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Chapter 7. Pathogenesis: The Origins of Disease

Like most other aspects of Chinese medicine, pathogenesis (the things that cause illness, pain, debility, and degeneration) is viewed differently in Western medicine. In the West, a diagnosis is made, increasingly by technological means, and then the disease is named based on that information. Treatment is given for that named disease, and in most cases, people with the same disease are given exactly the same treatment.

Chinese medicine recognizes the same diseases that Western medicine does, although some may be called by different names. A Western disease diagnosis represents one collection of symptoms that figures into a pattern of disharmony that the Chinese physician seeks to identify in order to treat the patient in the best way possible. The disease isn’t treated; it’s just a clue to the entire pattern. The whole person is treated to restore a healthy balance. That is one of the hallmarks of all holistic practices. Once balance is restored, the symptoms of the disease disappear.

For example, if someone’s pancreas is not able to produce the hormone insulin or produces it in insufficient quantities, they are said to have Type 1 diabetes (insulin dependent, formerly called juvenile onset). If they can produce insulin but their cells are not able to utilize it properly, they have insulin resistance and are said to have Type 2 diabetes (formerly called adult onset). Type 1 or Type 2 diabetes becomes the person’s diagnosis and the name of their disease. For the most part, everyone with Type 1 diabetes is treated exactly the same (taught to give themselves insulin injections, monitor blood sugar levels, and possibly make lifestyle modifications), while everyone with Type 2 diabetes is prescribed glucophage (metformin), thiazolidinediones, or related drugs to promote insulin uptake and may be instructed on leading a healthier lifestyle. For Type 1 diabetes, the Western approach is a true life saver and is the best first choice. This example serves to illustrate that different paradigms are used in each medical system, as we’ll see throughout the rest of this chapter. The Chinese view of diabetes is discussed in Chapter 8.

The Causes of Disharmony

What causes things to go wrong with our health, disturbing the harmonious balance among our organs and other aspects of our body, mind, and emotions and creating these patterns of disharmony?

Primary Causes of Pathology

1. External pathogenic factors (EPFs): These are the predominant climatic factors of the external, natural environment, along with the more subtle associated energies that are present even in parts of the world where observable seasonal changes are not very pronounced. As a category, they are characterized by their sudden onset.

2. Internal pathogenic factors (IPFs): These are commonly emotional in origin. Additionally, imbalances within and among the internal organs can create internal “climates” similar to those of the external environment, mimicking EPFs. Typically these produce a slower onset of symptoms than EPFs.

3. Epidemic diseases (pestilence): These are almost always from a combination of Wind and Fire EPFs.

4. Trauma: Any type of injury.

5. Miscellaneous factors such as insect and animal bites.

6. Diet and lifestyle considerations.

Note that while trauma and diet and lifestyle are presented here separately for greatest clarity, they are often considered to be categories of miscellaneous factors.

Individual constitution is also a factor, affecting a person’s susceptibility to EPFs and some IPFs. In comprehensive contemporary clinical practices, additional environmental factors are considered, due to so many toxic industrial pollutants in our air, food, and water, numerous side effects to most common over-the-counter and prescription drugs, and exposure to many types of destabilizing electromagnetic fields and other man-made radiant energies through various electronic devices and pervasive wireless technologies. Those are outside of the scope of this discussion.

Overview of External Pathogenic Factors

Most EPFs are seasonal aspects of nature, sometimes translated from the Chinese as “climates.” These are the six climates:

• Wind

• Summer Heat

• Fire

• Damp

• Dryness

• Cold

Under normal circumstances, healthy people will usually not be adversely affected by these seasonal changes, which are the “Six Qi” of the natural world. It’s only when they are observed causes of disharmony that they are considered pathogenic and are then traditionally called the Six Pernicious Influences or the Six Excesses.

Seasonal energies can cause disease if they are prolonged or intense, if they are perverse (a period of unusual Cold during the summertime or Heat during the wintertime, for example), if a person has a constitutional imbalance predisposing a sensitivity toward a particular environmental factor, or if a person is already suffering an imbalance from another cause that makes them susceptible to an environmental energy. Additionally, some people are very sensitive to energetic shifts and can feel unsettled, feel out of sorts, or become prone to illness during seasonal transitions.

Most EPFs have a typical seasonal association (Cold during the winter and Heat during the summer, for example), but almost all can occur during any season. In fact, multiple EPFs can and often do occur simultaneously. Being external, they only become pathogenic once they invade the body through the nose, mouth, or pores of the skin. All EPFs can affect every internal organ, but each organ is most sensitive to disruption or injury from a single specific EPF.

Of note, contemporary indoor environments often create human-made EPFs. For example, fans create Wind, air conditioners create Wind and Cold, and heating systems create Heat and Damp (radiators) or Heat and Dryness (central/electric heating).

Overview of Internal Pathogenic Factors

The main IPFs are emotional in origin. The range of human emotional experience is normal and healthy, but as with the climatic energies, they can become problematic and pathogenic when very intense or prolonged. These are the Seven Emotions:

• Joy

• Anger

• Sadness/Melancholy

• Grief

• Pensiveness/Worry

• Fear

• Fright

Each emotion has an affinity for a particular organ, although other organs may be affected secondarily. While emotions can injure specific organs, an organ compromised from another source can produce inappropriate emotional responses. For example, if a person harbors long-standing anger or resentment toward another, that will eventually create a pattern of disharmony within the Liver.

Conversely, if a person damages their Liver function from excessive alcohol consumption, anger is often inappropriately evoked, leading to the infamous barroom brawl or to the surly, grumpy, acerbic personality as a common manifestation of the chronic alcoholic.

Taken as one part of diagnostic criteria, the emotions can play a significant role in determining the correct diagnosis, which is the pattern of disharmony affecting the individual. This is an aspect of the holistic nature of Chinese medicine. All parts of the person’s life must be considered integral to the whole.

Examining that holism further, the individual person can be viewed as a microcosm of the larger macrocosmic environment, inseparably linked. IPFs can be generated by patterns of disharmony arising from organ imbalances when the organ’s function is compromised by an EPF, another IPF, or other causes of pathology. Many of these organ-generated IPFs reflect the same environmental factors found in the outside environment. There can be internally generated Wind, Damp, Heat, Dryness, and Cold, and the primary organ associations are the same as those found with EPFs. As all of the organs share a holistic interconnection, these IPFs can and often do affect more than the primary organ.

An EPF can work its way deeper into the body and become an IPF of the same type or transform into a different IPF altogether. In this case, the EPF is defined as external when it primarily affects the more external parts of the body: the skin, muscles, and sense organs. As it penetrates deeper into the body and directly affects the internal organs, it will be identified as internal. For example, external Wind on the surface of the body can cause fever or chills, sweating, nasal congestion, itchy eyes, and body aches. If it is allowed to penetrate deeper, it can easily affect the Liver. This can cause internal Liver Wind, or it may congest the Liver Qi sufficiently to generate internal Heat and cause a Flare-Up of Liver Fire, transforming into a Heat IPF.

The Six External Pathogenic Factors

It bears repeating that all environmental factors discussed here are only pathogenic when they produce a discernable adverse effect in relation to the body, which is the result of the body’s reaction to the environmental factor. Except in the most extreme circumstances, there is nothing intrinsically pathogenic about the seasonal energies as they exist in nature.

The symptoms given are typical presentations associated with each EPF. Not every person afflicted by an EPF will have all of the associated symptoms, and other symptoms besides those included here may be present.

Wind

• Prominent season: Spring

• Organ most affected: Liver

• Nature: Yang

Main Attributes and Associated Symptoms

Wind is the most ubiquitous and pervasive of the EPFs. While spring is its predominant season, it is present throughout the year. Because each season has its own energetic quality, capable of affecting people in numerous subtle ways, even robust people can be more vulnerable to Wind during spring.

Wind readily carries other EPFs along with it. This is why it’s referred to as “the agent of 1,000 diseases,” noted in the Suwen (The Book of Plain Questions), a Chinese medical classic originally dating as far back as 400 BCE. Wind can facilitate and combine with Damp, Heat, Dryness, and Cold when invading the body, making it the primary EPF in all infectious and epidemic diseases.

Wind Qi is characterized by upward and outward movement. It therefore readily affects the head and upper body and is a component of all types of colds and flus, along with many other ailments of the head. Wind alone can cause headaches, eye twitches, an aversion to wind, and itchy eyes, skin, and throat. Combined with Cold, it can cause a cold characterized by nasal congestion and sneezing with white or clear mucus, chills more than fever, and body aches. Combined with Heat, the cold is characterized by nasal congestion with yellowish mucus, fever more than chills, thirst, and a sore throat. In either case there may be a puffy face and absent or profuse sweating.

Wind can freely blow anywhere and is associated with movement and rapid change. Wind disorders are characterized by their sudden onset, with symptoms that can appear then disappear or appear in one part of the body, disappear, and then emerge at another part of the body. Hives, itchy skin bumps that appear suddenly and randomly change location, are caused by Wind. The Western biomedical name for this condition is urticaria, but even in the West it is colloquially called “wind rash.” Another example is joint pain that intermittently appears and disappears, moving among various joints throughout the body. This can be a presentation of some types of arthritis. It is called “Wandering Bi” or “Wind Bi” in Chinese medicine. (Bi Syndrome means “Painful Obstruction Syndrome” and is caused by pathogenic factors blocking the meridians.)

Internal disharmonies can generate Internal Wind, an IPF with many of the same presentations as External Wind. This is usually, although not exclusively, caused by some sort of Liver disharmony. Some common Liver patterns that produce Wind include Liver Wind, Liver Yang Rising, and Flare-Up of Liver Fire, in order of increasing severity. Each has its own distinguishing signs and symptoms, but the related Wind IPF symptoms are dizziness and vertigo (both are subjective sensations of internal movement), tremors, convulsions (physical movements, associated with the Liver’s governance of tendons and ligaments), headache, painful or red eyes (affecting the head from Wind’s upward movement), and both the biomedical and figurative versions of apoplexy. Medically, that means unconsciousness, usually from a stroke, again affecting the head. Used figuratively, it means “rendered speechless by extreme anger.” Anger is the emotion most associated with the Liver.

Summer Heat

• Prominent season: Summer

• Organ most affected: Heart. Clinically, all organs may be affected.

• Nature: Predominantly Yang, but as Summer Heat frequently combines with Damp (summer humidity), a Yin pathogen, it can have a mixed nature.

Main Attributes and Associated Symptoms

Unlike all other EPFs, Summer Heat, being defined as such, only occurs during the summer. While there is no exact IPF match for Summer Heat, Damp Heat has some presentations that are a close analogue that can be generated internally and is also an EPF that can occur in any season.

Summer Heat is a strong Heat that both scatters and consumes Yin fluids. Being a Yang pathogen, it has an upward directionality. Its ability to scatter will leave the pores open and induce profuse sweat. At the same time the nature of Heat is very drying. This combination can lead to dehydration, dry lips, mouth, and tongue, and a strong thirst. It will also cause urination to be scanty and dark yellow. Parts of the body, or the entire body, may look or feel hot, the complexion is usually red, and the person will avoid heat and prefer cold foods, beverages, and environments.

Heat’s upward surge can cause a high fever, dizziness, and mental restlessness. If it becomes more severe, it will cause heatstroke/sunstroke, where the exposure to high heat causes the body to lose the ability to cool itself down. This serious condition induces fainting and possible coma. Since the Heart both generates sweat and houses the mind, these demonstrate primary ways in which Summer Heat affects the Heart.

When mingled with Damp from summer humidity, symptoms of Spleen involvement occur, as the Spleen is most sensitive to Damp. These include low energy, poor appetite, loose stool or diarrhea, and a heavy sensation in the head or throughout the body, combined with the previous Heat symptoms.

Fire

• Prominent season: Summer

• Organ most affected: Heart. Clinically, all organs may be affected.

• Nature: Yang

Main Attributes and Associated Symptoms

Fire exists on a continuum of Mild Heat, Heat, and Fire. While summer is its predominant season, Fire can occur at any time of the year. It shares some of the same presentations as Summer Heat, excluding the Damp symptoms.

Its excess Yang nature consumes Yin fluids and induces an upward directionality. The image of fire in nature makes those traits easy to see, as fire consumes all it burns and prefers to rise whenever that is possible. The consumption of Yin causes dry lips, mouth, and throat, scanty, dark urine, and a drying of the intestines, causing constipation, with a desire for cold foods, beverages, and environments.

The upward burning quality of Fire can cause high fever, dizziness, mental restlessness, insomnia, profuse sweating, and red, painful swelling or ulceration of the lips, mouth, tongue, and gums.

Fire is an EPF that readily penetrates the body, disrupting organ functions and creating IPFs. Fire attacks the Liver both directly and by drying the tendons and ligaments, the Liver’s associated tissues. This generates Liver Wind, an IPF, with Wind symptoms such as dizziness, vertigo, headache, eye disorders, tremors, convulsions, and loss of consciousness.

When Mild Heat penetrates deeper and affects the Blood, it will initially quicken the pulse. Penetrating Fire can cause a syndrome called Reckless Marauding of Blood, a potentially serious bleeding disorder that forces blood out of the vessels. Symptoms may include nosebleeds, bleeding gums, coughing or spitting blood, blood in the urine and stool, and heavy uterine bleeding or hemorrhage.

Damp

• Prominent season: Late summer

• Organ most affected: Spleen

• Nature: Yin

Main Attributes and Associated Symptoms

Traditionally, Damp is the pathogen most prominent in late summer—what we might call “Indian summer”—mainly because in China that’s a particularly rainy season and Damp is found everywhere. While there is a seasonal Qi, an energetic quality, that makes people more predisposed to an invasion of Damp during late summer, in practice Damp is present year-round. Extended rainy weather, foggy environments on mountaintops or by the ocean, moist forests, and indoor environments like a damp basement apartment are all capable of generating pathogenic Damp. In most cases it takes prolonged exposure for Damp to create a health problem. There can, however, be an acute sudden onset of Damp. For example, if a person gets caught in a downpour, falls into a body of water, or sweats profusely and by choice or necessity keeps their wet clothes on, Damp can readily invade the body.

Damp is thick, heavy, sticky, cloying, and turbid. These qualities make it perhaps the most stubborn, intractable pathogen to eliminate. When it affects the head, it can cause dizziness, heaviness in the head, and a persistent dull headache around the entire head. This can cloud thinking and dull emotional expression, as its turbid quality creates an opaque muddiness and lack of clarity. When it enters the meridians, Damp can cause a heavy sensation throughout the body or in the arms, legs, and head and can cause stiff, achy, or sore joints. Combined with Wind, it generates Wind Damp Bi, a painful joint obstruction common to many types of arthritis.

Damp can manifest on the surface of the body, always with an unwholesome fluid aspect such as festering sores, weeping eczema, or profuse vaginal discharge. When combined with Heat, the fluids appear yellowish and often produce a bad odor. When combined with Cold, they will appear whitish or clear and have no odor.

As a Yin pathogen, the heaviness of Damp has a downward, sinking movement and often affects the lower body first. It readily obstructs the flow of Qi and can literally dampen the expression of Yang. This can cause a heaviness and fullness in the chest, abdominal distension, scant and difficult urination (often with dribbling), and incomplete bowel movements.

The Spleen is most affected by Damp, and if compromised by other factors, it will generate Damp as an IPF. The EPF and IPF manifestations of Damp are identical in relation to the Spleen. The heaviness of Damp suppresses the Spleen’s role of causing Qi to rise. As the Spleen struggles against the onslaught of Damp, Spleen Qi Deficiency is a common result. The combination of Damp and Deficiency causes abdominal fullness, loss of appetite, nausea, low energy, and loose stool or diarrhea. The Spleen’s transformation and transportation functions are also impaired. This further allows the already cloying Damp pathogen to linger. The downward trajectory can involve the Kidneys and impair aspects of their fluid metabolism, leading to edema.

As the pathogenic fluids linger, they produce mucus and Phlegm. Mucus is normally secreted by mucous membranes, primarily in the head and in the lining of the lungs and alimentary tract. Mucus in the nasal passages causes either a runny or stuffy nose and is most often no more than a temporary inconvenience from a cold or allergy. In the case of chronic sinusitis, a long-term nasal obstruction that does not respond to antibiotics or decongestants, or a chronic post-nasal drip, Damp is most often responsible and must be treated to resolve the condition.

In Western medical terms, phlegm is formed in the lungs and is always relatively thick and sticky when compared to mucus, which may appear watery. The Chinese perception is not exactly the same. It observes both “substantial” and “insubstantial” phlegm. Substantial phlegm is identical to the Western understanding: the thick, gelatinous substance you may cough up from your lungs from a cold or allergy or as a complication from smoking or other diseases. Insubstantial Phlegm is less dense, is less purely physical, and may obstruct channels as well as body tissue.

Insubstantial Phlegm can appear anywhere and is stagnant and obstructive. When lodged in the channels, its stagnant quality can cause surrounding tissue to aggregate. In the body, anything stagnant blocks the flow of Qi, Blood, or other body fluids. In doing so, it causes a type of friction that generates Heat. The Heat “cooks” the obstructing Phlegm, forming nodules, cysts, or tumors. Insubstantial Phlegm is also responsible for a pattern of disharmony called Phlegm Misting the Heart. Here there are no overt physical tissue changes, but there is an impairment of the Heart function of housing the mind. Symptoms may be as mild as confused or fuzzy thinking or as serious as wildly erratic behavior, mania, complete dissociation, and insanity. A stereotypical example is an unfortunate homeless person who may be seen having an animated conversation with or directing a shouting tirade at no one visible to others.

Dryness

• Prominent season: Fall

• Organ most affected: Lungs

• Nature: Yang

Main Attributes and Associated Symptoms

Dryness is the environmental energy of autumn, when the air becomes much drier in many parts of the world. Dryness is an EPF in its own right, but a person invaded by Heat or Fire during the summertime can have a resultant internal Dryness as an IPF. In such cases dry symptoms can be obscured, muted, or delayed by the Damp of late summer, but they readily manifest in autumn, exacerbated by external Dryness. In all cases Dryness consumes body fluids, resulting in dehydration. If Heat was the initial cause and still lingers, there will be additional Heat signs, such as redness and feverish sensations.

Dryness typically invades the body through the nose and mouth. As it is a Yang pathogen causing upward and outward movement, many of its external signs appear in the upper and outer parts of the body, such as dry mouth and lips and dry nasal passages and throat, accompanied by thirst. When Dryness moves more interiorly, it can cause constipation and reduced urination.

The Lungs are most affected by Dryness. They have the function of descending, dispersing, and moistening, as well as dominating the skin, all challenged by the effects of Dryness. Other signs include dry or chapped skin, dry body hair, possible shortness of breath, and a dry cough with little phlegm. If Heat is present, the phlegm may be bloody.

Cold

• Prominent season: Winter

• Organ most affected: Kidneys

• Nature: Yin

Main Attributes and Associated Symptoms

Cold is the predominant environmental energy of winter but can affect a person in any season when it may be unusually cold, when exposed to environments that are by nature cold, like hiking up mountaintops and swimming in cold rivers, or due to human-made environments, as when entering air-conditioned buildings after being out in the high heat of summer, which leaves the pores open and especially vulnerable to invasion by Cold.

As with every EPF, some people are more prone to Cold disorders than others, due to their constitution or a preexisting Cold disharmony. A common example occurs when two people walk into the ocean together. One may immediately dive in and feel invigorated, while the other may only be able to slowly wade in to their thighs or waist before needing to retreat to the shore. The latter person has an aversion to cold, one symptom factored in to the diagnosis of a possible Cold disorder.

The primary characteristics of a Cold disharmony are often the most obvious ones. The afflicted person will avoid cold environments and seek warm ones, exhibit a preference for warm or hot beverages, will feel cold subjectively and often be cold to the touch, and will wear more or heavier clothing than other people. The person’s complexion is pale or white. Other symptoms can include various clear or white bodily secretions, such as clear or white nasal mucus or phlegm, clear or watery vomit, and profuse clear urination. Cold can impair the digestive functions of the Stomach and Small Intestine, causing diarrhea with undigested food.

Cold is a Yin pathogen causing things to both slow and to constrict or condense, in the same way that flowing water will freeze into an unmoving block of ice. Such constriction obstructs the flow of Qi and by extension reduces Blood flow, causing painful contraction of the muscles and tendons, and closes the pores, causing a lack of sweat.

As Cold moves more interiorly, it can diminish or damage the body’s warming Yang Qi, notably of the Kidneys and Mingmen. In addition to the above symptoms, this causes inactivity, an excessive desire for sleep, reduced sexual energy and interest, and an overall loss of vitality.

Epidemic Diseases

Epidemic diseases are sometimes thought of as a separate class of EPFs, in that they affect a large segment of the population at the same time. From a Western perspective, these are usually caused by a virus, whether the latest strain of influenza or the polio epidemics of the twentieth century. Because they are most often airborne contagions, they are a type of Wind EPF, generating expected Wind symptoms, and because they typically cause feverish symptoms, they are also a Heat EPF, often a particularly virulent Wind Heat pathogen. Other EPFs and IPFs may be part of the clinical picture depending upon the exact presentation, but Wind Heat is almost always primary.

The Seven Emotions as Internal Pathogenic Factors

The six EPFs are considered external, although they can penetrate the body to create internal changes that generate IPFs. The Seven Emotions are exclusively IPFs. All emotions are normal and usually healthy expressions of human experience. Like the environments, they can become pathogenic if extreme or prolonged, and they may be the result of an internal disharmony within any Organ System. Also as with EFPs, while there is a primary organ associated with each emotion, the emotions can and do often influence more than one organ, since all the organs have various unique interrelationships. Some examples are provided below. Generally, the organs most susceptible to emotion-based disharmonies are the Heart, Liver, and Spleen.

The Seven Emotions and their healthier, more balanced counterparts were discussed in detail with their associated organs in Chapter 5. The following is a brief review with additional information about them as IPFs.

Joy

Joy is the emotion primarily associated with the Heart. Moderate joy is healthy and beneficial, not pathogenic. Its main pathogenic qualities arise from its ability to induce overexcitement or overstimulation, which scatters the Qi and may cause heart palpitations, arrhythmia, headaches, or fainting; when very excessive, it has a manic quality that disturbs the mind (the Heart houses the mind) and Shen/spirit. Milder manifestations include insomnia, vivid and unsettling dreams, and confusion. In more extreme cases, there can be wild mood swings, true mania, and other psychological disturbances.

One stereotypical example of joy injuring the Heart is that upon receiving very good news, such as winning the lottery, a person may become so excited that they have a heart attack.

Anger

Anger is the emotion primarily associated with the Liver. It can be an appropriately healthy response to life circumstances, and if expressed and resolved in a reasonable amount of time, it is not pathogenic. It can become pathogenic when it is a prolonged response to unchanging external events or when it is a person’s choice or nature to hold on to their anger.

Associated emotional variations include frustration and irritability, which can persist due to unsatisfying work or personal relationships, for example. Resentments held for a long time will injure the Liver, with passive-aggressive behavior being one result of a Liver disharmony. Depression is a related emotion that arises more from a deficient Liver condition, often a result of a long-standing frustration or from repressed anger.

Anger makes Qi rise and can cause headaches (especially migraine headaches) and dizziness, as anger may cause any of a few Liver patterns that generate Wind as an IPF. Liver Qi Stagnation is one common pattern that generates internal Heat due to its obstructive quality. Heat also rises and will add symptoms such as a red face. An idiomatic expression denoting anger is “hot under the collar,” referring to this phenomenon.

Anger causes Qi to rise and Heat rises, which can easily disturb the Heart, causing many Heart symptoms like restlessness and insomnia. Liver Qi Stagnation can cause abdominal distension and discomfort and can invade the Spleen and Stomach, with the accompanying symptoms of belching or nausea, loss of appetite, and diarrhea. These are examples of ways in which anger can affect both the Heart and Spleen secondarily to affecting the Liver.

Anger and any of its related emotions (frustration, irritability, resentment, or depression) will result if the Liver is damaged by an EPF, another IPF, or through the toxic effects of alcohol, recreational drugs, or prescription drugs. Since the Liver is responsible for the smooth, free flow of Qi, the instability and unpredictability inherent in these emotions adversely affects the flow of Qi and Blood, causing a generalized physical and psychological tension.

Sadness and Grief

Sadness and grief, two similar emotions related by degree of intensity, are primarily associated with the Lungs. Sadness consumes Qi. Since the Lungs govern Qi, they are the organs initially most affected by sadness. Grief, a more intense and often lingering form of sadness, consumes Qi more seriously.

All emotions affect breathing in their own ways, causing different, distinctive breathing patterns. Since the Lungs are intrinsically involved with the mechanics of breathing, it’s easiest to see how sadness and grief affect them. In grief-stricken people, the sound of their voice is described as “crying” in a Five Element context, even when they are not actually crying. Their inhalation is shallow, often sharp and brief, while their exhalation is more prolonged, and they usually take fewer breaths per minute. This is nearly identical to the breathing pattern of a person who is actively crying or sobbing. So while sadness is consuming their Qi, they are simultaneously taking in less atmospheric Qi on their inhalation and expending or dispelling more Qi with each exhalation, increasing the rate of Qi depletion.

While sadness may make someone feel tired and listless, unable to feel excited by or engaged in life, grief is much more debilitating and can seriously impact health when prolonged. This can happen to varying degrees at any age, but it’s most pernicious in the elderly, who may be facing age-related health problems. For example, when one spouse dies, it’s not uncommon for the other to die soon after, often within a few weeks or months. This can be directly attributed to grief consuming Qi, which is life force.

Sadness may also affect the Lungs secondarily, through the Heart. Joy primarily affects the Heart, but sadness is its polar opposite and so may also first affect the Heart. In that case, while joy scatters Qi, sadness makes it constrict and creates obstruction in the Upper Jiao, causing the feeling of “heavy-heartedness.” If persisting over time, this obstruction spreads and interferes with Lung function.

Lung 9, “The Great Abyss,” is the Influence Point of the vessels and can be used to strengthen a weak pulse from weakened Heart Qi. This demonstrates another relationship between the Heart and Lungs.

Because sadness depletes Lung Qi, most of its symptoms are related to the Lungs, including shortness of breath, heaviness in the chest, low energy, and possibly lowered immunity, especially in relation to the respiratory tract. Due to the Lungs’ pairing with the Large Intestine, constipation is often present. Depression and emotional fragility are also common. Afflicted this way, a person may become distant, avoiding further emotional attachment rather than face the potential pain of loss.

Pensiveness/Worry

Pensiveness, sometimes translated as contemplation or rumination, includes worry and overthinking. It is the emotion primarily associated with the Spleen.

Overthinking most obviously affects those involved in rigorous mental activities, such as students, and those who are engaged in mental work, whether academics, scientists, lawyers, or accountants. Worry usually involves an element of overthinking as well, as when a mother may obsessively worry about her children when they are out of her sight or when a person may worry about their job or financial security in uncertain economic times. Worry may create a pattern of circular thought, a compulsive way of viewing things from which there may seem to be no escape. This can have a stronger impact on emotional and physical health than overthinking alone.

Worry and overthinking both cause Qi to stagnate or “knot,” disturbing the Spleen’s functions of transportation and transformation and weakening Spleen Qi overall. This manifests as low energy, loss of appetite, poor digestion, abdominal distension (often with a tendency to accumulate body fat), and loose stool or diarrhea.

Fear and Fright

Fear and fright are two related emotions primarily associated with the Kidneys. They are sometimes considered different intensities of the same emotion, but there are some differences. Fear is a more generalized, pervasive, and often lingering sense of dread—a state of being. Fright is more situational, involving an element of immediate surprise or shock. A horror movie fan may experience numerous frights throughout the course of the movie, reflexively covering their eyes or grabbing the person next to them while gasping from fright. Once the movie is over, the frights are gone, but there may be a disturbing sense of fearful unease that lasts a while longer.

Both fear and fright deplete the Kidneys and make Qi descend. This affects Kidney function in numerous ways. With fright alone, the abrupt sinking of Qi may make a person lose control of their bladder and involuntarily urinate. Since the Kidneys control the two lower orifices, when fear and fright are both strongly present, as when a person may suddenly realize they are facing imminent death, they may lose control of their bladder and bowels. Since the Kidneys dominate growth and development, children are very susceptible to fear and fright and may feel insecure and powerless. Such children may be prone to bed-wetting or have other developmental problems. A fearful adult may have similar insecurities and lead an isolated life as a pathological form of self-protection. That emotional hardening may translate physically into arthritis, as the Kidneys dominate the bones, and to deafness, as the Kidneys open to the ears.

Fear and fright secondarily damage the Heart, causing palpitations or insomnia. Since the Heart houses the mind, anxiety and mental confusion can result and, if persistent, can set the stage for Alzheimer’s or similar mental deterioration.

Miscellaneous Factors

Most remaining causes of disease that follow are designated as miscellaneous, traditionally categorized as “not external, not internal,” since they are not caused by EPFs or IPFs. Diet and lifestyle are under the control of any sufficiently motivated individual and are often given the separate designation of lifestyle factors, especially in contemporary times.

Trauma

Trauma includes any type of injury involving bodily harm. The effects of emotional trauma are contained within the context of the Seven Emotions.

Trauma may be caused by a slip and fall, a workplace accident, a sports injury, a car accident, burns, a knife or gunshot wound, or any number of similar events. Its immediate effects range from minor cuts, scrapes, bruises, sprains, strains and contusions, and blistered or raw skin to broken bones, severe blood loss, and organ damage.

The pain, swelling, and discoloration of bruising comes from Qi stagnation, as the meridians and freely circulating Qi may both be damaged by injury, and from Blood Stasis, often accompanied by extravasation, which is blood leaving damaged blood vessels and pooling under the skin or within the body as well as causing visible external bleeding.

In trauma, Qi stagnation rarely exists by itself. The pain from Qi stagnation is characterized by a diffuse, dull ache most often seen in chronic pain conditions. However, Qi stagnation does occur to varying degrees in almost all traumatic injuries and is an additional factor in Blood Stasis, since Qi moves Blood. If the Qi is not moving, Blood will not move. Blood Stasis pain is sharp and focal, existing in a readily identifiable location except in some cases of deep internal bleeding. The stronger pain of Blood Stasis is able to mask the milder pain of Qi stagnation.

There are secondary issues around trauma that can be both long lasting and less apparent. If the Qi stagnation or Blood Stasis is not completely resolved within a short while after the initial injury, it can lodge within the body, causing lingering ache and intermittent pain, while laying the foundation for further degeneration. This can occur even when the initial injury seems to be healing normally.

Chinese traumatology is well able to deal with injuries, although it is not often used for emergency care in the Western world. Acupuncture may be useful in both acute and chronic pain management, to allay Qi stagnation, and to encourage tissue repair, but herbs are the main modality of choice. They can strongly break up Qi stagnation and Blood Stasis while at the same time stop bleeding and reduce inflammation. They also add things to the body that are necessary to rebuild it after tissue damage.

Many Chinese healers are martial artists and may be deeply disciplined in spiritual practices. Whether sparring with friends to improve one’s skill or fighting in earnest, traumatic injuries frequently occur. Not surprisingly, in communities where that is common, many herbal remedies for trauma have been formulated and refined for hundreds, and in some cases thousands, of years. The Shaolin monks, known since around 500 CE for their extraordinary martial skills, have hundreds of extremely effective “strike formulas” to treat everything from simple bruising to broken bones, severe bleeding, concussions, loss of consciousness, paralysis, and organ damage. Some Chinese physicians specialize in bone-setting and can reset dislocated joints as well as treat other joint dysfunctions in similar ways to chiropractors. (Bone-setting services are not legally available in the United States under Chinese medical licensure.)

Qigong, Taiji, and other movement practices are very beneficial in remedying chronic pain from Qi stagnation and Blood Stasis. While improving health in general, specific Qigongs exist to address specific conditions, and many standard Qigong practices can be modified to address those same concerns. Practitioners who are sufficiently adept can easily sense exactly where they may have pockets of obstruction or deficiency of any sort and consciously direct their Qi there to heal themselves.

This can also be very useful in acute conditions. As an example from my own life, in 2009 I suffered a serious bike accident and fractured my pelvis in four places. Since I wasn’t able to put any weight on my left leg for fear of displacing the fractured bones, potentially causing life-threatening organ damage, I was basically housebound for six weeks. While I did give myself acupuncture treatments and took the appropriate herbs, I spent a couple of hours each day running Qi through my pelvis while either sitting or laying on my back to accelerate my healing. After six weeks, the doctors told me my X-rays showed no signs that I’d ever fractured my pelvis.

Animal and Insect Bites

Animal bites cause many of the same complications as other types of trauma, including pain, swelling, broken skin, torn muscle, inflammation, and bleeding, all with accompanying Qi and Blood obstructions. Most common insect bites produce relatively mild Wind Heat symptoms, including redness, swelling, itch, and possibly pain.

Some insect and animal bites are more venomous and may induce numbness, convulsions, and paralysis, sometimes causing death. While recognized as being caused by a venomous bite, these symptoms indicate a severe Liver Wind disorder, possibly with Heat or other factors included. Some animal and insect bites contain infectious agents, bacteria, and viruses. They may cause high fevers with possible delirium, muscle aches, skin lesions, and bleeding disorders, indicative of a severe Blood Heat condition. They may also introduce parasites into the body, which can either cause skin nodules or cause poor appetite, low energy, abdominal distension, and bloody stool, indicative of Spleen Qi Deficiency.

Depending on the type of bite and the nature of the infection, many other symptoms are possible. While the obvious initial cause of the disease must be addressed and the toxic or parasitic agents expelled, the pattern of disharmony (Liver Wind, Blood Heat, and Spleen Qi Deficiency in these examples) must also be recognized and treated in order to alleviate the symptoms and return the patient to full health as soon as possible, just as in all other causes of pathology.

Imbalances in Diet and Lifestyle

When diet and lifestyle are out of balance, disrupting the natural harmony between Yin and Yang, they become causative factors of poor, declining health. They deplete Qi and make it more difficult to replenish what is lost, progressively weakening the body and reducing functionality at every level. This increases susceptibility to most other external and internal pathogenic influences, setting the stage for numerous patterns of disharmony.

Many of these factors will be familiar, as they are the type of common sense advice you might get from your family, friends, and media “health gurus” on TV or the Internet as much as you’d hear them from your healthcare provider. You may find some surprises and new slants on old ideas. Here are the basics of Chinese medical thought on dietary and lifestyle factors:

• Poor diet

• Too much or too little exercise

• Overexertion and stress with inadequate rest

• Excessive sexual activity

Diet

The first aspect of diet that can become imbalanced is the quantity of food consumed. Too much food eaten on a regular basis will cause a person to become overweight. This is the most prominent concern in the minds of most Westerners, where the weight loss industry is big business. From a Western point of view, excess weight directly causes or contributes to high blood pressure, heart disease, diabetes, metabolic syndrome, sleep apnea, fatty liver disease, kidney diseases (secondary to high blood pressure and diabetes), and even some types of cancer. Before those diseases manifest, the Chinese recognize imbalances in the Spleen and Stomach due to overeating, early warnings presenting symptoms such as bad breath, belching, acid reflux, vomiting, diarrhea, and a swollen or painful abdomen. Some common associated patterns of disharmony include Food Stagnation, Spleen Qi Deficiency, and Rebellious Stomach Qi. When these patterns are identified and remedied, the progression to the above Western diseases can be prevented.

Undereating is the counterpart to overeating and is a dietary imbalance leading to malnutrition. Whether by choice (following a strict weight-loss regimen) or life circumstance (poverty, for example), undereating reduces the amount of sustenance a person takes in. Inadequate nourishment weakens the Spleen, causing deficiencies of Qi and Blood. This sets up a downward spiral, since a weakened Spleen is less able to absorb nutrition, one of its primary functions. Any food eaten is not well absorbed and is consequently less nourishing, further weakening the Spleen.

Because the Spleen is responsible for transporting Qi throughout the body and is involved in generating Blood, the entire body is compromised. The weight that’s lost is largely muscle weight, so a person will feel weak and have low energy. Weiqi (defensive Qi) is also diminished, causing increased susceptibility to all types of EPFs. Paradoxically, a weakened Spleen will cause a loss of appetite, so a sufficiently undernourished person may not want to eat. Common associated patterns of disharmony include Spleen Qi Deficiency, and Qi or Blood Deficiencies of any organ are possible.

The next dietary concern involves eating one type of food excessively or to the exclusion of other foods. This can be due to geographical constraints and most often causes disease from specific nutritional deficiencies. For example, in some remote parts of the world polished white rice may be a common staple food, and even with the additions of some vegetables, a severe vitamin B1 deficiency may develop, causing beriberi. In other regions, the dietary staples may lack iodine, and an abnormal enlargement of the thyroid gland (a simple goiter) may result. These conditions are less common in the contemporary Western world, but diabetes, which is caused in large part by overeating sweet foods and carbohydrates that readily convert to sugars when digested, is nearly an epidemic. The related conditions of metabolic syndrome and nonalcoholic fatty liver disease, along with widespread obesity, are also caused by excessive consumption of sugary foods.

Another type of overconsumption of a food type relates to the Five Tastes and their organ correspondences. They can be causative factors of disharmony when one flavor is favored over all others.

Sweet is the flavor associated with the Spleen. While a small amount of sweet food can tonify the Spleen, a large quantity will damage Spleen Qi and adversely affect all its related functions. In the Chinese way of thinking, carrots and beets are considered sweet foods, while most fruits are very sweet. I know one Qigong master who is careful to eat no more than two or three fruits per week to avoid overtaxing his Spleen.

The Spleen is disrupted by eating predominantly cold and raw foods. Cold means both the common temperature of foods, such as ice cream or iced beverages, and foods whose energetics are cold. Mint is an easy flavor to identify as energetically cold, since it is used to create a sensation of coolness when added to food or drink. However, most vegetables and fruits are energetically cool or cold. Another example is watermelon, a favorite cooling, summertime treat. Raw foods, including salads, are also cooling.

Since balance is key in every aspect of Chinese medicine, eating a moderate amount of cool foods during the hot summer months is usually not harmful, unless a person already has a compromised Spleen. When eaten predominantly or in cold weather, they may easily damage Spleen Yang, strongly impairing digestive, transformation, and transportation functions and may cause Internal Cold and Damp syndromes. This can elicit abdominal distension and pain, low energy, diarrhea, and a tendency to feel chilled easily. Damp additionally causes Phlegm, with accompanying symptoms such as sinus congestion, heaviness in the chest with a phlegmy cough and other upper respiratory problems, dizziness, a dull, pervasive headache, fuzzy thinking, mucus in the stool, and a clear or whitish vaginal discharge.

Greasy foods also engender Damp, which the Spleen dislikes. Some examples include dairy products (cheese, milk, ice cream) and deep fried or fatty foods. Alcohol, drying in some contexts, engenders Damp when consumed. Damp causes obstruction that often creates Heat, so Damp Heat syndromes can occur. In addition to the above digestive problems and Damp symptoms, Damp Heat can cause bleeding hemorrhoids, bloody mucus, and severe abscesses or clusters of boils anywhere on the skin.

Spicy flavors influence the Lungs. Small amounts of spicy foods can benefit the Lungs, stimulate its functions, and be energizing. Too much, especially if spicy and hot, can dry the Lungs and disturb its functions of opening and closing the pores, which causes profuse sweating, and a reduced ability to descend and disperse, which causes dryness throughout the body, including dry skin and hair, with increased thirst and possibly a dry cough. Since spicy foods scatter Qi and any functional activity such as sweating expends Qi, there is an accompanying loss of energy, and Weiqi diminishes, making the body more vulnerable to external pathogens.

The Stomach receives all foods consumed and is vulnerable to excessive consumption of spicy hot foods. Stomach Yin is most easily injured in this case, both from the spicy heat and from the Lung’s reduced ability to moisten. This can cause heartburn, acid regurgitation, excessive hunger, bad breath, bleeding gums, and thirst for cold liquids.

Salty flavors influence the Kidneys. As with all flavors, used appropriately and in small quantities, salt can be beneficial to the Kidneys. Domesticated animals are given a little extra salt through salt licks so they will retain fluids and be encouraged to drink more water to stay well hydrated, especially in hot weather or when required to perform strenuous activities. Some wild animals seek it out for the same purposes. Salt was given to soldiers during World War II to prevent dehydration in hot jungle or desert environments, and it’s still an old-school supplement used by many athletes, particularly in football training camps during the preseason hot months of July and August.12 Specific to Chinese medicine, salty tastes can help break up cysts and nodules and are used to direct the healing effects of herbs to the Kidneys.

Since the Kidneys play a primary role in fluid metabolism, if salt is consumed excessively or for extended periods, it injures the Kidneys in ways that first manifest through their functions related to fluid metabolism: their governance of water, controlling the lower orifices, and grasping the Qi from the Lungs. Diarrhea is common, due to salt’s disruptive influence on the Stomach as well as its disruption of the functioning of the lower orifices. Other early symptoms may include scanty urination and fluid retention with swelling, a simple edema. Over time this may progress to the Western diseases of high blood pressure, pulmonary edema (fluid buildup in the lungs, causing breathing difficulties and heart problems), and a few types of kidney disease. It is a factor in adrenal insufficiency and some types of sexual dysfunction.

Sour is the flavor associated with the Liver, and bitter is associated with the Heart. In the United States, these present almost no problems since they are not popular flavors and are rarely overeaten the way sweet, spicy, and salty foods are. The main exception is coffee, a very popular bitter beverage, but most chain coffee shops hide its bitterness with multiple types of sugary flavorings and milk or cream, which are also sweet flavors. The bitter quality is there even if not fully tasted, and it affects the Heart.

Coffee scatters Heart Qi in a similar way to the IPF of joy. Both can be very exciting and make the heart beat faster. Caffeine itself is a very bitter alkaloid, largely responsible for coffee’s bitterness. Its effects on the Heart are very noticeable to anyone who drinks a cup more than once in a while. In many people the stimulation rapidly transforms into jitteriness and a big drop in energy—the “crash.” The energy drop comes both from the scattering of Heart Qi, and the depletion of Kidney Yang Qi. (Caffeine causes you to tap into your Kidney Yang reserves.) Both are initially stimulating, but the apparent energy boost one feels from coffee is not due to any energy contained within the coffee. If that were true, coffee, or caffeine, could be used to power many other things. What it does is deplete your own body of its stored reserves. It’s a little like spending time with a thief who takes you out and spends all kinds of money with you doing fun things. Only it’s not free money; it’s money that the thief is stealing from your own savings without your knowledge. What do you think happens when all your funds are gone? If you feel jittery from coffee or need to sleep soon after the stimulation wears off, those are indications that you are significantly depleting your reserves.

The final dietary cause of pathology is eating unclean food—that is, food that has spoiled, is moldy, or is contaminated with parasites. This is fairly straightforward, since it is a common cause of disease no matter what medical system is employed to diagnose it. The Chinese perspective includes impairment of the functions of the Stomach and Spleen, with symptoms such as stomach and abdominal swelling and pain, nausea, vomiting, and diarrhea. Fever may or may not be present. These symptoms are consistent with various types of food poisoning. The symptoms associated with parasites vary according to the type of parasite involved.

Other Lifestyle Factors

Balance is a key element in Chinese medical thinking when considering lifestyle. Activity is balanced by rest, wakefulness by sleep, work by play. When any component becomes excessive, the body becomes out of balance and prone to injury and illness.

Activity often becomes imbalanced due to the demands of work. That can mean excess mental work, physical work, or both. Mental overwork does not necessarily mean high-level intellectual endeavors. While people who work in the fields of high finance, medicine, academia, legislature, and science might seem to be most prone to mental overwork, those who do accounting, office work, computer programming, or any number of other jobs can expend just as much mental energy and are just as vulnerable to resultant job-related stresses.

Whether you put in long hours because you’re ambitious, find your work exciting, or want to get ahead or because it’s a necessity just to make ends meet, overwork causes the same imbalances. Overwork and mental expenditure depletes your Qi overall but in particular the Qi of your Heart, Spleen, and Kidneys. We’ve seen in Chapter 5 that the Heart houses the mind (consciousness), the Spleen houses thought (related to concentration, memorization, absorbing information, and other mental tasks), and the Kidneys house the willpower (primarily associated with goal-related activities, purposeful work, focus, and short-term memory).

Job-related stress is known to cause many heart conditions, such as hypertension, cardiovascular disease, and mental health problems, which are included in the Chinese understanding of the Heart. While usually not life-threatening, digestive disorders (related to Spleen and Stomach) and various sexual dysfunctions (related to the Kidneys) are widespread due to overwork.

Mental overwork is commonly accompanied by harmful secondary factors: eating low-quality “fast food” at irregular times and foregoing adequate sleep. These are particularly detrimental as they compound the exhaustion caused by mental overwork alone. The dietary irregularities further injure Spleen and Stomach Qi and possibly Stomach Yin. The Stomach and Spleen are responsible for restoring Qi and Blood on a daily basis. If they are not functioning normally, Qi and Blood are not adequately replenished. Sleep provides the deep rest necessary to restore and regenerate Qi, recharging your vitality. With inadequate sleep, that won’t happen.

Excessive physical work can cause many of the same types of Qi depletions as excessive mental work and can create a few other problems. Physical strain can cause Qi stagnation, with or without Heat (as inflammation), and additional Spleen and Kidney harm.

The Spleen dominates the muscles, so any overuse of muscle can weaken Spleen function. Overuse of any particular muscle group causes local Qi stagnation in the overused muscles and their related joints. That’s the root cause of the pain of repetitive stress injury, carpal tunnel syndrome, and other similar afflictions found in relatively sedentary people who type, mouse, or play video games excessively.

Injuries are compounded when combined with carrying or repeatedly lifting heavy objects. Postal delivery workers carry heavy mailbags, usually over one shoulder, and commonly get neck, shoulder, and low back tension and pain. Trash collectors lift trash barrels and toss their contents into trucks, using the same muscles in the same way repeatedly throughout the day.

The heavy lifting done by most construction workers can injure their low backs and knees, two parts of the body that reflect and influence Kidney health. The rapid, heavy vibrations endured by jackhammer operators damage muscle, bone, and nerves, causing numbness and pain. In addition to Spleen and Kidney injury, the Liver may be adversely affected in this case.

A variation of excess physical work is excessive exercise. Sensible exercise should be part of a healthy lifestyle, but when done improperly or excessively it causes overstrain and unhealthy physical stress, often leading to injury. If you typically sit at a desk all week, it’s not a good idea to push yourself to extreme limits during the weekend. This is exactly the cause of the “weekend warrior” syndrome that lands many people in the hospital emergency room with exercise-induced injuries. Similarly, some people seem to wake up one morning and realize they’ve gotten out of shape and immediately begin exercising at or beyond their physical limits in order to lose weight and feel stronger and healthier. Many do lose weight but often have poor muscle tone, appear gaunt, have digestive problems, and have lower energy caused by Spleen Qi depletion from overexercise.

Even when done properly, some exercises are more likely to cause the same types of Qi stagnation caused by overwork. Anyone involved in weight training (whether with free weights, with resistance machines, or by using their body weight for resistance) should incorporate cross-training, including cardio and flexibility exercises. Both promote the flow of Qi and blood, reducing the likelihood of Qi stagnation induced by weight lifting. In China, the wisest among people engaged in the most rigorous and demanding of physical martial practices balance those practices with others specifically designed to move Qi and blood, such as Taiji and Qigong, to reverse harmful stagnations and to increase the amount of Qi available, replenishing what was exhausted. Among those who don’t incorporate softer harmonizing practices, some may become very powerful in the short term but often die young from the accumulated effects of repeated injury (unresolved Qi stagnation and Blood Stasis), and from the declining health of the internal organs due to unreplenished Qi exhaustion.

In the short term, none of these excesses may cause a significant problem. If you need to occasionally make a big push to complete a work project or prepare for a final exam at school, it can cause some immediate Qi depletion. If you then revert back to a more balanced lifestyle, giving yourself the time and rest you need to replenish, you’ll be able to restore your healthy balance in a matter of days. It’s only when overexertion becomes your lifestyle that serious depletion can occur, causing long-term health issues.

Lack of exercise can be just as harmful as overexertion. Recently, even Western medicine has come to realize that excessive sitting, for example, poses many significant health risks, including a higher risk of death in general and from heart disease and cancer in particular. It causes high blood pressure, obesity, and high cholesterol (each of which produces a host of other diseases) as well as milder but still harmful problems such as back pain, muscle degeneration, and foggy thinking. Since the harmful effects of excessive sitting are not fully reversed by exercises, even among those who exercise regularly, a most recent slogan among media pundits and health-conscious Americans is, “sitting is the new smoking.” 13

Chinese medicine understood this approximately 2,200 years ago, as recorded in The Yellow Emperor’s Inner Classic (Huangdi Neijing), a book in two parts. The first part, Simple Questions, lists the Five Exhaustions: Excessive use of the eyes injures the Blood (Heart), excessive lying down injures Qi (Lungs), excessive sitting injures the muscles (Spleen), excessive standing injures the bones (Kidneys), and excessive exercise injures the tendons and ligaments (Liver).

The first four Exhaustions are due to physical inactivity (arguably, most people are physically inactive when overusing their eyes), while the fifth addresses the previously discussed dangers of overwork.

Excessive Sexual Activity

Aside from concerns about sexually transmitted diseases, the idea of sexual activity as a possible cause of pathology is a foreign one in the minds of most Westerners. Chinese medicine contends that excessive sex damages Kidney Jing, the importance of which is discussed in Chapter 5. The depletion of Kidney Jing from any cause creates many health complications and accelerates aging.

Sex can be a charged topic involving significant emotional issues, intimacy and esteem considerations, personal and religious morality, and still a fair amount of titillation—all of which are fodder for the ubiquitous manipulations of advertising, entertainment, and politics—and it shapes our perceptions independent of health considerations. In a memorable exchange between characters on the classic TV show M*A*S*H, Major Charles Winchester, asking about Captain Hawkeye Pierce, says “Why this constant preoccupation with sex?” Captain B.J. Hunnicutt quips, “A lack of occupation with sex.” 14

As much as it is one of the greatest sources of love and joy capable of being shared between two people, sex can also be a source of frustration and misery. In previous times the onus of sexual dissatisfaction was largely borne by women, who were labeled as frigid if they were unwilling or unable to experience sexual pleasure. Now with erectile dysfunction (ED) being the more prominent media focus, that onus has shifted to men. ED has become more of a health problem over the last few decades. This is in large part due to the inescapable plethora of man-made hormone-disrupting pollutants in our food, water, and air from various industrial contaminants and from the inclusion of similar hormone-disrupting chemicals found in plastics (including those in which our food is packaged), the can linings of canned foods, the ink in cash register checkout receipts, and in various cosmetic and personal hygiene products, to name just a few. Since these things appeal to consumer convenience as well as commercial profitability, they are not likely to change any time soon. While these factors were not part of the original landscape of Chinese medicine, they do play a role in contemporary sexual health.

For Men

Men are more at risk of depleting themselves through excessive sex than are women, and this potentially causes many health problems. Every ejaculation expends Kidney Jing and contains between 200 and 400 million sperm, along with hormones and other nutrients. Theoretically, each sperm is capable of creating a new life. This explains in part the stereotype of a man needing to sleep immediately after having sex. Much more energy has been expended than what can be accounted for from the physical activity of sex, even when rigorous. Chinese medical thinking contends that if a man has frequent ejaculatory sex, he expends a great deal of life energy and will consequently age faster, while experiencing the various declines of health that accompany typical aging.

Determining what constitutes excessive sex varies in part according to the criteria of the purpose of the sexual activity. For example, when using sex for spiritual cultivation, as in higher-level tantric yoga and Daoist sexual practices, men are taught to control their ejaculations and have injaculations, rarely actually emitting semen—the famous Tang Dynasty physician and Daoist adept Sun Simiao recommended one ejaculation out of every hundred instances of intercourse—so that energy can be channeled internally for physical rejuvenation and spiritual development. When having such nonejaculatory sex, there are no limits on sexual activity. The practice of ejaculation control is outside the scope of this book, but it is referred to in order to stress the importance the Chinese and other non-Western cultures place on semen retention and its role in preserving health and increasing longevity.

The Qi cultivation practice of Qigong has different criteria that can vary among different systems. Many advanced Qigongs require sexual abstinence for one hundred days while a person begins the practice in order to conserve Jing and Qi, helping to strengthen and consolidate the Qi body so that it may better hold the energetic charge of the practice and speed cultivation. In most Qigong systems, it is at least recommended that men avoid sex for up to two hours before and after their practice times. This ties in with the above understanding that ejaculation depletes a man’s Jing and by extension his Qi, Yang, and Yin. Having sex too soon after a practice will discharge too much energy and undo much of the benefit of the practice. After sex, the body continues to lose Qi for a period of time, until the man is rested and the Qi body is again consolidated. Practicing too soon after sex isn’t harmful, but it’s a waste of time, as it won’t store the Qi from the practice; it’s like pouring water through a sieve.

For men who are not involved in any such practices and are engaging in sex primarily for intimacy, procreation, or recreation, the criteria are purely for preserving health by avoiding undue depletion, which means aligning with the rhythms of nature. Even here there can be some variability, as not every person is physically and energetically the same. What’s excessive for one man may not be for another, based on relative strength, health, and age. It’s important to honestly gauge your personal circumstances to determine what that is for yourself. In his book The Tao of Health, Sex, and Longevity, Daniel Reid cites from “The Plain Girl” (the second book of the Huangdi Neijing, written around 100 BCE) these general guidelines recommended for ejaculatory frequency: At twenty, a man in good health may ejaculate twice per day. For a man of average health or less, no more than once per day. At thirty, a man in good health may ejaculate once per day. For a man of average health or less, no more than once every other day. At forty, a man in good health may ejaculate once every three days. For a man of average health or less, no more than once every four days. At fifty, a man in good health may ejaculate once every five days. For a man of average health or less, no more than once every ten days. At sixty, a man in good health may ejaculate once every ten days. For a man of average health or less, no more than once every twenty days. At seventy, a man in good health may ejaculate once every thirty days. A man of average health or less should abstain from ejaculation entirely.15

In his book The Tao of Sexology, Dr. Stephen Chang reports that some ancient Daoist texts recommend a stricter system, whereby ejaculation frequency in days should be limited to the man’s age × 0.2. That would mean a twenty-year-old should limit ejaculations to once every four days (20 × 0.2 = 4), a thirty-year-old to once every six days (30 × 0.2 = 6), and so on.16 While this too is a recommendation for health purposes and not spiritual cultivation, it is intended for those wanting superior rather than average health.

Since the seasons cycle each year, there is another consideration when aligning with rhythms of nature. Sexual activity should be at its peak during the springtime, when everything in nature is germinating and Yang is growing. During the wintertime, everything in nature is still and dormant, the peak of Yin. Sexual activity should be minimal during this time of conservation of Yang. Daniel Reid quotes the Han Dynasty master Liu Ching, recorded as having lived over 300 years: “In spring, a man may permit himself to ejaculate once every three days, but in summer and autumn he should limit his ejaculations to twice a month. During the cold of winter, a man should preserve his semen and avoid ejaculation altogether. … One ejaculation in winter is 100 times more harmful than an ejaculation in the spring.” 17

Except when working with spiritual, Qi, or longevity cultivation practices, these guidelines do not need to be strictly adhered to in most circumstances. They should serve as reminders, used to preserve or restore health in any instance where excessive sex, however that may be defined for you, may be causing health problems. Here are some indications to look for:

If you find yourself with lower energy for a day or two after having sex—one of my patients referred to it as having a “brownout”—your body is too weak to have sex at whatever frequency is causing that low energy. Other signs may include feeling cold after sex, chronic fatigue, irritability, catching colds easily or other signs of a weakened immune system, frequent day or night urination, dribbling after urination, and low back or knee pain. Loss of interest in sex, lowered libido, and ED are often the result of previously excessive sex. With serious imbalances, it might be necessary to eliminate sex until you have restored your health. Taking medication that treats ED only allows you to further deplete your body when it is already harmfully depleted. The hormone-disrupting pollutants and additives discussed at the beginning of this section accelerate and exacerbate these and other pathological changes related to sex.

For Women

While women are much more hormonally complex than men, they lose comparatively little Jing during sex and orgasm. Consequently, there are no recommended restrictions on frequency of intercourse for women. Women can lose Jing, Yin, Yang, Qi, and Blood during pregnancy and childbirth. Care should be taken to minimize those depletions and restore them to healthy levels as soon as possible postpartum.

One of the Six Extraordinary Yang Organs, the Uterus is both contained within the region of the Dantian and strongly related to the Kidneys. Anything that affects the Uterus can influence all of a woman’s physical energy through the Dantian, including the functional energy of all the organs, as well as influence Kidney Jing, Yin, and Yang. So while pregnancy is a healthy, natural process, it can stress the uterus and other parts of the body, and women may feel changes in their energy levels and overall health while some of their vitality is directed toward growing a healthy baby.

In a normal pregnancy, there are often signs of Liver Qi Stagnation (swollen, tender breasts, dizziness, and emotional changes), Spleen Qi Deficiency (fatigue, food cravings or aversions, hemorrhoids, and bleeding gums), Rebellious Stomach Qi (nausea, with or without vomiting, and heartburn, which may also come from Stomach Yin Deficiency), and various Kidney deficiencies (frequent and increased urination, backache, and vaginal discharge, which may also come from Spleen Qi Deficiency). Headaches are common and may come from various patterns of disharmony, most often involving the Liver or Spleen.

Barring complications, the energy lost during pregnancy and labor should cause no lasting depletion or imbalance for the mother, assuming adequate time is allotted for rest, good nutrition is maintained, and moderate exercise and other restorative practices are followed. However, if a woman becomes pregnant again too soon, before she has had time to recover fully from the previous pregnancy, that can cause a Jing depletion as significant as excessive sex will cause in a man, and it presents many of the same symptoms. Additional symptoms may include menstrual irregularities and chronic vaginal discharge. If that pattern is frequently repeated so that the woman bears many children in a short period of time, it can seriously compromise her health and accelerate aging.

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12. “Salt Tablets,” Internet FAQ Archives, The Gale Group, accessed May 10, 2016, http://www.faqs.org/sports-science/Pl-Sa/Salt-Tablets.html.

13. Marc T. Hamilton, et al., “Too Little Exercise and Too Much Sitting: Inactivity Physiology and the Need for New Recommendations on Sedentary Behavior,” Current Cardiovascular Risk Reports 2, no. 4 (July 2008): 292–98,
doi:10.1007/s12170-008-0054-8 PMCID: PMC3419586 NIHMSID: NIHMS182380.

14M*A*S*H, season 6, episode 5, “The Winchester Tapes,” first broadcast 18 October 1977 by CBS, directed by Burt Metcalfe and written by Everett Greenbaum and James Fritzell.

15. Daniel P. Reid, The Tao of Health, Sex, and Longevity: A Modern Practical Guide to the Ancient Way (New York: Fireside Publishing, 1989), 295.

16. Chang, Stephen T. The Tao of Sexology: The Book of Infinite Wisdom (San Francisco: Tao Publishing, 1986), 84–85.

17. Reid, The Tao of Health, Sex, and Longevity, 295.