and Five Phases 
My next big challenge at ACTCM was to unravel the mysteries of the Six Evils and the Five Phases. As with studying the TCM organs, I again needed to realize the historical background from which these concepts came and to appreciate how culture influenced Chinese thought.
The Six Evils
The Six Evils are Cold 
Fire
Summer Heat 
, Dryness 
Wetness 
, and Wind 
. During the Shang Dynasty (1800–1051 BC), the Chinese believed it was unhappy demons, the spirits of departed ancestors, that caused disease. Perhaps the living neglected to place food before their ancestors’ altars, perhaps they failed to burn enough incense to honor them, or they had not offered enough otherworld spirit money for them to use. Getting sick was a kind of wake-up call from their ancestors.
Later, in the Chou dynasty (1050–256 BC), beliefs shifted. The ancients saw how climatic changes seemed to influence health and began to believe that evil spirits associated with changes in the weather were the cause of disease. At the time of these TCM writings, infectious disease was the scourge of civilization, but the actual agents of infection, such as bacteria and viruses, were yet to be discovered. The work of Louis Pasteur, Joseph Lister, and Robert Koch, defining the germ theory, occurred in the 1800s; the work of Alexander Fleming, Howard Florey, and Ernst Chai, ushering in the era of antibiotics, did not take place until the 1900s. With only the tool of observation, the ancient Chinese attributed causes to what they were familiar with: changes in climate, believed to be brought on by evil spirits; indiscretion with food or drink; and extreme emotions.
Cold 
According to TCM, Cold evil appears often in winter. It attacks people through the skin. Even today, although we know a virus causes the common cold, the Chinese often continue to attribute colds to not wearing enough warm clothes. Under the skin is where Wei or Defensive Qi runs. Our lecturer explained that the symptoms of external Cold are “fear of cold [chills] and fever without perspiration.” To me, these symptoms sounded like the early stages of the flu.
Our ACTCM lecturer further explained that if the Cold evil overpowered the Defensive Qi, it could penetrate deeper, to the muscle layer, and then to the internal organs. With this progression, the patient would develop “a high fever, thirst, and profuse sweating. The Cold evil then turned into Heat.” This description fit the progression from an earlier to a later stage of the flu, or, for that matter, of any infectious disease.
The idea that the Cold evil, most likely the flu virus, enters through the skin and penetrates into deeper layers sounded preposterous. It is well known that the virus enters through the respiratory tract. Yet, I could see how, intuitively, the ancients would have assumed that it penetrated through the skin. When you first come down with the flu, you feel chilly and have goose bumps on your skin. Then the muscles begin to ache before the sneezing and coughing begin. That the Defensive Qi, most certainly meaning the immune system, runs under the skin seemed equally absurd. If I followed the ancients’ train of thought that the evil entered the body through the skin, though, it would be a logical corollary that the first line of bodily defense would also run under the skin.
TCM teaches that if the Cold evil gains entry into the internal organs, the evil is transformed into Heat, characterized by a high fever, thirst, and sweating. Most infectious diseases are accompanied by fever, so the meaning of internal Heat 
is easy to comprehend. There was even a book (now out of print) called The Heat Diseases, written in English, which was all about the treatment of infectious diseases. The Chinese character, 
, for the term “infection” or “inflammation” (no distinction was made between the two conditions because the cause of infection by microorganisms was not known), actually has two radicals for fire 
, one on top of the other.
I wondered why it was important to distinguish between the early “external” stage of the flu and the later “internal” stage. The reason, I found, is that the TCM treatment for each stage of an illness is different. In early stages of the flu, practitioners use acupuncture and herbs such as Ginger 
, Radix Ledebouriellae Sesloidis 
, and Herba Schizonepetae 
to warm the body. In the later stages, when there is excess Heat, clearing Heat and cleansing Toxin 
herbs (also known as cold-cleansing herbs) like Folium Istadis 
, Radix Isatis 
, Fructus Forsythiae 
, and Flos Lonicerae 
are used. Most cold-cleansing herbs have either antiviral or antibacterial actions.
Fire 
The symptoms of Fire were explained as “thirst, high fever, profuse sweating, bloodshot eyes, reddened face accompanied by delirium, and a bleeding tendency.” With a severe infection such as meningococcal meningitis, high fever with delirium is common; so are hemorrhagic rashes. Fire, then, is the evil causing severe infectious disease. I noted that description and cause are often interchangeable in TCM.
Summer Heat 
Our lecturer listed the symptoms of Summer Heat as “fever, profuse sweating, thirst, lethargy, dry mouth, cracked lips, constipation, and scant urine.” He went on to say, “Summer heat evil can accompany wet evil [inflammation accompanied by fluid overproduction] with an excess intake of cold drinks and raw food, resulting in anorexia, nausea, and vomiting.” The first set of symptoms of Summer Heat could fit either heat stroke or an infectious disease, but the second set, accompanying Wet evil, sounded more like an infectious gastroenteritis, commonly called food poisoning. What, I wondered, distinguished infectious gastroenteritis, an ordinary infection or Heat disease, to make it separately categorized as Summer Heat? It took a while for the answer to dawn on me. Whenever my patients travel to countries where sanitation might be questionable, I advise them to avoid eating cold raw food and encourage them to eat anything that is cooked and served hot. The reason, of course, is contamination. The heat of cooking will usually kill unfriendly organisms. I imagined what it must have been like 3,000 to 5,000 years ago without refrigeration. In the hot summer months, raw food left outside spoiled quickly and people became sick. So of course, the Summer Heat Evil must have been the culprit.
Dryness 
The list of conditions caused by Dryness includes “a hacking cough; blood-tinged sputum; chest cavity pain; fever; dry nose, throat, and sinuses; and fever accompanied by dry mouth, dry skin, cracked lips, dry tongue, and extreme thirst.” All these symptoms typify any respiratory infection, from pneumonia to pulmonary tuberculosis.
Symptoms of internal Dryness include nausea, vomiting, diarrhea, diaphoresis, and bleeding. These symptoms describe an infectious disease such as gastroenteritis, which leads to dehydration. But dryness is a result, not a cause, of these conditions. Are cause and effect being confused? Then I remembered: the ancients were simply saying that the Dryness Evil caused the dehydration. An understanding of Chinese grammar helps explain seeming discrepancies in how Chinese terms are used. Nouns and adjectives are interchangeable in Chinese, so the same word is used for the adjective “dry” and the noun “dryness.” Furthermore, with repeated usage, the term “Evil” was understood and dropped, and the descriptors Cold, Fire, Summer Heat, Dryness, Wetness, and Wind were used alone.
Wetness 
Understanding Wetness was a bit more challenging. Wet diseases involve abnormal fluid accumulation: the body either retains or produces too much fluid. Wet conditions in TCM include “leg heaviness and edema, milky vaginal discharge in the female, cloudy urine in the male, dysentery, and eczema.”
Edema, or excess fluid retention, can have many causes, such as kidney failure, heart failure, or cirrhosis of the liver. Many times, Western medicine uses diuretics to treat it. In TCM, edema is considered Spleen Wetness. Some Spleen herbs such as Sclerotium Poria Cocos 
are diuretics. Simply stated, whenever patients had abnormal fluid retention, the ancients believed the Wet Evil caused it.
Fluid overproduction from inflammation is what vaginitis, cloudy urine, dysentery, and eczema have in common. In all these conditions, the body reacts, whether to an infectious agent or to an allergen, with an immune response. The immune response causes the pores of capillaries, which are the body’s tiniest blood vessels, to open and leak fluid, resulting in tissue swelling and, sometimes, drainage. TCM classifies these conditions as Wet diseases. If the inflammation is from an infection, cold-cleansing herbs are used. If the inflammation is from an allergic reaction, such as with eczema, treatment is directed at controlling inflammation and the allergic response.
Wind 
When it came to Wind, I was stumped. At ACTCM, I was definitely out of my element. Although I was used to being in the minority, being of Chinese ancestry while growing up in white America and being a female entering the male-dominated field of medicine in the 1960s, there had never been a time when I felt more isolated than when I was a Western-trained physician studying at a TCM school. I felt like Gulliver in the land of Lilliputians. No one spoke my language.
Perhaps only one faculty member could understand my question, “What is Wind in Western terms?” Dr. K. was a Western-trained surgeon from China. At the time of the Cultural Revolution when intellectuals and anyone suspected of harboring Western ideas were persecuted, Dr. K. was imprisoned. After ten years, he finally escaped and made his way to the United States. By then in his sixties, it was unrealistic for him to resume his past career, so he began to pursue work in TCM, a field new to him. Like me, he had to learn a completely new paradigm. Perhaps because of the years of imprisonment, he did not volunteer his thoughts too readily. When I asked Dr. K. what he thought Wind stood for, he told me that Wind described diseases that had a rather abrupt onset and tended to move around in the body.
In the West, diseases are classified according to etiology (cause) or anatomic (body) systems. Without knowledge of either, early TCM practitioners classified diseases according to what they observed. They must have noted how wind played havoc with nature. Hurricanes could lift off roofs and cause extensive destruction. Storms came suddenly, often without warning, and moved through an area rapidly and unpredictably.
An English translation of a classic TCM text, Fundamentals of Chinese Medicine, published years after my TCM training, describes Wind thus:
Wind is the chief of a hundred diseases. It is light and buoyant by nature, and most easily invades the upper body and the fleshy exterior, causing headache, dizziness, red and swollen face and eyes. Wind often invades the lung, manifesting as nasal congestion, sore throat, and cough. (Wiseman 1996, 187)
The ancients observed that strong winds such as hurricanes seem to sweep things in an upward direction, lifting off roofs. They surmised that conditions affecting the upper part of the body were caused by Wind. Migraine headaches, sore throat, and respiratory infections are some upper body conditions attributed to Wind. A Chinese patient, while sitting in my office, described her symptoms that were typical of migraine headaches. As she talked, she remarked, “The headaches must be because of my being in the wind.” At that instant, she quickly covered her head with her scarf as if that would protect her from a recurrence. Old beliefs die hard.
Just as the direction of wind is changeable, some diseases such as hives and arthritis seemed to migrate from one location of the body to another. Wind was also thought to cause them.
The sudden and destructive nature of strong winds like hurricanes or tornadoes led the ancients to think that Wind must be the cause of sudden and severe illnesses. Tetanus, a disease caused by a bacteria entering through a dirty wound, is called wound Wind 
in Chinese. The ancients observed that after such a wound, the patient would suddenly get violently ill. In the West, we hardly ever see this disease because we immunize against it.
Stroke, called Wind attack 
, is also a condition with a sudden onset and of a severe nature, but the ancients observed that it seemed to come not from meteorological changes or external Wind but from some process within the body. So they explained these conditions as coming from internal Wind 
. TCM practitioners must have seen the association between people with excessive Liver Yang and the tendency to get strokes. People with too much Liver Yang have an overactive sympathetic system, leading to high blood pressure. TCM explained that excess Liver Yang could be transformed to Liver Wind and lead to strokes. Westerners also recognize that high blood pressure predisposes people to strokes.
Wind, like Qi, is often used in combination with another word to expand its meaning: arthritis is Wind Wet 
; gout is painful Wind 
. Unlike Qi, which can connote desirable or undesirable phenomena, depending on its modifier, Wind usually connotes something pathological. Wind can overlap with other Evils as the cause of some diseases. For instance, either the Cold Evil or the Wind Evil can cause the common cold. Overlapping and even conflicting concepts, while unacceptable to the highly compartmentalized Western mind, is not a problem for the Chinese, who easily reconcile conflicting concepts.
After having overcome the hurdles to understand its terms, I questioned why TCM so tenaciously preserves all these antiquated notions about disease when many concepts have been supplanted by modern science. Why do practitioners still use the term “Liver” when it means the sympathetic system, or “Cold Evil” when they know it is actually the flu virus? I came up with two explanations. One is cultural and the other is pragmatic.
The Chinese are traditionalists. They tend to preserve the teachings from previous generations even when the teachings conflict with newer findings. This peculiarly Chinese custom can be attributed to the interrelationship of two cultural factors: the concept of Face and the practice of ancestor worship, both deeply engrained in the Chinese psyche. Face is the Chinese ideal of preserving a person’s dignity. To save Face, you avoid humiliating or embarrassing a person. Face is what prevents a Chinese from telling you the truth when you ask, “How do you like my cooking?” Face is what prevents a Chinese from airing the family’s dirty laundry in public. Face is what drives patients with unsatisfactory treatment outcomes to find another doctor rather than tell the first one his or her remedy did not work.
Ancestor worship came about from the ancient belief that the world consisted of two groups: the living, inhabiting the physical world, and the dead, inhabiting the spirit world. The two groups had an interdependent relationship. The dead depended on sustenance from the living in the form of food, burning incense, and spirit money. The fortunes of the living were determined by how happy the dead were kept. The Chinese buried their dead on high mountains so that the departed could be closer to heaven. If they could find a mountain whose shape was that of a chair, that was even better. It would ensure that the departed loved one was comfortable in his or her new abode. The living were obliged not only to supply the needs of their dead ancestors but also to preserve their Face. Therefore, anything taught by ancestors, even if refuted by newer discoveries, became immutable. The Chinese would rather be syncretistic and accept multiple, incongruous teachings than risk the chance of offending any dead ancestors.
The other reason why TCM keeps its ancient teachings intact is that its entire system of treatment is based on the ancient ways of diagnosis. Many treatments were developed empirically and worked. Even if the explanation for them was wrong, as long as they worked, and everyone was familiar with the terminology, why change?
There is, for instance, an entire class of herbs called quelling Wind 
herbs. A common one is Radix Ledebouriellae Sesloidis 
whose Chinese name means “prevent Wind.” These herbs are used for early stages of the common cold, hay fever, hives, and joint inflammation. They seem to divert blood flow away from the nasal passages to the skin and extremities. Interestingly, these same herbs are also classified as relieving-surface 
herbs because of the ancient concept that the Cold Evil gains entrance to the body through the skin surface.
In the West, we treat infections with various types of antibiotics, each type tailored to fight the bacteria that tend to invade a particular part of the body. We have a class of antibiotics for fighting respiratory tract infections and another class for fighting skin infections and still another for fighting infections in the intestinal tract or genitourinary tract. We classify these drugs by studying the bacteria that seem to gravitate to certain areas of the body. Similarly, the ancient Chinese had a compendium of herbs for clearing Heat 
. These herbs were further classified as to which types of bodily Heat conditions they were best suited. For respiratory infections, practitioners used Flos Lonicerae 
, Fructus Forsythiae 
, and Folium Istadis 
, whereas for intestinal and urinary infections, they used Radix Scutellariae 
Rhizoma Coptidis 
, and Cortex Phellodendri 
. How were they able to determine these differences without a microscope or a lab? Their diagnostic tool was their sense of smell. Each type of bacteria causing infection gives off its own distinct odor. For the TCM practitioner, this ability to differentiate the type of Heat Evil by the whiff test became highly developed.
Five Phases 
While the Six Evils explain disease from the atmospheric perspective, the Five Phases or Five Elements Theory explains phenomena from an earthly perspective. This system, devised in 400 BC, attempts to explain all cosmic phenomena and their interrelationships. Its launching point is the recognition of five terrestrial elements: Wood, Fire, Earth, Metal, and Water. Each element has distinct attributes.
Wood 
is the bending and the straightening …
Fire 
is the flaming upward …
Earth 
is the sowing and reaping …
Metal 
is the working of change …
Water 
is the moistening and descending to low
places …(Wiseman 1996, 7–8)
Diverse phenomena, such as season, weather, direction, animate development, color, flavor, organs, tissue, and emotions, are classified according to their similarity to the elemental attributes. Regarding organs, some classifications are more self-evident than others. The Heart, associated with blood, which warms the body, is assigned to Fire; the Spleen, involved with transformation of food to energy, is assigned to Earth, which transforms seed to fruit; the Kidney, understandably, is assigned to Water. Others are a bit more obtuse, such as the Liver being assigned to Wood and Lung to Metal.
The system does not stop with just classification. If it did, the older English translation of 
as “Five Elements” would be appropriate. Now it is felt that the more accurate translation of 
is “Five Phases,” because the theory purports that there are interactions between the five elements, called the engendering 
, restraining 
, and overpowering 
cycles, rendering the system dynamic rather than static. Just as the elements interact, the TCM organs correspondingly interact with one another. The Chinese believed that disease begins with an imbalance in these interactions.
What is the relevance of this system to today’s practice of medicine? While there are entire schools of TCM practice devoted to the Five Phases system, I have found it difficult to treat patients by strictly adhering to it. The Chinese mind is typically very supple. Like the bamboo when the wind blows, it will bend rather than break. When I was living in Taiwan, I visited an art studio, shopping for a present for my brother. One painting caught my eye, but I had a couple of reservations. I told the artist, “Most Chinese paintings have a story behind them, and this one doesn’t.” He quickly proceeded to spin out a story for me about the man in the painting. I then said, “I like it except for the colors; they are a bit too dark.” The artist obligingly whipped out his paintbrush and dabbed some white snow on the canvas. The painting is now gracing a wall in my brother’s home. The left brain in a Chinese is permissive. It allows his right brain to bend anything to fit a metaphor. But even the staunchest devotee of the Five Phases system has to admit that adding an extra season just to fit them into the pattern of five is a bit contrived. Treating every patient’s condition using this paradigm is likewise a strain. There is a limit to how far any metaphor can be carried.
Table 1. Phenomena Categorized According to Five Phases Theory
Fig. 1. Five Phases Interrelationships.
Some schools of acupuncture have successfully applied the engendering and restraining cycle to selecting points for needling. The system categorizes herbs by their taste. While there is a relationship between an herb’s taste and its therapeutic properties, finding a correlation between taste and the corresponding organ can also be a strain. Modern books on TCM also point out limitations of the system (O’Connor 1981, 18; Wiseman 1996, 13–14). Nevertheless, the Five Phases Theory so permeates Chinese thought and customs that I realized I needed to be familiar with it as I explored Chinese medicine.
Having studied the Six Evils and Five Phases, my journey into TCM had taken me to ever wider vistas. I was learning not only Chinese medicine but also Chinese history, culture, and philosophy. It was turning out to be a far richer experience than I had anticipated.