1 Relationship between two principles in a pair
The relationship between two principles in a pair manifests as combination or mixture of the syndromes, transformation of syndromes and false manifestations in certain syndromes.
2.1.5.1.1 Relationship between extemal and internal syndromes
During the course of disease and under certain conditions, there may appear simultaneous internal and external disorder, transmission of pathogenic factors from the exterior into the interior and from the interior to the exterior.
Simultaneous external and internal disorder: At the same stage, there appear both external syndrome and internal syndrome. The causes of such a morbid condition are various. It may be caused by invasion of pathogenic factors into both the external and internal phases marked by appearance of both external syndrome and internal syndrome at the early stage, or by transmission of pathogenic factors into the interior when the external syndrome is not cured yet, or by contraction of new disease when old one is not cured yet, such as internal impairment followed by contraction of exogenous disease or contraction of exogenous disease followed by improper diet, etc.
Simultaneous appearance of both external and internal syndromes often appears together with cold and heat as well as asthenia and sthenia, usually manifesting as external heat and internal cold, external cold and internal heat as well as external sthenia and internal asthenia, etc. which will be discussed in the following sections.
External and internal transmission: During the course of disease and under certain conditions, external pathogenic factors fail to be relieved and transmit into the interior, bringing about internal syndrome; in some internal syndromes, pathogenic factors transmit from the interior to the exterior and produce some external symptoms.
Transmission of exterior pathogenic factors into the interior: Internal syndrome appears after external syndrome and external syndrome disappears with the appearance of the internal syndrome. Such a morbid condition is caused by hyperactivity of pathogenic factors, or by frequent deficiency of healthy qi, or by improper nursing, or by delayed or erroneous treatment that reduces resistance of the body and leads to transmission of pathogenic factors from the external to the internal. This morbid condition is usually seen in the course of exogenous diseases. For example, external syndrome manifests such symptoms like aversion to cold, fever, headache and body pain, whitish thin fur and floating pulse, etc. Transmission of exterior pathogenic factors into the interior and external syndrome transfo into internal syndrome can be distinguished by such changes like disappearance of aversion to cold and aversion to heat together with high fever, thirst with desire to drink, reddish tongue with yellowish fur and fast pulse, etc.
Transmission of pathogenic factors from the interior to the exterior: Under certain conditions in some internal syndromes, pathogenic factors transmit from the interior to the exterior, leading to the appearance of some external symptoms and alleviation of the internal syndrome. This is the result of proper treatment and nursing that have strengthened the resistance of the bod.y and driven pathogenic factors out of the body. For example, high fever, restlessness, chest oppression, cough and dyspnea in primary disease followed by disappearance of fever after sweating, or eruption of measles and milliaria alba as well as alleviation of restlessness, chest oppression, cough and dyspnea is the sign of pathogenic factors transmitting from the internal to the external.
Transmission of pathogenic factors from the exterior to the interior is a sign of aggravation of pathological changes, while transmission of pathogenic factors from the interior to the exterior signifies the decline of disease. Cognition of such changes is significant for judging the development and changes of diseases.
2.1.5.1.2 Relationship between cold syndrome and heat syndrome
Cold syndrome and heat syndrome, though different in nature, are correlated. They may simultaneously appear in one patient and manifest as mixture of cold and
heat. Under certain conditions, they may transform into each other. During the development of diseases, especially at severe stage, there may appear such phenomena like false cold and false heat.
Mixture of cold and heat: Cold syndrome and heat syndrome appear at the same time in one patient. It may be one stage at the development of a disease or signify two syndromes in one patient, i.e. a cold syndrome and a heat syndrome. The commonly encountered ones are upper heat and lower cold, upper cold and lower heat, external
cold and internal heat as well as external heat and internal cold.
Upper heat and lower cold syndrome:For example, there are heat symptoms like feverish sensation in the chest, halitosis and swelling pain of gums in the upper part of the body accompanied by cold symptoms like abdominal pain and preference for warmth and loose stool in the lower part of the body.
Upper cold and lower heat syndrome: For example, there are cold symptoms like cold stomachache, reduced appetite and vomiting clear drool in the upper part of the body accompanied by heat syndromes like scanty brownish urine, frequent micturition and painful urination in the lower energizer due to cold in the stomach and heat in the bladder.
External heat and internal cold syndrome: This syndrome is usually caused by frequent existence of internal cold complicated by invasion of pathogenic heat; or by impairment of yangqi in the spleen and stomach in external heat syndrome due to excessive taking of cold drugs. For example, in patients with asthenia of spleen and kidney yang complicated by invasion of exogenous pathogenic heat, there appear borborygmus, abdominal pain and diarrhea with indigested food cornplicated by fever, slight a version to wind and cold, headache and swelling sorethroat, etc.
External cold and internal heat syndrome.. This syndrorne may be caused in two ways. One is frequent existence of internal heat complicated by invasion of wind and cold. For example, manifestations of hyPeractivity of liver fire like susceptibility to irritation, flushed complexion, red eyes, dizziness, distending headache, bitter taste and dryness in the mouth are complicated by external cold symptoms like aversion to cold, fever, anhidrosis and cough. The other is cold pathogenic factors transmitting into the internal and transforming into heat prior to the relief of external cold. For example, symptoms of external cold syndrome like severe aversion to cold and slight fever, pain of head and body, anhidrosis and floating pulse followed by internal transmission of Pathogenic cold and continuous existence of external cold with the symptoms of internal heat syndrome like aggravation of fever, thirst, restlessness and reddish tongue.
In dealing with simultaneous appearance of cold syndrome and heat syndrome, trials should be made to distinguish the upper and the lower as well as the external and the internal. The differentiation of whether the cold is principal or secondary or whether heat is principal or seeondary is also essential for establishing therapeutic principles and deciding treatment.
Inter-transformation of cold and heat: Cold syndrome or heat syndrome of diseases signifies the conditions of yin and yang in the body. Under certain conditions, the states of yin and yang in the body vary. The cold or heat nature of the syndrome changes accordingly.
Transformation of cold syndrome into heat syndrome:
The patient shows cold syndrome first, and then heat syndrome. The cold syndrome disappears after the appearance of the heat syndrome. For example, the patient is
attacked by pathogenic cold and shows symptoms of external cold syndrome, such as aversion to cold, fever, headache and body pain, no sweating, white fur and floating-tense pulse. As the pathological conditions further develop, the cold pathogenic factors transmit into the interior and transform into heat, bringing about symptoms of internal heat syndrome, such as disappearance of aversion to cold, high fever, dysphoria, thirst, yellow fur and fast pulse, etc.
Transformation of heat syndrome into cold syndrome: The patient shows heat syndrome first, and then cold syndrome. When cold syndrome appears, heat syndrome disappears. Such a transformation may be either sudden or gradual. For example, chronic heat dysentery consumes yangqi and gradually transforms into asthenic cold dysentery. This transformation is slow. In patients with high fever, yang leakage with profuse sweating or yang exhaustion with excessive vomiting and diarrhea will lead to symptoms of asthenic cold syndrome (depletion of yang), such as sudden decrease of body temperature, cold limbs, pale complexion and indistinct pulse. This transformation is sudden.
The transformation between cold syndrome and heat syndrome lies in the confliction between pathogenic factors and healthy qi. Transformation of cold syndrome into heat syndrome indicates that the healthy qi is strong, yangqi is exuberant and pathogenic factors transforms into heat with yang. Such a morbid condition, though indicating further development of the pathological conditions, suggests normal strength of the healthy qi that is capable enough of resisting invasion of pathogenic factors.
Transformation of heat syndrome into cold syndrome indicates decline of the healthy qi, consumption of yangqi and no strength to resist pathogenic factors, suggesting predominance of pathogenic factors and asthenia of healthy qi, failure of the healthy qi to dominate over pathogenic factors and worsening of the pathological conditions.
False and true manifestations of cold and heat: In the development of certain diseases, especially at the critical stage of some severe diseases, cold syndrome or heat syndrome may show some manifestations contrary to the nature of the disease, therefore bringing about true cold and false heat syndrome or true heat and false cold syndrome. False manifestations usually cover up the nature of disease. In clinical treatment, cares should be taken to distinguish true manifestations from the false ones to avoid erroneous diagnosis.
True cold and false heat syndrome: Cold syndrome shows false heat symptoms. For example, in some patients with severe yang asthenia and internal cold syndrome, there appear such symptoms like cold limbs, dispiritedness, indigested diarrhea, clear and profuse urine and pale tongue with white fur together with the symptoms like heat syndrome, such as flushed complexion, feverish body, thirst and large pulse. However, flushed complexion only occasionally appears on the cheeks with pale complexion; the body is feverish, but the patient still wants more clothes and quilt; though thirsty, the patient prefers hot water and does not drink much; though large, the pulse is weak when pressed. Such a morbid condition is caused by internal exuberance of cold which drives declining yang outward known as ¡°predominant yin rejecting yang¡±.
True heat and false cold syndrome: Heat syndrome shows false cold manifestations. For example, in some
patients with severe internal heat syndrome, there appear symptoms of fever, thirst with preference for cold drinks, restlessness, scanty brownish urine, retention of dry feces and reddish tongue with yellow fur together with symptoms like cold syndrome, such as cold limbs and sunken pulse, etc. However, the patient feels cold in limbs, but scorching feverish over the chest and abdomen with aversion to heat; though sunken, the pulse is fast and powerful. This is due to internal exuberant heat stagnates yangqi and prevents it to reach the limbs. Such a morbid condition is caused by internal exuberant yang driving yin outward, known as ¡°exuberant yang rejecting yin¡±. Under such a condition, the severer the internal heat, the colder the limbs, which is known as ¡°severer heat and severer cold¡±.
Key points for differentiating false and true cold and heat syndromes.
Firstly, false manifestations usually appear over the complexion, limbs and superficies. However, the changes of viscera, qi, blood and body fluid are essential. So the manifestations of internal syndrome should be taken as the evidence for diagnosis, such as whether there are thirst, preference and aversion and how the tongue conditions and pulse states are.
Secondly, pay attention to the difference between false manifestations and true ones. For example, in false heat syndrome, flushed complexion only appears on the forehead and cheeks, and the colour is light, tender, floating and occasional; while flushed complexion in the true heat syndrome involves the whole face. Take false cold syndrome for example, though the limbs are cold, the patient does not want more clothes and quilt and the chest and abdomen feel scorching feverish; in true cold syndrome, cold limbs appears together with huddled posture in sleep and need more clothes and quilt.
2.1.5.1.3 Relationship between asthenia syndrome and sthenia syndrome
In the development of diseases, asthenia of healthy qi and sthenia of pathogenic factors oppose each other and are also related to each other. Therefore, asthenia syndrome and sthenia syndrome may appear simultaneously or transform into each other and appear in sequence. At the critical stage of diseases, there may appear false sthenia and false asthenia manifestations.
Mixture of asthenia and sthenia: Asthenia of healthy qi and sthenia of pathogenic factors exist simultaneously at the same stage in a patient. This morbid conditions is usually caused by pathogenic factors in a sthenia syndrome impairing healthy qi, or by invasion of new pathogenic factors in an asthenia syndrome with deficiency of healthy qi, or by accumulation of pathological substances in the body due to deficiency of healthy qi and dysfunction of viscera in an asthenia syndrome. Mixture of asthenia and sthenia may be a stage in the development of a disease or may appear as two syndromes at the same time in a patient in which one is asthenia and the other sthenia. This morbid condition may be further divided into asthenia syndrome complicated by sthenia, sthenia syndrome complicated by asthenia and equality of asthenia and sthenia according to the levels of asthenia and sthenia.
Sthenia syndrome complicated by asthenia: This syndrome is marked by predominance of pathogenic factors complicated by asthenia of healthy qi. For example, in an internal sthenic heat syndrome with the manifestations of high fever, flushed complexion, dysphoria, sweating, reddish tongue and full and large pulse, there appear at the same time such symptoms like thirst, scanty brownish urine and retention of dry feces. Such a morbid
condition is due to consumption of body fluid by predominant heat and exuberance of pathogenic heat.
Asthenia syndrome complicated by sthenia: This syndrome is marked by deficiency of healthy qi complicated by retention of sthenic pathogenic factors. For example, at the advanced stage of seasonal febrile disease, there appear such symptoms like low fever, dispiritedness, dry mouth, poor appetite, furless tongue and thin pulse, etc. Such a morbid condition is typical of asthenia syndrome complicated by sthenia marked by deficiency of healthy qi due to impairment of qi and yin by remaining heat.
Equality of asthenia and sthenia: This syndrome is marked by equal degree of the deficiency of healthy qi and sthenia of pathogenic factors. For example, tympanites due to failure of asthenic spleen and kidney yang to transform qi and transport fluid is marked by manifestations of sthenia syndrome like drum-like abdomen and scanty urine as well as by symptoms of asthenia syndrome like aversion to cold, cold limbs, pale complexion, aching weakness of loins and knees and deep-thin pulse, etc. In such a morbid condition, the degree of the deficiency of healthy qi and the degree of the sthenia of pathogenic factors are practically equal.
Transformation of asthenia and sthenia: In the development of a disease, the confliction of pathogenic factors and healthy qi is usually signified by transformation of asthenia and sthenia. Such a transformation usually appears as transformation of sthenia into asthenia and development of asthenia into sthenia in clinical practice.
Transformation of sthenia syndrome into asthenia: This transformation is marked by sthenia syndrome followed by asthenia syndrome in the course of a disease. Such a transformation of syndrome is usually due to hyperactivity of pathogenic factors, or retention of pathogenic factors in the body and impairment of healthy qi due to erroneous treatment and delayed treatment. For example, at the primary stage of exogenous disease, there appear such symptoms like high fever, flushed complexion, restlessness, or even coma and delirium, reddish tongue with yellow fur as well as full and large pulse which are the manifestations of sthenic heat syndrome. At the advanced stage, there appear such symptoms like dispiritedness, emaciation, dry throat and mouth, tremor of hands and feet, reddish and dry tongue, furless tongue as well as thin and fast pulse which signify the transformation of sthenia syndrome into asthenia syndrome due to prolonged retention of pathogenic heat exhausting liver and kidney yin in spite of the fact that pathogenic heat has already been eliminated.
Development of asthenia into sthenia: Such a development is marked by appearance of symptoms of sthenia syndrome in an asthenia syndrome due to deficiency of healthy qi, hypofunction of viscera and retention of such substances like phlegm, food, dampness, fluid and blood stasis in the body. For example, in the aged there usually appear such symptoms like palpitation and shortness of breath (which is worsened after movement and difficult to heal) followed by occasional chest oppression and stabbing pain, purplish tongue and thin and astringent pulse, etc. Such pathological changes are due to gradual asthenia of yangqi in the heart in the aged. The prolonged asthenia of yangqi in the heart is unable to transport blood, leading to slow circulation of blood and obstruction of the heart vessels. Though there appear chest oppression and stabbing pain, purplish coloration of the tongue
and retention of blood stasis, asthenia of yangqi in the heart still exists. That is why the nature of the syndrome
is mixture of asthenia and sthenia.
False and true manifestations of asthenia and sthenia: During the development of a disease, some asthenia syndromes and sthenia syndromes may show some false manifestations contrary to the nature of the disease known as true asthenia and false, sthenia syndrome and true sthenia and false asthenia syndrome. In the differentiation of syndromes, trials should be made to distinguish the false from the true in the complicated manifestations so as to differentiate the nature of disease.
True sthenia and false asthenia syndrome: The disease is essentially sthenic with the manifestations of some astbenic symptoms. Such a syndrome is usually caused by retention of sthenic pathogenic factors preventing yangqi or qi and blood from warming and nourishing the body. For example, in the sthenic heat syndrome due to retention of heat in the intestines and stomach, the appearance of cold limbs, loose stool and deep and slow pulse are like the manifestations of asthenic cold syndrome. However, the patient feels cold in limbs but scorching feverish over the chest and abdomen; the stool is loose, but foul in smell and yellow in colour, and the abdomen is painful and unpalpable; the pulse is deep and slow, but appears powerful when pressed. True sthenia and false asthenia syndrome is just what was known as ¡°asthenic manifestations in severe sthenia condition¡± in the past. Clinically attention should be paid to the differentiation of mixture of asthenia and sthenia syndrome due to consumption of healthy qi by sthenic pathogenic factors.
True asthenia and false sthenia syndrome: The disease is essentially asthenic with the manifestations of sthenia-like symptoms. Such a syndrome is usually caused by deficiency of yangqi due to prolonged disease fails to warm and transport, leading to hypofunction of the viscera.However, sthenic pathogenic factors have not been developed yet. For example, insufficiency of gastrosplenic qi and dysfunction of the spleen bring about some sthenia-like symptoms, such as abdominal distension and fullness or pain. Though there is abdominal distension and fullness, it is alleviated occasionally, unlike that of sthenia syndrome which never attenuates; though there is abdominal pain, but it is palpable, unlike that of sthenia syndrome which is unpalpable. True asthenia and false sthenia syndrome was known as "sthenia manifestations in severe asthenia syndrome" in the past. Clinically attention should be paid to the differentiation of mixture of asthenia and sthenia syndrome due to development of asthenia into sthenia syndrome.
Key points for differentiate true and false asthenia and sthenia:
Tongue states.: Tough tongue with thin fur is usually of sthenia syndrome; bulgy and tender tongue with thin fur is usually of asthenia syndrome.
Pulse conditions: Powerful pulse with spirit is of sthenia syndrome; weak pulse without spirit is of asthenia syndrome. Attention should be taken to differentiate whether the sunken pulse is weak or strong.
Voice: Sonorous voice is of sthenia syndrome; low and timid voice is of asthenia syndrome.
History of disease: This includes the constitution of the patient, causes of illness, duration of illness and treatment. Generally speaking, patients with strong constitution usually suffer from sthenia syndrome, while patients with weak constitution usually suffer from asthenia syndrome; diseases caused by six exogenous pathogenic factors are of sthenia, while diseases due to overstrain and chronic diseases are often of asthenia; new disease is usually sthenic , while chronic disease is often asthenic.
