What is the inquiry of cold and heat? It refers to asking the patient whether they have a fear of cold or a feeling of heat, emphasizing the patient’s sensations. The inquiry mainly focuses on the patient’s subjective symptoms and feelings. Therefore, the key point we emphasize is whether the patient themselves feels cold or hot, rather than using body temperature as the sole standard, not measuring temperature with a thermometer as the only criterion. In the context of cold and heat, there are two aspects: cold and heat. ◎ColdCold refers to the subjective feeling of being cold, where the patient feels a chill. This is a self-perceived sensation and falls under the category of inquiry. However, we can use palpation and pressure diagnosis to feel the temperature of the patient’s forehead, limbs, and chest and abdomen, and even use a thermometer to measure it. This belongs to our clinical data, but it is not the inquiry itself; the inquiry focuses on the patient’s own feelings. Cold refers to the patient’s own sensation of feeling cold. Cold can be divided into three types. One type is aversion to wind, which means feeling cold when encountering wind, and avoiding it can alleviate the sensation. When exposed to wind, one feels cold, or when a fan is turned on, one feels cold. Some people feel that they cannot be in hot weather and still have a fan blowing on them; why? Because when the fan blows, they feel cold, indicating an aversion to wind, which can be alleviated by avoiding it. The second type is called aversion to cold. Aversion to cold refers to the subjective feeling of being cold, where adding clothing or blankets or warming up by the fire does not alleviate the sensation. You might say, “If you feel cold, just wear more clothes or cover yourself with a blanket or warm up by the fire,” but at this time, they still feel cold. Even with clothes on or a blanket, they still feel cold; we call this aversion to cold. The third type is fear of cold, which also refers to the subjective feeling of being cold, but this aversion to cold can be alleviated by adding clothing or warming up. They feel a bit cold, but wearing more clothes makes them feel warm, or covering with a blanket makes them feel warm. This is how we categorize aversion to cold into three types. Among these three, the latter two types, aversion to cold and fear of cold, are our arbitrary classifications. What is the distinction? Aversion to cold usually refers to a new onset; fear of cold refers to a chronic condition. The purpose is to differentiate syndromes, which is beneficial for diagnosis. When you write symptoms, for example, if they often have aversion to cold and it alleviates with clothing or blankets, you would write a long description. However, when we describe the condition, we can simply mention fear of cold, indicating that this is a long-term sensation of cold that can be alleviated with clothing or blankets. If it suddenly appears, for instance, if they felt fine yesterday but woke up feeling very cold today, then it is a new onset. If they still feel cold after putting on a piece of clothing, this situation should be described as aversion to cold. ◎HeatWhat does heat refer to? It refers to the subjective feeling of heat in the whole body or in a specific area. This belongs to the patient’s self-perception, feeling hot all over or in a specific area, such as the palms and soles, or a specific area where there is a sore or boil, feeling a burning sensation in that area, or a burning sensation in the throat or nose. This is often accompanied by a temperature measurement, or when palpated, there is a feeling of heat, which also belongs to the category of heat. Why do patients experience feelings of cold and fever? Aversion to cold and fever, fear of cold or fever, arise from two aspects: one aspect is the nature of the pathogenic factor, which can reflect the nature of the pathogenic factor, indicating what type of pathogenic qi is causing the disease. The second aspect reflects the balance of yin and yang in the body. The internal balance of yin and yang can be reflected through the symptoms of cold and heat, thus mainly reflecting the nature of the pathogenic factor and the balance of yin and yang in the body. Because the cold is a yin pathogen, cold pathogens often manifest as a fear of cold and aversion to cold; heat is a yang pathogen, which easily leads to fever. Therefore, diseases with fever are generally heat syndromes, while diseases with fear of cold are generally cold syndromes. From the perspective of the internal balance of yin and yang, when the balance of yin and yang changes, feelings of cold or heat can arise. The mechanism is mentioned in the Neijing, stating, “When yang is excessive, there is heat; when yin is excessive, there is cold; when yin is deficient, there is heat; when yang is deficient, there is cold.” This is not caused by pathogenic qi; if it is pathogenic qi, cold pathogens generally lead to cold syndromes, while heat pathogens lead to heat syndromes. When yang is too vigorous, the yang qi in the body is too strong, not due to pathogenic qi, but due to this excess; when yin qi is too abundant, it can lead to feelings of cold; when yang qi is insufficient or deficient, it can lead to fever and aversion to cold; when yin qi or yin fluids are insufficient, it can lead to fever. This is the mechanism, reasoning from both pathogenic qi and the balance of yin and yang. So how do we inquire about cold and heat? In the inquiry, we mainly need to ask about their subjective feelings, emphasizing that their subjective feelings are primary. Do you feel cold or feverish? Some patients may have a high temperature, but they still feel cold and do not feel feverish; others may not have a high temperature, but they feel feverish. Therefore, the main focus should be on subjective feelings, while also conducting objective examinations. When inquiring, pay attention to whether there is a fear of cold or fever, whether they exist simultaneously or separately. If there is only a fear of cold, then it is certainly separate; or if there is only fever without feeling cold, that is also separate. Some patients may experience both fear of cold and fever simultaneously. You should ask about the duration, how long has it been? Is it a new onset or has it been ongoing? What is the degree of the sensation? Is the fear of cold severe? Do you feel a little cold, or just a bit when the wind blows? If you are indoors without wind, do you still feel cold? That would be classified as aversion to wind, wouldn’t it? You need to clarify this situation. What is the duration and are there any specific time characteristics? Some may have fever at specific times, such as at night, or even at specific hours. There are also specific areas; in ancient times, there was a saying, “the back feels cold like the palm of a hand,” indicating that when cold drinks are retained internally, there is a cold sensation in a specific area of the back. Which joints feel cold? Are the palms or soles feeling hot? This relates to the characteristics of the cold and heat in specific areas. What is the relationship between subjective and objective sensations? For example, if the temperature is now 38°C or 39°C, do you feel cold or feverish? What is the relationship between subjective and objective sensations? What is the relationship between the head, torso, and extremities? Is the head hot, the hands and feet cold, or is the chest and abdomen hot? You need to check the relationship between these three parts. What are the conditions for the increase and alleviation? Are there any conditions? Under what circumstances do you have a fever? Some people say that when they feel anxious, they have a fever; when they feel anxious, it feels like a fire rises, and they feel hot, indicating a psychological factor. What are the alleviating conditions? Finally, ask if there are any accompanying symptoms. First, what symptoms are closely related to aversion to cold and fever? Therefore, this inquiry can yield a lot of content regarding cold and heat, and you can ask about ten questions! Thus, we need to tell students not to just ask if the patient has a fever; otherwise, they will not be able to ask further questions. They need to pay attention to the inquiry method. Types of Cold and Heat The types of cold and heat can be divided into four categories. ◎Aversion to Cold and Fever What is aversion to cold and fever? It refers to the patient experiencing both aversion to cold and fever simultaneously, where the patient feels both cold and feverish at the same time. These two symptoms, one of aversion to cold and one of fever, exist simultaneously in the same person, and they feel both symptoms. This symptom is characteristic of exterior syndromes. When we talk about aversion to cold and fever, both feelings of cold and fever exist simultaneously, which is a characteristic manifestation of exterior syndromes. Logically, one would think that aversion to cold and fever are two extremes; in terms of yin and yang, one belongs to yang and the other to yin, and they should not exist simultaneously. However, in reality, they do exist. So what clinical situations can we summarize for this aversion to cold and fever? In summary, there are several situations: One is that the patient feels both cold and feverish. When you ask them, “Do you feel cold?” they say yes, and when you ask if they feel feverish, they also say yes. They feel a bit cold and a bit feverish. The second situation is that sometimes they feel cold and sometimes they feel hot. They feel cold for a while, then feel hot, and then feel cold again. The third situation is that when they remove clothing, they feel cold, and when they add clothing, they feel hot. They feel cold, but when they put on a piece of clothing, they feel hot and want to take it off; when they take it off, they feel cold again. Some people describe this situation as aversion to cold and fever. The fourth situation is when they feel cold subjectively, but objectively they have a fever. They say they feel cold, but when you measure their temperature, it is elevated. Strictly speaking, this fourth situation does not belong to what we call aversion to cold and fever. The fourth situation should not be classified as aversion to cold and fever, as we define aversion to cold and fever as the patient feeling both cold and feverish simultaneously, rather than just feeling cold while having a measured fever. Why does aversion to cold and fever occur simultaneously? The mechanism is due to the invasion of external pathogens at the body surface. This type of six excesses of pathogens invades our body surface, and the righteous qi and evil qi are in conflict. This conflict occurs at the body surface, indicating that the righteous qi is not able to disperse, which is a manifestation of the conflict between righteous and evil qi. The conflict between righteous and evil qi indicates that a battle has begun, and when a battle occurs, there will certainly be fever. However, if the righteous qi is not able to disperse, it cannot perform its function of opening and closing the pores, leading to a reflection of the body’s resistance to evil. This reflection of resistance, whether it is aversion to cold or fever, is a manifestation of the body’s righteous qi resisting evil. Both aversion to cold and fever are responses to the body’s resistance to evil, indicating a dynamic response. Why do we feel cold? It is to gather energy, closing the pores to prevent the yang qi from dispersing, thus increasing energy. Why do we feel hot? It is the righteous qi resisting evil. Therefore, whether it is aversion to cold, fever, pain, or sneezing, we need to understand that these symptoms are all responses to the body’s resistance to evil, reflecting the conflict between righteous and evil qi. Thus, the Suwen states, “When the pores are open, there is sweating and cold; when they are closed, there is heat and oppression.” Why do we feel both cold and hot? It is due to the opening and closing of the pores. When they are open, external pathogens invade, leading to a feeling of cold; when they are closed, heat accumulates, and there is no dispersion, leading to a feeling of heat. This is the mechanism of aversion to cold and fever. Classification of Aversion to Cold and Fever The third classification is that aversion to cold and fever itself needs to be further classified. The first major category of cold and heat is aversion to cold and fever existing simultaneously. When this occurs, we need to further differentiate the severity of aversion to cold and fever, determining which is more severe: the aversion to cold or the fever. This differentiation helps to identify the nature of the external pathogen and the nature of the evil qi. The first type is when aversion to cold is severe and fever is mild. When you ask the patient, they say they feel very cold, but the fever is not very pronounced. They feel very cold, indicating a wind-cold exterior syndrome. The mechanism is clear: because cold is condensing and stagnating, when the cold pathogen invades the muscle surface, the skin and pores are in a closed state, and the righteous yang is trapped inside, leading to a deficiency of yang qi at the body surface, thus causing the sensation of cold. The second situation is when fever is mild and aversion to wind is present. There is a slight fever, indicating that we are dealing with aversion to wind. What is aversion to wind? We have discussed it before: it means feeling cold when encountering wind, and avoiding it can alleviate the sensation. When there is no wind, they do not feel cold. This indicates that both aversion to cold and fever are mild, suggesting a wind-cold exterior syndrome. The wind is a light pathogen, and the symptoms of aversion to cold and fever are not very pronounced, indicating a mild wind pathogen. The third situation is when fever is severe and aversion to cold is mild. The fever is more pronounced, and when you ask the patient, they say they feel hot, but they still have a slight sensation of cold. This indicates a wind-heat exterior syndrome. All three situations involve wind pathogens, but this one leans more towards heat. The wind-heat pathogen is a yang pathogen, and when yang is excessive, it leads to heat symptoms. The wind-heat pathogen opens the pores, so there is still a slight aversion to cold. For aversion to cold and fever, we need to analyze and understand several issues: First, aversion to cold and fever is a characteristic symptom of exterior syndromes. It involves both the righteous and evil aspects, and the relationship between the two is crucial. It is important to determine the nature of the pathogenic qi and the severity of the symptoms. For example, aversion to wind indicates a lighter pathogenic influence, while severe aversion to cold and mild fever indicates a wind-heat pathogen. The relationship between the severity of the pathogenic influence and the state of the righteous qi is also important. Due to these factors, we generally see that when the pathogenic influence is mild, aversion to cold and fever are also mild. For example, in cases of aversion to wind, the pathogenic influence is mild. When the pathogenic influence is severe, such as in cases of heat stroke or exposure to high temperatures, the symptoms of aversion to cold or fever become more pronounced. When both the righteous and evil qi are strong, the symptoms of aversion to cold and fever are generally more obvious. When the evil qi is strong and the righteous qi is weak, the symptoms often present as severe aversion to cold and mild fever. Thus, we see that the presence of aversion to cold and fever is not merely a matter of experiencing pathogenic qi; it is also closely related to the state of the righteous qi. For instance, we often observe that individuals with weak constitutions may experience mild fever even when exposed to external pathogens. Western medicine often notes that patients with severe bacterial infections may not exhibit high fevers or elevated white blood cell counts due to their weakened immune systems. Conversely, children often develop high fevers quickly when they are sick due to their strong yang constitution. Second, the simultaneous presence of cold and heat is an important basis for diagnosing exterior syndromes. To diagnose an exterior syndrome, the presence of aversion to cold is essential. If a patient reports no aversion to cold, then there is no exterior syndrome. The diagnosis of an exterior syndrome must include either aversion to cold or the simultaneous presence of aversion to cold and fever. The Shanghan Lun states, “In exterior syndromes, there may be fever or no fever, but there must be aversion to cold.” Aversion to cold is a necessary condition, while fever may or may not be present. Therefore, later interpretations suggest that “for every degree of aversion to cold, there is a degree of exterior syndrome.” If a patient has even a slight aversion to cold, it indicates the presence of an exterior syndrome. If there are no symptoms of aversion to cold, it suggests that there is no exterior syndrome. These two statements are important to remember: in the Yijian, it states, “When there is an external pathogen, cold and heat occur simultaneously without intervals; when there is internal injury, cold and heat occur alternately and not simultaneously.” What does this mean? It is a crucial basis for distinguishing between external and internal injuries. If it is an external pathogen, “cold and heat occur simultaneously without intervals,” meaning that both aversion to cold and fever exist simultaneously. This is not an alternating pattern; it is not that one feels cold and then hot, or vice versa. It is simultaneous, indicating the presence of an external pathogen. Therefore, the presence of aversion to cold and fever is a significant indicator of exterior syndromes, while internal injuries may present with alternating cold and heat symptoms. What is aversion to wind? Aversion to wind refers to feeling cold when encountering wind, and avoiding it can alleviate the sensation. What is aversion to cold and fear of cold? Aversion to cold refers to a sudden onset of cold sensation, while fear of cold refers to a long-term, chronic sensation of cold that can be alleviated by adding clothing or warmth. What is strong heat and tidal heat? Strong heat refers to high fever that persists without subsiding, while tidal heat refers to fever that occurs at specific times or intensifies at certain times. Strong heat is classified as a heat syndrome, indicating strong yang qi and robust resistance, while tidal heat is related to the depth of the pathogenic influence and the timing of the fever. Why does aversion to cold occur with warmth? The occurrence of aversion to cold and warmth can be understood through the conflict between righteous and evil qi, as well as the state of the pores. The conflict between righteous and evil qi leads to the sensation of cold, while the state of the pores determines whether the body can disperse heat or not. What are the causes of mild fever? Mild fever can arise from various causes, including qi deficiency, blood deficiency, yin deficiency, and qi stagnation. It is essential to consider the overall symptoms to determine the underlying cause of the mild fever. What is the concept of alternating cold and heat? Alternating cold and heat refers to the symptoms of cold and heat occurring in an alternating manner, with clear boundaries. There are two types: those with fixed timing and those without fixed timing, often seen in half-exterior and half-interior syndromes, or in cases of malaria.
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