Causes of Misdiagnosis in the Early Stage of Exogenous Diseases (Part 1)

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The fundamental reason for misdiagnosis in the early stage of exogenous diseases is the inability to accurately discern the nature of the external pathogens, especially the inability to accurately distinguish between cold pathogens and heat pathogens.

Originally, the distinction between exogenous cold pathogens and exogenous heat pathogens in the early stage is 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 exhibit characteristics of exogenous heat pathogens in the early stage, such as “fever with thirst,” while also having “aversion to cold.” Understanding the mechanism of this “aversion to cold” is key to correctly discerning the nature of cold and heat in the early stage of exogenous diseases.

If the mechanism of “aversion to cold” is due to cold pathogens attacking the exterior, binding the defensive qi, and preventing it from warming the flesh, then this “aversion to cold” is a concomitant symptom of exogenous heat pathogens in the early stage, meaning that exogenous heat pathogens (essentially lung heat syndrome, as the warm pathogen first attacks the lungs) coexist with exogenous cold pathogens.

At this time, it is only necessary to clearly distinguish the primary and secondary severity of lung heat and exterior cold, whether to clear lung heat as the main focus, or to disperse exterior cold as the main focus, or to clear lung heat and disperse exterior cold equally. Theoretically, there should be no diagnostic errors.

If the mechanism of “aversion to cold” is caused by heat pathogens, then this “aversion to cold” is an inherent manifestation of exogenous heat pathogens in the early stage. Currently, this is clearly the mainstream viewpoint.

For example, the textbook on Warm Diseases states that “the Wei (defensive) stage syndrome refers to the type of symptoms caused by the initial invasion of warm pathogens into the human body, leading to dysfunction of the defensive qi. Its 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.”

Here, 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 outside is constrained by warm pathogens, losing its function of warming and nourishing the flesh, resulting in aversion to cold.”

(Lin Peizheng, Gu Xiaohong, eds.: Warm Disease Theory, China Traditional Chinese Medicine Press, 3rd edition, July 2012, p. 24)

If this is the case, the resulting situation is:

Exogenous cold pathogens in the early stage: aversion to cold and fever;

Exogenous heat pathogens in the early stage: fever with aversion to cold.

The main manifestations of exogenous cold pathogens in the early stage and exogenous heat pathogens in the early stage are the same, namely fever with aversion to cold.

So, in this case, how do we distinguish between cold and heat?

The method in textbooks is: in the early stage of cold damage (i.e., exogenous cold pathogens), “aversion to cold is severe, fever is mild”; in the early stage of warm disease (i.e., exogenous heat pathogens), “fever is severe, aversion to cold is mild.”

(Lin Peizheng, Gu Xiaohong, eds.: Warm Disease Theory, China Traditional Chinese Medicine Press, 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.

For example, the Ma Huang Tang syndrome of exogenous cold pathogens in the early stage has severe “aversion to cold” and also severe “fever”. The Nei Jing describes it as “due to cold, the body feels like burning charcoal, sweating is the way to disperse it”;

while the Sang Ju Yin syndrome and Yin Qiao San syndrome of exogenous heat pathogens in the early stage do not have severe fever.

In other words, according to the methods in textbooks, it is impossible to guide doctors to clearly distinguish the nature of cold and heat in the early stage of exogenous diseases, which makes misdiagnosis in the early stage of exogenous diseases inevitable.

In fact, this is a very simple issue. As long as the formation mechanism of “aversion to cold” is correctly understood, there will be no diagnostic errors and no misdiagnosis.

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 exogenous cold pathogens in the early stage. Other external pathogens (except dampness) 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 the textbooks do, that “the yang qi outside is constrained by warm pathogens”?

For such a simple issue, why can’t the academic community correct it?

This is because authoritative figures represented by the medical sage Zhang Zhongjing, warm disease master Ye Tianshi, and Wu Jutong have some 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 “cooling and dispersing exterior”.

Let us take a look at the statements of these three masters and their misleading effects on the academic community.

Zhang Zhongjing in the Shang Han Lun

The “contradiction” between cold damage and warm disease

In the Shang Han Lun, the first clause states: “The disease of the Taiyang stage 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 Taiyang disease, if there is fever and thirst, but no aversion to cold, it is a warm disease.”

These two original texts are clearly contradictory.

According to the first clause, any Taiyang disease is characterized by aversion to cold; while in the sixth clause, the warm disease, although called Taiyang disease, does not have aversion to cold. One of these two original texts must have a problem, and it is now recognized that the sixth clause has a problem.

There are two possibilities for the problem in the sixth clause: either warm disease is not Taiyang disease, or warm disease is aversion to cold.

Most editions of the Shang Han Lun textbooks and most physicians believe that warm disease is Taiyang disease and that warm disease is aversion to cold. If warm disease is Taiyang disease and is aversion to cold, then it is an exterior syndrome.And Taiyang disease must be an exterior syndrome, characterized by aversion to cold.

The cause of Taiyang cold damage and Taiyang wind stroke is cold pathogens, so it is called wind-cold exterior syndrome; the cause of Taiyang warm disease is heat pathogens, so it should be called wind-heat exterior syndrome.

Thus, the wind-heat exterior syndrome is generated. It can be seen that the emergence of wind-heat exterior syndrome originates from the errors of the medical sage Zhang Zhongjing.

Although the phrase “not 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 distinction between cold and heat, it is reasonable to consider the degree of aversion to cold and fever.

Injury from cold leads to severe aversion to cold and mild fever; injury from heat leads to severe fever and mild aversion to cold. Thus, the phrase “not aversion to cold” in the outline of warm disease in the sixth clause was changed to “slight aversion to cold.” This modification seems impeccable.

Therefore, judging the nature of the exterior syndrome based on the severity of aversion to cold and fever has become the gold standard and is found in all TCM textbooks.

I believe that the error in the sixth clause is that warm disease should not be called “Taiyang disease.”

First, Zhang Zhongjing was a pragmatic physician, and the Shang Han Lun records clinical facts. What he observed in the early stage of cold damage was fever with aversion to cold, while in the early stage of warm disease, it was fever without aversion to cold and thirst.

Therefore, interpreting the “not aversion to cold” in the original text of the early stage of warm disease as “slight aversion to cold” is unfounded.

“Slight aversion to cold” emphasizes a mild degree; we are now worried that Zhang Zhongjing overlooked the degree issue.In fact, Zhang Zhongjing had already distinguished the degree of “aversion to cold.”

For example, in the third clause of cold damage, it states “must have aversion to cold,” while in the second clause of wind stroke, it states “aversion to wind,” which is a milder form of “aversion to cold.”

Also, in clauses 234, “Yangming disease, with a slow pulse, profuse sweating, and slight aversion to cold, indicates that the exterior has not resolved, and it is permissible to induce sweating, suitable for Gui Zhi Tang,” 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 Nei Jing as “the body feels like burning charcoal”; while in the early stage of warm disease, the fever is generally not severe, as seen in the Yin Qiao San syndrome and Sang Ju Yin syndrome.

Second, Zhang Zhongjing did not grasp the development and treatment methods of warm disease at that time, as can be proven by a comprehensive analysis of the Shang Han Lun.

Zhang Zhongjing’s understanding of the development and changes of cold damage is clear, and his system of differentiation and treatment is rigorous, while warm disease is only mentioned in the sixth clause, with some symptoms equivalent to warm disease being recorded in the fire-reversal transformation syndrome, lacking a systematic understanding of its development and changes, let alone a treatment system.

What Zhang Zhongjing observed in the early stage of warm disease is exactly what is recorded in the sixth clause, because warm disease is also an exogenous disease and is in the initial stage, so Zhang Zhongjing believed it should belong to Taiyang disease;

however, Taiyang disease should be characterized by aversion to cold, while patients with warm disease do not have aversion to cold. The lack of aversion to cold contradicts the first clause, so whether warm disease should be labeled as “Taiyang disease” and where it should be placed is a dilemma for Zhang Zhongjing;

later, not knowing how to handle it well, he labeled it as “Taiyang disease” and placed it in the sixth clause.

Why do I believe Zhang Zhongjing was indecisive? Because if he could confirm that warm disease is Taiyang disease and an exterior syndrome, it should have been placed in the fourth clause, not the sixth clause.

In fact, placing it in the sixth clause did not resolve the issue, and it still contradicts the first clause.

I believe it should be placed in the Yangming disease section.

Because in the Shang Han Lun, the distinction between Taiyang disease and Yangming disease is based on whether there is aversion to cold along with fever; aversion to cold indicates Taiyang disease, while no aversion to cold, or even aversion to heat, indicates Yangming disease.

Ye Tianshi in the Wen Re Lun

“In the case of Wei sweating, it cannot be self-justified”

To be continued…

Note:Cover image source: Shetu Network.

You may also like, click to read the original text:

The “Return” of the Three Brothers of Fire, Heat, and Warmth – Analysis of the Causes of Exogenous Diseases Series (Part 1)

Is the saying “Wind is the leader of all diseases” correct? – Analysis of the Causes of Exogenous Diseases Series (Part 2)

Xing Su San is not a remedy for dryness – Analysis of the Causes of Exogenous Diseases Series (Part 3)

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