Seeing the Clinical Character of Chinese Medicine Through the Prevention and Treatment of Outside-Qi Disease
Seeing the Clinical Character of Chinese Medicine Through the Prevention and Treatment of Outside-Qi Disease
Li Zhizhong
October 28, 2012
Outside-qi disease is illness brought on by outside evils — generally the six excesses: wind, cold, summer-heat, damp, dryness, fire. What sets outside-qi disease apart? It comes directly from the six excesses' excess or deficiency, or from self-care lapses that let evil in — including illnesses where outside evil shifts body temperature; the Neijing's Heat-Disease Chapter says, "Heat disease is of the shanghan kind."
Outside-qi diseases that drew societal — even global — attention: 2003 SARS, 2005 avian flu, 2009 H1N1.
The TCM book that explains outside-qi disease most accurately and clearly — held canonical — is Shanghan Zabing Lun. Composed by Zhang Zhongjing in the late Eastern Han, it splits into the Shanghan Lun and Jinkui Yaolüe. The Shanghan Lun was compiled by Wang Shuhe, the Jin court physician, who gathered the Shanghan-related parts of various manuscript copies. The "han" in Shanghan means injury by evil — the outside-cause angle; shanghan equals heat disease by the Neijing angle.
The whole knowledge-structure of Chinese medicine
If TCM's academic system is a fruit-laden tree: traditional culture is the root; the foundational-science system represented by the Huangdi Neijing is the trunk; the basic clinical system represented by the Shanghan Zabing Lun is the main branch — its two principal sub-branches being outside-qi and miscellaneous disease; the smaller branches, leaves, flowers, fruits are the internal, surgical, gynecological, pediatric and other specialties along with formulas, herbs. With root gone, the tree dies. Cut at the root and lose the trunk to other uses or set it aside — what becomes of the smaller branches, the flowers, the fruits? An old saying: dry branches, withered leaves, shriveled fruit — no life-force. Over a hundred years of Western inroads, Western scientism has spread and Chinese culture has broadly declined; TCM's decline within it is nearly unavoidable. Total westernization throws away TCM's foundational-science system and clinical-technical system, leaving only experience. Today TCM looks lively, but it is flowery and unsubstantial — that is the essence of TCM's malady today, that is the crisis: we have thrown out the root — traditional culture. After 100 years' effort, the trunk is gone, the main branch is gone; the leaves and fruit before us have no life.
If we call human knowledge science, it has three layers. The first is science — foundational theory; like mathematics, it speaks only of quantity-relations, not application. The second is technology — solves real life problems, meets daily material need. Where is technology's life? In science. Without the development of physics, chemistry, mathematics, no modern high-tech: planes do not fly, satellites do not launch. The third is experience — knowledge's earliest layer. Experience repeats and grows richer; but without science as base, after a hundred years it remains the same. From this we say: in studying TCM, its foundational scientific system must be clear.
What does the Huangdi Neijing contain, scientifically? Four blocks: (1) zàng-xiàng — TCM physiology base; (2) etiology-and-pathogenesis; (3) treatment-principles in large coverage; (4) diagnostic methods.
The whole TCM scientific system has six great categories: zàng-xiàng, pathogenesis, diagnosis, treatment-principle — and herbs, formulas. Four are Neijing's. Herbs are most discussed in Shennong Bencao Jing. Formulas — the earliest still-transmitted authoritative treatment is the 113 formulas of Shanghan Zabing Lun.
The whole system of Shanghan Zabing Lun, summed: one theoretical thread runs through seven links. The thread is the six categories. The seven links: zheng (pattern), diagnosis, pivot, principle, formula, herb, effect.
Zheng — the clinical pattern; the patient's clinical presentation. How recognized? By senses and rational thought. Recognition of pattern is the diagnostic method. By diagnostic method we judge the pivot (mechanism). By the pivot we set the principle of treatment. By the principle we choose the formula. The base formula must be adjusted for this patient — modifications. Finally — pattern, method, pivot, principle, formula, herb — the standard for whether the whole thinking is right is: the patient must answer; disease must respond; check whether the effect is there. These seven links turn over and over in the TCM doctor's daily clinic. Without familiarity with TCM theory and pattern-discernment, with only a few herbs and a few formulas, fitting them to patients — one will never become a good TCM.
TCM's character and strength in treating outside-qi disease
A common misunderstanding: TCM is empirical medicine. Loud, mainstream — yet wrong. It throws away the whole clinical-science system of the Neijing and the Shanghan Zabing Lun.
For TCM's character in treating outside-qi disease, a brief look back.
Begin with Zhang Zhongjing himself. In the original preface to Shanghan Zabing Lun: "My clan was large, over two hundred. From the Jian-An reign onward, less than a decade — two-thirds of them died. Of these, shanghan accounted for seven in ten." Of his 200-plus clan, in the decade before he wrote the book, perhaps 140–150 died — and of those at least 100 from shanghan, that is, outside-qi disease. So Zhang resolved to move his heart and bear his nature. He wrote: "Moved by the loss of past generations, grieved by the helplessness in untimely death, I worked diligently with the old teachings, broadly chose many formulas, drawing on the Suwen, the Nine Volumes, the Eighty-One Difficulties, the Great Discourse on Yin and Yang, the Embryo Drug Records, with pulse-and-pattern discernment, and composed the Shanghan Zabing Lun."*
Move heart and bear nature matters for understanding TCM today. Mencius: "When Heaven would lay a great task on a man, it must first vex his heart, fatigue his sinews, starve his body, leave him in want, and disorder his deeds — thus to move his heart and bear his nature, and so increase what he cannot do." Without bitter toil and the loss of family lives, Zhang could not have made such a contribution. How did he evaluate his own work? "Although it cannot cure all diseases, one may yet see disease and know its source. Look it through, and you have grasped more than half." The more than half was modesty; two thousand years' history shows: the Shanghan Zabing Lun has not been put aside.
Second: a brief note on the Six Channels of Shanghan Lun, a difficulty for students.
The Six Channels split into three yang and three yin. The three yang — taiyang, yangming, shaoyang — describe outside-qi disease while right qi is not yet deficient. The three yin — taiyin, shaoyin, jueyin — describe stages when the right qi has weakened.
Taiyang — the "tai" is initial: disease just begun, the first gate of outside-qi disease. Onset: headache, chills, alternate fever, sneezing, clear-runny nose. The earliest stage.
Yangming: by the Neijing, "two yangs jointly bright". The evil flourishes; right qi flourishes; right vigorous, evil substantial — both at full, contend strongly. High fever to 39, even 42°C — frightening to laymen; but right qi flourishes, one dose may resolve.
Shaoyang: not like the other two — characterized by qi-mechanism blocked. With qi-and-blood not running, qi clogs; heat is pent within and cannot vent. So among the three yang: taiyang the initial, yangming qi-mechanism open with right-vigor and evil-substantial, shaoyang qi-mechanism blocked — substantial pattern.
A long course depletes right qi — either yang or yin — and enters the three yin.
The first gate of the three yin is taiyin — tai again meaning initial: right qi insufficiency just appearing. Shaoyin compares somewhat with yangming: although deficient, qi-mechanism is not blocked. Jueyin: right qi already deficient, evil not gone, and qi-mechanism blocked. Jinkui Yaolüe puts it well: "When the five storehouses' primal-and-true flows freely, the person is at peace." Disease scarce, or easy to cure. With primal-and-true not flowing — substantial is shaoyang; deficient is jueyin. With right and evil contending, vigorous is yangming; deficient is shaoyin. Right qi exhausted plus qi-mechanism blocked together — jueyin — eight in ten will die.
After Shanghan Lun, the Wenbing school developed outside-qi study. Many wrote — its two representatives: Ye Tianshi and Wu Jutong.
On TCM's historical efficacy against outside-qi disease: from the Western Han to today, China saw 321 epidemic or outside-qi outbreaks — never with mass-mortality. By Western medical history, in the 17th–18th centuries, 150 million died of smallpox in Western Europe. The 1918 Spanish flu, from Spain across Europe and to the Americas, killed over 25 million — some sources, 30 million. Had any one of China's 321 outbreaks matched Europe's, with our population and territory tens of millions or hundreds of millions might have died. Why are the people of our land still so many? Tied to Shanghan Lun and the whole of China's outside-qi study — and to the broader medical system the Neijing built. Forget Chinese medicine's role in the nation's continuity — unfilial children indeed.
The author of Science and Civilisation in China is not Chinese but Joseph Needham of Britain; the work, in the 1960s, came to prominence in our country. Strictly speaking, Needham wrote a technology history; he understood Chinese culture not deeply, especially TCM. On medicine — from practical, clinical-effect angles — comparing East and West, he said Western medicine surpassed Chinese in overall effect around 1900. If we check carefully, what gave Western medicine the overall lead was first surgery, and second a breakthrough in outside-qi — antibiotics in the 1930s. In fact, in treating outside-qi, TCM is not worse than antibiotics; in some ways we may be stronger. Especially against viral outside-qi, the West is nearly helpless. The virus sits in cells; by Western theory, the drug must enter the cell and kill the virus — they have not invented such a drug.
The internal-and-external cause interact thinking of disease
TCM differs from the West on outside-qi etiology, in one line: internal and external causes interact and bring disease. The Western view is external determinism: only the outer, not the inner. In the Shanghan Lun's six channels, each contains inner-and-outer relations. Taiyang is right-vigorous, evil-substantial. To speak only of evil, not of right, is not the TCM view. The Neijing: "Wind, rain, cold, summer-heat — without the body being empty, evil alone cannot injure. He who, surprised by storm and rain, does not fall ill — because the body is not empty, evil alone cannot injure. The empty-evil wind, meeting one's own form, two empties meeting, then lodges in the form." Empty here has two senses: outer evil; an inner state of right-qi deficiency or qi-mechanism blocked. Both must combine for disease. From this: nature and the human are co-existent, not antagonistic.
On SARS' coronavirus and the human: by TCM view, the relation is co-existence, not opposition. Neijing: the human arises from Heaven-Earth's qi, formed by the four-seasons' law. In Heaven-Earth's qi there are viruses; in the four seasons too. Without viruses, the human body would not produce antibodies — what Western medicine calls the immune system. So the human is not passive before viruses; the matter is how to regulate one's constitution.
By Western external-determinism, with virus comes SARS. Not so. In 2003 Hong Kong's 6.8 million, infected 1,755, or 0.25% — 99.75% did not fall ill. So internal and external interact; the inner is the root deserves attention. If we see only the 0.025% and forget the 99.975%, what kind of doctor are we? In 2004, a year after SARS, HKU's virology institute surveyed: about 35,000 in Hong Kong had been infected by the SARS coronavirus (antibodies present); only 1,755 fell ill — 5%. The other 95% did not. Which do we care about?
This study proves the human-virus relation is co-existence — viruses common; disease not common. The 5%-vs-95% comparison shows: most can immune the virus down. Only those with serious body trouble, sharp right-qi weakness, severe qi-blockage may be killed by it. TCM mobilizes resistance, lifts immune function — so most do not fall ill. TCM stresses prevent before disease.
What caused SARS to break out? Multi-factor — not the virus alone.
First, 2002–2003 winter — by reports, the coldest in 40 years; heavy snow. Neijing: "Cold-injured in winter, must fall to warmth-disease in spring." In severe cold people huddle near stoves, eat hot foods to ward off cold — easily building inner heat in excess.
Second, by qi-fortune doctrine, 2003 is guiwei; the year's mark: fire-movement deficient — yang not flourishing. From Great Cold to Pure Brightness, temperatures swung five times in two months, diurnal range up to 8 or 10°C. With careless dress, illness follows.
Third — a social factor. Cases concentrated in cities; poor ventilation; many office workers; high stress; richer food; inner heat. Generally, with fire and food, a cold easily lodges. So we did not care enough for the inner side. From inner-and-outer interaction, SARS's pathogenesis: outer cold, inner heat.
Why so many gaps in 2003's prevention? Three: (1) Western medicine, deep in external determinism, saw only the virus. (2) The coronavirus took long to identify; from blood to result, 3–5 days — those critical TCM treatment days were spent waiting. (3) Before identifying it, large teams were pulled to develop a vaccine — wasted resources. And Western medicine had no foresight; with no specific drug, only ribavirin and large steroid doses. Its disease-typing tells: SARS in four phases — early, severe, acute, recovery. Early — ribavirin + steroid; severe — same; acute (close to death) — same, only bigger dose.
For prevention — Heaven-and-human as one, body-and-mind unity — TCM character. The era's slogan-set: careful living-and-rising, moderate diet, adapt to cold and warm, restrain anger, drink plenty, regulate stool, avoid warm tonics, away from virus. Seven of eight TCM. Careful living-and-rising, moderate diet, adapt to cold and warm, restrain anger — all Neijing phrases; means follow the four seasons. Drink more water — metabolism quickens; the virus cannot stay. Regulate stool — inner heat gone. Three openings — stool, urine, qi-and-blood — let the virus have nowhere to lodge; what is there to fear?
In Hong Kong I stressed: do not tonify. My first SARS patient — 36 — was already at jueyin. Before illness he was weak; he bought six red-ginseng roots and ate them in three days. At 15 g each, 30 g/day at least — even fire arises; why would virus not come? The Chinese have made tonic-taking everyday — beware.
Whole picture in the heart; the focus before the eyes
Whole picture — at onset already know where the disease may go: yin or yang clear; whether right-qi is empty; whether qi-mechanism flows. Yang side: taiyang to yangming and shaoyang. Yin side: taiyin first, then shaoyin and jueyin. Focus — where to begin.
By the six channels, the first gate is taiyang — strategy: catch the three yangs, treat in taiyang. Unless a person at onset already shows three-yin deficiency, first catch the three yangs so the disease does not enter the three yin. Treat in taiyang — kill at onset. Not boasting: across SARS, Hong Kong had 1,755 cases / 299 deaths — 17%. Mainland China was 5.9%. Guangdong, where SARS first appeared, mortality 3.6%. Guangzhou University of Chinese Medicine took 45 SARS patients — three zeros: zero deaths, zero infections among staff, zero transfers out. Mainland's 5.9% vs. Guangzhou's 3.6% — why higher? Beijing at first hid SARS from society — Western medicine only. May 8, Wu Yi as Health Minister convened the meeting to bring TCM in; doctors went in that day. Seven days later the trend dropped.
SARS is also a hard-to-meet experience of my life. I treated two SARS cases in Hong Kong with two doses, six hours apart — fever down within twelve hours.
On catch the three yangs, treat in taiyang, three lines: seize the first gate of surface pattern; seize the first method of dispelling cold and clearing-and-venting heat; select the first formula for clinical onset. With cold gone, surface fever gone, qi-mechanism opened, inner heat cleared — disease cannot stay; right qi flourishes, virus is naturally extinguished.
No pride. I began studying TCM in 1962, started work in late 1966 — five years' study. The Cultural Revolution began; we carried medicine boxes to the grass roots; outside-qi cases were many. People joked, calling me Li-One-Dose — fever down faster than the West. Because we treat both disease and person.
What's the difference between TCM and the West in outside-qi disease? TCM lifts the person; the West kills the virus. Like Bush going after Bin Laden — the bomber drops heavy bombs without knowing where. Virus unknown — large doses of unsatisfying anti-virals. Hong Kong used ribavirin at 10× normal, steroids 5–10×. Western medicine, on viral and bacterial disease alike, eyes only the enemy, no person. TCM lifts the person — vigorous yang, open qi-mechanism, the inner-outer interaction's pathological appearance improved — and the disease is gone.
In the end, in Hong Kong's SARS, TCM never officially got in. I treated two cases — both in secret. Open entry to big hospitals came only after May.
What Western medicine should reflect on is the method. If no drug — say so. Why not let TCM in? Today's China revised the Infectious Disease Law after SARS — full Western-voice, still no TCM. During SARS, TCM watched helplessly, even requested to fight at the front — no answer. Group after group died. Was SARS not a heavier outside-qi disease?
Around Winter Solstice 1998, Beijing had a major outside-qi outbreak; I was at an outpatient clinic. Around Winter Solstice we used Daqinglong Decoction; after Winter Solstice — as yang rises — Xiao Chaihu plus Daqinglong, two doses often enough. The West: an IV, an injection, a thousand or two RMB minimum; and for viral, no specific drug anyway.
In 2004 at the cross-Strait three-region SARS conference in Taiwan, my paper was placed first — the chair and many scholars said: this is the most valuable theoretical-and-clinical synthesis after SARS. Because afterward many rushed to make "SARS treatment standards" — but not at theoretical or pattern-discernment level; at formula-and-herb level, Western-style typing: early, severe, acute, recovery. These four phases do not represent any pathogenetic feature — only severity. Who does not know severity?
Modern science has spread too hard. From the Opium War, from our inner-and-outer troubles, we have been at war with our own tradition. Under that, TCM's fate could not be untouched. August 14, 2003 — Hong Kong convened a meeting; 13 Western experts plus Zhong Nanshan from the mainland — a 14-person SARS expert panel reviewing Hong Kong's treatment. The day before, I received notice; without sleeping, I wrote a piece — Reflections on SARS. The closing said: WHO's relevant departments in fighting SARS used modern-scientism methods that violate the traditional-medicine strategy passed by WHO's 26th Assembly. I asked WHO to apologize to the world's medical world — and especially to China, and especially to TCM. Hong Kong is a free-speech society; I used that. I have the right to speak; I think what I say is right; I should speak — this is not only TCM's problem but the world's people's life-and-death. WHO does not acknowledge China's two-system reality — and so TCM could not reach SARS's front line. Zhong Nanshan, one of the few in the panel knowing Chinese, said: Professor Li, I will translate your remarks in full and bring them to WHO's senior officials. We should rejoice for Chinese medicine — TCM still carries the mission of restoring humankind, and it belongs not to us alone but to the world.