Zhang Zhongjing's Approach to Critical and Emergency Diseases Seen Through the Guizhi Tang Line of the Shanghan Lun

Zhang Zhongjing encountered an enormous number of critical and emergency cases in his life, as can be seen from the preface to his Shanghan Lun. In it he wrote: "My clan has long been large, over two hundred. Since the Jian'an era, in fewer than ten years, two-thirds have died, and seven of every ten deaths were from cold damage." In other words, within ten years, two-thirds of his clan died, about 70% of them from cold damage.

The dates in this passage may be erroneous. Professor Liu Duzhou verified that "Jian'an era" here is likely a scribal error for "Jian'ning era," because no great plague raged that frequently during the Han Jian'an period; only the Jian'ning period saw such a lethal epidemic. The situation Zhang describes is appalling; from this passage we can imagine how terrible the casualties from infectious disease were.

In the late Han, medicine and drugs were scarce and plagues raged. Practicing in such an age, Zhang encountered many critical cases. Critical care was not as advanced as today, and Zhang worked out a series of methods for critical illness in actual practice. The most important was continuous, frequent dosing—a distinctive approach I now introduce.

I first quote the original Guizhi Tang line:

"Taiyang stroke: the yang pulse floats and the yin pulse is weak. Floating yang means heat arises spontaneously; weak yin means sweat comes forth spontaneously. With huddling aversion to cold, splashing aversion to wind, and steaming fever, nasal snorting and retching, Guizhi Tang governs. Guizhi Tang formula: Guizhi (Cinnamon twig) 3 liang (peeled), Shaoyao (Paeonia) 3 liang, Gancao (Licorice) 2 liang (honey-fried), Shengjiang (Fresh ginger) 3 liang (sliced), Dazao (Jujube) 12 pieces (broken). Crush the five above; boil in 7 sheng of water over low heat to 3 sheng, strain, and take at a suitable temperature one sheng. Shortly after taking, sip a bit more than one sheng of hot thin congee to support the drug's force. Cover with blankets for about one shichen (two hours) until the whole body is moistly suffused, faintly as if sweating—this is best. Do not let sweat pour like water, or the disease will surely not be eliminated. If after one dose the sweat comes and the disease resolves, stop further dosing; the dose need not be finished. If no sweat comes, take again as before. If still no sweat, shorten the interval between doses; within half a day, finish three doses. If the disease is severe, take the medicine day and night and observe through a full cycle. If one dose is finished and the pattern remains, make another. If no sweat appears, take up to two or three doses. Avoid raw and cold, slippery and mucusy, meat and wheat, five pungents, wine and cheese, and foul, rank foods."

This passage contains an enormous amount of information. First, Zhang concisely describes Guizhi Tang's indications: fever, spontaneous sweating, aversion to cold and wind, nasal snorting, and retching. He gives the formula composition: Guizhi 3 liang (peeled), Shaoyao 3 liang, Gancao 2 liang (honey-fried), Shengjiang 3 liang (sliced), Dazao 12 pieces (broken). He describes preparation: cut the herbs into pieces, add 7 sheng of water, decoct over low heat to 3 sheng, and take one sheng each time.

Along with Guizhi Tang, Zhang gives auxiliary methods to promote sweating: "sipping hot thin congee." The patient drinks hot thin congee after taking the medicine, which promotes sweating while supplying nutrition (carbohydrates) and fluid. This is not enough; he also requires "covering with blankets for about one shichen" to induce sweating.

Because treating "Taiyang stroke" hinges on inducing sweating—what TCM calls the "sweating method." So besides the herbs, auxiliary sweating measures are needed. In ancient times there were no IV glucose; when patients fell ill, nutrition faltered, and heavy sweating risked dehydration. Hot thin congee is a carbohydrate that supplies sugar and prevents dehydration—two birds with one stone. Covering to sweat is another good method. These two aids plus Guizhi Tang make sweating easier.

To what degree should one sweat? Zhang gives the rule: "the whole body moistly suffused, faintly as if sweating, is best." In plain language: make the patient's whole body clammy, as if about to sweat—that is the optimal state. He also says: "Do not let sweat pour like water, or the disease will surely not be eliminated." In other words, the physician must not induce a pouring sweat, or the disease will not be cured. This is a matter of degree: a pouring sweat easily causes collapse. Infectious-disease patients who collapse may briefly defervesce, but the disease soon rebounds.

So treatment must not push to a pouring sweat or collapse the patient. By extension, when using any sweating method, treat only until the patient's whole body is clammy, as if sweating—that is optimal. Going too far is as bad as falling short; excessive sweating worsens the disease. What if we overdo it in practice? Dust on rice flour (modern people may use baby powder from the supermarket) to quickly stop sweat. This is mentioned in the Shanghan Lun. From such details, Zhang was a remarkable, experienced clinician who knew that over-sweating causes major problems.

Patients vary individually, and each responds differently to Guizhi Tang. Zhang says: "If after one dose the sweat comes and the disease resolves, stop further dosing; the dose need not be finished. If no sweat, take again as before. If still no sweat, shorten the interval; within half a day, finish three doses." If the patient sweats and recovers after a single dose, stop subsequent dosing. Even if the rest is already decocted, do not drink it. Treatment should "stop when the disease is hit"; once the problem is resolved, further medication may overshoot and over-sweat.

What if the patient does not sweat after dosing? Continue, still following the previous method: hot congee and blankets to aid sweating. If after this the disease still does not resolve with sweat, subsequent dosing must "shorten the interval." That means the gap between doses should be shortened. "Within half a day, finish three doses" means the patient should drink the 3 sheng of decocted medicine within half a day—three doses in about six hours, i.e., one dose every two hours on average.

Zhang's dosing method differs from today's. Doctors and patients have long been used to 2-3 doses a day, and few ask patients to take medicine every two hours. Thus in ancient times, diseases like the common cold were usually cured in a day, while modern doctors cannot achieve this effect and may even delay the patient.

Since COVID I have felt this keenly. The COVID virus greatly damages human immunity; many people have been constitutionally weakened since, and colds linger and are hard to resolve. Routine treatment often drags on for weeks or even one or two months; some patients even die of cold-triggered pneumonia and pleural effusion.

I have treated post-COVID colds and rescued patients who developed severe complications from lingering colds, using Zhang's frequent-dosing approach, with surprisingly good results. Of course, I did not use Guizhi Tang itself but personalized prescriptions tailored to each patient. But in dosing method I follow Zhang's approach in the Shanghan Lun, and also follow his dietary cautions. Some patients and families who boldly adopted this dosing and sweating-aid approach did very well, improving greatly or recovering within a day or two.

Zhang's dosages were actually large. One Han liang was roughly 15 g in modern grams. Converted to modern measure, Guizhi Tang would be roughly: Guizhi 45 g, Baishao 45 g, Zhi Gancao 30 g, Shengjiang 45 g, Dazao 12 pieces. Modern doctors generally do not prescribe this; we usually prescribe one-third or less. I see most doctors prescribe Guizhi Tang as: Guizhi 9-15 g, Baishao 9-15 g, Zhi Gancao 6-10 g, Shengjiang 9-15 g, Dazao 3-7 pieces.

This dose pales beside Zhang's. Moreover, when treating Taiyang stroke, if the patient was not fully relieved, Zhang would decoct and administer multiple doses within a day and night. He says: "If the disease is severe, take the medicine day and night and observe through a full cycle. If one dose is finished and the pattern remains, make another. If no sweat appears, take up to two or three doses. Avoid raw and cold, slippery and mucusy, meat and wheat, five pungents, wine and cheese, and foul, rank foods."

Zhang would "observe through a full cycle" when treating such patients—like a modern inpatient physician closely watching the patient. Perhaps he was even more diligent, observing very carefully and knowing the patient's condition at all times. If the disease was critical, he dosed day and night without stopping.

After one dose, if symptoms remained, he would "make another." In other words, a day need not be limited to one dose; two or three could be used. Three doses mean nine administrations—basically every two hours except when the patient sleeps. Zhang's daily dose for a critical patient was roughly nine times a modern doctor's. He also required dietary restrictions—"avoid raw and cold, slippery and mucusy, meat and wheat, five pungents, wine and cheese, and foul, rank foods"—because post-infection patients have poor appetite and digestion, so the stomach and intestines should be spared irritation.

This treatment is highly effective for immunocompromised patients, rapidly curing their acute conditions. People with normal immunity may drag through infectious disease, but those with pre-existing conditions and low immunity cannot delay for even a day once severe symptoms appear. What I have heard and seen in recent years is heartbreaking: two close people of mine, both in their forties, died suddenly from a minor cold triggering severe complications. I keep hearing and seeing such tragedies; had such patients received Zhang's approach in time, they would not have died.

Whenever such things happen, I am struck by another passage from Zhang's preface: "I marvel that the scholars of our age never devote themselves to medicine and pharmacy, never refining their skill, to treat their rulers and parents above, rescue the poor below, and preserve their own bodies and lives in the middle. Instead they race after glory and power, tiptoeing after the influential, assiduously pursuing only fame and gain. They exalt the branch and neglect the root, beautify the exterior and wither the interior. When the skin is gone, to what will the hair cling? Suddenly struck by an evil wind, seized by an unusual illness, disaster at hand, they tremble in fear. They stoop and humble themselves, imploring shamans and priests; when all is exhausted, they resign to heaven, holding their lifetimes of lifespan and their most precious instrument and entrusting them to ordinary doctors, to be handled as they please. Alas! Their bodies are already dead, their spirits extinguished, turned into something alien, buried deep in the springs, while others weep in vain. How pitiful!"

The problems of Zhang's age persist today. People still chase fame and fortune while neglecting their health. When illness comes, they cannot get proper treatment and can only pin hope on feeble ordinary care in crisis. When treatment fails, they just drag on, minor illness becoming major, until death—truly lamentable.

When confronting critical illness, what is most needed is a physician of rich clinical experience and decisive style, who quickly halts progression, avoids a worse course, uses formulas flexibly, observes changes at all times, and cares for the patient wholeheartedly. Unfortunately, modern medicine cannot do this. Modern TCM has mostly abandoned Zhang's method, rigidly adhering to 2-3 doses a day. The result is often delayed patients: someone who need not die dies of a seemingly trivial cold. How regrettable.

In my early years I also worked in ICUs, joining resuscitations of dying critical patients using purely TCM methods, often reviving the apparently dead. The herbs I used were not exotic—common herbs, mostly bought locally near the patient, with no special hunt for expensive wonder drugs. In fact, where are all the fake drugs? As long as the physician composes the formula correctly and administers it properly, the effect is excellent.

TCM students should read valuable medical literature word by word, not skipping a single sentence or character. Careful clinicians write medical works with no wasted words. We must learn the details of their treatment and dare to try these methods in practice. Reading and practicing this way, our clinical efficacy naturally improves over time.