Xiao Xiangru notes: Zhang Kouqi, a disciple from the Shanxi Liulin County People’s Hospital, has become a renowned physician in Shanxi. With rich clinical experience and quick thinking, he seems to be born for Traditional Chinese Medicine (TCM). After entering the school, he thoroughly understood and accurately applied my “Diagnosis and Treatment System for External Pathogenic Diseases in the Early Stage,” surpassing his teacher!
In the coming days, I will serialize his summary of common formulas and patterns for treating external pathogenic diseases in clinical practice for everyone’s reference.
For a long time, infectious diseases have been the greatest threat to human health, and external pathogenic diseases are an important component of infectious diseases.
The “Shang Han Lun” (Treatise on Cold Damage) and “Wen Bing Tiao Bian” (Differentiation of Warm Diseases) are classic texts studying external pathogenic diseases, revered by TCM practitioners and passed down through the ages, which sufficiently illustrates the importance of external pathogenic diseases.
However, treating external pathogenic diseases is not easy. The development history of TCM over thousands of years is essentially a history of fighting against external pathogenic diseases.
Zhang Zhongjing established the six meridian differentiation system, which relatively well addressed the exterior symptoms caused by cold pathogens, but said little about warm diseases; it was not until the Ming and Qing dynasties that the warm disease school was formed, proposing the differentiation of Wei, Qi, Ying, and Blood, and the treatment system for external warm diseases was basically established.
Thus, theoretically, the TCM theory of external pathogenic diseases should be increasingly perfected and reach a state of excellence.
However, there are still many issues in the treatment of external pathogenic diseases.
“For a long time after I became a doctor, I felt fear in treating the early stage of external pathogenic diseases because I could not distinguish the nature of cold and heat in the early stage of external pathogenic diseases. This prompted me to focus on and think about this issue.
I found that not only I could not distinguish the nature of cold and heat in the early stage of external pathogenic diseases, but also the vast majority of doctors, including many famous doctors, faced this problem, and my doctoral supervisor, Professor Shi Zhensheng, also encountered this issue.”
This is a statement made by my master, Mr. Xiao Xiangru, in his monograph “Reconstruction of the Diagnosis and Treatment System for External Pathogenic Diseases in the Early Stage.”
In my clinical career, I have had the opportunity to encounter and treat many external pathogenic diseases, but sometimes the results were not very good, and I have had many failed cases.
A common cold often cannot be resolved with a single sweat, leading to prolonged cough or even the development of other symptoms.
I dare not theoretically doubt the correctness of traditional TCM theories, but I continuously correct treatment methods in practice.
Later, I intermittently learned some methods from later physicians, such as Liu Hejian, for treating external pathogenic diseases: Shuangjie San, Fangfeng Tongsheng San, Shuangjie Mahuang Tang, etc., but they were also effective and ineffective.
In 2016, after I had the opportunity to attend my master’s complete course on the “Shang Han Lun,” I gradually gained a correct understanding of the etiology and pathogenesis of external pathogenic diseases and their differentiation and treatment, applying it in clinical practice with good results.
The fundamental reason for the misdiagnosis of external pathogenic diseases in the early stage is the inability to distinguish between cold and heat, which stems from unclear concepts and theoretical confusion.
In the “Shang Han Lun,” Article 6 states: “In Taiyang disease, if there is fever and thirst, but no aversion to cold, it is a warm disease.” Clearly, warm diseases do not have aversion to cold. However, Zhang Zhongjing classified it under the category of Taiyang disease, which is characterized by aversion to cold, indicating that the concept of Taiyang disease is unclear.
Ye Tianshi stated in “Wen Re Lun”: “It is permissible to sweat in Wei.” However, warm diseases avoid sweating with pungent and warm herbs.
Wu Jutong explicitly stated in his annotations to “Wen Bing Tiao Bian”: “Warm diseases avoid sweating; sweating not only does not resolve the condition but also leads to other ailments.”
Wu himself also included pungent and warm herbs like Jingjie and Douzhi in the Yinqiao San for clearing lung heat, reflecting his contradictory mindset in distinguishing cold and heat in the early stage of external pathogenic diseases.
The modern TCM textbooks differentiate cold and heat in external pathogenic diseases as follows:
External cold pathogen: severe aversion to cold, mild fever;
External heat pathogen: severe fever, mild aversion to cold.
However, the actual clinical situations we encounter are: in cold damage like Mahuang Tang syndrome, both aversion to cold and fever are severe; in warm diseases like Yinqiao San syndrome, fever is not severe, there is no aversion to cold, and even aversion to heat.
Clearly, the methods in textbooks are a result of closed-door reasoning. According to the methods in textbooks, we cannot distinguish between cold and heat, making misdiagnosis inevitable.
To accurately distinguish the nature of external pathogens in the early stage of external pathogenic diseases and clarify cold and heat, it is crucial to clarify two concepts and master one principle.
Exterior syndrome: is caused by the invasion of cold pathogens, characterized by “aversion to cold” in external pathogenic diseases. Taiyang disease is an exterior syndrome.
Warm disease: is caused by the invasion of heat pathogens, characterized by “fever and thirst, no aversion to cold” in external pathogenic diseases.
Warm diseases and cold damage have different pathogen natures, infection pathways, and transformation rules.
Master the principles of treatment based on the urgency of external pathogenic diseases.
In clinical practice, external pathogenic diseases often present with various forms such as exterior cold with interior heat, severe exterior cold with mild interior heat, mild exterior cold with severe interior heat, and both exterior and interior being severe. Treatment should be flexible based on the principle of urgency, either treating the exterior first and then the interior, or vice versa, or treating both simultaneously.
Below are some external pathogenic diseases I have treated over the past few years, especially during last year’s flu season, which basically include common formulas and patterns for external pathogenic diseases in our clinical practice, now organized for everyone’s reference.
Mahuang Tang
In the “Shang Han Lun,” Article 35 states: “In Taiyang disease, if there is headache, fever, body aches, low back pain, joint pain, aversion to wind, and no sweating with wheezing, Mahuang Tang is the main treatment.”
Key points for differentiation:
1. Strong constitution;
2. Severe aversion to cold and fever;
3. No sweating;
4. General joint and muscle pain; some patients may initially have no fever but have aversion to cold and muscle joint pain, which is often Mahuang Tang syndrome.
5. Floating and tight pulse;
6. Pale tongue with thin white coating.
Case 1
Xue, male, 13 years old. Initial diagnosis date: December 25, 2017.
The patient started to have a fever three days ago and self-medicated with Western medicine and Yinqiao detox granules, but the fever did not subside.
Upon examination: fever, body temperature 39°C, aversion to cold, occasional chills, no sweating, general muscle soreness, cough, no phlegm, discomfort in the upper abdomen, poor appetite, pale tongue with thick greasy white coating, bad breath, floating and tight pulse.
Cold pathogens bind the exterior, food stagnation in the interior.Prescribed pungent and warm herbs to induce sweating and eliminate stagnation.
Mahuang Tang with modifications:
Mahuang 15g, Guizhi 12g, Xingren 10g, Zhi Gan Cao 6g, Binglang 10g, Chao Laifuzi 10g.
After taking one dose, sweating occurred, and the fever subsided; continued after stopping.
Discussion:
The child has a strong constitution, severe aversion to cold, and fever, with no sweating, and a floating tight pulse, which is a typical Taiyang cold damage exterior excess syndrome; the thick greasy coating and bad breath indicate food stagnation; although the illness has lasted three days, the exterior syndrome still exists.
In the “Shang Han Lun,” Article 5 states: “If there is no Yangming or Shaoyang syndrome after two or three days of cold damage, it is not transmissible.” Mahuang Tang was still used to induce sweating and eliminate stagnation, resolving the condition with one sweat.
Currently, in clinical practice, the Daqinglong Tang syndrome seems to be more common than the Mahuang Tang syndrome, which I feel is related to not seeking timely medical attention and misdiagnosis after external pathogenic invasion.
In the early stage of exterior syndrome, if the opportunity is seized and Mahuang Tang is decisively used, it often resolves with one sweat and one dose, but the opportunity is fleeting and needs to be taken seriously.
Daqinglong Tang
In the “Shang Han Lun,” Article 38 states: “In Taiyang wind stroke, if the pulse is floating and tight, with fever, aversion to cold, body aches, and no sweating with irritability, Daqinglong Tang is the main treatment. If the pulse is weak and sweating occurs with aversion to wind, it should not be taken; if taken, it will lead to reversal and muscle spasms, which is a reversal condition.”
Key points for differentiation:
1. Typical Taiyang cold damage manifestations: fever, aversion to cold, body aches, no sweating, floating and tight pulse, or floating and rapid pulse with strength.
2. Cold pathogens in the exterior not resolving, leading to stagnation of Yang Qi and transformation into heat, causing irritability.
In clinical observations, exterior syndrome often presents with red tongue, dry mouth, and dry throat, and in severe cases, sore throat, all indicating internal heat, commonly seen in Daqinglong Tang syndrome.
Case 2
Hao, male, 13 years old. Initial diagnosis: January 23, 2018.
Started to have a fever on the evening of January 22.
Upon examination: fever, body temperature 38.9°C, aversion to cold, no sweating, sore throat, worsened when swallowing, red tongue, thin white coating, floating and rapid pulse. Examination revealed congestion in the throat, with no enlargement of the tonsils.
Taiyang cold damage with internal stagnation heat.Prescribed pungent and warm herbs to resolve the exterior and clear internal heat.
Daqinglong Tang with modifications:Mahuang 20g, Guizhi 10g, Xingren 10g, Gan Cao 6g, Sheng Shigao 60g, Jiegeng 10g, Banlan Gen 30g, Huangqin 10g, Sheng Jiang 15g, Dazao 4 pieces.
Two doses.
On the morning of the 24th, the family called, stating that after taking half a dose, the fever subsided, and after finishing one dose, the sore throat also stopped. The patient returned to school and continued after stopping.
Discussion:
Aversion to cold, fever, and no sweating indicate Taiyang cold damage, with cold pathogens binding the exterior.
Sore throat and red tongue indicate internal heat; thus, Shigao was used heavily, along with Jiegeng, Banlan Gen, and Huangqin to clear heat, benefit the throat, and detoxify.
The original formula of the “Shang Han Lun” uses Shigao the size of a chicken egg and Mahuang six taels, indicating that the exterior cold is heavier than the interior heat. In this case, both exterior and interior are severe, so slight adjustments were made to treat the exterior and clear the interior simultaneously.
Case 3
Li, male, 3 years old. Initial diagnosis: October 30, 2017.
Fever for one day, body temperature 39°C, aversion to cold, no sweating, cough, no phlegm, poor appetite, normal urination and defecation, red tongue with little coating, floating and rapid pulse.
Cold pathogens bind the exterior, with internal stagnation heat.
Daqinglong Tang with modifications:Mahuang 10g, Guizhi 5g, Xingren 5g, Shigao 15g, Zhi Gan Cao 3g, Chao Laifuzi 5g, Sheng Jiang 10g, Dazao 3 pieces.
Two doses.
Second diagnosis: November 3, 2017.
After taking the above medicine, the fever subsided, but there was still a slight cough, with little phlegm, nasal congestion, and clear and turbid nasal discharge, red tongue with little coating. Modified Erchen Tang with Xingren, Jiegeng, Qianhu, and Huangqin. Cured after three doses.
Discussion:
This case involves a child patient with high fever, aversion to cold, and no sweating, indicating cold pathogens binding the exterior, while the red tongue indicates internal heat. The exterior cold is severe while the interior heat is mild, so the original formula of Daqinglong Tang was used to resolve the exterior and clear internal heat, with slight modifications for digestion.
After the fever subsided, the cough persisted, so Erchen Tang was modified to transform phlegm and promote lung function, leading to recovery.
Case 4
Liu, female, 53 years old. Initial diagnosis date: April 5, 2018.
Fever for one day, body temperature 38.7°C, aversion to cold, no sweating, general pain, dry throat, pale tongue with white coating, floating and weak pulse.
Prescribed Daqinglong Tang:Mahuang 20g, Guizhi 10g, Xingren 10g, Gan Cao 6g, Shigao 30g, Sheng Jiang 15g, Dazao 4 pieces.
One dose.
Second diagnosis: April 6, 2018.
After taking the above medicine, the fever subsided, but there was still slight pain and poor spirit.
Prescribed Ren Shen Bai Du San:Ren Shen 10g, Yunling 10g, Chuanxiong 10g, Qianghuo 6g, Duhuo 6g, Zhike 10g, Jiegeng 10g, Zhi Gan Cao 10g, Chaihu 10g, Sheng Jiang 15g, Dazao 4 pieces.
Two doses.
Third diagnosis: May 10, 2018.
Complained of continuous sweating since the last cold, with general aversion to cold, pale tongue with white coating, and weak pulse.
Prescribed Guizhi Jia Fuzi Tang:Guizhi 10g, Baishao 10g, Zhi Gan Cao 6g, Zhi Fuzi 10g, Sheng Jiang 15g, Dazao 4 pieces, Huangqi 30g.
Five doses.
After taking the above medicine, sweating gradually stopped, and aversion to cold also decreased, leading to gradual recovery.
Discussion:
This case involves a middle-aged female patient with a slightly weak constitution. Although she presented with aversion to cold, fever, no sweating, and general pain, resembling Mahuang Tang syndrome, the floating and weak pulse indicated the use of Guizhi Tang.
However, there was a mistaken belief that Guizhi Tang’s sweating power was weak and might not achieve the effect of sweating and reducing fever, leading to hesitation and the choice of Daqinglong Tang, believing that the formula’s increased Mahuang would enhance sweating power; Shigao could moderate the dryness of Mahuang and Guizhi; Sheng Jiang and Dazao could support the righteous Qi.
Although sweating and fever subsided after taking the medicine, the patient still had poor spirit and persistent muscle pain, leading to the belief that the exterior pathogen had not been completely resolved and the righteous Qi was deficient, so Ren Shen Bai Du San was used to support the righteous Qi and resolve the exterior. Afterward, although muscle pain was relieved, sweating did not stop, and aversion to cold persisted, prolonging the condition for a month.
Exterior Yang deficiency and disharmony of Ying and Wei led to the use of Guizhi Jia Fuzi Tang to harmonize Ying and Wei, warm Yang, and consolidate the exterior, leading to gradual recovery.
Zhang Zhongjing cautioned in Article 38 of the “Shang Han Lun”: “If the pulse is weak and sweating occurs with aversion to wind, it should not be taken; if taken, it will lead to reversal and muscle spasms, which is a reversal condition.” This is not an empty warning and should be remembered.
Ge Gen Tang
To be continued……
Copyright Statement:This article is original and first published on the WeChat public account: Xiao Xiangru Channel (ID: xiaoxiangru0011). Respect knowledge and labor; no authorization is needed for reprinting, but please be sure to indicate the original author.
Note:The cover image is sourced from Shetu Network.
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You may also like, click to read the original text:
Good treatment begins with addressing external pathogens — Preface to “Reconstruction of the Diagnosis and Treatment System for External Pathogenic Diseases in the Early Stage”
The reasons for misdiagnosis in the early stage of external pathogenic diseases (Part 1) — Zhang Zhongjing’s “Contradiction”
The reasons for misdiagnosis in the early stage of external pathogenic diseases (Part 2) — Ye Tianshi and Wu Jutong’s “Fallacies”
