Differentiation of Syndromes

1. Differentiation of syndromes according to eight principles—
1. Exterior and interior – Exterior and interior form two principles relating to the depth of the diseased area and generalizing the direction of the development of the disease.
1. Exterior syndromes refer to diseases resulting from invasion of the superficial portion of the body of exogenous pathogenic factors and are marked by sudden onset with short duration. Exterior syndromes are usually mild and superficial as they are located on the superficial portion of the body and are the early stage of exogenous diseases.
2. Interior syndromes may result from transmission of exogenous pathogenic factors to the interior if these are not eliminated in time, or they may be caused by direct attack on the Zang-fu organs by exogenous pathogenic factors. Interior syndromes are mostly severe and deep, as the pathogenic factors are in the interior of the body, damaging the Zang-fu organs.
2. Cold and heat – relate to two different natures of disease. Diseases caused by pathogenic heat, summer heat or dryness are mostly heat syndromes, and those caused by pathogenic cold are mostly cold syndromes.
3. Xu (deficiency) and Shi (excess) – are two principles used to analyze and generalize the opposing force of the anti-pathogenic and pathogenic factors during the course of the disease.
1. Syndromes of the Xu (deficiency) type refer to those diseases in which the function of the human body is week, the anti-pathogenic factor insufficient and the co-ordination of yin and yang impaired, while the influence of the pathogenic factor has already become inconspicuous.. The syndrome of Xu type often mingles with that of the cold nature.
2. Syndromes of the Shi (excess) type refer to those diseases in which the body function is not to the point of impairment and the anti-pathogenic factor is still of sufficient strength, while the pathogenic factor is hyperactive and sever struggle proceeds between the anti-pathogenic and pathogenic factors.. Syndromes of Shi type and of heat nature often intermingle.
4. Yin and Yang – Clinical manifestations are concerned, those characterized by hyperactivity, excitation, fidgeting and red complexion come mostly within yang syndromes, while those characterized by hyperactivity, inhibition, quiescence and pale complexion come mainly within the yin.
2. Differentiation of Syndromes (According to the Theory of Zang-fu) – Differentiating diseases according to the theory of Zang-fu is to identify visceral diseases by basing on their physiological conditions, as each of them exerts different physiological functions. When disorder occurs in a Zang or fu organ, it may be confined to that particular organ, or it may impart its influence to or be influenced by disorder of other organs. A description of the main syndromes of each of the Zang-fu organs is as follows:
1. Heart
1. Weakness of the Qi (vital energy) of the heart
1. Clinical manifestations: Palpitation and shortness of breath aggravated by exertion, pale tongue, thin pulse of the Xu type of missed-beat pulse. If there is evidence of Xu (deficiency) of the yang of the heart, there may be chills, old limb, pallor and purplish lips, Exhaustion of the yang of the heart may show in profuse sweating, mental confusion and fading thin pulse.
2. Pathology: This syndrome is usually caused by asthenia after a long illness or mental irritation which injures the Qi of the heart. When the Qi of the heart is week, if fails to pump blood normally, resulting in palpitation, shortness of breath and lack of pulse of the Xu type or missed-beat pulse. Long duration of weakness of the Qi of the heart may lead to weakness of the yang of heart. When the body lacks yang, it lacks energy and heat, and manifestations such as chills, cold limbs and pallor occur. In case of exhaustion of the yang of the heart, the defensive Qi of the body surface can no longer protect the essential Qi and lets it dissipate. Manifestations are profuse sweating and fading pulse.
2. Insufficiency of the yin of the heart
1. Clinical manifestations: Palpitation, insomnia, dream-disturbed sleep, mental restlessness, low fever, red tongue, lack of or rapid pulse.
2. Pathology: This syndrome is usually due to damage of yin by a febrile disease or to mental irritation which consumes the yin of the heart. Insufficiency of the yin of the heart often leads to hyperactivity of the fire (yang) of the heart, resulting in the above manifestations. Insufficiency of the yin of the heart may cause insufficiency of the blood of the heart. In that case, the yin and blood are not sufficient to nourish the heart, the heart fails in its function of housing the mind, and there appear symptoms of insomnia, poor memory and disturbed sleep.
3. Stagnation of the blood of the heart
1. Clinical manifestations: Palpitation, cardiac retardation and pain, cyanosis of lips and nails, dark purplish tongue or purple spots on the tongue, and lack of or rapid pulse.
2. Pathology: This syndrome is often due to mental irritation leading to stagnation of Qi or blood, or insufficiency of the Qi of the heart after a long illness.
4. Hyperactivity of the fire of the heart
1. Clinical manifestations: Ulceration, swelling and pain of the mouth and tongue, insomnia accompanied with a feverish sensation, flushed face, bitter taste in mouth, hot and dark yellow urine, red tongue and rapid pulse.
2. Pathology: This syndrome is often due to mental irritation which causes depression of Qi.
5. Derangement of the mind
1. Clinical manifestations: Mental depression, dullness, muttering to oneself, weeping, laughing without apparent reason, incoherent speech, mania, and in severe cases – consciousness and even coma.
2. Pathology: This syndrome is often due to mental irritation which causes depression of Qi. The body fluid stagnates to form damp-phlegm which causes blurring of the heart and mind. If the depressed Qi turns into fire and phlegm-fire disturbs and heart, mental restlessness results, with incoherent speech and mania. Blurring of the mind by phlegm-damp or phlegm-fire may be a contributing cause of coma. High fever, coma and delirium resulting from invasion of the pericardium by heat are due to pathogenic heat sinking deep in the interior of the body to disturb the mind.
2. Syndromes of the liver
1. Depression of the Qi of the liver
1. Clinical manifestations: Hypochondriac and lower-abdominal pain, distending sensation of the breasts, discomfort in the chest, belching, sighing, sensation of a foreign body in the throat, and irregular menstruation in women.
2. Pathology: This syndrome is usually due to mental irritation causing depression of the Qi of the liver and stagnation of the Qi of the Liver Channel.
2. Flare-up of the fire of the liver
1. Clinical manifestations: Dizziness, distending sensation in the head, headache, red eyes, bitter taste in mouth, red tongue with yellow coating, and wiry and rapid pulse.
2. Pathology: This syndrome is often due a long standing depression of the Qi of the liver which later turns into fire.
3. Stagnation of cold in the channel of the liver
1. Clinical manifestations: Lower abdominal pain and swelling. The scrotum may be cold and contracted, which can be alleviated by warmth. The tongue is pale with white coating, the pulse deep and wiry or slow.
2. Pathology: The channel of the liver curves around the external genitalia and passes through the lower abdominal region. When cold, which is characterized by contraction and stagnation, stays in the channel of the liver, stagnation of Qi and blood may occur and cause lower abdominal pain and swelling of the testis. Cold and contraction of the scrotum are also due to this characteristic of pathogenic cold.
4. Insufficiency of the blood of the liver
1. Clinical manifestations: Dizziness, blurring of vision, dryness of the eyes, pallor, spasm of tendons and muscles, numbness of limbs. In women, scanty light colored menstrual flow with prolonged cycle.
2. Pathology: This syndrome often occurs after hemorrhage or other chronic diseases in which blood is consumed and that which is stored in the liver continuously decreases, failing to nourish the channels. Xu (deficiency) of blood may cause rising of the wind so that spasm of tendons and muscles and numbness of limbs appear. Upward disturbance of the wind is the cause of dizziness and blurring of vision. Insufficiency of the blood of the liver and disturbance in the function of storing blood result in emptiness of the Chong Channel, which is the cause of the menstrual abnormality.
5. Stirring of the wind of the liver by heat.
1. Clinical manifestations: High fever, convulsion, neck rigidity and in severe cases – coma.
2. Pathology: This syndrome is due to transmission of pathogenic heat from the exterior to the interior, which burns the yin of the liver and deprives tendons and vessels of nourishment. Pathogenic heat in the interior stirs up endogenous wind, eliciting high fever, convulsion, and neck rigidity. Coma is due to pathogenic heat affecting the pericardium and disturbing the mind.
3. Syndromes of the spleen
1. Weakness of the Qi (vital energy) of the spleen
1. Clinical manifestations: Pale complexion, anorexia, loose stools, edema, and lethargy. There may be an expanding and a bearing-down sensation of the abdomen and prolapsed of the rectum and uterus, or chronic hemorrhage such as purpura, bloody stools and uterine bleeding; pale tongue, week pulse of the Xu type. If there is evidence of Xu (deficiency) of the yang of the spleen, there may appear cold manifestations such as chilliness and cold limbs in addition to the symptoms and signs mentioned above.
2. Pathology: This syndrome is often caused by irregular food intake, excessive mental strain or protracted chronic disease, which results in weakness of the Qi of the spleen and impairs its function of transportation and transformation, which consequent poor appetite and loose stools. Accumulation of fluid in the interior is the cause of edema. Paleness and lethargy are due to lack of essence of food, providing no source for blood formation. When the Qi of the spleen is weak, it loses its ability to uplift tissue, so that there is expansion and a bearing-down sensation in the abdomen, and prolapse of the rectum and uterus. Weakness of the Qi of the spleen, which controls blood, is also the cause of various kinds of chronic hemorrhage. Xu (deficiency) of the yang of the spleen is the cause for chilliness and cold limbs, as yang is warmth-producing.
2. Invasion of the spleen by cold-damp.
1. Clinical manifestations: Fullness and expansion in the chest and epigastrium, poor appetite, heaviness of the head, general lassitude, borborygmus, abdominal pain, loose stools, white sticky tongue coating, weak pulse.
2. Pathology: This syndrome usually occurs after chilling by rain or it may be due to over eating of raw or cold food. In either case, pathogenic cold-damp injuries the spleen, impairing its functions of transportation and transformation and resulting in poor appetite, borborygmus, abdominal pain, loose stools, white sticky tongue coating and a thin pulse.
4. Syndromes of the lung
1. Invasion of the lung by pathogenic wind
1. Clinical manifestations: Itchy throat, cough, chills and possible fever. If wind is accompanied by, chilliness is accented, with nasal obstruction, watery nasal discharge, expectoration of mucoid sputum, and thin white tongue coating. If wind is accompanied with heat, fever is prominent, with redness, swelling soreness of the throat, purulent nasal discharge, expectoration of purulent sputum and yellow tongue coasting.
2. Pathology: Invasion of the lung by exogenous pathogenic wind disturbs its dispersing and descending function. Normal respiration of the lung is affected, producing cough and nasal obstruction. Cold, as a yin pathogenic factor, is liable to damage yang Qi. When wind is accompanied with cold, chilliness will be more severe than fever, and there will be watery nasal discharge and white sputum. Heat as a yang pathogenic factor is liable to consume yin fluid. In the case of wind accompanied by heat, fever becomes the more prominent symptom, with thick nasal discharge and purulent sputum.
2. Retention of damp-phlegm in the lung.
1. Clinical manifestations: Cough, shortness of breath and expectoration of much dilute, white creamy sputum. Appearance is generally elicited by cold. The tongue coating is white and sometimes sticky.
2. Pathology: This syndrome is usually due to disturbance in the normal circulation of body fluid, the accumulation of which causes formation of damp-phlegm. When damp-phlegm stays in the lung and blocks the passage of Qi, the function of dispersion and descending will be impaired, followed by the occurrence of the above mentioned symptoms.
3. Retention of phlegm-heat in the lung
1. Clinical manifestations: Cough, shortness of breath or asthmatic breathing, expectoration of much thick purulent yellowish-green sputum, or even bloody foul-smelling pus. There may be chills and fever, red tongue with yellow coating and rapid pulse.
2. Pathology: This syndrome is usually caused by invasion of exogenous wind-heat or wind-cold which later develops into heat. The heat mixes with phlegm in the body which remains in the lung blocking the passage of Qi, disturbing the lung’s dispersing and descending function, and causing cough and shortness of breath or asthmatic breathing. Heat exhaust body blood, causing expectoration of purulent sputum. When phlegm-heat blocks the vessels of the lung, there will be blood stagnation or ulceration leading to expectoration of fouled purulent sputum specked with blood.
4. Insufficiency of the yin of the lung
1. Clinical manifestations: Dry unproductive cough or cough with sticky sputum scanty in amount or blood-tinged, afternoon fever, feverish sensation in palms and soles, dry mouth, night sweating, red tongue, thing and rapid pulse.
2. Pathology: This syndrome is usually due to chronic lung disease which consumes the yin of the lung and results in insufficiency of body fluid. The lung is deprived of nourishment resulting in dysfunction in dispersing and descending, and producing dry mouth. Xu (deficiency) of yin causes endogenous heat, which squeezes out body fluid and injures the vessels. Afternoon fever, feverish sensation in palms and soles, night sweating and expectoration of bloody sputum result.
5. Syndromes of the kidney
1. Weakness of the Qi (vital energy) of the kidney.
1. Clinical manifestations: Soreness and weakness of the lumbar region and knee joints, frequent urination, polyuria, dribbling of urine after urination, enuresis, incontinence of urine, nocturnal emission and even infertility, shortness of breath, asthmatic breathing, and thin pulse.
2. Pathology: This syndrome is usually due asthenia after a long illness, senile feebleness or congenital deficiency. Weakness of the Qi of the kidney causes inability of the urinary bladder to control urination, hence the enuresis, incontinence of urine and frequency and urgency or urination. The kidney stores essence. But when the Qi of the kidney is weak, it fails in this function, and nocturnal emission, and even infertility. When the Qi of the kidney, which organ controls the reception of Qi, is weak, it fails to help the lung perform its function of descending. Subsequent upward attack of the Qi of the lung results in shortness of breath and asthmatic breathing.
2. Insufficiency of the yang of the kidney
1. Clinical manifestations: There may occur the same manifestations as in the syndrome of weakness of qi of the kidney, chiefly aching and coldness of the lumbar region and knee joints, chilliness, pallor, impotence, edema of the lower limbs, pale tongue, deep and thin pulse.
2. Pathology: This syndrome usually occurs after a prolonged illness in which the yang of the kidney is injured. It maybe due to excess sexual activity, which injures the yang of the kidney. In either case, the yang of the kidney fails to warm the body, which explains the chilliness, aching and coldness in the lumbar region and knee joints, and impotence.
3. Insufficiency of the yin of the kidney.
1. Clinical manifestations: Manifestations may be similar to those in the syndrome of weakness of the Qi of the kidney.
2. Pathology: This syndrome usually occurs after a long illness in which the yin of the kidney is impaired. It may be due to over indulgence in sex, which consumes the essence of the kidney. Xu (deficiency) of yin causes endogenous heat which consumes body fluid, the result being a feverish sensation in palms and soles, night sweating, hot deep-yellow urine and constipation.
6. Syndromes of the pericardium – The syndromes of the pericardium seen clinically are invasion of the pericardium by heat. Their main manifestations are high fever, coma and delirium due to the sinking of pathogenic heat deep into the interior which disturbs the mind.
7. Syndromes of the small intestine – Disturbance of the function of the small intestine in digestion and absorption is usually included in dysfunction of the spleen in transportation and transformation.
8. Syndromes of the gall bladder
9. Damp-heat in gall bladder
1. Clinical manifestations: The sclera and skin are bright yellow. Complaints of pain in the coastal and hypochondria region or severe pain in the right upper abdomen with bitter taste in the mouth. Some patients may vomit sour bitter fluid. The tongue coating is yellow and sticky.
2. Pathology: The function of the gall bladder to store and excrete bile depends upon the normal function of the liver in promoting the free passage of Qi. Exogenous pathogenic dam-heat, heat caused by depression of the liver, or endogenous damp-heat caused by long indulgence in alcohol or rich food may accumulate in the liver and gall bladder and impair their function in promoting the unhindered passage of Qi so that bile cannot be secreted and excreted freely. An overflow of bile causes jaundice, bitter taste in the mouth and vomiting of sour and bitter fluid. Stagnation of the Qi of the liver and gall bladder leads to stagnation of blood, causing hypochondriac and colicky pain in the right upper abdomen. This syndrome is closely related to the liver, it is also known as the syndrome of damp-heat in the liver and gall bladder.
10. Syndromes of the stomach
1. Retention of food in the stomach
1. Clinical manifestations: Pain in the epigastric region, loss of appetite, foul belching and sour regurgitation. There may be vomiting and the tongue has a thick sticky coating.
2. Pathology: This syndrome is usually caused by overeating, which leads to the retention of undigested food in the stomach. The Qi of the stomach ascends instead of descending as it should.
2. Retention of fluid in the stomach due to cold
1. Clinical manifestations: Fullness and dull pain in the epigastric region which is generally aggravated by cold and alleviated by warmth, succession-sound in the epigastric region, vomiting of watery fluid, white sticky tongue coating, thin or slow pulse.
2. Pathology: This syndrome usually follows chilling after being caught in rain, or eating to much raw or cold food. In either case, the cold is congealed in the stomach causing stagnation of its Qi and causing pain. Prolonged illness injures the yang Qi of the spleen and stomach so that the body fluid is retained into stomach instead of being transported and transformed, hence the vomiting of watery fluid and suction-sound in the epigastric region.
3. Hyperactivity of the fire of the stomach
1. Clinical manifestations: Burning pain in the epigastrium, thirst, and preference for cold drinks, vomiting undigested food or sour fluid, swelling and pain of the mouth, ulceration and bleeding, foul breath, red tongue with dry yellow coating.
2. Pathology: This syndrome is usually due to over eating of rich food, which accumulates heat in the stomach. The heat consumes body fluid and causes the Qi of the stomach to ascend. Foul breath and mouth ulceration are due to fire element in the stomach.
4. Syndromes of the large intestine
1. Damp-heat in the large intestine.
1. Clinical manifestations: Fever, abdominal pain, loose dark stools with offensive smell, and frequency of bowel movements. The stool may have red and white mucus in it with a burning sensation of the anus, and tenesmus. The tongue is red with yellow coating and pulse rolling and rapid.
2. Pathology: This syndrome is usually caused be eating too much raw or cold food, or eating unclean or spoiled food. It may also be due to invasion by pathogenic summer heat and damp. Damp-heat accumulates in the large intestine and blocks the passage of Qi, causing disturbance in it function of transmission and transformation, producing diarrhea, abdominal pain and dark, foul-smelling stools. Damp-heat may injure the blood vessels of the large intestine, producing the red mucus in the stool. Damp-heat presses downward, causing burning sensation in the anus, and tenesmus.
2. Stasis of the large intestine
1. Clinical manifestations: Expansion and fullness in the abdomen, abdominal pain intensified upon pressure, constipation, nausea and vomiting, white sticky tongue coating, deep pulse of the Shi type.
2. Pathology: This syndrome is usually due to retention of food, parasites or blood stagnation causing obstruction of Qi and functional derangement of the large intestine, causing the constipation, abdominal expansion and pain. The nausea vomiting result from the Qi of the large intestine impeding of descending of the Qi of the stomach.
3. Stagnation of blood and heat in the large intestine
1. Clinical manifestations: Severe or drilling fixed pain in the lower abdomen which the patient is reluctant to have pressed, constipation or mild diarrhea. There may be fever and vomiting, red tongue with yellow sticky coating.
2. Pathology: This syndrome is usually due to in adaptability of the individual to weather changes, over eating, or vigorous walking which causes stagnation of heat and blood and retardation of Qi. Heat injures the vessels of the large intestine, causing local inflammation or abscess formation – the cause of the drilling pain in the lower abdomen. If the stomach is affected by failure of its Qi to pass downward, there may be nausea and vomiting.
11. Syndromes of the urinary bladder
1. Damp-heat in the urinary bladder
1. Clinical manifestations: Frequency and urgency of urination, difficult urination scanty in amount and with reddish tinge, burning pain in the urethra. There may be blood clots or stones in the urine, red tongue with yellow coating, fairly rapid pulse.
2. Pathology: Damp-heat injures the urinary bladder, causing disturbance in its function of storing and discharging urine, and producing the frequency and urgency of urination. When damp-heat injures the blood vessels of the urinary bladder there may appear stagnation of blood and heat, leading to hematuria or blood clots in the urine. Prolonged retention of damp-heat in the bladder will result in the formation of stones.
2. Disturbance in the function of the urinary bladder
1. Clinical manifestations: Dribbling urination, week stream, or even retention of urine, accompanied by weakness of the lumbar region and knee joints, intolerance to cold, pallor, pale tongue with white coating deep thin pulse of the Xu type.
2. Pathology: This syndrome is usually due to insufficiency of the yang of the kidney and impairment of its function of dividing the clear fluid from the turbid, which further causes disturbance of the urinary bladder in discharging urine and the above mentioned symptoms. Manifestations of cold follow insufficiency of the yang of the kidney, such as intolerance to cold, cold extremities, weakness of the lumbar region and knee joints and pallor.
12. Sanjiao syndromes are involved in syndromes of the Zang and fu organs relating to the upper, middle and lower jiao. Obstruction of the upper jiao.
3. Differentiation of syndromes according to the theory of channels and collaterals –
4. This is to differentiate diseases on the basis of the physiology of channels and collaterals. It gives direct guidance to clinical therapy by acupuncture and moxibustion.
5. As each of the channels follows its specific course of circulation, the free flowing of the Qi of the channel and sufficiency of the Qi (vital energy) and blood, or their opposites, are bound to be manifested at the area supplied by the channel. The twelve regular channels respectively connect with and pertain to the Zang-fu organs. Disorders of the channels may affect the corresponding Zang-fu organs, and disorders of the Zang-fu organs will be reflected at the corresponding channels. To determine which channel is affected by studying the location and characteristics of the symptoms and signs.
6. The main pathological manifestations of the twelve regular channels and the eight extra channels may be described as follows:
1. Pathological manifestations of the 12 regular channels
1. The lung channel of hand-taiyin. Cough, asthma, hemoptysis, congested and sore throat, sensation of fullness in chest, pain in the supraclavicular fossa, shoulder, back and the anterior border of the medial aspect of the arm.
2. The large intestine channel of the hand-yangming. Epistaxis, watery nasal discharge, toothache, congested and sore throat, pain in the neck anterior part of the shoulder and anterior border of the extension aspect of the upper limb, borborygmus, abdominal pain, diarrhea, and dysentery.
3. The stomach channel of the foot-yangming. Borborygmus, abdominal expansion, edema, epigastric pain, vomiting, feeling of hunger, epistaxis, deviation of the eyes and mouth, congested and sore throat, pain in the chest, abdomen and lateral aspect of the lower limbs, fever, mental disturbance.
4. The spleen channel of foot-taiyin. Belching, vomiting, epigastric pain, abdominal expansion, loose stools, jaundice, sluggishness and general malaise, stiffness and pain at the root of the tongue, swelling and coldness in the medial aspect of the thigh and knee.
5. The heart channel of hand-shaoyin. Cardialgia, palpitation, hypochondriac pain, insomnia, night sweating, dryness of the throat, thirst, pain in the medial aspect of the upper arm, feverishness in palms.
6. The small intestine channel of hand-taiyang. Deafness, yellow sclera, sore throat, swelling of the check, expansion and pain in the lower abdomen, frequent urination, pain along the posterior border of the lateral aspect of the shoulder and arm.
7. The urinary bladder channel of foot-taiyang. Retention of urine enuresis, mental disturbance, malaria, ophthalmodynia, lacrimation when exposed to wind, nasal obstruction, rhinitis, epistaxis, headache, pain in the nape, upper and lower back, buttocks and posterior aspect of lower limbs.
8. The kidney channel of foot-shaoyin. Enuresis, frequent urination, nocturnal emission, impotence, irregular menstruation, asthma, hemoptysis, dryness of the tongue, congested and sore throat, edema, lubago pain along the spinal column and the medial aspect of the thigh, weakness of the lower limbs, feverish sensation in soles.
9. The pericardium channel of hand-jueyin. Cardialgia, palpitation, mental restlessness, stifling feeling in chest, flushed face, swelling in the axilla, mental disturbance, spasm of the upper limbs, feverishness in palms.
10. The sanjiao channel of hand-shaoyang. Abdominal expansion, edema, enuresis, dysuria, deafness, tinnitus, pain in the outer canthus, swelling of the checks, congested and sore throat, pain in the retroauricular region, shoulder, and lateral aspect of the arm and elbow.