5. CONCEPTS of ECOLOGY, SYNDROMES and CAUSES of DISEASE in TCM
TCM teaches that Nature (all of creation, macrocosm and microcosm) is a unity which reflects the interplay of Qi, Yin-Yang, the Five Phases, the material and the immaterial. As we are wed to Nature, we feel Her claws or Her caress. And if we ravish Nature, or sow black seed at the time of white seed-sowing, or work against Her changeless Laws, we plant a bastard harvest, which we will reap. And we will weep alone, groan long in the hell of a Man-made night.
Health is a relative state. Optimal adaptation to prevailing circumstances (and the ability to adapt to new ones, if needed) are important factors in health. Healthy people adapted to living high up in the Andes mountains may have Packed Cell Volumes which would indicate serious dehydration or disease in people living in, say, Belgium. Adaptation to internal changes are also important. What may be healthy sport for a strong young man may kill a weak old man.
Many factors regarded by TCM to be involved in health are discussed below but TCM was also aware of acute causes of illhealth: trauma/wounds; undernutrition, genetic influences. (Modern Chinese medicine also recognises many other causes, as in western concepts: stress, toxicities, infection, parasitism, nutrient imbalances and deficiencies, metabolic and hormonal imbalances, senility etc).
Health depends on self-control: Chinese/Japanese parents dote on children, but their children are programmed very early in life to develop a high degree of self-discipline. This helps them to develop self-control of body and mind, which is perfected further in adulthood, to a degree which puts many westerners to shame. Mastery of the self was also part of the training and lifestyle of the oriental monks, who were said to be very healthy and resilient. The secret of good health is to strive for physical and mental control and to live in balance with Nature and with the Laws of Nature.
As part of Nature, the human or animal organism is influenced by Natural Laws, forces and energies. We dance or writhe to Nature's rhythmic tune. Conversely, the activities of the organism influences Nature for good or ill. Today's specific problems of environmental pollution (production and preservation of food to be eaten out of season by the use of chemical preservatives; dumping of toxic metals and chemicals, nuclear waste; the ozone hole/greenhouse effect etc) may not have been foreseen by the ancients but the global philosophy of Yin-Yang would have predicted them- we are creators and destroyers, a mixture of good and evil. A more recent law of physics can be adapted and extended to apply to biological systems: "To every action, in due time, there is an equal and opposite reaction". We decorate, or foul, our den, which, in time, empowers, or overpowers, us.
Avoidance of attack is the first law of self-defence. This implies that self-training to heighten one's awareness, perception and intuition have a prime defensive role. Strength (Qi) and skill (physical and mental) to deflect or minimise an unavoidable attack is the second law of self-defence. Rapid adaptation to prevailing circumstances is the key to survival.
Adaptation implies the ability to respond optimally to challenge. Clean air, exercise of mind, good food and a fit mind-body helps to develop Qi and to direct it when and where it is needed.
a. Qi IN RELATION TO DISEASE
Qi (the vital force and defence energy of the body and mind) comes from different sources: Ancestral Qi (genetic energy), Qi from Heaven (the energy of life) and from earth (vital energy from air, food). Healthy lung and gastrointestinal function are vital to balanced Qi. Deep breathing exercises (imagining the air being drawn down as far as the pelvis) and visualisation of Qi streaming through the Channel system (in the correct direction of Qi flow, and in time with deep, slow breathing) are part of TAI Qi and Qi KUNG exercise systems which are used to counter stress and attain physical/mental wellbeing.
Health and disease are determined by the amount and balance of Qi in the organism. The healthy body/mind has a perfect balance of Qi which can circulate freely in the body through the Channel network, the collateral Channels, the deep Channels and the organs. Adepts can direct Qi (by conscious or subconscious control) to circulate to those parts which may need extra Wei (Defensive) Qi. In the body, upset Qi (Excess of Yin or Yang, Deficiency of Yin or Yang etc) is the cause and result of disease.
If the Wei (Defensive) Qi is weak, disease can invade from outside (see 4b below). Body Qi can also take many forms: Qi of Kidneys, Qi of life (semen) etc. Blockage of Qi flow, whether caused by trauma, scar tissue or other causes) is followed by functional or organic disease of the affected COS.
b. INTERACTION BETWEEN ENVIRONMENT AND THE ORGANISM
"Man (the organism) stands between Heaven and Earth". This ancient teaching infers the external environment (extra-terrestrial and terrestrial energy) can influence us and that we can influence the heavens and earth. Natural environmental forces (Qi) include magnetism, gravity, electromagnetic fields, solar, lunar and planetary influences etc. Others include geophysical/geopathological fields, as known to the practitioners of Feng Shui (Chinese diviners, who would shun the valley where no bird sings). We must cope with seasonal changes, which can predispose to their own Syndromes, or types of disease. To dress and work outdoors in the depths of winter as if it were the middle of summer (or vice-versa) can seriously imbalance Qi and cause disease. The wise one wears thick skins in snow, fine silk in sun.
In Yin-time live a Yin-type life; in Yang-time, Yang.
THE SIX EVILS
TCM recognises six climatic causes of disease: Heat, Summer-Heat; Damp, Dryness, Cold and Wind.
Each one of the Six Evils (type of perverse energy which attacks the body from the Exterior) has a preference for a specific COS in the Five Phase Cycle:
Perverse Energy Heat, Summer-Heat Damp Dryness Cold Wind
Phase attacked Fire Earth Metal Water Wood
Yin SYSTEM attacked HT, PC SP LU KI LV
Yang SYSTEM attacked SI, TH ST LI BL GB
These "devils" gain access to the body via the skin-holes (the AP points). Pathogenic Qi can reach the Interior of the body via the superficial and deep course of the Channels in two ways:
a. if, relative to the force of the attack, the Wei Qi is weak (unable to deflect the acute attack), or
b. if the condition is not treated successfully (by increasing Wei Qi using TCM/TAP at that stage).
Once the inner organs are invaded, the condition is serious and may become chronic, life-threatening and difficult to treat.
Apart from the preferred organ, other organs and functions can be attacked, using routes in the Five Phase Cycle (Sheng and Ko and reverse-Ko routes). For example, Summer-Heat can attack HT-PC (heatstroke, circulatory collapse, heart attack), the mind (febrile hallucination, heatstroke) and also the SI (summer gastroenteritis). Wind can attack LV, the eyes, GB, the muscles and the mind (anger, jealousy) etc and can also counter-attack LU (via a reverse Ko route: Wood (LV) is controlled by Metal (LU)).
Treatment at that stage aims to increase the adaptive reactions of the primary organ attacked and the general resistance of the body in an attempt to expel the invader. (Treatment can include induction of vomition, purgation, diuresis, sweating etc if the invader can be expelled by these routes).
c. THE ROLE OF THE EMOTIONS IN DISEASE
Each of the Five Phases is associated with specific emotions. Balance of the emotions is important, as imbalance in any one of them can imbalance the Qi, to weaken the corresponding COS:
Phase |
Emotion |
Sound expressed |
HT Fire |
Pleasure/Joy/Excitement |
Laughter |
SP Earth |
Anxiety/Obsession/Meditation |
Singing/Whistling |
LU Metal |
Grief/Sorrow/Melancholia |
Weeping |
KI Water |
Fear/Fright |
Sighing/Moaning |
LV Wood |
Wrath/anger |
Shouting/Screaming |
For example, too much excitement/pleasure/joy can weaken the HT COS (angina, heart attack etc) and one of the signs of HT disorder is too much laughter/excitability. Too much anxiety (obsession) can weaken the SP COS and one of the signs of SP disorder is a tendency to obsession and sing (to oneself) a lot. Similarly for the other organs (LU, KI, LV).
Psychosomatic disease: The Chinese were among the first people to note an association between the emotions/psyche and disease. They were aware of the importance of psychosomatic disease before the time of Christ. Similarly, in imbalance of a Channel, the appropriate emotions can be fostered and used in the Ko Cycle to redress the imbalance. For instance, in grief (Deficient Metal), stimulation of laughter/joy, pleasure can reduce grief and strengthen LU via the Ko Cycle (Fire controls Metal). Fear (Deficient KI) can be helped by stimulating meditation, singing, or whistling (Earth controls Water).
DISEASE CLASSIFICATION BY THE EIGHT PRINCIPLES (the EIGHT TYPES)
The Eight Principles classify disease by 4 categories:
a. Yin or Yang
b. Hot or Cold
c. Shi (Excess) or Xu (Deficiency)
d. External or Internal.
a. Yin and Yang Syndromes
Balance of Yin and Yang Qi is the normal state. Disease is classified according to its disturbance of Yin and Yang Qi. However, Yin organs may have Yin or Yang diseases (and Yang organs likewise). If Yin or Yang (or both) deviate from the normal level, a state of relative Excess (Shi) or Deficiency (Xu) exists.
Yin type |
Yang type* |
|
| Activity | Hypo-withdrawn ,inhibited, quiet | Hyper-, excited, fidgety |
| Body and limbs | Cold, seeks warmth | Hot, avoids warmth |
| Pulse | Deep and slow | Shallow and fast, bounding |
| Tongue | Pale, moist | Red, dry, coated |
| Respiration | Feeble | Rapid and strong |
| Thirst | No | Yes |
| Urine | Clear, copious | Scanty, coloured |
| Complexion, skin | Pale | Red |
| Attack site** | Interior, deep (internal organs) | Exterior, superficial (Channels and their collateral branches) |
| Onset | Cause chronic | Cause acute |
| Progression | Inwards and downwards | Outwards and upwards |
* Moxa (heat cautery) is usually contraindicated in Yang and Hot Syndromes.
** Internal or External attack sites can not always be classified as Yin or
Yang respectively. Yin organs can be attacked by Yang diseases and vice
versa.
Collapse of Yang and the Collapse of Yin are other Yin-Yang Syndromes:
Collapse of Yang: Profuse cold sweat; respiration feeble; pallor; prefers hot drinks; skin cool; limbs cold; dislikes cold; listless; pulse of Xu type (thready and fading); tongue pale and moist.
Collapse of Yin: Sticky sweat; respiration rapid and short; face red; thirst and prefers cold drinks; skin hot; limbs warm; dislikes heat; restless; pulse of Xu type (thready and rapid); tongue red with little saliva.
To complicate matters, the law of Yin-Yang implies that change can occur; one Syndrome can change to another: "Cold with fullness moves downwards and transforms into Heat; Heat, with fullness, moves upwards and transforms into Cold" (Turner and Low, 1981). Also, some of the features of Cold and Hot Syndromes can give misleading impressions of Yin-Yang balance- they may be False Yin or False Yang conditions. Collapse of Yang resembles a false Yin Syndrome and Collapse of Yin resembles a false Yang Syndrome.
NORMAL BALANCE OF Yin AND Yang Qi
Yang Yin
Resistance normal ..........+++++-----............
| || |
| || |
__________|___||___|____________
b. Hot and Cold Syndromes
Hot Syndromes are caused by pathogenic Heat, Summer Heat and Dryness (3 of the Six Evils). Cold Syndromes are caused by pathogenic Cold. Also, Excess (Shi) of Yin or Yang can cause Cold and Hot Syndromes of the Shi type respectively.
Cold Syndrome of the Shi (Excess Yin) type: Chills; limbs cold; no thirst; pallor; excess sputum; asthmatic breathing; indigestion; vomiting; abdominal pain, worse on pressure; stools loose; urine clear and copious; pulse deep and slow; tongue pale with white sticky coating; craves warmth.
Cold Syndrome of the Shi (Excess Yin) type
(Excess Yin consumes or weakens Yang)
Yang Yin
-----
Resistance normal ...............| |............
+++++| |
| || |
__________|___||___|____________
Hot Syndrome of the Shi (Excess Yang) type: Continuous high fever; thirst; face flushed, eyes red; abdomen full and distended, worse on pressure; consciousness; delirium; constipation; urine concentrated; pulse rapid; tongue red to deep red, with dry yellow coating; craves cold.
Hot Syndrome of the Shi (Excess Yang) type
(Excess Yang consumes or weakens Yin)
Yang Yin
+++++
Resistance normal ..........| |.................
| |-----
| || |
__________|___||___|____________
c. Shi (Excessive) and Xu (Deficient) Syndromes
In TAP, the needling technique depends on whether the Syndrome is Shi or Xu type. In Shi type (Excess) the needling method is Xie (reducing type), to dispel the Excess Qi. In Xu type (Deficiency) the needling method is Bu (reinforcing type), to stimulate the Deficient Qi. The TCM rule of needling is Shi needs Xie but Xu needs Bu:
Shi Syndrome needs Xie needling;
Xu Syndrome needs Bu needling.
Palpation pressure on the affected areas helps to distinguish the Shi and Xu Syndromes. In Shi (Excess), with Yang fullness, pressure aggravates discomfort. In Xu (Deficiency), with Yang emptiness, pressure alleviates discomfort.
In Shi Syndromes, body resistance is normal but the body is attacked by an exogenous pathogenic factor. The prognosis is not serious if the attacking factor can be expelled, thereby preventing the disease from reaching the internal organs.
Shi (Excess) Syndromes: Disease recent; elation; robust constitution; restless; spastic; voice sonorous; breathing coarse; chest and abdomen full and distended; abdominal pain, worse on pressure or palpation; constipation; tenesmus; urination painful or difficult; urine scanty and concentrated; pulse of Shi type (coarse, rapid, full); tongue red and coated; skin warm.
Syndromes of Shi (Excess) type are usually (but not always) of the Hot type:
Hot Syndrome of the Shi (Deficient Yin) type
(Deficient Yin allows Yang to predominate)
Yang Yin
Resistance lowered .........+++++.................
| |
| |-----
__________|___||___|____________
Xu (Deficiency) Syndromes: Disease chronic; listless, depressed; weak; asthenic appearance; apathy; pallor; lies curled-up; voice weak; breathing feeble; palpitation; shortage of breath; tinnitus; vision blurred; insomnia; memory poor; sweating; night sweats; abdominal pain, relieved by pressure or palpation; loose stool; nocturnal spermatorrhoea; enuresis; copious clear urine; pulse of Xu type (fine, weak, irregular); tongue pale, with thin coating; skin cold.
In Xu Syndromes, body resistance is lowered and the disease can reach the internal organs more easily. The prognosis is more serious. Deficiency (Xu) of Yin or Yang can cause Hot or Cold Syndromes of the Xu type respectively. In both cases, resistance is low.
Xu (Deficiency) Syndromes are usually (but not always) of the Cold type:
Cold Syndrome of the Xu (Deficient Yang) type
(Deficient Yang allows Yin to predominate)
Yang Yin
Resistance lowered ...............-----............
| |
+++++| |
__________|___||___|____________
An example of the Yin Xu Syndrome (Cold Syndrome of the Xu type): Chills; limbs cold; pallor; no thirst; listless; apathy; weak; sweating; stool loose; urine copious and clear; pulse slow and deep; tongue pale with white coating.
But, as in most aspects of Chinese thought, the paradox exists also, the Yang Xu Syndrome (Hot Syndrome of the Xu type): Afternoon fever; malar flush; mouth and throat dry; insomnia; restlessness; feverish feeling in palms and soles; night sweats; constipation; urine concentrated; pulse rapid and thready; tongue red with little coating.
d. External and Internal Syndromes
External Syndromes result from invasion of the superficial areas of the body by exogenous factors. Onset is sudden and duration is short. Exterior Syndromes are usually mild. They are the early signs of exogenous disease but may develop to Internal Syndromes.
Internal Syndromes result from penetration of exogenous factors to the Interior of the body, as in an External type which was unsuccessfully controlled, or by direct attack of the organs by exogenous factors. Internal Syndromes are usually severe and involve functional or organic damage of the organs. Dysfunction of the organs is also an Internal Syndrome.
Both External and Internal Syndromes can be complicated by Cold, Heat, Xu (Deficient) and Shi (Excess) Syndromes.
External Syndromes:
Cold: Fever; no sweating; chills; pulse superficial and strong; tongue coating thin and white
Hot: Fever; intolerance of wind; may sweat; mild thirst; pulse superficial and rapid; tongue coating thin and yellow.
Xu: Sweating; intolerance of wind; pulse superficial and slow
Shi: No sweating; general aches; pulse superficial and strong; tongue coating white
Internal Syndromes:
Cold: Chills; cold limbs; pallor; no thirst; stool loose; urine clear and profuse; pulse deep and slow; tongue pale
Hot: High fever; thirst; irritable and restless; face flushed; eyes red; constipation; yellow scanty urine; pulse rapid; tongue red with yellow coating.
Xu: Breathing feeble; apathy; lassitude; palpitation; dizziness; pulse deep; tongue flabby and pale, with white coating
Shi: Breathing coarse; voice strong; irritability; fullness of chest; distended abdomen; constipation; pulse deep; tongue rough, with thick coating
Thus, TCM has a set of 8 criteria (the Eight Principles) to define disease Syndromes (the type (nature) of disease), based on the clinical signs. By combining one type from each of the 4 categories (Yin or Yang; Hot or Cold; Shi or Xu; External or Internal), 8 possibilities arise (1 X 2 X 2 X 2 = 8). Syndrome classification by the Eight Principles is discussed further in Lee and Cheung (1978); The Essentials of Chinese AP (1980); Turner and Low (1981); Porkert (1983).
As well as classification by the Eight Principles, Syndromes are classified according to the main organs involved and the energy imbalance in them. Each of the following strangely-named Syndromes has defined clinical and functional upsets:
LU Syndromes: LU Yin Deficiency; Wind attack on LU; LU Damp-Phlegm Retention; LU Heat-Phlegm Retention
LI Syndromes: Damp-Heat invasion of LI; LI Obstruction; Blood and Heat Obstruction of LI
ST Syndromes: Retention of food; Retention of fluid; ST Fire Excess
SP Syndromes: SP Qi Deficiency; Cold-Damp invasion of SP
HT Syndromes: HT Qi Deficiency; HT Yin Deficiency; Obstruction of HT Blood; Excess HT Fire; disturbed Shen (mental derangement)
SI Syndromes: SI Heat
BL Syndromes: Damp-Heat invasion of BL; BL dysfunction
KI Syndromes: KI Qi Deficiency; KI Yin Deficiency; KI Yang Deficiency
PC Syndromes: Heat invasion of PC
GB Syndromes: Damp-Heat invasion of GB
LV Syndromes: LV Qi Deficiency; LV Fire Excess; Cold Obstruction of LV; LV Blood Deficiency; LV Wind stirred by Heat
There are many other types of Channel Syndromes (see Porkert 1983).
Disease is classified also according to the main Channel involved (LU, LI, ST, SP, HT, SI, BL, KI, PC, TH, GB, LV). It may be classified also by disturbance in the Eight Mai (Vessels or Extra Channels): GV; CV; Chong; Dai; Yang Chiao; Yin Chiao; Yang Wei; Yin Wei). Each of these Channels and Vessels has its own symptomatology.
6. DIAGNOSIS IN TCM
TCM Diagnosis was based on four principles: looking, listening, feeling and smelling, i.e. on input signals from 4 of the 5 senses (sight, hearing, touch and smell).
LOOKING: The patient is inspected carefully for any abnormalities of gait, posture, swellings (oedema, inflammation etc), atrophy, muscle spasm, paralysis etc. Great attention is paid to the skin and face (colour, texture, sweat), ears (abnormal blotches, scales, flakes, papules), tongue (colour, saliva, coating) and iris. Colour and consistency of stools, urine and other secretions/excretions are noted.
LISTENING: The case history is taken. The emotions, symptoms and sounds (strength of voice, respiration, abnormal gut and joint sounds etc) are noted.
FEELING: The patient is palpated carefully to check skin temperature (hot or cold); variation in skin temperature, for instance one limb colder than the other; location of abnormal swellings, muscle tension, flaccidity; location of Ahshi (tender) points. Great attention is paid to palpation of the Mu and Shu points, the Xi, Yuan and Luo points. Tenderness at these points can indicate the COS involved.
Channel diagnosis by point sensitivity: In severe disorders of a Channel, many points along the Channel may show abnormal tenderness to pressure palpation, electric current or heat. This is especially true for the Ting (most distal) points at the nail of a toe or finger). Ting (Well, near the nail) point sensitivity is the basis of the diagnostic methods of Akabane (Japanese diagnosis by measuring heat sensitivity) and Voll (German electrodiagnosis). The Shu and Mu points may also be tender. Other important points (which may be tender in Channel disorders) lie below the knee or elbow: the Five Phase Points, the Luo, Yuan and Xi points.
Pulse Diagnosis is the ultimate in TCM diagnostic palpation. According to TCM, the pulse in the distal, middle and proximal positions on the left radial artery reflects the energy status of the SI, GB and BL Channels on superficial palpation and the HT, LV, KI Channels on deep palpation respectively. The pulse in the distal, middle and proximal positions on the right radial artery reflects the energy status of the LI, ST, TH Channels on superficial palpation and the LU, SP, PC Channels on deep palpation respectively. Porkert (1983) describes 31 different pulse types.
Some TCM practitioners claim to be able to make an accurate energetic diagnosis in human patients (which Channels are involved and whether they are hyper- or hypo-active) on the basis of Pulse Diagnosis alone ! However, many translations of Chinese medical AP texts ignore or pay little attention to the classical pulse types.
Classical Pulse Diagnosis is a controversial issue, even in China and Japan. Recent studies (doppler ultrasonography or use of pressure transducers to measure pulse characteristics) cast great doubt on the objective validity of Classical Pulse Diagnosis. Most veterinary AP texts ignore it. In my opinion, pulse diagnosis is not objective but some people can make accurate diagnosis by the Pulses by subjective (psychic, extra-sensory perceptive) means, as in medical radiaesthesia/medical divination and Extra-Somato Projection.
SMELLING: In TCM, the practitioner smells the breath, the skin and excreta of the patient. TCM attributes typical smells to various disorders. For instance, in Earth disorders (SP, ST, diabetes), there may be a sweet (ketone) smell; in Water disorders (KI, BL), there may be a putrid smell (uraemia, ammonia) etc.
The aim of TCM/TAP diagnosis is to establish (a) the nature of the disease in terms of the Eight Principles and the Six Evils and (b) the COSs involved.
Having assessed the patient by the four principles (looking, listening, feeling and smelling), the nature and location of the disorder is defined in traditional terms. Steps are then taken to remove or alleviate the cause, or to enhance the body's Wei (Defensive) Qi, or to re-balance any energetic imbalances which have been diagnosed.
TCM diagnosis was developed at a time when knowledge of internal anatomy and physiopathology were primitive. Millennia had to pass before the development of current western concepts of biochemistry, microscopy, immunology, bacteriology, genetics, Selye's concepts of the Stress Reaction, concepts of nutrition (mineral, vitamin and essential amino-acid imbalances etc) and biotechnology.
In spite of ignorance of modern medicine, the ancient Chinese had one very important concept: They knew that vital energy (Qi, Vix Naturae) was the key to health and recovery from disease; they taught that the body healed itself by its own natural defense systems; the aim in healing is to stimulate and enhance those mechanisms, thereby attaining balance (homeostasis).