T cells. During the non-allergy season, there is no need to be concerned with antigen-stimulating antibodies. The treatment involves supporting suppressor T cells and reducing B cells. When the allergy season comes, there will be closer to normal levels of antibodies to fight the antigens, and the illness will improve or even be healed.



A Treatment of symptoms


During an asthma attack, the airway becomes constricted and inflammation and excess mucus production block the bronchi, resulting in laboured breathing. This process occurs when elevated levels of IgE react to allergens in the environment. If we attempt to address the problem by increasing the production of T cells, we may actually exacerbate the symptoms. This is because additional T cells stimulate B-cell production, which will further increase IgE levels. Instead, we should work on reducing inflammation, dilating the airway, reducing smooth muscle spasm and preventing mast cells from releasing histamine.

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Jan 19, 2017 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Overview of Chinese medicine and autoimmune diseases, and the role of Yin deficiency

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