Causes of Misdiagnosis in the Early Stage of Exogenous DiseasesXiao XiangruThe fundamental reason for misdiagnosis in the early stage of exogenous diseases is the inability to accurately identify the nature of the external pathogens, especially the distinction between cold pathogens and heat pathogens.Initially, the differences between exogenous cold pathogens and exogenous heat pathogens are clear: the characteristic of exogenous cold pathogens in the early stage is “aversion to cold,” while the characteristic of exogenous heat pathogens in the early stage is “fever with thirst and no aversion to cold.”However, clinically, some patients may exhibit characteristics of exogenous heat pathogens such as “fever with thirst” while also having “aversion to cold.” Understanding the mechanism of this “aversion to cold” is key to correctly distinguishing the nature of exogenous diseases in their early stages.If the mechanism of “aversion to cold” is due to cold pathogens attacking the exterior, binding the defensive qi (wei qi), and preventing it from warming the flesh, then this “aversion to cold” is a concurrent symptom of early exogenous heat pathogens, specifically exogenous heat pathogens (essentially a lung heat syndrome, as the warm pathogen first attacks the lungs).At this point, it is necessary to clearly distinguish the primary and secondary severity of lung heat and exterior cold, whether to clear lung heat as the main treatment, or to disperse exterior cold as the main treatment, or to address both clearing lung heat and dispersing exterior cold equally. Theoretically, this should not lead to diagnostic errors.If the mechanism of “aversion to cold” is caused by heat pathogens, then this “aversion to cold” is an inherent manifestation of early exogenous heat pathogens, which is evidently the mainstream view. As stated in the textbook on febrile diseases, “The wei (defensive) syndrome refers to the type of symptoms caused by warm pathogens initially invading the human body, leading to dysfunction of the defensive qi. The main clinical manifestations are: fever, slight aversion to wind and cold, headache, no sweating or little sweating, cough, slight thirst, thin white tongue coating, red tip of the tongue, and floating rapid pulse.”It is believed that the formation mechanism of “aversion to cold” is that “warm pathogens enter through the mouth and nose, first invading the lung’s defensive qi. The yang qi of the exterior is constrained by warm pathogens, losing its function of warming and nourishing the flesh, resulting in aversion to cold.(Lin Peizheng, Gu Xiaohong, eds.: Febrile Diseases, China Traditional Chinese Medicine Publishing House, 3rd edition, July 2012, p. 24)In this case, the situation formed is:Early exogenous cold pathogens: aversion to cold and fever;Early exogenous heat pathogens: fever with aversion to cold.The main manifestations of early exogenous cold pathogens and early exogenous heat pathogens are similar, namely fever with aversion to cold. In such cases, how do we distinguish between cold and heat? The method in textbooks is: for cold damage (i.e., exogenous cold pathogens) at the onset, “aversion to cold is severe, fever is mild”; for warm diseases (i.e., exogenous heat pathogens) at the onset, “fever is severe, aversion to cold is mild” (Lin Peizheng, Gu Xiaohong, eds.: Febrile Diseases, China Traditional Chinese Medicine Publishing House, 3rd edition, July 2012, p. 12).However, clinical facts show that according to the methods in textbooks, it is impossible to clearly distinguish the nature of cold and heat in the early stage of exogenous diseases. In the case of exogenous cold pathogens, the symptoms of Ma Huang Tang (Ephedra Decoction) show that “aversion to cold” is very severe, and “fever” is also very severe, described in the Inner Canon as “caused by cold, the body feels like burning charcoal, sweating is the way to disperse it,” while in the case of early exogenous heat pathogens, the symptoms of Sang Ju Yin (Mulberry Leaf and Chrysanthemum Decoction) and Yin Qiao San (Honeysuckle and Forsythia Powder) do not show severe fever. This means that according to the methods in textbooks, it is impossible to clearly distinguish the nature of cold and heat in the early stage of exogenous diseases, making misdiagnosis inevitable.In fact, this is a very simple issue; as long as the formation mechanism of “aversion to cold” is correctly understood, diagnostic errors will not occur, and misdiagnosis will not happen. As mentioned earlier, “aversion to cold” is the manifestation of cold pathogens binding the defensive qi, preventing it from warming and nourishing the flesh.Because cold pathogens have the nature of constraining and stagnating, they can bind the defensive qi, leading to “aversion to cold,”therefore, “aversion to cold” is a characteristic of early exogenous cold pathogens; other external pathogens (except damp pathogens) cannot bind the defensive qi and cannot lead to “aversion to cold,” especially heat pathogens cannot lead to “aversion to cold.” Heat pathogens have the nature of rising and dispersing; how can it be said, as textbooks do, that “the yang qi of the exterior is constrained by warm pathogens”?Why can’t the academic community correct such a simple issue? It is because the authorities represented by the medical sage Zhang Zhongjing, the master of warm diseases Ye Tianshi, and Wu Jutong have erroneous statements on this issue, and on this basis, the academic community has formed a complete erroneous system, namely the “wind-heat exterior syndrome” and “spicy-cool resolving the exterior.”Next, let’s look at the statements of these three masters and their misleading influence on the academic community.1. The first and sixth clauses of the “Treatise on Cold Damage” contradict each otherThe first clause of the “Treatise on Cold Damage”: “The disease of the sun is characterized by a floating pulse, stiffness and pain in the head and neck, and aversion to cold.” The sixth clause states: “In the case of sun disease, if there is fever and thirst, but no aversion to cold, it is a warm disease.”Clearly, these two original texts contradict each other. According to the first clause, any sun disease is characterized by aversion to cold; while the sixth clause describes a warm disease, which is also called sun disease, yet does not have aversion to cold. One of these original texts must have a problem, and it is now generally recognized that the sixth clause has the issue. There are two possibilities regarding the problem of the sixth clause: either warm disease is not a sun disease, or warm disease is characterized by aversion to cold.Most editions of the “Treatise on Cold Damage” textbooks and the majority of physicians believe that warm disease is a sun disease and that warm disease is characterized by aversion to cold. If warm disease is a sun disease and is characterized by aversion to cold, then it is an exterior syndrome. Because sun disease is an exterior syndrome, the characteristic of exterior syndrome is aversion to cold.The causes of sun cold damage and sun wind are cold pathogens, hence it is called wind-cold exterior syndrome; the cause of sun warm disease is heat pathogens, so it should be called wind-heat exterior syndrome.Thus, the emergence of wind-heat exterior syndrome originates from the error of the medical sage Zhang Zhongjing.Although the phrase “no aversion to cold” in the outline of warm disease in the sixth clause has been changed to “aversion to cold,” it still does not seem perfect, because if both cold and heat pathogens cause “aversion to cold,” then there is no distinction between cold and heat. To show the difference between cold and heat, the degrees of aversion to cold and fever were considered. If injured by cold, then aversion to cold is severe and fever is mild; if injured by heat, then fever is severe and aversion to cold is mild. Thus, the phrase “no aversion to cold” in the outline of warm disease was changed to “slight aversion to cold.” This modification seems impeccable, and thus judging the nature of exterior syndrome based on the severity of aversion to cold and fever became the gold standard, found in all traditional Chinese medicine textbooks.I believe that the error of the sixth clause is that warm disease should not be referred to as a “sun disease.”First, Zhang Zhongjing was a pragmatic physician; the clinical facts recorded in the “Treatise on Cold Damage” reflect what he observed. The initial stage of cold damage is characterized by fever and aversion to cold, while the initial stage of warm disease is characterized by fever without aversion to cold and thirst.Therefore, interpreting the original text’s “no aversion to cold” in the initial stage of warm disease as “slight aversion to cold” is unfounded. “Slight aversion to cold” emphasizes a mild degree, and we are now concerned that Zhang Zhongjing overlooked the degree issue.In fact, Zhang Zhongjing had already distinguished the degree of “aversion to cold,” as in the third clause of cold damage, which states, “must have aversion to cold,” while in the second clause of wind, it states, “aversion to wind,” where “aversion to wind” is a milder form of “aversion to cold.”Moreover, in clauses 234, “yangming disease, with a slow pulse, profuse sweating, and slight aversion to cold, indicates that the exterior has not resolved, and sweating can be induced, suitable for Gui Zhi Tang (Cinnamon Twig Decoction),” it clearly mentions “slight aversion to cold.” From clinical practice, the severity of aversion to cold and fever cannot distinguish the nature of cold and heat; for instance, in cold damage, fever can be very severe, described in the Inner Canon as “the body feels like burning charcoal”; while in the initial stage of warm disease, fever is generally not severe, as seen in the symptoms of Yin Qiao San and Sang Ju Yin.Second, Zhang Zhongjing did not grasp the development and treatment methods of warm diseases at that time, as can be proven by a comprehensive analysis of the “Treatise on Cold Damage.” The understanding of the development and changes of cold damage is clear, and the differentiation and treatment system is rigorous. However, warm disease is only mentioned in the sixth clause, and in the section on fire counteracting transformation, some symptoms equivalent to warm disease causing wind and blood movement are recorded, but there is no systematic understanding of its development and changes, let alone a treatment system.The manifestations of warm disease in its initial stage that Zhang Zhongjing observed are recorded in the sixth clause, as warm disease is also an exogenous disease and is in the early stage. Therefore, Zhang Zhongjing believed it should belong to sun disease, but sun disease should be characterized by aversion to cold, while warm disease patients do not have aversion to cold. The contradiction between “no aversion to cold” and the first clause is not consistent, so Zhang Zhongjing hesitated about how to handle it, and ultimately, not knowing how to resolve it, he labeled it as “sun disease” and placed it in the sixth clause.Why do I believe Zhang Zhongjing hesitated? Because if he could confirm that warm disease is a sun disease and an exterior syndrome, it should have been placed in the fourth clause, not the sixth clause. In fact, the issue of placing it in the sixth clause has not been resolved, and it still contradicts the first clause. I believe it should have been placed in the section on yangming disease. Because in the “Treatise on Cold Damage,” the distinction between sun disease and yangming disease is based on whether there is aversion to cold along with fever; aversion to cold indicates sun disease, while no aversion to cold, or even aversion to heat, indicates yangming disease.2. The statement “in the wei, sweating is possible” in the “Treatise on Warm Heat” cannot be self-consistentIn the eighth clause of the “Treatise on Warm Heat”: “Generally speaking, after the wei, it refers to qi; after the ying, it refers to blood. In the wei, sweating is possible; when it comes to qi, it can clear qi; when it enters the ying, it can still penetrate heat and transform qi, such as rhinoceros horn, black cohosh, and antelope horn; when it enters the blood, it is feared to consume blood and move blood, and it must cool blood and disperse blood, such as raw earth, peony root, donkey-hide gelatin, and red peony.”If the sweating method is equivalent to resolving the exterior, then Ye Tianshi’s statement “in the wei, sweating is possible” should refer to exterior syndrome. Similarly, because the cause of warm disease is heat pathogens, the exterior syndrome of warm disease is also wind-heat exterior syndrome. This is another strong basis for the establishment of wind-heat exterior syndrome.However, Ye Tianshi did not propose specific clinical manifestations of wei syndrome, and he also had inconsistent statements. For example, in the “Treatise on Warm Heat,” he states, “The lung governs qi and is associated with wei, while the heart governs blood and is associated with ying,” meaning that qi and wei are both affected by heat pathogens invading the lungs, while blood and ying are both affected by heat pathogens entering the heart. Because “warm pathogens first invade the lungs, then counteract the heart.” This means that the nature of the symptoms of qi and wei is the same, and the nature of the symptoms of blood and ying is the same.He also states, “The cold damage pathogen lingers in the exterior, then transforms into heat and enters the interior; warm pathogens transform the fastest, not yet transmitted to the heart, and the pathogen is still in the lungs. The lung governs qi, which is associated with the skin and hair, hence it is said to be in the exterior. Initially, use spicy-cool light agents; if there is wind, add mint and burdock; if there is dampness, add reed root and talc. Either penetrate wind outside of heat, or drain dampness below heat, without clashing with heat, otherwise it will be isolated.”What is referred to as wei syndrome and exterior syndrome is actually lung heat syndrome.Because the lung has the function of governing qi and externally connecting with the skin and hair, it can also be called exterior syndrome. The treatment method for exterior syndrome, or wei syndrome, is initially to use spicy-cool light agents, namely Sang Ju Yin, which is essentially a formula for clearing heat and dispersing the lungs.Ye Tianshi then states, “If the previous spicy-cool method does not resolve the wind, it is gradually wanting to enter the ying. If the ying is affected by heat, then the blood is affected, leading to restlessness of the heart and spirit, insomnia at night, or subtle spots appearing, then qi medicine must be withdrawn.” This clearly indicates that the previous statement about “in the wei, sweating is possible” refers to “qi medicine,” not resolving the exterior medicine.This point can be further supported by evidence later. When discussing the tongue, Ye Tianshi states, “When discussing the heat transmitted to the ying, the tongue color must be deep red. Deep red means a dark red color. Initially transmitted, the deep red color is mixed with yellow and white, indicating that the evil in the qi division has not yet been eliminated; the wei and ying can be harmonized.”Since the evil in the qi division has not yet been eliminated, how can the treatment method be said to be “draining the wei”?It can be seen here that Ye Tianshi’s concept of “wei” and “qi” is the same, and the essence of this concept is what we now refer to as the concept of “qi division syndrome.”In other words, Ye Tianshi’s concept of wei syndrome is contradictory; most of the time he believes that wei and qi are the same, which is lung heat syndrome; only in the phrase “in the wei, sweating is possible” can wei be considered as exterior syndrome. However, if we consider his own statement that “warm pathogens first invade the lungs,” then the initial stage of warm disease is lung heat syndrome, and the treatment method for lung heat syndrome is not sweating, which seems difficult to reconcile.Furthermore, Ye Tianshi did not propose specific clinical manifestations and did not have sufficient basis to determine that wei syndrome is exterior syndrome. We can analyze the basic manifestations of wei syndrome based on Ye Tianshi’s discussion. The opening statement of the “Treatise on Warm Heat” clearly states: “Warm pathogens first invade the lungs,” which indicates that the nature of the initial stage of warm disease, i.e., wei syndrome, is heat pathogens invading the lungs, which is lung heat syndrome. The manifestations of lung heat syndrome can include: fever, thirst, sore throat, cough, red tip of the tongue, thin white or dry yellow tongue coating, and floating rapid pulse. There should not be aversion to cold.Because the formation mechanism of aversion to cold is that cold pathogens bind the defensive qi, preventing it from warming and nourishing the flesh. Heat pathogens do not have the nature of constraining and stagnating, and cannot bind the defensive qi, so aversion to cold cannot occur. Without aversion to cold, it is certainly not an exterior syndrome.3. The symptoms of Yin Qiao San in the “Treatise on Warm Disease” do not matchIn the “Treatise on Warm Disease, Upper Jiao Section”the second clause states: “All warm diseases begin in the upper jiao, in the hand taiyin.”The third clause states: “The taiyin disease is characterized by a pulse that is neither slow nor tight but rapid, or the two cun pulse is particularly large, with heat in the skin, headache, aversion to wind and cold, body heat with spontaneous sweating, thirst, or no thirst, and cough, especially severe heat in the afternoon, known as warm disease.”The fourth clause states: “In taiyin wind-warm, warm heat, epidemic, and winter warm, if there is aversion to wind and cold at the onset, Gui Zhi Tang (Cinnamon Twig Decoction) is the main treatment; but if there is heat without aversion to cold and thirst, the spicy-cool balanced agent Yin Qiao San is the main treatment.”Wu Jutong explains the first half of this clause as follows: “Although it is called warm disease, if there is aversion to wind and cold, it is clear that the warmth is generated internally, and the wind-cold attacks from the outside, forming a syndrome of internal heat and external cold,” hence Gui Zhi Tang (with the dosage of cinnamon twig being twice that of peony) is used to first resolve the wind-cold in the exterior.The fifth clause states: “In taiyin warm disease, if aversion to wind and cold has been resolved by taking Gui Zhi Tang, but the remaining symptoms do not resolve, then Yin Qiao San is the main treatment.”This clause’s self-commentary states, “If aversion to cold has been resolved, then there is no wind-cold, only the remaining warm disease.”The spicy-cool balanced agent Yin Qiao Sancontains: Lian Qiao (Forsythia) 1 liang, Yin Hua (Honeysuckle) 1 liang, Ku Jie Geng (Bitter Platycodon) 6 qian, Bo He (Mint) 6 qian, Zhu Ye (Bamboo Leaf) 4 qian, Sheng Gan Cao (Raw Licorice) 5 qian, Jie Suan (Mustard Seed) 4 qian, Dan Dou Chi (Fermented Soybean) 5 qian, Niu Bang Zi (Burdock Seed) 6 qian, Lu Gen (Reed Root).Grind the above into a powder, take 6 qian each time, decoct with fresh reed root until the aroma is strong, then take it; do not over-boil, as lung medicines should be light and clear; over-boiling will thicken the flavor and enter the middle jiao.The above is Wu Jutong’s discussion related to Yin Qiao San in the “Treatise on Warm Disease.” There are several issues that need to be questioned.First, the location of warm disease in its initial stage is in the lungs, which is consistent with Ye Tianshi’s statement that “warm pathogens first invade the lungs.”Second, the clinical manifestations of warm disease in its initial stage include: a pulse that is neither slow nor tight but rapid, or the two cun pulse is particularly large, with heat in the skin, headache, aversion to wind and cold, body heat with spontaneous sweating, thirst, or no thirst, and cough, especially severe heat in the afternoon.Notably, “aversion to wind and cold” is mentioned here. Wu Jutong believes that “aversion to wind and cold” is an inherent manifestation of warm disease, and his self-commentary states: “The aversion to cold in warm disease indicates that the lung is associated with the skin and also governs the exterior, hence it also has aversion to wind and cold.”Third, the treatment for warm disease in its initial stage is Gui Zhi Tang for those with aversion to wind and cold; for those without aversion to wind and cold, Yin Qiao San is used.According to Wu Jutong’s self-commentary, “Although it is called warm disease, if there is aversion to wind and cold, it is clear that the warmth is generated internally, and the wind-cold attacks from the outside, forming a syndrome of internal heat and external cold, hence Gui Zhi Tang is used (with the dosage of cinnamon twig being twice that of peony) as a spicy-warm method to resolve the exterior, allowing for slight sweating, thus resolving both cold and heat evils.”Warm heat evils are the qi of spring and summer; if there is no aversion to wind and cold, then there is no concurrent cold wind, which is not the spicy-cool autumn metal qi, and is insufficient to resolve it. Gui Zhi is spicy-warm, and using it to treat warmth is to use fire to assist fire, hence it is modified from the Inner Canon’s method of “wind invading internally, treated with spicy-cool, assisted by bitter and sweet.”Here, Wu Jutong believes that aversion to wind and cold is concurrent with external cold, which means there is an exterior syndrome, so it is necessary to first resolve the exterior using Gui Zhi Tang; for those without aversion to wind and cold, there is no concurrent external cold, so Gui Zhi Tang should not be used to resolve the exterior, but rather the spicy-cool balanced agent Yin Qiao San should be used. What is the purpose of using Yin Qiao San? In his self-commentary on Yin Qiao San, he believes it is “purely to clear and purify the upper jiao,” which is evidently not resolving the exterior, but rather clearing lung heat. Because “warm pathogens first invade the lungs,” “all warm diseases begin in the upper jiao, in the hand taiyin.”Fourth, through the above analysis, it can be seen that Wu Jutong’s understanding of “aversion to cold” appearing in the initial stage of warm disease is contradictory. In his self-commentary on the third clause, he believes that warm disease itself can also present “aversion to cold,” while in the self-commentary on the fourth clause, he believes that “aversion to cold” has concurrent external cold.However, in his subconscious, he ultimately still regards “aversion to cold” as an inherent manifestation of warm disease, so he simultaneously states that the main symptom of Yin Qiao San is “heat without aversion to cold and thirst,” while also including in the formula clearly spicy-warm resolving the exterior herbs such as Jing Jie (Schizonepeta) and Dan Dou Chi. It is precisely this self-contradiction that has allowed the erroneous theory that the initial stage of warm disease is wind-heat exterior syndrome and that Yin Qiao San is a spicy-cool resolving the exterior agent to become widely accepted.Fifth, from Wu Jutong’s original intention, the purpose of using Yin Qiao San is undoubtedly to clear lung heat.From the use of Yin Hua (Honeysuckle) and Lian Qiao (Forsythia) as the name of the formula and as the main herbs, with the largest dosage, this emphasizes the heat-clearing effect of Yin Qiao San, as both Yin Hua and Lian Qiao are renowned heat-clearing and detoxifying herbs. The other herbs in the formula, aside from Jing Jie and Dan Dou Chi, are also heat-clearing herbs. Therefore, I believe that when using Yin Qiao San for warm disease in its initial stage without aversion to cold, the Jing Jie and Dan Dou Chi should be removed from the formula.This article is authored by:Xiao Xiangru, Professor and Doctoral Supervisor at Beijing University of Chinese Medicine; the first doctoral student in nephrology at the China Academy of Chinese Medical Sciences; a national key academic leader in nephrology. Awarded the title of “Bethune-style Good Doctor.” Author of works such as “Xiao Xiangru on Treating Nephropathy,” “Lectures on the Treatise on Cold Damage,” “Specific Formula Syndromes,” and “Reconstruction of the Differentiation and Treatment System for Early Exogenous Diseases.”
Those who love traditional Chinese medicine should plan for the long term!
The road to the revival of traditional Chinese medicine is right beneath our feet: return to Zhang Zhongjing!
“Return to Zhang Zhongjing” series live broadcast replay
First live session:“The Leader of Zhang Zhongjing’s Group Formulas” – The Specific Formula Syndrome of Gui Zhi TangSecond session:The Current Situation of Traditional Chinese MedicineThird session: The Decline of Traditional Chinese Medicine is Due to Deviating from Zhang Zhongjing’s Correct DirectionFourth session: The Road to the Revival of Traditional Chinese Medicine Must Return to Zhang ZhongjingFifth session: “Specific Formula Syndromes” is the Standardized System of Traditional Chinese MedicineSixth session: The Correlation of Formula Syndromes in the Treatise on Cold Damage and the Similarities with Western Clinical GuidelinesSeventh session: The Textbooks’ Understanding of the “Holistic Concept” is Incorrect
Click the text to view the live broadcast replay