By Eric Brand

In the West, we constantly hear people expressing fear about supplementation during external contraction, and this fear often centers on the phrase “tonifying the pathogen.” However, Chinese books basically never talk about “tonifying the pathogen” or “supplementing evil.” Where does this idea come from and is it a valid way of thinking about the situation?

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Naturally, basic principles of correct treatment emphasize the Nei Jing statement of fact that “vacuity [is treated by] supplementation, repletion [is treated by] draining.” In the case of external contraction, cases that present with repletion should not be treated with supplementing methods. In clinic, many cases of external contraction do present with repletion and shouldn’t be treated with supplementation. However, this is nothing exotic or particular to external contraction; it is just a basic principle of appropriately matching the treatment to the pathocondition.

Similarly, it is also not appropriate to use unopposed astringency without outthrusting agents in cases of external contraction where evil lies at the surface of the body; this is referred to as “shutting the door while the intruder is still inside.” This is specific to external contraction but it is conceptually different than the idea of “tonifying a pathogen,” because here we are referring to using containing methods for a condition that must be outthrusted. Once again this is nothing exotic, just straight Chinese medical theory.

In cases where there is simultaneous qi, yin, or yang vacuity in conjunction with external contraction, we have a special category of formulas to address conditions of mixed vacuity and repletion. Formulas such as Jia Jian Wei Rui Tang (Solomon’s Seal Variant Decoction), Ma Huang Xi Xin Fu Zi Tang (Ephedra, Asarum, and Aconite Decoction), and Ren Shen Bai Du San (Ginseng Toxin-Vanquishing Powder) are designed especially for conditions of external contraction with insufficiency of yin, yang, and qi respectively. There is obviously a major precedent for supplementing in cases of external contraction; in fact, a whole chapter of any formula textbook is dedicated to such formulas. (As a side note, the remarkable efficacy of Blue Poppy’s formula Cold Quell is also due to its ability to supplement vacuity while resolving the exterior.)

As a student, I often heard about people talking about “tonifying the pathogen” at school. Years later as a teacher at PCOM, I heard many students continuing to repeat this concept. Yet I cannot find a single reference in any Chinese text to this idea about “tonifying the pathogen,” and I’ve never heard the phrase bu xie (supplementing evil/tonifying a pathogen) spoken by a Chinese doctor. The idea of “tonifying the pathogen” or at least the tendency to blow it up into a big deal instead of just emphasizing correct pattern differentiation and treatment appears to be a Western invention.

Where did this idea come from? My guess is that it originally started early on in the 1970s and 1980s, when many of the teachers in the West had limited English ability and few Westerners studied the Chinese literature. I suspect that the idea took hold and developed a life of its own because it had never been properly debunked. I've tried to look around the English literature to trace the origin of this concept with mixed results. I can only easily find two English references to “tonifying the pathogen” in the literature, but these references give us a clue as to how misinformation can be insidiously persistent (especially when the misinformation comes from celebrity authors that dominate the board exams). Naturally, I would reverse my stance completely if I saw information in the Chinese literature that referenced this concept, but so far I’ve never seen any.

A few examples can be found on pgs 1124 and 1125 of Maciocia’s Foundations of Chinese Medicine, Second Edition. He mentions that “tonifying qi in acute exterior conditions tends also to ‘tonify’ the pathogenic factor…” This is a classic example of an author interspersing their own ideas into a text instead of basing their information on Chinese sources that can be verified or supported by peer review. On the previous page, he mentions that “the approach of tonifying upright qi is applicable only in interior conditions, as exterior conditions are by definition of the excess type, being characterized by the presence of an exterior pathogenic factor. Only in very few cases of exterior conditions is it necessary to combine expelling the pathogenic factor with tonifying upright qi.”

To me, these quotes completely distort the Chinese medical understanding. There is widespread consensus that external contraction often co-exists with vacuity, so the idea that combined vacuity and repletion is a rare thing in external contraction is really a minority viewpoint rather than a basic statement of fact. If any one single source is elevated to the prominence that Maciocia’s text enjoys in public opinion and licensing examinations, that source has a responsibility to the profession to present information in an accurate way that reflects the Chinese understanding of the situation. To me, it is irresponsible for an author to intersperse ideas that can’t be supported in the Chinese literature without noting that the ideas are the author’s own theory rather than a consensus viewpoint in professional Chinese medicine.

Unfortunately, Bensky’s Materia Medica also states that “tonifying herbs strengthen the processes of the body, including pathogenic processes, such as those associated with external pathogenic influences.” It is a shame to see this same concept repeated in the Bensky text, because generally Bensky’s work is several steps up from Maciocia’s in terms of its academic rigor and I generally hold that Materia Medica text in high regard.

With multiple authors and countless teachers spreading these ideas, it is no surprise that many beginning students have the idea that “tonifying a pathogen” is a concept that is indigenous to mainstream Chinese medicine. It goes without saying that supplementation shouldn’t be given to a patient that presents with a repletion condition, but there is just no need to make it any more complicated than that.

This all basically comes down to a problem of translation and a lack of standards. Ideally, the English literature should reflect the knowledge base found in the Chinese literature, because a solid foundation in the Chinese consensus is an essential starting point for a mature discussion of ideas. English students deserve to access the exact same material that Chinese students are exposed to, without any unnecessary simplification or distortion.

At present, there is wide variation in the degree to which authors translate with transparency and attention to preservation of the source material of Chinese medicine, and this creates a lot of room for Western creations and confusion to the students in future generations. It is a shame that we live in a world where a few gringos who happened to write early bestsellers are regarded as the ultimate authorities in the West, and no amount of authentic Chinese source material will be enough to overcome these myths now that they have taken hold.