The Concept of Disease in An Ancient Chinese Medical Text,: The Discourse On Cold-Damage

The Concept of Disease in an
Ancient Chinese Medical Text,

The Discourse on Cold-Damage
Disorders (Shang-han Lun)
Downloaded from http://jhmas.oxfordjournals.org/ at New York University on June 24, 2015

DEAN C. EPLER, JR.
?HERE was no single or unified concept of disease in

the texts that were compiled during the formative
period of Chinese medicine between the fourth century
B.C. and the third century A.D. Some authors saw
disease primarily as a collection of manifest symptoms,
while others understood it as an alteration to a normal
underlying physiological condition. Still others viewed it on the basis of
numerological correlations and microcosm-macrocosm interactions.
There were thus three different levels in the presentation of disease. Often
two or three of these levels may be found in a single text. A particularly
useful work to illustrate something of the diversity of disease concepts
in this early period is the second century A.D. treatise, the Discourse on
Cold-Damage Disorders, by Chang Chung-ching. It is one of the most
important and influential of all Chinese medical texts, one which deals
with most of the major epidemic and infectious diseases as well as a host
of common ailments.
Little is known of the author of the Discourse on Cold-Damage Disorders.
He was born around A.D. 150 in what is now Honan province and died
in 219, so was a near contemporary of Galen.1 As was the usual practice
at the time he received his medical education by serving as an apprentice
to an established physician. He was also said to have been granted a
1. Most available material on Chang's life can be found in Okanishi Tameto, Sung t-ch'ien i-chi-k'ao
(Researches on Medical Works of the Sung and Earlier), 4 vols, Taipei, Ku-t'ing Book Company, 1969,
2, 313-3 26. There is no information on his family background but it was most likely upper-class.
© I 9 8 8 BY THE JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, INC.
ISSN OO22-5O45 VOLUME 43 PAGES 8 TO 35
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Epler : An Ancient Chinese Medical Text 9
scholarly degree and to have been appointed to the government bureau-
cracy, but there is some confusion about this.2 In the preface to his treatise
he wrote that many members of his family and clan had died during
epidemics of feverish diseases. Finding no useful remedies to help them
he was led to study "the ancient medical texts" and to collect medicinal
formulas which then formed the basis of his discourse on disorders
caused by cold. His opinion of the practices and knowledge of other
physicians of the day was harsh. He claimed that they neglected to
consult the classic texts, relying instead on a quick glance and a glib

tongue.3 At the same time, he was critical of his fellow scholars and
officials whom he accused of ignoring the study of medicine and concern-
ing themselves only with a quest for power and personal profit. Their
lives, he stated, were too important to entrust to "common physicians"
yet without medical skills they would be helpless in the face of illness.
Hence medicine, in both theory and practice, was not considered the
prerogative of a professional medical caste but was a subject to be pursued
by all members of educated society. The scholar-official was expected
to be able to use his medical knowledge; it was not a topic of purely
theoretical or philosophical interest. The distinction between him and
the professional was not one of knowledge but was due mostly to the
fact that the latter earned his living through his practice.4
As is the case with other ancient Chinese medical texts, the original
form of Chang's text is now unknown. Initially entitled a Discourse on
the Diverse Disorders Caused by Cold Damage (Shang-han tsa-ping lun),5 it
was first edited within a century of Chang's death by an imperial physi-
cian, Wang Shu-ho, an author in his own right of an extensive study of
pulsation. Later, in the twelfth-century, the text passed through the hands
of a government bureau established to prepare editions of all the old
medical classics. Not long afterwards, in 1143, another edition was pre-
pared by the physician Ch'eng Wu-chi who appended a commentary
2. Okanishi, (n. i) (Researches), 2, 313-314.
3. Shang-han lun (Discourse on Cold-Damage Disorders), Preface. There are many editions of this
text; the two consulted for this paper are: Chang Chung-ching, Chu-chieh shang-han lun, with
commentary by Ch'eng Wu-chi, Shanghai, Commercial Press, 1955, and the Chu-chieh shang-han
lun with additional collation by Wang Chi-ch'uan, Peking, People's Hygiene Press, 1978. Chu-chieh
means explanatory notes. References are to chuan (chapter) and sub-chapter of both editions and to
page number of the Commercial Press edition.
4. For a biography of a professional physician who was in practice about Chang's time see
Kenneth DeWoskin, trans., Doctors, Diviners, and Magicians ofAncient China. Biographies ofFang-shih,
New York, Columbia University Press, 1983, pp. 140-152.
5. This title has been translated "Cold Noisome and odier Diseases" by Manfred Porkert in The
Theoretical Foundations of Chinese Medicine, Cambridge, MIT Press, 1974, p. 71.
io Journal of the History of Medicine : Vol. 43, January 1988
and separate explanatory text.6 These later editors were not historians
attempting to preserve or restore a text; they were concerned with its
practical use and stated in their prefaces that they rearranged and some-
times excised or modified passages that did not seem clear.7 Furthermore
at some time part of the original Discourse may have been lost, since it
was first described as having sixteen chapters (chuan) while later cata-
logues list it with ten.8 It has also been suggested that many of the
passages dealing with pulsation may have been inserted by Wang Shu-ho
and this is certainly plausible.9 Thus it is obviously not possible to de-

scribe Chang's medical thought as completely or with the same degree
of certitude as is possible for much of the work of Galen, for example.
Chang's treatise, in its present form, does not contain any extended
discussion of human biology or medical theory. It consists of a collection
of formulas and short passages, often somewhat disjointed, whose over-
all organization is vague. Descriptions of diseases and syndromes, diag-
nostic principles, explanations of pathology and physiology, discussions
of etiology, and recipes for medicines are not always presented in a fixed
and consistent order. Chang's main purpose was to provide a practical
textbook for readers who he assumed had a knowledge of medical prin-
ciples and basic terminology. Because the Discourse was not intended as
an inquiry into the theoretical nature of illness, there is neither a general
definition of disease nor a consideration of the wider aspects of it.'"
Disease itself is an arbitrary designation, one which is culturally influ-
enced and closely related to values." It has been described in moral,
6. On Ch'eng Wu-chi and his edition sec Okanishi, (n. i) (Researches), i, 359-371.
7. On the Sung medical bureau see Miyashita Saburo, "Sogen no i-ryo (Medical care in the Sung
and Yuan dynasties)," in Yabuuchi Kiyoshi, ed., Sogen jidai no kagaku gijutsu shi (Tlie History of
Science and Technology in the Sung and Yilan Period), Kyoto, Kyoto University Institute for Humanistic
Science, 1967, 123-170. Also, Robert P. Hymes, "Not quite gentlemen? Doctors in Sung and
Yuan," Chinese Science, 8: 9-76, 1987.
8. It is often suggested that a text called the Chin-leuei yao lileh (Survey of the Essentials of the Golden
Casket), ascribed to Chang, may contain some of the missing chapters but this text has a great many
Sung additions and differs considerably from the Discourse on Cold-Damage Disorders. See Okarushi,
(n. 1) (Researches), 2, 379.
9. See Yabuuchi Kiyoshi, ChQgoku bunmei no keisei (The Formation of Chinese Culture), Tokyo,
Iwaname Book Company, 1974, p. 309.
10. For general discussions of the medical ideas of this period see Yabuuchi, (n. 9) (Formation),
pp. 291 ff. and Miyashita Saburo, "Chugoku kodai no shippei lean to ryohO (The ancient Chinese
view of disease and therapy)," Tihd Gakuhd, 30: 227-252, 1959.
11. See Lester King, "What is disease," Phil. Sci., 21: 193-204, 1954, and Henry Cohen, "The
evolution of the concept of disease," in Brandon Lush, ed., Concepts of Disease, Oxford, Pergamon
Press, 1961, 159-169. Among other articles consulted on the natureof disease were Horacio Fabrega,
"The scientific usefulness of the idea of disease." Persp. Biol, 22: 545-554, 1979; Horacio Fabrega,
"Concepts of disease: Logical features and social implications," Persp. Biol., 15: 583-615, 1974;
12
physiological, anatomical, psychological, and social terms. In the his-
tory of Western medical thought, diseases have been seen both as entities
each with their singular and recognizable characteristics and as deviations
from the normal states of individuals.13 In the Discourse the general word
for disease is ping. It is not the equivalent of any single English word.
There was not the distinction, for instance, that is sometimes made
between "disease" as what is treated by the physician and "illness" as an
"experience of sickness" or what is suffered by the patient.14 Ping was
used for both chronic and acute conditions, including wounds and le-

sions, for both serious or fatal ones as well as for only discomfort (dis-
ease).15 It was also used to indicate an underlying physiological state: an
organ or vessel would be called ping when, in a typical case, its healthy
or normal pneuma (ch'i) was deficient or plethoric. Perhaps its most
frequent usage is.in a similar sense to "syndrome" or a collection of
symptoms. A translation that encompasses some of this range of usage
is "disorder" but that word is not always appropriate. The following
passage will serve as an illustration of ping in context:
(i) In those with dampness-disorder (shih-ping), the upper part of the body is
aching and painful. There is a fever, the face is sallow, and the breathing labored.
There is a headache; the nose is blocked and irritated. The pulse is large. The
sick person (ping-jen) is able to eat and drink naturally. [Conditions] in the
abdominal region are harmonious and without disorder (ping); the disorder [and
the symptoms] are in the head. [The head] has been hit by cold and therefore
the nose has become blocked. If medication is taken in through the nose, then
[the disorder] will be cured.16
This description could be that of the common cold. The presentation
has several familiar elements; it is a clinical picture with a name, etiology,
symptoms, brief pathology, treatment, and prognosis. It shows how
ping means the overall condition (dampness-disorder), localized symp-
Lelland J. Rather, "Towards a philosophical study of the idea of disease," in Chandler McC. Brooks
and Paul F. Cranfield, eds., The Historical Development of Physiological Thought, New York, 1959,
PP- 35O-373-
12. See Walter Riese, The Conception of Disease: Its History, Its Versions, and Its Norms, New York,
Philosophical Library, 1953.
13. See Cohen, (n. 11), and Owsei Temkin, "The scientific approach to disease: Specific entity
and individual sickness," in Owsci Temkin, Tlie Double Face ofJanus, Baltimore, Johns Hopkins
University Press, 1977, pp. 441-455.
14. This distinction is not always made; see for instance Christopher Boarse, "On the distinction
between disease and illness," Philos. and Pub. Affairs., y 49-68, 1975.
15. Lester King, Medical Thinking. A Historical Preface, Princeton, Princeton University Press,
1981, p. 140.
16. Chang, (n. 3) (Discourse), 2.4, p. 57.
12 Journal of the History of Medicine : Vol. 43, January ig88
toms (those in the head), and the underlying physiological state (harmony
in the abdomen and disorder in the head). Here a characteristic of the
written language is important: there was no distinction between singular
and plural and so not only can ping equal the whole of the English phrase
"symptoms of a disease" but also "diseases," "symptoms," "syndrome,"
and "syndromes."
Chang did not use the word when he wished to single out one or
another symptom. He would not, for example, refer to the blocked nose
or the headache of "dampness-disorder" as ping. When he wanted to

mention only a symptom, in its meaning either as subjective evidence
of disease or as a manifestation arising from a disease, he would use the
form of "those who are vomiting" or "those with nose-bleeds" or "those
suffering from diarrhea."17
There is one term that appears in a few passages in this treatise that
does mean "symptom" or at times "sign" (as objective evidence of disease
perceptible to the physician).18 The word is hou, which was occasionally
used by Chang when writing about specific forms of pulsation. In general
usage, hou can mean to await or expect, to ask after, or to foretell. In
Chang's and other early medical texts a given rate or amplitude of the
pulse would be called hou and it is in this sense that it is the equivalent
of a sign, or evidence meaningful to the physician but not to the patient.
For instance, "The joints are aching, painful, and irritated. The pulse is
deep and slender: this is said to be a sign (hou) of 'dampness-
rheumatism.'" 19 The term hou is used extensively by some authors but
is comparatively rare and not of major significance in Chang's text.20
Another term that could indicate symptoms of disease was cheng, a
word that in general usage meant evidence, testimony, or proof. In the
Discourse it was a word which could be used to describe a syndrome that
dictated a given treatment or, in other words, it meant "indications" that
called for a certain remedy. For example, fever, perspiration, and stiff
neck were indications that called for the administration of a decoction of
cassia bark.21 In one case cheng was used to refer to a set of symptoms
17. Ibid., 3.6, p. 94; 6.12, p. 202.
18. Dodand's Medical Dictionary, Philadelphia, W. B. Saunders, 26th edition, 1981, p. 1200. Also
sec Lester King, "Signs and symptoms,"JAMA., 206: 1063-1066, 1968.
20. For examples in other ancient texts see Mo-diing (Canon on the Streams), Mo-ching chiao-shih
edition, Peking, People's Hygiene Press, 1984, 4.1; Huang-ti nei-ching su-wen (Inner Canon of the
Yellow Emperor: Plain Questions), Peking, People's Hygiene Press edition, 1978, 20; and Nan-ching
(Canon of Difficult Issues), Nan-ching cheng-i edition, Taipei, World Book Co., 1972, 16 and 18.
21. Chang, (n. 3) (Discourse), 4.7, p. 133. Agren gives a Western analogy to this concept: "to
22
indicating that a condition was improving. The use oicheng as "indica-
tions" reflects the significance of treatment in Chang's medical thought,
of symptoms first and foremost as something to be treated.
Of the three terms used in discussions of disease, ping, hou, and cheng,
the first, ping, was overwhelmingly of greatest importance in Chang's
text. Disorders {ping) were defined and described by Chang on two
levels. On the first level, he has used only manifest symptoms as the
basis for identification and a system of classification. Conditions were
named either for their etiology (dampness-disorder, cold-damage disor-

der) or for a major symptom (feverish or heat disorder). The conditions
so named were classified and distinguished from each other only by
differences in visible symptoms; there were no references to underlying
anatomical or physiological changes. There is an obvious problem here:
many individual cases of illness may appear in some respects similar to
each other, to follow the same pattern, yet also will have many variant
symptoms or features. If each variation is considered a separate species,
there will be nearly as many diseases as there are cases. Chang and other
ancient Chinese writers recognized that one disease could appear in varied
forms. They proposed that a single causative factor, cold or heat or wind,
could produce a number of syndromes all sharing two or three identical
symptoms. A disease at this conceptual level, therefore, was defined not
by a complete or generalized clinical picture but instead on the basis of
two or three predominant symptoms. This can best be made clear by
three examples from the Discourse.
First there is a condition called "dampness-disorder," thought to be
caused by a damp or moist atmospheric factor. This disease is defined
or delimited by three symptoms: "In those in whom dampness has
produced a disorder, the entire body is aching, there is a fever, and the
body appears to have a dusky sallow hue."23 These three symptoms
represent the defining characteristics of the disease and those syndromes
sharing to some degree these three were classified as dampness disorders,
even though they may have differed in other respects. One example of
such a syndrome has been given in the translation (1) above: it has the
label a dinical picture of labial cyanosis, dyspnea, and leg edema a 'digitalis manifestation type,'"
would be similar. See Hans Agren, "Patterns of tradition and modernization in contemporary
Chinese medicine," in Arthur Kleinman et al., eds., Medicine in Chinese Cultures: Comparative Studies
in Health Care in China and Other Societies, Washington D.C., Department of Health, Education,
and Welfare, 1974, 37-51, p. 39.
23. Ibid., 2.4, p. 55.
three defining symptoms (aches, fever, and saUowness) plus a blocked
nose, headache, and normal appetite. There can be wide variations in
the additional features of this disorder:
(2) An individual with dampness-disorder may perspire but only from his head.
His back is stiff and he wishes to be kept well-covered and sit by the fire. If he
was given a purgative prematurely then there will be vomiting. There is fullness
in the chest and urination is not easy. There is a white coating on the tongue.
There is heat in the groin [lit., the field of cinnabar] and cold in the center of
the chest. He is thirsty and wants water and if he is not able to drink it, then
the mouth is parched and irritated.24

While this syndrome is difficult to identify exactly, most of the dampness
disorders were probably cold and flu-like ailments. The symptoms in
this as well as other categories of disease are usually manifest abnor-
malities and mostly unpleasant, high in what elsewhere has been nicely
called "intrinsic nastiness."25 ""
The second example in Chang's text of the categorization of disease
by selected defining symptoms is a condition called huo-luan, literally
"sudden disturbance."
(3) It was asked, "There is a disorder marked by outbreaks of fever, pain in the
head, body aches, aversion to cold, vomiting, and diarrhea. As what disorder
is this classified?" The reply, "This is named sudden-disturbance. There is natur-
ally-occurring vomiting [that is, not deliberately induced as treatment] and
diarrhea. In addition, when the diarrhea ceases, there will still be further out-
breaks of fever.>>26
Huo-luan is now the expression used for cholera. Although the symptoms
Chang gives could include cases of cholera, the expression for him meant
an entire class of syndromes all featuring the defining symptoms of
vomiting, diarrhea, and recurring fever. As with dampness-disorder,
there are several variants of "sudden-disturbance," all sharing the three
defining symptoms but differing in other details. These variants, and
not the basic picture, are of most significance to Chang since they are
24. Ibid., 2.4, p. 56.
25. By Jonathan Miller in the B.B.C. television scries The Body in Question, and, in slightly
different form, in the book of the same name (New York, Random House, 1978, p. 46). However
when compared to both medical and non-medical literature in Greece and Rome, there is less
emphasis placed on the physical appearance of the patient. (The characteristic rash of typhoid for
instance does not seem to have been noted.) There is nothing as graphic as Thucydides' description
of the plague or, later, Eusebius' appalling picture of the illness of Galerius. Nor do the Chinese
texts match the description of patients found in the Hippocraric case histories.
his basis for prescribing treatments. That is, treatment was not prescribed
at the onset for the entire course of the disease and its three major
symptoms but rather was specific to each variant syndrome. For exam-
ple, "With 'sudden-disturbance' there may be headache, outbreaks of
fever, and body aches and pains. When [the outbreaks of] fever are
frequent and there is a wish to drink water, 'five-tuber-powder' acts on
(chu) the [disorder]. When chills are frequent and one does not drink
water, 'regulating-the-center' pills will act."27 Any additional variation
in the symptoms then called for further modification of the medicines:

"When vomiting is frequent then leave out the atractylis [from the for-
mula] but add three ounces (Hang) of fresh ginger." Yet, "If there is
frequent diarrhea continue to use the atractylis; when there is also trem-
bling add two ounces of Poria cocos."28
The third example from the text also illustrates these principles of
defining disease by outstanding symptoms and using the many variations
as the basis for treatment: this is the disease given by the title of Chang's
tract, cold-damage disorder. The phrase cold-damage (shang-han) has
two distinct usages in the ancient medical texts. It was a general statement
of etiology applicable to all fevers: "Whenever there has been damage
from cold then it will result in diseases with fever (or heat.je); although
the fever (heat) may be very severe the disorder need not prove fatal."29
Chang did not use different words for cold and chills or heat and fever:
he used han for the former two andje for the latter two. The implication
of this will be discussed below.
But in addition to referring to all diseases featuring fevers, cold-damage
could also denote a specific feverish or heat disorder. There is some
disagreement and confusion over the two usages. One ancient author
stated that "feverish (or heat) disorders are all in the category of cold-dam-
ages,"30 while another wrote, "There are five cold-damages all in the
category of feverish (heat) disorders."31 A third agreed that there were
five cold-damages and gave each a name; wind strike, damp-warmth,
cold-damage, feverish (heat) disorder, and warmth disorder.32 Chang
27. Ibid., 7.13, p. 206. Regulating- the-center pills consist of ginseng, ginger, Glycyrrhiza root,
and rhizome of Atractylodes. "To act" is the Chinese word chu which usually means to master or
preside over. It is difficult to translate; given many of the conditions described it cannot possibly
mean "to cure."
29. Ibid., 2.3, p. 42.
30. Su-wen (Plain Questions), (n. 20), 9.31.
31. Mo-ching (Canon on the Streams), (n. 20), 7.1.
32. Nan-ching (Canon on Difficult Issues), (n. 20), 58.
16 Journal of the History of Medicine : Vol. 43, January 1988
used the phrase cold-damage both for a general categorization and for a
specific disease. In most cases he was indicating a specific disease, a
disease which can now be identified as typhoid fever.33 Typhoid fever
can vary considerably in its symptoms, in duration from one or two to
several weeks, and in severity from mild to fatal. Modern descriptions
of the disease are, as a result, often presented as typical or generalized
cases.34 Chang, however, concentrated on presenting numerous variant
syndromes each recognized as belonging to the cold-damage disorder
by its characteristic fever. Many of the other symptoms that are now

included as an integral part of the clinical picture of typhoid were noted
by Chang only when they happened to appear as features of one or
another of the variant syndromes.
Chang has recorded a very wide variety of symptoms in addition to
the fever; for instance at one stage of the disease there might be retching,
fever, coughing, and "sometimes there is a thirst, sometimes diarrhea,
sometimes choking, sometimes difficulty with urination, sometimes
fullness of the small intestine, and sometimes labored breathing."35 He
has treated each day of the disease as a variant syndrome with many
possible symptoms; for example,
(4) Five to six days after the onset of cold-damage disorder there may be a wind
strike.3* There are alternating chills and fever and there is a distressing fullness
in the chest and rib area. The [sick person] remains perfectly silent and has no
wish to eat or drink. The heart is irritated and there is a tendency to vomit.
Sometimes there is irritation in the center of the chest but no vomiting, some-
times there is thirst, sometimes there is pain in the abdomen, sometimes there
is a palpable blockage below the ribs. Sometimes there are palpitations below
the heart and urination is not easy. Sometimes there is no thirst while there is a
slight fever in the body. Sometimes there is coughing. Minor bupleurem decoc-
tion acts in these cases.37
This is only one of several descriptions of the findings on the fifth or
sixth day of the disease. Several descriptions of possible conditions on
33. The basic source on ancient disease, YQ Yun-hsiu, Ku-tai chi-ping ming hou su i (Glosses on
Ancient Names and Symptoms of Disease), Peking, People's Hygiene Press, 1953, does not have a
separate entry for typhoid. It is discussed in relation to other diseases; sec for instance p. 133.
34. See for example Paul B. Beeson and Walsh McDermott, eds, Cecil-Loeb Textbook of Medicine,
2 vols., Philadelphia, W. B. Saunders, 1 ith ed., 1963, 1, 236.
36. "Wind-strike" means simply to be struck or hit by blowing wind. It could also refer to a
distinct syndrome, as noted above.
37. Chang, (n. 3) (Discourse), 3.6, p. 96. Bupleurem decoction contains Bupleurem, ScuteUaria,
ginseng, Glycyntuza root, Pinellia rhizome, ginger, and large jujubes.
other days are given as well. For example, "Four to five days after [the
onset] of cold-damage disorder the body may be feverish and there may
be an aversion to wind. The neck is stiff and there is fullness below the
ribs. The hands and feet are moist and there is a thirst. Minor bupleurum
decoction acts on this."38
In both of these passages a suggested treatment has been included; this
was also seen in the descriptions of dampness-disorder and sudden-dis-
turbance. Much of Chang's entire treatise is taken up with passages of
this kind, numerous syndromes of the different disorders with only

slight variations but each with its own treatment. Compare the following
two with translation (4) above, all describing the same time period after
the onset:
(5) Five to six days after [the onset] of cold-damage disorder, [the patient may
have been given] a purgative, but the fever in the body has not gone away. There
is a knotting and pain in the heart. [This indicates that the condition] is not yet
about to be relieved. Gardenia-berry decoction acts in this case.39
(6) Five to six days after [the onset] of cold-damage disorder, [the patient may
have already been given medicine] to induce perspiration and may further have
been given purgatives. There is fullness in the chest and rib area and there is a
slight congestion. Urination is not easy. There is thirst but no vomiting. Perspi-
ration comes only from the head. There are recurring chills and fever and the
heart is irritated. This means that the condition has not been relieved. Bu-
pleurum, cassia bark, and ginger decoction will act in this case.40
These different syndromes were not always arranged chronologically in
Chang's text. A passage on cold-damage disorder might be followed by
one on an entirely different disorder, that in turn by a description of the
tenth day of cold-damage, then a depiction of the fourth or fifth day,
without any discemable pattern.41 The effects of treatment are fully inte-
grated into the pictures of the syndromes. The side-effects that may result
from a particular medication were included along with the symptoms
due to the disorder. In several syndromes Chang has noted the effects of
mistaken treatment, of treatment given contrary to the indications.42 The
38. Chang, (n. 3) (Diuoursc), 3.6, p. 100.

39. Ibid., 3.6, p. 92.
40. Ibid., 4.7, p. 124.
41. There is no way of knowing how much of the present text arrangement is Chang's or due
to later editors.
42. For example, Chang, (n. 3) (Discourse), 2.5, p. 68. There does not seem to be any concept
of legal malpractice at this time. See Paul Unschuld, "Arzneimittelbrauch und heterodoxe Hciltatig-
keit in kaiserlichen China," Sudhoffs Arrhiv, JI: 353-386, 1977.
well-known mental symptoms and clouding of consciousness that gave
typhoid its Greek name43 were not considered as defining symptoms of
cold-damage disorder but are found in some of the syndromes. In one,
incoherent speech and wild babbling are included as symptoms along
with the fever44 and in another, translation (4) above, the perfect silence
of the patient suggests a stupor. They were not necessary for a condition
to be classified as cold-damage disorder; only the characteristic fever was
required for that.
These three examples, dampness-disorder, sudden-disturbance, and

cold-damage disorder, illustrate one level of conception of disease in this
text, a conception based only on the manifest symptoms. One of the
questions raised by this conception is the role of individual case histories
in Chang's thought. There are unequivocal examples of case histories in
ancient Chinese medicine: in the second century B.C. in response to an
imperial command the physician Ch'un-yii I presented a record of
twenty-five of his cases that included the name of the patient, the diag-
nosis, an explanation of the pathology, the treatment, and the outcome.45
However, this record appears only in the biography of the physician
included in a first century B.C. historical chronicle; in the strictly medical
texts, this type of presentation is rare.46 An impersonal style, without
reference to the circumstances of the individual patient was the rule in
the ancient writings. The nature of the language must be considered here;
there were no verb tenses, subjects could be left unstated, and active and
passive voices were not distinguished.47 Yet as some texts do show, indi-
vidual cases could be described and it is clear that Chang, and others,
deliberately chose not to present diseases in that way. Nor did Chang
acknowledge any connection between an individual's constitution or
situation and the different forms a single disorder might take. He did not
see the varieties as the result of "the particular nature of each individual,"
unlike those Hippocratic writers who, while accepting diseases to some
extent as entities, insisted on the uniqueness of each individual as a factor
43. Richard Hunter, "Psychiatry and neurology: Psychosyndrome or brain disease." Proc. Roy
Soc. Mai., 66: 359-365, 1977.
44. Chang, (n. 3) (Discount), 2.3, p. 53.
45. These cases are found in the Shih-chi or Records of the Grand Historian by Ssu-ma Ch'ien, chuan
(chapter) 105. There is a translation by Robert Bridgeman, "La m6decine dans la chine antique,"
Melanges Chinois et Bouddhupic, 10: 1-213, 1955.
46. There are a few examples in Mo-ching (Canon on the Streams), (n. 20), 9.2.
47. For example the phrase shen t'ung could mean the body aches or his (her or their) body (bodies)
aches (ached or will ache). The anaent Chinese writers could be more precise but at least in the
medical texts often were not.
48
in the form a disease took. Not all ancient Chinese writers shared
Chang's disregard of individual characteristics. Some constructed cate-
gories of physical and personality types which were related to general
health and susceptibility to disease. Others repeatedly stressed the impor-
tance of the patient's physical condition when deciding on treatment.49
An important factor in determining Chang's approach to, and concep-
tualization of, disease at this first level was the nature of the diseases being
considered. He was concerned primarily with infectious diseases that
occurred as epidemics. Many people would fall ill at the same time with

roughly similar symptoms but among the many cases wide individual
variations would be equally evident.50 He assumed that there were
specific causes responsible for the different dominant symptoms that he
used to define his disease categories, for instance cold as the cause of
fevers and dampness as the cause of body aches, fever, and sallowness.
To explain the many additional symptoms that could accompany the
defining symptoms he had recourse to a deeper conceptual level as de-
scribed below.
Relying only on manifest symptoms as a basis for differential diagnosis
is difficult. There is no way of knowing how successful the ancient
Chinese physicians were in applying the lessons of texts like Chang's:
there is evidence of disagreements over diagnoses and a tendency to
simplify many medical concepts in practice.51 Certain diseases presented
fewer problems than others; some have such characteristic symptoms
that they can serve as standards of comparison. Several times Chang
described symptoms as "similar in appearance to nileh disorder."52 NUeh
was a feverish disease prevalent in autumn.53 Yet it is not always easy to
discern his reasoning when he would confidently classify syndromes as
one disorder or another. In part this is due to the briefness of his descrip-
tions and the style of writing.
48. Cohen, (n. n ) and Temkin, (n. 13).

49. Sec for example Huang-fu Mi, Chen-chiu chia-i ching (Canon on the Foundations of Acupuncture
and Moxabustion), Chen-chiu chia-i ching chiao-shih edition, 2 vols., Peking, People's Hygiene Press,
1979. However, Chinese medicine at this time did not require the long and dose relationship between
physician and paoent that Greek dietetic medicine did: see Owsei Temkin, "Medical ethics and
honoria in late antiquity," in Charles E. Rosenberg, ed., Healing and History, New York, Science
History Publications, 1979, pp. 2-26.
50. On epidemics see Guenter Risse, "Epidemics and medicine: The influence of disease on
medical thought and practice," Bull. Hist. Med., 53: 505-519, 1979.
51. See for example case 22 of Ch'un-yO I recorded in Records of the Grand Historian, (n. 45).
53. Yd, (n. 33) (Glosses), pp. 131, 235.
20 Journal of the History oj Medicine : Vol. 43, January ig88
(7) It was asked, "There is a disorder of 'chest-coagulation' and one of 'organ-
coagulation. ' What are their characteristics?" The reply: "When there is pain on
pressure and [the pulse of the pneuma/blood] stream at the ts'un [position] is
shallow and at the ch'ih [position] is deep,54 the name for this is 'chest-coagula-
tion.'" "How is 'organ-coagulation' characterized?" The reply: "It is similar in
characteristics to 'chest-coagulation.' Eating and drinking are normal [lit., as
they were previously]. There is often diarrhea. The [pulse of the] stream at the
ts'un is shallow and at the kuan is small, slender, deep, and fast. The name for
this is 'organ-coagulation.' If the white coating on the tongue is smooth, the
condition is not likely to be curable.""

There is another description of "organ-coagulation" elsewhere in the
text:
(8) There is a disorder in which there was formerly a blockage below the ribs
that has now extended to the side of the navel. Pain radiates to the small intestine
then enters into the groin area. This is named 'organ-coagulation' and is fatal. *"
Taken singly, these two pictures suggest quite different disorders and
why some symptoms should be included in one and not the other is a
difficult question to answer. To complicate the issue further "chest-
coagulation," here a disorder (ping), could also be considered only a
symptom in an unrelated syndrome (ping) featuring fever and pain in the
chest.57 This is only one example of the problems associated with differ-
ential diagnosis. While the basic principles in thinking about disease
exemplified by dampness-disease, sudden-disturbance, and cold-damage
disorder could be applied in some conditions, they may have been
difficult to apply in others.
One notable feature of the conceptualization and categorization of
disease described to this point is the absence of any reference to the
underlying physiological or pathological processes that might be thought
to produce the symptoms. The entire classification was made only on
the basis of the manifest symptoms. But in the Discourse there is a second
level of conceptualization which is based on a view of disease as it relates
to the body's physiology and anatomy.
In several of the translations above the initial cause of the syndrome
54. The pulse will be discussed later. The throbbing of the stream was detected by placing three
fingers over the radial artery at the wrist; the pulse under each fingertip was considered on its own.
The three positions where the fingertips lay were the ch'ih, kuan, and ti'un. "Shallow" and "deep"
refer to pulses felt with light and heavy pressure of the fingertips.
56. Ibid., 4.7, p. 134.
57. Ibid., 4.7, p. 118.
was given and was usually a climatic factor, especially wind and cold.
With this etiology, Chang has followed a well-established medical and
non-medical tradition in die Chinese texts in ascribing disease to die
weather or to atmospheric conditions prevalent in certain localities.58 But
this indicates only the primary cause of disease; the means or mechanism
by which a factor in the atmosphere actually affects the normal physiol-
ogy is still to be explained. One early text states that the agent is ch'i or
pneuma, which in turn is synonymous with weather and other phe-
nomena: "In heaven there are six pneumas . . . The six pneumas are yin,
yang, wind, rain, darkness, and light." Excesses of these six are respon-

sible for six classes of disease.59 hi this scheme cold (han) sicknesses are
the result of an excess of yin pneuma while heat (Je) sicknesses are the
result of an excess of yang pneuma.
Later medical writers modified this scheme extensively. Instead of
postulating six categories of pneuma, Chang and others seem to have
recognized only two, each of which then displayed a range of characteris-
tics. Pneuma (ch'i) was conceived of as both substance and energy: Chang
implies it is a fluid-like vapor but one that must have an innate energy
or ability to be active and to activate. The two forms of pneuma could
be broadly categorized as bright, warm, or dry or dark, cool, or damp.
The former were forms of yang pneuma, the latter forms of yin pneuma.
Thus yin and yang were no longer just two of six forms of pneuma but
were the only forms, each subsuming several others. In addition to the
diverse forms of weather, the atmosphere of each season had its charac-
teristic pneuma, which could be placed on a spectrum of being com-
pletely yang in summer to completely yin in winter with gradations of
yinness and yangness in between.60 The pneuma was the active agent
that could affect the body. The interaction between pneuma and the body
was described in two different, and not always precise, ways.
58. An example can be found in a text called die Yileh- ling (Monthly Ordinances), now incorporated
into the Li-dii (Book of Rites): see Lu Gwei-Djen and Joseph Needham, "Records of disease in ancient
China," in Don Brodiwell and A. T. Sandison, eds, Disease in Antiquity, Springfield, Charles
Thomas, 1967, 222-237.
59. The passage is found in die historical chronicle die Tso-chuan or The Chronicle of Master Tso:
see Lu and Needham, (n. 58). The entire passage can be found in James Legge, trans., The Chinese
Classics, 5 vols., Hong Kong, Hong Kong University Press, 2nd ed., 1968, 5, 580-581.
60. The words yin and yang now regularly appear in English writings but it should be noted
diat die Chinese did not make the distinction between the adjectival and noun forms which is
necessary in English. (Compare "blue" and "blueness.") They did not, as used in the ancient medical
texts, refer to forces or energy or entities. Radier, they are responsible for characteristics. That which
is hot or in motion upward or in a higher location for instance is characterized by yangness and die
opposite by yinness.
In some passages the term tu, banefiilness, the present-day word for
poison, was applied.61 One passage refers to, "an encounter with moist
heat which transforms to create warm-banefulness and warm-baneful-
ness creates a very serious disorder.I>62 The pneuma of any season could
create a banefiilness; this need not then produce immediate disease but
could lie dormant in the body until the following season. Cold for in-
stance could produce cold-damage disorder after exposure in winter, or
a banefiilness could be contained within the musculature and create
"warmth-disorder" in spring or "hot-disorder" in summer.63 Chang pro-
vided no details of any physiological changes involved.

The second, and far more important description of the mode of action
of the pneuma, centered on the word hsieh, meaning heterodox or that
which is opposite to what is correct or upright, hi Chang's and other
early medical texts it signifies any pneuma which is able to cause disease,
that is, is pathogenic. It appears that any atmospheric pneuma could be
pathogenic, but particularly that associated with unseasonable weather
conditions. Some authors devised complex theories of etiology and pa-
thology based on cosmological and numerological concepts to explain
further the interactions between man and pneuma.64 Chang largely ig-
nored these theories, yet did not offer a detailed and comprehensive
alternative of his own.65 In some instances in his text the pathogenic
pneuma was said to enter the body through the pores, then to enter the
circulatory system where it affected the condition of the blood and the
body's own pneuma. It could then move on into the organs.66 Neither
the term hsieh nor tu carried a sense of moral judgment in which the
sufferer invited the disease by his actions or behavior nor did they imply
a defilement, a pollution, or uncleanliness as did the early Western con-
cept of infection.67 The pathogenic pneuma that invaded and clashed

62. Ibid., 2.3, p. 46.
63. Ibid., 2.3, pp. 37—38.
64. See for example Su-wtn (Plain Questions), (n. 20), 2.5. The system of correspondences is
discussed extensively throughout Porkert, (n. 5) Theoretical Foundations.
65. Chang is by no means alone among ancient Chinese medical writers in ignoring numerolog-
ical and correspondence theories; these theories are similarly missing from many of the essays now
in the Inner Canon of the Yellow Emperor (n. 20). (There are two versions of this text one of which
consists of two parts, the Plain Questions, cited earlier, and me Divine Pivot or Ung-shu.)
66. Chang, (n. 3) (Discourse), 2.3, p. 47. This concept is dearly described in, for instance, Su-wen
(Plain Questions), (n. 20), 11.39 wd 17.62.
67. See Owsei Temkin, "An historical analysis of the concept of infection," in The Double Face
of Janus, (n. 13), 456-471, esp. pp. 457, 459. Also Vivian Nurton, "The seeds of disease: An
with the body's pneuma would be a pneuma of, for instance, wind or
cold, not a distinctly evil or consciously malicious species.68
Once the initial cause of a disease has been explained, there are still
important questions to be answered. How does an invading pneuma
affect the normal physiology and anatomy? How are specific observable
symptoms related to specific underlying pathological changes? The an-
swers to these questions lie in large part in Chang's basic concepts of
physiology and anatomy which focus almost exclusively on the system
of circulation of blood and pneuma in the body. Chang and all other
ancient writers used the word mo when referring to this system. Mo did

not indicate only the channel or vessel through which the circulating
contents, the blood and pneuma, flow but rather both the channel and
its contents. It is not unlike the English word "river"—an often ambig-
uous word referring to water, a channel, or both.69 Mo was also the word
used to designate the throbbing or pulsation detectable on the wrist and
elsewhere. This throbbing, unlike the modern pulse concept, was not
thought to be associated simply with the heartbeat or a movement of
vessel walls, but was apparently seen to be due to the movement of
pneuma.70
The mo, which will be translated here as "streams," were first described
in medical texts of the fourth or fifth century B.C. where the courses of
eleven streams running the length of the arms and legs and connecting
with the major organs were given.71 This was not a cardiocentric system
and, although based on and incorporating the major veins and arteries,
it was not anatomically accurate, often linking two or more distinct
vessels, both veins and arteries, together as one stream. The picture was
modified over the next few centuries; by the time Chang was writing it
consisted of a system of twelve streams each one running from an extrem-
ity to the head or trunk where it was connected with one of twelve
explanation of contagion and infection from the Greeks to the Renaissance," Med. Hist., 27: 1-34,
1983.
68. Hsieh can mean "heterodox" or "depraved" or "evil," that which is opposed to what is upright
and correct (dteng). Hsieh pneuma was certainly something bad to the medical writers in the sense
that it caused disease but this does not make it synonymous with sinfulness.
69. Translations of mo like "vessel" or "channel" or "tract" refer only to one aspect of it, the
substrate. While the substrate is an implicit aspect of mo, as it is of river, it is not the most important
one. Most emphasis was placed on the contents, especially on their condition and how they were
flowing.
70. See for example Mo-thing (Canon on the Streams), (n. 20), 4.5.
71. Text in Wtt-shih-erh ping-fang (Treatmentfor Fifty-two Types of Disorders), Peking, Wcn-wu Press,
'979. PP- 10-20. Also see Akahori Akin, "In-y6 joichi myaku kyu kei no kenkyu (Translation and
study of the 'Yin-yang shih—i mo chiu ching")," TShS GakuhS, 53: 299-340, 1981.
organs. All of the streams carried both blood and pneuma. They were
connected to each other in an undescribed fashion and thus blood and
pneuma travelled through each stream-bed and organ in turn, circulating
in a grand tour of the body.72
In this anatomical and physiological system the pneuma played the
key role; the basic disease process involved an alteration of its normal
condition. When an external pathogenic pneuma invaded and clashed
with the body's own pneuma, the condition of the latter, its rate, rhythm,
and volume of flow, would be changed. The nature of the change was

dependent on the type of pathogenic invasion and would be revealed by
variations in the throbbing or pulsation detected on the wrist.73 This
explains why the Chinese equivalent of taking the pulse was of funda-
mental importance. Different forms of the pulse were direct manifesta-
tions of the way in which the pneuma was flowing and its overall condi-
tion everywhere in the body. This condition in turn could reveal the
presence and the type of disease-producing agency. The pulse was not
simply a single sign: rather it was a guide to the physiological state of
the entire body and the whole of a pathological process.74
Disorders of the pneuma were most often described as local deficien-
cies or plethoras, blockages, or amassings. In addition, the streams could
be flowing too fast or too slow, or could be weak or feeble, agitated or
irregular. These conditions were related to localized pain, swellings, vom-
iting, fever, chills, or any other of the numerous symptoms of the disor-
ders described in Chang's text. But what is the basis for the relationship
between a particular symptom and a particular underlying pneumatic
abnormality? The difficulty in answering this question, in understanding
the relationships, rests on the absence of a concept of disease as dysfunc-
tion. Chang did not, with some exceptions, view symptoms as indicative
of a dysfunction or failure of a structure or substance to perform its
designated activity or role in the body. For instance, a lack of appetite is
not the result of a dysfunction in the digestive system nor is the utter
silence, in translation (4) above due to brain dysfunction. Chang and
72. See for example Ung-shu ching (Canon of tlie Divine Pivot), Peking, People's Hygiene Press
edition, 1979, 4.15-4.18.
73. There was considerable variation in how die pulse was co be taken. Basic principles are
described in Mo-ching (Canon on the Streams), (n. 20) 1.1-1.6. Chang occasionally refers to the pulse
on die ankle as well as die wrist but most practitioners seem to have used only the wrist.
74. The equivalent of taking the pulse was referred to as "examining die mo," that is, all aspects
of the streams. But die throbbing itself became an aspect of increasing importance as time passed.
Mo-dting (Canon on the Streams), (n. 20) 1.1 lists twenty-diree types.
many other medical writers of the ancient period believed that the internal
structures of the body, the organs, ducts, and vessels, functioned pass-
ively, acting as containers and passageways.75 They did not describe them
as producing or secreting substances or as having a motion of their own
(pumping action or peristalsis for example) that directly affected their
contents.76 Most physiological processes were ascribed to activities of the
pneuma associated with the organs and to other contents of structures,
including blood and mental faculties.77 Since the structures played no
active part in physiological processes, most pathological processes were
not associated with structural dysfunction.78

As far as Chang was concerned, the overt symptoms (ping) did not
need to be mechanistically linked to an underlying pneumatic disorder
{ping). This does not mean that he did not possess a concept of cause and
effect. It only means that the symptoms were often not produced by an
intermediate reaction of the body's structure to a pathogenic agency but
were the direct result of that agency itself. An illustration might be
helpful at this point:
(9) The pulsation [of the pneuma/blood streams] may be shallow and rapid.
The shallow is brought about by wind, the rapid is brought about by deficiency.
Wind brings about fever (heat), deficiency brings about chills (cold). If wind
and deficiency clash with each other then there is shivering and aversion to cold."
This passage was not intended simply as a clinical diagnosis: it would

not be necessary to take the pulse to learn that the patient is shivering
and averse to cold. Its purpose was to explain the cause of the observable
symptoms. The condition of the stream allows the identification of the
pathogenic agents. The observable symptoms, the shivering and aversion
to cold, are associated with the heat and cold in the body, the result, in
75. See for example Ling-shu thing (Divine Pivot), (n. 72), 2.8. A three part organ, the san-chiao,
is a partial exception but even here no physical motion of the structure seems to have been involved
See Ling-shu 4.18.
76. See for example Ling-shu eking (Divine Pivot), (n. 72), 6.32, where there is no indication that
passage of food through the body is in any way assisted by secretions or motion of the structures
though which it passes.
77. The ancient medical texts do not contain any extensive discussions of normal anatomy and
physiology beyond descriptions of die courses of the streams. However, normal physiology can
sometimes be deduced from discussions of pathology; see for example Ling-shu dung (Divine Pivot),
(n. 72), 12.80 where a theory of vision can be found.
78. For an exception see Ling-shu ching (Divine Pivot), (n. 72), 9.63, where die bladder is said to
curl up and become impassable.
a way not explained, of a clash of the pathogenic agencies. They were
not ascribed to any involvement of organs or tissues of the body.
The connection between wind and heat or between deficiency and
cold is open to interpretation. One possible interpretation is suggested
by the following passage in which symptoms similar to those given in
translation (9) above are found:
(10) It was asked, "There is a disorder in which there is shivering, aversion to
cold, and recurrent outbreaks of fever (heat). What is this?" The reply: "When
there is insufficiency in the yin [pneuma/blood] streams, yang [pneuma] goes

out and descends in them. When there is insufficiency in the yang [pneuma/
blood] streams, yin [pneuma] goes out and rises in them." "What is meant by
'an insufficiency in yang?'" The reply: "When the pulse"" at the ts'un-k'ou [posi-
tion on the wrist] is feeble, the term for this is 'insufficiency in yang.' If yin
pneuma ascends and enters amidst yang areas, then there is shivering and aver-
sion to cold." "What is meant by 'an insufficiency in yin?'" The reply: "When
the pulse at the ch'ih [position on the wrist] is weak, the term for this is 'insuffi-
ciency in yin.' If yang pneuma sinks down and enters yin areas then there are
outbreaks of fever (heat)."81
The overt symptoms in translation (10) are directly related to the presence
of yin or yang pneuma. This may be why Chang did not use different
words for fever and heat and for chills and cold; the sensation or percep-
tion of heat or cold in the body was nothing other than hot or cold
pneuma. The relationship between wind and heat in translation (9) would
imply that wind was infused with a yang pneuma which would account
for the presence of heat in the body. A deficiency could mean a lack of
either blood or pneuma; the absence of either would result in yinness
and cold is associated with yinness. Pneuma was not the only substance
in the body that was characterized by yinness or yangness; every part of
the body was. Thus the head, the front of the body, hot pneuma, and
pneuma flowing in some parts of the body all shared one characteristic
and that was yangness. Implicit throughout Chang's text is the assump-
tion, as in translation (10), that all aspects of the body have a normal
relationship to each other dependent upon their characteristic yinness
and yangness. There is always yang pneuma in the body; the pathological
symptoms in translation (10) arise when that pneuma is not in its normal
place but has entered areas characterized by yinness.82
80. Bear in mind that the word for pulse and the streams is the same.
81. Chang, (n. 3) (Discount), 1.1, p. 1.
82. Ch'eng Wu-chi throughout his commentary to the Discourse explains passages by referring
to yin and yang.
Because Chang normally did not describe pathological processes as
dysfunctions does not mean that he deliberately rejected the concept of
dysfunction in favor of a consistently applied theoretical alternative. Al-
though a pathology derived ultimately from behavior said to be due to
yin and yang characteristics predominates in his text, Chang was aware
of ideas of function and dysfunction in human biology. Such ideas are
not missing; rather, they do not form the basis for a unified approach to
explanations of disease. He saw disease at two different levels, one con-
sisting of overt symptoms and the other of underlying physiological

changes. He clearly stated that the symptoms were caused by the invasion
of the body by external disease-producing pneuma which interacted
with the body's normal pneuma. Since this normal pneuma coursed
throughout the body in the streams, the site of the pathogenic interaction
between the invading and normal pneuma could also be in the streams.
This belief provided an important link between overt symptoms and
underlying disorder that has not appeared in the passages cited so far. It
made possible a classification scheme that accounted for both the location
and the progress of a disease.
In the medical texts of the fourth or fifth century B.C., along with
descriptions of the course of each stream, a number of symptoms were
listed that were associated with a disorder of that stream. For example,
the foot-minor-yin stream was said to run up the inner surface of the leg
from the ankle through the knee and thigh, to enter the abdomen, follow
the spinal cord, come out to the liver, enter the ribs, and ascend to the
tongue. A disorder of this stream would result in several symptoms,
including burning in the feet, pain in the ribs and along the spinal cord,
liver pain, abdominal congestion, irritation in the heart, thirst, and
coughing.83 The site of each symptom lay roughly along the course of
the stream or in the organs to which it was either connected or passed
near.
This basic concept underwent considerable expansion and alteration
over the next few centuries. By the time it appeared in Chang's treatise
it incorporated taking the pulse to indicate the stream affected. It was
used to explain the entire course of a disease over a period of several days
by relating the succession of symptoms to a spread of the disorder from
one stream to another:
(11) When the pulsation at the ch'ih and ts'un [positions] is shallow, [this means
83. Wu-shih-erh ping-fang (Fifiy-two Disorders), (n. 71). p. 5.
that] the major-yang [stream] has contracted the disorder. There will be an
outbreak in one or two days. Because the [major-yang] stream ascends and is
connected to the "wind-storer,"84 the head and neck will therefore be painful
and the loins and spine will be stiff. When the pulsation at the ch'ih and ts'un is
long, the yang-ming [stream] has contracted the disorder. There should be an
outbreak on the second or third day. Because this stream goes around the nose
and has a connection with the eyes, the body is therefore feverish, the eyes ache,
the nose is dry, and one is not able to sleep. When the pulsation at the ch'ih and
ts'un is taut, the minor-yang [stream] has contracted the disorder. There should
be an outbreak on the third or fourth day. Because this stream follows along

the ribs and has a connection to the ears there is therefore pain in the chest and
rib area and deafness.85
The next few days of the disease are similarly described. The major-yin
stream contracts the disorder and because its course extends through the
stomach and reaches the throat, there is fullness in the abdomen and
dryness in the throat. Then the minor-yin stream becomes disordered.
It threads through the kidneys, has a connection with the lungs, and is
attached to the root of the tongue; therefore there is dryness of the mouth
and thirstiness. Finally the chiieh-yin stream is affected and because it
courses through the pubic region and is connected to the liver, there is
"irritation, fullness, and shrinkage of the scrotum."86
This illustrates how this concept could be used to explain the entire
course of a disorder, why symptoms appeared on different days and in
different parts of the body. Numerous variations were possible. The
disorder could affect one stream after another or could affect different
combinations of streams simultaneously. For example,
(12) If someone is acted on twice by cold [pneuma], on the first day the major-
yang [stream] receives [the cold pneuma]. If it and the minor-yin stream are
both disordered, then the head aches, the mouth is dry, and there is an irritating
fullness and thirstiness. On the second day the yang-ming stream receives [the
cold pneuma]. If it and the major-yin stream are both disordered then there is
fullness in the abdomen, the body is feverish, there is no wish to eat, and there
is delirious speech.87
The process of recovery could then be explained by the reverse of the
causal process, with the disorder disappearing from each stream in turn:
84. The "wind-storer" is the name of a point on one of the cervical vertebrae.
86. Ibid., 2.3, p. 44.
87. Ibid., 2.3, p. 45.
(13) If one is not affected a second time by cold and there is no further transmis-
sion [through the streams] and no addition of a foreign pneuma, then on the
seventh day the disorder in the major-yang [stream] dissipates and the pain in
the head is somewhat lessened. On the eighth day the disorder in the yang-ming
stream abates and the fever in the body lessens somewhat. On the ninth day the
disorder in the minor-yang stream abates and the deafness improves. On the
tenth day the disorder in the major-yin stream abates, the abdomen somewhat
returns to normal, and one thinks of eating and drinking.88
By the twelfth day the pathogenic pneuma is gone and the patient is
returning to normal.

These three passages, translations (11), (12), and (13), indicate an
attempt to account for the appearance of the symptoms and course of a
disease in anatomical and physiological terms and to provide a com-
prehensive scheme that would explain the entire clinical picture. The
word ping has been used throughout: it refers to an abnormal condition
in the streams and to the associated symptoms. The abnormality is trans-
mitted from one stream to another. This transmission was not described
in detail but most likely was viewed as a movement of the pathogenic
pneuma that entered the body through the circulation system and caused
the normal pneuma and blood in each stream to become disordered. Not
only each stream but each organ could be affected; the pneuma in each
would become disordered, producing symptoms.89 The symptoms were
associated only with the condition or state of the blood and pneuma in
a stream or organ which is underlying or adjacent to the site of a percep-
tible abnormality. This is not only true of pain, the location of which
follows the course of the disordered stream, but also of symptoms like
dryness of the nose, lack of appetite, and delirium. These do not imply
any structural dysfunction or physical change or damage to the organs
involved. The emphasis was primarily on the pneuma and the various
changes induced in it by the agent or cause of the disease. These changes
could account for both mental and physical symptoms. The former were
fully incorporated into the disease picture but were not conceived of in
psychological terms, in terms of brain dysfunction. The ancient Chinese
failed to understand the role of the brain and did not postulate a distinct
nervous system. Mental and emotional states or activities were localized
in several organs and hence were affected by the condition of the local
88. Ibid.
89. Examples of this o n be found in Su-wen (Plain Questions), (n. 20). 9.32, where symptoms
of heat (Je) in each of the organs are described.
pneuma and blood. Pneumatic disruption was responsible for symptoms
like fear, confusion, delirium, sorrow, and other emotional and mental
states.
In translations (11) to (13), the course of a single disease was spread
over several days and involved disorders in several streams. However, a
disease could also be the result of a disorder in only a single stream; the
entire set of symptoms need not require any transmission of the disorder
to other streams. This concept allowed for the development of a system of
classification in which diseases were named for the stream that was the site

of the disorder: major-yang disorder (ping), yang-ming disorder, minor-
yang disorder, minor-yin disorder, major-yin disorder, and chueh-yin
disorder. These six were used as names of syndromes thought to be
related to a disorder in one or another of the streams.90 Examples of
major-yang disorders will serve to illustrate how Chang applied this
classification.
Typically, "In major-yang disorders the pulse (mo) may be shallow,
the head and neck stiff and painful, and there may be aversion to cold."9'
In some respects this type of presentation is similar to that seen in trans-
lations (2) to (8). There were numerous variants of major-yang disorders,
all with a set of shared characteristics plus a range of differing additional
symptoms. Once again it was the variations that were the basis for pre-
scribing treatment. "In a major-yang disorder there may be a headache,
fever, perspiration, and aversion to wind. Cassia bark decoction acts on
this,"92 while,
(14) A major-yang disorder: the head aches and there is a fever. The body aches
and there is pain in the loins. The bones and joints are aching and painful. There
is aversion to wind. There is no perspiration but there is labored breathing.
Ephedra decoction acts on this.93
Chang in his presentation of major-yang disorders has associated the
symptoms with a physiological disturbance in an underlying anatomical
90. I believe that the evidence from the Discourse and other ancient texts sobdly supports this
interpretation. Other interpretations suggest that the references of major yang, etc., disorders do
not refer to the streams. See for example Lu Gwei- Djcn and Joseph Needham, Celestial Lancets,
Cambridge, Cambridge University Press, 1980, p. 93. For other views see Yabuuchi, (n. 9) (forma-
tion), p. 312; Akahori Akiri, "In-yO joichi myaJcu kyO-kei to Su-mon (The Yin-yang shih-i mo chiu
eking and the Su-wen)", Nippon igaku-shi zasshi, 25: 277-288, 1979, and Miyashita, (n. 10).
92. Ibid., 2.5, p. 63. Cassia bark decoction was made from cassia bark, ginger, jujubes, Glycyr-
rhiza, and peony roots.
93. Ibid., 3.6, p. 75. Ephedra decoction was made from Ephedra, cassia bark, Glycyrrhiza, and
apricot kernels.
feature. This is unlike his symptom-based classification, in which no
reference was made to any underlying disorder. However, in neither
presentation does Chang normally give any indication of duration or the
sequence of symptoms; that seems to be found only when he notes the
transmission of the disorder from one stream to another.
The two systems of classification were not fully integrated, examples
of one being presented alongside the other and interspersed at random.
They offered parallel accounts of a disease, the one providing an anatom-
ical and physiological foundation missing in the other. Thus the diseases

defined as cold-damage disorder or dampness disorder on the basis of
their symptoms could also be defined as major-yang or major-yin or
other stream disorders. This does not mean, though, that the physiolog-
ical picture was consistently and systematically used as a foundation for
a complete understanding of the symptom-based picture, that, for in-
stance, translations (11) to (13) were seen as necessary adjuncts to the
many individual syndromes that made up cold-damage disorder.
Chang thus has two ways of viewing the same syndrome. But there
are places in his text where a further step has been taken, where there is
a degree of integration between the two conceptual levels. For example,
"In a major-yang disorder there may be a fever, perspiration, an aversion
to wind and a retarded pulse (mo): the term for this is 'wind-strike.'"94
Or, "In a major-yang disorder there may be fever and thirst but no
aversion to cold; this is 'warmth-disorder.'"95 At another point, Chang
has presented a series of major-yang disorders that he then equates with
different types of spasms. This series includes what is probably menin-
gitis:96
(15) In a [major-yang] disorder the body is feverish and the feet cold. The neck
is stiff and tense. There is an aversion to cold. Periodically the head is feverish,
the face red and the vessels (streams, mo) of the eyes red. The head alone shakes
and there are sudden episodes when one is not able to speak. The back is rigidly
arched. This is 'rigidity-spasm.'"97
In each of these cases both systems are used: a stream-classified disorder
has been combined with a specific symptom-classified one, thereby pro-
viding the latter with a physiological and anatomical dimension.
One aspect of major-yang and other stream-named disorders is to an
94. Ibid., 2.5, p. 59.
95. Ibid., 2.5, p. 60.
96. YD, (n. 33), (Glosses), p. 142.
extent puzzling. In theory the characterizing symptoms of each of the
six categories of disorders are related to the course of the streams and
the associated organs. However, the connection is often difficult to dis-
cern, especially with symptoms like fever and perspiration that can affect
the entire body. In practice it appears that only two or three symptoms
were considered essential when determining what stream was disordered.
Although major-yang disorders could have numerous symptoms as-
sociated with the course of the stream, Chang has also presented a simpler
picture: "Damage from cold brings about three kinds of disorder in

major-yang: spasms, dampness, and fevers."98 Most major-yang disor-
ders are those featuring fever, headache, and perspiration prevalent in
illnesses like typhoid, flu-like illnesses, and other feverish diseases.
Major-yang disorders, in other words, paralleled, but at a different level,
cold-damage disorders.
Syndromes related to the other five streams were similarly categorized
on the basis of one or two essential symptoms. The yang-ming stream
was connected with the large intestine and stomach and yang-ming
disorders were those featuring stomach pain or upset which was thought
to be caused by damage to the stomach's normal pneuma." Thus
stomach-aches were a sign to the physician that yang-ming was disor-
dered; associated symptoms could be explained by reference to the course
of the stream or by assuming other streams were also disordered. For
instance in the following case the patient was suffering from a feverish
disease (major-yang) when, after treatment, stomach symptoms ap-
peared. This was a sign that the disorder had been transmitted from the
major-yang stream to the yang-ming:
(16) It was asked, "What is the source of contracting a yang-ming disorder?"
The answer: "In a major-yang disorder, there are outbreaks of perspiration. If
[the patient] is given a purgative or a diuretic, this [will result in] the loss of
gelatinous and liquid matter and the stomach will become dry and burning. It
is thus that [the disorder] is transferred and becomes associated with the yang-
ming stream. The [patient] does not defecate; there is an internal plethora and
constipation. This is termed yang-ming."'00
The stomach distress was the sign that yang-ming had become disordered
and this was considered the cause of the constipation. Other symptoms
could also result from the basic stomach disorder: yang-ming syndromes
98. Ibid., 2.4, p. 54.
99. Ibid., 5.8, p. 141.
100. IbkL, 5.8, p. 142.
include vomiting and inability to eat.101 Additional symptoms could ac-
company the stomach-related distress: there could be fever, perspiration,
chills, and jaundice.102 As with major-yang disorders there were dozens
of syndromes each calling for its specific remedy.
Chang included only a few examples of disorders of the other four
streams.103 Minor-yin disorders are the most interesting. The minor-yin
stream was connected with the heart, with a branch to the eyes and the
kidneys. Disorders in this stream displayed very diverse symptoms and
were often serious or fatal. The defining symptoms, the signs that iden-
tified disorders in the minor-yin stream, were a very weak pulse and

sleepiness (mei), probably meaning torpor or coma.104 Other mental
symptoms, including delirium and dizziness, were sometimes additional
features of minor-yin syndromes.105 One syndrome included bleeding
from the nose, mouth, and eyes, and another severe coldness of the body,
hands, and feet; both were fatal. Vomiting and diarrhea were sometimes
noted. In severe cases a course of several days, ending in coma and death,
was described. Throat pain or ulcers were also a sign of minor-yin
disorders. Both the heart and kidneys were regarded as especially impor-
tant organs and the former was thought to be the seat of mind. As with
the other five stream disorders, the course of the stream itself seems to
have become less significant. The practitioner's main concern was with
the symptoms; a stomach-ache, for instance, or pronounced sleepiness
would be enough to allow him to know he was dealing with a yang-
ming or minor-yin disorder.
The stream-based classification provided Chang with an alternative to
the symptom-based one. But more, it was an attempt to go beyond the
manifest symptoms and to understand the physiological and anatomical
foundations of the disease process. It should be noted that neither system,
nor the limited synthesis between them, originated with Chang. All are
found, with some differences, scattered throughout earlier texts.106 Chang
succeeded in drawing together and adapting this earher material, perhaps
adding some of his own, to present a detailed picture of febrile diseases.
Chang did not provide a single, unified principle by which to view
101. Ibid., 5.8, p. 146.
102. Ibid., 5.8, p. 142.
103. There are a few examples of chQeh-yin disorders in Chang, (n. 3) (Discourse), 6.12, pp.
189-190 which suggest diabetes.
105. Ibid., 6.11, p. 173-181.
106. For example Su-wtn (Plain Questions) (n. 20), 9.31, and Ling-shu ching (Divine Pivot), (n. 72),
5-23-
disease. This does not mean that there is no evidence of consistency or
basic principles; in this regard what disease was not assumed to be is
significant. First, there is no suggestion of any supernatural element, any
role for spirits or deities as causative factors. Such beliefs were prevalent
among most of the population although, judging from the extant texts,
most medical writers tended to share Chang's views.107 Second, there is
no suggestion of disease as punishment or as a retribution brought on
the individual by his own actions or moral character.108 This idea was
found in ancient China but in limited contexts. It was of some political

importance as a device to criticize the emperor but had little influence
on medical thought.109 Third, the five phases and numerological theories
current at the time were not used by Chang in his discussions of disease.
Here he differed with other medical writers who were strongly influenced
by those theories. This does not mean, however, that he was not in the
main stream of medical thought in ancient China.
Whether Chang classified disease on the basis of symptoms or on the
basis of underlying physiological disorders, he saw it as a manifest abnor-
mality brought about by an outside physical factor acting on the body.
While implicitly recognizing the fundamental role of yin and yang
categorization, he concentrated on describing the behavior of pneuma
(ch'i). He was aware of entities, repeatable clinical pictures, but he also
was aware of the great number of variations a single disease may have.
Unlike some other medical writers of his period he did not ascribe these
variations to differences in the constitution of the individual sufferer. He
knew that disease was a process in which a disorder could spread through-
out the body but did not use this as a basis for prognosis. Except for
noting conditions that could or could not be treated and some which
would prove fatal, Chang ignored the sequence of symptoms in favor
of presenting independent syndromes that the practitioner was likely to
encounter on each occasion he saw a patient.
Chang left many questions about the nature of disease unanswered.
He was providing a practical text for people whom he could assume to
107. See for instance Lee T'ao, "A short history of infectious disease in China," Chin. Med.J.,
50. 172-183, 1936: Lee has translated a short essay by the third century A.D. aristocrat Ts'ao Chih
that shows the differences of beliefs at the time. Ts'ao mocks the common bebef among the people
that epidemics were caused by demons or ghosts rather than atmospheric factors.
108. Compare Owsei Temkin, "Health and disease," in The Double Face of Janus, (n. 13), 419-440,
and Riese, (n. 12) Conception, esp. p. 16.
109. See for example Han Ying, Han-shih wai diuan, trans, by James Hightower, Cambridge,
Harvard University Press, 1952, pp. 84-87. Also David Knechtges and Jerry Swanson, "Seven
stimuli for the prince: The Ch'i-fa of Mei Ch'eng," Monumenta Serica, 2a: 99-116, 1970-71.
share a common background knowledge of the then-current medical
thought. The attempt to relate the manifest symptoms to an underlying
physiological condition is perhaps the most interesting feature of his text.
It was made possible by the ancient picture of the vascular system and
the notion that the pulse reflected the condition of the pneuma and thus
could reveal the entire internal state of the body. The emphasis was on
condition, not on function; symptoms did not need to be mechanically
related to a structural dysfunction but only to a change in the normal
condition. Chang's concepts were based on a view of human anatomy

that further dissection and experimentation would have revealed as incor-
rect. Even so, he formulated his concepts on the basis of available data
to provide a rational explanation both for disease and for its treatment.
1431 South Third
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The Concept of Disease in an

Ancient Chinese Medical Text,

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?HERE was no single or unified concept of disease in

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38. Chang, (n. 3) (Diuoursc), 3.6, p. 100.

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48. Cohen, (n. n ) and Temkin, (n. 13).

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61. Chang, (n. 3) (Discourse), 2.3, p. 37.

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This passage was not intended simply as a clinical diagnosis: it would

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