Syndrome differentiation of the organs is the most widely used method in today’s clinical practice of Traditional Chinese Medicine (TCM) and is the focus of this presentation. Through syndrome differentiation, we can determine whether the patient’s current condition is one of deficiency or excess, what type of deficiency or excess it is, and the location of the pathological changes, whether in the organs (zang) or the bowels (fu), and which specific organ or bowel is involved.
(1) Differentiation of Disease Nature
The nature of diseases can generally be divided into two categories: deficiency (xu) and excess (shi). Deficiency refers to insufficient vital energy (zhengqi), while excess refers to an abundance of pathogenic factors (xieqi). The insufficiency of vital energy primarily manifests in four aspects: qi deficiency, blood deficiency, yin deficiency, and yang deficiency, which are the four basic types of deficiency syndromes. Of course, these deficiency syndromes can also coexist, with common combinations including qi and blood deficiency, yang deficiency, yin and blood deficiency, and both yin and yang deficiency. Pathogenic factors can arise from external sources or develop internally, but they generally fall into several categories: cold, heat, dampness (phlegm), dryness, wind, qi stagnation, and blood stasis. Similarly, these pathogenic factors can also coexist, with common examples being wind-cold, damp-heat, phlegm-stasis, and qi and blood stagnation. There are also some special pathogenic factors, such as food accumulation, parasites, and stones, which do not have universal significance and will not be discussed in detail here.
The primary task of TCM syndrome differentiation is to identify the patient’s current condition, whether it is a deficiency syndrome, an excess syndrome, or a mixture of both. If it is a deficiency syndrome, is it qi deficiency, blood deficiency, or yang deficiency? If it is an excess syndrome, is it phlegm-dampness, cold, heat, or qi stagnation and blood stasis? Below, I will list the most common and representative symptoms of these deficiency and excess syndromes for your reference in practice.
Deficiency Syndromes
Qi deficiency: fatigue, weakness, reluctance to speak, weak and deep pulse; Blood deficiency: insomnia (with vivid dreams), dry eyes, scanty and pale menstrual flow in women; Yin deficiency: tidal fever, night sweats, five hearts heat (palms and soles), red tongue with thin coating, thin pulse; Yang deficiency: aversion to cold, preference for warmth, cold limbs, loose stools, clear and frequent urination, pale tongue with abundant moisture, weak and slow pulse. Below are explanations for some symptoms that may be difficult to understand.
Regarding qi deficiency symptoms: The most important function of qi is to promote the movement of tangible substances in the body, such as blood and body fluids, and to stimulate the organs to perform normal physiological activities; it is the source of energy for the body. When qi is insufficient, it cannot provide adequate energy, leading to a series of phenomena characterized by a preference for rest over activity, as described above.
Regarding insomnia with vivid dreams: When the body is active, blood is distributed throughout to nourish the limbs and organs; during rest, blood returns to the liver, which is said to store blood. As the spirit enters the heart, the soul also returns to the liver to rest. The soul requires a large amount of blood for nourishment to achieve peace and tranquility. When there is a deficiency of blood in the liver, the soul cannot be nourished, leading to restlessness and various dream experiences.
Regarding qi and blood deficiency: This was mentioned in the previous physiological chapter, but let’s recall it briefly. The basic relationship between qi and blood is that “qi is the commander of blood, and blood is the mother of qi.” Qi is formless and cannot exist in isolation; it must rely on tangible blood to avoid being dissipated. When blood is insufficient, qi has no place to attach, leading to simultaneous deficiency. The saying goes, “If the skin does not exist, where will the hair attach?” Therefore, when blood is deficient, it is very easy to see manifestations of qi deficiency as well. Conversely, in cases of qi deficiency, blood deficiency may not necessarily be present.
Regarding the timing of fever: Generally speaking, fever is a manifestation of the struggle between the righteous and the evil. Since a battle is taking place, it is necessary to prepare all military supplies. If the body is yin deficient, with insufficient strategic reserves, it is best not to act rashly. It is better to wait until the afternoon or even after dark when the yin energy of the heavens gradually increases; the body receives support from the heavens, and the yin energy becomes stronger, allowing the battle between the righteous and the evil to truly begin. Therefore, yin deficiency fever usually occurs in the evening. The later the fever occurs, the more severe the yin deficiency. Tidal fever refers to a fever that occurs at regular intervals, like the ebb and flow of tides.
These symptoms are the foundational knowledge for clinical syndrome differentiation. To help everyone quickly grasp this knowledge, I have specially compiled a few mnemonic verses. I hope that friends interested in learning TCM can memorize them, as they will help cultivate your ability to recognize syndromes. Below, I will also use mnemonic verses for the excess syndromes and the five organ syndromes to aid memory. No further elaboration will be provided. Qi deficiency leads to fatigue and reluctance to speak, blood deficiency leads to dry eyes and vivid dreams; yin deficiency shows a small red tongue and night sweats, yang deficiency shows cold limbs and weakness.
▌ Excess Syndromes
Cold syndrome: cold body and limbs, always feeling cold, slow and deep pulse;
Heat syndrome: red face, body heat, irritability, red tongue, yellow coating, rapid pulse;
Phlegm-dampness syndrome: heavy head, limbs feel heavy, sticky stools, greasy tongue coating;
Dryness syndrome: dry mouth and thirst, dry stools;
Wind syndrome: tremors, tilting, wandering;
Qi stagnation: chest tightness, abdominal distension, fullness under the ribs, tendency to sigh;
Blood stasis: dark purple lips, tongue with petechiae or purpura, prominent and dark veins under the tongue. Heat is red and yellow, cold is clear and cold, phlegm-dampness is heavy, tongue and stools are sticky; wind causes tilting and wandering, qi stagnation causes fullness and dark purple stasis. Let me also provide some tips on a few issues:
Regarding the knowledge expansion of differentiating cold and heat: The symptoms discussed above are some typical manifestations in the process of syndrome differentiation. In practice, it is also necessary to expand this knowledge to gradually activate the static knowledge. Taking cold and heat as an example, I will demonstrate some methods to activate knowledge. The descriptions of heat syndrome above seem quite detailed, but in reality, these symptoms are merely representative of typical heat manifestations. Redness is associated with heat; in addition to a red tongue and red face, it can also extend to red acne, red rashes, and red, swollen, painful gums, all of which belong to heat syndrome. Yellow is also associated with heat; in addition to yellow tongue coating, it can also extend to yellow, thick nasal discharge and phlegm, yellow pus, and yellow urine, all of which belong to heat syndrome. Conversely, lighter colors often reflect cold syndrome. For example, a pale white tongue, white coating with abundant moisture, dull-colored lumps, white, clear, thin phlegm, and clear, frequent urination, etc. Using this method as an example, you can carefully observe various common symptoms in daily life based on the understanding of various symptoms and think about whether they are deficiency or excess, cold or heat.
Regarding the relationship between dryness syndrome and yin-blood deficiency: Dryness is mainly due to a lack of yin, blood, and body fluids in the body, leading to insufficient nourishment. It can be caused by external pathogens or arise internally. However, in terms of treatment, the methods for dryness and yin-blood deficiency are largely similar. Therefore, in future presentations, unless in special circumstances, I will not discuss dryness syndrome separately.
Syndrome differentiation is a key step in the clinical diagnosis and treatment of diseases in TCM, and the differentiation of disease nature is of utmost importance in TCM syndrome differentiation. 
Next, we will illustrate how TCM differentiates the nature of diseases with two case studies.
Case 3 Yang, female, 66 years old, reported that she underwent a total hysterectomy six months ago due to heavy vaginal bleeding. Two months after the surgery, she gradually developed generalized fatigue and aversion to cold. Twenty days ago, after catching a cold, she experienced afternoon fever (body temperature 37.4°C) that started with aversion to cold followed by fever. She received intravenous antibiotics (details unknown) with no relief. Since the onset of the illness, she has felt fatigued, dry mouth with little desire to drink, poor appetite, abdominal distension after eating, occasional belching, and difficulty with bowel movements, having a bowel movement only once a day. Her tongue is pale, with a thin white coating, and her pulse is thin and slightly rapid.
▌ Analysis: This patient is older and has suffered from surgery, which has further weakened her already declining vital energy. Observing her overall condition: fatigue, aversion to cold, dry mouth with little desire to drink, poor appetite, etc., all indicate a picture of qi deficiency. Her fever is a result of qi deficiency being unable to resist the pathogenic factors, only manifesting in the afternoon when the yang energy is stronger, aided by the heavenly yang energy, which is also a sign of qi deficiency. The treatment should primarily focus on tonifying qi. Antibiotics, which are generally used to clear heat, are more effective for excess heat syndromes. They are often ineffective for patients like this.
Case 4 Zhao, male, 46 years old. He has experienced intermittent fullness and pain in the right hypochondrium for six months, with poor appetite and a bitter taste in the mouth, and slightly dry stools. In the past week, the pain has intensified, accompanied by vomiting and a strong desire for cold drinks. His tongue tip is red, with a yellow greasy coating, and his pulse is wiry and rapid.
▌ Analysis:
This patient shares symptoms of poor appetite and constipation with Case 3. However, the main issues in this case are concentrated in the fullness and pain in the hypochondrium, bitter taste, and strong desire for cold drinks. Combined with the tongue and pulse signs, this indicates an excess syndrome, with no deficiency present. Among the excess syndromes, it includes qi stagnation, heat, and dampness. A comprehensive analysis suggests that this is a case of damp-heat obstructing the flow of qi. The treatment should focus on clearing damp-heat and regulating qi to relieve pain.
In the process of differentiating disease nature, it is also important to pay special attention to the patient’s constitution.
Next, I will present three cases of urticaria patients, hoping to provide some insights.
Case 5 Female, 34 years old, farmer. She has experienced recurrent urticaria for three years, with poor results from Western medicine allergy treatments, seeking treatment in TCM. Symptoms include wind rash that appears in patches, with a wandering location and itching; her diet is primarily meat-based, with slightly dry stools, red tongue with yellow coating, and a rapid and strong pulse.
Case 6 Female, 45 years old, farmer. She has experienced recurrent urticaria for six months, with no effect from Western medicine allergy treatments. Currently, the rash is scattered all over her body, appearing intermittently, with unbearable itching, and oozing after scratching; she is very averse to cold, needing to wear autumn clothes even in the hot summer, and does not feel hot even when sweating; her tongue is pale, and her pulse is weak and without strength.
Case 7 Male, 57 years old, driver. He has had urticaria for three months. The rashes are large and located above the neck, with increased itching at night, bleeding after scratching; he has difficulty falling asleep, is irritable, and has a strong desire for smoking and drinking; his tongue is red, and his pulse is slippery, rapid, and strong.
▌ Analysis: Urticaria is located in the skin, belonging to the exterior, and the treatment should primarily focus on dispersing and resolving the exterior. However, for patients with different constitutions, specific treatment methods must be adopted. Among the three patients mentioned, Case 5 has the most typical presentation of urticaria. The patient has a relatively strong constitution, and direct use of exterior-releasing methods combined with interior-regulating methods can achieve good results. Case 6 is different; the patient has a very cold constitution with severely deficient yang energy. In this case, simply using exterior-releasing methods will not be effective; it is necessary to primarily use a large amount of warming yang herbs to support yang energy, allowing the effects of exterior-releasing herbs to be fully realized. Case 7 has a hot constitution, with heat in the blood. From the location of the rash, timing of the onset, and bleeding after scratching, it is evident that the treatment needs to increase the proportion of herbs that clear heat from the blood. Specific knowledge regarding medication will be detailed in the next lecture, so please continue to pay attention.
(2) Differentiation of Disease Location
In TCM, the human body is viewed as a whole, with the core being the five organs. Therefore, most diseases in the human body ultimately relate to the five organs through various pathways. For example, issues in the six bowels, such as the stomach and intestines, are often attributed to the spleen; problems like urticaria and rhinitis are often related to the lungs; and weakness in the lower back and knees is associated with kidney deficiency, etc.
Next, let’s look at how TCM attributes disease locations to the five organs and the criteria for this attribution.
Lung: cough, wheezing, phlegm; Heart: palpitations (heart flutter), insomnia, heart pain;
Spleen: poor appetite, abdominal distension, abdominal pain, diarrhea, constipation;
Liver: distension under the ribs (hypochondrium), wiry pulse;
Kidney: weakness in the lower back and knees, abnormal urination, sexual dysfunction.
Lung diseases manifest as cough, phlegm, and wheezing; heart diseases manifest as palpitations, pain, and insomnia; spleen diseases manifest as digestive issues and reduced appetite, abdominal distension, and pain; liver diseases manifest as wiry pulse and distension under the ribs; kidney issues manifest as weakness in the lower back and knees and difficulty with urination.
By combining the nature of the disease with its location, we can form a deeper understanding of the patient’s condition. Next, I will provide two case studies to demonstrate the thought process and procedure of TCM organ differentiation.
Case 8 Li, female, 42 years old, worker. She has a history of abdominal pain and diarrhea for over three years. Symptoms occur with fatigue and poor diet. One month ago, due to fatigue and cold exposure, her old condition recurred, with bowel sounds and diarrhea, passing watery stools mixed with mucus, with a sensation of heaviness, weakness in the limbs, shortness of breath, reluctance to speak, frequent bowel movements in the morning and forenoon, but none in the afternoon, with routine stool tests showing no abnormalities. Diagnosed with “allergic enteritis,” she has not improved with either TCM or Western medicine. She was hospitalized for three months without significant improvement. Her tongue is pale, with tooth marks on the edges, thin white coating, and a weak, slow pulse.
▌ Differentiation of Disease Nature:——Deficiency (qi deficiency). Basis: weakness in the limbs, shortness of breath, reluctance to speak, frequent bowel movements in the morning and forenoon, but none in the afternoon, pale tongue with tooth marks, thin white coating, weak and slow pulse. Differentiation of Disease Location:
——In the spleen. Basis: abdominal pain, diarrhea.
▌ Comprehensive Analysis:
The main symptom presented by the patient is diarrhea. Based on the above analysis, the disease location is in the spleen, and the disease nature is qi deficiency. The TCM diagnosis is diarrhea due to spleen qi deficiency. Although the patient exhibits some symptoms of dysentery, such as pus and blood in the stool and urgency, the overall symptoms do not support an excess syndrome; this dysentery is also attributed to qi deficiency. The treatment should focus on tonifying qi and strengthening the spleen.
Case 9 Ji, female, has suffered from “chronic bronchitis and emphysema” for over six years. Recently, after catching a cold, she experienced coughing and wheezing, with excessive phlegm and chest tightness, palpitations, and shortness of breath, especially worsened with activity. Her lips are purple, her tongue is moist and slightly swollen, with a white greasy coating, and her pulse is deep and slippery.
▌Differentiation of Disease Nature:——Deficiency (qi deficiency). Basis: worsens with activity. ——Excess (phlegm-dampness). Basis: moist and slightly swollen tongue, white greasy coating, deep and slippery pulse. ——Excess (qi stagnation). Basis: chest tightness. ——Excess (blood stasis). Basis: purple lips. Differentiation of Disease Location:
——In the lung. Basis: cough and phlegm. ——In the heart. Basis: palpitations.
▌ Comprehensive Analysis: The main disease of the patient is cough and wheezing. The disease location is in the lung and heart, with a mixed nature of deficiency and excess, characterized by phlegm-dampness obstruction, qi stagnation, and blood stasis, along with signs of qi deficiency. Specifically, the primary disease location is in the lung, as the lung disease has long affected the heart. The primary nature of the disease is excess phlegm-dampness. Long-term obstruction of phlegm-dampness in the lung leads to qi stagnation and blood stasis, causing damage to the qi of the heart and lung due to prolonged coughing and obstruction of pathogenic factors. The treatment should focus on eliminating dampness, resolving phlegm, and promoting lung qi, supplemented with blood-activating and qi-tonifying methods.
What appears to be a simple case becomes quite complicated when analyzed using the above methods. In fact, what I am guiding you through is the most basic thought exercise, the simplest method, and the most solid approach. All future flexibility and adaptability will need to be based on this foundation. Starting from this solidified model is a shortcut to learning clinical thinking in TCM.
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