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There are eight fundamental aspects of illness: cold, heat, deficiency, excess, exterior, interior, yin, and yang. The methods of differentiation in TCM revolve around these principles.
The differentiation of cold and heat in a disease is primarily based on symptoms such as thirst or lack thereof, the ability to retain fluids, preferences for hot or cold foods, irritability, and changes in urination and bowel movements. For instance, if a patient is thirsty, can retain fluids, prefers cold foods, is irritable, has short and red urination, and has a rapid pulse, this indicates heat. Conversely, if a patient is not thirsty, or has a false sense of thirst, prefers hot soups, has cold extremities, clear and long urination, loose stools, and a slow pulse, this indicates cold.
The differentiation of deficiency and excess is based on the presence or absence of sweating, abdominal distension and pain, changes in distension, pain response to pressure, the duration of the illness, and the strength of the pulse. If a patient has no sweating, persistent abdominal distension, pain that resists pressure, a recent onset of illness, a robust constitution, and a strong pulse, this indicates excess. If a patient has profuse sweating, fluctuating abdominal distension, pain that eases with pressure, a long-standing illness, a weak constitution, and a weak pulse, this indicates deficiency.
The differentiation of exterior and interior is based on symptoms such as fever and chills, headache and abdominal pain, nasal congestion and dry mouth, the presence or absence of tongue coating, and the floating or sinking pulse. If a patient has fever with chills, headache, nasal congestion, a tongue without coating, and a floating pulse, this indicates an exterior condition. If a patient has tidal fever with aversion to heat, abdominal pain, dry mouth, yellow or black tongue coating, and a sinking pulse, this indicates an interior condition.
Regarding the differentiation of yin and yang, in summary, heat is yang, excess is yang, and exterior is yang; cold is yin, deficiency is yin, and interior is yin. Cold pathogens affect the exterior, representing yin within yang; heat pathogens invade the interior, representing yang within yin. Cold pathogens can enter the interior, representing yin within yin; heat pathogens can reach the exterior, representing yang within yang. The distinction between true yin and true yang is also different. For example, if the pulse is rapid and weak, with signs of deficiency heat, dry mouth, and constipation, this indicates true yin deficiency; if the pulse is large and weak, with fatigue, pale lips, cold muscles, and undigested food, this indicates true yang deficiency.
The distinctions of cold, heat, deficiency, excess, exterior, interior, yin, and yang are fundamentally these. However, a patient with heat symptoms who prefers hot drinks is seeking harmony; a patient with cold symptoms who prefers cold drinks but cannot drink is exhibiting false thirst. A patient with heat symptoms and loose stools is experiencing heat-induced diarrhea; a patient with cold symptoms and hard stools is experiencing yin constipation. A patient with heat symptoms and cold extremities is experiencing deep heat with deep cold; a patient with cold symptoms who is irritable and wants to sit in muddy water is experiencing yin irritability. A patient with sweating and excess symptoms is experiencing heat pathogens penetrating the interior; a patient with no sweating and deficiency symptoms is experiencing insufficient fluids. A patient with aversion to cold and interior symptoms is directly affected by cold; a patient with aversion to heat and thirst and exterior symptoms is experiencing a warm disease that has reached the exterior. This is the principle of yin and yang transformation, which is crucial for treating diseases, and differentiation should not be delayed.
The Eight Principles of differentiation is the overarching framework for various differentiation methods in TCM.
Differentiation refers to the analysis and identification of disease symptoms, which is the primary process and method for understanding and diagnosing diseases. Differentiation involves recognizing and analyzing symptoms. Symptoms refer to the comprehensive manifestation of the body’s disordered relationship with pathogenic factors and conditions, as well as the internal organs, meridians, qi, blood, and body fluids. Therefore, clarifying a specific symptom is a summary of the pathological conditions during the disease’s development, including the causes, locations, strengths of the pathogenic and righteous forces, and the balance of yin and yang.
The process of differentiation is based on theories of the internal organs, meridians, qi, blood, body fluids, and pathogenic factors, and involves synthesizing, summarizing, analyzing, reasoning, judging, and clarifying the internal relationships and interactions among various pathological changes based on the symptoms and signs collected through the four diagnostic methods: observation, listening, inquiry, and pulse-taking. This allows for an understanding of the disease and accurate diagnosis.
Differentiation and treatment are two crucial interrelated aspects of TCM theory, methods, formulas, and medicines in clinical practice. Differentiation is the foundation for understanding diseases, while treatment is the corresponding therapeutic approach based on the differentiated symptoms. Differentiation is the premise and basis for treatment, while treatment is the objective and objective standard for verifying the correctness of differentiation.
Symptoms refer to individual signs, which are recognized similarly in both TCM and Western medicine, such as headache, fever, cough, palpitations, and nausea.
Disease refers to the name of the illness. In TCM, only a few disease names correspond with Western medicine, such as measles, diphtheria, tetanus, asthma, dysentery, and heat stroke, while most terms differ. Due to the differences in theoretical systems, the understanding of diseases varies. Western medicine’s understanding of diseases is based on human anatomy and pathophysiology, with clinical diagnosis relying on the patient’s subjective symptoms, physical examination, and laboratory tests. TCM believes that diseases result from imbalances in yin and yang, and clinical differentiation primarily relies on the patient’s symptoms and signs (such as tongue and pulse), without necessarily determining the disease name but clarifying the symptoms.
Symptoms, or syndromes, are a shorthand for evidence and manifestations. They are not merely symptoms or subjective feelings but a group of syndromes that represent TCM’s diagnosis of diseases. Symptoms are a set of specific clinical manifestations (symptoms, signs, etc.) that encompass the causes, locations, nature of the disease, and the comparative strength of the righteous and pathogenic forces. Symptoms are derived from analyzing symptoms and signs, summarizing them into concepts that better explain the essence of the disease.
TCM differentiation has developed through long-term clinical practice, employing various methods, primarily including the Eight Principles, differentiation based on pathogenic factors, differentiation based on qi, blood, essence, and body fluids, differentiation based on internal organs, differentiation based on defensive qi, nutritive qi, and blood, differentiation based on the three burners, and differentiation based on the six meridians. Among these, the Eight Principles is the overarching framework for various differentiation methods.
The Eight Principles of differentiation categorize symptoms into eight types: yin, yang, exterior, interior, cold, heat, deficiency, and excess, based on a comprehensive analysis of the materials obtained through the four diagnostic methods. This categorization helps to explore the nature of the disease, the depth of the pathological changes, the severity of the condition, the strength of the body’s response, and the comparative strength of the righteous and pathogenic forces. The Eight Principles is a fundamental method of differentiation in TCM, encompassing the commonalities of various differentiation methods and playing a crucial role in simplifying complex diagnoses.
Although the manifestations of diseases are extremely complex, they can generally be categorized into the Eight Principles. The overall categories of diseases include yin and yang; the depth of the disease can be classified as exterior or interior; the imbalance of yin and yang, with yang excess or yin deficiency indicating heat symptoms, and yang deficiency or yin excess indicating cold symptoms; the strength of the pathogenic and righteous forces, with strong pathogenic qi indicating excess symptoms and weak righteous qi indicating deficiency symptoms. Therefore, the Eight Principles of differentiation analyzes the myriad changes in diseases according to the simple dichotomy of exterior and interior, cold and heat, deficiency and excess, yin and yang, revealing the contradictions in the pathological changes, thus identifying whether the disease is exterior or interior, cold or heat, deficiency or excess, and whether it belongs to yin or yang. This is the fundamental spirit of the Eight Principles.
1. Exterior and Interior
Exterior and interior refer to the depth and severity of the disease. Generally speaking, the skin, muscles, and superficial meridians belong to the exterior; the internal organs, blood vessels, bone marrow, and internal meridians belong to the interior. Exterior symptoms indicate a superficial disease with mild severity; interior symptoms indicate a deep disease with severe severity.
(1) Exterior Symptoms
Exterior symptoms are those that occur superficially in the skin. Generally, they arise when external pathogens invade the body through the skin and nose, leading to a series of symptoms as the righteous qi (defensive qi) resists the pathogens, often seen in the early stages of external diseases. Exterior symptoms are characterized by sudden onset, short duration, superficial location, and mild severity. They are commonly seen in the early stages of external heat diseases, such as upper respiratory infections, acute infectious diseases, and other initial stages of infectious diseases.
Main symptoms: fever with chills (or aversion to wind), headache, thin white tongue coating, and floating pulse, often accompanied by soreness in the limbs and joints, nasal congestion, and cough.
Due to the differentiation of external pathogens into cold and heat, the ability of the righteous qi to resist external pathogens varies, leading to further classifications of exterior symptoms into exterior cold, exterior heat, exterior deficiency, and exterior excess.
1. Exterior Cold Symptoms
Main symptoms: significant aversion to cold, mild fever, pronounced pain in the head and body, no sweating, clear nasal discharge, and no thirst. The tongue is pale red, with thin white and moist coating, and the pulse is floating and tight.
Pathogenesis: Cold pathogens are constrained in the superficial layers, leading to a struggle between the righteous and pathogenic forces, resulting in aversion to cold and fever. The pathogenic qi invades the superficial meridians, causing stagnation in the flow of defensive qi and blood, leading to soreness in the head, body, and limbs. The pulse is floating due to the struggle between the righteous and pathogenic forces.
Treatment principle: Release the exterior with warming herbs.
Common formulas: Ma Huang Tang (Ephedra Decoction).
2. Exterior Heat Symptoms
Main symptoms: significant fever, mild aversion to cold, headache, sore throat, sweating, thick nasal discharge, and thirst. The tongue is slightly red, with thin white coating that is not moist, and the pulse is floating and rapid.
Pathogenesis: The struggle between the righteous and pathogenic forces leads to fever and aversion to cold. Heat pathogens invade the defensive layer, causing sweating to escape. Heat damages body fluids, leading to thirst. Heat pathogens are present in the exterior, hence the floating and rapid pulse.
Treatment principle: Release the exterior with cooling herbs.
Common formulas: Yin Qiao San (Honeysuckle and Forsythia Powder).
3. Exterior Deficiency Symptoms
Main symptoms: exterior symptoms with aversion to wind, aversion to cold, and sweating. The tongue is pale, with thin white coating, and the pulse is floating and weak.
Pathogenesis: The patient has a weak constitution, and the defensive yang is not firm, leading to aversion to wind and sweating, with a floating and weak pulse.
Treatment principle: Harmonize the nutritive and defensive qi, and release the muscle layer.
Common formulas: Gui Zhi Tang (Cinnamon Twig Decoction).
4. Exterior Excess Symptoms
Main symptoms: fever, aversion to cold, body aches, and no sweating. The tongue is pale red, with thin white coating, and the pulse is floating and strong.
Pathogenesis: The pathogenic qi is strong, and the righteous qi is not weakened; the pathogens are constrained in the superficial layers, leading to a struggle between the righteous and pathogenic forces, with the sweat pores tightly closed, resulting in fever and aversion to cold without sweating, and a floating and strong pulse.
Treatment principle: Release the exterior with warming herbs.
Common formulas: Ma Huang Tang (Ephedra Decoction).
Distinguishing between exterior cold and exterior heat is based on the severity of aversion to cold and fever, as well as tongue and pulse characteristics. Exterior cold symptoms are characterized by significant aversion to cold and mild fever, while exterior heat symptoms are characterized by significant fever and mild aversion to cold. In exterior cold symptoms, the tongue coating is thin white and moist, and the pulse is floating and tight; in exterior heat symptoms, the tongue coating is thin white and not moist, and the pulse is floating and rapid. Additionally, wind-cold pathogens can transform into heat, and exterior cold symptoms can evolve into exterior heat symptoms as external pathogens invade the superficial layers.
Distinguishing between exterior deficiency and exterior excess is based on the patient’s constitution, with sweating and lack of fluids as indicators. Exterior excess symptoms are characterized by exterior symptoms without sweating, commonly seen in younger and stronger individuals; exterior deficiency symptoms are characterized by exterior symptoms with sweating, commonly seen in older or chronically ill individuals.
(2) Interior Symptoms
Interior symptoms are those that occur deeper within the body (in the internal organs, qi, blood, bone marrow, etc.).
The causes of interior symptoms can generally be classified into three categories: first, the progression of exterior symptoms, where the exterior pathogens do not resolve and penetrate into the interior, affecting the internal organs; second, direct invasion of external pathogens into the internal organs, such as abdominal cold or excessive consumption of cold foods leading to interior cold symptoms; third, internal injuries from emotional disturbances, overexertion, or dietary factors that directly impair the functions of the internal organs, such as dizziness and pain in the liver, palpitations and shortness of breath in the heart, cough and wheezing in the lungs, abdominal distension and diarrhea in the spleen, and low back pain and urinary retention in the kidneys. Therefore, the clinical manifestations of interior symptoms are complex, and all symptoms that are not exterior symptoms belong to interior symptoms. In external diseases, interior symptoms require differentiation based on pathogenic factors, defensive qi, nutritive qi, and blood, while in internal injuries, differentiation based on internal organs is primary. Interior symptoms need to be differentiated into interior cold, interior heat, interior deficiency, and interior excess (discussed in the context of cold-heat and deficiency-excess differentiation).
Distinguishing between exterior and interior symptoms is primarily based on the patient’s history, the nature of the symptoms, and changes in tongue coating and pulse. Generally, new or short-term illnesses are more likely to be exterior symptoms, while long-standing or chronic illnesses are more likely to be interior symptoms. Fever with aversion to cold indicates exterior symptoms; fever without aversion to cold or only cold without fever indicates interior symptoms. Exterior symptoms often show no changes in tongue coating or only slight redness at the edges and tip of the tongue; interior symptoms often exhibit abnormal tongue coating, with a floating pulse indicating exterior symptoms and a sinking pulse indicating interior symptoms.
(3) Half Exterior Half Interior Symptoms
Half exterior half interior symptoms refer to conditions where the pathogenic factors are neither fully in the exterior nor have completely entered the interior, resulting in symptoms that are neither typical of exterior nor interior symptoms.
Main symptoms: alternating chills and fever, chest and hypochondriac fullness, bitter taste and dry throat, irritability, nausea, loss of appetite, and dizziness. The tongue tip is red, with a combination of yellow and white coating, and the pulse is wiry.
Pathogenesis: The struggle between the righteous and pathogenic forces occurs in the half exterior half interior state, leading to alternating chills and fever. The pathogens affect the half exterior half interior, causing the gallbladder meridian to be affected, resulting in fullness in the chest and hypochondriac region, while heat in the gallbladder and disharmony between the liver and stomach lead to irritability, dizziness, nausea, and loss of appetite.
Treatment principle: Harmonize and resolve the exterior and interior.
Common formulas: Xiao Chai Hu Tang (Minor Bupleurum Decoction).
(4) Simultaneous Exterior and Interior Disease (Mixed Exterior and Interior)
Simultaneous exterior and interior disease refers to the occurrence of both exterior and interior symptoms at the same time. There are three common scenarios: first, the initial onset of the disease presents both exterior and interior symptoms; second, at the onset of the disease, only exterior symptoms are present, but later, as the pathogenic factors penetrate into the interior, interior symptoms appear while exterior symptoms remain unresolved; third, the original disease has not yet resolved, and new exterior symptoms arise, such as pre-existing internal injuries combined with external pathogens, or pre-existing external conditions that have affected digestion, which also belong to simultaneous exterior and interior disease. The treatment principle is to resolve both the exterior and interior.
2. Cold and Heat
Cold and heat are the two principles used to differentiate the nature of diseases, summarizing the two types of symptoms that reflect the balance of yin and yang in the body. Generally, cold symptoms indicate insufficient yang qi or the presence of cold pathogens, while heat symptoms indicate excessive yang qi or the presence of heat pathogens. In other words, excess yang leads to heat, excess yin leads to cold, yang deficiency leads to cold, and yin deficiency leads to heat. Differentiating between cold and heat is the basis for using warming or cooling herbs in treatment, as cold is treated with heat and heat is treated with cold.
(1) Cold Symptoms
Cold symptoms arise from the invasion of cold pathogens (such as cold or damp pathogens) or from yang deficiency and excess yin, leading to weakened yang qi and reduced functional activity. Cold symptoms can be divided into exterior cold symptoms and interior cold symptoms; exterior cold symptoms have been discussed in the context of exterior symptoms, while here we refer to interior cold symptoms.
Main symptoms: aversion to cold, cold extremities, no thirst or preference for hot drinks, pale complexion, cough with white phlegm, abdominal pain relieved by warmth, loose stools, and clear and long urination. The tongue is pale, with white coating, and the pulse is deep and slow.
Pathogenesis: Yang deficiency and excess yin lead to cold symptoms, resulting in aversion to cold and cold extremities, while cold in the spleen and stomach leads to abdominal pain relieved by warmth, and weak yang qi results in a deep and slow pulse.
Treatment principle: Warm the middle and dispel cold.
Common formulas: Fu Zi Li Zhong Tang (Aconite Decoction to Regulate the Middle).
(2) Heat Symptoms
Heat symptoms arise from the invasion of heat pathogens (such as wind, heat, or fire pathogens) or from excess yang and yin deficiency, leading to excessive yang qi and depletion of yin fluids, resulting in hyperactivity of bodily functions. Heat symptoms can be divided into exterior heat symptoms and interior heat symptoms; exterior heat symptoms have been discussed in the context of exterior symptoms, while here we refer to interior heat symptoms.
Main symptoms: fever without aversion to cold, irritability, thirst with a preference for cold drinks, red complexion, yellow and thick phlegm, abdominal pain relieved by coolness, dry and hard stools, and short and red urination. The tongue is red, with yellow coating, and the pulse is rapid.
Pathogenesis: Excessive yang leads to fever and a preference for coolness, while heat damages body fluids, leading to thirst, short and red urination, and dry and hard stools. The rapid pulse indicates excessive heat.
Treatment principle: Clear heat.
Common formulas: Bai Hu Tang (White Tiger Decoction).
(3) Excess Heat and Deficiency Heat
Excess heat symptoms caused by the invasion of heat pathogens differ from deficiency heat symptoms caused by the depletion of yin fluids or hyperactivity of bodily functions, as shown in the table below.
Table 3-3: Differentiation between Excess Heat and Deficiency Heat
Classification
Common Symptoms
Different Symptoms
Treatment Principle
Common Formulas
Qi Deficiency
Pale or sallow complexion, fatigue, low voice, spontaneous sweating, reduced appetite, pale and swollen tongue, weak pulse
Shortness of breath, fatigue with exertion, etc., with a weak pulse
Tonify qi
Si Jun Zi Tang (Four Gentlemen Decoction)
Yang Deficiency
Aversion to cold, cold extremities, clear and long urination, diarrhea with clear stools, slow pulse
Tonify yang
Shen Qi Wan (Kidney Qi Pill), Ren Shen Rong Wan (Ginseng and Deer Antler Pill)
Blood Deficiency
Weight loss, dizziness, blurred vision, insomnia, palpitations, thin pulse
Pale complexion, numbness in hands and feet, pale lips and nails, pale tongue, weak pulse
Nourish blood
Si Wu Tang (Four Substance Decoction)
Yin Deficiency
Low fever or tidal fever, red cheeks, five-center heat, dry mouth, dry throat, night sweats, red tongue, thin and rapid pulse
Nourish yin
Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill)
From the above table, it can be seen that qi deficiency and yang deficiency both indicate insufficient yang qi, hence the clinical manifestations are similar, with symptoms such as pale complexion, fatigue, and spontaneous sweating. However, there are distinctions: qi deficiency is characterized by deficiency without cold symptoms, while yang deficiency is characterized by deficiency with cold symptoms—aversion to cold, cold extremities, and slow pulse. Blood deficiency and yin deficiency both indicate insufficient yin fluids, hence the clinical manifestations are similar, with symptoms such as weight loss, dizziness, palpitations, and insomnia. However, there are distinctions: blood deficiency is characterized by deficiency without heat symptoms, while yin deficiency is characterized by deficiency with heat symptoms—low fever or tidal fever, dry mouth, and dry throat.
(2) Excess Symptoms
Excess symptoms arise either from a robust constitution where external pathogens invade, or from internal dysfunctions of the internal organs leading to pathological products such as qi stagnation, blood stasis, phlegm accumulation, or food stagnation.
Clinical manifestations vary based on the nature of the pathogenic factors and the internal organs affected, characterized by strong pathogenic qi and weak righteous qi, with a fierce struggle between the two. Common symptoms include high fever, red complexion, irritability, delirium, loud voice, abdominal distension and pain that resists pressure, excessive phlegm, constipation, difficulty urinating, or the presence of blood stasis, edema, food stagnation, or parasitic accumulation, with thick and greasy tongue coating and a strong pulse.
Treatment principle: Drain excess and attack pathogens is the main method for treating excess symptoms, as excess should be drained. However, different methods such as draining fire, promoting bowel movements, expelling water, dispelling phlegm, regulating qi, invigorating blood, and eliminating stagnation will be discussed in relevant chapters.
Distinguishing between deficiency and excess can be considered from several aspects: new or acute illnesses are often excess, while chronic or long-standing illnesses are often deficiency; external pathogens are often excess, while internal injuries are often deficiency; robust individuals are often excess, while weak individuals are often deficiency; and clinical symptoms and signs can be referenced in the table below for differentiation.
Table 3-5: Differentiation between Deficiency and Excess
Symptoms
Four Diagnostic Methods
Yin Symptoms
Yang Symptoms
Observation
Pale or dark complexion, heavy body, curled up posture, fatigue, weak spirit, pale and swollen tongue, white and slippery tongue coating
Flushed or bright complexion, restlessness, dry and cracked lips, red tongue, thick tongue coating, possibly cracked or black with prickles
Listening
Low voice, quiet and few words, weak breathing, shortness of breath
Loud voice, restless and talkative, possibly delirious, coarse breathing, wheezing
Inquiry
Reduced appetite, preference for warmth, no thirst, bland taste, loose stools, clear and long urination or reduced urination
Dry mouth and bitter taste, preference for coolness, irritability, dry stools, short and red urination
Pulse
Pain relieved by pressure, cold body, deep pulse, thin, rough, slow, weak, or powerless pulse
Pain that resists pressure, warm body, floating pulse, surging, slippery, rapid, strong pulse.
(3) Loss of Yin and Loss of Yang
Loss of yin and loss of yang are two dangerous syndromes that occur during the disease process, often seen in cases of high fever, profuse sweating, severe vomiting and diarrhea, or excessive blood loss, leading to rapid loss of yin fluids or yang qi, commonly seen in patients in shock. Although loss of yin and loss of yang fall under the category of deficiency symptoms, due to the special nature of the condition and the severity of the disease, they are distinguished from general deficiency symptoms.
The clinical manifestations of loss of yin and loss of yang, in addition to various critical symptoms of the primary disease, include varying degrees of sweating. However, loss of yin sweating is hot, sticky, and salty, often accompanied by hot skin, warm extremities, thirst with a preference for cold drinks, and a rapid, weak pulse; loss of yang sweating is profuse, cool, and not sticky, often accompanied by aversion to cold, lethargy, cold extremities, and a weak spirit, with a faint pulse that is about to disappear. Since yin and yang are interdependent, depletion of yin fluids leads to the dispersion of yang qi, while depletion of yang qi leads to the inability of yin fluids to generate, thus the clinical manifestations of loss of yin and loss of yang are difficult to separate, and they can rapidly transform into one another, only differing in their primary and secondary characteristics.
The treatment for loss of yin and loss of yang focuses on supporting the righteous qi and stabilizing the condition. For loss of yin, the approach is to tonify qi, gather yin, and generate fluids to prevent loss of yang, commonly using formulas such as Sheng Mai San (Generate the Pulse Powder); for loss of yang, the approach is to tonify qi, stabilize the condition, and revive yang, commonly using formulas such as Du Shen Tang (Reinforcing Ginseng Decoction) and Shen Fu Tang (Ginseng and Aconite Decoction).
The differentiation and treatment of loss of yin and loss of yang are summarized in the table below.
Table 3-7: Differentiation between Loss of Yin and Loss of Yang
Sweating
Extremities
Other Symptoms
Tongue
Pulse
Treatment Principle
Loss of Yin
Hot, salty, and sticky sweat
Warm and aversion to heat
Flushed complexion, whole body heat, irritability, confusion, shortness of breath, thirst with a preference for cold drinks
Red and dry tongue
Rapid and weak pulse or large pulse
Tonify qi, gather yin
Generate fluids
Loss of Yang
Cool, bland, and non-sticky sweat
Cold and aversion to cold
Pale complexion, cold body, lethargy, confusion, weak pulse, no thirst or preference for hot drinks
Pale, moist, and smooth tongue
Weak or faint pulse
Tonify qi, stabilize the condition
Revive yang
5. The Interrelationship of the Eight Principles and the Application of Differentiation
The distinctions between exterior and interior, cold and heat, deficiency and excess, and yin and yang are not merely isolated and static but are complex, interrelated, and capable of transformation. In summary, there exists a relationship of compatibility, mixing, and transformation among the Eight Principles.
(1) Compatibility
Compatibility refers to the simultaneous appearance of symptoms from two or more principles. For example, in the early stages of an external heat disease, there may be exterior symptoms, but further differentiation is needed to determine whether there is concurrent cold or heat, leading to classifications of exterior cold and exterior heat. In chronic diseases, deficiency symptoms may also require further differentiation to determine whether they are deficiency cold or deficiency heat. The appearance of compatible symptoms should not be treated equally; rather, there is a primary and secondary relationship. For instance, exterior cold and exterior heat symptoms are primarily exterior symptoms, with cold or heat being secondary; treatment should focus on releasing the exterior, using warming or cooling herbs accordingly. Similarly, deficiency cold and deficiency heat symptoms are primarily deficiency symptoms, with cold or heat being secondary; treatment should focus on tonifying deficiency, using warming or cooling methods as appropriate. When exterior and interior symptoms are compatible, the primary principle must be determined based on the specific condition.
(2) Mixing
Mixing refers to the simultaneous appearance of opposing symptoms, such as cold-heat mixing, deficiency-excess mixing, and exterior-interior mixing (commonly referred to as simultaneous exterior and interior disease). Additionally, during the progression of a disease, some false appearances may arise, such as true heat and false cold, or true cold and false heat. Therefore, during the differentiation process, careful observation and comprehensive analysis are necessary to discern the essence and avoid misdiagnosis and mistreatment, which could delay the condition.
(3) Transformation
Transformation refers to the ability of symptoms from one principle to transform into those of its opposing principle. The relationships between exterior and interior, cold and heat, deficiency and excess, and yin and yang are both opposing and capable of transformation under certain conditions. For example, exterior cold symptoms such as aversion to cold and fever may transform into interior heat symptoms if the condition progresses or treatment is inadequate. Excess symptoms may transform into deficiency symptoms due to mismanagement or inadequate treatment, leading to prolonged illness, where the pathogenic qi diminishes but the righteous qi is also harmed, gradually transforming into deficiency symptoms. Deficiency symptoms may lead to the accumulation of phlegm, dampness, qi stagnation, or blood stasis, resulting in various excess symptoms. Transformation occurs under specific conditions, and during differentiation, it is essential to continuously assess changes in the pathogenic mechanisms, diagnose and treat promptly to prevent the disease from worsening and promote recovery.
When applying the Eight Principles of differentiation, the first step is to differentiate between exterior and interior to determine the location of the disease; then differentiate between cold and heat, deficiency and excess, to understand the nature of the disease and the comparative strength of the righteous and pathogenic forces; finally, the overall situation can be summarized using yin and yang.
Summary
The Eight Principles of differentiation is a method for diagnosing diseases by summarizing and analyzing them from the perspectives of exterior and interior, cold and heat, deficiency and excess, and yin and yang. Although it should be combined with differentiation based on pathogenic factors, defensive qi, nutritive qi, and blood for a more comprehensive diagnosis, it serves as the foundation for various differentiation methods, simplifying complex diagnoses.
The Eight Principles are not static but can transform under certain conditions; exterior symptoms can progress to interior symptoms as the disease worsens, while interior symptoms can resolve as the condition improves. Heat symptoms can transform into cold symptoms, and excess symptoms can transform into deficiency symptoms, often due to the righteous qi gradually recovering. Conversely, cold symptoms can transform into heat symptoms, and deficiency symptoms can transform into excess symptoms, often due to the righteous qi being unable to overcome the pathogenic qi.
Although the Eight Principles have distinct manifestations, they are rarely isolated; rather, they exist in complex relationships of compatibility and mixing, and may sometimes present false appearances. Therefore, during the differentiation process, it is crucial to conduct thorough investigations, connect the dots, and grasp the essence of the disease, enabling accurate analysis, correct diagnosis, and appropriate treatment.
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“TCM Differentiation Formula”; with this table, you will know at a glance.
Observing the tongue and fingers, differentiating for health, holding onto wellness, and eliminating all diseases.
A TCM practitioner who cannot differentiate and treat is certainly not a good TCM practitioner.
Six Meridian differentiation: the simplest method for pulse and symptom differentiation.
TCM treatment for shingles: differentiation thoughts and methods.
Discussing differentiation and treatment based on “Gu Yuan Gao” and “mis-supplementing leading to disease”.
Essentials of internal organ differentiation: summarizing key points of internal organ diseases.
Professor Zhang Shicheng: differentiation and treatment is the soul of TCM, while the preparation of medicinal slices is fundamental to Chinese medicine!
Impressive! Check out the differentiation thoughts summarized by others.
A set of easily understandable and graspable internal organ differentiation methods for beginners.
A method for quickly identifying diseases: 81 methods for quick differentiation.
Shang Han’s three yang: 64 questions on heat diseases (differentiation thoughts for three yang heat symptoms).
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