Classic Proverbs on Diagnosis in Traditional Chinese Medicine

Chinese Medicine Book Club Issue 1015

One issue daily, accompanying the growth of TCM practitioners

IIntroduction: This article encompasses the essence of the Ten Questions Song, distilling the wisdom of physicians throughout history regarding diagnosis. For the editor, the inspiration is significant~ (Editor/Zhang Yajuan)

Selected Proverbs on Clinical Diagnosis from Various Dynasties

Compiled by Yu Bohai

• “Aversion to cold belongs to the exterior; even if there are interior symptoms, if there is slight cold, it is still an exterior condition.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Aversion to Cold, Part Two”

Note: This statement indicates that aversion to cold is the main basis for diagnosing exterior cold syndrome. Exterior cold syndrome is caused by cold evil attacking the exterior, leading to stagnation of the defensive yang. Aversion to cold is a symptom that must be present in exterior cold syndrome, as stated in the “Treatise on Cold Damage”: “In Taiyang disease, there may be fever or no fever, but there must be aversion to cold…” Therefore, Cheng states: “Aversion to cold belongs to the exterior.” If exterior cold syndrome is not treated or is mismanaged, the exterior evil can penetrate inward, but as long as the symptom of aversion to cold remains, it indicates that the exterior condition has not resolved. The saying “for every bit of aversion to cold, there is a corresponding exterior condition” reflects this idea. This statement is not only significant for distinguishing between exterior and interior conditions but also serves as an important basis for medication.

• “If a disease has fever and aversion to cold, it arises from yang; if there is no fever and aversion to cold, it arises from yin.” — “Treatise on Cold Damage: Differentiating Taiyang Disease Pulse and Symptoms”

Note: In this text, “yang” and “yin” represent Taiyang disease and Shaoyin disease, respectively. The original intent of this statement is to use fever with aversion to cold and absence of fever with aversion to cold (this aversion to cold should be understood as fear of cold) as key points for differentiating between Taiyang disease and Shaoyin disease. Clinically, this can also serve as a distinguishing point between exterior cold syndrome and interior deficiency cold syndrome. When fever and aversion to cold are present, the disease belongs to the exterior syndrome; if there is no fever and aversion to cold, the disease belongs to the interior deficiency cold syndrome. Although fever with aversion to cold and absence of fever with aversion to cold are the main distinguishing points between exterior cold syndrome and interior deficiency cold syndrome, clinical application should also consider the four examinations comprehensively and analyze thoroughly, rather than adhering rigidly to one point.

• “Internal injury causing aversion to cold can be relieved by warmth; external invasion causing aversion to cold cannot be relieved even near a fire.” — Ming Dynasty, Fang Yu “Medical Forest: Volume Seven”

Note: Internal injury causing aversion to cold is due to yang deficiency; encountering warmth assists the yang qi, thus aversion to cold can be temporarily alleviated. External invasion causing aversion to cold is due to cold evil attacking the exterior; one should induce sweating to expel the cold evil through sweat, and merely adding layers of clothing or getting close to fire does not help in dispelling the cold, hence aversion to cold persists. Clinically, this can serve as one of the bases for distinguishing between internal injury and external invasion causing aversion to cold.

• “If sweating occurs with aversion to cold, it indicates exterior deficiency; if there is no sweating and aversion to cold, it indicates exterior excess.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Aversion to Cold, Part Two”

Note: This statement indicates the key points for distinguishing between exterior deficiency syndrome and exterior excess syndrome. Exterior cold syndrome is caused by the invasion of wind-cold evil, but due to differences in constitution and the density of the pores, there are distinctions between exterior deficiency syndrome and exterior excess syndrome. The distinguishing points can certainly be discerned from the pulse, such as a floating and weak pulse for exterior deficiency syndrome and a floating and tight pulse for exterior excess syndrome, but the presence or absence of sweating is the main distinguishing point. This saying has guiding significance for clinically distinguishing the deficiency and excess of exterior cold syndrome.

• “Intermittent chills and fever indicate malaria; if there is no regularity, it indicates various diseases.” — Qing Dynasty, He Mengyao “Medical Notes: Cold and Heat”

Note: The intermittent chills and fever of malaria often occur at fixed times, with alternating chills and high fever; other diseases, such as Shaoyang disease, have no fixed timing for the alternating chills and fever, with chills and fever occurring at irregular intervals.

• “Internal injury causing fever occurs intermittently; external invasion causing fever is continuous and severe. For internal injury, the palms are hot; for external invasion, the backs of the hands are hot.” — Qing Dynasty, Cheng Benxuan “Medical Treatise: Examining Symptoms”

Note: This statement describes the different characteristics of internal injury fever and external invasion fever, which can serve as a reference for clinical diagnosis of internal injury and external invasion fever.

• “Afternoon tidal fever occurs; it belongs to Yangming. Afternoon tidal fever is a sign of excess that can be purged.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Tidal Fever, Part Five”

Note: These two sayings indicate that “afternoon tidal fever” is a heat pattern characteristic of excess in the Yangming bowel. It also points out that “afternoon tidal fever” is a sign that can be purged. The term “afternoon” refers to the time between 3 PM and 7 PM. Yu Jiayan states: “Afternoon refers to the time of Shen and You, which is the peak time of Yangming.” During this time, if there is excess heat in the stomach and intestines, the two yangs combine, thus causing “afternoon tidal fever.” Since “afternoon tidal fever” arises from tangible excess heat in the stomach and intestines, it can be purged; once the evil heat is expelled, the tidal fever will resolve. This saying is clinically relevant and can serve as a reference.

• “Tidal fever has a periodic nature; general fever does not have a fixed time.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Tidal Fever, Part Five”

Note: This statement explains the differences between tidal fever and general fever. Tidal fever, like the tide, has a certain time pattern; whereas general fever does not have a fixed time pattern. Tidal fever can occur in the afternoon, after meals, or in damp-warm conditions, and is seen in Yangming bowel excess, fire excess, and damp-warm diseases.

• “The deeper the cold, the deeper the heat; the milder the cold, the milder the heat.” — “Treatise on Cold Damage: Differentiating Jueyin Disease Pulse and Symptoms”

Note: This statement discusses the severity of heat in relation to cold. Heat cold, or true heat-false cold syndrome, is caused by deep-seated heat evil, with the yang qi stagnating internally and unable to reach the extremities. Due to the varying degrees of heat stagnation, the severity of the extremities’ coldness also varies; the more severe the coldness, the deeper the heat stagnation, and vice versa. This statement has certain reference value for diagnosing the severity of heat cold conditions.

• “Only cold evil harms people; it does not cause sweating.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Spontaneous Sweating, Part Six”

Note: The “Complete Book of Jingyue” states: “Sweat is produced by yin and released by yang… and its opening and closing depend on the defensive qi within the yang.” This indicates that the secretion of sweat is related to the defensive qi; if the pores are closed, there is no sweating, and if the pores are open, there is sweating. However, among the six evils, heat, summer heat, dampness, and wind can all cause the pores to open and induce sweating, while cold primarily has a constricting nature, and when cold evil attacks the exterior, the pores become blocked, and the body fluids are retained, hence there is no sweating.

• “Sweating has yin and yang; yang sweating is hot sweating; yin sweating is cold sweating.” — Ming Dynasty, Zhang Jiebin “Complete Book of Jingyue: Twelve Volumes on Sweating”

Note: Hot sweating refers to sweating that occurs with symptoms of heat, flushed face, thirst, etc., indicating a pattern of excess heat; if sweating occurs with cold limbs and pale complexion, it indicates a pattern of deficiency. For example, sweating due to loss of yang is classified as cold sweating, thus differentiating sweating based on temperature attributes. Heat belongs to yang, and cold belongs to yin; hence hot sweating is yang sweating, and cold sweating is yin sweating.

• “If yang is deficient and sweating occurs, one must tonify the qi; if yin is deficient and sweating occurs, one must nourish the essence; if heat is excessive and sweating occurs, one must cool it to resolve.” — Ming Dynasty, Zhang Jiebin “Complete Book of Jingyue: Transmission of Loyalty”

Note: This statement discusses several treatment methods for sweating. If sweating occurs due to insufficient yang qi, one should tonify the qi and stabilize the exterior; if sweating occurs due to yin deficiency and internal heat, one should nourish the yin essence, and when yin is sufficient, the heat will subside, thus stopping the sweating. If the evil heat is excessive and causes sweating, one should clear heat and drain fire; once the heat is cleared and the fire is calmed, the sweating will stop.

These three methods for treating sweating are all fundamental approaches. They serve as guidelines for clinical treatment of sweating.

• “Sweating on one side causes one side to wither.” — “Plain Questions: Treatise on Vital Energy”

Note: “Sweating on one side” refers to sweating that occurs on one side of the body. “Withering” refers to hemiplegia. The cause of unilateral sweating is often due to phlegm, dampness, or blood stasis obstructing the meridians, leading to poor circulation of qi and blood, or disharmony of the nutritive and defensive qi. This condition is often a precursor to stroke, or a sequela of stroke.

• “Sweating of the hands and feet indicates heat accumulation in the stomach.” — Jin Dynasty, Cheng Wujis “Theory of Cold Damage: Sweating of Hands and Feet, Part Nine”

Note: This statement uses sweating of the hands and feet to infer the location of the disease. The extremities are the foundation of all yang, deriving qi from the stomach. Sweating of the hands and feet indicates dryness and heat in the Yangming stomach, forcing the body fluids to leak out and reach the extremities. Stomach heat is the most common pathogenesis for sweating of the hands and feet, but cold conditions in the Yangming during cold damage can also lead to sweating of the hands and feet; the former is heat, and the latter is cold, one is excess and the other is deficiency. The former is often accompanied by hard stools and small, smooth bowel movements; the latter is often accompanied by initially hard stools followed by loose stools and difficulty urinating. Careful differentiation is necessary, and one should not generalize based on heat alone.

• “There are two types of sweating on the head: one is due to evil heat obstructing, and the other is due to internal yang qi depletion.” — Ming Dynasty, Zhang Jiebin “Complete Book of Jingyue: Treatise on Cold Damage”

Note: “Head sweating” refers to sweating that occurs only on the head, with no sweating on other parts of the body. Head sweating can be classified into deficiency and excess; if sweating occurs due to internal dryness or damp-heat stagnation, and there is no sweating elsewhere, the evil heat cannot be released, thus causing sweating on the head, which is often seen in damp-heat jaundice. If sweating occurs due to yang qi deficiency, it is classified as loss of yang sweating, indicating a critical condition.

• “If sweating occurs and the pulse is still rapid, it indicates death.” — “Plain Questions: Treatise on Heat Disease”

Note: In heat diseases, if there is significant sweating, the pulse should be calm, indicating that the evil heat has been expelled with the sweat, which can overcome the evil. If sweating occurs and the pulse remains rapid, it indicates that the righteous qi cannot overcome the evil, and the evil qi has penetrated inward, indicating a poor prognosis. This statement is significant for assessing the transition of heat disease and sweating.

• “Food stagnation leads to aversion to food.” — Yuan Dynasty, Zhu Zhenheng “Danxi’s Heart Method”

Note: Aversion to food refers to poor appetite and dislike of food, which is one of the main symptoms of dietary irregularities harming the stomach and intestines, leading to food stagnation in the stomach.

• “(Diet) preference for cold indicates middle heat; preference for heat indicates middle cold.” — Ming Dynasty, Li Ting “Introduction to Medicine: Inquiry on Symptoms”

Note: This statement uses the patient’s preferences for cold or hot food to determine the cold or heat attributes of the disease. Li’s statement is practical, especially for patients with stomach diseases, often using this inquiry as a primary basis for differentiating between cold and heat syndromes.

• “If there is heat in the stomach, one desires cold drinks; if there is cold in the intestines, one desires hot drinks.” — Ming Dynasty, Zhang Jiebin “Classified Treatise: On Treatment”

Note: The patient’s preferences for cold or hot food often serve as an important basis for determining the nature of the disease and are key points for differentiating between cold and heat syndromes. For example, a preference for hot drinks and aversion to cold drinks indicates a cold syndrome; a preference for cold drinks and aversion to hot drinks indicates a heat syndrome. This is the essence of Jingyue’s statement.

• “The two excretions are the portals of the body; regardless of internal injury or external invasion, one must observe these to discern their cold, heat, deficiency, and excess.” — Ming Dynasty, Zhang Jiebin “Complete Book of Jingyue: Transmission of Loyalty”

Note: This statement emphasizes the importance of inquiring about the two excretions. Observing the two excretions can help discern the deficiency and excess, cold and heat of the disease. The classics state: “Observe the external response to measure the internal condition,” which reflects this principle. Through changes in the two excretions, one can observe the prosperity or decline of the five organs and six bowels, as well as the severity of evil qi. Urine is governed by the bladder, which is interrelated with the kidneys; therefore, inquiry about the frequency and quality of urination, changes in urine color, and sensations during urination can reveal the strength of the qi transformation function, the abundance or deficiency of body fluids, and the metabolic status of the lungs, spleen, and Sanjiao. For example, deficiency cold syndromes often present with clear and frequent urination, while deficiency heat syndromes may present with short and red urination. Although bowel movements are produced by the intestines, observing their characteristics, color, odor, quantity, and sensations during defecation can directly reflect the function of the spleen and stomach. For instance, food stagnation in the stomach can lead to constipation, while spleen and stomach deficiency cold can lead to loose stools. This is also a basis for diagnosing the cold and heat, deficiency and excess of other organs. Thus, inquiring about the two excretions is an important part of collecting medical history and diagnosing diseases, which should be remembered.

• “Incontinence of urine indicates kidney failure.” — Qing Dynasty, He Mengyao “Medical Notes: Four Examinations on Urination”

Note: The kidneys open to the two yin, and the excretion of urine is governed by kidney qi. If kidney qi declines and loses its ability to contain, then incontinence occurs. This condition is one of the signs of collapse. If accompanied by confusion of consciousness, it often indicates a poor prognosis.

• “In heat diarrhea, the stool color is yellow, the anus is burning and painful, and the stool is expelled like boiling soup.”“Food stagnation diarrhea… must have a foul odor like rotten eggs.” — Yuan Dynasty, Zhu Zhenheng “Danxi’s Heart Method: Diarrhea”

Note: Danxi points out the key points for diagnosing heat diarrhea and food stagnation diarrhea, which are practical. Heat diarrhea is caused by evil heat descending into the large intestine, hence the burning and pain in the anus during defecation; food stagnation diarrhea is due to food accumulation in the stomach and intestines, leading to foul odor and sour belching.

• “Cold in the stomach causes rumbling and diarrhea.” “Heat in the stomach causes yellow stools like porridge.” — “Spiritual Pivot: Master Transmission”

Note: Diarrhea refers to the expulsion of undigested food, while “porridge” refers to foul-smelling stools. The above two statements indicate the different symptoms caused by cold dampness and heat accumulation in the stomach and intestines, although the symptom descriptions are not comprehensive, they highlight key characteristics, providing a basis for clinical diagnosis of the two types of diarrhea.

• “White dysentery belongs to qi; red dysentery belongs to blood.” — Qing Dynasty, Wang Hong “Observational Diagnosis: Principles of Stool Observation”

Note: Dysentery is often caused by damp-heat, cold-damp, or epidemic toxins obstructing the intestines and corrupting qi and blood. If the cold-damp evil stagnates in the qi aspect or injures the spleen yang, it leads to white dysentery, hence the saying: “White dysentery belongs to qi,” often seen in cold-damp dysentery or deficiency cold dysentery. If damp-heat is abundant in the blood aspect, injuring the blood vessels, it leads to red dysentery, hence the saying: “Red dysentery belongs to blood,” often seen in epidemic dysentery or damp-heat dysentery leaning towards heat. If there is both red and white dysentery, it indicates injury to both qi and blood, with damp-heat being predominant, often seen in damp-heat dysentery. This saying is a commonly used rule for diagnosing the nature of dysentery, but in clinical application, one should not rigidly adhere to the “red and white” distinction; rather, one should consider all four examinations comprehensively for a complete understanding.

• “Dysentery is not outside of damp-heat; the cause is primarily in the Yangming channel.” — Qing Dynasty, Chen Xiuyuan “Medical Consensus: Volume Five”

Note: This statement discusses the etiology and affected areas of dysentery. Chen believes that Yangming is the residence of abundant qi and blood; dampness is a yin evil, and if dampness overcomes heat, it injures the qi aspect of Yangming, leading to white dysentery, while if heat overcomes dampness, it injures the blood aspect of Yangming, leading to red dysentery. If both dampness and heat are abundant, both red and white dysentery can be present.

• “Blood in the stool indicates proximity… blood after stool indicates distance.” — Ming Dynasty, Zhang Jiebin “Complete Book of Jingyue: Blood Syndromes”

Note: The above three statements indicate methods for diagnosing the location of blood in the stool and prognosis from different angles. Zhang points out that blood before stool indicates proximity, with the disease located in the anus or rectum; blood after stool indicates distance, with the disease located in the stomach. Wang uses the color of the blood in the stool to infer the location of the disease, with bright red indicating that the blood has been retained for a short time and is close to the anus; black indicates that the blood has been retained for a long time and is located in the stomach. Both Zhang and Wang’s statements capture the key points for diagnosing blood in the stool, and both methods should be combined for clinical application.

• “(Urine) clarity and turbidity indicate exterior and interior conditions; redness and whiteness indicate cold and heat; frequency and infrequency indicate excess and deficiency.” — Qing Dynasty, Wang Hong “Observational Diagnosis: Principles of Urine Observation”

Note: Wang’s statement uses the clarity, color, and frequency of urine to infer the exterior and interior conditions, the nature of the disease, and the strength of the evil and righteous qi, serving as one of the clinical bases for distinguishing between exterior and interior, cold and heat, deficiency and excess. If cold evil is in the exterior, it has not entered the bladder, thus the urine is clear. If damp-heat descends, the bladder’s qi transformation is impaired, leading to turbid urine. Red indicates heat, while white indicates cold; if there is excess heat internally, the body fluids are consumed, leading to short and red urine; if kidney qi is insufficient, the lower source is deficient, leading to clear and frequent urination.

• “Red and white urine indicate cold and heat; yin deficiency leads to red and shallow, while damp-heat leads to white and turbid.” — Qing Dynasty, Wu Qian “Golden Mirror of Medicine: Four Examinations Key Points”

Note: The color of urine can objectively reflect the nature of the disease, thus the color of urine becomes an important basis for diagnosing disease attributes. This statement is practical for clinical use.

• “Not knowing and urinating is incontinence; knowing but unable to hold it is incontinence.” — Qing Dynasty, He Mengyao “Medical Notes: Enuresis: Incontinence”

Note: He points out the differences between enuresis and incontinence. Enuresis occurs during sleep, with the individual unaware, hence “not knowing and urinating is incontinence.” Incontinence occurs during the day, hence “knowing but unable to hold it is incontinence.” In fact, both can be classified as enuresis, just different types. The cause of enuresis is primarily due to bladder dysfunction, but it is marked in the bladder and originates in the Sanjiao, as stated in the “Classified Evidence Treatment”: “The bladder primarily stores urine. The function of urination is governed by the qi transformation of the Sanjiao.” The Sanjiao’s qi transformation involves the upper jiao in the lungs, the middle jiao in the spleen, and the lower jiao in the kidneys; thus, enuresis should be attributed to the lungs, spleen, and kidneys.

I Copyright Statement This article is excerpted from Selected Proverbs on Clinical Diagnosis from Various Dynasties. Compiled by Yu Bohai. Edited by Zhang Yajuan, Proofread by Xiao Xiaofei, A Cheng. Copyright belongs to the relevant rights holders. If there are any improper uses, please feel free to contact us for negotiation. I Submission Email [email protected]

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