Treating Exterior Conditions in Jing Fang
October is a significant month in many ways. As the nights draw in, we begin to move from the warmth and abundant Earth of late summer into the Yin of autumn and winter. Children go back to school, and seasonal coughs and colds begin to pop up with increasing regularity.
Of course, nowadays Western Medicine understands these illnesses as triggered by the presence of bacteria, viruses and even fungi (in the case of a disease such as aspergillosis). This wasn’t always the case, however – Germ Theory developed in the 19th Century. In early medical systems diseases were attributed to the supernatural, or to imbalances in vital substances. Chinese medicine was the first medical system to develop the concept of disease as something that could be caused by environmental factors attacking or invading the body. The ‘Six Evils’ (wind, cold, summer-heat, dampness, dryness, and fire/heat) are outlined in the Huangdi Neijing, but a more complete understanding of external aetiologies is described in depth in the Shang Han Lun (Treatise of Cold Damage).
The Shang Han Lun & Jing Fang Understanding of External Pathogens
In the Shang Han Lun, Zhang Zong Jing described the body as having ‘Six Divisions’ or ‘Six Syndromes’. These divisions describe three different layers of the body, the exterior, the interior and a layer that is between the interior and exterior. Each of these layers has a yang aspect and a yin aspect, making six in total.
The exterior layer, known as ‘Taiyang’ is the part of the body that is directly affected by external pathogens. The Taiyang syndromes are the first to be discussed in the Shang Han Lun, and make up the largest number of clauses and descriptions, alluding to the importance of correctly treating this layer for the maintenance of health. When the body’s Wei qi, or Defensive qi (understood as yang energy supported by body fluids) is strong, pathogens are repelled and illness is short-lived. As the pathogen attacks the surface of the body, the body’s natural response is to push body fluids outwards and upwards, releasing the exterior and promoting sweating, in order to move the pathogen back out from the external layers.
The Shang Han Lun
The Shang Han Lun was written by Zhang Zhong Jing (the “Hippocrates of Chinese Medicine”), during the Han dynasty. After an epidemic killed most of the 200 or so villagers where he lived, he felt an obligation to his ancestors and humanity to study medicine. He became an apprentice of Zhang Bo Zao, a renowned doctor at the time. Through his studies and practice he developed the Shang Han Lun diagnostic system, the earliest known diagnostic tradition in Chinese Medicine, which is outlined in his two foundational texts, the Shang Hang Jia Bing Lun (Treatise on Cold Injury and Miscellaneous Disease) and the Jin Gui Yao Lue (Essentials from the Golden Chamber). The central thesis of the Shang Han Lun is that external pathogens, particularly cold, can penetrate the exterior parts of the body, and will move deeper internally if the Yang Qi is not strong enough to push them out. As they move interiorly they cause more complex and chronic conditions, as seen in pathologies characterised by heat, deficiency, dryness, and stasis affecting the internal organs.
This is reflected in the pulses with a floating pulse, as well as exterior symptoms such as pain and stiffness of the nape and head, along with aversion to cold. If Wei qi is insufficient, either because of a lack of Yang energy or a deficiency in body fluids, then these pathogens can move deeper, causing more severe or long lasting illnesses. When a pathogen is in the external layer, it can cause either a Shang Han (“Cold Damage”) or Zhong Feng (“Wind Strike”) disease. These are two distinct pathologies, with different presentations, treatment principles, and formula groups. Shang Han are seen as an ‘excessive’ Taiyang syndrome, whilst Zong Feng is seen as a ‘deficient’ Taiyang syndrome. They are often seen as common colds and flus, but also can be seen in migraines and headaches, muscular-skeletal problems, cyclical fevers, skin diseases and more.
These two syndromes make up the Yang aspect of the exterior syndromes. It is also worth mentioning that the Yin aspect of the exterior is classified as Shaoyin. Shaoyin pathologies are understood as diseases on the exterior with significant deficiency (of yang and body fluids). As such, they present with more severe aversion to cold, along with symptoms such as chronic and severe pain, with cold often penetrating deeper into the joints causing deformities, difficulty with movement and flexibility, neurological symptoms, as well as severe fatigue and a desire to sleep.
Shang Han: Excessive Taiyang Syndrome
Shāng hán (伤寒) is translated as ‘cold damage’, which give a clear indication of the main symptoms and location of this syndrome or pattern. Shāng (伤) means damage: there is an affliction of or illness in the body. Dr Feng Shi Lun also points out that the phonetically similar shàng (上) means ‘upper’, which refers to the location of the disease, on the outermost layer, as well as the common predominance of symptoms in the upper part of the body. Han (寒) translates to cold, reflecting the strong aversion to cold that is a key symptom of the syndrome.
The key passage regarding Shang han syndromes is Clause 3:
太陽病，或已發熱，或未發熱，必惡寒，體痛，嘔逆，脈陰陽俱緊者，名為傷寒。
In Tai Yang disease, whether fever is already present or not yet present, there is necessarily aversion to cold, body aches, and retching or nausea. When the pulse is tight at both the yin and yang positions, this is called cold damage.
Therefore, this syndrome can present with or without a fever, but there must be aversion to cold. “Body aches” are also commonly seen, referring to any aches or pains of the muscles and joints, which get worse with exposure to cold, while the tight pulse reflects the excess of body fluids on the exterior, as the fluids are pushed outwards in an attempt to move the pathogenic cold outside the body.
This syndrome, therefore, presents with aversion to wind, reflecting weakness in the wei qi which causes the pores of the skin to remain open, resulting in spontaneous sweating without releasing the pathogen. As with the Shang han, there is the presence of heat, as the body increases its temperature in order to release the pathogen by promoting sweating.
| Key Symptom | Pathomechanism |
|---|---|
| Aversion to cold | Presence of cold and constraint of Wei qi |
| Fever or heat sensations | Struggle between Wei qi and pathogenic factors – the body raises its temperature in an attempt to promote sweating. |
| Lack of sweating | The body attempts to push the pathogen upwards and outwards, towards the shoulders/neck, causing an excess of yang qi and body fluids, leading to tension. |
| Pain | Body fluids and qi become excessive, as they attempt to push out the pathogen, causing stagnation in the channels |
| Tension in neck and upper back | The body attempts to push the pathogen upwards and outwards, towards the shoulders/neck, causing an excess of yang qi and body fluids, leading to tension |
| Headache, dizziness, nausea | The upwards movement of body fluids leads to ‘ben tun’ (upsurging qi). |
| Floating and tight pulses | As the body tries to push the pathogen out, qi and body fluids become excessive (seen in the tight quality of the pulse) on the exterior (reflected in the floating quality) |
The most important formula group for treating a Shang han syndrome is Ma Huang Tang and its variations. Key to these formulas is the presence of ma huang – a herb which has a strong action on the exterior, powerfully promoting sweating to allow the body to expel cold pathogens. In Ma huang tang, the other three herbs, Gui zhi, Xing ren and Zhi gan cao work with Ma huang to help regulate the exterior, descend upsurging qi (cough, headache, etc) and provide some support to the body fluids in their role of expelling cold.
Zhong Feng: Deficient Taiyang Syndrome
The Zhong feng syndrome, like the Shang han, is located on the exterior. It differs from the Shang Han presentation in several ways. Zhong feng (中風) is translated as ‘wind strike’. This gives us a key symptom in this syndrome – aversion to Wind (feng 風). The character zhong (中) translates as middle, giving us the important understanding that the pathogen has penetrated a deeper layer of the exterior.
Clause 2 of the Shang Han Lun describes the Zhong feng syndrome:
太陽病，發熱汗出，惡風，脈緩者，名為中風。
In Tai Yang disease, when there is fever, spontaneous sweating, aversion to wind, and a moderate pulse, this is called wind strike (zhong feng).
This syndrome, therefore, presents with aversion to wind, reflecting weakness in the wei qi which causes the pores of the skin to remain open, resulting in spontaneous sweating without releasing the pathogen. As with the Shang han, there is the presence of heat, as the body increases its temperature in order to release the pathogen by promoting sweating.
The key symptoms of a Zhong feng are as follows:
| Key Symptom | Pathomechanism |
|---|---|
| Strong aversion to wind | Weakness of Wei qi opens the pores – the body is more susceptible to attack from wind. |
| Fever or heat sensations | Struggle between Wei qi and pathogenic factors – the body raises its temperature in an attempt to promote sweating. |
| Spontaneous sweating | As the pores are open (due to weak Wei qi), sweating is spontaneous or incessant. |
| Muscle and joint pain, stiffness, cramping and weakness. | Excessive sweating damages the body fluids, leading to body fluid deficiency on the exterior |
| Tension in neck and upper back | The body attempts to push the pathogen upwards and outwards, towards the shoulders/neck, causing an excess of yang qi and body fluids, leading to tension |
| Floating and moderate pulses | As the body tries to push the pathogen out, qi moves to the exterior, reflected in the floating quality of the pulse. The relative deficiency of the body fluids is reflected in the moderate quality of the pulse. |
Gui zhi tang and its variations are the key formulas for treating Zhong feng syndromes. Gui zhi fortifies wei qi, regulates the exterior and slightly promotes sweating to release the pathogen. The other herbs in Gui zhi tang support the function of Gui zhi, and reflect the deficiency of body fluids present in the Zhong feng syndrome, as compared with a Shang Han. Bai shao nourishes body fluids, as well as harmonising ying and wei qi, resolving tightness, weakness and pain of the muscles. Sheng jiang, da zao and zhi gan cao all work together to warm the interior and nourish body fluids, while sheng jiang also supports gui zhi to release the exterior by promoting sweating.
Gui zhi tang variations are the most numerous formula group in the Shang Han Lun, reflecting the frequency of the Zhong feng presentation in clinic, the importance effectively dealing with pathogens at this level, and of usefulness and adaptability of Gui zhi tang in treating a wide range of symptom patterns.