Processes of Disease
2.2a Introduction to processes of disease
Classification of disease
Within conventional medical thought, diseases can be classified according to specific, clearly defined criteria. There are various methods of classification that all share the potential benefit of clarifying those features that disparate diseases may have in common, thus aiding communication about these diseases.
Diseases may be classified according to cause, and this is known as classification by etiology. Understanding the language of etiology is essential for the discussion of prevention of disease. A classification system that focuses on the disease mechanisms (pathogenesis of disease) is a prerequisite for beginning to understand which treatments may be most effective for different diseases and also for predicting outcome (prognosis).
All systems of medicine, be they holistic or conventional, have their own systems of classification of etiology and pathogenesis.
Etiology of disease
Etiology, literally meaning the study of causes, is the term used to describe the causation of disease. From a conventional medical viewpoint, the cause of disease can be simplified into a few distinct categories, including:
•congenital defects (acquired between the time of conception and birth)
•physical trauma (including extremes of temperature and radiation)
•effects of drugs, chemicals and toxins
•degeneration (resulting from overuse and aging)
•iatrogenic condition (caused by medical treatment) – this category will, of course, overlap with any one of the others
•unknown cause – the terms idiopathic and essential may be ascribed to diseases of unknown cause (e.g. idiopathic thrombocytopenic purpura and essential thrombocythemia).
The seven processes of disease
Pathogenesis (literally, the birth of disease) is the term used to describe the physical basis of how disease develops in terms of the basic biological processes of disease. The diverse forms of the disease process can be grouped into seven broad categories:
•inflammation (redness, swelling, heat, pain or loss of function of tissues)
•tumors (excessive or inappropriate growth of cells)
•abnormal immune mechanisms (either under- or overactive immune responses)
•thrombosis, embolism and infarction (excessive or inappropriate clotting)
•degeneration (wearing out of tissues through aging or trauma)
•metabolic abnormalities (homeostatic biochemical functions of the cells become imbalanced)
•genetic abnormalities (the cells carry defective genetic material that means they function in a less than healthy way).
From the perspective of the study of clinical medicine, classification of the processes of disease is important because it generates principles of causation of disease that can then be applied to all diseases. For example, if the process of inflammation is understood, this will aid in the study of any one of the diseases that involves inflammation, such as arthritis, dermatitis, meningitis and pneumonia. Because the understanding of the first four basic processes of disease is fundamental to the study of the pathology of all diseases, they are explored in some depth in this text, in Sections 2.2b, 2.2c, 2.2d and Chapter 2.3.
The remaining three processes of disease – degeneration, metabolic disease and genetic disease – are now briefly attended to.
Degeneration is the result of aging. In general, aging (senescence) involves cell loss and atrophy of tissues. Rapidly regenerating active tissue may, through the process of senescence, become replaced with tough, fibrous, less active tissue, and organs may cease to function as effectively. Deformities (e.g. of skin, joints or bones) become commonplace. Degenerative diseases are discussed later, according to the physiological system that they affect.
The category of metabolic abnormality embraces all diseases that result from imbalance in the homeostatic function for metabolism (the chemical processes that go on continuously in living cells). These include common diseases such as diabetes, and hypothyroidism. Again, the metabolic disorders are discussed throughout the text according to the physiological system that they affect.
The principles of genetic (congenital) abnormalities have been discussed in Section 1.1b, under the heading “Mutation.”
An understanding of the processes of disease can aid thinking about disease from the perspective of another medical system. If it is possible to consider each process of disease in terms of corresponding pathological descriptions described in another medical system, it is possible to take these correspondences and use them to help describe pathological processes in all manner of diseases. For example, inflammation always involves the generation of redness and heat in tissues. According to Chinese medicine, redness and local heat always corresponds to the Pathogenic Factor of Heat. Therefore, it would be reasonable to conclude that all inflammatory diseases will be described, amongst other things, in terms of Heat in Chinese medicine. In this section, all the processes of disease are also interpreted in terms of Chinese medicine, and this will provide the foundation for the Chinese medicine interpretations of all the individual diseases described later in the text.
In summary, it cannot be overstated how much the understanding of the basic processes of disease can enrich the understanding of conventional pathology. An added benefit is that processes of disease can also inform us about Chinese medical pathology and so help us to understand what sort of Chinese medical disease descriptions (syndromes) might be relevant in the diseases described by Western medicine.
Information box 2.2a-I
Processes of disease: comments from a Chinese medicine perspective
As a general introduction, it is important to explain the rationale for comparing the conventional view of the processes of diseases with a Chinese medicine understanding of pathology. As stated in the text, in the study of clinical medicine classification of the processes of disease is important because it generates principles of causation of disease that can then be applied to all diseases. For example, an understanding of the process of inflammation will aid in the study of any disease that involves inflammation, such as arthritis, dermatitis, meningitis and pneumonia.
An important aspect of this system of classification from our point of view is that, although the understanding of conventional processes would have involved knowledge that would not have been familiar to the ancient Chinese, the manifestations of the processes in signs and symptoms are consistent within each process. It is these that are the bridge between the two systems of medicine.
Inflammation will always have characteristics of heat and swelling, and degeneration will always involve a drying and withering of tissue. As observable phenomena, these would form the basis for making a diagnosis in Chinese medicine. However, the way in which the heat and swelling is generated in each individual case does not share the same consistent internal process as understood in the conventional view, and looking for parallels of process is a trap for the unwary.
When a patient presents with a condition that results from one or more of the seven processes of disease, it can reasonably be expected that the symptoms and signs normally associated with those processes are evident. The meaning and importance of the signs and symptoms can then be assessed within the entirely different understanding of the manifestation of symptoms and signs described in Chinese medicine. What this means is that the symptoms and signs of the conventionally described processes of disease will help point to the Chinese medicine syndromes that might be expected to be discerned in any medical condition, first assuming the underlying process of disease is recognized.
A Chinese energetic interpretation of inflammation
Inflammation is a basic response to tissue damage that results in increased blood flow to the tissues, swelling from increased tissue fluid, pain as a result of the release of irritant cell contents and loss of function of the body part as a result of pain and swelling. Together these factors result in the five characteristics of inflamed tissue described in medicine as redness, swelling, heat and pain (or in Latin, as “rubor, tumor, dolor, calor”), and loss of function.
In Chinese medicine the characteristics of redness and heat would point to Heat, either locally or generally. The excess tissue fluid would often be associated with an underlying Pathogenic Factor such as Damp, especially if there was any oozing of liquids or the swelling was considerable. The swelling in a clearly defined area would itself point to local Stagnation, usually of Qi or Blood, and the character of the pain would indicate which. If inflammation is confined to one peripheral body part, the term Bi Syndrome may be applied in Chinese medicine, as this describes localized manifestations of Pathogenic Factors in the Channels, particularly in the region of the joints.
In conclusion, inflammation in the body might be described as evidence of localized or generalized Heat with Qi or Blood Stagnation, often with underlying Damp.
A Chinese energetic interpretation of tumors
Tumors result from excessive and inappropriate overgrowth of tissue cells. The underlying problem from a conventional medicine perspective is that the genetic control of cell multiplication has become disordered, and the immune system has failed to recognize and control the growth of these disordered cells.
In Chinese medicine, substantial masses that do not move easily are often regarded as manifestations of either Phlegm or Blood Stagnation (or sometimes a combination of both). Blood Stagnation is characterized by hardness and intense boring pain with violaceous color changes. Phlegm is more often associated with numbness, and will usually develop against a backdrop of Heat and Damp, which will manifest in other signs and symptoms. For long-standing masses to develop there has to be a pre-existing state of Stagnation of Qi, as it is only healthy Qi moving freely that prevents the development of Stagnation and Phlegm. Usually this means there has been underlying Deficiency of Qi together with chronic emotional factors causing the Stagnation of Qi. However, some masses can manifest against a background of good Upright Qi, the strength of which ideally should be considered when determining priorities in treatment.
Chinese medicine recognizes that in addition to Qi Stagnation and the ensuing Accumulation and Blood Stagnation that a cancerous lump may also be manifesting the presence of a Heat Toxin that could well be environmental in origin, and so Chinese medical treatments for cancer would include herbs for clearing Toxins.21,22
In conclusion, tumors in the body might be described as evidence of Phlegm and/or Blood Stagnation (with possible additional Heat Toxins) having developed on an underlying background of Stagnation of Qi with likely Qi Deficiency.
A Chinese energetic interpretation of abnormal immune mechanisms
Abnormal immune mechanisms fall into two broad categories: those involving an insufficient response to infection, and those involving inappropriate responses, where there is hypersensitivity to specific stimuli or the misrecognition of the body’s own cells as a threat.
In Chinese medicine, the functions of a healthy immune system are reflected in the concept of healthy Upright Qi. The foundation of healthy Upright Qi lies in Kidney Essence and also Spleen Qi, and both are the basis of healthy Wei Qi.
Some of the patterns of abnormal immune responses, for example, type I allergic hypersensitivity, which manifest features of acute invasion of Pathogenic Factors, are reflected in recognized patterns of disruption of Wei Qi, and suggest deficiencies either in Wei Qi or in the underlying Kidney Essence itself. The allergen is seen in Chinese medicine as a Toxic Pathogenic Factor, to which healthy people are resistant. In the case of allergy, it is usually chronic Spleen Qi that leads to Wei Qi insufficiency and allows for invasion of Pathogenic Wind Cold (causing rhinitis, for instance) or Wind Heat (urticarial itch). Susceptible individuals may also be susceptible because of chronic Phlegm or Heat affecting their system. These Pathogenic Factors may then become manifest following exposure to the environmental trigger.23 Others, for example, in multisystem autoimmune disease, present much more of a pattern of Toxic Pathogenic Factors against a background of long-term chronic deficiency that very often appears to be rooted in Spleen Qi Deficiency with Liver Qi Stagnation and resulting Deficiencies of Liver Blood, Kidney Yin and Yang.24
In conclusion, inappropriate immune responses might be described as evidence of Chronic Deficiency of Qi and, in particular, Spleen Qi leading to Deficiency of Wei Qi in the case of allergy, and a wider pattern of mixed chronic Deficiency and Excess in multisystem autoimmune disease. Deficiency of Kidney Essence may well, of course, be at the root of either condition.
A Chinese energetic interpretation of thrombosis, embolism and infarction
Excessive blood clotting in the peripheral parts of the body is characterized by intense pain, coldness, violaceous coloration and loss of function if severe (e.g. arterial blood flow restriction in the lower leg) or by swelling, less intense pain and local inflammation (venous thrombosis) if less severe. Thrombosis in the brain can lead to stroke and, of the other internal organs including the heart, severe life-threatening illness.
The former symptoms of pain, coldness and purple coloration are all associated with what is described in Chinese medicine as Stasis of the flow of Blood, and there are numerous factors, including the Deficient states of Qi, Blood and Yang Deficiency, and also the more Full conditions of Qi Stagnation and Cold that can predispose to Blood Stasis. In most cases of Stasis unrelated to trauma, the patient will be depleted in some way. Causative patterns include Depleted Blood, Qi and Yang Deficiency, which all predispose to invasion of factors that can impair the flow of Blood and Qi, such as Toxic Cold, Heat and Phlegm. Dietary and lifestyle factors as well as emotional imbalance will all contribute to Blood Stasis. Blood Stasis can then also in itself engender Heat, Phlegm, and also Wind.
Peripheral venous thrombosis results from a significant region of blood clot in a deep vein, often resulting from sustained inactivity. The substantial accumulation of solid mass is suggestive of the concept of Phlegm resulting from Blood Stasis in Chinese medicine, and indeed, the symptom of swelling with less intense pain in venous thrombosis is consistent with this. The inflammation seen with venous thrombosis is also suggestive of Heat. Peripheral venous thrombosis can dramatically extend and progress to pulmonary embolus, which, if mild, leads to severe localized chest pain and, if severe, collapse and death. These suggest Blood Stagnation and Phlegm misting the Orifices of the Heart respectively. Again, the severe Phlegm-related Syndrome seems to be a progression from Blood Stasis in pulmonary embolus.
In angina there is restriction of blood flow to the heart. This manifests as severe stabbing pain in the chest and in Chinese medicine this is understood as Blood Stasis resulting from various factors including severe Deficiency of Blood and Qi (such as occurs in old age) and with invasion of Cold or Phlegm Heat blocking the Channels leading to Blood Stasis and pain. If severe, there can be coronary thrombosis, a result of total blockage of coronary arteries. There are life-threatening arrhythmias that might relate in Chinese medicine to extreme Heart Qi/Yang Depletion due to the Heart lacking in nourishment from Blood and Qi. These may cause loss of consciousness, again, a manifestation of Phlegm misting the Orifices of the Heart.25
A stroke also suggests Phlegm misting the Orifices of the Heart.
In conclusion, thrombosis, embolism and infarction might be described as evidence of Blood Stasis and Qi Stagnation and resulting from prior Deficiency, and with subsequent invasion of Pathogenic Factors that contribute to formation of Phlegm. In severe cases, Yin and Yang may be consumed, and this will manifest in severe life-threatening illness.
A Chinese energetic interpretation of degeneration
In conventional medicine, degeneration of tissues involves excessive cell death, poor healing responses and the formation of less vital tissues, with excessive fibrous tissue and deposits of substances such as calcium salts that impede healthy function. The resulting tissues tend to be less springy and soft and resilient, and may also manifest with deformities (lumps and bumps).
In Chinese medicine language, all these changes, if seen across large areas of the body, would be primarily described in terms of broad deficiencies of Yin and Yang, as these substances are expressed in the vitality and healthy function of the tissues respectively. More particularly, they are linked with a deficiency rooted in the Kidneys, and are characteristic of the aging process as Kidney Essence becomes depleted. The deposits and deformities are evidence of a widespread impairment in flow of Qi, leading to an accumulation of Pathogenic Factors such as Phlegm and Damp and Blood Stagnation. If these are localized, there may be evidence of local Qi or Blood Stagnation impairing the flow of Qi to part of the body, in which case there may be pain and purplish discoloration.
In conclusion, degeneration of a body part might be described as evidence of Deficiency or Yin and/or Yang, in particular, of Kidney Qi/Essence, leading to a tendency to Qi and Blood Stagnation and an accumulation of Phlegm/Damp and other Pathogenic Factors.
A Chinese energetic interpretation of metabolic abnormalities
The metabolic diseases are complex and have diverse symptoms depending on the fundamental abnormality. Most metabolic diseases will be manifest in the function of all the body tissues and so reflect a fundamental and profound state of imbalance.
Chinese interpretations of metabolic disease will be equally complex, and are likely to describe deep deficiency. Often these conditions will fit in to the category of “Knotty Disease”26 in Chinese medicine. This is because a profound and prolonged deficiency will often result in full Pathogenic Factors, which create complex patterns of signs and symptoms. As in conventional medicine, the effects are likely to be widespread in the energetic system rather than confined just to Channels.
A Chinese energetic interpretation of genetic abnormalities
A genetic abnormality may affect every cell in the body (if present from the time of conception), or may be the result of a developmental problem in the womb and thus affect some body parts and not others. From a conventional medicine perspective, there is no doubt that a congenital abnormality will compromise the health of the child and, unless carefully managed, is likely to affect the growth and development of the affected child.
The ancient Chinese interpreted congenital disease (i.e. a condition present from the time of birth) as a Deficiency of Kidney Essence (Jing). Zhang Jing Yue (c.1563–1640; original name, Zhang Jie Bin) described the Ming Men (which he associated with both kidneys) as the source of Essence and the foundation of full health: “Ming Men is the mansion of both water and fire, the house of Yin and Yang, the sea of Essence and Blood, the nest of Life and Death. If the Ming Men is depleted and damaged, the five Zang and six Fu lose their sustenance, and the Yin and Yang will become sick, causing all types of disorders.”27
To the Chinese, Kidney Essence was passed to the fetus from the parents at the time of conception. It was what determined a person’s constitutional strength and vitality, and is fundamental to healthy growth and development.28,29 Kidney Essence underlies the health of all the organs, and so more specific imbalances will often be present as the visible sequelae of the congenital disorder (e.g. of Spleen and Lung Qi in cystic fibrosis).
In conclusion, a congenital problem might be described as evidence of primarily Jing Deficiency, but may be described as a specific Organ Deficiency, depending on where the underlying genetic defect manifests.
The physiology of acute inflammation
Inflammation is the term used to describe a complex bodily response to damage. It is derived from the Latin, meaning to set on fire, reflecting the fact that two manifestations of inflammation are heat and redness. Two other important features are swelling and pain. These characteristics of inflammation have been familiar to doctors over many centuries. They were noted by the 1st-century Roman medical encyclopedist Celsus as calor (heat), tumor (swelling), rubor (redness) and dolor (pain).30
Inflammation has one other major characteristic in that it leads to loss of function of the affected body part. Swelling and pain largely contribute to this loss of function. In mild disease, loss of function can be beneficial, as it encourages the patient to rest the inflamed area, and this should promote healing. For example, inflammation of the voice box (laryngitis) may give rise to discomfort and malaise. This means that the patient avoids talking, and may wish to rest in bed. Both these responses will promote healing.
In severe disease, the loss of function can jeopardize the health of the whole body, and is not beneficial. For example, inflammation of the lining of the brain resulting from bacterial infection (meningitis) leads to swelling of the brain and carries the risk of coma and death.
The five characteristics of inflammation are listed in Table 2.2b-I.
Pain or tenderness
Loss of function
When a body part is inflamed, it is often medically described by the suffix “-itis.” This may be added on to the common name for the affected organ or, more usually, to the Latin term for the organ. Hence in tonsillitis, dermatitis, laryngitis, osteomyelitis and tendonitis we would expect to find inflammation of the tonsils, skin, larynx, bone marrow and tendons, respectively.
The trigger for inflammation is tissue damage. When tissues are damaged, cells are ruptured and release their contents. The presence of cell contents in the extracellular space has a powerful effect on the immune system and the capillary cells. The released chemical contents of cells signal to the immune system and capillary cells that there is cell debris that needs removing, that repairs may need to be performed, and that there might be foreign bodies and infectious organisms to be eradicated. Their presence induces responses in immune and epithelial cells that bring about the inflammatory response, and thus begins the process of healing. The chemicals released include the inflammatory mediators including prostaglandins, histamine, serotonin (5HT) and bradykinin.
The purpose of inflammation in health is protective. It enables isolation and inactivation of foreign material and damaged tissue, and leads to its removal from the body.
Some of the key players in the inflammatory response to tissue damage (described below) are illustrated in Figure 2.2b-I.
A cardinal response in inflammation is that blood flow to the damaged area increases, a result of widening of the small blood vessels (vasodilatation). This response is termed hyperemia (literally meaning more blood). Hyperemia leads to the increased warmth and redness that are characteristic of inflammation. Hyperemia also contributes to tissue swelling.
Another response of the blood vessels to inflammatory chemicals is that gaps form between the epithelial cells of the vessels so that molecules and fluids move out of capillaries into the fluid surrounding the tissue cells. In this way important proteins such as antibodies and fibrinogen enter the site of the damage. This reaction, known as exudation, leads to the swelling that is characteristic of inflammation. Fibrinogen, one of the 12 clotting factors in the blood, is converted to fibrin once it enters tissue fluid, and in this way it forms a meshwork that contains the inflamed area and thus prevents the spread of any infection that may be present. Antibodies bind to foreign antigens at the site of the inflammation and so form immune complexes that are then engulfed by phagocytic cells such as neutrophils.
Figure 2.2b-I The inflammatory response
Migration of leukocytes
Various forms of leukocytes, which are the basis of the immune system, are attracted from the blood and the tissue fluid to the site of the damage by the chemicals (chemotaxins) that have been released as a consequence of the damage. Neutrophils are amoeba-like white cells that appear rapidly at the site of inflammation. These have the capacity to engulf and digest any material that presents foreign antigens in the form of an immune complex. In this process, the phagocytic cells may die, releasing their greenish cell contents. It is these discharged cell contents that contribute to the green color of pus, which is usually only formed as a consequence of a heavily infected wound. Macrophages are slower moving, larger phagocytic cells, which, after a few hours, also enter the site of inflammation to engulf and digest cell debris, microbes and dead neutrophils.
Increased body temperature
If the bodily response of inflammation is sufficiently large, interleukin-1, a chemical released by macrophages, can lead to an increase in the core temperature of the body. The fever that results leads to more efficient activity of phagocytes and also encourages the patient to rest. Fever is thus understood to be beneficial to the healing process in inflammation.
The chemicals released by damaged and inflammatory cells tend to irritate the local nerve endings, so leading to the acute pain and intense tenderness associated with inflammation.
Resolution of acute inflammation
In uncomplicated situations, the inflammatory process leads to removal of damaged cells, dirt and infectious organisms, and provides a clean environment for the process of wound healing. The redness, swelling, pain and heat resolve, the function of the area is restored and healing is complete, with or without scar formation.
The resolution of inflammation may be hindered by a poor blood supply, the presence of a foreign body or as a response to certain organisms. In the case of chronic inflammation, after a time increasing numbers of lymphocytes get attracted to the area and the scar tissue-forming cells, the fibroblasts, are continually activated, meaning excess scar tissue may be formed. The chronic skin ulcer described in Section 2.1b is an example of chronic inflammation.
Tuberculosis is an example of an infection in which the slow-growing infectious organism Mycobacterium tuberculosis encourages a chronic inflammatory response and the formation of clusters of immune cells around foci of infection known as granulomas. These tiny clusters of immune cells are characteristic of this disease, and are evidence to the pathologist of its ability to induce damaging chronic inflammation.
Information box 2.2b-I
Inflammation: comments from a Chinese medicine perspective
Redness and warmth signify the presence of Heat in Chinese medicine. The characteristics of pain, with aversion to pressure, and a purplish discoloration suggest a degree of Blood Stagnation. In Chinese medicine, Blood Stagnation can lead to Heat, and Heat can be a cause of Blood Stagnation. Therefore, these Pathogenic Factors are inextricably interrelated in inflammation.
Excess tissue fluid and the swelling and oozing that result could be equated with the Pathogenic Factor of Damp. This may be localized or systemic, in which case there may well be underlying patterns of Spleen Deficiency.
The pathology of inflammation
Boils and abscesses
Boils and abscesses result from excess pus collecting within the tissues at a site of inflammation. Abscesses are simply big boils; there is no clear-cut difference between the two. Pus is more likely to collect if a foreign body is present at the site of inflammation and also if certain pyogenic organisms are present. The most common pyogenic organism to cause medical problems is Staphylococcus aureus, one of the many normal and healthy (commensal) skin bacteria.
A collection of pus is a problem because it is a reservoir of microbes that are not in close contact with a blood supply. Because of this it inhibits full resolution of the inflammation. It is also a source of chemicals that act as pyrogens (i.e. lead to fever and malaise).
A boil or abscess ideally heals by means of discharge of pus to the surface. For example, a stye (a boil on the edge of the eyelid) will ideally come to a point after a few days, which then breaks open to release the pus and allow healing.
This ideal outcome is not always achieved. In some cases the pus does not discharge fully, and the channel leading from the pus to the skin does not heal fully, remaining as a sinus that discharges pus in the long term. This can lead to long-term ill health, as the body is always in a state of dealing with infection. An infection in the bone (osteomyelitis) can easily lead to sinus formation, because the bone is relatively protected from the immune system, and thus chronic inflammation can readily develop in bone. This is a particular problem with shrapnel wounds in combat-related injuries, in which case there may be a continual discharge of pus from the bone through a sinus to the skin.
When a sinus is formed, the discharge of pus can go two ways: the first is into closely apposed organs (e.g. stomach and bowel, or bladder and bowel) so that a permanent channel known as a fistula is formed between them. This can have severe consequences. One common cause of a fistula is Crohn’s disease, a form of inflammatory bowel disease. Diverticulitis of the bowel is another cause of fistula.
If the pus is not discharged at all, it is eventually phagocytosed. This is a common occurrence with small boils (pustules) such as occur in severe acne. Instead of discharging fully, these form tender lumps that gradually become less painful. This form of healing is more likely to lead to scarring resulting from chronic inflammation, as fibrous tissue is formed to fill the cavity formed by the pus, and this can have severe cosmetic consequences.
The most appropriate medical treatment of boils and abscesses promotes natural resolution. Astringent medication in the form of hot packs (poultices) can be applied to the site of a superficial abscess to encourage the pus to discharge outwards.
Resolution can be assisted surgically by lancing, where a clean wound is made in the skin to allow natural drainage of the pus. A larger abscess may be drained by inserting a sterile tube to connect with the outside for a few days. When the pus has drained, the tube is removed and, ideally, the cavity will then heal by the process of primary wound healing.
Antibiotics are often given to prevent spread of infection whilst the abscess is healing, although in some cases this treatment may be inappropriate. With adequate drainage, most abscesses will resolve without the need for antibiotics. Paradoxically, antibiotics can prevent full drainage of an abscess, as they may inhibit the process of pointing of the abscess to the surface, thus leading to a more chronic situation.
Fibrosis (scar tissue formation)
Chronic inflammation may be characterized by excessive scar tissue formation (fibrosis). This can be damaging, as scar tissue can cause shrinkage of tissues and damage to the integrity of organs. Cirrhosis is an example of the result of chronic inflammation of the liver. In cirrhosis, scar tissue takes over the space of the healthy liver cells and may result eventually in liver failure. Scar tissue in the abdominal or pelvic cavity can cause adhesions between organs, and may promote obstruction of organs and infertility.
The main treatment for fibrosis is surgical removal of scar tissue, in as much as this is possible. Physiotherapy and massage may be used to encourage the stretching of contracted areas of skin and muscle.
Information box 2.2b-II
Boils and abscesses: comments from a Chinese medicine perspective
In Chinese medicine, boils and abscesses are manifestations of Damp and Heat with Blood Stagnation and Heat Toxin in severe cases. Full resolution represents clearance of these Pathogens; therefore, poultices, lancing and drainage are energetically appropriate treatments that can facilitate full cure.
Antibiotics may actually suppress full cure in the conventional sense of the term, as the causative microorganisms may remain relatively protected from the drug deep within the walled-off center of the abscess. From a Chinese medical perspective antibiotics are Cold and Toxic in nature, and so may actually exacerbate the root cause of the problem that is likely to include Spleen Qi Deficiency (leading to poor health of the tissues). Nevertheless, there are situations in which antibiotic treatment is necessary to prevent the dangerous spread of infection from an abscess (e.g. in a brain abscess).
A discharging sinus or fistula suggests Chronic Damp Heat, usually on a background of marked deficiency such as Qi or Yin Deficiency.31
An abscess that does not discharge, but instead resolves to form a hard painless or painful lump under the surface of the skin, might be described in Chinese medicine in terms of Accumulation of Phlegm, which may be the consequence of the action of Heat on Damp, with underlying stasis of Blood and Qi.