Optimal Healing: A Guide to Traditional Chinese Medicine, 1st Edition

Chapter 5. The Eight Entities 

For several consecutive years in the 1980s, I served on my hospital’s medical quality assurance committee. Our purpose was to analyze hospital cases with less than optimal outcomes and make recommendations for improving the quality of care. One year the committee observed that the hospital autopsy rate was consistently dropping. Ours was a teaching hospital involved in training residents. It was important to maintain a certain autopsy rate for teaching purposes. We brainstormed what factors were influencing families to grant or refuse autopsies. My charge was to research cultural and ethnic biases as factors.

To research the Chinese population, I interviewed my Chinese friends and patients on the subject. The message I kept hearing was that the Chinese prefer to be left whole. The Chinese have a revulsion to being cut, either in life or in death. One patient quoted her mother as saying, “I want to die with all my body parts intact.” A Chinese surgical colleague told me that when he performed a limb amputation, he commonly saved the limb for the family to eventually bury with the patient. I was reminded of the elaborate burial sites discovered in Xian where the emperor was buried with life-sized statues of an entire army.

The Influence of Taoism 

Later, as I read more about the history of Chinese medicine, I discovered what a profound influence Taoism had on it. Taoism’s basic tenet is that there is an order to the universe. That order is maintained by a balance of dualistic forces. Any disruption of that balance results in a catastrophe. The role of man is to live in harmony with that order, the Tao. If anything adverse happens to a person or his family, a Taoist believer assumes that somehow he must have done something by either commission or omission to disrupt the harmony of the Tao. An individual is considered a microcosm, therefore all Taoist principles apply to him as well in regard to health and disease. Being aware of this mindset has helped me to better understand my Chinese patients.

A Western physician colleague once commented that Chinese patients don’t believe in chronicity of disease. They seem to loathe the idea of taking maintenance drugs such as antihypertensives and often stop the drugs once they are told their blood pressure has become normal. From a Taoist perspective, illness comes from an imbalance in dualistic forces; once the balance has been restored, normality should persist.

A family I knew dealt with a member’s death from a heart attack by consulting with an oracle who told them the death occurred because they had painted their house the wrong color. No consideration was given to the patient’s years of chain smoking. To a Westerner this may sound absurd, but not to a Taoist.

Taoism’s pervasiveness runs deep. Many Chinese are not Taoists, but they are still influenced by its thinking. They seem to feel more culpable than other patients for abnormal test results. Chinese patients who test high for cholesterol often exclaim, “Why do I have high cholesterol? I hardly eat any fat.” Less familiar with genetic predisposition to high cholesterol, they subconsciously think their adverse cholesterol report was caused by something they did. When my Chinese patients are diagnosed with a serious disease such as cancer, they often ask about what they should or shouldn’t eat. To a Western-trained physician, the question seems irrelevant, but not to someone steeped in the Taoist worldview.

Taoism idealizes wholeness and forbids anatomical dissection. Consequently, the ancient Chinese were unfamiliar with human anatomy. Taoism, coupled with the Chinese custom of Victorian-like modesty, predestined TCM’s approach to be noninvasive. Prudishness was carried to such a point in ancient times that women did not visit physicians, who were usually male. Instead, their husbands used a doctor’s doll, a carved ivory representation of a nude woman lying on her side. The husband would describe his wife’s symptoms to the doctor, pointing to the ailing part of the anatomy on the doll. Based on that information, the doctor would diagnose and treat the patient. This practice continued until China became a republic in the twentieth century when, under the influence of the American-educated Madame Chiang Kai-shek, the practice was banned.

In imperial times, a court physician was not even allowed to touch a female member of royalty. If a princess became ill, the physician was allowed to feel her pulse only indirectly. This was done via a string bound to her wrist and extended to another room where the physician sat to study the pulsations. This seemed so incredible to me that I sought verification from several sources. One of them was a TCM practitioner who came from a long line of TCM physicians and whose grandfather had been a court physician during the Qing dynasty. He told me that because diagnosing princesses was such an arduously difficult assignment, usually only the best among the court physicians was chosen to treat them.

Court physicians were considered dispensable and were readily beheaded if their diagnosis or treatment was not to the emperor’s satisfaction. During the Han Dynasty in the second century AD, the emperor’s physician was the famous Hua Tuo . He is considered the father of surgery in China. The emperor ordered him beheaded because he did not like the diagnosis of brain tumor Hua Tuo had given him. I often thought how foolish the emperors were to kill off their best doctors. They could not have been that easy to replace.

Understandably, Chinese physicians honed their skills very carefully. Like blind people, who develop a heightened sense of touch and hearing to compensate for their handicap, Chinese physicians, with the limitations imposed by cultural mores, learned to develop noninvasive methods of diagnosis and treatment to a far greater degree than Western physicians ever did. For them, the only tools available consisted of accounts of the patient’s history coupled with keen observation, which included tongue diagnosis, pulse diagnosis, and the use of their four senses of sight, hearing, smell, and touch. It used to puzzle and annoy me that my Chinese patients insisted on bringing me a sample of their stool even when I told them it was not necessary. I now realize that my patients’ practice was a holdover from the TCM custom of smelling excreta as part of the physical diagnosis of disease.

In the West, everything is compartmentalized, whereas in Chinese culture, all elements of life blend together. With the Taoist concept of wholeness, lines drawn between various disciplines are indistinct. Medicine merges with martial arts, religion, and diet. Interrelationships are perceived between the patient and his internal as well as external environment. Elements of a patient’s internal environment include his constitution; his history–such as a severe illness, surgery, or trauma–which might cause weakening in certain organ systems; his food and alcoholic intake; and his spiritual and emotional state. For women, the timing of their menstrual cycles and whether they are pregnant are also considered part of the internal environment. The elements of a patient’s external environment include the stresses of daily life and the season with its climatic changes. In today’s setting, pollution must be considered as well.

My teacher and mentor, Dr. Lai, once saw a patient with kidney failure. When I asked him what the cause of the kidney failure was, he said that the patient was holding three jobs and worked himself to the ground. My reaction was, That doesn’t answer my question. I needed to know what his renal biopsy showed, what was the basis of his disease on a cellular level. I realize now, from an Eastern medical perspective, the patient’s overwork was a major factor.

A patient from northern China once showed Dr. Lai an herbal prescription he brought from his home province in order to get a second opinion. Dr. Lai is a native of Canton, a southern Chinese province with a temperate climate. He astutely noted that the prescription contained far more spicy-warm types of herbs than he customarily prescribed. He explained that in northern China, the weather is very harsh and cold. Northern Chinese herbalists habitually prescribe more warming herbs than southern Chinese herbalists do. He said that since the patient now lived in San Francisco, where the climate is temperate, the spicy-warm components of the prescription needed to be scaled down.

The Eight Entities: Four Pairs of Dualities

Ym/Yang

Out of Taoism evolved the concept of Yin and Yang. These two words represent the two contrasting sides of a prominence, such as a hill or mountain. Yin is the dark, cool, and moist shady side; Yang is the bright, warm, and dry sunny side.

The Chinese observed that throughout the cosmos there seemed to be a dualism requiring balance. In the field of physics, each atom has a positive and negative charge that balances the other (an atomic explosion occurs when they are separated). In visual art, you need both light and shade for contrast. The sun heats; the wind cools. Winter is followed by spring. There is no such thing as a vehicle with an accelerator but no brake. This truth also applies to our bodies. We are female or male. We have a set of muscles that flex and another set that extends. We have a sympathetic and a parasympathetic nervous system. Our hormones have a turning-on and a shutting-off mechanism. Our blood stays in our blood vessels in a liquid form, but if we did not have a clotting mechanism when wounded, we would bleed to death. The Chinese have categorized all these dualistic forces as belonging to either Yin or Yang.

It is remarkable that the Chinese could condense all phenomena into this one simple concept. What comes to mind are the words of a sage Chinese physician who said, “It is simple but not easy.” Whenever there was a disturbance in nature, the Chinese attributed it to an imbalance in Yin and Yang. Table 2 shows some dualities in medicine that fall into the Yin/Yang system of categorization.

Recent medical literature reflects an increasing awareness among scientists of dualistic forces at work in the human body that need to be balanced for normalcy. In TCM, they would be considered Yin/Yang dualities.

Table 2. Yin/Yang Categorization of Common Conditions

The story of COX-2 inhibitors is a prime example. In our aging population, degenerative joint disease is commonplace. Western medicine relies heavily on nonsteroidal anti-inflammatory drugs (NSAIDs) to treat this chronic problem. While the drugs are effective in reducing the pain and inflammation of arthritic conditions, they are well known to carry the risk of stomach ulcers and GI bleeding. The reason for this adverse effect is that the older NSAIDs blocked the production of hormones called prostaglandins. Some prostaglandins cause inflammation, so blocking them was good for arthritis, but some prostaglandins protect the lining of the stomach, so blocking them was bad for the stomach. Traditional NSAIDs are known to block both enzyme pathways involved in prostaglandin production. These two pathways have been named COX-1 and COX-2 for short. Since prostaglandins mainly from the COX-2 pathway caused inflammation and prostaglandins from COX-1 protected the stomach, drug researchers thought that developing an NSAID that selectively blocked only the COX-2 pathway would be ideal. Such a drug would give the patient relief from the pain of inflammation without causing stomach ulcers or bleeding. Their efforts resulted in the development of COX-2 inhibitors.

Table 3. Yin/Yang Duality of the COX-1 & COX-2 Pathways

For a while, it seemed as if the COX-2 inhibitor was going to be the ideal NSAID. Western medicine further found a link between inflammation and colon cancer. It seemed people who used NSAIDs were less likely to develop colon cancer. Therefore, a study was begun to look for the protective effects of COX-2 inhibitors against colon cancer. A large number of patients, all prone to colon cancer, were randomly given either a COX-2 inhibitor or a placebo. The study was to test, after three years, if there was a difference between the two groups’ development of colon cancer. Partway through the study, however, they discovered that people in the group receiving COX-2 inhibitors developed significantly more heart attacks and strokes than those in the placebo group, and the study was stopped. The COX-2 inhibitor drug, Vioxx (Rofecoxib), was voluntarily pulled from the market by its manufacturer (Bresalier, et al. 2005). A more recent study with another COX-2 inhibitor drug, Celebrex (Celecoxib), was completed and showed that subjects taking the drug did have a lower rate of colon tumors but had a higher rate of adverse cardiovascular events. Because of this risk, the drug is not recommended for prevention of colon cancer (Bertagnolli, et al. 2006).

A recent hypothesis was formulated to explain this adverse effect of COX-2 inhibitors. In nature, a prostaglandin called thromboxane, produced through the COX-1 pathway, causes platelets to become stickier, blood vessels to constrict, and the blood vessel wall muscle to grow—all factors that lead to blockage of blood vessels. These effects are normally balanced by prostaglandins called prostacyclins, made through the COX-2 pathway, which have the opposite effect. Prostacyclins discourage platelet stickiness, dilate blood vessels, and discourage the blood vessel muscle wall from growing. When the COX-2 pathway is blocked, prostacyclin production is blocked, and the effects of thromboxane then predominate, making patients more prone to heart attack and strokes (Solomon, et al. 2005). In Eastern terms, thromboxane made through the COX-1 pathway is Yang, and prostacyclin made through the COX-2 pathway is Yin. A balance of the two is needed to maintain normalcy in blood vessels.

In overwhelming infections, such as with meningococcal meningitis, sometimes the patient’s own immune response is so exuberant that it actually harms the patient. It’s as if the body goes overboard in its response to infection, and the excessive production of mediators of inflammation to fight the bacteria cause the host to become sicker. For these cases, Western practitioners use steroids to tone down the host’s unchecked inflammatory response. Recently, medical researchers discovered that a Yin/Yang duality exists in the normal immune response. Some host immune cells make not only inflammatory cytokines but also anti-inflammatory cytokines to balance the response. In fatal cases, however, these bimodal adaptive immune cells that can dampen inflammation die in large numbers, leaving a heightened, unchecked inflammatory response (Hotchkiss and Karl 2003).

Another syndrome receiving much attention, especially with Iraq war veterans, is post-traumatic stress disorder (PTSD). A journal article describes the condition thus: Patients with PTSD have an inordinately prolonged reaction to a traumatic event. They have hyperarousal and frequently relive the event. Researchers found that sufferers of PTSD have abnormally low cortisol levels. In the presence of low cortisol levels, norepinephrine, a fight or flight hormone, acts on the nervous system unchecked. The effect of norepinephrine not balanced by cortisol leads to a constant panic-like state (Yehuda 2002). The TCM observer would interpret PTSD as an imbalance in Yin and Yang. The Yang of norepinephrine is excessive relative to the low Yin level of cortisol.

Besides Yin and Yang, the Chinese established three other pairs of dualities: External/Internal, Cold/Hot, and Solid/Deficient (also called Substantial/Insubstantial). The four pairs of dualities make up the Eight Entities. The Eastern way of disease classification is distinct from the Western way. The East purports that disease originates from an imbalance in the dualistic forces that operate to maintain normality. Eastern practitioners classify diseases in terms of which force is in excess or deficient causing the imbalance. The classification is descriptive in nature. TCM treatment is directed at reversing the imbalances by tonifying (replenishing) the deficiencies. If the patient has an excess of Yang, Yin-promoting treatment is used. If the patient has excess Heat, cooling treatments are used. The key to TCM diagnosis is to find the imbalances.

Yin 

In TCM, there are four kinds of body substance: Qi, Blood, Essence , and Fluid. Qi and Blood have been discussed in chapter 3. Essence  refers to sperm and ova, the sources of life. A common Chinese term, Jing Shen , meaning mental alertness, is a composite of the Chinese words for essence and spirit. Western and TCM practitioners alike recognize that mental alertness is manifested in the eyes. Fluid is everything in liquid form and belongs to the Yin category of the Yin/Yang paradigm.

When we eat, we salivate, and our digestive juices begin to flow. The entire lining of the ear, nose, throat and respiratory tract secretes a filmy liquid called mucous. These fluids have various antibodies protecting us from infections. All these normal fluids are Yin fluids. A deficient supply of Yin fluids causes disease. In a condition called Sjogren’s syndrome, the glands secreting fluids throughout the body stop functioning. People with this condition have very dry mouths and are prone to tooth decay because they lack protective saliva.

One of my patients, Dan, was prone to getting prolonged bouts of coughing after having a cold or the flu. One season, he came to see me at the onset of his flu. I asked him when and how it started. He was able to pinpoint the exact time. It was after a very spicy Szechuan dinner. “As soon as I got home, I could feel my throat getting dry and hurting,” he said. From the TCM perspective, Dan suffered from a loss of Yin fluid, caused by the spicy food, and as a result, he became ill. The TCM treatment he needed was to restore Yin fluid with herbs such as Folium Eriobotryae  and Cortex Mori Radicis  as well as cold-cleansing herbs for his flu.

Yin fluid also represents the entire body’s normal state of hydration. In most cases, Yin fluid connotes a good and normal fluid as opposed to Wet Evil, which connotes pathologic fluid.

Yang 

Yang is on the other end of the spectrum. If Yin represents the parasympathetic nervous system, Yang represents the sympathetic nervous system, which gears the body for fight or flight. It causes the body to be at full alert, with heightened senses, augmented heartbeat and breathing, and so on. With trauma, Yang forces stimulate clotting to go into high gear. In an immune response to outside invasion, Yang forces predominate. Such potent chemicals as interferon or tumor necrosis factor fall into the Yang category. Any inflammatory response also falls into the Yang category.

Heat/Cold

Heat 

The entities of Heat and Cold are similar to Yin and Yang, Heat being Yang and Cold being Yin.

Our lecturer described patients with Heat conditions as being “restless, with red lips, red face, talkative, thirsty, constipated, having a rapid strong pulse, and often having fever.” All infectious diseases fall into this category. They are treated with cold-cleansing herbs, which have antibacterial, antiviral, antipyretic, and anti-inflammatory actions. In addition to infectious diseases, Heat conditions can include such disparate states as dehydration, hyperthyroidism, and mania. The latter conditions are treated with another type of “cold or cooling” herbs that act to decrease sympathetic action and stimulate parasympathetic action.

Cold 

Cold conditions, on the other hand, are those in which “the patient is quiet, pale, with cold extremities, not thirsty, prefers warm liquids, likes to sleep curled up, and has an aversion to cold.” The conditions I could think of that fall into this category are hypothyroidism, dysmenorrhea, and migraine headaches, all seemingly disparate conditions from a Western perspective. To treat Cold conditions, TCM practitioners use warming herbs, which tend to improve circulation.

It used to puzzle me when Chinese patients asked me if their cough was a Cold  or Hot cough  There is no such distinction in Western medicine. After studying TCM, it occurred to me that a Hot cough described an acute respiratory infection, whereas a Cold cough is one that lingers after the acute infection, characterized by fever and colored sputum, has ended. In retrospect, a lingering Cold cough was what I had after my pneumonia. Western medicine now calls it hyperactive airway disease. The scientific explanation for a Cold cough is that after an acute respiratory infection, the lining of the bronchial tubes becomes injured. The normal cilia (hairs), which help sweep away debris, and the mucous secreting glands, which help lubricate the bronchial passages, have not totally recovered their functions. For that reason, the cough reflex becomes hypersensitive, and coughing occurs when there is any increase in the air turbulence in the bronchial tubes caused by breathing cold air, talking, or laughing. The Western treatment principle is to dilate and relax the bronchial tubes with inhaled medications commonly used for asthma.

For a Hot cough, the TCM treatment principle is to clear heat , clean the toxin , rid the sputum , and stop coughing  by using “lowering lung Qi ” herbs. For a Cold cough, the TCM prescription includes the aforementioned but omits the “clearing heat and cleaning toxin” herbs, and, in order to restore normal mucous secretions, adds herbs to “promote lung Yin .“

To the Chinese mind, determining whether something is Hot or Cold is of prime importance, because it determines what type of treatment to choose. Moreover, since the Chinese medical paradigm includes food, patients want the information to guide them in food selection. If someone has a Hot type of illness, he should eat cool  or cold type foods, and if he has a Cold type of illness, he should eat warming  foods (see chapter 11).

Internal/External

After I learned about Cold Evil, the Western equivalent being the flu or other viruses, and the TCM explanation of their mode of entry into the body, the concept of Internal/External was easy to understand. The dual entities of Internal and External describe the early and late stages of an infectious disease.

Internal 

The ancient Chinese believed that infectious agents, such as the flu virus, entered the body through the skin. If the Wei Qi (immune system) were not strong enough to defend the body against it, the virus would advance by invading deeper into the internal organs. Recently, a friend told me her mother had a bout of prolonged fever and consulted a TCM practitioner for it. Curious as to the cause, I asked what the TCM diagnosis was. The practitioner told my friend’s mother she had Internal Heat. That answer failed to satisfy my Western mind, but I now realize that the explanation is as far as this ancient method can go.

External 

Whereas Internal is a more advanced stage of an infectious disease, external refers to an early stage of an infectious disease. This classification is needed because TCM treatment is based on the disease stage. In the early, External stage, “surface relieving” herbs that improve circulation to the skin and extremities are used. In a more advanced stage, “clearing Heat and cleaning toxins” herbs are used.

Solid/Deficient

When these two entities were derived, it was in the context of infectious diseases.

Solid 

A Solid condition describes what happens when someone has an acute infection and his body mounts an immune response to it with fever, rapid heart rate, and so forth. Blood Stasis and ecchymosis conditions (see chapter 3) are considered solid. Most tumors and cancers are similarly called Solid diseases.

Deficient 

A Deficient condition occurs when the body is weakened, fatigued, and enervated. In antiquity, this condition most commonly occurred as the aftermath of a serious infectious disease. Addison’s disease, or adrenal gland insufficiency, with symptoms of severe weakness, fatigue, and lightheadedness, can be considered the extreme version of the Deficient state. Addison’s disease can occur after a bout of tuberculosis where the infection destroys the adrenal gland. In addition to describing generalized debility, Deficiency can describe poor organ function. Someone with weak lungs, for example, is said to have lung Deficiency. The term is also used to describe an abnormally low level of a body substance, such as Yin Deficiency or Blood Deficiency.

After learning about the Eight Entities, I could not help wondering, since so much of TCM is about infectious disease, how is it relevant today, when we can treat infections so easily? If I had a patient with a urinary tract infection or strep throat, I would simply prescribe antibiotics, and the patient would begin to get better within forty-eight hours. Why revert to prescribing herbs? Herbs had to be boiled like a soup. Besides, most of these concoctions tasted so terrible. It seemed so impractical. My next task was to find out how TCM applied to contemporary life.

“The superior doctor prevents sickness; the mediocre doctor attends to impending sickness; the inferior doctor treats actual sickness”