Syndrome Differentiation. REVIEW Dr Igor Mićunović Ph.D

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1 Syndrome Differentiation REVIEW Dr Igor Mićunović Ph.D

2 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.

3 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.

4 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.

5 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.

6 The eight principle syndromes

7 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.

8 Complicated as the clinical manifestations of diseases may be, they are classified under the eight principles. 1. the classification of syndromes Yin or Yang; 2. the location of disease exterior or interior; 3. the nature of disease cold or heat; 4. the states of health Qi and pathogenic factors deficiency or excess

9 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.

10 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.

11 Exterior syndrome 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. Battlefield border

12 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.

13 Symptom 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.

14 Principle of treatment Relieve the exterior syndrome with drugs pungent in flavor ginger

15 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.

16 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

17 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.

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

19 Identification of exterior and interior syndrome Exterior syndrome Interior syndrome New disease, short duration Fever, aversion to cold, or to wind White thin tongue coat (relatively normal) Superficial pulse Old disease, long duration Fever caused by exogenous pathogens but without aversion to cold or to wind; or fever due to endogenous damages 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.

20 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.

21 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.

22 Main points for distinguishing exterior and interior syndrome 1. 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 2. 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 3. Pulse condition Exterior syndrome superficial pulse Interior syndrome deep pulse

23 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.

24 Symbol of heat and cold syndrome Heat syndrome Cold syndrome

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

26 Symptom 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

27 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.

28 Symptom 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

29 Identification of cold and heat syndrome Cold syndrome Aversion to cold, cold limbs, 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 Fever, aversion to heat, preference for cold Dry mouth, thirst, desire for cold fluid Flushed complexion, congested eyes Restlessness Short micturition, with dark coloured urine Dry stools Red tongue with yellow dry coat Rapid pulse

30 Principle of treatment Cold syndrome Warm to expel cold Heat syndrome Clear away heat and reduce fire

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

32 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.

33 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

34 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.

35 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

36 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

37 Principle of treatment Nourish the deficiency Reinforce Yang in case of Yang deficiency Reinforce Yin in case of Yin deficiency

38 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.

39 Common manifestations 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.

40 Principle of treatment Reduce the excess Different methods for reducing the excess should be used depending on different pathogenic factors.

41 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

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

43 Item Deficiency Excess Fever Aversion to cold Tongue Burning sensation in the chest, palms, soles, and slight afternoon fever Alleviated by warmth Flaccid with little or no coating High fever Not alleviated by warmth Thick coating Pulse Forceless Forceful

44 Treatment principles Deficiency syndrome replenish Excess syndrome purge

45 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.

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

47 1.Yin syndrome is characterized by deficiency of Yang Qi and excess of Yin in the body. Different symptoms are show in different Yin syndromes.

48 Manifestation The Yin syndrome is a generalization of interior, cold, and deficiency syndromes. 1. Listlessness, lassitude and low voice are the manifestations of deficiency syndrome. 2. Cold form, chills in the limbs, absence of thirst,,foul stools and increased amount of clear urine are the signs of exterior cold. 3. Pale and enlarged tongue, deep and slow pulse, or weak, thready and choppy pulse indicate deficiency cold.

49 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.

50 Manifestation The Yang syndrome is a generalization of exterior, heat, and excess syndromes. 1. Aversion to cold and fever seen at the same time are characteristics of the exterior syndrome. 2. Flushed face, restlessness, dry mouth, desire for drink, short micturition with dark color urine are the manifestation of heat syndrome. 3. Loud voice, rough breathing, dry stools are the symptoms of excess syndrome. 4. Dark red tongue with yellow dry coat, the pulse may be superficial rapid, or full and big, or rolling pulse indicate excess heat.

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

52 Differentiation between Yin and Yang syndromes Interrogation Palpation Yin syndrome 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

53 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. 0 nor mal Yi n Yang

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

55 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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