One should ask about cold and heat, then about sweating; third, inquire about the head and body, fourth about bowel movements; fifth, about diet, sixth about the chest; seventh, about deafness, eighth, thirst should also be discerned; ninth, ask about old illnesses, tenth about causes, and also consider medication changes; for women, it is essential to ask about menstrual periods, whether they are delayed, rapid, or have irregular bleeding; additionally, brief words for pediatrics, variola and measles should all be verified.
— Zhang Jingyue’s “Ten Questions Song”
Ancient physicians placed great importance on the patient’s complaints. The most famous is the “Ten Questions” chapter in Zhang Jingyue’s “Complete Works of Jingyue” from the Ming Dynasty:
“One should ask about cold and heat, then about sweating; third, inquire about the head and body, fourth about bowel movements; fifth, about diet, sixth about the chest; seventh, about deafness, eighth, thirst should also be discerned; ninth, ask about old illnesses, tenth about causes, and also consider medication changes; for women, it is essential to ask about menstrual periods, whether they are delayed, rapid, or have irregular bleeding; additionally, brief words for pediatrics, variola and measles should all be verified.”
This is referred to as the “Ten Questions Song”. The first eight questions pertain to inquiry, while the ninth and tenth questions involve pulse diagnosis, observation, and listening.
In modern times, the “Ten Questions Song” has been modified and enriched, with the latter part changed to: “Ninth, ask about old illnesses, tenth about causes, and also consider medication changes; for women, it is essential to ask about menstrual periods, whether they are delayed, rapid, or have irregular bleeding; additionally, brief words for pediatrics, variola and measles should all be verified,” making it quite comprehensive.
However, the first to eighth questions proposed by Jingyue are quite cumbersome and impractical. In fact, it is rare for a doctor to ask a patient from cold and heat to thirst without end. This method is necessary for external heat illnesses, but for general miscellaneous diseases, it is unnecessary and may even provoke the patient’s resentment, leading to being ridiculed as a doctor who only “asks about illness and prescribes medicine”.
What should be asked in diagnosis?
The author believes that inquiries should focus on common, tangible aspects of daily life that everyone can feel. These are the essential activities of “eating, drinking, defecating, urinating, and sleeping”.
Eating refers to food intake; drinking refers to water consumption; defecating refers to bowel movements; urinating refers to urination; sleeping refers to rest. Although the terms may seem crude, they reflect the overall living conditions of ordinary people and patients, and since they are common language, they are easier for the public to understand.
On the surface, this approach is simple and clear, but its connotation is rich and profound. Starting inquiries from these aspects can help discern the majority of syndromes, including their internal and external conditions, cold and heat, deficiency and excess. To avoid digressing, this book will only briefly discuss these topics, with more detailed content to be elaborated in other works.
First question: “Eating”
Can you feel hunger? Can you eat? Is there any discomfort after eating? When one feels empty and urgently wants to eat, it often indicates a deficiency syndrome. If there is a feeling of heaviness in the stomach, it often indicates a sinking of the middle qi; if accompanied by palpitations and shortness of breath, it often indicates a deficiency of heart and spleen blood.
If one feels empty when hungry and wants to eat quickly, but feels bloated after eating, it indicates a deficiency of the spleen with qi stagnation, a mixed syndrome of deficiency and excess.
If one feels empty when hungry, eats little and feels comfortable, but feels bloated or even painful after eating, especially if there is tenderness above the navel, it does not indicate a deficiency syndrome but is caused by blood stasis.
Those with liver qi stagnation often know hunger and can eat, but feel bloated and uncomfortable after eating; those with liver qi depression will not feel hungry and have no desire to eat, as if “food is hard to swallow”.
If food feels stuck in the middle and difficult to pass after eating, it indicates dampness and qi stagnation in the spleen. There are also those who feel hungry but do not want to eat; if they feel restless and have a dry mouth and tongue, it indicates insufficient stomach yin; if they feel sore in the lower back and weak in the legs, it indicates kidney yin deficiency.
If warmth brings comfort, it indicates a cold syndrome; if coolness brings comfort, it indicates a heat syndrome; if one desires to eat cool foods but feels uncomfortable after eating, it indicates a mixed cold-heat syndrome.
Generally, exterior syndromes do not affect eating, but if one feels a sensation of qi rising from the lower part of the sternum, it may be accompanied by nausea and hinder eating, which requires careful differentiation.
If one feels weak all over when hungry, and the condition worsens, it often indicates a deficiency syndrome. If one knows hunger but can endure for several hours and function normally, it often indicates an excess syndrome.
Second question: “Drinking”
Are you thirsty? When are you most thirsty? Is there any discomfort after drinking? Distinguishing between a preference for cold or hot drinks can help differentiate between heat and cold syndromes, which is well known and will not be repeated here.
It should be noted that if one feels dry mouth and wants to drink at night or in the morning, it often indicates yin deficiency.
If drinking does not quench thirst and one urinates immediately after drinking, it often indicates dysfunction of the three burners, with different implications for bladder qi transformation and kidney yang deficiency.
If there is a splashing sound in the stomach after drinking, and severe palpitations occur, it indicates water retention in the middle burner. If one feels dry in the throat and wants to drink, but only sips and stops, and then drinks again shortly after, it often indicates yin deficiency; if one only wants to rinse the mouth without swallowing, it indicates blood stasis.
Third question: “Defecating”
When do you have bowel movements? What is the nature of the stool? Is there any discomfort before, during, or after defecation? General differentiation of diarrhea, dysentery, and constipation is well covered in internal medicine texts and will not be discussed here.
It should be noted that one should not consider infrequent bowel movements over several days as constipation if the stool is normal and there is no discomfort.
To differentiate between cold and heat, if the stool is clear and watery, and the anus is not hot, it indicates cold; if the stool is yellow and sticky, and the anus is burning, it indicates heat.
If one feels comfortable after defecation, regardless of the stool’s nature, it indicates an excess syndrome; if one feels more fatigued and weak after defecation, even experiencing palpitations, it indicates a deficiency syndrome.
Moreover, if liver qi stagnation occurs without spleen deficiency, one may experience loose stools with abdominal pain before defecation, and the pain may lessen but not disappear after defecation, with a feeling of incomplete bowel movements; if the spleen is already deficient, one may also have loose stools with abdominal pain before defecation, but the pain may disappear after defecation, and the stool may feel smooth and complete.
This is because in the former case, the spleen is not deficient and can resist, while in the latter case, the spleen is deficient and lacks the power to resist.
Fourth question: “Urinating”
What is the frequency, volume, and nature of urination? Is there any discomfort before or after urination? Normal urination has a light yellow color, and there is no discomfort before or after urination.
If the urine volume decreases and the color turns dark yellow, in the case of an external illness, it indicates that the disease has moved from the exterior to the interior; in miscellaneous diseases, it indicates that there is already internal deficiency heat. Such patients may also experience a burning sensation in the urethra during urination.
Difficulty urinating or incomplete urination is often seen in those with poor liver qi regulation.
Frequent urination at night with a large volume often indicates kidney deficiency.
If one urinates immediately after drinking and feels thirsty after urination, it often indicates dysfunction of the three burners; this condition often occurs during the day and should not be considered solely as “diabetes insipidus”; once yang is regulated and water is transformed, the condition can resolve itself.
There are also those who frequently urinate due to tension; the previously mentioned Ganmai Dazao Decoction syndrome applies here.
Fifth question: “Sleeping”
Is it easy to fall asleep? Do you wake up easily? Is it easy to fall back asleep after waking? Do you wake up early? Do you have many dreams? Are they chaotic or frightening dreams?
Insomnia patients are very common in outpatient clinics, so inquiring about sleep status is very necessary. After treatment, insomnia often resolves, and other symptoms may improve as well.
In miscellaneous diseases, those who eat and sleep normally tend to have easier treatments, while the opposite is often more difficult.
“Yang enters yin to sleep”; those who have difficulty falling asleep often do so due to obstruction or disturbance from pathogens, whether it be clearing heat, transforming phlegm, digesting food, relieving depression, or dispelling stasis, all can yield results when treated appropriately.
If one wakes easily, sleeps intermittently, and finds it difficult to fall back asleep, it may indicate both excess and deficiency; the excess is as mentioned above, while the deficiency may be due to yin deficiency with excess fire, heart and spleen blood deficiency, or liver blood insufficiency, leading to sleeplessness, with yin deficiency and excess fire being the most common.
Waking early is often seen in cases of heart and spleen blood deficiency or liver blood insufficiency.
Unrestful sleep, waking intermittently, accompanied by dizziness and leg weakness, often indicates liver yang rising, disturbing the liver spirit; if accompanied by sadness and poor appetite, it indicates liver qi stagnation, leading to liver spirit malnourishment.
Frequent nightmares often indicate heart and gallbladder qi deficiency.
In general, if normal sleep can significantly alleviate the condition, it often indicates a deficiency syndrome; if one has normal sleep but the condition does not improve, or feels more fatigued and heavy after waking, it may be due to damp obstruction, qi stagnation, or blood stasis, all indicating an excess syndrome.
How can we obtain essential information about diseases? It is through the patient’s subjective feelings. To understand the patient’s subjective experiences, detailed and purposeful inquiries are necessary, making diagnosis a crucial part of disease diagnosis and treatment.
Because the importance of inquiry in exploring the root causes of diseases is irreplaceable, traditional Chinese medicine practitioners throughout history have placed great emphasis on the use of inquiry. The famous Ming Dynasty physician Zhang Jingyue summarized the inquiry experiences of predecessors and categorized the content of inquiry into the “Ten Questions Song”, which later generations have modified and supplemented based on this “Ten Questions Song”, becoming a reference model for TCM diagnosis.
“The Ten Questions Song of Traditional Chinese Medicine”:
One should ask about cold and heat, then about sweating; third, inquire about the head and body, fourth about bowel movements,
Fifth, about diet, sixth about the chest; seventh, about deafness, eighth, thirst should also be discerned;
Ninth, ask about old illnesses, tenth about causes, and also consider medication changes;
For women, it is essential to ask about menstrual periods, whether they are delayed, rapid, or have irregular bleeding;
Additionally, brief words for pediatrics, variola and measles should all be verified.
This “Ten Questions Song” is concise and covers almost all aspects of inquiry, but in practical application, we still need to conduct purposeful and targeted inquiries based on the characteristics of the disease, and it is not necessary to strictly follow the “Ten Questions Song”. Below, we will select the main parts of the “Ten Questions Song” to explore the mysteries and key points of TCM diagnosis.
First, ask about cold and heat
The sensations of cold and heat in the body during illness can generally manifest in four situations: aversion to cold with fever, only cold without heat, only heat without cold, and alternating cold and heat. Below, we will detail the manifestations and significance of these four types of cold and heat.
Aversion to cold with fever. The body feels cold, even when wearing more clothes, covering with blankets, warming by the fire, or raising the room temperature, the feeling of cold cannot be alleviated; this feeling of aversion to cold is termed “aversion to cold” in TCM. The sensation of aversion to cold often appears together with fever; the higher the fever, the more pronounced the aversion to cold, and even chills may occur, so we often refer to it as aversion to cold with fever. This brings us to the concept of qi. Qi has the functions of protecting the body, opening and closing the pores, and warming the body. When external pathogens invade the body, they must first contend with qi. When the body’s righteous qi is strong, the evil qi cannot affect the body, and one does not become ill. When the body’s righteous qi is deficient or in certain specific situations (such as exposure to cold), the protective function of qi declines, allowing evil qi to invade the body and engage in a “battle” with the internal righteous qi. During this battle, the warming and pore-opening functions of qi are obstructed, leading to the appearance of aversion to cold. The struggle between righteous qi and invading evil qi generates heat, resulting in fever. Modern medicine believes that the mechanism of infectious fever primarily involves two factors: one is that the microorganisms invading the body are phagocytized by white blood cells, releasing endotoxins that alter the body’s temperature regulation center, causing fever; the second is that when white blood cells complete phagocytosis and die, they generate heat, leading to fever. When we return to TCM’s explanation, it remarkably aligns with these two factors. The struggle between righteous and evil qi is a vivid representation of these two factors. The appearance of aversion to cold with fever actually indicates that the body’s righteous qi is still relatively strong, and the evil qi is being fiercely resisted at the surface level by the internal righteous qi, which is why TCM classifies diseases with aversion to cold and fever symptoms as “exterior syndromes”. Based on the severity of aversion to cold and fever, TCM further categorizes them into exterior heat syndrome (light aversion to cold, heavy fever) and exterior cold syndrome (heavy aversion to cold, light fever).
Only cold without heat. The term “only” in classical literature means only or merely; thus, only cold without heat refers to the patient experiencing cold without any sensation of heat. This type of cold is also referred to as “aversion to cold” in TCM. The fundamental difference between aversion to cold and aversion to cold with fever is that the sensation of aversion to cold can be alleviated by adding clothes, blankets, or warming up. There are generally two situations for only cold without heat:
One is “excess cold syndrome”: external cold pathogens invade the body, causing cold pain in the abdomen, joints, and limbs, which can be alleviated or reduced by applying heat. This cold is due to the stagnation of qi and blood caused by cold pathogens, leading to various pains. In this case, the body does not have material deficiency;
The second is “deficiency cold syndrome”: the body’s yang qi is deficient and cannot warm the body, leading to various symptoms of aversion to cold, abdominal pain, cold limbs, and a preference for warmth. Since this cold syndrome is caused by the body’s own yang qi deficiency, it results in a decline in warming function.
Both excess cold syndrome and deficiency cold syndrome can cause cold pain in the body, and both can be alleviated by warmth. How do we differentiate between them? TCM proposes two methods of differentiation. The first is based on the different nature of the pain exhibited by the two cold syndromes. The pain in excess cold syndrome is caused by qi and blood stagnation due to cold, so it is often severe and resistant to pressure; while the cold pain in deficiency cold syndrome is due to the decline of the body’s yang qi warming function, so it is often characterized by a dull ache that prefers to be rubbed or pressed. This distinction is a key point for differentiating all excess pain from deficiency pain. The second is based on the different systemic symptoms exhibited by the two cold syndromes. Excess cold syndrome is caused by cold invading the body locally, so besides the cold pain in the affected area, there are often no systemic symptoms; deficiency cold syndrome is caused by deficiency of the body’s yang qi, which has warming and promoting effects, so in addition to systemic aversion to cold, it often has various manifestations of organ function decline, such as fatigue, lack of energy, poor appetite, loose stools, and nocturnal emissions.
Only heat without cold. Only heat without cold is the opposite of only cold without heat, indicating that the patient experiences fever without any sensation of cold. Depending on the degree of fever and accompanying symptoms, there are mainly three types: high fever, low fever, and tidal fever.
High fever. High fever refers to a temperature above 39°C, often caused by external heat invading the internal organs. In addition to high fever, there are often symptoms such as flushed face, severe headache, thirst for cold drinks, and profuse sweating.
Low fever. Low fever refers to a lower degree of fever (usually between 37°C and 38°C). This type of heat syndrome is often caused by internal material deficiency leading to an imbalance in heat production and dissipation, commonly seen in qi deficiency fever, yin deficiency fever, and fluid damage fever. Qi deficiency fever is due to the consumption of original qi, leading to a disorder in the opening and closing of sweat pores, resulting in a low fever, often accompanied by other manifestations of qi deficiency, such as shortness of breath, spontaneous sweating, fatigue, and poor appetite. Due to fatigue, the consumption of original qi is exacerbated, so qi deficiency fever often worsens after exertion. Yin deficiency fever is due to the consumption of original yin, disrupting the balance between original yin and original yang, leading to relative excess of original yang and resulting in low fever. Yin deficiency fever often presents as a more regular fever occurring in the afternoon or at night, resembling the ebb and flow of tides, which is why TCM also refers to it as “tidal fever”. The phenomenon of tidal fever in yin deficiency is also related to the movement patterns of yang qi in the body. First, let’s look at how the “yang qi” in nature changes. The sun is the source of “yang qi” in nature, and it undergoes daily changes of rising and setting. Therefore, the “yang qi” in nature has a pattern of rising in the morning, being abundant at noon, and retreating at night. All living things grow and reproduce in accordance with the changes in nature’s “yang qi”, and humans are no exception. To adapt to nature, the “yang qi” in the body must also change with the changes in nature’s “yang qi”. In the morning, after waking from sleep, the body’s “yang qi” emerges from the kidneys (the kidneys store original yang) to the limbs and internal organs, providing energy for daily activities, reaching its peak at noon, and gradually retracting in the afternoon, returning to the kidneys at night, allowing the organs to gradually enter a resting state and thus facilitating sleep. From the movement patterns of “yang qi”, we can see that the afternoon and night are when “yang qi” begins to retract and gradually returns to the kidneys. Under normal circumstances, the original yin stored in the kidneys and original yang are mutually restraining and roughly equal, thus maintaining a balanced internal environment in the body. If the original yin is deficient, when the original yang returns to the kidneys, the balance between original yin and original yang is disrupted, leading to fever. This is why yin deficiency fever often presents as tidal fever in the afternoon or at night. Additionally, since this fever is not caused by excessive heat production in the body, it often has a low temperature or only presents as a subjective feeling of heat without an actual increase in body temperature, which is also a major characteristic of yin deficiency fever.
In addition to qi deficiency and yin deficiency, another situation that can cause low fever is fluid damage fever. This situation is commonly seen in the later stages of heat diseases, where evil heat damages the body’s fluids, or excessive sweating, vomiting, or diarrhea leads to significant loss of body fluids. This type of fever caused by fluid damage often accompanies symptoms such as dry mouth, dry skin, and other signs of lack of moisture.
Tidal fever. We have already mentioned the meaning of tidal fever in yin deficiency fever, which refers to the phenomenon of fever or increased temperature occurring at specific times. It is characterized by a regular pattern, similar to the ebb and flow of tides. In addition to the previously mentioned yin deficiency tidal fever, common tidal fevers also include yangming tidal fever and damp-heat tidal fever. Yangming tidal fever is caused by evil heat accumulating in the intestines, as the large intestine is classified as the yangming meridian in meridian theory. This type of tidal fever often occurs between 3-5 PM, when the body’s yang qi is running in the yangming meridian, causing the yang qi and evil heat to coincide, leading to fever or increased temperature. Additionally, since the evil heat is in the large intestine, it often leads to dry stools, abdominal distension, and constipation, thus also being referred to as “yangming bowel excess syndrome”. Damp-heat tidal fever is caused by the combined invasion of damp and heat, leading to fever. This type of tidal fever often appears in the afternoon, characterized by skin that initially feels cool to the touch but becomes increasingly hot after prolonged contact. This phenomenon in TCM is referred to as “body heat not rising”; however, due to the sticky nature of dampness, the heat’s dissipation in the body is delayed, which is why it is often felt in the afternoon.
Damp-heat tidal fever and yin deficiency tidal fever both occur in the afternoon; how do we differentiate between them? Damp-heat tidal fever is caused by the accumulation of damp-heat in the body, which often manifests as a yellow greasy tongue coating; yin deficiency tidal fever is caused by the deficiency of original yin, which often presents as a red tongue with little coating. By observing the differences in tongue coating, we can effectively distinguish between the two.
Alternating cold and heat. Alternating cold and heat refers to the alternating occurrence of aversion to cold and fever, meaning that when there is aversion to cold, there is no fever, and when the aversion to cold subsides, fever occurs. During fever, there is no aversion to cold, which distinguishes alternating cold and heat from aversion to cold with fever. Alternating cold and heat is mainly seen in malaria and TCM’s “Shaoyang disease”. Malaria is a disease caused by malaria parasites, which reproduce in the body, destroying red blood cells and producing symptoms of alternating cold and heat. During an attack, it often starts with chills, and no amount of blankets can alleviate it, followed by fever that can reach a point where one feels like they want to soak in ice water. This type of alternating cold and heat often has a certain pattern, with some occurring once a day and others every two or three days. It is often accompanied by severe headaches, thirst, and profuse sweating. In addition to malaria, “Shaoyang disease” can also lead to symptoms of alternating cold and heat. The concept of “Shaoyang disease” originates from Zhang Zhongjing’s “Treatise on Febrile Diseases” from the Han Dynasty: “The disease of Shaoyang is characterized by bitter mouth, dry throat, and dizziness.” What is the mechanism of Shaoyang disease? First, let’s look at what Shaoyang is. Shaoyang is a description of a part of the human body in TCM. TCM divides the body into yin and yang parts; the back and the dorsal side of the limbs belong to yang, while the abdomen and the inner side of the limbs belong to yin. The yang part is the main area for the body to resist external evil qi, while the yin part is the main area for the internal organs to function. The yang part can be further divided into three levels: the outermost layer is called “Taiyang”, the innermost layer is called “Yangming”, and the middle layer between “Taiyang” and “Yangming” is called “Shaoyang”. Shaoyang disease occurs when evil qi invades the Shaoyang level. As mentioned earlier, when evil qi invades the body, if the body’s righteous qi is strong, it often engages in a battle with the evil qi at the surface (the Taiyang level), leading to symptoms of aversion to cold and fever. If the righteous qi is deficient and cannot effectively resist the evil qi at the Taiyang level, the evil qi will invade the Shaoyang level. Once the evil qi invades, the righteous qi cannot reach the Taiyang level, and the skin cannot receive the warming effect of yang qi, leading to aversion to cold. However, at this point, the body’s righteous qi has not weakened to the point of being unable to resist the evil qi, so the righteous qi will gradually accumulate strength to resist the invasion of evil qi. Once the righteous qi accumulates to a certain extent and can counterbalance the evil qi, a battle will occur, leading to fever. This is why the alternating cold and heat of Shaoyang disease occurs. The occurrence of alternating cold and heat depends on the relative strength of the righteous and evil qi and their mutual combat situation, so it often occurs at irregular times. Shaoyang is also the location of the gallbladder meridian, so when evil qi invades this level, in addition to alternating cold and heat, symptoms such as bitter mouth, dry throat, and dizziness may also occur due to dysfunction of the gallbladder.
Second, ask about sweating
Sweat is the fluid secreted by the body’s sweat glands. TCM believes that the formation of sweat is the result of “yang acting on yin”, meaning that sweat is the result of the body’s yang qi vaporizing the internal fluids and expelling them through the sweat pores. Therefore, by asking about sweating, we can understand the functional status of the sweat pores and the adequacy of the body’s yang qi and fluids, thus better judging the nature of the disease. For example, if two patients both exhibit aversion to cold and fever, but one sweats while the other does not, the difference in sweating can provide us with valuable insights. In Zhang Zhongjing’s “Treatise on Febrile Diseases”, the type with sweating is referred to as “Taiyang Wind Syndrome”, while the type without sweating is referred to as “Taiyang Cold Syndrome”. What does this mean? The concept of “Taiyang” refers to the outermost layer of defense in the body. Here, “Wind” and “Cold” do not refer to the modern medical concepts of stroke and cold, but rather refer to being harmed by wind evil and cold evil, respectively. This indicates that aversion to cold and fever with sweating is the result of wind evil invading the body, while aversion to cold and fever without sweating is the result of cold evil invading the body. Why does wind evil cause sweating while cold evil does not? The characteristic of wind evil is to open and disperse, while the characteristic of cold evil is to constrict and solidify. Wind evil opens and disperses, causing the sweat pores to open, hence sweating; cold evil constricts and solidifies, causing the sweat pores to close, hence no sweating. The same aversion to cold and fever can reflect completely different disease natures through the presence or absence of sweating. Without the aid of inquiry, how can we obtain such valuable information?
Next, let’s look at two abnormal sweating situations—spontaneous sweating and night sweats. Through these two types of abnormal sweating, we can assess the status of the body’s yang qi and yin fluids. Spontaneous sweating refers to the patient sweating continuously without being able to stop, sweating more after activity or exertion, often soaking through clothing. This type of abnormal sweating is termed “spontaneous sweating”. Spontaneous sweating is often due to weakness of the body’s yang qi, which cannot secure the sweat pores, leading to continuous leakage of fluids. Night sweats refer to sweating during sleep, which stops upon waking, resembling a thief entering the room to steal while one is asleep, hence the term night sweats. Generally, TCM texts classify night sweats as a sign of yin deficiency; however, in reality, night sweats can be due to both yin deficiency and yang deficiency. Yin deficiency night sweats often occur in the first half of the night, with tidal heat and irritability before sweating, and sweating occurs after the heat; yang deficiency night sweats often occur in the second half of the night or early morning, often presenting as cold sweats, cold hands and feet, and cold limbs.
Third, ask about headaches
The head is the area with the densest distribution of meridians in the body, and different meridians have different distribution areas in the head. Therefore, headaches in different areas reflect the location of the evil qi in different meridians. Since meridians are directly related to the internal organs, the location of the headache can also reflect the organs affected by the disease. The forehead and brow ridge area correspond to the pathway of the Stomach Meridian; if pain occurs in this area, it indicates that the evil qi is in the Yangming Meridian or Stomach; the temples correspond to the pathway of the Gallbladder Meridian; if pain occurs here, it indicates that the evil qi is in the Shaoyang Meridian or Gallbladder; the occipital and neck area corresponds to the pathway of the Bladder Meridian; if pain occurs here, it indicates that the evil qi is in the Taiyang Meridian or Bladder; the top of the head corresponds to the pathway of the Liver Meridian; if pain occurs here, it indicates that the evil qi is in the Jueyin Meridian or Liver; the teeth correspond to the pathway of the Kidney Meridian; if headache radiates to the teeth, it indicates that the evil qi is in the Shaoyin Meridian or Kidney; additionally, if the headache is accompanied by diarrhea, it indicates that the evil qi is in the Taiyin Meridian or Spleen.
Fourth, ask about bowel movements
Food enters the body and, after being digested by the spleen and stomach, the refined substances are absorbed in the small intestine to provide nutritional support, while the remaining waste is expelled through the large intestine. The power required for the large intestine to expel waste relies on qi, so by inquiring about bowel movements, we can understand the functional status of the spleen, stomach, and large intestine, as well as the adequacy of qi. Below, we will introduce several common abnormal bowel movement situations.
Constipation. This refers to dry, hard stools that are difficult to pass, with reduced frequency of bowel movements, sometimes not having a bowel movement for several days, accompanied by abdominal distension and discomfort. The formation of constipation is mainly related to two factors: one is the motility of the intestines, and the other is the moisture level in the intestines. Qi provides the driving force for the expulsion of waste from the intestines; if qi is insufficient, the motility of the intestines decreases, leading to prolonged retention of waste in the intestines, resulting in constipation. This type of constipation is often accompanied by symptoms of fatigue, weakness, and poor appetite due to qi deficiency. In addition to the driving force of qi, external cold evil can also affect the motility of the intestines. Cold evil has the characteristics of constriction and solidification, so when cold evil invades the large intestine, it can lead to intestinal spasms, preventing the smooth expulsion of waste, which is referred to as “cold constipation” in TCM, often accompanied by cold pain in the abdomen, cold limbs, and a preference for warmth.
Constipation caused by decreased moisture in the intestines is due to a reduction in the substances that moisten the intestines, such as original yin, blood, and fluids, leading to excessive dryness in the intestines. This type of constipation is often seen in the elderly or patients with significant blood loss or fluid loss, often accompanied by symptoms such as dry mouth, irritability, insomnia, dry throat, and dry skin.
Diarrhea. Diarrhea is the opposite of constipation, referring to loose, watery stools that are not formed, with an increased frequency of bowel movements. Food enters the body and, after being processed and digested by the spleen and stomach, the remaining waste is expelled through the large intestine. Any disruption in this process can lead to abnormal bowel movements. The dysfunction of the spleen and stomach in processing and digesting food is closely related to the formation of diarrhea. Due to the decline in the function of the spleen and stomach, food cannot be properly processed, leading to excessive moisture entering the intestines, resulting in diarrhea or watery stools. Therefore, when diarrhea occurs, the first consideration should be the weakness of the spleen and stomach function. If the diarrhea contains undigested food, such as green vegetables, and the stool still has vegetable leaves, we refer to this as “undigested food in the stool”. This situation is related to the weakened function of the spleen and is closely related to insufficient original yang in the kidneys. Why is “undigested food in the stool” related to insufficient original yang? The ancients had a good analogy to explain this: food must be decomposed and absorbed by the body, first going through the process of digestion in the stomach and processing in the spleen. The stomach’s function of digesting food is akin to cooking rice; in this process, the stomach is like the pot, and the original yang is like the fire beneath the pot. Only when the original yang is strong can the food entering the stomach be properly digested into substances that the body can decompose and absorb. If the original yang is deficient, the food cannot be properly digested, just as rice cannot be cooked without fire, leading to the phenomenon of “undigested food in the stool”. Therefore, if a patient reports the occurrence of “undigested food in the stool”, it is necessary to consider that the patient has a deficiency of original yang.
Another type of diarrhea is related to emotional factors. Whenever there is emotional distress or depression, abdominal pain and diarrhea may occur, with pain alleviating or reducing after defecation, often accompanied by abdominal distension, reduced appetite, and lack of desire to eat. This is referred to as “painful diarrhea” in TCM. The occurrence of this type of diarrhea is related to the dysfunction of the liver’s ability to regulate qi. As mentioned earlier, the liver belongs to wood and its main function is to regulate and smooth the flow of qi and blood, as well as emotions. If emotions are repressed, it can lead to dysfunction of the liver’s ability to regulate, which TCM refers to as “liver qi stagnation”. When qi stagnation occurs in the liver, the liver cannot perform its regulatory function, leading to a sense of frustration and the need to vent, which results in the liver affecting the spleen. This is because the liver belongs to wood and the spleen belongs to earth; wood can control earth. Therefore, when liver qi stagnation occurs, the liver seeks to vent through the spleen, resulting in dysfunction of the spleen’s processing and the large intestine’s ability to expel waste, leading to “painful diarrhea”. After defecation, the stagnant qi is temporarily released, so the symptoms may alleviate or reduce.
I have a female colleague in her forties who once became upset over a trivial matter and subsequently developed a strange illness: every time she ate, she would experience abdominal pain and diarrhea, but when she did not eat, she felt completely normal. Various examinations, including ultrasound and gastroscopy, found no abnormalities, and she suffered for half a month. Since I had treated her successfully before, she called me again for help. Without tongue coating and pulse information, I was hesitant to be certain, but I believed that her body was weak, and her spleen and stomach function was not very strong. This time, emotional distress led to liver qi stagnation affecting the spleen, resulting in abdominal pain and diarrhea upon eating. Therefore, I prescribed a formula to soothe the liver, relieve depression, and strengthen the spleen: 30g of fried Atractylodes (Bai Zhu), 15g of white peony (Bai Shao), 3g of Siler (Fang Feng), 6g of dried tangerine peel (Chen Pi), 6g of Aconite (Fu Zi), 6g of dried ginger (Gan Jiang), 6g of licorice (Gan Cao), and 12g of Poria (Fu Ling). Three days later, the patient called to say that the formula worked wonders; after taking the first dose, she no longer experienced abdominal pain when eating, and after three doses, she was completely well. The treatment of this patient relied entirely on inquiry. The information obtained through inquiry can significantly reflect the characteristics and essence of the disease, serving as one of the best bases for diagnosing and treating diseases.
Fifth, ask about dietary preferences
The spleen and stomach are the main organs for digesting food in the body, so by inquiring about dietary preferences, we can understand the functional status of the spleen and stomach and the nature of the disease’s cold and heat. For example, if appetite is excessively strong and one feels hungry shortly after eating, even with a large intake, the person may lose weight, which often indicates hyperfunction of the spleen and stomach, commonly associated with stomach fire; while poor appetite, lack of desire to eat, and abdominal distension often indicate insufficient function of the spleen and stomach. Additionally, preferences for certain foods can reflect the nature of the disease. For instance, if one prefers hot drinks when thirsty, it indicates internal cold; if one prefers cold drinks, it indicates internal heat; if one feels thirsty but only wants to hold water in the mouth without swallowing, it often indicates the presence of blood stasis. Furthermore, aversion to certain foods can also be a good method for diagnosing diseases. Aversion is a subjective emotion of the body; if one has an aversion to something, it indicates that it has caused harm or damage to the body, leading to this aversion. If a certain food causes discomfort in the stomach, one will have an aversion to it the next time they encounter it. Diseases are similar; if a certain evil qi or substance affects the body and causes illness, the body will also develop an aversion to that evil qi or substance. For example, if cold evil harms the body, one will feel aversion to cold; if wind evil harms the body, one will feel aversion to wind; if heat evil harms the body, one will feel aversion to heat; if there is an aversion to food, it often indicates food injury. We can utilize this characteristic of the body by asking patients if they have an aversion to any specific food to understand the cause of the disease.
Sixth, ask about tinnitus
Tinnitus refers to the subjective perception of sound in the ears, which may resemble cicada sounds or thunder. Tinnitus can be classified into deficiency and excess types; deficiency tinnitus is often caused by liver and kidney essence and qi deficiency, while excess tinnitus is often caused by excessive liver and gallbladder fire. The modern founder of TCM otolaryngology, Professor Yu Zuwang, proposed a good method for differentiating between deficiency and excess tinnitus by asking patients how tinnitus responds to external noise. If tinnitus worsens in the presence of external noise, or if the patient feels anxious, it is often excess tinnitus; if tinnitus is drowned out by external noise, or if the sound diminishes or disappears, it is often deficiency tinnitus; if there is no significant change, other manifestations should be assessed to determine its deficiency or excess nature.
Seventh, ask about taste
Taste refers to the abnormal sensations in the mouth. The spleen opens to the mouth, while the liver and gallbladder belong to wood and can restrain the spleen and earth; the kidneys belong to water and are restrained by the spleen and earth. The stomach and spleen both belong to earth and are interconnected through meridians. Therefore, the abnormal tastes in the mouth are often related to the functional status of the spleen, stomach, liver, gallbladder, and kidneys. Common abnormal tastes include:
1. Bland taste. This indicates a deficiency in spleen and stomach function, often accompanied by reduced appetite, abdominal distension, and loose stools.
2. Sweet or greasy taste. This indicates insufficient transformation by the spleen, with internal dampness.
3. Sour taste. This indicates that liver wood is invading stomach earth or that the stomach itself is dysfunctional, leading to poor downward movement of stomach qi and causing acid reflux.
4. Bitter taste. This indicates heat disease or excessive gallbladder fire. TCM believes that the five flavors (sour, sweet, bitter, salty, and spicy) each have their own five-element attributes: sour belongs to wood, sweet belongs to earth, bitter belongs to fire, salty belongs to water, and spicy belongs to metal. Based on these five-element attributes, they correspond to the five organs: sour enters the liver, sweet enters the spleen, bitter enters the heart, salty enters the kidneys, and spicy enters the lungs. This provides a basis for using changes in the patient’s taste to infer the nature of the disease and the affected organs (the relationship between the five flavors and the five organs is detailed in Chapter 19).
5. Salty taste. As mentioned earlier, salty taste belongs to water and enters the kidneys, so kidney diseases often present with a salty taste.
6. Sour and spoiled taste. This is often caused by food injury, where food accumulates in the stomach and ferments over time, producing a sour and spoiled taste.
Eighth, ask about menstruation
Menstruation is a unique physiological phenomenon in mature women, and TCM believes it is closely related to “kidney qi” (i.e., original yin and original yang). Generally, the first menstruation occurs between the ages of 12 and 15, with a cycle of about 28 days between periods. Each menstruation lasts for 3 to 5 days, with a red color and no blood clots. The average age of menopause is around 49 years. By inquiring about the menstrual cycle, volume, color, and quality, we can understand the nature of the disease’s deficiency and excess, cold and heat. If the menstrual cycle is more than a week early for three consecutive cycles, we refer to it as early menstruation. If early menstruation is accompanied by dark red color, thick texture, and heavy volume, it is often caused by blood heat. Blood heat refers to the invasion of heat evil into the blood, causing the blood to flow rapidly and unable to remain stable in the vessels, similar to boiling water, leading to early menstruation. If early menstruation is accompanied by light red color, thin texture, and heavy volume, it is often caused by qi deficiency. Qi has a stabilizing effect on blood; if qi is deficient, blood can easily seep out, leading to early menstruation. If the menstrual cycle is more than a week late for three consecutive cycles, we refer to it as late menstruation, with light red color, thin texture, and light volume, indicating blood deficiency, which is caused by a lack of material basis for menstruation. This is akin to a reservoir running dry, naturally unable to release water downstream. If the menstrual color is dark purple with blood clots and light volume, it indicates that cold evil has congealed the blood, leading to late menstruation. In women with obesity, if late menstruation or amenorrhea occurs, it is often due to phlegm-damp obstructing the meridians, preventing menstruation from occurring on time. For such cases of late menstruation or amenorrhea, conventional blood-nourishing and menstrual-regulating medicines often have poor effects, and since most blood-nourishing medicines are greasy, they may exacerbate internal phlegm-damp. In such cases, using methods to transform phlegm and eliminate dampness can effectively remove phlegm-damp from the meridians and restore the normal menstrual cycle.
Ninth, ask about leukorrhea
Leukorrhea is a type of mucus secreted by the cervical mucosa in women. Under normal circumstances, there may be a small amount of leukorrhea to moisten the cervix and vagina. If the secretion is abnormally increased, or if the leukorrhea changes in color or odor, it is a sign of disease, referred to as “leukorrhea disease” in TCM. In previous chapters, we discussed that excessive mucus secretion falls under the category of “internal dampness” in TCM, but the characteristics of leukorrhea can reflect the cold and heat nature underlying the dampness. If the leukorrhea is white, abundant, clear, and odorless or has a fishy smell, it often indicates cold dampness. If the leukorrhea is yellow, abundant, thick, and has an odor, it often indicates damp-heat.
Tenth, ask about children
Pediatrics in ancient China was also known as “mute medicine”. Children often cannot accurately and thoroughly describe their discomfort, so for pediatric diseases, it is usually necessary to inquire about the child’s parents or family members to understand the situation. Based on the characteristics of pediatric diseases, it is important to inquire about the child’s birth situation (such as the mother’s pregnancy and breastfeeding conditions, whether there were any complications during birth, or premature birth, which can help assess the child’s physical condition), vaccination history (which is significant for diagnosing infectious diseases), and detailed progression of the illness. The progression of the child’s illness is crucial for diagnosing pediatric diseases. Information about places the child has been, things or people they have come into contact with, food they have eaten, clothing conditions, and living environment can provide valuable diagnostic clues, and if we can utilize this information well, it often leads to unexpected gains.
Here, I would like to share a story about the famous Qing Dynasty physician Ye Tianshi, from which we can also gain some insights. At that time, there was a wealthy man in Suzhou whose five-year-old son suddenly fell ill, experiencing unbearable pain all over his body; anyone who touched his skin would cause him excruciating pain. The wealthy man hurriedly sent someone to call for a doctor, but the local famous physicians could not determine the cause of the illness. Some believed it was due to wind-cold, while others thought it was due to internal blood stasis. However, various treatments for dispelling wind and dampness or activating blood and resolving stasis yielded no improvement. At this point, someone suggested it might be due to “evil spirits”, so they called monks and Taoists to perform rituals, but the child’s condition still did not improve, and he became increasingly emaciated due to the pain. The wealthy man then remembered Ye Tianshi, the most renowned physician in Suzhou, and thought that if he could invite him to treat his son, there would surely be hope.
When Ye Tianshi arrived at the wealthy man’s home, he saw that the child had smooth skin, without redness or swelling, appearing completely normal. However, upon touching the child’s skin, the child immediately cried out in pain. When he checked the pulse, it was very gentle, indicating that there was likely no serious illness. Yet, the child’s expression of pain did not seem feigned. This strange illness was the first time Ye Tianshi had encountered, and he furrowed his brow in thought for a while but could not come up with an explanation. Therefore, he carefully inquired with the servants about where the wealthy man’s son had been before the onset of the illness and what he had come into contact with. The servants said that the young master had not gone anywhere; that day he had taken a nap and then sat under a pomegranate tree in the courtyard, and after returning, he fell ill. The only thing he had come into contact with was a stone bench under the tree. Ye Tianshi said, “Take me to see it.” The servants led Ye Tianshi to the courtyard. There, he saw a large, lush pomegranate tree, its branches thick with leaves, and the sound of cicadas buzzing. He looked up at the leaves for a moment, then walked over to the stone bench and examined the ground beneath the tree. Then, with confidence, he told the wealthy man, “Your son’s illness can be cured, but I need a medicinal guide. If you can provide it, I can cure your son; if not, I cannot help.” The wealthy man quickly replied, “As long as you can cure my son, I will do anything. What do you need as a medicinal guide?” Ye Tianshi said, “I need three hundred pounds of glutinous rice, and once it is reduced to three taels, that will be my medicinal guide.” The wealthy man thought this was easy to do and immediately sent someone to steam the glutinous rice.
But how could so much glutinous rice be eaten at once? To cure his son, the usually stingy wealthy man decided to be generous and had his servants distribute the glutinous rice to the common people at the door. Once the three hundred pounds of glutinous rice was reduced to three taels, Ye Tianshi took the rice and formed three small rice balls. He then removed the child’s clothing and gently rolled one rice ball over the child’s body. Strangely enough, after rolling it over, the child’s pain was reduced by more than half. Ye Tianshi then took the second rice ball and rolled it over the child’s skin again. After using all three rice balls, the child’s pain completely disappeared. The wealthy man was overjoyed and praised Ye Tianshi’s superb medical skills. Ye Tianshi simply smiled and did not respond. When he returned home, his apprentice asked him, “Master, what illness did that child have? And what method did you use to treat him? I have never seen you use this before!” Ye Tianshi smiled and said, “I was also puzzled at first, but when I arrived at the courtyard, I understood. The pomegranate tree was the cause of the illness.” The apprentice was even more confused, “How could a pomegranate tree cause pain? I have never heard of that before!” Ye Tianshi explained, “I saw several caterpillars crawling on the pomegranate tree, and I knew that the hairs on those caterpillars were the reason for the child’s pain, which was not visible externally. The reason I needed three hundred pounds of glutinous rice was that glutinous rice is sticky and can adhere to the hairs embedded in the skin, thus removing the root cause of the illness and stopping the pain. As for the three hundred pounds of rice, I was using it to help the poor, which also counts as accumulating virtue for him.” After reading this story, while admiring Ye Tianshi’s medical skills and ethics, we can also appreciate the irreplaceable role of inquiry in discovering the causes of diseases.
In clinical differentiation, the information obtained through inquiry accounts for the largest proportion and is the most important aspect.
Detailed inquiries are beneficial for accurately judging the causes, locations, and nature of diseases, which is of great significance for determining treatment.
My family’s four generations of traditional Chinese medicine have lasted for a hundred years, and I now share the experience of inquiry from my family, hoping it will benefit my peers.
The main content of my inquiries: general items, chief complaints, and medical history, current symptoms, etc.
1. Basic information:
Name, gender, age, height, weight, ethnicity, occupation, marital status, place of origin, address, etc.
Generally speaking, young and middle-aged individuals with sufficient qi and blood often have excess syndromes; elderly individuals with deficient qi and blood often have deficiency syndromes.
Why do I ask about age?
Because if it is a difficult disease like interstitial lung fibrosis, older patients already have poor lung function, and the regeneration of body cells is also slow. If they also have diabetes, hypertension, or even cor pulmonale, it becomes even more challenging to regulate. Even using the famous formula “Nourishing Yin and Transforming Fibrosis Decoction” for differentiation and adjustment may require two treatment courses to see significant improvement. The body requires blood and qi for survival, and the lungs govern qi and respiration, so older patients with severe interstitial lung disease are unlikely to achieve clinical recovery in a short time.
Why do I ask about place of origin?
China is vast and diverse, with different climates affecting the body. Northeastern people, for example, face cold weather and often drink liquor to prevent cold and promote blood circulation, leading to a higher incidence of respiratory diseases. Additionally, cold weather primarily affects the lungs, as the lungs govern qi and respiration, and the skin, so respiratory diseases like bronchitis and asthma are common in northeastern populations. In contrast, people from the central plains, such as Beijing, Tianjin, Hebei, and Henan, consume more salty foods, leading to a higher incidence of hypertension. In the Sichuan and Chongqing regions, the abundant water and humidity require a diet rich in spicy foods, resulting in fewer cardiovascular diseases. Southern people prefer sweet foods and eat very lightly, so hypertension is less common. As a qualified TCM doctor, one must understand astronomy and geography to accurately differentiate and benefit the local population.
Why must I ask about residence?
Because people living in plains are affected by the heavy fog and haze in the north during winter, which can negatively impact the treatment of interstitial lung disease and other respiratory conditions; those living in mountainous areas are often exposed to dampness and cold, requiring attention to colds; urban dwellers face severe air and noise pollution, which is detrimental to recovery; while those living in clean, oxygen-rich areas far from the city can benefit significantly from using “Nourishing Yin and Transforming Fibrosis Decoction” to treat interstitial lung fibrosis.
Why do I ask about occupation?
For example, those who have long worked in coal mining, gold mining, or as street cleaners often develop bronchitis, asthma, pneumoconiosis, or interstitial lung disease due to poor air quality; chefs tend to be overweight and have more cases of hypertension; drivers often suffer from lumbar spondylosis and back pain; white-collar workers and teachers frequently experience cervical spondylosis and neck pain; farmers often suffer from chronic fatigue and back pain throughout their lives; those working in water may be prone to dampness; officials may have heart disease due to stress and fear of retaliation for wrongdoing.
Why do I ask about height and weight?
Overweight individuals often have excessive dampness, and overweight patients with interstitial lung disease tend to have more phlegm, hypertension, and high blood sugar, requiring dietary adjustments for weight loss; thin patients with interstitial lung disease often have lung yin deficiency, prone to low-grade fever, five-center heat, night sweats, dry cough with little phlegm, and dry stools, requiring the use of specialized formulas like “Nourishing Yin and Transforming Fibrosis Decoction” along with lung-nourishing and yin-replenishing herbs like lily and others, which can lead to significant symptom improvement in no time; additionally, it is necessary to enhance appetite and strengthen the spleen, as the spleen and stomach are the source of qi and blood production. If one eats well and digests well, their constitution and immunity will improve, leading to the absence of diseases.
2. Ask about main symptoms:
The chief complaint is usually the main reason for the patient’s visit and represents the primary conflict of the disease. An accurate chief complaint can help the doctor determine the general category of the disease and the urgency of the condition, which is of significant diagnostic value. Generally, the main symptoms should not exceed three aspects; too many will make it difficult to distinguish the primary from the secondary.
3. Ask about medical history:
Etiology:
Inquire about the environment and time of onset, whether there are any obvious causes or triggers, whether there is a history of infectious disease exposure, the severity of the onset, the initial symptoms and their location, nature, duration, and degree.
Progression:
Inquire in chronological order about the main changes in the condition from onset to the time of consultation, the nature, location, and degree of symptoms, whether there are any significant changes, whether there are any regular patterns, and whether there are any factors or triggers affecting the changes.
Treatment history:
Inquire about the entire process from the onset of the disease to the time of consultation, including any diagnoses and treatments received. Where did the patient seek medical attention initially? What examinations were performed? What were the results? What was the diagnosis? What treatments were given? What medications were taken, including dosage, method, duration, and effects? Were there any adverse reactions?
The current medical history is a major component of the entire disease history. Understanding the current medical history can help the doctor analyze the condition, explore the patterns of the disease, and provide a basis for determining the diagnosis.
Asking about the onset time can help determine whether the current disease is in the exterior or interior, whether it is excess or deficiency; asking about the cause of onset can help infer the pathogenic factors such as cold, heat, dryness, dampness, etc.; asking about any history of infectious disease exposure can provide a basis for diagnosing certain infectious diseases, such as measles or dysentery; clarifying the progression of the disease can help understand the struggle between righteous and evil qi, making preliminary judgments about the strength of the body’s righteous qi and the prognosis. Clarifying the diagnosis and treatment process is also an important reference for determining treatment.
4. Ask about lifestyle and diet:
Lifestyle and dietary habits:
This includes the patient’s habits, experiences, dietary preferences, work-life balance, and work situation. Inquire about the place of birth, residence, and any areas where the patient has lived for a long time. Also, inquire whether the patient has experienced significant emotional stress. Additionally, ask about lifestyle habits, dietary preferences, and whether there are any smoking or drinking habits. For women, inquire about menstrual and reproductive history. Inquire about the nature of work, intensity, and whether the work schedule is normal.
Family and hereditary history:
This refers to the health conditions of the patient’s immediate family or close relatives, including any infectious or hereditary diseases. Many infectious diseases are closely related to close contact with others, such as tuberculosis. Some hereditary diseases are closely related to blood relations, such as hemophilia, sexually transmitted diseases, and conditions that may arise from consanguineous marriages, leading to weakened constitutions or mental retardation.
Inquiry is the most important part of experienced TCM diagnosis, generally following the order of Zhang Jingyue’s “Ten Questions Song”.
The “Ten Questions Song” is: “One should ask about cold and heat, then about sweating; third, inquire about the head and body, fourth about bowel movements; fifth, about diet, sixth about the chest; seventh, about deafness, eighth, thirst should also be discerned; ninth, ask about old illnesses, tenth about causes, and also consider medication changes; for women, it is essential to ask about menstrual periods, whether they are delayed, rapid, or have irregular bleeding; additionally, brief words for pediatrics, variola and measles should all be verified.”