A brief look at the term irritability / vexation(烦 fan)
through the lens of the
Discussion of Cold Damage (Shang Han Lun)
by: Jason Blalack
In Chinese medicine, our understanding of technical terms shapes our clinical picture and ultimately how we treat. One such term that recently peaked my interest was the term 烦 (fan), translated as vexation (Wiseman) or irritability (Eastland Press). These translations seem reasonable since modern dictionaries define it as:
1. vexed, irritated; annoyed, terribly upset, worried mood, or
2. to trouble
However sometimes our assumed meaning, based on a translation or modern understanding, is different than how it is used in various Chinese medicine contexts, especially historically.
Thus 烦 (fan), can have very different meanings depending on the context it is used. I would like to present a brief analysis of how it is used in the Discussion of Cold Damage (Shang Han Lun), in which it occurs around 90 times. It is found in numerous compounds, which help define it, such as Heart irritability (心烦 xin fan), internal irritability (内烦 nei fan), irritability and restlessness (烦躁 fan zao), irritability thirst (烦渴 fan ke), restlessness and irritability (躁烦 zao fan), vexing pain (疼烦teng fang), among many others.[i] Understanding how it was classically used helps us understand its meaning today.
Hence, the understanding of these terms, and the passages that they are contained in, have direct clinical relevance today because they make up our core understanding of key symptomatology for patterns such as shao yin with Kidney yang deficiency and formulas such as xiao chai hu tang (Minor Bupleurum Decoction).
Understanding these terms does not come without complication. As with many classical texts there is controversy. Some choose to understand the term more literally, some with a more modern slant, others strive to look at the time periodâ€™s understanding and pick apart the context. Let us look at a few perspectives from the Discussion of Cold Damage, which should be noted, is just one of many.
In general, Zhang used irritability (烦 fan) to mean:
- Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao)
- To show that a symptom was of a serious nature
1. Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao) in the Heart is the most general type of usage for 烦 (fan) . According to mainstream view this relates to symptoms related to the essence-spirit, not unlike how we understand the terms in English. Consider the line 24:
When in Greater yang disease, the patient initially had taken gui zhi tang, but instead [becomes] fan (烦) and [the condition] is unresolved…”
Looking at how fan (烦) was used in Han dynasty gives an added perspective of the term. For example in the shuo wen jie zi (the first Chinese dictionary, complied by Xu Shen, 121 A.D.) it defines 烦 (fan) as a “heat headache.” Discussion of Cold Damage commentators such as Hao Wan-Shan’s[ii] emphasize the importance of this symptom. It is a “hot type headache, where there is heat and also pain.” Hence this 烦 (fan) here has the additional meaning of heat irritability (烦热 fan re) or even just feverishness (发热 fa re). Actually one may interpret this above passage (line 24) as just having an increased fever. Other lines with a similar usage include: 38, 46, 102, 107, 118, and 264.
Consequently, many believe that this aspect of heat is an important component of understanding the term irritability (烦 fan) in a medical context and if we do not see heat, then it is not irritability. In addition irritability in the heart (心烦 xin fan) will also need to have this heat sensation which is especially present in the chest. This may be an objective or subjective feeling.
2. 烦 (fan) used to express the seriousness of a symptom. For example, in line 156, it says “…give xie xin tang. If the focal distention is unresolved and the person is thirsty, has a severe dry mouth (口燥烦 kou zao fan)…”. Some textbooks tend to interpret this as “… and the person is thirsty, has a dry mouth, has vexation….”
Line 240 begins with “病人烦热 (bing ren fan ren) …” Although some textbooks understand this as “When the patient has heat vexation” others interpret this as “When the patient has severe heat…”
Other instances of this type of usage are lines 174, 175, and various passages in the Essentials from the Golden Cabinet (see endnote[iii]). Hence we get dramatically different interpretations depending on how one understands this 烦 (fan).
3. Nausea: Modern day Chinese medicine uses 恶心 (e xin) for nausea, however this technical term was not used in the Discussion of Cold Damage, or the Inner Classic. Zhang Zhong-Jing instead used phrases such as 欲吐不吐 (yu tu bu tu) line 282 or 温温欲吐 (wen wen yu tu) line 324 among others, to express nausea.
Commenters such as Li Xinji believe that 心烦 (xin fan) refers to nausea in some instances. His argument is that 烦 (fan) according to historical record has this meaning of “entangled disturbance (搅扰纠结 jiao rao jiu jie)“, with commentary explaining this as being a “frequent disturbance”. Heart (心 xin) in Chinese medicine often refers to the location below the heart or stomach duct. Hence this is a “churning disturbance in the stomach duct region”, hence nausea.
For example, in Line 96, which is a key passage for xiao chai hu tang (Minor Bupleurum Decoction) says,
When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, 烦心喜呕 (fan xin xi ou) 胸中烦而不呕 (xiong zhong fan er bu ou).”
Here 心烦 (xin fan) is often interpreted as irritability and restless within the Heart. However Li Xinji points out that if we look at what comes before and after this term, “no desire to eat”, 心烦 (xin fan), “likes to vomit” it makes sense that this actually refers to nausea. He further says, this 心烦 (xin fan) has nothing to do with spirit-light symptoms of the Heart (神明之心 shen ming zhi xin).
Also notice line 326, “…pain and heat in the HEART (心中疼热 xin zhong teng re), hunger with no desire to eat…” – This “heart” here also refers to the stomach.
Hence looking back at line 96, the next series of characters are “irritability in the chest without vomiting (胸中烦而不呕 xiong zhong fan er bu ou).” This 胸中烦 (xiong zhong fan) has the meaning of irritability and restless within the heart (chest). So the whole passage is:
When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, nausea (心烦 xin fan) with a tendency to vomit, or [there is] irritability and restless within the heart without vomiting, or thirst…”
There are other instances where 烦 (fan) and 心烦 (xin fan) refer to nausea, such as in lines 282, 315, and 355. Notice how the surrounding symptoms are specifically gastrointestinal symptoms such as desire to vomit, dry retching etc.. Understanding things in this manner explains many contradictions in passages such as in line 282.
For example line 282 discusses a shao yin disease with Kidney yang deficiency. One of the symptoms mentioned is 心烦 (xin fan) which is often understood as irritability and restless in the heart. However if one looks at the surrounding symptoms, as we did above, we see;
In shao yin disease, [there is] a desire to vomit, but no vomiting ( or: with an inability to vomit), nausea (心烦 xin fan), and a desire to sleep…”
Does “irritability in the heart (心烦 xin fan)” a heat symptom, make sense when there is lower burner deficiency and cold? Some commentators justify this by explaining the irritability in the heart as a “contradictory” symptom caused by the “lower burner struggling with exuberant yin cold which is pushed upward, where it harasses the Heart.” In my opinion, a more likely explanation is the same pathodynamic proposed for the “desire to vomit”, which is, turbid yin counterflowing upward, causing disharmony of the Stomach qi that disturbs the normal downbearing.
In summary, the ideas presented above are just one opinion, as there are many valid interpretations. They are presented to hopefully widen oneâ€™s clinical gaze. No one knows for sure of Zhang Zhong-Jing exact intentions but we can try these ideas out in the clinic and see what makes the most sense.
As a comparison it is interesting to look at a modern Chinese medicine Chinese language dictionary’s definitions for 烦 (fan):
- Heat (热 re)
- Irritability and restlessness (烦躁 fan zao)
- Internal heat irritability in the Heart (内热心烦 nei re xin fan)
It further defines 心烦 (xin fan) as “irritability heat and oppression in the Heart (心中烦热郁闷 xin zhong fan re yu men).”
These entries in and of themselves are a bit circular in definition and hard to grasp, which is what led me on this quest to begin with. As we have seen above, these terms have a large variety of meanings that are not as straight forward as some may like.
Throughout history people use terms in different ways, figuring out the true meaning is never easy. Therefore this essay probably brings up more questions than gives answers, but that is the nature of Chinese medicine. Becoming comfortable with contradictions and varying interpretations and how to make use of them is a useful clinical skill.
For further reference, here are 11 translations for the term 心烦 (xin fan):
- Restless feelings and agitation in the chest
- Anxious feeling or restlessness in the chest
- Anxious restlessness
- Heat in the chest and suffocation (usually translated as ‘anxious agitation’)
- Mental restlessness
- A restless feeling in the chest
- Heart vexation
- Cardiac vexation
- Irritability of the heart
- A feeling of restlessness, heat, and oppression in the region of the heart
English translations have an even more difficult task, because readers often assume they understand the meaning of a technical term based on a seemingly transparent phrase, e.g. “mental restlessness.” Each translation evokes a bit of a different meaning.
However instead of being limited to a single author’s translation of a phrase we can begin to make use of the large breadth of possibilities and usages. Hence none the above are necessarily wrong, if matched to the correct context. However most likely they are going to fall short in certain instances or other people will simply have a different opinion on the meaning. However if we can keep in mind open I think it can help us find some truth in our own clinical experience.
Thank you for reading this essay. Feel free to leave any comments, corrections, or questions?
[i] I purposely chose to use very literal translations, because as we will see, the meaning of these terms can be very different based on the context of a given passage. Also for convenience I chose to mostly use irritability for 烦 (fan), but this, as well as vexation, is an incorrect portrayal in some instances.