Cold and heat are two fundamental principles for distinguishing the nature of diseases, representing specific manifestations of the excess and deficiency of Yin and Yang. Differentiating cold and heat is essentially differentiating the excess and deficiency of Yin and Yang. The identification of cold and heat patterns is one of the bases for treatment and medication.
Cold Syndrome (Han Zheng)
Cold syndrome is characterized by the invasion of cold pathogens or Yang deficiency with an excess of Yin, manifesting as suppressed or diminished physiological activity of the body. It is often caused by external cold pathogens or prolonged internal injury leading to the depletion of Yang Qi, resulting in an excess of Yin cold. The main clinical manifestations include: aversion to cold or preference for warmth, pale tongue with a white coating, cold limbs, curled posture, clear and prolonged urination, loose stools, and a slow pulse.
Pattern analysis: Insufficient Yang Qi or damage from external pathogens fails to exert its warming effect, leading to cold limbs and a pale complexion; excess of Yin cold does not harm body fluids, hence the preference for warmth and lack of thirst; Yang deficiency fails to transform fluids, resulting in clear and cold secretions such as phlegm, saliva, and urine; cold pathogens damage the spleen, or prolonged deficiency of spleen Yang leads to poor transformation and results 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 fails to promote blood circulation, hence the slow pulse; cold constricts and contracts, causing the pulse to feel tight.
Heat Syndrome (Re Zheng)
Heat syndrome is characterized by the invasion of heat pathogens or an excess of Yang with damage to Yin, manifesting as hyperactivity of the body’s physiological functions. This syndrome is often caused by external heat pathogens, a pre-existing excess of Yang, internal transformation of cold pathogens into heat, emotional distress leading to fire, or excessive consumption of spicy foods resulting in internal heat accumulation.
The clinical manifestations include: fever with a preference for coolness, thirst with a preference for cold drinks, red face and eyes, restlessness, yellow and thick phlegm, constipation, short and red urination, red tongue with a yellow and dry coating, and a rapid pulse.
Pattern analysis: Excess Yang heat leads to aversion to heat and preference for coolness; severe heat damages Yin, resulting in short and red urination; depletion of fluids leads to thirst for cold drinks; fire rises, causing a red face and eyes; heat disturbs the mind, leading to restlessness; fluids are scorched by Yang heat, resulting in yellow and thick secretions; heat pathogens injure blood vessels, causing bleeding; intestinal heat and fluid depletion lead to constipation; a red tongue with a yellow coating indicates heat syndrome, while a dry tongue with little fluid indicates Yin injury; excess Yang heat accelerates blood flow, hence the rapid pulse.
Distinguishing Cold and Heat Syndromes
Distinguishing between cold and heat syndromes cannot be based solely on one symptom; a comprehensive observation of all disease manifestations is necessary to reach a correct conclusion. Clinically, differentiation is often based on changes in the patient’s complexion, preferences for cold or heat, warmth or coldness of the limbs, thirst, urination and defecation conditions, tongue appearance, and pulse characteristics (Table 6-1).
Relationship Between Cold and Heat Syndromes
Although cold and heat syndromes have essential differences in the excess and deficiency of Yin and Yang, they are interconnected. They can coexist in a patient, presenting as mixed cold and heat symptoms, and under certain conditions, they can transform into one another. In critical stages of illness, false appearances may also occur.
1. Mixed Cold and Heat Cold and heat syndromes coexist, referred to as mixed cold and heat. Clinically, this includes symptoms such as heat above and cold below, cold above and heat below, exterior cold with interior heat, and exterior heat with interior cold. For example, a patient may simultaneously exhibit symptoms of upper heat with frequent vomiting and abdominal pain with a preference for warmth and loose stools, indicating mixed cold and heat syndrome. When cold and heat are present together, it is crucial to distinguish between exterior and interior, upper and lower, as well as the relative severity of cold and heat, which is vital for treatment.
2. Transformation Between Cold and Heat Clinically, cold syndrome may appear first, followed by heat syndrome, where the cold symptoms disappear upon the emergence of heat symptoms, indicating transformation from cold to heat. Conversely, if heat symptoms appear first and then transform into cold symptoms, this indicates transformation from heat to cold.
Transformation between cold and heat reflects the further development of the condition. For instance, in certain warm diseases, during critical stages, severe heat toxins can deplete the body’s original Yang, leading to a sudden transformation from robust heat and red eyes to a pale complexion, cold limbs, and profuse sweating, indicating a critical Yang deficiency and transformation from heat to cold. Similarly, in wind-cold obstructing the lungs, initial symptoms may include cough, clear and thin phlegm, and a white slippery tongue, but due to improper treatment, prolonged cold pathogens can transform into heat, resulting in symptoms such as fever, yellow and thick phlegm, chest pain, yellow tongue coating, and a rapid pulse, indicating transformation from cold to heat. The mutual transformation of cold and heat syndromes reflects the balance of pathogenic and righteous Qi; transformation from cold to heat indicates that righteous Qi is still strong, while cold pathogens are transforming into heat; transformation from heat to cold often indicates that pathogenic factors are strong and righteous Qi is weak.
3. True and False Cold and Heat In the course of illness, generally, the essence of the disease and its manifestations are consistent, meaning heat syndrome shows heat manifestations, and cold syndrome shows cold manifestations. However, in critical stages of illness, true heat may present with false cold, and true cold may present with false heat, where cold syndrome shows heat manifestations and heat syndrome shows cold manifestations. Due to the inconsistency between clinical symptoms and the essence of the disease, careful differentiation is required.
(1) True Heat with False Cold: Also known as Yang excess with Yin constraint, due to excessive internal heat deeply hidden, Yang Qi is constrained and cannot express outwardly, leading to false cold phenomena in the extremities. For example, cold limbs and a deep pulse may seem like cold syndrome, but the patient may not prefer warmth, and may exhibit thirst for cold drinks, dry mouth, foul breath, delirium, short and red urination, and constipation, indicating that the internal heat is true while the external cold manifestation is false.
(2) True Cold with False Heat: Also known as Yin excess with Yang constraint, due to excessive internal cold, Yang Qi is extremely weak, failing to control Yin, leading to a situation where Yang Qi floats outward, causing Yin and Yang to be out of sync. Clinical manifestations may include body heat, red face, thirst, and a large pulse, resembling heat syndrome, but the patient may prefer warmth, have cold limbs, thirst for warm drinks, drink little, have a large but weak pulse, and exhibit clear and prolonged urination, loose stools, pale tongue, and white coating, indicating that the true condition is internal cold while the external manifestation is false heat.
To differentiate between true and false cold and heat, one must understand the entire course of the disease and pay attention to the following observations:
1. The appearance of false manifestations often occurs in the extremities, skin, and complexion, while the internal manifestations of organs, Qi, blood, and fluids accurately reflect the essence of the disease. Therefore, when diagnosing, one should rely on internal symptoms, tongue appearance, and pulse characteristics.
2. False manifestations are ultimately different from true manifestations; for example, false heat may present as a red face that is pale and only slightly red on the cheeks, while true heat presents as a fully flushed face; false cold often manifests as cold limbs, while the chest and abdomen may feel hot to the touch, or the whole body may feel cold but not want to be covered; true cold is characterized by curling up and desiring warmth.
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