Essentials of Complementary and Alternative Medicine (June 1999)

PRINCIPAL CONCEPTS AND BASIC THEORIES
The fundamental concepts of TCM are yin-yang and the five element theory (Wu Xing). These two concepts explain changes in the universe and the phenomena of 
nature, including human beings.
Yin-Yang Theory
According to TCM, the universe is a whole that is made up of the unity of two opposite components (
Fig. 12.1
). Yin usually represents things relatively inactive, 
descending, internal, cold, and dark;  yang usually represents things relatively active, ascending, external, hot, and bright (
Table 12.1
). All physiological functions of 
the body, as well as the signs and symptoms of pathological change, can be differentiated on the basis of  yin and yang characteristics (
Table 12.2
). However, the 
natures of yin and yang are not absolute—they are relative concepts.  Yin and yang are interdependent and can transform into each other. The equilibrium of  yin and 
yang ensures that the harmony of the body is maintained. Normally, a healthy person with no symptoms of illness is considered to have equilibrium between  yin and 
yang. A typical yin deficiency syndrome may be exemplified by menopause syndrome (e.g., hot flashes, night sweats). A typical  yang deficiency syndrome may be 
exemplified by hypothyroidism, with symptoms including pale color, cold limbs, or edema.

F
IGURE
 12.1. The Yin-Yang symbol.
Table 12.1. Examples of  Yin-Yang Opposite Characters
Table 12.2. Syndrome Differentiation According to Yin and Yang
Wu Xing (Five Element Theory)
The five element theory (also known as the five phase theory) in TCM developed from an ancient Chinese philosophy that views the universe as consisting of five 
basic elements: wood, fire, earth, metal, and water. The theory explains the relationships between the human body and the external environment as well as the 
physiological and pathological relationships among the internal organs within the human body (
Table 12.3
).
Table 12.3. Classification According to  Wu Xing: Five Elements Theory
The dynamic physiological relationships among these five elements are shown in 
Figure 12.2
. Interpromotion (see 
Fig. 12.2A
) means that one element promotes or 
generates the other element in the order of wood, fire, earth, metal, and water. For example, wood promotes or generates fire; fire promotes or generates earth. 
Interaction (see 
Fig. 12.2B
) means that one element acts on or controls another in a different order. For example, wood acts on or controls earth; earth acts on or 
controls water (see 
Fig. 12.2
). Each element represents an internal organ in the body. For example, the liver is associated with wood, the heart with fire, the spleen 
with earth, the lung with metal, and the kidneys with water. Clinically, pathological changes occur if these dynamic balances are interrupted or destroyed.
F
IGURE
 12.2. Interpromotion and interaction relationships among the five elements. (Reprinted with permission from Liu G, Hyodo A, eds.  Fundamentals of 

Acupuncture and Moxibustion. Tianjin: Tianjin Science and Technology Translation and Publishing Corporation, 1994:21.)
Major Components of TCM
Major components of the TCM system include Qi, blood, body fluid, the  Zang-Fu (internal organs) , and the Jing-Luo (meridian and collateral systems, or pathways, 
within which Qi and blood are circulated through the entire body to maintain equilibrium). These theories explain how the human body maintains its vitality and health 
physiologicalally.
Q
I
Qi denotes vital energy and is an essential substance for maintaining the activities of life. The origins of  Qi include congenital  Qi, which is inherited from the parents, 
and acquired Qi, which is obtained from the food eaten and air inhaled. According to the location and functional characteristics of  Qi, it has different names: primary 
Qi, pectoral Qi, nutrient Qi, and defensive Qi. In general, Qi has five functions:
1. Promoting
2. Warming
3. Defending
4. Governing
5. Qihua (transforming)
B
LOOD
Blood originates from the food essence developed in the spleen and stomach. Blood is dominated by the heart, stored in the liver, and controlled by the spleen. Blood 
has the function of nourishing the organs and tissues of the body.
Both Qi and blood serve as the material basis for life activities.  Qi is classified as  yang and blood as yin because Qi mainly promotes and warms, whereas blood 
nourishes and moistens. The relationship between  Qi and blood can briefly be summarized as follows:
Qi generates blood
Qi is the driving force of blood
Qi keeps blood flowing within the vessels
Blood is the “mother” of Qi (i.e., Qi originates from and is carried by the blood)
B
ODY
 F
LUID
Body fluid refers to all normal liquids of the body, such as saliva, tears, nasal discharge, sweat, semen, and urine. Body fluid can reach the skin and hair exteriorly, 
and the internal organs interiorly to moisten these organs and tissues. The formation, distribution, and excretion of body fluid is a complicated process involving many 
organs. The key organs in this process are the lung (regulates the water passage), spleen (transports and transforms water), and kidney (dominates water metabolism 
and the reproductive system).
Z
ANG
-F
U
 (I
NTERNAL
 O
RGANS
)
The theory of the Zang-Fu explains the physiological functions and pathological changes of the internal organs through the observation of the outward manifestations 
of the body. The five zang are the solid organs, considered  yin organs, which are the heart, liver, spleen, lung, and kidney. The six  fu are the hollow organs, which 
belong to the yang category, consisting of the gallbladder, stomach, small intestine, large intestine, urinary bladder, and  Sanjiao (triple warmer, which are three 
compartments—above the diaphragm, the abdomen, and the lower abdomen). The physiological functions of the  zang organs are to manufacture and store essential 
substances (e.g., vital essence, which is a function of the health of the kidney;  Qi; blood; and body fluid). The functions of the  fu organs are to receive and digest food, 
and transmit and excrete the wastes. Although some of these physiological functions are similar to those in Western medicine, others are very different. For instance, 
the heart is said not only to control the blood circulation, but also to take charge of mind activities; the main function of the spleen is digestion, which is very different 
from its function in Western medicine.
J
ING
 (M
ERIDIANS
) 
AND
 L
UO
 (C
OLLATERALS
)
The theory of the Jing and Luo describes the energy system of the body that deals with the travel and distribution of the  Qi. The meridians, or pathways, are the main 
trunks that run longitudinally and interiorly-exteriorly within the body, whereas the collaterals, or networks, are the branches running vertically and horizontally 
throughout the body. There are 12 regular meridians and 8 irregular meridians. The meridians and collaterals relate to the  Zang-Fu organs interiorly and connect to 
the extremities and acupuncture points exteriorly, integrating the  Zang-Fu, tissues, and other organs into a whole.  Qi flows through the meridians and participates in 
the homeostatic regulation of various body functions; 361 points are distributed along the meridians and serve as both pathognomic signs of disorder and as loci for 
acupuncture treatments. Thus, the Jing-Luo regulate Qi and blood, balance yin and yang, and keep the functions and activities of all parts of the body in harmony. 
One of the meridians of the Jing-Luo system, as illustrated in a classic textbook from the seventeenth century, is shown in 
Figure 12.3
.
F
IGURE
 12.3. An example of the meridian system: the stomach meridian. It starts from the head and face descending through the anterior part of the trunk and the leg, 
and ends at the toes. This meridian also connects internally with the organs of the stomach and spleen. The acupuncture points on this meridian can be used for 
treating the systems of gastrointestinal and oral facial disorders. (Reprinted with permission from Liu G, Hyodo A, eds. Fundamentals of Acupuncture and 
Moxibustion. Tianjin: Tianjin Science and Technology Translation and Publishing Corporation, 1994:83.)
PROVIDER–PATIENT INTERACTION
Patient Assessment
The pathogenic factors of TCM can be classified into three categories: external, internal, and other (neither internal nor external). The six external factors are wind, 
cold, summer-heat, dampness, dryness, and fire. Normally, they are natural environmental factors and are not harmful to the human body. However, when they are 

excessive, or when the defensive Qi of the human body declines, these six factors may cause diseases and symptoms. The characteristics of each external factor are 
listed in 
Table 12.4
. The internal factors refer to the seven emotions: joy, anger, melancholy, worry, grief, fear, and fright. Any of these emotions expressed too 
strongly or frequently can disturb body processes and cause disease. The other factors include dietary irregularities, obsessive sexual activity, taxation fatigue, 
trauma, and parasites.
Table 12.4. The Properties and Pathogenic Characteristics of the Six Exogenous Factors
The Si Zhen (four diagnostic methods) are the examination approaches for TCM differentiation of syndromes:
1. Inspection
2. Auscultation and olfaction
3. Inquiry
4. Palpation.
The aim of the approaches is to collect and analyze information that reflects the status of the body conditions and to determine the pattern of syndromes.
I
NSPECTION
Inspection refers to the visual assessment of the patient's  Shen (vitality or spirit), complexion, facial expression, posture, color, and nature of the secretions and 
excretions. The observation of the Shen is important in assessing the prognosis; good spirit suggests a favorable prognosis. Another major component of inspection is 
the observation of the tongue, in particular the shape, color, markings, and coating. For instance, a pale white tongue with a white coating indicates a cold syndrome 
and deficiency of yang or blood, whereas a deep red tongue with a yellow coating is the sign of a heat syndrome.
A
USCULTATION
Auscultation is the act of listening to the patient's voice for loudness, strength, clearness, stuffiness, slowness, or rapidity during speaking. The practitioner should be 
aware of any abnormal sounds, such as hiccups, eructation, asthma, cough, dyspnea, and sighing to differentiate the status of a disease.
O
LFACTION
Olfaction is evaluating the odors of breath, body, and excreta. For example, a sour odor in the mouth is often associated with a digestive disorder of the stomach. Foul 
urine is primarily caused by dampness and heat in the body.
I
NQUIRING
Inquiring is the act of interviewing the patient to obtain related information about the patient's illness, including the time of onset, the cause and the course of the 
illness, the location of symptoms, and past history. Inquiring also involves a broad scope of information about the patient's quality of life, including appetite and diet, 
bowel movement, thirst, urination, sleep, dreams, body temperature (chill/fever), perspiration, conditions of the head, eyes, nose, ears, and throat, status of the trunk 
(chest/abdomen/back) and limbs, spirit/emotions, pain, menstruation (cycle, duration, amount, color, quality, cramps, and leukorrhea), and pregnancy.
P
ALPATION
Palpation is a diagnostic method in which the practitioner learns the condition of the patient by palpating the body and the pulse. Body palpation includes using tactile 
sensation to survey for local coldness, heat, softness, hardness, tenderness, abdominal masses or other abnormal situations in the skin, hands, feet, and abdomen. In 
pulse palpation, the practitioner typically uses three fingers (i.e., index, middle, and ring fingers), which are placed on the radial arteries of the wrists. The pulse is 
divided into three sections known as  Cun, Guan, and Chi. The region corresponding to the styloid process of the radius at the wrist is  Guan, with Cun just distal and 
Chi just proximal to it. Each hand has three pulse locations corresponding to particular internal organs: the left hand pulses represent the condition of the heart ( Cun), 
liver (Guan), and kidney (Chi), and the right hand pulses represent the condition of the lung ( Cun), spleen (Guan), and kidney (Chi). The pulse is assessed in seven 
aspects: speed, depth, strength, fluency, size/shape, tension, and rhythm. A normal pulse is smooth, even, and forceful, with a frequency of four beats per breath. 
Classically, 28 types of abnormal pulse have been identified. For example, a superficial pulse means that it is easily felt with gentle, but not with a firmer, touch. This 
often indicates an exterior syndrome, such as the early stages of a common cold. A surging pulse is broad, large, and forceful, like a roaring wave that comes on 
powerfully and then fades away. This often indicates excessive heat (e.g., high fever). A tense pulse feels tight and forceful like a stretched rope. It might be indicative 
of pain.
Differential Diagnosis
B
IAN
 Z
HENG
 (D
IFFERENTIATION
 
OF
 S
YNDROMES
)
The information collected through the four diagnostic methods (i.e., inspection, auscultation and olfaction, inquiring, and palpation) reflects the pathological changes 
of the internal organs and the condition of an illness. The differential diagnosis is based on a comprehensive analysis of this information. Several methods of 
differentiation of syndromes have been developed over the course of the history of TCM clinical practice (
Table 12.5
). Among them, the differentiation of syndromes 
according to the eight principles (i.e.,  yin and yang, exterior and interior, cold and heat, excess and deficiency) can be used for diagnosis in all clinical situations. The 
differentiation of syndromes can also be done according to the theories of the  Qi, blood and body fluids, the  Zang-Fu organs, the six Jing (meridians), and the Wei, Qi, 
and Ying (see 
Table 12.5
).

Table 12.5. Traditional Chinese Medicine: Major Types of Differentiation of Syndromes
An example helps to illustrate the TCM diagnostic approach. A patient presents with a chief complaint of insomnia. In TCM, there are multiple pathologies that can 
cause insomnia. By using the four diagnostic methods, this patient with insomnia is also found to have mental restlessness, palpitations, dryness of the throat, 
backache, nocturnal emission, hot flashes, and night sweats. A red tongue with little coating is observed, and a thin, thread-like and rapid pulse is felt. According to 
the TCM differentiation described previously, this syndrome is identified as “disharmony between the heart and kidney.” Insomnia, mental restlessness, palpitations, 
dryness of the throat, red tongue, and rapid pulse are the manifestations of hyperactivity of the heart. According to TCM theory, the normal functioning of the heart 
includes controlling mental activities and housing the mind. Backache, nocturnal emission, hot flashes, night sweats, and thready pulse indicate kidney  yin deficiency. 
According to the concept of the five elements, the heart is the organ of fire belonging to  yang, and the kidney is the organ of water belonging to  yin (see 
Table 12.3
). 
Normally, heart fire (i.e., the warm nature of the organ) descends to warm kidney water, and kidney water (i.e., the cool and moist nature of the organ) ascends to 
nourish heart fire; the equilibrium of these is known as the “harmony of heart and kidney.” When this physiological relationship is disrupted by pathogenic factors such 
as strain, stress, prolonged illness, congenital deficiency, or obsessive sexual activity, disharmony occurs. In the case just described, kidney water has failed to 
balance heart fire. After the differentiation of syndromes is made, a principle of treatment can be determined to rebalance the disharmony between the heart and the 
kidney (discussed later in this chapter).
THERAPY AND OUTCOMES
Treatment Options
Since ancient times, the first and most important principle of TCM has been the prevention of illness through proper lifestyle. The  Yellow Emperor's Inner Classic 
states that people in the earliest times in China were able to remain healthy because they had a balanced diet, slept and awakened at regular hours, and remained 
active while avoiding excessive stress. They refrained from overindulging in wine and sex, exercised regularly, and protected the body during harsh weather and 
seasonal changes. They were thus able to maintain their health against pathogenic factors (
9
).
Practitioners of TCM carefully observe their patients for signs and symptoms of disease, which can be corrected with lifestyle changes and therapy before the disease 
can fully develop. As Huang Di, the author of the  Yellow Emperor's Inner Classic, said:
In the old days, sages treated disease by preventing illness before it began, just as a good government or emperor was able to take the necessary steps to 
avert war. Treating illness after it has begun is like suppressing revolt after it has broken out. If someone digs a well when thirsty, or forges weapons after 
becoming engaged in battle, one cannot help but ask ‘Are not these actions too late?'(
9
).
There are several basic principles of treatment under the TCM system.
C
ONTROLLING THE
 I
NCIDENTAL
 S
YMPTOM
 (B
RANCH
) 
OF A
 D
ISEASE
 W
HILE
 T
REATING THE
 F
UNDAMENTAL
 C
AUSE
 (R
OOT
)
In urgent situations, one treats the incidental symptom; in chronic conditions, one treats the fundamental cause; and, in complicated cases, one treats both at the 
same time. For example, easing a patient's breathing during an asthma attack would be considered treating the incidental condition. When the patient's symptoms 
have subsided, the fundamental cause of the disease is treated by addressing the deficiency of the internal organ, to enhance and thereby prevent or decrease 
further asthma attacks.
R
EGULATING
 Y
IN AND
 Y
ANG
Conditions are balanced with appropriate measures (e.g., applying heat for the cold condition, applying cold for the heat condition, reinforcing the deficiency, and 
reducing the excess). For example, the patient who has excess heat accompanied by constipation may be treated with herbs that clear the bowel, eliminating the 
constipation and excess heat.
R
EINFORCING
 A
NTIPATHOGENIC
 Q
I
 
AND
 E
LIMINATING
 P
ATHOGENIC
 F
ACTORS
When a person is frequently ill with a common cold, for example, the TCM practitioner focuses on preventing the onset of illness with certain Chinese herbs, 
appropriate diet, and exercise to enhance antipathogenic  Qi. If the person currently has a cold, the practitioner provides Chinese herbs in conjunction with 
acupuncture treatment to eliminate pathogenic factors through sweat.
Description of Treatments
After the principle of the treatment is decided, one or more of the following modalities is then selected: Chinese herbal medicine, acupuncture/moxibustion,  Tui Na 
(Chinese massage and acupressure), mind/body exercise (e.g.,  Qi Gong, Tai Ji Quan, Gong Fu) and Chinese dietary therapy.
Z
HONG
 Y
AO
 (C
HINESE
 H
ERBAL
 M
EDICINE
)
Zhong Yao has been an integral part of Chinese culture and medical practice for nearly 1600 years. The source of the Chinese  materia medica includes plants, 
minerals, and animal parts. Each of the Chinese medicines (or herbs) possesses four natures (i.e., cold, cool, hot, warm) and five flavors (i.e., pungent, sweet, sour, 
bitter, salty). Chinese herbal medicines are classified based on their function, such as heat-clearing, expectorants and antitussive, dampness-eliminating, and 
interior-warming (
1
, 
10
).
Although each herb has its individual functions and indications, classic Chinese herbal medicine uses a combination of various herbs in a formula. The earliest herbal 
formulas can be traced back to the end of the third century 
BC
, when approximately 280 formulas for 52 ailments were recorded in the  Ma Wang Tui tomb document 
(
11
). By the time of the Ming dynasty (1368–1644), more than 60,000 formulas had been recorded in the 1406 book  Formulas of Universal Benefit (Pu Ji Fang) (
2
, 
8
, 
12
). A typical Chinese herbal formula usually includes four components:
1. The chief (principal) ingredient, which treats the principal pattern or disease.
2. The deputy (associate) ingredient, which assists the chief ingredient in treating the major syndrome or serves as the main ingredient against a coexisting 
symptom.
3. The assistant (adjutant) ingredient, which enhances the effect of the chief ingredient, moderates or eliminates the toxicity of the chief or deputy ingredients, or 
can have the opposite function of the chief ingredient to produce supplementing effects.
4. The envoy (guide) ingredient, which focuses the actions of the formula on a certain meridian or area of the body or harmonizes and integrates the actions of 

the other ingredients.
For example, Four-Gentleman Decoction ( Si Jun Zi Tang) is a Chinese herbal formula used for fatigue, reduced appetite, loose stools, pale tongue, and weak pulse, 
which occur because of the deficiency of spleen and stomach  Qi and dampness in the digestive system (
11
). The formula consists of four ingredients: radix ginseng 
(Ren Shen), rhizona atiactylodis macrocephalae ( Bai Zhu), sclerotium poriae cocos (Fu Ling), and radix glycyrrhizae uralensis ( Zhi Gan Cao). Among these, radix 
ginseng is the chief herb. Sweet and warm, it enhances the spleen  Qi. Rhizona atiactylodis macrocephalae is the deputy herb, bitter and warm, which can strengthen 
the spleen and dry dampness. Sclerotium poriae cocos is the assistant herb, sweet and bland, which can assist the chief and deputy herbs in strengthening the 
spleen and leaching out dampness. Radix glycyrrhizae uralensis is the envoy herb, sweet and mild, which can harmonize the other three herbs and regulate the 
spleen Qi. These herbs are formulated to enhance, or tonify, the functioning of the internal organs (in this case, spleen and stomach). This tonification is one of the 
eight common methods used in Chinese herbal therapy. The other seven methods include diaphoresis, emesis, purging, mediation, warming, cooling, and elimination 
(
11
).
Z
HEN
 J
IU