伤寒有五：有中风，有伤寒，有湿温，有热病，有温病。 – 难经
In the time of Mr. Zhang Zhongjing, all externally contracted diseases were classified Cold Damage (伤寒).
Cold Damage was the umbrella term for all classifiable infectious diseases then. The Classic of Difficulties gives us the five sub-categories: Wind Strike (中风), Cold Damage (伤寒), Damp-Warmth (湿温), Hot Diseases (热病) and Warm Diseases (温病).
Zhang’s classic tome On Cold Damage is revolutionary. Why? Because it unveils a theoretical framework for classifying disease based on the signs and symptoms exhibited. Mr. Zhang used a six-channel theretical framework, which later people have come to understand as a mapping out of the diseases process – from the 3 yang channels into the 3 yin channels. During the disease process, the sick person would manifest heat and cold symptoms. This language of heat and cold is the bedrock upon which herbs (also classified thus) were chosen to deal with the illness.
In fact, after Zhang’s time, later scholars spent much time writing and interpreting his work, which was a theoretical masterpiece, then as it is today.
A copious half of the book focuses on the Greater Yang (太阳) channel, which later scholars have understood as the first pass, the initial encounter with disease. Whether or not this has any basis, we will find a heavy documentation with regards to Wind Strike (中风) and Cold Damage (伤寒), both of which see the disease etiology as Wind or Cold entering the body. Both these ‘external pathogens’ then begin a process that moves inward from the outside, and when it reaches the innermost parts, the person dies.
In China today, within the sub-culture of Chinese Medicine, there are the people who still hold steadfast to such an understanding of diseases; they use this theory to treat disease. Even though the Cold Damage sect are a minority today, and many practitioners see it as one of many systems, there are those who swear by this one framework only.
In the earlier time notwithstanding, from the late Han up till the early Song dynasty, almost everyone used Mr. Zhang’s framework to treat diseases.
There was a running phrase: The method should not depart from On Cold Damage; the method should abide by Zhang Zhongjing’s.
We can see here how he had become a medicine god that some had come to follow without too much critical thought. In fact, the herd who saw Zhongjing as the one and only also came up with other self-uplifting aphorisms, like this one in particular: If one discusses Cold Damage but does not read Zhang Zhongjing’s books, it’s like saying you are Confucian but not know the Six Classics of Confucius.
Many of the doctors before the Song era would be using herbs in a formulaic manner as dictated in On Cold Damage. While likely that such manner of practice works sometimes, it may not be the most effective method if used blindly.
Two formulas and their variants were used and stuck to for goodness knows how long, only because they were created by the much-revered Zhang Zhongjing. Cinnamon Twig Decoction (Gui Zhi Tang) was the solution for Wind Strike, while Ephedra Decoction (Ma Huang Tang) was used to treat Cold Damage. On hindsight, these are formulas with herb components more suitable for diseases linked to Wind and Cold. Are these formulas suitable for other sub-categories like Damp-Warmth, Hot Disease and Warm Disease? Perhaps yes? Perhaps not too.
An aside: Herbs are classified into the framework accorded in the Chinese Medicine framework, by flavor and by the channels they enter. This was a theoretical framework borne of an ancient past, and while they no longer sound scientific to the intellectuals of today, this framework was discussed and improved upon by the intellects of many a foregone era.
Zhugong (朱肱) in his book Living Scroll of Cold Damage-type Patterns (伤寒类证活人书) was vocal about the need to use herbs more flexibly.
“桂枝汤自西北二方居人，四时行之无不应验。自江淮间，唯冬及初春可行，自春末及夏至以前，桂枝证可加黄芩半两，夏至后有桂枝证，可加知母一两、石膏二两，或加升麻半两。若病人素虚寒者，正用古方，不再加减也。” – Zhugong
Zhugong voices a very reasonable suggestion regarding the use of Cinnamon Twig Decoction, which is warm in nature. He says that the people in the north can use it to good effect at any time of year, but for the people in the south, only in the the winter and early spring should it be used. From the end of spring to the peak of summer, we should add Skullcap (黄芩). After the peak of summer, consider adding Anemarrhena (知母) and Gypsum (石膏), or Cimicifuga (升麻). If the person is of deficient-Cold constitution, use the original formula.
Beautiful. Zhugong is suggesting that we add herbs of a cold nature to an essentially warm-natured decoction. In a nutshell, he encourages the act of modifying the original decoction depending on geography, season and personal constitution.
During the Jin-Yuan era, discussion was rife and tempers flared. One man who emerged within this pre-revolutionary mess as a man named Liu Wansu (刘完素) who later came to be known as the founder of the ‘cold sect’ (寒凉派). His focus was on the use of ‘cold’ herbs to remove the ‘heat’ characteristics of most externally contracted disease. An analogous phrase using today’s medical jargon would be “inflammation is the substance of all infectious disease.”
Mr. Liu was most famous for getting patients to ‘shit out’ the pathogen, although he also applied vomiting and perspiration to his repertoire of treatment methods. While the form of his methods is congruous with that used during the medicine god’s era – vomit, sweat, shit – the substance of his core herbs couldn’t be more different from Mr. Zhang’s.
Would Zhang have have declared war on this different manner of treatment? We don’t know, but being of open mind and ingenious spirit, Zhang might have found resonance with Liu’s ideas. But why did those who made him a medicine god raise such a ruckus?