The Shang Han Lun (傷寒論, Shānghánlùn) is widely considered as one of the most significant books in the development of Chinese medicine, and an important component for the understanding of Chinese medicine thought. However, there is a vast misconception of its contents, a misconception revealed even by the difficulty in translating the title of the book. The English name – “Treatise of Cold Damage” gives the impression that the book deals mainly with the penetration of cold pathogens into the body. In fact, the Shang Han Lun is an artful and intricate description of the different conformations comprising the human physiology, and of all the pathologies characteristic of each of these conformations.
The misunderstanding comes from a translation gap between the Chinese term “cold” and the English translation of it. We read cold in its narrow sense – having low temperature. However, in its broader sense in Chinese, “cold” (or 寒hán) is also a term which represents all the pathogens that can harm our body. And indeed, the text mentions all the various pathogenic factors, including: cold, heat, fire, dampness, fluids, dryness, phlegm, and blood stagnation. The text details the specific pathogens that tend to cause harm to each of the six conformations and the unique characteristics of the conformations’ pathology. The treatments suggested in the text, focus not only on combating the pathogen, but also on rehabilitating the body through mending the healthy mechanism of the damaged conformation’s qi.
The text supplies the therapist with the tools necessary for differential diagnosis, allowing the identification of both the harmful pathogen and the damaged conformation, and then suggests the accurate treatment accordingly. The text guides the therapist to acknowledge the power and abilities of the Zheng Qi (the vital or upright qi in our body) in each of the conformations, and to help the Zheng Qi deal with the Xie Qi (the evil or harmful qi).
The Shang Han Lun’s theoretical foundation of human physiology is based on the classic Yin-Yang theory: Man is a product of Nature and so man reflects the qualities of Nature and is affected by its cycles. The Ling Shu chapter 71 demonstrates the connection between Nature and the human body:
“Heaven is round, the earth is square. Man’s head is round, his feet are square so as to correspond to the shape of heaven and earth”
(tr. Paul U Unschuld)
The 6 conformations model is an extension of this theoretical understanding. The body has 6 conformations, each with its own characteristic Zheng Qi. 3 conformations possess a Yang quality, and 3 possess a Yin quality:
Su Wen ch. 66:
“The qi of both yin and Yang may be present in large or small quantities, hence one speaks of the three yin and three Yang”
(tr. Paul U Unschuld)
The Shang Han Lun deals extensively with the clinical significance of the physiological and pathological differences between Yin and Yang conformations. Generally speaking, while the pathogen is still in the Yang conformations, we consider the pathology to be an excess syndrome, because the Zheng Yang can still fight the pathogenic factor. However, the moment the pathogen enters the Yin conformations, the Zheng Yang has been defeated and we are dealing with a deficiency syndrome.
The qualities of Yang conformations
Su Wen ch. 6 describes the functionality of each of the Yang conformations as a part of the whole body:
“Tai Yang governs the exterior and is in charge of opening and dispersal. Yang Ming governs the interior and is in charge of closing and storage. Shao Yang governs the space between the exterior and interior and is in charge of pivot mechanism. The activities of the three channels are not in conflict but are intimately related, and their combined name is one Yang”
(tr. Greta Young)
“Governs the exterior and is in charge of opening and dispersal”: in the Tai Yang conformation, the Yang is at its strongest. According to the Shang Han Lun line 9, the Tai Yang conformation peaks between 9am and 3pm, when the sun is highest in the sky and shines the brightest. The body’s Tai Yang derives its power from the sun, making it more dynamic and open to the outer world. It is this quality of the Tai Yang that allows it to naturally interact with the outer world, and so act as the body’s defense system. The Yang in the Tai Yang conformation flows and acts in the outer part of the body, warms and nourishes the muscles, regulates body temperature, controls the skin pores, and protects the body from external pathogens.
Shang Han Lun line 1 describes the outline of a Tai Yang pathology:
“In disease of greater Yang, the pulse is floating, the head and nape are stiff and painful, and there is aversion to cold”
(tr. Craig Mitchell, et al)
This first line describes a framework for all Tai Yang pathologies. These three symptoms represent the essence of Tai Yang disharmony:
- Floating pulse – represents the tendency of Zheng Qi to rise upwards and outwards to fight the intruding pathogen. Additionally, this can manifest as the sudden onset of superficial rashes, itch, heart palpitation, hyper-reaction to external stimuli, etc. The image is of an alert body, going to battle against an external intruder. This leads to both physical and emotional sensations of strong activity in the outer body layers.
- Occipital head ache and stiff nape – pain and stiffness are indications of damage to the movement of the Wei Qi. The occipital area and the nape of the neck are specific areas where the Tai Yang channel flows. However, as later lines will demonstrate, the Tai Yang conformation affects not only the head and nape, but the entire spine, and the general function of all the muscles in the body. Stagnation in the flow of Wei Qi can also manifest as stuffy nose with heavy breathing, shortness of breath, and general muscle pain or discomfort.
- Aversion to cold – in situations where there is external damage to the Tai Yang, the aversion to cold is a result of damage to the external Zheng Qi – the Wei Qi or protective qi, responsible for warming the skin and muscles.
To accurately diagnose Tai Yang damage, all 3 symptoms need to present. So, for example, difficulty breathing without aversion to cold and without over stimulation of the external body layers can point to pneumonia – which is already an internal disease.
“Governs the interior and is in charge of closing and storage”: in the Yang Ming conformation, the Yang aspect of expanding and radiating outwards, is less significant. According to the Shang Han Lun line 193, the Yang Ming conformation reaches its peak between 3pm and 9pm. During the afternoon and evening the sun is much weaker than during midday, and so we don’t feel its warmth externally. However, as external heat has been absorbed during the day, it has accumulated inside the body even after sunset. We can see a similar phenomenon in sea water – while the sun is hot in the morning, the water itself is cool. In the evening, after absorbing the heat of the sun throughout the day, the water will be warmer and retain the heat long after sunset.
And so we can understand the mechanism of the Yang Ming conformation. It deals with Yang absorbed and accumulated internally. While its power can’t be seen externally, it has much power and strength internally. The Yang Ming conformation acts with the strength of the stomach and large intestine organs and channels. It controls the digestive system of the body including receiving food, letting it digest and ferment, and preparing it to be transformed, absorbed, and finally excreted. The heat from the Yang Ming conformation radiates internally into the Tai Yin conformation, working in a cooperation that is necessary to the functionality of the body metabolic system.
Yang Ming pathology is outlined in line 180 of the text:
“In disease of the Yang Ming, the stomach domain is replete”
(tr. Craig Mitchell, et al)
Additionally, Ling Shu ch. 2 states:
“The large and small intestines pertain to the stomach which is Yang Ming”
(tr. Greta Young)
Indicating that disease in the Yang Ming refers to sickness in the digestive system, including the stomach, large, and small intestines.
What does replete mean? Replete (or excess) is discussed in Su Wen ch. 28:
“When evil qi is abundant, it is excess; if essential qi is depleted, it is deficiency”
(tr. Greta Young)
Excess is determined according to the state of the Zheng Qi vs. the presence of the Xie Qi: if any pathogenic factor is present, it is an excess state. If the Zheng Qi is weak, it is a deficiency state. So, according to the definition of Yang Ming pathology in Shang Han Lun line 180, Yang Ming damage is a state of pure excess, i.e. a pathogenic factor is present, and the Zheng Yang is not deficient. The text describes the main pathogenic factors that have tendency to harm the Yang Ming conformation, as heat and dryness.
As stated before, an important characteristic quality of the Yang in the Yang Ming conformation is the immense power hidden in the heat absorbed into the body. And so, every pathology of the Yang Ming conformation will be accompanied by an aggressive and powerful reaction. This kind of reaction includes various symptoms of the channel, along with what we call “the 4 bigs” – big heat, big thirst, big sweating, and big pulse. This presentation represents the intensive reaction of Yang Ming conformation. Additionally, damage to the organ presents an extreme stagnation of the intestines with constipation, stomach ache, and hard stomach. These symptoms testify as well to the excess and intensity of the body’s reaction. Whenever Yang Ming is harmed, the following symptoms present very clearly the Yang reaction of this conformation:
- Aversion to heat – often with excessive sweating. In the Yang Ming there is abundant heat accumulated within, which is necessary as a resource for various internal functions. Therefore, when the conformation reacts to a pathogenic factor, it naturally produces intense heat. This heat might sometimes appear only during the afternoon or the evening, when the Yang Ming qi is most active.
- Thirst with strong desire to drink – this symptom points to the damage extreme heat can do to the body and specifically to the stomach fluids. This kind of thirst relates to the character of the condition of the Zheng Qi in the syndrome characterizing the Yang Ming: Thirst does indicate damage to the body fluids, but the ability to drink large amounts indicates there is no weakness of Zheng Qi in the conformation.
“Governs the space between the exterior and interior and is in charge of pivot mechanism”: Of the three Yang conformations, Shao Yang has the weakest Yang, hence its name – shao (small). According to the Shang Han Lun line 272, Shao Yang peaks between 3am and 9am. Shao Yang is similar to the sun at sunrise, it isn’t blinding or hot, but its appearance fills the world with vitality, movement and light. This is also the effect of the Shao Yang conformation on the body – it invigorates and moves, gives the sensation of excitement, vitality and strength, motivating all the body processes, both emotional and physical.
The Shao Yang conformation acts with the strength of the organs and channels of the gallbladder and triple heater. Through the triple heater, the Shao Yang affects the function of the Tai Yang. Through the gallbladder, the Shao Yang affects the function of the Yang Ming. Shao Yang is the driving force and catalyst for both internal and external processes, and therefore, an integral player in both the immune system and the digestive-metabolic system. Moreover, it is the axis allowing the external Tai Yang conformation and the internal Yang Ming conformation to communicate with one another in a productive regulating way, crucial to the healthy functioning of the body.
Another interpretation of seeing Shao Yang as half internal half external relates to its anatomic location:
- The bladder channel flows on the back of the body, seen as external. The stomach channel flows on the front of the body, seen as internal. The gallbladder channel flows on the sides of the body, between internal and external.
- Tai Yang governs the external tissues of the body, i.e. skin, muscles, and upper respiratory system. Yang Ming governs the internal organs of the body, i.e. the digestive tract. Shao Yang governs the areas between the external and the internal, i.e. diaphragm, connective tissues, thoracic cavity, and gallbladder organ.
Shao Yang pathology is outlined in line 263 of the text:
“in disease of the lesser Yang, (there is) a bitter taste in the mouth, dry throat, and dizzy vision”
(tr. Craig Mitchell, et al)
This line defines the general framework for Shao Yang disease. The three symptoms shouldn’t be seen as the main symptoms, but as examples hinting to the characteristics of the conformation in its pathological state. A tendency to fire, and to qi and phlegm stagnation:
- Bitter taste – bitter is the taste associated with fire. The Shao Yang’s Yang is weak, but full of vitality. So when a pathogen interferes with its normal function, pathological fire can very easily develop. Additional symptoms can be red eyes, dizziness, pain, tinnitus and even deafness, disquiet, and fever. In some cases we can see alternating heat and cold more relevant to channel pathology, or ongoing heat, more connected to the organ. Alternating heat and cold is a good example of the character of the struggle between the conformation’s Yang and a penetrating pathogen. The Yang is vital and vigorous, and so it can create heat. It is however weak, and so cannot maintain the struggle too long, allowing the pathogen to temporarily take over and cause chills. Some scholars attribute alternating heat and cold to represent any disease of progressing/remitting nature, with unclear progress.
- Dry throat – This symptom signifies the ability of Shao Yang pathology to damage body fluids. Unlike the great thirst of Yang Ming pathology, Shao Yang thirst isn’t accompanied by a desire to drink. The nature of the damage to body fluids in common Shao Yang pathology has more to do with the appearance of phlegm due to interruptions in the flow of body fluids in the triple heater. The clinical manifestation of phlegm can be in all parts of the body, as the triple heater affects the entire body.
- Dizziness – This symptom represents the tendency of Shao Yang pathology to manifest as damage to the ability to control the flow in the body. Since the Shao Yang layer acts as the axis between internal and external, controlling flow in the body is an important part of its healthy function. Shao Yang pathology will include qi stagnation along the Shao Yang channels and in its organs. This can present as dizziness, vertigo, temporal headaches, sensations of pain or fullness in the chest, stringy pulse. Along with the physical symptoms, there is great importance to the emotional and mental aspects associated with Shao Yang pathology. The symptom here is an emotional state where the patient is detached from the vitality inherent to the Shao Yang, and so unable to feel joy, happiness, excitement, or interest.
Line 97 of the Shang Han Lun states:
“the zang and fu are interconnected, and (so) the pain will be low (down), the evil is high (up)”
(tr. Craig Mitchell, et al)
High and low here refers to the 5 elements control cycle, the controlling element is called “high” while the controlled element is called “low”, e.g. in the wood-earth relationship wood would be high and earth would be low. Meaning, the clinical presentation of the liver qi stagnation syndrome is related to the Shao Yang conformation (and not necessarily to the Jue Yin conformation). Pathology in this conformation presents as mood swings, headaches, hypochondriac pain, frontal headaches, eye pain, vision problems, etc.
The wood–earth relationship is also clinically manifested very clearly in Shao Yang pathology:
- The gallbladder affects the digestive system, and in pathological cases attacks the stomach, leading to nausea, vomiting, and rebellious stomach qi. This can also result in constipation.
- Liver attacking spleen will cause symptoms of stomach pain and general stomach discomfort, interchanging diarrhea and constipation, etc.
In conclusion, after deconstruction of the Yang conformations into separate qualities and pathologies, let us remind ourselves the end of the quote from the Su Wen describing the conformations:
“The activities of the three channels are not in conflict, but are intimately related, and their combined name is Yang”
— Translated from Hebrew by Ariel Levental —