The relationship between warm disease (温病, wen bing) and cold damage (伤寒, shang han)
By Qin Bo-Wei (秦伯未)
This small essay in taken from Qin Bo-Wei’s larger Warm Disease thesis that was written in 1963. This essay was published in The Lantern Volume 8 No.2, May 2011, as part of a larger three-part essay entitled Some Issues in Warm Disease by Qin Bo-Wei.
Warm disease (温病 wen bing) is a type of illness1. Warm disease theory, though, is also a current of thought. This current of thought has been very influential, and when set up in opposition to the cold damage (shang han) current, there have been many debates among our predecessors, some of which remain unresolved.
However, I believe that warm disease theory is a development of cold damage theory. Consequently, if we make an extra effort to dispel the differences between them, we can greatly improve the clinical application of Chinese medicine’s externally contracted disease studies.
To properly discuss this issue, it is fundamental that one has basic knowledge of the topic coupled with clinical experience. Then it is important to ask, what is the origin of the disagreements between the warm disease and cold damage currents? What are the clinical differences? Do they have commonalities? If these issues can be clarified then we will be able to correctly approach these schools of thought, thereby integrating them.
The way I see it, cold damage is the contraction of a cold pathogen, and warm disease is the contraction of a warm pathogen. Hence each has a different cause for the onset of disease. Cold damage considers the six channels as their guiding principle, and generally views things as moving from exterior to the interior. On the other hand, warm disease considers the three burners as their guiding principle, and generally views things as moving from upper to lower2. They also have differing methods of pattern differentiation.
Furthermore, cold damage conditions use a warming method, and in the beginning stages use an acrid and warm strategy. Ultimately the method of returning yang is used. On the other hand, warm disease conditions use a cooling method, and in the beginning stages use an acrid and cool strategy. Ultimately the method of rescuing yin is used. Therefore, the treatment principles are also different.[As fundamental as these may sound], in the clinic all of these points are actually a source of disagreement, and have been the basis for long-term debate. Hence, this issue is by no means so simple.
Although the causes of cold damage and warm disease are different, they similarly come about from external pathogens, and the beginning stages are both exterior patterns.Consequently, they similarly use resolve exterior methods. In addition, if the exterior pathogen does not resolve, it similarly will transfer into the interior, and then transform into heat. Consequently they both will then require a clear heat and open the bowels method. It should be noted that cold damage theory similarly has damage to yin, and warm disease similarly has damage to yang. Hence looking at the onset and course of disease of both, we have to acknowledge that although there are differences they have common ground.
From a pattern differentiation perspective, although the six stages of cold damage emphasises transmission from exterior to interior, it also can be divided into the upper and lower. Although the three burners of warm disease emphasise transmission from upper to lower, it also can be differentiated into the exterior and interior. Furthermore, the fundamental theory of Chinese medicine has its core in zang-fu organs, and this has a relationship with the exterior, interior, upper, and lower aspects [of the body].
Moreover, Chinese medicine is unable to deviate from channel and collateral theory. Hence in pattern differentiation of the six stages and three burners it is fundamental to understand the horizontal and vertical aspects. For example, clinically we see the taiyang pattern of six stages as an upper burner disease. Yangming, shaoyang and tai yin patterns are middle burner diseases. Shao yin and jue yin patterns are lower burner diseases. The relationship of the internal organs is also identical. The diagrams will help illustrate this point.
To go a step further, we can look at the herbal prescriptions used for cold damage and warm disease. For example, cold damage essentially uses acrid warm resolve the exterior formulas such as Ma Huang Tang (Ephedra Decoction). Warm disease uses acrid cold resolve the exterior formulas such as Sang Ju Yin (Mulberry Leaf and Chrysanthemum Drink) and Yin Qiao San (Honeysuckle and Forsythia Powder). Of course there are differences, but cold damage also has the acrid cold formula Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction). If you use Ma Xing Shi Gan Tang, is it true that you don’t need Sang Ju Yin and Yin Qiao San? Or if you use the newer Sang Ju Yin and Yin Qiao San, do you not need the older Ma Xing Shi Gan Tang? I think that these all can co-exist.
In addition, cold damage unblocks the bowels using the purging of the Cheng Qi Tang (Order the Qi Decoction) family of formulas and the moist purging of Ma Zi Ren Wan (Hemp Seed Pill). Warm disease also uses the Cheng Qi Tang (Order the Qi Decoction) family of formulas and equally puts forward the nourish yin, moist-purging formula, Zeng Ye Tang (Increase the Fluids Decoction). In addition the warm disease current puts forward the method of combining both Cheng Qi Tang (Order the Qi Decoction) and Zeng Ye Tang (Increase the Fluids Decoction).
In regard to impaired consciousness, delirious speech, and damage of yin patterns, cold damage uses only the purging drain fire of the Cheng Qi Tang (Order the Qi Decoction) family of formulas. In comparison, warm disease uses Zi Xue Dan (Purple Snow Special Pill) and Zhi Bao Dan (Greatest Treasure Special Pill) to open the orifices and clear the Heart which appropriately combines the ideas of nourishing yin and moist purging. However, I consider all of these ideas not only to be essentially the same, but step-by-step developments based on our predecessor’s ideas which consequently have increased our clinical effectiveness.
In fact, warm disease makes use of many cold damage formulas by flexibly applying the concepts to the clinic, such as with modifications of Fu Mai Tang (Restore the Pulse Decoction). Cold damage’s Fu Mai Tang (Restore the Pulse Decoction) fundamentally treats Heart yang insufficiency with simultaneous Heart blood deficiency. Warm disease modifies this formula by subtracting the support yang medicinals, Ren Shen (Ginseng Radix), Gui Zhi (Cinnamomi Ramulus), Sheng Jiang (Zingiberis Rhizoma recens) and Da Zao (Jujubae Fructus) and adding Bai Shao (Paeoniae Radix alba) to safeguard the yin. This turns it into a key formula that nourishes the Liver and Kidney. This kind of skill at using ancient formulas even further illustrates how the warm disease current is a development out of the foundation of cold damage.
Among the warm disease books, Systematic Differentiation of Warm Pathogen Diseases (Wen Bing Tiao Bian, 1798) is one of the most complete. In its first clause it says, “This book follows the method of Zhong Jing’s Discussion of Cold Damage.” In the second clause it says, “Although this book was written for warm disease, it actually can be helpful in understanding cold damage.”
It can be seen that the [ancient] warm disease scholars had no disagreement with the cold damage scholars; hence to put these two currents against each other makes no sense.
Furthermore, since cold damage and warm damage currents already exist, the proponents of each should mutually respect and value each other, eliminating their prejudices. There is a responsibility to unify these two currents, turning it into a completely integrated Chinese medicine externally contracted disease theory.
Translated by: Jason Blalack
Original Essay from: Some Ideas I Have Learned About Warm Disease published in 1963.
1. First mentioned in Chapter 4 of Basic Questions (素问 Su Wen).
2. Actually Zhang Ji (张机) in the Essentials of the Golden Cabinet (Jin Gui Yao Lue) first introduced treating internal disharmonies via differentiation of the three burners.
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