Fever, Chills and a Cold? Can You Take Tonic Herbs During an External Infection? Ming-Dynasty Doctor Zhang Jingyue: Treat External Illness by Telling Deficiency from Excess — “No Tonics for Cold Damage” Is a Big Mistake

💬 Note from Doctor Luo: Dear friends, good morning, everyone. Today we continue with Doctor Zhang Jingyue’s medical thought. I have been busy these past many days and haven’t done the voice narration of the case studies. Last time I told you about an old man who caught cold damage — he had an external infection, shivered all over, but could not sweat — how did Doctor Zhang Jingyue treat him? Today I want to explain the thinking behind it thoroughly: when treating an external infection, should we expel the pathogen, or support the upright qi? This is one of the most important questions in the whole development of Chinese medicine.

Opening: a fight that has raged for centuries — external infection: expel the pathogen or support the upright qi?

Look around us: COVID, influenza A — wave after wave of external infections, and we are always battling them. When treating an external infection, should we drive out the pathogen or strengthen the body? Which matters more? — This argument has actually been raging inside Chinese medicine for several hundred years, and it flared up again during COVID.

💬 Note from Doctor Luo: In the COVID treatment, you could see this very dispute. Some doctors, when the patient could not sweat, prescribed nourishing herbs like dang gui (angelica) and shu di huang (prepared rehmannia) — the patient sweated and recovered. But other doctors objected: I have treated many patients who, during an external infection, took these tonics — prepared rehmannia, angelica — and look how heavy their dampness became — the tongue coating is thick. I say we should nourish yin, use prepared rehmannia and so on to tonify; if fluids are insufficient and there is phlegm, how do you dissolve the phlegm? Because the fluids are insufficient, you supplement. And the other side retorts: no, absolutely no tonics, you cannot recklessly tonify at this time. These arguments really do exist.

So what is the truth? To be frank: a person in basically normal health, whose upright qi has not been seriously damaged, catches an external infection and is usually cured quickly by dispersing methods — dispersing cold, or clearing heat and removing toxins. But there really are very many people whose upright qi is insufficient. Zhang Jingyue wrote this clearly back in the Ming dynasty. He wrote several special essays on it; the first is called Lun Xu Xie Zhi Fa — On the Method for Treating Deficient Pathogens.

First, a recap of last time: Liu Wei Hui Yang Yin — sweat came out, the illness resolved

Let me first complete the earlier story. The old man from last time caught cold damage — he shivered all over and could not sweat. Zhang Jingyue gave him Liu Wei Hui Yang Yin (Six-Ingredient Yang-Returning Decoction) — prepared rehmannia, ginseng, dried ginger, cinnamon, angelica, plus aconite. This formula is very famous.

💬 Note from Doctor Luo: One dose and the sweat poured out. Then everyone said: that’s a lot of sweat, shall we keep drinking? Reboil the leftover herbs and drink again. He said drink again? Already this much sweat — won’t drinking more make it worse? — Drink it anyway! After the second round the sweating stopped, and with further regulation the man recovered. I skipped over this case for many days without explaining it fully; the reasoning behind it is very deep.

Doctor Zhang Jingyue’s answer: the hinge of life and death in cold damage lies entirely in two words — deficiency and excess

In Lun Xu Xie Zhi Fa, Zhang Jingyue says that cold-damage treatment has a rough principle: what is at the exterior, disperse it — you caught cold, use warming, dispersing herbs to push it out; what has entered the interior, attack it — when the pathogen has gone deep, attack it. But! In cold-damage illness there is a hinge of life and death, a point where the illness turns — where is it? Entirely in the two words: deficiency and excess.

💬 Note from Doctor Luo: He quotes: “Where the pathogen gathers, the qi must be deficient” — that is from the Huang Di Nei Jing. Why does the pathogen come? It must be that your upright qi is insufficient — only then does the pathogen arrive. So “cold damage mostly strikes people who were invaded because of deficiency” — the ones who catch cold damage are generally the weak. But today’s doctors do not examine deficiency and excess; they ignore it. The moment they see an external cold-damage infection they announce: “No tonics for cold damage!” — those are the five words Zhang Jingyue hated most. No tonics for cold damage? Don’t tonify, just attack the pathogen! Dispersing, purging — every attacking method is thrown in.

Zhang Jingyue says: you should know that those who recover after attack were never deficient to begin with. If attacking cures them, they were not deficient in the first place; their upright qi was not weak. And since the upright qi is not weak, the pathogen naturally cannot harm them — the upright qi holds it off. When external pathogens enter, they want to travel a circuit through the channels; when the upright qi recovers it pushes the pathogen out, and the illness recedes on its own.

💬 Note from Doctor Luo: So Zhang Jingyue spoke a great truth: for this kind of external infection in a person of strong qi, “whether you treat it or not, it heals.” What does that mean? When the upright qi is sufficient, the pathogen cannot really affect the person; with this kind of cold, whether you take medicine or not, you recover by yourself — nothing to worry about. Modern medicine calls this a “self-limiting illness.” But there are exceptions, because not everyone’s upright qi is strong.

Why are there so many deficient people? Look at the Qinhuai River in the late Ming

Why did Zhang Jingyue emphasize deficiency so much? Because his era looked exactly like ours. In the Ming dynasty life was fairly prosperous; Zhang Jingyue later lived in the Jiangnan region, and life was good. The late Ming had an indulgent, extravagant, luxurious atmosphere — those examination candidates, after taking the imperial exams in Nanjing, what did they do? They all ran off to the Qinhuai River.

💬 Note from Doctor Luo: The “Eight Beauties of Qinhuai” — that was the fashion of the day. You can hardly imagine it — everyone went; if you didn’t go, you seemed out of style. The literary leader Qian Qianyi — who did he finally marry? Liu Rushi, the famous courtesan; Mao Pijiang, the great talent — who did he marry? Dong Xiaowan. That was the social atmosphere of the time. People ate well, dissipated in every way, and the deficient were especially numerous — just like today. Can you say everyone who caught cold damage had strong upright qi? Not necessarily.

So Zhang Jingyue wrote Lun Xu Xie Zhi Fa to discuss exactly this: deficiency-ridden cold damage — an external infection carrying deficiency — is the most fearsome kind; it is very troublesome.

Deficiency-ridden cold damage is the most dangerous: the more you attack, the weaker; “how could the patient not die?”

If you do not know the strategy of “securing the root to defend against the enemy” — of building up the upright qi to resist the external pathogen — and instead attack recklessly, that is staking everything on one throw. Which attacking-and-dispersing medicine does not enter the stomach first? Before the pathogen even meets the medicine, the stomach may already be injured — because the stomach is weak. If you use bitter-cold or great-heat medicines, can the qi avoid being exhausted? Can it avoid becoming even more deficient? And if it becomes more deficient, the pathogen will go deeper. The deficiency grows, and still you attack — Zhang Jingyue says: how could the patient not die? The person may be finished.

💬 Note from Doctor Luo: He says: in all cold-damage cases, whenever a patient dies of cold damage, what must there have been? A prior depletion of the vital qi — the upright qi was insufficient from the start. External pathogens are not that heavy; it is always because the upright qi was deficient, and then it collapsed. “This is the universal malpractice of the whole profession.” So whenever you see a patient whose pulse has no spirit, with deafness and trembling hands, weariness and timid breath, aversion to cold and fondness of warmth, faint speech, and a pale bluish complexion — all the signs of deficiency and depletion — you must think of securing the vital qi! If the upright qi is already insufficient and you still vigorously induce sweat to release the exterior, you will surely destroy the yang; if the visceral qi is already deficient and you mistakenly attack internally with aggressive herbs, you will surely destroy the yin — the patient will die, and the illness will only get worse with treatment.

How to tonify? Li Yin Jian as the base, plus chai hu or ma huang

So how do you treat this situation? Zhang Jingyue says: a person whose upright qi is chronically insufficient occasionally feels the cold pathogen, and the pathogen has not yet gone deep — look at these deficient patients: they now have fever and body aches, a rapid but not surging pulse (mai shu bu hong), and no internal fire signs. The pulse beats fast but is not grand, and there is no fire inside. What do you use? Li Yin Jian (Regulating Yin Decoction) plus chai hu (bupleurum), or plus ma huang (ephedra) — one or two doses and it works like magic.

💬 Note from Doctor Luo: What is Li Yin Jian? Prepared rehmannia, angelica, dried ginger, aconite, ginseng — actually it is the same as the Liu Wei Hui Yang Yin used for that old gentleman, with cinnamon added. What does Li Yin Jian do? It supplements essence and blood, supplements fluids, and warms the yang — cinnamon and aconite warm the yang; angelica and prepared rehmannia nourish the blood and fluids. This is Zhang Jingyue’s tonifying formula.

Zhang Jingyue further refines: for deficiency in the yang aspect, use chai hu as the guide, with Bu Zhong Yi Qi Tang (Tonify the Middle and Replenish Qi Decoction), Ba Zhen Tang (Eight Treasures Decoction), Li Yin Jian, Wen Wei Yin (Warming the Stomach Decoction) and the like; for deficiency in the yin aspect — when the leaves wither and the water is exhausted, meaning yin deficiency with insufficient fluids, unable to produce sweat — use Bu Yin Yi Qi Jian (Nourishing Yin and Replenishing Qi Decoction) with San Chai Hu Yin (Three-Bupleurum Drink) as the guide, San Yin Jian (Three-Yin Decoction), Zuo Gui Yin (Restore the Left [Kidney] Drink) and so on, to nourish yin. Zhang Jingyue took this very seriously.

Doctor Luo’s experience: Liu Wei Hui Yang Yin plus 30 g of huai shan yao

💬 Note from Doctor Luo: I particularly esteem Liu Wei Hui Yang Yin. When I use it I always add ginseng, and beyond the ginseng I add something else: shan yao — 30 g of huai shan yao (Chinese yam) goes in. Zhang Jingyue said this was his most commonly used first formula, and I also use it as my clinical first formula.

I think quite a lot of doctors really have not realized that supporting the upright qi is extremely important during an external infection. Very many people have insufficient upright qi. When the external infection burns hot, or when it turns cold and the symptoms are severe, what does everyone usually think of first? Expel the pathogen, bring down the fever. In fact, for a great many people, you must support the upright qi — this is the voice of experience.

💬 Note from Doctor Luo: Any practitioner of Chinese medicine who does not understand what Zhang Jingyue is saying, and argues against it, can only be someone who has seen too few patients. Once you have seen enough patients you know — there are too many people whose upright qi is truly very insufficient, especially in this age; the deficient are everywhere. How deficient have I seen people? Standing in the blazing summer sun in thick clothes, sweating not a single drop — not one. Why deficient? Yin deficiency, insufficient body fluids. With prepared rehmannia and angelica, following Zhang Jingyue’s approach, one bowl of the decoction and the sweat pours out. It is like rain: with no clouds, how can it rain? You must nurture the clouds fully, and only then will the rain fall. Some people’s pathogen simply will not retreat because the upright qi is insufficient: look, the pathogen seems fierce — fever, sore throat, chills all over — you think it needs dispersing and push outward with all your might, but it will not disperse. Why? The upright qi is too deficient! Even ginseng with a little dried ginger, boiled as a drink, works. Once the upright qi is sufficient, the body can “go back to work,” and the condition improves at once — the fever starts to drop by itself, with no fever-reducing medicine at all. What happened? The upright qi had been insufficient.

How can Bu Zhong Yi Qi release the exterior? — Yang deficiency is qi deficiency; yin deficiency is blood deficiency

Later Zhang Jingyue wrote a special essay called Bu Zhong Yi Qi Shan Jie Han Biao — Tonifying the Middle and Replenishing Qi Skillfully Releases the Cold Exterior. I once said that shan yao can release the exterior, and a colleague challenged me: how can shan yao release the exterior? — This is the very principle: supporting the upright qi IS releasing the exterior.

💬 Note from Doctor Luo: This essay of Zhang Jingyue’s asks directly: tonics tonify the middle — how can they also release the exterior? He says: “Yang deficiency is qi deficiency” — a yang-deficient person certainly has insufficient upright qi; “when qi is deficient within, how can it reach the body surface?” If you do not tonify the qi, can the exterior be released? If you do not support the upright qi, can the external pathogen residing between the skin and muscles be resolved? So whenever the pulse is faint, weak and powerless — or both inch positions are short and small, with much cold — the condition belongs to yang-deficient cold damage, with yang deficiency very evident. “Yin deficiency is blood deficiency” — when yin is deficient, blood is deficient too; yin includes essence, blood and fluids — these liquid substances are depleted. “If the blood is deficient, how can it transform fluids?” If you do not supplement the essence, can sweat be produced? And releasing the exterior requires inducing sweat. So whenever the pulse is floating and hollow, insubstantial — or both foot positions have no root, with much heat — the condition belongs to yin-deficient cold damage. Some people’s qi is too weak to reach the body surface; some people’s yin is deficient so there is no fluid reaching the surface; the external pathogen cannot be driven out, and sweat will not come — in these cases, tonifying the middle, nourishing the blood and nurturing yin IS releasing the exterior! Zhang Jingyue already stated this with complete clarity, and people are still arguing about it today.

The measure of tonification: like drinking wine, one spoon is one spoon

But tonifying does not mean reckless supplementation. Zhang Jingyue says: when tonifying, you must weigh the dose appropriately — it is like drinking wine: if a man can drink one spoon, giving him a whole barrel will not do; if your body fluids only need a little moisture, forcing in a huge amount will not do either — as I said earlier, you cannot pour in a whole vat, or you will end up with heavy dampness. And if a man can drink a barrel, giving him a tiny cup will not do either.

💬 Note from Doctor Luo: So dosage must be considered — this is Zhang Jingyue’s wisdom from experience. We know to support the upright qi, but to what degree — you proceed step by step; sometimes you must tonify urgently with a large dose, and then switch to slow, gentle supplementation. This is a matter of judgment. Later Zhang Jingyue wrote another essay, Shang Han Wu Bu Fa Bian — Refuting “No Tonics for Cold Damage” — many physicians claimed that in cold damage there is no method of tonification. Zhang Jingyue wrote a whole essay refuting them: how can there be no tonification? Even Xiao Chai Hu Tang (Minor Bupleurum Decoction) contains ginseng! Zhang Zhongjing used tonics in very many places!

A fever is nothing to fear: that is the upright qi fighting the pathogen

Now back to our own problem: very many people panic the moment the fever rises. Let me tell you: a fever of 38 degrees — are you afraid? Don’t be!

💬 Note from Doctor Luo: What is the fever doing? It is your immune system — the upright qi — fighting the pathogen inside your body. There is no great harm in it. Some people never run a fever for years; catching one is actually good for you: the upright qi does a sweep of the body, and some pathogens are attacked and cleared by the heat. That can be a good thing. So external-infection symptoms are not as terrifying as people think. But you must know: sometimes the fever simply will not break — why? The upright qi is insufficient! Far too many people today have insufficient upright qi — many people’s way of life now resembles the late Ming: comfortable living, every kind of dissipation, exhaustion, overthinking, and the upright qi collapses. After a child’s cold, everyone takes a little Bu Zhong Yi Qi; some people’s fever will not drop and symptoms will not ease — it is stuck there — hurry and support the upright qi! There is certainly a component of upright-qi deficiency in there. Either tonify qi, or nourish yin.

Liu Wei Hui Yang Yin I consider quite comprehensive: prepared rehmannia and angelica nourish the blood, ginseng tonifies qi, add a little cinnamon, aconite and dried ginger to warm the yang — it is a very good, very complete formula.

💬 Note from Doctor Luo: In the case study last time this formula was used. Everyone said — isn’t this formula very simple? Let me tell you: this is a very important formula. The way of thinking we must learn is: the way of supporting the upright qi. Very often, to turn a situation around you must tonify the upright qi — once the upright qi is replenished, the body immediately gains capacity and strength, and at once begins to drive out the pathogen. The reason the pathogen has never been removed is that the upright qi was insufficient.

During the COVID pandemic we met many situations like this. Of course, when you use tonics there is debate in Chinese medicine: how can you use prepared rehmannia and angelica? What is this all about? — This is not something invented in modern times; Zhang Jingyue used it in ancient times. It is the voice of experience, it genuinely works, and it is extremely effective for the patient’s recovery.

💬 Note from Doctor Luo: Today we talked about Zhang Jingyue’s thought. I think Zhang Jingyue was extremely accomplished — a doctor who can explain every detail so comprehensively is truly worth learning from: he tells you all sides of every question. Some people only see one side and miss the other, and a piece is missing; Zhang Jingyue basically tells you everything — fully worthy of being taken as a teacher. Go and study him.

Compiled from Doctor Luo Dalun’s commentary on Doctor Zhang Jingyue’s case studies; the original cases come from Jing Yue Quan Shu (Complete Works of Jingyue, published 1624).