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Cold and heat are the two fundamental principles for distinguishing the nature of diseases. Cold syndromes and heat syndromes reflect the excess and deficiency of yin and yang in the body. An excess of yin or deficiency of yang manifests as a cold syndrome; an excess of yang or deficiency of yin manifests as a heat syndrome. The differentiation of cold and heat syndromes is of great significance in treatment. As stated in the “Suo Wen: The Great Discussion of True Principles”: “Cold should be treated with heat,” and “Heat should be treated with cold,” indicating that the treatment methods for the two are exactly opposite. Therefore, the differentiation of cold and heat syndromes must be precise and accurate.
1. Cold Syndrome
A cold syndrome is a pathological condition characterized by cold nature. It can be caused by the invasion of cold pathogens or by the body’s own deficiency of yang and excess of yin.
Due to the different causes and locations of cold syndromes, several different patterns can be identified. For instance, the invasion of cold pathogens can affect the exterior or penetrate to the internal organs, leading to distinctions between exterior cold and interior cold. The causes of interior cold can be due to the invasion of cold pathogens or a deficiency of yang, thus leading to the differentiation between excess cold and deficient cold. Here, we will first analyze the common characteristics of cold syndromes.
【Clinical Manifestations】 The clinical manifestations of various cold syndromes are not entirely consistent, but common symptoms include: aversion to cold, preference for warmth, pale complexion, cold limbs curled up, lack of thirst, clear and thin phlegm, clear and thin nasal discharge, clear and frequent urination, loose stools, pale tongue with white and slippery coating, and a slow or tight pulse.
【Syndrome Analysis】 Insufficient yang qi or injury from external cold prevents it from performing its warming function, resulting in cold body and limbs, curled posture, and pale complexion. Excessive internal cold does not harm body fluids, hence the lack of thirst. Yang deficiency cannot transform fluids, leading to clear and cold discharges such as phlegm, nasal discharge, and urine. Cold pathogens injure the spleen, or prolonged deficiency of spleen yang leads to impaired transformation and transportation, resulting in loose stools. Yang deficiency fails to transform, and internal cold dampness arises, leading to a pale tongue with a white and slippery coating. Weak yang qi results in insufficient force to promote blood circulation, hence a slow pulse; cold constricts, causing the pulse to be tight when exposed to cold.
2. Heat Syndrome
A heat syndrome is a pathological condition characterized by heat nature. It can be caused by the invasion of heat pathogens or by the body’s own deficiency of yin and excess of yang.
Based on the different causes and locations of heat syndromes, several different patterns can also be identified. For example, external heat pathogens or heat invading internally can lead to distinctions between exterior heat and interior heat. Among interior heat, there can be excess heat due to invasion or deficiency heat caused by weakness. Here, we will analyze the common characteristics of heat syndromes.
【Clinical Manifestations】 The manifestations of various heat syndromes are also not entirely consistent, but common symptoms include: aversion to heat, preference for cold, thirst for cold drinks, red face and eyes, irritability, yellow and thick phlegm, hemoptysis, short and red urination, dry and hard stools, red tongue with yellow and dry coating, and a rapid pulse.
【Syndrome Analysis】 Excessive yang heat leads to aversion to heat and preference for cold. Fire heat injures yin, depleting body fluids, resulting in short and red urination; the depletion of fluids leads to thirst for cold drinks. Fire rises, causing a red face and eyes. Heat disturbs the mind, leading to irritability. Body fluids are scorched by yang heat, resulting in yellow and thick secretions. Heat pathogens injure blood vessels, causing hemoptysis. Intestinal heat and fluid depletion lead to constipation. A red tongue with yellow coating indicates heat syndrome, while a dry tongue with little fluid indicates yin injury; excessive yang heat accelerates blood flow, resulting in a rapid pulse.
3. Differentiation between Cold and Heat Syndromes
To differentiate between cold and heat syndromes, one cannot rely solely on a single symptom; a comprehensive observation and analysis of all disease manifestations is necessary, especially regarding preferences and aversions to cold and heat, thirst or lack thereof; the complexion’s redness or paleness, the temperature of the limbs, as well as the characteristics of urination, stool, tongue, and pulse should be observed in detail.
4. Relationship between Cold and Heat Syndromes
Although cold and heat syndromes are fundamentally different, they are interconnected. They can appear simultaneously in the same patient, presenting as mixed cold and heat symptoms, and can also transform into each other under certain conditions, resulting in cold transforming into heat or heat transforming into cold. During the progression of a disease, especially in critical stages, false cold or false heat phenomena may also occur.
（1）Mixed Cold and Heat
When cold and heat syndromes appear simultaneously in the same patient, it is referred to as mixed cold and heat. There are different types of mixed cold and heat, including upper and lower mixed cold and heat, and exterior and interior mixed cold and heat.
1. Upper and Lower Mixed Cold and Heat: The upper and lower parts of the patient’s body exhibit different cold and heat characteristics, referred to as upper and lower mixed cold and heat. This includes upper cold and lower heat, and upper heat and lower cold. The terms upper and lower are relative concepts. For instance, if the diaphragm is the boundary, the chest is considered upper, and the abdomen is lower. The upper abdomen (stomach area) is also considered upper, while the lower abdomen (bladder, large and small intestines) is considered lower.
（1）Upper Cold and Lower Heat: The patient exhibits cold symptoms in the upper body and heat symptoms in the lower body at the same time. For example, cold pain in the stomach area, vomiting clear phlegm, while also experiencing frequent urination, painful urination, and short red urination, indicating cold in the stomach and heat in the bladder. This is a case of cold in the middle jiao and heat in the lower jiao, with the middle jiao being above the lower jiao.
（2）Upper Heat and Lower Cold: The patient exhibits heat symptoms in the upper body and cold symptoms in the lower body at the same time. For example, the patient has heat in the chest and cold in the intestines, presenting with heat symptoms in the chest such as irritability, sore throat, and dry mouth, along with abdominal pain and preference for warmth, and loose stools in the lower cold syndrome, indicating upper heat and lower cold.
2. Exterior and Interior Mixed Cold and Heat: The patient has the same disease but exhibits different cold and heat characteristics in the exterior and interior, referred to as exterior and interior mixed cold and heat. This includes exterior cold and interior heat, and exterior heat and interior cold.
（1）Exterior Cold and Interior Heat: The patient has the same disease in the exterior and interior, with cold in the exterior and heat in the interior. This is commonly seen in cases where there is pre-existing internal heat, and the patient is also exposed to wind-cold, or where an external pathogen transforms into internal heat while the exterior cold has not resolved. For example, aversion to cold with fever, no sweating, headache, body aches, shortness of breath, irritability, and thirst, with a floating and tight pulse indicating cold in the exterior and heat in the interior.
（2）Interior Cold and Exterior Heat: The patient has the same disease in the exterior and interior, with heat in the exterior and cold in the interior. This is commonly seen in cases where there is pre-existing interior cold and the patient is also exposed to wind-heat; or where the exterior heat syndrome has not resolved, leading to damage to the spleen and stomach yang. For example, the patient may present with fever, headache, cough, and sore throat as exterior heat symptoms, while also experiencing loose stools, clear and frequent urination, and cold limbs as interior cold symptoms.
In differentiating mixed cold and heat syndromes, it is crucial to distinguish between the upper and lower parts of the body, as well as the exterior and interior. The key is to clarify the relative amounts of cold and heat. If there is more cold than heat, the treatment should primarily focus on cold, while also addressing the heat symptoms; if there is more heat than cold, the treatment should primarily focus on heat, while also addressing the cold symptoms.
（2）Transformation between Cold and Heat
1. Transformation of Cold Syndrome into Heat Syndrome: The patient initially has a cold syndrome, which later develops into a heat syndrome, with the cold symptoms gradually disappearing. This transformation is often due to an excess of yang qi in the body, causing the cold pathogen to transform into heat, or it may occur due to improper treatment, such as excessive use of warming and drying herbs. For example, a patient may initially present with exterior cold syndrome, showing aversion to cold and fever, with no sweating, a white tongue coating, and a floating and tight pulse. As the condition progresses, the cold pathogen invades internally and transforms into heat, with the aversion to cold symptoms subsiding, and symptoms of high fever, irritability, thirst, yellow tongue coating, and rapid pulse appearing, indicating a transformation from exterior cold to interior heat.
2. Transformation of Heat Syndrome into Cold Syndrome: The patient initially has a heat syndrome, which later develops into a cold syndrome, with the heat symptoms gradually disappearing. This transformation is often due to an excess of pathogens or deficiency of the body’s righteous qi, leading to functional decline; it may also occur due to improper treatment or loss of yang qi. This transformation can be gradual or rapid. For example, chronic heat dysentery may lead to a gradual transformation into deficient cold dysentery due to depletion of yang qi. In contrast, a patient with high fever may experience sudden drops in body temperature, cold limbs, pale complexion, and a weak pulse due to excessive sweating or vomiting, indicating a rapid transformation into deficient cold syndrome (loss of yang).
The transformation of cold and heat syndromes reflects the dynamics of excess and deficiency. The transformation from cold to heat indicates that the body’s righteous qi is still strong, and the cold pathogen is transforming into heat; the transformation from heat to cold often indicates an excess of pathogens and deficiency of righteous qi, where the righteous qi cannot overcome the pathogens.
（3）True and False Cold and Heat
When cold or heat syndromes reach an extreme point, sometimes false phenomena may appear that are opposite to the essence of the disease, such as “true cold appearing as heat” or “true heat appearing as cold,” known as true cold and false heat, or true heat and false cold. These phenomena are often seen in critical stages of the disease, and if not carefully observed, can easily lead to life-threatening situations.
1. True Cold and False Heat: This is a condition where true cold exists internally, but false heat is observed externally. The mechanism of this condition is due to excessive internal cold obstructing yang externally, leading to a phenomenon where excessive yin appears to be yang, also known as “excessive yin obstructing yang.” The internal excess of yin obstructs yang externally, resulting in a false appearance of yang. Symptoms may include: body heat, flushed face, thirst, and a large pulse that seems to indicate heat syndrome, but the patient, despite feeling hot, desires to cover themselves with blankets, has a thirst for hot drinks but cannot drink much, and the flushed face appears intermittently rather than a full red face typical of true heat. The pulse is large but weak upon palpation. Additionally, cold limbs, clear diarrhea, and clear and frequent urination may be present. Therefore, the heat appearance is false, and the essence of the disease is yang deficiency and excessive cold.
2. True Heat and False Cold: This is a condition where true heat exists internally, but false cold is observed externally. The mechanism of this condition is due to excessive internal heat, where yang qi is obstructed internally and cannot reach the extremities, or where excessive yang internally obstructs yin externally, also known as “excessive yang obstructing yin.” The characteristics of this condition, where internal heat is excessive, lead to cold extremities, are habitually referred to as “yang collapse” or “heat collapse.” The more severe the internal heat, the more severe the cold extremities, known as “the deeper the heat, the deeper the cold.” Symptoms may include: cold hands and feet, a deep pulse that seems to indicate cold syndrome, but the patient has a hot body and does not dislike heat, rather dislikes cold, with a deep and rapid pulse that is strong, along with symptoms of thirst for cold drinks, dry throat, foul breath, short and red urination, dry and hard stools, or heat dysentery. This condition of cold extremities and a deep pulse indicates false cold, while the essence of the disease is internal heat.
To differentiate between true and false cold and heat, one should not only understand the entire process of the disease but also pay attention to the following two aspects:
1. The appearance of false phenomena often occurs in the extremities, skin, and complexion, while the internal manifestations of the organs, qi, blood, and body fluids often reflect the true essence of the disease. Therefore, when differentiating syndromes, the internal symptoms, tongue appearance, and pulse characteristics should be the main basis.
2. False phenomena are different from true phenomena. For example, the flushed face in false heat is a pale complexion with only a slight red hue on the cheeks, appearing intermittently, while true heat presents with a fully flushed face. False cold often manifests as cold extremities, while the chest and abdomen may be hot to the touch, or the entire body may feel cold but the patient does not want to be covered, while true cold is characterized by a curled posture, desiring warmth.
Appendix: The Key to Differentiating Yin and Yang Syndromes
Yin and Yang Differentiation
1. The Golden Key to Yin and Yang Differentiation: Yin Syndrome: Lips and mouth are bluish-white, eyes lack spirit, voice is low, breathing is short, but desires sleep; body feels heavy, reluctant to speak, sensitive to cold; food has no taste, vomiting clear fluids; tongue is bluish and slippery or black and moist; white or light yellow and slippery coating; saliva fills the mouth, no desire to drink; thirst with a desire to drink but cannot swallow; or thirst for hot drinks; clear and frequent urination, loose stools; foul breath, mixed cold and heat; more cold than heat, unable to eat; pulse is weak and lacks spirit, indicating a yin syndrome. Although the tongue may have no coating, the mouth is moist, and the two excretions are self-regulating, indicating a yang syndrome. Yang Deficiency: Face and lips are red, spirit is not weary, unaware of sleep; foul breath, coarse voice, bright sound; aversion to heat, light body, dry stools; red and yellow urine, short and difficult urination; thirst for cold drinks, drinking without rest; six pulses are long, large, and strong; tongue coating is dry and yellow or black and yellow, with no body fluids, mouth feels prickly; irritability, tidal fever, or night sweats; dry cough with much or little phlegm; pulse is strong and has spirit, indicating a yang syndrome. Thirst for cold drinks, body feels hot; two excretions are not smooth, irritability, delirium; body feels cold as ice, appears lifeless, indicating extreme heat lurking internally, yang not reaching the exterior, appearing as pure yin; at this time, it is necessary to examine the breath; although the breath may be slightly hot, the root of the tongue may be red but not blue, it is urgent to purge and preserve body fluids, do not mistake it for a yin syndrome, which could endanger life.
Yin and Yang Differentiation: True and False Mixed Diseases
2. Yin Cold and Yang Heat are Yin and Yang, only in true and false can one make a distinction. True heat leads to thirst, yellow urine, spirit disturbance, and restlessness. True cold leads to frequent urination, pale complexion, lack of spirit, fatigue, and desire to sleep. True heat leads to thirst for cold drinks, false heat leads to a desire to rinse the mouth without swallowing; true heat leads to dry stools and a red face. False heat leads to a flushed face with clear urination; true heat leads to a rapid pulse. True cold leads to a weak pulse, while true heat leads to a dry tongue with yellow coating. True cold appearing as yang is excessive yang, while true heat appearing as yin is cold limbs.
True and False Cold and Heat should be carefully considered; yin and yang syndromes are clearly defined. True heat and yang syndrome suffer from cold, while true cold and yin syndrome require warming decoctions. Understanding the transformation of yin and yang, difficult and mixed diseases can be treated. The primordial extremes are water and fire; when water and fire are balanced, there are no chronic diseases. Spleen yang deficiency leads to loose stools, which can harm the liver; hepatitis B virus is rampant, and Aconite and Ginger are effective. Kidney yang deficiency leads to frequent urination, with essence leaking and eyes not moist; dizziness and low back pain are also causes, and the Four Reverse Decoction can save the yang. Leukemia is a cold and yin evil, penetrating the marrow and increasing white blood cells; Western medicine only knows how to kill white blood cells, blindly depleting yang qi. This disease is a yin disease in TCM, and the treatment is based on the principles of the Lesser Yin Disease, using the Four Reverse Decoction, which is simple, effective, and miraculous. AIDS is a separation of yin and yang; Western medicine can detect it through blood tests, while ordinary blood tests show one line, but AIDS blood shows two separations. Treating the spirit with the balance of yin and yang, if yin and yang are separated, the spirit is lost; harmonizing yin and yang with TCM is simple, effective, and miraculous.
Clear and empty the six channels and eight trigrams for another explanation. The eight trigrams encompass heaven and earth, explaining physics easily; three lines form a hexagram, and eight pure hexagrams, three lines form one hexagram. One yin and one yang is the Lesser Yin (hexagram Li), two yang embracing yin is the heart (Li), and two yin embracing yang is the kidney (Kan). The Lesser Yin contains essence and fluids, while the Lesser Yin injures yang, leading to limbs not extending (yang qi decreases), aversion to cold, curled posture, and desire to sleep; excessive yin leads to floating tongue root, tonsils swelling, headache, and high blood pressure; cold limbs are the cause, and the Four Reverse Decoction can support the kidney yang, while the Lesser Yin cold transformation has nowhere to hide. The Lesser Yin injures essence and fluids, leading to irritability, thirst, and short and red urination; Huanglian and Ejiao can be decocted and tasted.
The Greater Yang has three yang (hexagram Qian, strong), in the body’s surface protecting strongly; when the Greater Yang is obstructed, it leads to heat due to stagnation; sufficient spleen yang leads to sweating; Ma Huang Decoction can be urgently decocted, and sweating disperses cold to strengthen the exterior. Insufficient spleen yang leads to loose skin, aversion to wind, sweating, and deficiency of the protective qi; Guizhi Decoction can be decocted to relieve this. If there is no heat and aversion to cold, it is a Lesser Yin disease; Aconite, Ginger, and Licorice in the Four Reverse Decoction; if there is also a cough, use Ma Huang and Aconite in the Four Reverse Decoction.
The second section
Six Channels Yin and Yang Differentiation and Treatment: Clear and empty the medicinal properties of yin and yang; pungent and sweet disperse heat, bitter, sweet, and sour are cold. For yin syndromes, use yang medicines; for yang syndromes, use bitter, sweet, and cold medicines. In the case of the Greater Yin disease, if there is no appetite, cough, or abdominal fullness, the Greater Yin damp earth needs to be dried; Cangzhu, Yiyiren, and Banxia are effective. If dampness is heavy and heat is light, use Aconite and Ginger; removing dampness will eliminate heat. If heat is heavier than dampness, use the Four Marvelous Powder to clear dampness and heat. Yinchentang can clear jaundice, while the yin jaundice can be treated with Atractylodes and Aconite Decoction. In the case of Lesser Yin disease, if the patient desires to sleep, is sensitive to cold, and has a weak pulse, use Aconite and Ginger, along with raw and roasted Licorice for assistance. For the Lesser Yang disease, if there is a cold and heat alternation, Xiao Chai Hu Decoction should be used; or use Danggui and the Four Reverse Decoction to boost yang qi and expel pathogens. In the case of Yangming disease with fullness in the stomach, use the Three Purging Decoction; if the Yangming channel is not yet solidified, use the Baihu Decoction to eliminate excess heat.
Fever without cold symptoms indicates a Greater Yang disease; clear the lungs and disperse cold with Ma Huang Decoction; sweating indicates a deficiency of protective qi; Guizhi Decoction should be decocted. If there is no heat and aversion to cold, it is a Lesser Yin disease; Aconite, Ginger, and Licorice in the Four Reverse Decoction; if there is also a cough, use Ma Huang and Aconite in the Four Reverse Decoction.
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