Chapter Ⅰ　Differentiation of Symptoms, Pulses and Treatment of Taiyang Pattern

In Taiyang pattern there must be floating pulse, headache with stiff nape, and aversion to cold.

An outline for differentiation of Taiyang pattern.

The term Taiyang pattern in Shanghan Lun refers to the most superficial layer of the human body facing the invasion by exogenous pathogen first,so Taiyang pattern among the six meridian patterns usually refers to the wind-cold exterior syndrome in the early stage of exogenously affected diseases.

Since exogenous invasion by wind-cold leads to an intense struggle between vital Qi and the exogenous pathogen in the body surface, Qiblood going outward results in a floating pulse, Qi-blood stagnation in the Taiyang meridian brings about headache with stiff nape, and defensive Qi failing to warm the body surface, and invasion of exogenous pathogens on the exterior body result in the aversion to cold. Moreover, fever is not mentioned here, because aversion to cold is serious but fever is relatively slight and appears later in wind-cold exterior syndrome.

In general, this article has been thought of the differentiation program for Taiyang pattern, and all of Taiyang syndromes in Shang han Lun should have such three symptoms to a different extent.

Although these three symptoms are the principal basis for diagnosis of Taiyang pattern clinically, however, they may have different concrete manifestations in different patients and are not typical in some cases. For example, the floating pulse is often combined with other pulses, such as tense, moderate, rapid, thready and wiry pulses; headache may be commonly seen, but a stiff nape only seen in a minority of cases; and aversion to cold probably varies in degree, such as aversion to wind,intolerance of cold or even cold-shivering.

Meanwhile, fever and aversion to cold often occur in combination, and the fever in Taiyang pattern is usually mild and appears a bit later. Of course, the patients suffering from Taiyang pattern may have the other symptoms, such as stuffy nose with running nose, aching all over,uncomfortable or itchy throat, cough, etc.

The Taiyang pattern marked by fever, sweating, aversion to wind, and moderate pulse is known as wind invasion syndrome.

A guideline for differentiation of Taiyang wind invasion syndrome.

Taiyang wind invasion syndrome is a principal syndrome of the Taiyang pattern mainly caused by the patient’s body with deficiency of defensive Qi and simultaneous invation by an exogenous wind-cold pathogen leading to disharmony between nutritive Qi and defensive Qi. This is also called windcold exterior deficiency syndrome. Here “ Taiyang pattern” signifies the basic pathogenesis and manifestations mentioned previously in Article 1.Furthermore, fever and aversion to wind indicate an exterior syndrome arising from the wind pathogen attacking the body surface, and spontaneous sweating suggests weak defensive Qi failing to secure nutritive Qi and thus resulting in excessive opening of sweat pores. The observed moderate pulse here means loosened and a little feeble, due to exterior deficiency. In regard to Article 1 and 2, Taiyang wind invasion syndrome must present spontaneous sweating, aversion to wind, low fever, headache,and a floating-moderate pulse, all resulting from disharmony between nutritive Qi and defensive Qi due to exogenous invasion of the wind pathogen into body surface where defensive Qi is deficient.

This article points out an mixture type of excess with deficiency in the exogenous disease, namely, wind-cold exterior deficiency syndrome, and its focus for syndrome differentiation on spontaneous sweating with aversion to wind. It also suggests that both constitutional deficiency and the affected wind pathogen together play a decisive role in the occurrence of exogenously contracted diseases.

The Taiyang pattern marked by the presence or absence of fever, certain aversion to cold, body aches, vomiting and a tense pulse felt over Cun , Guan and Chi portions, is called cold invasion syndrome.

A guideline for differentiation of Taiyang cold invasion syndrome.

Taiyang cold invasion syndrome is another principal syndrome of Taiyang pattern caused by the body with a sound defensive Qi invaded by exogenous cold pathogen leading to stagnation of both defensive Qi and nutritive Qi with a severer obstruction of the meridian Qi due to cold pathogen tightening the body surface inward, also called wind-cold exterior excess syndrome. Whether fever is present or not, or fever appearing early or late,depends on a strong or weak defensive Qi obstructed by the cold pathogen.Severe aversion to cold with no sweating originates from exogenous cold tightening the exterior, then closing the sweat pores and obstructing the outward flow of Yang Qi. Body aches result from stagnation of meridian Qi and contraction of tendons-vessels by the cold invasion, vomiting from an adverse ascending of stomach- Qi induced by the pathogen, and tense pulse indicates severe cold attacking the exterior. Connecting with Article 1, main presentations of Taiyang cold invasion syndrome include aversion to cold,fever, no sweating, headache, body aches and floating-tense pulse.

Comparing Taiyang cold invasion syndrome with Taiyang wind invasion syndrome, the former is mainly caused by a sound defensive Qi struggling against cold pathogen, and then serious stagnation of Qi-blood in the meridian, thus manifested as absence of sweating, aversion to cold, fever,severe pain and floating-tense pulse; whereas, the latter by deficient defensive Qi against wind pathogen, resulting in disharmony between nutritive Qi and defensive Qi, manifested as spontaneous sweating,aversion to wind, milder fever, mild aches and floating-moderate pulse.

The Taiyang pattern characterized by fever, thirst and absence of aversion to cold, is known as warm disease. If there is a generalized scorching fever after inducing sweating, it is named wind-warmth, which manifests as floating pulse on the Cun, Guan and Chi portions,spontaneous sweating, heavy sensation of the body, sleepiness, coarse snoring sounds while respiration, and slurred speech. If the warm disease is treated with purgatives, there would be dysuria, eyeballs fixed upward, and both urination and stool incontinence. If the warm disease is treated by fire therapy, there would be slightly yellow skin, and paroxysmal convulsions like epileptic attacks, and a dark-lusterless complexion like being fumigated by smoking in the severe cases. The first mistreatment may protract the course of the disease, and the second mistreatment may lead to a quicker death.

A guideline of Taiyang warm disease and its deteriorated syndromes caused by different mistreatment.

Taiyang warm disease is one type of Taiyang pattern caused by the windheat pathogen and mainly marked by higher fever without obvious aversion to cold, thirst, headache, and floating-rapid pulse. However, it also suggests that “cold-induced disease” in a broad sense in Shanghan Lun refers to all of exogenous febrile diseases, and should be treated by pungent-cool drugs to relieve this exterior syndrome.

Taiyang warm disease would worsen and then be transformed into various deteriorated syndromes due to different erroneous treatment. A wrong diaphoresis with pungent-warm drugs may lead to a deteriorated syndrome called “wind warm” due to intense internal heat damaging Qi and body fluid, and disturbing the mind, so manifesting as high fever, profuse sweating, heavy body sensation, lethargy, coarse snoring sounds, slurred speech and a floating-swift-forceful pulse. Wrong purgation may result in serious Yin exhaustion and stir up liver wind, thereby presenting as dysuria or anuria, eyeballs fixed upward and both urinary and stool incontinence.Fire therapy, including warm-needling, direct moxibustion and hot medicated compress, cannot be used for heat syndromes, otherwise it would bring about extreme heat inducing liver wind, urgent jaundice with slightly yellow skin, frequent convulsion-like attacks of epilepsy, and a darklusterless complexion like being fumigated by smoke. A patient is going to die if such therapeutic mistakes are continuously made twice.

This article had a profound influenc on the theories of Warm disease in the later ages. According to the major books of warm disease in Qing Dynasty, pathogenesis, symptoms, developing direction and treatment in the early stage of the warm disease are quite different from those in the cold-induced disease in a narrow sense. For example, a warm disease in early stage marked by severe fever, slight aversion to cold, less sweating,headache, thirst, sore throat, thin-dry tongue coating and a floating-rapid pulse, should be treated with pungent-cool drugs to expel wind-heat pathogen instead of pungent-warm drugs that mainly induce sweating,and Yinqiao San（银翘散）is a suitable formula.

Moreover, it easily turns into an intense internal heat, and further damages Yin instead of weakening Yang, disturbs the mind, and stirs up liver wind, thus manifesting as high fever, lethargy or coma, convulsion,acute jaundice and other serious and dangerous symptoms in the extreme stage of the warm disease. It is therefore necessary to clear away heat to detoxify, nourishing Yin, opening clear orifices and extinguishing liver wind, which have become commonly used therapeutic principles in the management of warm disease.

Finally, this article also proves on the contrary that warm disease can’t be treated by diaphoresis with pungent-warm drugs and fire therapy,however, purgation with bitter-cold drugs can be used for interior excessheat syndrome instead of Yin deficiency syndrome in the warm disease.

On the first day of cold-induced disease, the pathogen invades Taiyang . If the pulse is still floating, it suggests the disease hasn’t transferred; if there is severe nausea with vomiting, or restlessness, and a rapid and hurried pulse, it indicates the disease has transferred from Taiyang pattern into another one.

On the second or third day of cold-induced disease, if there are no symptoms and signs of Yangming or Shaoyang pattern, this indicates that Taiyang pattern hasn’t transformed.

Judgment of a transference of cold-induced disease depends upon the appearance of basic corresponding symptoms and pulse instead of the days calculated in advance.

Transferring sequence of exogenous cold-induced disease in Shanghan Lun originated from Huangdi Neijing, i.e., Taiyang→Yangming→Shaoyang→Taiyin→Shaoyin→Jueyin from the first day to the sixth day. However, Zhang Zhongjing thought the course of any disease doesn’t limit within only one fixed way to transfer, and it depends on a lot of factors, so patients’ disease courses are always variable and ever changing, and diagnosis of transference of pattern or syndrome must be based primarily on the presenting symptoms, and it may keep the previous pattern without any transference if the main symptoms and pulse remain unchanged.

For this reason, judging the transference of Taiyang pattern must be according first to the clinical manifestations on hand instead of the others.Here, severe nausea with vomiting or restlessness and a rapid-hurried pulse can be observed respectively as the representative symptoms of Shaoyang or Yangming pattern, indicating that the Taiyang pattern has transferred into Shaoyang or Yangming pattern. However, if such symptoms have not appeared, the transference should be excluded.

The viewpoint that transference of a disease from one pattern into another pattern is diagnosed on the basis of whether the main symptoms of another pattern are present or not, fully embodies Zhang Zhongjing’s valuable spirit of seeing truth in facts, which can be thought of not only as a theoretic source of Bianzheng Lunzhi, but also being one to be followed in clinical practice by the TCM doctors in later ages.

Disease characterized by fever with aversion to cold belongs to Yang pattern, while that by aversion to cold without fever to Yin one.

The key point for syndrome differentiation between Yin pattern and Yang pattern in the cold-induced disease.

Patterns of Taiyang, Yangming and Shaoyang belong to Yang syndrome,characterized by different typess of fever, i.e., Taiyang by fever with aversion to cold, Yangming by high fever without aversion to cold, and Shaoyang by alternate fever and chills. However, patterns of Taiyin, Shaoyin and Jueyin belong to Yin syndrome, characterized by different degrees of aversion to cold without fever. This is then considered a generalized clinical feature between syndromes of Yang and Yin in the Shanghan Lun.

Taking fever as a key symptom for deciding whether the Yang pattern or the Yin one in Shanghan Lun has been guiding TCM practice, especially in differentiation between Yang and Yin natures of disease up to now.However, this is but a general law, as there are some exceptions clinically.For instance, there is no fever but only aversion to cold acutely at the beginning of Taiyang cold invasion syndrome, and there is fever without aversion to cold in Shaoyin heat-transformation syndrome.

When a patient feels a hot body and desires for more clothes, it indicates cold in the bone marrow with heat in the skin; while a patient has a cold body and no desire for more clothes, it means heat in the bone marrow with cold in the skin.

Identifying a true or false cold and heat syndrome by means of patient’s desire for cold or heat.

Fever and aversion to cold are the chief symptoms of heat and cold syndromes, and simultaneous aversion to cold and fever are thought of the first manifestation of exterior syndrome. However, fever or aversion to cold may occasionally be false presentations of the real cold or heat syndromes, especially in the course of exogenous diseases. Therefore, this article points out that the patient’s desire can be seen as an important basis for differentiating between true heat and cold syndromes.

Generally speaking, patient’s desire for warmth or cool usually is a key point for differentiating true cold or heat in the interior body according to Huangdi Neijing. Here, feeling “a hot body” or “a cold body” belong to false symptomatology of the exterior, and desire or no desire “for more clothes” belongs to true symptomatology of the interior. Meanwhile, cold or heat “in the skin” signifies a false cold or heat symptom externally, but cold or heat “in the bone marrow” signifies presence of true cold or heat syndrome internally.

A patient’s desire or aversion can accurately reflect the nature of disease,so it has been used as one of the principal basis for judgment of the true pathogenesis of the patient. For example, desire for warm drinks and putting more clothes on suggests a cold syndrome or Yang deficiency,while desire for cold drinks and further undressing indicate a heat syndrome or Yin deficiency; abdominal pain getting better with applied pressure signifies a deficiency syndrome, and while it worsens when pressure is applied denotes an excess one.