Preliminary Establishment of TSD

Treatise on Exogenous Febrile Diseases and Miscellaneous Diseases (the later physicians divide it into two books: Treatise on Febrile Diseases⁵⁴and Synopsis of the Golden Chamber) establishes the typical model of TSD and integrates medical theory, principle, prescription, and herb for clinical practice. The preliminary establishment of the TSD model is the specific manifestation of the idea of syndrome differentiation advocated in The Classic of Internal Medicine in clinical practice. The publication of Treatise on Exogenous Febrile Diseases and Miscellaneous Diseases symbolizes the great reform of medical practice from intuitionistic experience into theory-instructed experience.

3.3 Preliminary Establishment of TSD 31

The Treatise on Febrile Diseases distinguishes the concepts of disease and syndrome.

The concept of disease in Treatise on Febrile Diseases is not a complete process includ-ing specific etiology, the form of onset, pathogenesis, development and prognosis, but a generalization of pathological manifestations of a certain kind of pathological phenomenon.

There are six diseases in Treatise on Febrile Diseases: taiyang disease, yangming disease, shaoyang disease, taiyin disease, shaoyin disease, and jueyin disease. “Taiyang disease is manifested as floating pulse, stiffness and pain of head and neck, and aversion to cold”;

“Yangming disease is manifested as high fever, polydipsia, polyhidrosis, full and large pulse, constipation and abdominal pain”; “Shaoyang disease is manifested as bitter taste in mouth, dry throat and dizziness”; “Taiyin disease is manifested as abdominal distension and even vomiting, inability to get food down, diarrhea and abdominal pain”; “Shaoyin disease is manifested as faint and thin pulse and sleepiness”; and “Jueyin disease is manifested as polydipsia, polyuria, hunger without appetite, and incessant diarrhea if treating it with purgative therapy.”

Syndrome, according to Treatise on Febrile Diseases, is the combination of symptoms reflecting the essence of a certain disease. It can be divided into two categories: syndrome of disease and syndrome of prescription. The former refers to the pathological stage of a certain disease, e.g., “for taiyang disease, if the syndrome is of such clinical manifestations as fever, sweating, aversion to wind and floating pulse, it is called wind-attack syndrome of taiyang disease” and “if the syndrome is of such clinical manifestations as aversion to cold, pain in limbs, vomiting and tight pulse, it is cold-attack syndrome of taiyang disease.” The second category, the syndrome of prescription, refers to the syndrome that a certain prescription is mainly targeted at, e.g., “the syndrome with such clinical manifestations as floating and slow pulse, exterior heat and interior cold, as well as diarrhea with undigested food should be treated with Sini Tang (Decoction for Resuscitation), and is called the syndrome of Sini Tang (Decoction for Resuscitation)” and “The syndrome with such clinical manifestations as floating pulse, fever, dry mouth with desire for drink and dysuria should be treated with Zhuling Tang (Umbellate Pore Decoction), and is known as the syndrome of Zhuling Tang (Umbellate Pore Decoction).”

Treatise on Febrile Diseases records more than thirty kinds of syndromes of disease (such as cold-attack syndrome, wind-attack syndrome, cold-attack syndrome, syndrome of blood accumulation, and syndrome of yang exhaustion), and 113 kinds of syndromes of prescription (such as the syndrome of Guizhi Tang, the syndrome of Baihu Tang, and the syndrome of Chaihu Tang). Syndrome is the key of TSD for any disease, even for the complicated disease involving two or three meridians. For example, “Taiyang disease, manifested as stiffness of nape and back, absence of sweating, and aversion to wind, should be treated with Gegen Tang,” “the disease involving both taiyang and yangming manifested as absence of sweating, aversion to wind and diarrhea, should be treated with Gegen Tang” and “the disease involving both taiyang and yangming manifested as dyspnea and fullness in chest should be treated not with purgation but with Mahuang Tang.” These show that the same disease with different syndromes should be treated with different therapeutic methods and different diseases with the same syndrome should be treated with the same therapeutic method. Therefore, syndrome is the basis to decide the therapeutic methods. It is not the simple combination of symptoms, but the essence of disease. Although the theoretical cognition of syndrome has not yet been proposed at that time, medical treatment has been made based on syndrome differentiation in practice.

In addition, Treatise on Febrile Diseases has already standardized 150 symptoms, includ-ing thirty kinds of general symptoms (such as fever, aversion to wind, sweatinclud-ing, sponta-neous sweating, jaundice, and arthralgia of limbs), twenty kinds of head symptoms (such as headache, dizziness, bitter taste in the mouth, red eyes, and dryness of nose), ten kinds

32 Chapter 3 Clinical System of TCM: Formation and Development of symptoms of four limbs (such as cold limbs, cold extremities, and spasm), sixty kinds of visceral symptoms (like restlessness, insomnia, palpitation due to fright, murmuring in an unconscious state, hiccup, vomiting, diarrhea, and dysuria), twenty kinds of symptoms of chest and abdomen (like fullness in the chest and hypochondrium, hypochondriac fullness and rigidity, abdominal pain, abdominal distention and fullness, epigastric stuffiness and pain, pain and heat in the heart, hypochondriac pain and lump), and twenty kinds of pulse conditions (such as floating pulse, sunken pulse, rapid pulse as well as knotted pulse, and slow-regular-intermittent pulse). Some common symptoms appear many times in the book and some only once or twice. For example, “fever” appears more than one hundred times in Treatise on Febrile Diseases, e.g., “in taiyang disease, the syndrome with such clinical manifestations as fever, sweating, aversion to wind and floating pulse is called wind-attack syndrome of taiyang disease” and “if patients who just suffer from shaoyang disease have fever and sunken pulse, they should be treated with Mahuang Fuzi Xixin Tang”; “aversion to cold” and “sweating” both appear more than seventy times; as for “headache,” “aversion to cold” and “alternate attack of chills and fever” and other symptoms, some symptoms appear dozens of times and some only more than ten times. Analyzing these common ex-ogenous symptoms that repeatedly appear, we can generalize the law of these symptoms and their combination with other symptoms. It is the content of syndrome differentiation.

Only when the law of syndrome variation is grasped, can treatment be made based on syndrome differentiation. As to syndrome differentiation of “sweating” and “no sweating,”

for instance, “Taiyang disease that is manifested as headache, fever, sweating and aversion to wind should be treated with Guizhi Tang,” “after treated with the method of diaphoresis, if patients who suffer from Taiyang disease have such symptoms as aversion to wind, dysuria and spasm of limbs, they should be treated with Guizhi Jia Fuzi Tang,” “Taiyang disease that is manifested as headache, fever, lumbago, arthralgia, aversion to wind, no sweating and dyspnea should be treated with Mahuang Tang” and “Taiyang disease which is manifested as stiffness of nape and back, absence of sweating and aversion to wind should be treated with Gegen Tang.” All of them show that the exterior syndrome with sweating should be treated with Guizhi Tang Serial Decoctions and the exterior syndrome with no sweating should be treated with Mahuang Tang Serial Decoctions.

The precise differentiation of primary symptoms in Treatise on Febrile Diseases shows that at that time ancient Chinese have learned a lot about the relationship between prescription and syndrome.

To reflect the essence of syndrome, treatment should be done on the differentiation between primary symptoms and secondary symptoms, as well as their laws of variation. For example,

“fever with no sweating” and “fever with sweating” have the same primary symptom of

“fever,” but the essences of syndromes are different in secondary symptoms concerning

“sweating,” and therefore their therapeutic methods are different. The former is treated using Mahuang Tang with Herba Ephedrae (Chinese ephedra herb) as monarch herb, and the latter using Guizhi Tang with Ramulus Cinnamomi as monarch herb. These therapeutic practices based on prescription-syndrome relation are distinct from previous practices based on drug-symptom relation, though the former relies on the latter. It can be expounded with the difference between herbs in the principal prescription and those in the class prescription.

For example, among six kinds of Mahuang Tang Serial Decoctions, Mahuang Tang is the principal prescription and Da Qinglong Tang is one of its class prescriptions. The syndromes treated with Mahuang Tang are headache, fever, lumbago, arthralgia, aversion to wind, no sweating and dyspnea; the syndromes treated with Da Qinglong Tang are floating and tight pulse, fever, aversion to cold, general pain, no sweating and dysphoria. The symptoms listed above are similar, but the symptom of dysphoria only appears in the syndrome of Da Qinglong Tang, so Da Qinglong Tang is composed of Mahuang Tang and Gypsum Fibrosum,

3.4 Accumulation of Therapeutic Experiences 33