Aram A. Akopyan LAc. Diplomat Oriental Medicine

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Six Stages of Modern Diseases

Written by Aram A. Akopyan LAc. Dipl. O.M.

Six Stages of Modern Disease - comparative analysis attempts to study and analyze the classical theory of disease progression through the Chinese Medicine Six Stages.

Practical application of the theory to identify, classify and treat modern ailments as presented by Dr. Yitian Ni, LAc OMD. The document is organized to first present a base explanation of the six stages theory and in particular, the Shao Yang or Lesser Yang stage, in order to establish a common frame of understanding, according to the classics. Secondly, the document will explain the interpretations and practical applications of Shao Yang Theory by Dr. Ni as presented in “Modern Disorders and Shao Yang Channels, Practical application of Shao Yang Theory” published in California Journal of Oriental Medicine Volume 11, No 2 Spring 2000. Third the author will analyze, compare and contrast the two theories and identify areas of differences or similarities, and his understanding of the implications. The author will draw upon various sources and his understanding of the subject of oriental medicine to illustrate his points. For references and bibliography, contact author.

Classical Shao Yang Theory, Background

Shao Yang, or lesser Yang defines a stage in a six-stage pattern differentiation for identifying and treating diseases.

These stages represent the three Yang and three Yin vessels of the body. According to the Shang Han Lun , exogenous cold pathogens traverse these six stages, as they attack the body’s Yang. Figure 1 illustrates the relative depth of these stages (non-linear), the possible progression of exogenous pathogens and the relative strength of the righteous QI. The pathogens interaction with the body’s defenses manifests in various syndromes, and depending on the relative strength and weakness of the pathogen and said defenses, energetic vectors and symptom severity will vary. Note the critical location of Shao Yang. It is the middle “gate keeper” of the exterior, located between Tai Yang the most external, and hence most exposed area, and the Yang Ming, The Most interior of the Yang Channels. The pathogenic factor first encounters the body’s righteous QI (Wei QI) at the Tai Yang. If the QI is strong, the pathogen is defeated here. However when the righteous Qi is compromised, the pathogen progresses further, and may enter the Shao Yang stage . Here it oscillates between the exterior and interior, causing symptoms and manifestations most common of a struggling condition. Struggling because the righteous QI and the pathogen are combating in turns. When the pathogen prevails there is aversion to cold, when the righteous QI wins out there is heat. This presents the most characteristic symptom of Shao Yang, alternating fever and chills. The pulse is said to be fine and string taught. The Shao Yang is associated with San Jiao and Gall Bladder meridians. The lingering struggle causes stagnation of QI in these meridians and eventually their respective organs. The stagnant Liver/Gall bladder QI causes chest and rib side fullness, bitter aftertaste in the mouth (Gall Bladder organ), dry mouth (Gall Bladder meridian clasping the throat) and may flare up and attack the Spleen and the Stomach (wood attacking earth), or in some cases the heart (houses the Shen, hence the symptoms of taciturnity). Furthermore, since the San Jiao is the central distribution pathway for essential energetic and material components of the body powered by the Spleen and Stomach, the struggle in this San Jiao channel may further impact Spleen and Stomach function, manifesting with nausea and vomiting.

A physiological description of the Shao Yang as the “Pivot” is described in the Shang Han Lun as a critical component in distributing vital QI to various organs and regions of the body. A variety of complicated and combined syndromes are possible as a result of the pathogen settling at the Shao Yang and jumping to exterior and interior stages in a nonlinear fashion. One such pathomechanism is where an exogenous pathogen enters the Shao Yang stage directly , due to underlying Qi and Blood Vacuity. This particular pathomechanism is of interest since it describes a Qi and Blood vacuity condition, which by western physiology illustrates an immune deficient patient.

The nature of the Shao Yang stage requires a specific treatment principle and must be adhered to strictly to avoid exacerbating the condition. Since the pathogen is lodged between the exterior and interior, simply releasing the exterior will not resolve the condition, and in fact diaphoretics are generally contraindicated, unless a combined presentation is present with exterior patterns predominating. The alternating nature of the syndrome and the association to the Liver Gallbladder dictate a principle treatment of harmonizing the interior and exterior, and restoring the flow of constrained QI. The prescribed treatment is the Minor Bupleurum decoction, the key ingredient being the root of Bupreurum (Chai Hu). The herb enters the Liver, Gall Bladder, San Jiao and Pericardium meridians. It spreads constrained liver QI, treats disharmonies between the liver and the spleen and specifically resolves Shao Yang disorders. Pharmacologically it is an antipyretic, antibacterial and antiviral, and has cardiovascular, CNS and respiratory effects. The treatment principle and prescribed formulas are adjusted according to the combinations and complications of the Shao Yang syndrome. A varied acupuncture, cupping, and moxa treatments combined with dietary and energetic exercises is also prescribed but is not discussed here. It is important to stress these key aspects of the Shao Yang location, associated meridians, organs, syndrome manifestations, and treatment principles because they will serve to illustrate and explain a modern application of the theory to describe an evolutionary change in pathogenic and immunity functions.

Modern practical application of Shao Yang theory

Practical applications of traditional Chinese theories find themselves uniquely positioned to address pathologies that sometimes even current medicine has difficulties classifying, clearly defining and effectively treating. Such syndromes as Chronic Fatigue Syndrome (CFS) , Irritable Bowel Syndrome (IBS) , Crohn’s disease , Fibromyalgia and Neuromyesthenia are just few of such complex pathologies that have managed to elude the rigid methodical tendencies of western medicine to box and catalogue every disease into a neat package. In attempting to understand and treat these disorders, practitioners of Oriental Medicine have employed the classical theories to help explain and enlighten these complex modern pathologies.

A specifically focused effort by Dr. Yitian Ni successfully applies the traditional Shao Yang theory to explain, classify, and treat these and many other modern diseases. In her research paper published in the California Journal of Oriental Medicine, Dr. Ni articulates her fundamental premise, that due to an underlying impairment to the righteous QI (from various immune deficiencies, mutated pathogens, inappropriate and unbalanced lifestyles and mental and emotional stresses), a host of disease syndromes have found the means to invade the Shao Yang stage directly, and evolve into chronic conditions, manifesting acutely only when the conditions are favorable. These pathogens can be exogenous or endogenous, hot or cold in energetic nature and may attack variety of systems including: (a) connective tissues, joints, tendons and bones, (b) digestion and metabolism, (c) endocrine system (d) Lymphatic and immune system, (d) nervous system.

Dr. Ni further illustrates how a prolonged exposure to the various stressors, and in particular poor diet, long term mental strain and imbalanced life style, can develop endogenous Shao Yang syndromes without the presence of a pathogenic trigger. This preexisting endogenous Shao Yang condition creates the ideal environment for complications due to even the most minor exogenous pathogens, since the Wei Qi and Jing are in such debilitated condition that they cannot fight even a weak pathogen. Her premise sets the stage for describing variety of debilitating disorders that take advantage of the underlying immune depression and establish an energetic niche where they can coexist with the weakened righteous Qi within the body and lay in wait. The patterns presented by these disorders are categorized into four classes. These are:

1.   Lingering and recurring infections and inflammations with chronic low-grade fever or the perception of heat by patient, sometimes with chills. General aches that do not respond to or get worse with antibiotics and anti-inflammatory drugs.
2.   Imbalanced immunity, either autoimmune or immunodeficiency conditions
3.   Chronic pain that does not respond to analgesic treatments
4.   Miscellaneous symptoms such as itching, discoloration, abnormal growths, including tumors, fibroids, cysts etc.

Each of these patterns has a logical correlation to the classical Shao Yang syndromes modified only by the relative strength of the modern pathogens and the debilitated righteous QI. For example lingering recurring infections and inflammations and the low-grade fever may be due to the relentless struggle between the deficient immune system and the pathogen. Musculosckeletal pains can be attributed to the involvement of the liver as its QI becomes constrained and prevents free-flow. The abnormal growths can be attributed to continual accumulations of toxins due to lack of circulation and filtration of the lymphatic system, which is part of the San Jiao.

Dr. Ni further leverages the classic Shao Yang theory to determine and implement treatment principles that effectively address the root causes for these complex diseases. Her approach relies on similar harmonizing treatment principles and combines specific targeted acupuncture, dietary and herbal strategies to eliminate the pathogen, treat the root, strengthen the righteous Qi, restore function, and ameliorate the branch presentation. She specifically outlines differential herbal treatment principles for various combined Shao Yang pathologies some of which are listed below:

Patterns, Symptoms and indications

Patterns, Symptoms and indications			Prescribed herbal treatment
Shao Yang with Damp Heat		(Damp predominant)
	Symptoms include: Classic Shao Yang plus heavy sensation on body, muscle and joint pain, tiredness, sleepiness, does not feel refreshed after rest, chest and epigastria stuffiness, no appetite or stress eating, sticky, sensation in the mouth, boggy brain. Tongue with sticky yellow possibly curd like coating, and string taught and slippery pulse.		Xiao Chai Hu Tang He Huo Xiang Zheng Qi San (classic bupleurum plus Agastache powder to rectify the QI and alleviate damp conditions.

Shao Yang with Damp Heat		(Heat Predominant)
	Symptoms include: Classic Shao Yang plus Damp typical Damp Heat signs depending on burner location.
	LIV/GB – Distention and burning pain in costal and hypochondriac region with scapular or shoulder pain, Possible jaundice, indigestion, heartburn, bitter taste in mouth		Xiao Chai Hu Tang He Hao Qin Qing Dan Tang Jia Jian Modified minor Bupleurum decoction plus Artemisia Annua and Scutelleria Decoction to Clear the Gall Bladder Heat
	ST/SP/LI - Abdominal bloating, sour regurgitation, heartburn, flatulence, indigestion, lack of appetite, abnormal bowel movements, diarrhea, constipation or sticky stools, Tenesmus, abdominal cramping.		Xiao Chai Hu Tang He Ban Xia Xi Xin Tang Minor Bupleurum decoction plus Pinellia decoction to drain the epigastria.

Shao Yang with QI and Blood Vacuity
	Symptoms include: Classic Shao Yang plus listlessness, no stamina, waking up tired, spontaneous sweating, weak voice, shortness of breath, depression, pale tongue, weak pulse.		Xiao Chai Hu Tang He Bu Zhong Yi Qi tang Jia Augmented minor Bupleurum decoction plus Tonify the middle and augment the QI decoction.

Shao Yang with QI and Yang Vacuity
	Symptoms include: Classic Shao Yang plus aversion to cold, chill sensations in lower abdomen and lumbar, soar and weak lumbar and knees, indigestion, loose bowels, impotency, lassitude, copious clear urination, lack of libido, delayed menstruation, amenorrhea, infertility, pale swollen tongue, deep week pulse.		Xiao Chai Hu Tang He Ren Shen Lu Rong Wan Augmented minor Bupleurum decoction Ginseng and cornu cervi Pill to tonify the Yang)

Dr. Ni’s acupuncture treatment protocols include intradermal needling, cupping, moxa and tapping. Her unified approach guides her selection of meridian points according to the differential pattern presentation and addresses the various related organs and channels accordingly. Dr. Ni also recommends colon and liver cleansing and detoxification protocols including five day modified fasting, liver flushing drinks, and green meal recommendations.

Analysis

The key to successfully applying the classical Shao yang theory in identifying and treating modern pathology is the understanding of the interaction between the pathogenic energy (Qi) and body’s defensive mechanisms (Righteous Qi), and in understanding debilitation of the righteous Qi. This interaction creates an energetic pendulum that illustrates the etiologies, manifestations, disease vectors and effected organ systems; it also dictates the appropriate treatment principles. The human being is not an isolated entity, it is energetically and materially part of the surrounding environment, as such, it is not uncommon for the human body to host any number of pathogenic entities at any given time. These entities exist in symbiotic or parasitic configurations. The Human immune system simply maintains homeostasis to protect the body. In doing so, it often overlooks many such pathogens and simply keeps them in check. However, any impairment to the immune system will tilt the pendulum (Figure 2) and create favorable conditions for many such dormant pathogens to awaken with renewed fervor, and even more importantly, create such a debilitated immune environment, that other exogenous pathogens, even weak ones can enter the system with little or no resistance. Under normal circumstances, the righteous Qi is continually replenished and strengthened by body’s various integrated systems. As the human species increases in numbers and complicates its relationship to the surrounding symbiotic ecosystems, greater and greater stressors are introduced into our bodies. The end result of these stressors is an unbalanced living, debilitated righteous QI, and compromised immune system, setting the stage for complex hard to treat syndromes that develop chronicity with alternating acute presentations. To clearly understand the etiology and effects of the debilitated Righteous QI or compromised Immune system as described by the Shang Han Lun or Dr. Ni, the following four major trends are analyzed.

The four trends are:

1. An increased level of mutations and evolutionary changes occurring within the bacterial and viral communities. As evidenced with every major advancement and population growth of the human species throughout history, our common parasitic and symbiotic cohabitants also mutate and evolve. These mutagenic and adaptogenic abilities allow pathogens to enter our body and either completely elude our immune systems through stealth, or establish a non-invasive dormancy and remain within our systems for long periods of time. Overconfident and overindulgent use of many of the current antibacterial and antiviral pharmaceuticals have over time given some of the most strongest pathogens immunity against the drugs. Some of these bacteria and viruses can communicate this immunity through DNA to other species, further complicating treatment. From a TCM point of view this translates to stronger pathogens and more specifically pathogens that enter and linger in the Shao Yang stage and strike only when the conditions are right.

2. The heavy industrialization and unbalanced use of the natural resources of our planet have put a great strain on our environmental and ecological systems. Air, water, terrain pollution and ozone depletion, undoubtedly affect all living organisms, including the human species by creating toxins that reduce our immune abilities. From a TCM point of view this greatly impacts the environment we live in and since all life is interwoven together and with surroundings: for any action there is an equal and opposite reaction.

3. Dietary and life style changes have greatly impacted the human species ability to maintain a strong and vital immune system. The increased fat, dairy, gluten and genetically and chemically altered foods place a great burden on the hunter-gatherers digestive system and impair our absorptive efficiencies. Obesity, and gastrointestinal conditions are some of the most common today. From a TCM point of view, the Spleen/Stomach are the central junction of the San Jiao and the single source of replenishing Jing. With this damaged, all other vital functions are impaired, and the Righteous QI weakens. It’s worth noting that Spleen/Stomach pathology is also very common in the Oriental Medicine practices, especially in the industrialized west.

4. The sympathetic and parasympathetic nervous systems of the human species are designed to maintain a harmonious balance of stimulation and inhibition (rest). The body cannot maintain balance under sustained sympathetic stimulation, but unfortunately, today people find themselves under constant stressors and stimulus that force a dangerously high degree of sympathetic stimulation. This not only further impairs digestive and absorptive functions, but also impacts mental and emotional states creating a population living in a constant state of anxiety, depression, and rage. From a TCM point of view, emotions are closely related to various organ systems and are linked to their pathology. General state of imbalance of the emotional and mental state further debilitates the righteous QI, disturbs the SHEN and weakens the prognoses.

Dr. Ni has effectively integrated these trends into her application of the Shao Yang theory to illustrate an energetic pendulum between the compromised righteous Qi and the pathogen, where neither one is completely victorious, and depending on other factors either one can gain the upper hand temporarily. This stalemate condition allows for even the most common and most rudimentary of ailments to cause havoc within the body. The various organ and functional systems affected by these ailments as outlined by Dr. Ni include the following:

a. Joints and tendons are classically associated to the wood element (Liver). And Since Shao Yang stage pathogens affect the free flow of Liver QI and cause stagnation, this can manifest in various joint and tendon problems. Explaining fibromyalgia and rheumatoid arthritic conditions. And even though bones in classical TCM theory are associated with the water (Kidney) element, the Gall Bladder meridian has a strong connection to them as well.

b. Digestion and metabolism are the fundamental means for the organism’s sustenance and energetic replenishment. Any impairment to these can lead to general mal-absorption and weakened energy. Since the Spleen and stomach comprise the central junction of the circle of wellness (San Jiao) responsible for absorption and distribution of energy and nutrients throughout the body, they are easily affected when the Shao Yang stage is engaged with a pathogen.

c. The endocrine system and in particular the thyroid which is the effected organ of the hypothalamus – thyroid hormonal axis, produces variety of hormones essential in maintaining homeostasis and promoting health. Proximal passage of the various Shao Yang affiliated meridians to the thyroid may account for adverse effects on the endocrine system due to pathology in the Shao Yang Stage.

d. Lymphatic system is a major part of the San Jiao due to the proximal locations of the lymph nodes to the Shao Yang meridians and hence can easily be affected by any pathology in the San Jao. This illustrates the impact of the Shao Yang syndromes on the immune system and since the lymphatic system also serves to cleanse and recycle the body’s fluids of toxic and pathogenic factors, impairment to the system may cause accumulation of these toxins and over a long period of time formation of abnormal growths.

e. The nervous system, and in particular the Vagus (10th cranial) nerve of the parasympathetic nervous system plays a key role in maintaining homeostasis by exerting its effects on varied organs essential in marinating health, including gastrointestinal organs, digestive organs, cardiovascular and respiratory organs. Several key acupuncture points located on the Shao Yang meridians are directly connected to the nervous system, especially in the upper body, and hence play a major role in pathology and treatment of the nervous system.

Conclusions

Although Dr. Ni’s application of the Shao Yang theory varies in some key points from the classic, it serves to successfully enlighten and explain many of the modern pathologies from logical, clinical and scientific points of view. Some primary areas of the two theories are listed to illustrate differences and similarities of the two theories.

a. The Shang Han Lun specifically describes externally contracted cold pathogens attacking the body’s Yang. Whereas Dr. Ni’s theory includes cold and hot pathogens.

b. The classic theory describes the following modes of developing Shao Yang Syndromes. Exogenous pathogens attacking the Shao Yang stage directly. Pathogens progressing to Shao Yang from Tai Yang stage, and the ensuing underlying internal disharmonies manifesting with Shao Yang symptoms. Furthermore, the pathogens in the classical theory have active vectors and tend to move from stage to stage.

c. In the modern theory, the progression of the pathogen differs from the classic theory in that it does not attack the Tai Yang. It directly attacks the Shao Yang, and has the tendency to settle and linger in this stage. Furthermore, the modern theory accounts for non-pathogenic Shao Yang syndromes primarily developing from long-term behavioral imbalances of the patient.

Her treatment principles and clinical notes clearly define an approach that addresses many modern diseases that have been classified as untreatable or palliative by modern medicine.

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