The differentiation of cold and heat is one of the specific contents of the Eight Principles Differentiation (referring to the eight categories of syndromes: Yin-Yang, Interior-Exterior, Cold-Heat, Deficiency-Excess, which are the fundamental principles of TCM differentiation). The characteristic of the Eight Principles Differentiation lies in grasping the overall, certain, and relevant aspects of the disease’s occurrence and development. Cold and heat are the two most basic principles used to differentiate the etiology and nature of diseases.
Cold syndrome refers to the symptoms manifested when the body is invaded by cold pathogens or when there is insufficient Yang Qi. Symptoms include aversion to cold, cold pain, preference for warmth, pale and moist tongue with white coating, and a tight or slow pulse. The characteristics are cold, pale, thin, moist, and still.
Heat syndrome refers to the symptoms manifested when the body is invaded by heat pathogens or when Yang Qi is excessive and Yin fluids are insufficient. Symptoms include fever, preference for coolness, thirst for cold drinks, red face, irritability, yellow and thick phlegm, short and yellow urine, and dry constipation; the tongue is red with a yellow coating, dry with little fluid, and the pulse is rapid. The characteristics are heat, red, thick, dry, and active.
1. Aversion to Cold and Fever
Refers to the simultaneous occurrence of aversion to cold and fever in the patient. This is commonly seen in the initial stage of externally contracted diseases and is a major symptom of exterior syndromes. For example, in the case of typhoid fever, the Taiyang and Shaoyang syndromes, as well as the Wei and upper-jiao syndromes of warm diseases, can all be observed. In exterior syndromes, aversion to cold is the main symptom and often precedes fever, thus the simultaneous presence of aversion to cold and fever is an important basis for diagnosing exterior syndromes.
1.1. Aversion to Cold and Fever, Simultaneously Present
1.1.1. Severe Aversion to Cold, Mild Fever
This means the patient feels a significant aversion to cold with only mild fever. This is often caused by the invasion of cold pathogens, as cold is a Yin pathogen that obstructs the Wei Yang, causing the skin to lose warmth and resulting in aversion to cold; when the cold pathogen binds externally, the Wei Yang loses its ability to disperse, leading to a mild fever. This belongs to the exterior cold syndrome. If accompanied by headache and body pain, thirst without sweating, a floating and tight pulse, and a pale tongue with a white coating, it is often due to wind-cold binding the exterior; if there is no sweating and wheezing, with thin white phlegm, a floating and tight pulse, and a pale tongue with a slippery white coating, it is often due to wind-cold attacking the lungs; if there is mild headache without sweating, dry lips and throat, with thin phlegm, a dry white coating, it is often due to cool dryness syndrome.
1.1.2. Severe Fever, Mild Aversion to ColdThis means the patient has a significant fever with only mild aversion to cold. This is often caused by the invasion of warm pathogens, as warmth is a Yang pathogen, and when Yang is excessive, it leads to heat. The Wei Qi resists the pathogen at the skin level, and when the pathogen and the righteous Qi are in fierce contention, the exterior heat becomes more pronounced. Exterior heat is often accompanied by wind pathogens; when wind-heat attacks the exterior, the pores open and release, leading to mild aversion to wind-cold, thus belonging to the exterior heat syndrome. If accompanied by headache without sweating, sore throat and cough, thirst with dry nose, thin yellow coating, and a floating and rapid pulse, it is often due to wind-warm exterior syndrome; if accompanied by headache with little sweating, body heaviness and pain, thirst and irritability, thin greasy coating, it is often due to summer-warm exterior syndrome; if accompanied by headache and sore throat, thirst with dry lips, dry cough with sticky phlegm, thin yellow coating with little fluid, it is often due to warm-dry exterior syndrome.
1.1.3. Mild Fever, Spontaneous Sweating with Aversion to Wind
This means the patient has mild fever and spontaneous sweating, with a feeling of aversion to cold when encountering wind. This is often caused by a deficiency of righteous Qi in individuals who are susceptible to wind pathogens, belonging to the exterior deficiency syndrome. Due to insufficient righteous Qi, the body is weak against pathogens, and the pathogen is not strong, leading to mild fever; the Wei Yang is weak, the skin pores are not secure, and the Yin does not guard internally, resulting in spontaneous sweating. Wind is a Yang pathogen, and its nature is to disperse; thus, the loose pores lead to exterior deficiency and spontaneous sweating with aversion to wind. This syndrome is often accompanied by headache and body pain, alternating cold and heat, dry retching without thirst, thin white coating, and a floating and slow pulse.
1.1.4. Severe Aversion to Cold, Significant Fever
This means the patient feels a significant aversion to cold along with a notable fever. This is often caused by individuals with excessive Yang who are invaded by wind, cold, and damp pathogens, as the cold and damp pathogens obstruct Yang Qi, causing the skin to lose warmth and resulting in aversion to cold; with internal heat and excessive Yin pathogens obstructing, the external cold and internal heat lead to a fierce contention between the righteous and the pathogenic Qi, resulting in both aversion to cold and fever, thus belonging to the exterior cold and interior heat syndrome. This syndrome is often accompanied by severe headache and neck pain, body pain without sweating, bitter taste in the mouth, mild thirst, red tongue with white coating, and a floating and tight pulse.
1.2. Aversion to Cold and Fever, Occurring Sequentially
1.2.1. Initial Chills Followed by High Fever
This means the patient initially feels chills and then develops high fever without sweating. This is often caused by the invasion of wind-cold pathogens or epidemic toxins, belonging to the syndrome of excessive pathogens and deficient righteous Qi. The former is often due to cold pathogens binding the exterior, blocking the pores, and the Yang Qi being restrained by Yin pathogens, leading to chills and no sweating, headache and body pain, followed by high fever, thin white coating, and a floating and tight pulse. The latter, such as in the case of malaria, begins with the righteous Qi being unable to resist the pathogen, leading to chills and shivering, and the Ying and Wei Qi striving to expel the pathogen, resulting in a fierce contention between the righteous and the pathogenic Qi, thus chills cease and high fever ensues, followed by sweating, heat subsiding, and body cooling, along with thirst, fatigue, short and red urine, and constipation, red tongue with white coating, rapid and weak pulse, also belonging to the exterior cold and interior heat syndrome.
1.2.2. Alternating Cold and Heat
This means the patient experiences fever without aversion to cold and aversion to cold without fever. This syndrome is characterized by the alternating occurrence of cold and heat, thus referred to as Shaoyang syndrome in the “Shang Han Lun”. Shaoyang is located between Taiyang and Yangming, where the pathogenic Qi is neither at the exterior of Taiyang nor has it reached the interior of Yangming, thus it is often referred to as a half-exterior, half-interior syndrome. Based on the timing and pattern of the cold and heat, there are two common clinical types:
①. Irregular Occurrence: This refers to the patient experiencing cold and heat at different times throughout the day without a regular pattern, commonly seen in Shaoyang syndrome, where the external pathogen attacks the exterior, and the pathogenic and righteous Qi are in contention between the exterior and interior, leading to alternating occurrences of aversion to cold and fever, thus belonging to the half-exterior, half-interior syndrome. Clinically, it is often accompanied by dizziness, bitter taste in the mouth, dry throat, irritability, and fullness in the chest and hypochondria due to cold stagnation transforming into fire.
②. Regular Occurrence: This refers to the patient experiencing alternating aversion to cold and fever at regular intervals, either once or twice a day, or every two days, commonly seen in epidemic diseases such as malaria and influenza. This is due to the malaria pathogen invading the body, hiding between the half-exterior and half-interior, where it contends with Yin, leading to cold, and contends with Yang, leading to heat, thus alternating occurrences of cold and heat, with rest periods, more cold than heat, clinically often accompanied by headache, body aches, no thirst or preference for warm drinks, fullness and discomfort in the chest and hypochondria, white and greasy coating, and a wiry and tight pulse, indicating cold pathogens stagnating at the exterior.
2. Only Cold, No Heat
This means the patient only feels aversion to cold without any fever. This is often seen in the early stages of externally contracted diseases and is one of the main symptoms of exterior syndromes, thus the ancient saying, “For every bit of aversion to cold, there is a corresponding exterior syndrome.” However, this cannot be said absolutely, as clinically there are cases where aversion to cold is not prominent but exterior syndromes exist, and conversely, aversion to cold can also be seen in the extreme or late stages of externally contracted diseases, accompanied by Qi deficiency or Yang deficiency leading to aversion to cold, and syndromes belonging to deficiency cold.
2.1. Aversion to Wind
This means the patient feels cold when encountering wind, and avoiding it can often relieve the symptoms. This is often caused by wind pathogens attacking the exterior, leading to disharmony between Ying and Wei, as wind has a dispersing nature, and when wind pathogens attack the exterior, the skin pores become loose, leading to aversion to wind and sweating, thus belonging to the wind-cold syndrome. If accompanied by mild fever and sweating, headache and body pain, dry retching without thirst, thin white coating, and a floating and slow pulse, it is often due to wind-cold exterior deficiency; if accompanied by body heat and sweating, joint pain and discomfort, difficulty in flexing and extending, white greasy coating, and a soft pulse, it is often due to wind-damp exterior syndrome; if accompanied by fever, headache, sweating, dry mouth and sore throat, red tip of the tongue, thin yellow coating, and a floating and rapid pulse, it is often due to wind-warm exterior syndrome; if accompanied by skin rashes and itching, fatigue, and loss of appetite, it is often due to wind-rash exterior syndrome; if accompanied by facial swelling, difficulty in urination, and sore throat with cough, it is often due to wind-water exterior syndrome.
2.2. Aversion to Cold
This means the patient feels cold and aversion to cold, and even adding clothing or getting close to fire does not relieve the symptoms. This is often caused by the invasion of cold and damp pathogens, as both cold and damp are Yin pathogens that obstruct and stagnate, leading to Yang Qi being restrained by Yin pathogens, causing Qi and blood stagnation, and the skin pores losing warmth, resulting in aversion to cold. This syndrome, if accompanied by fever without sweating, headache and body pain, nasal congestion and runny nose, cough and wheezing, thin white coating, and a floating and tight pulse, is often due to wind-cold binding the exterior; if accompanied by body heat without sweating, dry throat and dry nose, dry cough with little phlegm, thin white coating with little fluid, and a floating and slippery pulse, it is often due to cool dryness syndrome; if accompanied by significant fever, severe headache and neck pain, body pain without sweating, sore throat and thirst, red tongue with white coating, and a floating and tight pulse, it is often due to exterior cold and interior heat; if occurring in summer, accompanied by fever, headache, body heaviness, joint pain, no sweating or slight sweating, dry mouth without thirst, red tongue with thin greasy coating, and a floating and slippery pulse, it is often due to summer-dampness injuring the exterior; if cold is more than heat, with intermittent occurrences, body pain and fatigue, chest tightness and fullness, thick white greasy coating, or white like accumulated powder, and a slow pulse, it is often due to hidden pathogens in the membrane; if aversion to cold without heat, or body temperature is low, without sweating, cold limbs, fatigue, low voice, pale complexion, pale tongue with white coating, and a deep and weak pulse, it is often due to Yang deficiency with external invasion or cold pathogens directly entering the Yin.
2.3. Chills and Shivering
This means the patient feels aversion to cold and shivers, showing involuntary trembling while feeling cold. This is often caused by the invasion of Yin pathogens or epidemic toxins, as cold pathogens are often Yin and turbid, obstructing the meridians, leading to Qi and blood stagnation, and the skin pores being closed, with insufficient Yang Qi to warm, resulting in chills and shivering, often belonging to the syndrome of excessive pathogens and deficient righteous Qi, or exterior cold and interior heat syndrome. If the exterior symptoms are just beginning, chills may be accompanied by no sweating, headache and body pain, followed by high fever, thin white coating, and a floating and tight pulse, often due to cold pathogens binding the exterior; chills may be accompanied by high fever, headache without sweating, body discomfort, sore throat and cough, dry mouth and dry nose, thin yellow coating, and a floating and rapid pulse, often due to exterior cold and interior heat; if chills suddenly occur, with intermittent occurrences, chills cease and then heat occurs, followed by sweating, along with thirst, fatigue, short and red urine, constipation, red tongue with white coating, and a rapid and weak pulse, it is often due to malaria chills; if during the course of an externally contracted disease, chills and shivering suddenly appear, with cold limbs and a weak pulse, after much suffering, followed by heat and sweating, this is referred to as the chills of sweating. Clinically, the appearance of sweating indicates the contention between excessive pathogens and deficient righteous Qi, and reflects the Wei Qi resisting the pathogen or the Zang Qi resisting the toxin. Generally, if the righteous Qi is still strong, Yang recovers and sweating occurs, indicating the expulsion of the pathogen; if the righteous Qi is weak, it often indicates that the righteous cannot overcome the pathogen, leading to the escape of Yin and Yang. If after chills, sweating occurs and heat subsides, with a calm pulse and cool body, it often indicates that the righteous has overcome the pathogen, and the illness is gradually improving; if after chills, sweating occurs but heat does not resolve, with restlessness, thirst, rapid pulse, red tongue with dry coating, it often indicates excessive heat toxins, depletion of fluids, and loss of Yin; if after chills, there is no fever, or even a drop in body temperature, with cold limbs, low voice, pale complexion, pale tongue with white coating, and a weak pulse, it often indicates excessive pathogens and deficient righteous Qi, leading to Qi collapse and Yang loss.
2.4. Aversion to Cold
This means the patient feels cold and aversion to cold, but adding clothing or getting close to fire can relieve the symptoms. As described in the “Yi Zhi” – “When externally contracted aversion to cold occurs, even close to a fierce fire it does not resolve, it must be resolved by the exterior. Internal injury aversion to cold can be relieved by warmth.” Clinically, this type of aversion to cold without accompanying exterior symptoms is actually due to internal injury from cold pathogens. Aversion to cold symptoms are often seen in internal excess cold and internal deficiency cold. The former is often seen in new illnesses, where the Zang Qi is insufficient, and cold pathogens directly invade the Zang-fu or meridians, leading to Yang Qi being restrained by Yin pathogens, causing the patient to suddenly feel aversion to cold, with cold limbs and rigidity, cold pain in the chest and abdomen, pain that resists pressure, relieved by warmth; or abdominal pain with vomiting, bowel sounds and diarrhea; or cough and wheezing, phlegm and Qi counterflow, all belong to the syndrome of pathogenic Qi entering the interior. The latter is often seen in chronic illnesses, where the body’s Yang Qi is deficient, leading to a loss of warmth. The patient feels aversion to cold, accompanied by a pale complexion, curled up with cold limbs, fatigue, pale tongue, and a slow and weak pulse, often belonging to the syndrome of deficient Yang Qi.
3. Only Heat, No Cold
This means the patient only feels heat without any aversion to cold, or even experiences aversion to heat. If an externally contracted disease transitions from aversion to cold and fever to only heat without aversion to cold, it is an important sign that the six excesses have entered the interior and transformed from heat, often belonging to the syndrome of excessive Yang and deficient Yin.
3.1. High Fever
This means the patient experiences high fever, with body temperature often exceeding 39°C, persisting without subsiding, without aversion to cold but rather aversion to heat. This is often due to the six excesses entering the interior, where the righteous and pathogenic Qi are in contention, leading to excessive Yang heat and internal heat steaming. This is commonly seen in the peak or extreme stages of externally contracted heat diseases, such as the Yangming syndrome of typhoid fever and the Qi, Ying, and Blood syndromes of warm diseases, as well as the middle-jiao syndromes of damp-heat diseases. Among these, high fever seen in the peak stage is often due to middle-jiao or Qi syndromes; high fever seen in the extreme stage is often due to Ying or Blood syndromes. If this syndrome is accompanied by profuse sweating, thirst for cold drinks, constipation, and red and yellow tongue with a dry coating, it often indicates excessive stomach heat; if accompanied by cough and wheezing, chest tightness and pain, yellow and thick phlegm, dry sweating, red tongue with yellow coating, and a rapid pulse, it often indicates obstructive heat in the lungs; if accompanied by delirium, or unconsciousness, red and purple tongue, and thin and rapid pulse, it often indicates heat closing the heart; if accompanied by restlessness, severe agitation, upward gaze, unconsciousness, stiff neck, and retraction of the neck, red tongue with yellow coating, and a wiry and rapid pulse, it often indicates excessive heat stirring wind; if accompanied by restlessness, delirium, profuse rashes, vomiting blood, nosebleeds, blood in stool, and blood in urine, it often indicates excessive heat stirring blood; if accompanied by headache, profuse sweating, irritability, or rashes, purple tongue, and rapid pulse, it often indicates both Qi and blood being burned. If this occurs in the summer heat, accompanied by thirst, profuse sweating, chest tightness, heaviness, and short urination, red tongue with yellow and greasy coating, it often indicates damp-heat obstructing the middle-jiao; if it occurs in the summer and autumn, accompanied by diarrhea with pus and blood, urgency in the rectum, burning pain in the abdomen, red tongue with yellow and greasy coating, it often indicates damp-heat dysentery. If accompanied by swollen and painful joints, restricted movement, general discomfort, thirst, and irritability, red tongue with white greasy coating, and a rapid pulse, it often indicates wind-damp-heat bi syndrome.
3.2. Tidal Fever
This means the patient experiences fever that occurs like a tide, with high fever occurring once a day, peaking and then subsiding. This is commonly seen in the middle and later stages of externally contracted heat diseases. If the body temperature fluctuates several times a day, or if the fever occurs irregularly (such as irregular fever), it does not belong to the category of tidal fever. However, the fever in malaria, although it has rest periods, or occurs once a day, is often accompanied by alternating cold and heat, making it easy to distinguish from tidal fever. Due to different causes and syndromes, the heat can vary in intensity and timing. If the fever peaks in the afternoon (i.e., during the time of Shen), accompanied by constipation or watery diarrhea, abdominal distension and pain that resists pressure, irritability and delirium, yellow and thick coating, and a deep and forceful pulse, it often indicates tidal fever due to excess in the bowels; if the body heat does not rise in the afternoon, with sweating and heat subsiding, then rising again, accompanied by heaviness and discomfort in the chest and abdomen, loose stools, bland taste, and short and red urine, yellow and greasy coating, and a slippery and rapid pulse, it often indicates damp-warm tidal fever; if the body heat is especially severe at night, accompanied by restlessness, delirium, dry mouth, rashes, or various bleeding disorders, purple tongue with little fluid, and a thin and rapid pulse, it often indicates Ying and blood tidal fever; if the high fever has subsided but the remaining pathogens have not cleared, with morning light and evening heavy symptoms, heat in the palms and soles more than on the back of the hands and feet, accompanied by fatigue, irritability, dry mouth, red tongue with little coating, and a thin and rapid pulse, it often indicates Yin deficiency tidal fever.
3.3. Low-Grade Fever
This means the patient experiences low-grade fever, with body temperature generally not exceeding 38°C, or only feels feverish while having a normal temperature. This is often seen in the later stages of externally contracted heat diseases, commonly indicating that the organs are already deficient, and the remaining pathogens have not been completely eliminated. For example, if the peak has passed but low-grade fever persists, it is often accompanied by dry cough with little phlegm, dry throat, hoarseness, dry mouth and thirst, weight loss, poor appetite, constipation, and red tongue with thin coating that lacks moisture, often indicating lung and stomach Yin deficiency; if high fever has subsided but the body heat does not cease, often accompanied by fatigue, irritability, shortness of breath, profuse sweating, and yellow urine, red tongue that is dry, and a weak pulse, it often indicates heat injuring Qi and fluids, leading to persistent body heat, or heat in the palms and soles, often accompanied by flushed cheeks, dizziness, tinnitus, frequent dreams, fatigue, dry mouth, dry throat, red tongue with little coating or no coating, and a thin and rapid pulse, often indicating liver and kidney Yin deficiency.
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