Syndrome Differentiation

Outline

Syndrome differentiation in TCM is a method to analyses and recognize the syndrome of disease. In other words, it is also a process in which the location, nature, occurrence and development of a disease as well as the condition of health Qi and pathogenic factors are identified according to the clinical data obtained from the four diagnostic methods.

 From

the above it becomes obvious that syndrome differentiation is the premise and foundation of treatment.  Correct differentiation and appropriate treatment are the prerequisite for achieving the hoped-for results.

There are a number of methods to differentiation of syndromes in TCM, such as  differentiation of syndromes according to the eight principle;  differentiation of syndromes according to the theory of Qi, blood and body fluid;  differentiation of syndromes according to the Zang-Fu theory;  differentiation of syndromes according to the theory of six meridians;  differentiation of syndromes according to the theory of three jiao.

 Each

method, while having its own features and laying stress.  They should be applied flexibly and accurately so as to understand a disease comprehensively,  thereby providing the basis for treatment.

The eight principle syndromes

The eight principle syndromes
 refer

to Yang and Yin, exterior and interior, cold and heat, deficiency and excess.  Is the most important syndrome in TCM.

2. 3. 4. 5.

Complicated as the clinical manifestations of diseases may be, they are classified under the eight principles. the classification of syndromes——Yin or Yang; the location of disease——exterior or interior; the nature of disease——cold or heat; the states of health Qi and pathogenic factors——deficiency or excess

Exterior and interior
 Are

two principles for differentiating the location and severity of diseases.  Exterior: the surface skin and body hair, the muscle, the channels.  Interior: Zang-Fu organs, the blood vessels, the bones marrow.

Exterior syndrome
 indicates

the exterior parts of body is affected by exogenous pathogenic factors and the disease is in its primary stage and relatively mild.

Exterior syndrome

Battlefield border

If the enemy invades our border, our army will go out for fight, and then the border will become the battlefield at this moment. the exterior parts of body is affected by exogenous pathogenic factors and the disease is in its primary stage and relatively mild.

 Exogenous

pathogenic factors intrude human body through body hair and skin, muscle, and channels, or through mouth and nose, characterized by rapid onset and short duration.

Symptom
1.

2. 3.

4.

Fever, and superficial pulse, white thin coat ——a fright between health Qi and pathogenic factors. Aversion to cold ——the hindrance of the defensive Qi fails to warm the body. Nasal obstruction, nasal congestion, itching and pain in the throat, and cough——lung is impaired by pathogenic factors. Headache——the unsmooth flow of Qi and blood caused by pathogenic factors.

Principle of treatment
 Relieve

the exterior syndrome with drugs pungent in flavor

ginger

Interior syndrome
 indicates

the disease is in the interior parts of the body, such as Zang-Fu organs, Qi and blood, and marrow.  It is commonly seen in the intermediate and late stages of diseases caused by exogenous pathogenic factors or diseases which result from internal injury.

Interior syndrome

if our army are unable to resist the enemy's invasion, then the enemy will invade into our city, even the capital, the condition is more serious at this time. the disease is in the interior parts of the body.

Battlefield capital

Symptom
 Is

characterized by a wide variety of symptoms and with different disease location.  Such as high fever, disphoria, coma, thirst, abdominal pain, constipation, or diarrhea, vomit, short micturition with dark color urine, yellow or white, thick and greasy tongue coat, deep pulse.

Principle of treatment
 2. 3. 4. 5. 6.

Different treatments according to the various causative factors. Such as Warm the interior Clear away heat Relieve constipation Promote digestion Reinforce Yang

Identification of exterior and interior syndrome
Exterior syndrome Interior syndrome New disease, short duration Old disease, long duration Fever, aversion to cold, or Fever caused by exogenous to wind pathogens but without aversion to cold or to wind; or fever due to endogenous damages White thin tongue (relatively normal) coat Remarkable change in tongue and tongue coat, e.g. yellow tongue coat, thick and slimy coat, dark red tongue, pale tongue, etc. Deep pulse, or full and rapid pulse, etc.

Superficial pulse

Half-exterior and half-interior syndrome
 It

indicates that during the penetration of exogenous pathogenic factor from exterior to interior,  Or the exteriorization of interior syndrome, the pathogenic factors just come to its half way  Disease location is neither exterior nor interior, but in between.

Symptom
 Alternating

fever and chills, nausea, vomit, distressing fullness in the chest and hypochondriac region, restlessness, bitter taste in the mouth, dry throat, no desire for food and drink, vertigo, wiry pulse.

Main points for distinguishing exterior and interior syndrome
1.   4.   7.  

changes of cold and heat Exterior syndrome——fever accompanied by aversion to cold Interior syndrome——fever without aversion to cold, or aversion to cold without fever Tongue condition Exterior syndrome——comparatively mild, and tongue coating remains unchanged Interior syndrome——relatively sever, with changes in the tongue coating by the dysfunction of some Zang-Fu organs Pulse condition Exterior syndrome——superficial pulse Interior syndrome——deep pulse

Heat and cold syndrome
 Are

two principles used to differentiate the nature of diseases.  Heat and cold syndrome reflect the states of Yin and Yang in the body.  Zhang Jingyue held that, “cold and heat are mutations of Yin and Yang”.

Symbol of heat and cold syndrome

Heat syndrome

Cold syndrome

Cold syndrome

is attributable to the invasion of pathogenic cold factor, or depletion of Yang, or excess of Yin.

Cold

Symptom
1.

2. 3.

4. 5.

Cold form, cold limbs, somber with white complexion, curled-up recumbent posture, desire for warmth——Yang Qi is insufficiency or impaired by exogenous pathogenic factors and fail to warm the organism. Tasteless in the mouth——excess of Yin cold, do not harm to body fluid, so there is not thirst. Phlegm, saliva and nasal discharge, long micturtion with clear urine, thin or watery stools ——Yang being insufficient and incapable of steaming the fluid. Tense pulse——cold is congealing Slow pulse——Yang being insufficient, not enough strength to mobilize the circulation of Qi and blood

Heat syndrome

denotes to symptom complex that is attributed to invasion of pathogenic heat, or excess of Yang, or depletion of Yin, or hyperactivity of the organism .

Symptom
1. 2.

3. 4. 5. 6. 7. 8. 9.

Aversion to heat and preference for cold—— exuberance of Yang produce excessive heat Thirst, desire for cold drink, short micturition with dark colored urine——consumption of body fulid by heat Yellow, thick phlegm and nasal discharge——fluid decocted by Yang heat Flushed face——upflaming of fire Restless——fire impaired the heart Hemorrheage——fire burn the collateral veins Dry stool——heat in the intestine Dry tongue——Yin fulid is impaired Red tongue with yellow coat, and rapid pulse—— indication of heat syndrome

Identification of cold and heat syndrome
Cold syndrome Aversion to cold, cold preference for warmth Testlessness, no thirst Somber white complexion Quiet Long micturition with clear urine Thin or watery stools Pale tongue with white moist coat Slow pulse or tense pulse Heat syndrome limbs, Fever, aversion to heat, preference for cold Dry mouth, thirst, desire for cold fluid Flushed complexion, congested eyes Restlessness Short micturition, coloured urine Dry stools Red tongue with yellow dry coat Rapid pulse with dark

Principle of treatment
 

Cold syndrome Warm to expel cold

 

Heat syndrome Clear away heat and reduce fire

Main points for distinguishing between cold and heat syndromes
Manifestation Aversion to cold or heat Thirst Complexions Four limbs Stools Urine Tongue Cold syndrome Aversion to cold, preference for heat Absence of thirst Lightly pale Cold Loose Clear and profuse Pale tongue, white and moist coating Heat syndrome Aversion to heat, preference for heat Thirst with preference for cold drinks Flushed Warm Constipation Yellow and scanty Red tongue, yellow coating

Deficiency and excess syndrome
 Are

two principles for differentiating the states of pathogenic factors and health Qi.  Deficiency syndrome chiefly denotes to insufficiency of health Qi.  Excess syndrome denotes to excess of pathogenic factors.

Deficiency syndromes

Include deficiency of Yin, Yang, Qi, blood, essence and body fluid, Zang-Fu organs. Caused by congenital insufficiency or postnatal malnutrition.

Yellow river

 There

are two major types of deficiency that are frequently observed in clinical practice.  The etiology of deficiency is mainly the damage of Yang and Yin.

1.Yang deficiency
 

Impairment of Yang leads to warming, moving, and containing dysfunction: Manifestation: Pale or withered yellow complexion, spiritlessness, lassitude, palpitation, shortness of breath, cold form, chills in the limbs, spontaneous sweat, urinary and fecal incontinence, pale and enlarged tongue, vacuous, deep, and slow pulse; Cold syndrome

2.Yin deficiency

Deficiency Yin syndrome in which Yin is damaged and unable to restrict Yang,and that Yin fails to nourish and moisten the organism: Manifestation: feverish, sensation in palms, soles and chest, emaciation, flushed cheeks, dry mouth, dry throat, night sweat, tidal fever, red tongue with less coat, vacuous, thready and rapid pulse. Heat syndrome

Principle of treatment
 Nourish

the deficiency  Reinforce Yang in case of Yang deficiency  Reinforce Yin in case of Yin deficiency

Excess syndrome

Is caused by attack of exogenous pathogenic factors or dysfunction of the viscera that leads to interior retention of phlegm, fluid, dampness and blood stasis.

Common manifestations
1. 2. 3.

4.

5.

6. 7.

High fever——excessive heat Dysphoria, coma, delirium——heat impaired the function of the heart Chest distress, abdominal distention pain that aggravated by pressure——stagnation of Qi and blood Coarse breathing, rattling sound in the chest and throat——accumulation of profuse phlegm block the lung Diarrhea or dribbling and pain urination, dry stools, constipation——pathogenic dampness factor in the body repletion, forceful pulse——fierce struggle between health Qi and pathogenic factor Tongue with thick greasy coat——turbid damp steaming up.

Principle of treatment
 Reduce

the excess  Different methods for reducing the excess should be used depending on different pathogenic factors.

Identification
   

Excess syndrome Health Qi is not weak Pathogenic factor is strong Conflict is fierce

   

Deficiency syndrome Health Qi is weak Pathogenic factor is strong pathogenic factors prevail over health Qi

Main points for distinguishing between excess and deficiency syndromes
Item Duration of disease Constitution Spirit Voice and breathing Pain Chest and abdomen Distention and fullness Deficiency Chronic disease Weak Listlessness Low voice, weak breathing Alleviated by pressure No pain on pressure Sometimes alleviated Excess New disease Strong, in most cases Restlessness Sonorous voice, coarse breathing Pain on pressure Aggravated by pressure Not alleviated

Fever

Aversion to cold Tongue Pulse

Burning sensation in the chest, palms, soles, and slight afternoon fever Alleviated by warmth Flaccid with little or no coating Forceless

High fever

Not alleviated by warmth Thick coating Forceful

Treatment principles
 

Deficiency syndrome replenish

 

Excess syndrome purge

Yin and Yang (P82)
 Yin

and Yang is a pair of principle used to summarize the other three pairs of principle and are also the key principles in the eight principles.  So the other three pairs of principles are classified under either Yin or Yang.

 

Exterior, heat and excess syndromes are classified into the category of Yang, Interior, cold and deficiency syndromes fall into the category of Yin.

1.Yin syndrome
 is

characterized by deficiency of YangQi and excess of Yin in the body.  Different symptoms are show in different Yin syndromes.

Manifestation
 2. 3.

4.

The Yin syndrome is a generalization of interior, cold, and deficiency syndromes. Listlessness, lassitude and low voice are the manifestations of deficiency syndrome. Cold form, chills in the limbs, absence of thirst, ,foul stools and increased amount of clear urine are the signs of exterior-cold. Pale and enlarged tongue, deep and slow pulse, or weak, thready and choppy pulse indicate deficiency-cold.

2.Yang syndrome
 is

characterized by the hyperactivity of Yang-Qi and hyperfunctions of the Zang-Fu organs, resulting from excess of Yang-heat in the body.  Different symptoms are show in different Yang syndromes.

Manifestation
 2.

3.

4. 5.

The Yang syndrome is a generalization of exterior, heat, and excess syndromes. Aversion to cold and fever seen at the same time are characteristics of the exterior syndrome. Flushed face, restlessness, dry mouth, desire for drink, short micturition with dark color urine are the manifestation of heat syndrome. Loud voice, rough breathing, dry stools are the symptoms of excess syndrome. Dark red tongue with yellow dry coat, the pulse may be superficial rapid, or full and big, or rolling pulse indicate excess heat.

Differentiation between Yin and Yang syndromes
Yin syndrome Inspection Pale or dim complexion, heaviness of the body, lying in a curled-up posture, lassitude, listlessness, pale and delicate tongue, moist and slippery coating Yang syndrome Malar flushed face, feverishness, preference for cold, irritability, restlessness, dry and cracked lips, crimson tongue, yellow or staleyellow coating, even dry, dracked, or dark and thorny tongue Sonorous voice, irritability, polylogia, coarse and asthmatic breathing, rattle in the throat, shouting and yelling

Auscultation Low voice, quietness, and olfaction disinclination to talk, weak breathing, short breath

Differentiation between Yin and Yang syndromes
Yin syndrome Interrogation Foul stools, loss of appetite, tastlessness in the mouth, absence of irritability and thirst, or preference for hot drinks, and increased amounts of clear urine or scanty urine Abdominal pain alleviated by pressure, chills, cold feet, and deep, faint, thready, unsmooth, and forceless pulse Yang syndrome Dry or hard stools, or constipation, stools with foul smell, no desire to eat, dry mouth, irritability, preference for drinking, yellow and scanty urine Abdominal pain aggravated by pressure, warm body and feet, superficial, rapid, smooth, and forceful pulse

Palpation

3.Collapse of Yin and Yang

In a critical stage of disease, Yin and Yang may be exhausted simultaneously, Yin humor is dried up, and Yang is collapsed, both of them can no longer support each other. Such dissociation of Yin and Yang implies death.

50 40 30 20 10 0 normal Yin Yang

Conclusion
 The

eight principles are the guiding principle for syndrome differentiation and treatment.

Review
     

Exterior syndrome indicates the exterior parts of body is affected by exogenous pathogenic factors and the disease is in its primary stage and relatively mild. Interior syndrome indicates the disease is in the interior parts of the body. Heat and cold syndrome reflect the states of Yin and Yang in the body. Deficiency syndrome chiefly denotes to insufficiency of health Qi. Excess syndrome denotes to excess of pathogenic factors. Yin and Yang is a pair of principle used to summarize the other three pairs of principle and are also the key principles in the eight principles.

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