3 Semi-Exterior and Semi-Interior

(3) Semi-Exterior and Semi-Interior

This refers to disease locations situated between the exterior and interior, most commonly due to pathogenic factors invading the Shaoyang Gallbladder Meridian. Clinical manifestations mainly include alternating chills and fever, chest and flank fullness, irritability and nausea, reluctance to eat, bitter taste in the mouth and dry throat, and string-like pulse.

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The identified exterior and interior syndromes are rarely purely exterior or purely interior; in clinical practice, they often appear in complex combinations, such as exterior and interior both being hot, both being cold, both being deficient, both being excess, exterior heat and interior cold, exterior cold and interior heat, exterior deficiency and interior excess, exterior excess and interior deficiency, and so on. As long as one grasps the basic principles for differentiating exterior and interior syndromes, even these complex presentations are not difficult to diagnose correctly. Additionally, if an exterior syndrome develops first and then an interior syndrome emerges, it indicates progression from exterior to interior; if an interior syndrome appears first and then an exterior syndrome arises, it could either be progression from interior to exterior or a newly developed exterior syndrome, though the latter is usually more likely.

3. Cold and Heat

Cold and heat are two fundamental categories for determining the nature of a disease. Cold syndromes are typically caused by cold pathogenic factors or by deficiencies in the zang-fu organs, meridians, muscles, or qi and blood; heat syndromes, on the other hand, are usually triggered by heat pathogenic factors or by excesses in the zang-fu organs, meridians, muscles, or qi and blood. In TCM diagnosis, differentiation between cold and heat is often based on whether the patient feels thirsty, the characteristics of bowel movements, the temperature of the limbs, the pulse, and the tongue coating.

(1) Clinical Characteristics of Cold and Heat

Cold syndromes manifest clinically as cold and non-warm extremities, aversion to cold, pale complexion, lack of thirst but preference for hot drinks, clear and long urine, loose and odorless stools, thin white tongue coating, and slow pulse. Heat syndromes, by contrast, present with fever and thirst, preference for cold drinks, flushed face, restlessness, dry and hard stools, anal burning, short and reddish urine, red tongue with yellow coating, and rapid pulse.

(2) Locations Where Cold and Heat Occur

The occurrence of cold and heat usually has specific locational characteristics, such as the zang-fu organs, meridians, qi and blood, triple burner, and exterior-interior. Cold and heat in the zang-fu organs are discussed in zang-fu differentiation; cold in the meridians is covered in six-channel differentiation; cold and heat in the triple burner are introduced in triple-burner differentiation; qi and blood are shared by all five zang and six fu organs and can also be glimpsed in zang-fu differentiation.

(3) True vs. False Cold and Heat

There are generally two situations: true heat with false cold, and true cold with false heat. In the case of "true heat with false cold," patients exhibit symptoms such as hard, dry stools, abdominal fullness and pain, craving for cold drinks, and short, reddish urine—classic signs of heat—while simultaneously showing pale complexion, cold limbs, and a faint, weak pulse—classic signs of cold. The hallmark of this condition is that at first glance many cold symptoms appear, but upon closer examination, heat is found at the core. This is often referred to as "excessive yang inside, suppressing yin outside," which corresponds to what Western medicine calls "warm shock" or "shock due to acute abdominal conditions." On the other hand, "true cold with false heat" is characterized by a body that feels hot but does not want to remove clothing, a thirst for water but reluctance to swallow, a large, strong pulse that feels weak under firm pressure, a flushed face but cold limbs, and restless limbs yet clear mental state. The defining feature of this condition is that cold resides internally while deficient yang floats outward, often described as "excessive yin inside, suppressing yang outside," sometimes called the "daiyang" syndrome. In Western medical symptomatology, this often corresponds to autonomic nervous system and endocrine disorders.

4. Deficiency and Excess

Deficiency of righteous qi is considered deficiency, while excessive invasion of pathogenic qi is considered excess; the basic meaning of deficiency and excess lies in the relationship between the strength of pathogenic and righteous qi. Constitution varies in strength, pathogenic factors vary in intensity, and treatment differs between tonifying and purging. The purpose of distinguishing deficiency and excess is to determine the correct therapeutic approach. Should one attack or tonify? It all depends on whether the condition is deficient or excess. "If excess, purge; if deficiency, tonify." If the distinction between deficiency and excess is incorrect, even a slight error can lead to major consequences—deficiency treated as excess or excess treated as deficiency is a grave taboo for physicians.

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(1) Clinical Manifestations of Deficiency and Excess

Anyone with insufficient righteous qi or deficiency in yin-yang qi and blood falls under the category of deficiency syndrome. Causes of deficiency include congenital weakness, improper post-illness recuperation, and prolonged illness without proper treatment.

Congenital weakness is mostly attributed to kidney deficiency, while acquired deficiency is mostly attributed to spleen deficiency.

From a modern medical perspective, deficiency syndrome generally refers to the decline of physiological functions. Of course, aside from congenital decline in physiological function, most cases are due to prolonged illness or inadequate post-illness rehabilitation. The most common clinical manifestations of deficiency syndrome include emaciation, low voice, poor appetite, fatigue, blurred vision, hearing loss, pale and swollen tongue, and weak, fine pulse.

Deficiency syndrome is broadly divided into qi deficiency, blood deficiency, yin deficiency, and yang deficiency. Qi deficiency includes spleen qi deficiency, kidney qi deficiency, and lung qi deficiency; blood deficiency includes heart blood deficiency and combined heart-spleen deficiency; yin deficiency includes lung yin deficiency, kidney yin deficiency, and liver-kidney yin deficiency; yang deficiency includes spleen yang deficiency, kidney yang deficiency, combined spleen-kidney yang deficiency, and heart yang deficiency. In recent years, there have been numerous reports on spleen yin deficiency and liver yin deficiency, and several monographs have already been published. These deficiency-related syndromes associated with the zang-fu organs are discussed in detail in zang-fu differentiation.

Any condition characterized by excessive pathogenic qi, where pathogenic qi fiercely clashes with righteous qi, falls under the category of excess syndrome. The fundamental cause of excess syndrome is the conflict between righteous and pathogenic qi. When the body is strong, ordinary pathogenic qi usually cannot cause disease; when the body is weak, ordinary pathogenic qi can indeed trigger illness, but most of these illnesses are actually deficiency syndromes. For example, if pathogenic qi is strong and righteous qi is weak, the resulting illness is often a deficiency syndrome as well; only when both pathogenic and righteous qi are strong does the clash between them result in an excess syndrome. Clinical manifestations of excess syndrome include high fever and intense thirst, hard stools, short and reddish urine, coarse breathing and loud voice, abdominal pain with tenderness to palpation, fever with chills and no sweat, heightened excitement, and a large, powerful pulse.

In summary, during an excess syndrome, physiological functions are in a state of pathological hyperactivity, pathogenic qi is strong, and the body's ability to resist disease is also robust.

(2) True vs. False Deficiency and Excess

The Yizong Baidu states: "Great excess may show signs of deficiency, while extreme deficiency may show signs of excess." Zhang Jingyue adds: "Extreme deficiency may paradoxically present with signs of excess, while great excess may paradoxically present with signs of deficiency—this must be carefully distinguished. For example, if a disease is triggered by emotional disturbances, overeating, exhaustion, alcohol or sexual indulgence, or congenital weakness, and eventually manifests as fever, constipation, bloating, delirium, or pseudo-rash, it may initially appear to be an excess condition, but in reality, it is a deficiency. Similarly, if external pathogenic factors remain unresolved and linger in the meridians, food stagnates and accumulates in the zang-fu organs, or stagnant qi builds up and remains unrelieved, or stubborn phlegm and blood stasis persist, prolonged illness can lead to apparent deficiency, when in fact the underlying condition is excess. In such cases, one should address the root cause rather than being misled by external symptoms." The distinction between true and false deficiency and excess follows the same principle as the distinction between true and false cold and heat: whenever encountering such situations, a comprehensive analysis is required, taking into account the strength of the constitution, the age of the disease, careful examination of symptoms, and detailed pulse diagnosis, in order to discern the genuine from the spurious and retain the truth.

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1. Spleen and Stomach Differentiation

(1) Spleen and Stomach Qi Deficiency

Pale complexion, poor appetite, fatigue, and shortness of breath are the basic symptom cluster of this syndrome. If accompanied by edema, abdominal distension, or loose stools, it is termed "spleen unable to transform"; if accompanied by hemoptysis, hematemesis, hematochezia, or epistaxis, it is termed "spleen unable to control blood"; if accompanied by drooping eyelids, uterine prolapse, gastric prolapse, or wandering spleen, it is termed "middle qi descending." The treatment for spleen and stomach qi deficiency is to strengthen the spleen and replenish qi, with Si Jun Zi Tang (from the Bureau of Formulas) as the foundational formula. For spleen unable to transform, one should strengthen the spleen and replenish qi, dispel dampness, and use Xiang Sha Liu Jun Zi Tang (also from the Bureau of Formulas); for spleen unable to control blood, one should strengthen the spleen and replenish qi, guide blood back to the spleen, and use Gui Pi Tang (from the Jisheng Fang); for middle qi descending, one should strengthen the spleen and replenish qi, raise yang and lift the sinking qi, and use Bu Zhong Yi Qi Tang (by Li Dongyuan). Xiang Sha Liu Jun Zi Tang, Gui Pi Tang, and Bu Zhong Yi Qi Tang are all derived from Si Jun Zi Tang, because spleen unable to transform, spleen unable to control blood, and middle qi descending all stem from spleen and stomach qi deficiency.

(2) Spleen and Stomach Yang Deficiency

This syndrome develops from spleen and stomach qi deficiency, so it still exhibits the four basic symptoms of pale complexion, poor appetite, fatigue, and shortness of breath; however, yang deficiency brings additional symptoms—chilliness and cold limbs, spontaneous sweating. Since the spleen is responsible for transformation, when its function is impaired, abdominal distension, edema, and loose stools appear. These three aspects combine to form the spleen and stomach yang deficiency symptom cluster. The treatment for spleen and stomach yang deficiency is to strengthen the spleen and warm the center, with Lizhong Tang (from the Shanghan Lun) as the foundational formula. This formula is also similar to Si Jun Zi Tang, because spleen and stomach yang deficiency is likewise derived from spleen and stomach qi deficiency.

(3) Cold-Dampness Trapping the Spleen

Headache with chills and fever, fullness in the upper abdomen, nausea and vomiting, intestinal rumbling and diarrhea, slippery and moist pulse—treatment involves releasing exterior cold and dispersing dampness, with Huoxiang Zhengqi San (from the Bureau of Formulas) as the standard remedy. The spleen is inherently weak; once exposed to wind-cold, internal dampness combines with external cold, leading to this syndrome. Therefore, this symptom cluster consists of two parts:

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(5) Exuberant Stomach Fire

Dry mouth, bad breath, oral ulceration, toothache and gum swelling, bleeding gums, burning sensation in the stomach, red tongue with yellow coating, and rapid pulse—treatment involves clearing stomach fire, using Qingwei San (by Li Dongyuan). The hallmark of this syndrome is the oral cavity, because the mouth is the gateway to the spleen and stomach, located at the top, and fire tends to rise upward, directly affecting the mouth, thus forming this syndrome.

(6) Stomach Yin Deficiency

Burning sensation in the stomach, dry mouth with no drinking, red tongue with little coating, and a thin, rapid pulse. At the same time, there are symptoms of bone-steaming heat, five-heart discomfort, and night sweats—treatment involves nourishing yin and strengthening the stomach, using Yangwei Tang (by Ye Tianshi) and Shashen Mai Men Dong Tang (by Zhang Zhongjing). This syndrome comprises two parts:

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It can descend along the meridians to the small intestine, "the small intestine is the organ responsible for receiving and transforming substances, expelling waste," and it has the function of separating clear from turbid. When the small intestine is hot, the urine becomes red and turbid. Oral ulcers occur because the moisture in the small intestine rises upward due to the fiery nature of the fire. For excessive heart fire, treatment involves purging fire and calming the spirit, using Huanglian A Jiao Tang (by Zhang Zhongjing); for heart fire transferring heat to the small intestine, treatment involves guiding the heat downward, using Dao Chi San (from the Pediatric Medicinal Evidence Directly Explained).

(4) Phlegm Obstructing the Heart Orifice

Confusion of consciousness (restlessness, mania, laughter, speech), slippery pulse, and greasy tongue are the basic symptoms of this syndrome. Treatment involves removing phlegm, opening the orifice, and calming the spirit, using Sheng Tie Luo Yin (from the Medical Insights). The heart governs the spirit, and when the heart orifice is blocked, consciousness becomes confused; the slippery pulse and greasy tongue are manifestations of phlegm in the pulse and tongue, because the blockage of the heart orifice is caused by phlegm.

(5) Blood Stasis in the Heart

Pain in the front of the heart, radiating pain to the arms, palpitations and shortness of breath, purple-dark tongue, and a sticky, intermittent pulse are the basic symptoms of this syndrome. Treatment involves activating blood circulation, removing stasis, and promoting the flow of yang, using Guanxin II (a collaborative formula from Beijing) and Gualou Xiebai Banxia Tang (by Zhang Zhongjing). A sticky, intermittent pulse and a purple-dark tongue indicate blood stasis; pain in the front of the heart and palpitations with shortness of breath indicate that the site of blood stasis is in the heart.

3. Liver Disease Differentiation

(1) Liver Qi Stagnation

Bitter taste in the mouth, dry throat, irritability, fullness in the chest and flanks, and string-like pulse are the basic symptoms of this syndrome. If accompanied by abdominal distension, loss of appetite, and nausea, it is liver-stomach disharmony; if accompanied by something stuck in the throat that cannot be swallowed or expelled, it is liver qi rising upward (plum pit syndrome). For liver qi stagnation, treatment involves soothing the liver and relieving qi, using Chaihu Shugan San (from the Jingyue Complete Works); for liver-stomach disharmony, treatment involves soothing the liver and harmonizing the stomach, using Xiaoyao San (from the Bureau of Formulas); for liver qi rising upward, treatment involves soothing the liver and lowering qi, using Banxia Houpu Tang (by Zhang Zhongjing). The liver is naturally upright; when it becomes stagnant, it rebels against the stomach (liver-stomach disharmony) as the first manifestation; when it rises upward and attacks the throat (plum pit syndrome) as the second manifestation. Both are products of liver qi stagnation.

(2) Liver-Gallbladder Fire

Bitter taste in the mouth and dry throat, irritability, fullness in the chest and flanks, dizziness and headache, tinnitus and red eyes, palpitations and shortness of breath, short and reddish urine, and string-like, rapid pulse—treatment involves clearing liver fire, using Longdan Xiegan Tang (from the Medical Treasure Mirror). This syndrome is often caused by long-term stagnation turning into fire, and its basic symptoms consist of two parts:

Liver qi stagnation: bitter taste in the mouth and dry throat, irritability, fullness in the chest and flanks. Fire rising upward: dizziness and headache, flushed face and red eyes, short and reddish urine, rapid pulse.

(3) Liver Yin Deficiency

Dizziness and vertigo, lower back pain and tinnitus, bone-steaming heat, five-heart discomfort, night sweats, numbness and tremors in the limbs, red tongue with little coating, and string-like, thin pulse—treatment involves nourishing water and supporting wood, using Qiju Dihuang Wan (from the Medical Grade).

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The liver and kidneys share a common origin; liver yin draws nourishment from kidney yin, so the manifestations of liver yin deficiency consist of three parts:

(4) Internal Movement of Liver Wind

Clinically, it usually presents in three forms:

Extreme heat generates wind | > Symptoms include high fever, accompanied by palpitations, convulsions, collapse, and string-like, rapid pulse; treatment involves purging fire and calming the spirit, using Lingyang Gouteng Tang (wind and fire agitating each other) | > (from the Popular Treatise on Cold Damage). | > | > Main manifestations are headache and tinnitus, hemiplegia and aphasia, facial and eye deviation (deviation: tilting), convulsions and coma; treatment involves | > Soothing the liver and extinguishing wind, using Zhen Gan Xi Feng Tang (from the Medical Records of the Central and Western Integration). | > | > Main clinical manifestations are tremors, numbness, convulsions, muscle twitching, etc.; treatment involves nourishing blood and extinguishing wind, using Da | > Ding Feng Zhu (from the Warm Disease Differentiation). +----------------------+ Excessive yang generates wind | | (All sudden rigidity belongs to wind) | +----------------------+ Blood deficiency generates wind | (Blood does not nourish the sinews) | (5) Cold stagnation in the Liver Meridian

Lower abdominal pain, shrinkage of the scrotum, and heavy descent of the testicles—treatment involves warming the liver and dispelling cold, using Nuangan Jian (from the Jingyue Complete Works). The lower abdomen, scrotum, and testicles are all areas through which the Foot Jueyin Liver Meridian runs.

4. Lung Disease Differentiation

Lung cold cough | > Symptoms include headache, fever with chills, cough with copious sputum, thin and clear sputum, floating and tight pulse; treatment involves releasing exterior cold, stopping cough and removing phlegm, using | > Ma Huang Tang (from the Shanghan Lun), this syndrome is a wind-cold exterior syndrome combined with cough. | > | > Symptoms include headache, fever with chills (more heat than cold), thirst, frequent drinking, restlessness, cough with sputum, red tongue, and rapid pulse; treatment involves clearing | > heat, ventilating the lungs, and stopping cough, using Ma Xing Shi Gan Tang (from the Shanghan Lun), this syndrome is a wind-heat exterior syndrome combined with cough. | > | > Dry mouth, dry throat, dry nose, cough with sputum, sticky sputum, red tongue with little moisture—treatment involves clearing dryness and saving the lungs, using Qingzao Jiufei Tang | > (from the Medical Gate Law). In TCM, "any dry syndrome must have three drynesses"—dry mouth, dry throat, and dry nose—and this syndrome is composed of these three drynesses | > together with sticky sputum and cough. | > | > Sputum congestion, coughing with difficulty breathing and lying down—treatment involves guiding phlegm and ventilating the lungs, using Suzi Jiangqi (from the Bureau of Formulas) and Tingli Da | > Zaixie Fei Tang (by Zhang Zhongjing). | > | > Pale complexion, shortness of breath, spontaneous sweating, cough with sputum, fat and pale tongue, and moist, thin pulse—treatment involves strengthening the lungs and replenishing qi, using | > Bu Zhong Yi Qi Tang (by Li Dongyuan), which is the main formula for nurturing earth to produce gold. +------------+ Lung heat cough | +------------+ Lung dry cough | +------------+ Phlegm obstructing the lungs | +------------+ Lung qi deficiency | (Continued on next page)

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Kidney does not store essence |

Kidney does not take in qi | For those with basic symptoms of kidney yang deficiency accompanied by shortness of breath and wheezing, treatment involves warming the kidney and taking in qi, using Du Qi Wan (from the Medical Duty Assignment Compilation). Life gate fire declines | > For those with basic symptoms of kidney yang deficiency accompanied by five o'clock diarrhea, treatment involves warming the kidney and stopping diarrhea, using Si Shen Wan (from the Internal Medicine Abstract). Yang deficiency causes water to overflow | For those with basic symptoms of kidney yang deficiency accompanied by generalized or localized edema, treatment involves warming yang and transforming water, using Zhen Wu Tang (by Zhang Zhongjing).

Appendix: ① Lower yuan deficiency and cold: bedwetting, frequent urination, nocturnal urination, cold lower abdomen—treatment involves warming and tonifying the lower yuan, using Suquan Wan (from the Women’s Good Prescription). ② Bladder damp-heat: frequent urination, urgent urination, painful urination, cold lower abdomen—treatment involves clearing heat and draining dampness, using Ba Zheng San (from the Bureau of Formulas).

The above-mentioned zang-fu differentiation clinical symptoms can appear individually, but in most cases, several zang-fu syndromes often occur in combination. For example, heart-spleen deficiency syndrome, spleen-kidney yang deficiency syndrome, liver-kidney yin deficiency syndrome, and so on. Heart-spleen deficiency syndrome results from the combined manifestation of heart blood deficiency and spleen qi deficiency, meaning that it includes both the pale complexion, poor appetite, fatigue, and shortness of breath characteristic of spleen qi deficiency, as well as the palpitations, forgetfulness, insomnia, and frequent dreaming characteristic of heart blood deficiency. The representative formula for treating this syndrome is Gui Pi Tang, which contains ingredients such as dangshen, baizhu, fuling, and huangqi to strengthen the spleen and replenish qi, as well as yuanzhi, yuanrou, and fried jujube seeds to nourish the heart blood. As long as one understands the individual zang-fu syndromes, it is easy to analyze, understand, and recognize their combined clinical manifestations.

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(1) Taiyang Syndrome

Headache, fever with chills, and floating pulse constitute the basic symptom cluster of Taiyang Syndrome. If accompanied by no sweat and tight pulse, it is classified as Shanghan.

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The domestic literature has also observed the cardiac systolic time interval (STI) in patients with coronary heart disease and heart qi deficiency syndrome●, finding that patients with coronary heart disease and heart qi deficiency exhibit prolonged electromechanical systolic time (QS₂), shortened left ventricular ejection time (LVET), prolonged pre-ejection period (PEP), and an increased PEP/LVET ratio, suggesting a close relationship between heart qi deficiency and left ventricular function. Using the PEP/LVET ratio—the most sensitive and reliable indicator of left ventricular function—as the standard, they set the upper limit of normal at 0.37; any value exceeding this threshold was considered indicative of abnormal left ventricular function. Statistical results showed that the abnormality rate was 94.7% in the heart qi deficiency group with coronary heart disease, 91.7% in the heart qi and yin deficiency group with coronary heart disease, while no abnormalities were found among other patients with coronary heart disease. In addition, some researchers used myocardial imaging to examine left ventricular function in patients with heart qi deficiency, confirming that these patients indeed have left ventricular dysfunction. Furthermore, studies on 95 patients with different syndrome differentiation types revealed that cardiac dysfunction, reduced cardiac output, and insufficient blood perfusion to systemic tissues are the pathological basis for the development of heart qi deficiency.

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Functions that it does not possess. In traditional Chinese medicine, the lung’s functions extend beyond respiration; concepts such as “the lung governs qi,” “the lung is associated with the skin and hair,” and “the lung and large intestine are internally related” are all key components of TCM organ theory. In recent years, researchers have conducted experimental studies to explore the essence of these concepts. Although the findings are still preliminary, they do indicate that the functional aspects of the lung in TCM do have a material basis.

1. The Lung and Large Intestine Are Internally Related

In recent years, domestic research has explored the internal relationship between the lung and large intestine through experiments, consistently concluding that this traditional TCM organ theory has a material basis. First, it has been observed that severe intestinal dysfunction—such as various forms of paralytic ileus, mechanical obstruction, and necrotizing enteritis—is often accompanied by respiratory failure. A typical example of concurrent intestinal and respiratory disorders is adult respiratory distress syndrome (ARDS). Why do severe intestinal diseases lead to respiratory complications? Modern medicine has yet to provide a satisfactory answer. However, from the perspective of traditional TCM, the consensus across classic texts like the "Inner Canon" and "Difficult Questions," as well as works on Shanghan and Jin Gui, and all subsequent Tang and Song dynasty writings regarding the relationship between the lung and large intestine, seems entirely logical. This theory has proven effective when applied clinically.

To uncover the true nature of this concept, some researchers conducted a systematic clinical study on 48 ARDS patients, finding that among the 48 cases, 25 had pre-existing intestinal dysfunction prior to the onset of ARDS, while 23 did not. The so-called intestinal dysfunction was not merely ordinary gastrointestinal dysfunction; among the 25 cases, 21 had paralytic ileus, 3 had mechanical obstruction, and 1 had mesenteric arterial embolism, with 16 subsequently developing toxic shock. All 25 patients with severe intestinal dysfunction suddenly developed acute respiratory failure 1–3 days after the onset of intestinal symptoms, characterized by rapid breathing—often exceeding 28 breaths per minute—along with decreased arterial oxygen partial pressure (PaO₂ < 8 kPa), elevated A-aDO₂ (greater than 4 kPa during spontaneous breathing and over 13.3 kPa during pure oxygen administration). These findings clearly demonstrate that severe intestinal dysfunction can lead to lung damage.

Building on these insights, some researchers created animal models by clamping the superior mesenteric artery to induce ischemic intestinal dysfunction, resulting in grade II or higher lesions in the lungs of the affected animals, whereas the lungs of unclamped animals showed no similar changes. At the same time, when equal numbers of animals were subjected to clamping of the renal artery or lower limb arteries, no corresponding pulmonary changes were observed in the same animals. Additionally, comparing groups of animals where the superior mesenteric artery was clamped versus those where no arteries were clamped, the clamped group tested positive for endotoxins in their blood after 90 minutes of clamping, while the unclamped group remained negative for endotoxins even after 90 minutes of exposure to the superior mesenteric artery.

These experiments demonstrate that intestinal dysfunction causes lung lesions, confirming the material basis of the TCM theory that the lung and large intestine are internally related. Preliminary evidence also suggests that this causal relationship may be linked to the production of endotoxins in the bloodstream. Currently, in addition to the aforementioned experiments, some researchers have created permanent semi-ligation at the distal rectum, leading to pulmonary lesions; others have refined the clamping and semi-ligation methods, using external ligation to induce reversible narrowing of the distal rectum, thereby triggering a series of pathological changes in the lungs. The results show that this improved model essentially achieves the intended purpose: a series of pulmonary lesions. Beyond validating the “lung and large intestine are internally related” theory, this approach allows for external release of the narrowing, restoring the model to normal—a feature that not only facilitates repeated use of the model but also provides better conditions for further exploration of the theory's essence. Under this modified animal model, artificial formation of dry stool accumulation in the large intestine leads to signs of Yangming腑实 in the animal model, resulting in specific pulmonary lesions, including pulmonary congestion, pulmonary hemorrhage, and pulmonary necrosis. Electron microscopy reveals swelling and necrosis of alveolar epithelium and macrophages, while other organs remain unaffected. Experiments show that feeding the model animals with Dachengqi Tang significantly improves pulmonary symptoms.

2. The Lung Governs Qi

In TCM, the phrase “the lung governs qi” encompasses not only the lung’s respiratory function but also other intrinsic functions of the lung itself. Research in this area is relatively scarce. According to a report from the Pulmonary Function Research Laboratory of Zhejiang Provincial Hospital of Traditional Chinese Medicine, they selected pulmonary function tests—direct indicators of lung qi activity—to observe and study the lung’s ventilation function. The results showed that in chronic obstructive pulmonary disease, patients with lung qi deficiency exhibited abnormal pulmonary function, while those without lung qi deficiency mostly had normal function, with only a few showing mild abnormalities. Statistical analysis revealed significant differences between the two groups. Among the abnormal cases, most patients with lung qi deficiency suffered moderate to severe ventilation impairment, and these impairments were predominantly mixed-type, markedly more severe than those in the non-deficient group. Many current literature reports consider closed lung volume, flow-volume curves, and lung compliance to be highly sensitive indicators for early diagnosis of small airway diseases.

In clinical practice of TCM, early stages of such diseases often lack clear diagnostic markers, making the measurement of these indicators particularly important. These indicators, ranging from low to high, correspond directly to the degree of lung qi deficiency.

The results obtained from 53 patients without lung qi deficiency in this study indicate that approximately half of them already exhibit microscopic changes indicative of lung qi imbalance. This demonstrates that the concept of lung qi and “the lung governs qi” in TCM does have a material basis. Although experimental research in this area remains limited, it has already provided preliminary evidence. As future research in this field deepens, the true nature of TCM’s lung theory will inevitably be gradually revealed.

(“Integrated Chinese and Western Medicine Research,” March 1997)

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㉑ Liu Youzhang et al. Exploration of the Essence of TCM “Spleen” at the Subcellular Level (to be published)

㉒ Sun Bigang et al. Clinical Exploration of the Essence of TCM Spleen Deficiency. “Journal of Anhui College of Traditional Chinese Medicine,” 1983, Vol. 3, p. 3

㉓ Guangzhou Institute of Traditional Chinese Medicine Spleen and Stomach Research Lab. Exploration of Spleen Theory. “New Traditional Chinese Medicine,” 1980, Supplement (No. 2), p. 1

㉔ Jiang Chuanmei et al. Observation of Certain Immune Indicators in 96 Cases of Chronic Hepatitis and Their Relationship with TCM Syndrome Differentiation. “Journal of Integrated Chinese and Western Medicine,” 1982, Vol. 2, No. 3, p. 147

㉕ Zheng Yuanliang et al. Preliminary Study on Lymphocyte Electrophoresis Measurement in Patients with Spleen Deficiency. “Journal of Integrated Chinese and Western Medicine,” 1988, Vol. 8, No. 2, p. 90

㉖ Zhang Shiping et al. Preliminary Study on the Association Between Five Types of TCM Syndromes Including Spleen Deficiency and Human Leukocyte Antigen. “Journal of Integrated Chinese and Western Medicine,” 1987, Vol. 7, No. 9, p. 53

㉗ Chen Jiewen et al. Exploration of Sympathetic Nervous System Function in Patients with Spleen Deficiency. “Journal of Guangzhou Institute of Traditional Chinese Medicine,” 1984, Vol. 1, p. 59

㉘ Zhang Yuxian et al. Preliminary Exploration of the Essence of Spleen Deficiency. “Journal of Traditional Chinese Medicine,” 1983, Vol. 24, No. 8, p. 72

㉙ Yin Guangyao et al. Study on the Relationship Between Plasma Cyclic Nucleotides and Gastric Mucosal Intestinal Epithelial Metaplasia in Patients with Spleen Deficiency—Analysis of 42 Cases. “Journal of Integrated Chinese and Western Medicine,” 1983, Vol. 3, No. 2, p. 104

㉚ Guangzhou Institute of Traditional Chinese Medicine Spleen and Stomach Research Lab. Research on Spleen Theory. “Chinese Digestive Journal,” 1981, Vol. 1, No. 4, p. 298

㉛ Chen Guozhen. Exploration of the Essence of Liver Depression and Spleen Deficiency. “Journal of Integrated Chinese and Western Medicine,” 1985, Vol. 5, No. 12, p. 732

㉜ Matsumoto Katsuhiko. Discussion on the Five Organs. “Kampo Research,” 1979, Vol. 4, p. 129

㉝ Jin Yiqiang. Exploration of Approaches and Methods for Studying the Essence of TCM Liver Image. “Journal of Integrated Chinese and Western Medicine,” 1990, Vol. 10, No. 2, p. 114

㉞ Jin Yiqiang et al. Study on the Essence of Liver Yang Hyperactivity. “Journal of Integrated Chinese and Western Medicine,” 1988, Vol. 8, No. 3, p. 136

㉟ Liu Yaguang. “Modern Natural Science and TCM Theory.” Fujian Science and Technology Press, 1980, p. 390

㊱ Li En. “Prostaglandins and Modern Medicine.” People’s Health Publishing House, 1985, pp. 29–30

㊲ Wolf S. The Pharmacology of Placebos. Pharmacol Rev 1959, Vol. 11, p. 689

㊳ Wolf S. Effect of Suggestion and Conditioning on the Action of Chemical Agents in Human Subjects—the Pharmacology of Placebo. J Clin Invest 1950, Vol. 29, p. 100

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Wolf Set al. An Experimental Approach to Psychosomatic Phenomena in Rhinitis and Asthma. J Allerg 1950, Vol. 21, p. 1

D Beikof, Yao Chengyu et al. Detailed Explanation of “Cerebral Cortex and Viscera”—People’s Health Publishing House, 1954, pp. 149, 156

④Stron Ds et al., Translated by Jianyu Gan—“Human Neuroanatomy”—Shanghai Science and Technology Press, 1963, p. 322

⑫ Smirnov, Zhu Zhixian et al.—“Psychology”—People’s Education Publishing House, 1957

③Li Shaozhi et al.—“Traditional Chinese Medicine Journal,” 1988, Vol. 29, No. 2, p. 130 Fan Liangqing et al.—“Traditional Chinese Medicine Journal,” 1981, Vol. 23, No. 7, p. 28 Shi Zaixiang et al.—“Traditional Chinese Medicine Journal,” 1982, Vol. 24, No. 12, p. 58 Ren Shusheng et al.—“Tianjin Traditional Chinese Medicine,” 1985, Vol. 2, p. 36

①Wang Jinda et al.—Clinical Significance and Essence of the “Lung and Large Intestine Are Internally Related” Theory in Chinese Medicine—“Journal of Integrated Chinese and Western Medicine,” 1982, Vol. 2, p. 77

B Feng Xuerui et al.—Experimental Study on “Lung and Large Intestine Are Internally Related”—“Tianjin Traditional Chinese Medicine,” 1988, Vol. 4, p. 235

Han Guodong et al.—Experimental Study on the “Lung and Large Intestine Are Internally Related” Theory—“Traditional Chinese Medicine Journal,” 1990, Vol. 2, p. 48

0 Wang Huisheng et al.—Preliminary Exploration of the Relationship Between Lung Qi Deficiency and Changes in Lung Function—“Traditional Chinese Medicine Journal,” 1983, Vol. 2, p. 63

③Liu Zhongyan—Respiratory Physiology of the Airway and Related Respiratory Function Tests—“Zhejiang Medical Journal,” 1980, Vol. 2, p. 943

②Wandai—Small Airway Diseases and Early Diagnostic Methods—“Chinese Journal of Tuberculosis and Respiratory Diseases,” 1979, Vol. 27, p. 113

Basic Principles of TCM Syndrome Differentiation and Treatment by Pei Zhengxue

Over nearly two millennia of development, traditional Chinese medicine has, through dialectical reasoning and symptom-based cause-seeking, established a series of fundamental principles for syndrome differentiation and treatment, including “Eight Principles Differentiation,” “Organ Differentiation,” “Six Meridians Differentiation,” “Wei-Qi-Ying-Blood Differentiation,” “Triple Burner Differentiation,” and “Etiology Differentiation.” These differentiation methods serve as the main framework for TCM’s clinical syndrome differentiation and treatment theory, giving TCM its distinctive characteristics. When integrating Chinese and Western medicine and drawing on the best of both traditions, it is essential to first emphasize the basic principles of TCM syndrome differentiation and treatment in order to fully showcase TCM’s unique advantages, such as its “macroscopic” perspective, “holistic view,” and “view of the body’s response.”

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Clinical syndromes are complex and ever-changing, but ultimately they can be categorized into two main types: excess yin and deficiency yang, or excess yang and deficiency yin. During syndrome differentiation, one must first distinguish between yin and yang, then further differentiate between exterior and interior, cold and heat, deficiency and excess, ensuring a clear hierarchical structure and accurate diagnosis. The “Plain Questions·Great Treatise on the Correspondence of Yin and Yang” states: “Yin and yang are the way of heaven and earth, the guiding principle of all things, the parents of change, the origin of life and death, the abode of the divine, and the foundation of healing—treatment must always seek the root cause.” The “Plain Questions” also says: “A skilled diagnostician first distinguishes yin and yang by observing color and taking the pulse.” Zhang Jingyue further stated: “Whenever diagnosing and treating, one must first examine yin and yang—this is the cornerstone of medical practice. If yin and yang are ignored, treatment will inevitably go awry. Though medical practice may seem complex, it can be summed up in one word: yin and yang.” From this we can see the crucial role of yin and yang in syndrome differentiation and treatment.

(1) Basic Manifestations of Yin and Yang Syndromes

The basic manifestations of yin syndrome include: listlessness, dull complexion, vacant gaze, weak voice, feeling cold with cold limbs, slow movements, poor appetite and little drinking, clear and long urine, loose stools, thin white tongue coating, and a slow, fine pulse. In short, any condition involving decline in bodily functions, nutritional deficiency, or organ degeneration generally falls under the category of yin syndrome.

The basic manifestations of yang syndrome include: exuberant spirit, flushed face, bloodshot eyes, loud voice, aversion to heat and preference for coolness, restlessness and hyperactivity, thirst and coarse breathing, short and reddish urine, dry and hard stools, thick yellow and dry tongue coating, and a rapid, strong pulse. In short, any condition involving heightened bodily functions, adequate nutrition, or new organic changes in organs generally falls under the category of yang syndrome.

However, the yang and yin syndromes encountered in clinical practice are rarely as straightforward as the examples above. More often, they present as “yang within yin” or “yin within yang,” forming complex syndromes such as “exterior and interior combined,” “cold and heat intermixed,” or “deficiency and excess coexisting.” Some patients exhibit yin deficiency with yang excess, others have yin excess with yang deficiency, some suffer from both yin and yang deficiency, while others experience both yin and yang excess. Given the complexity of yin and yang clinical presentations, it is essential during clinical differentiation to clearly identify the true nature of yin and yang, their mutual transformation, and which is predominant, in order to provide an accurate basis for treatment.

(2) Yin Deficiency and Yang Deficiency

The kidneys are the foundation of innate constitution, housing both true yin and true yang. The right kidney serves as the “Mingmen,” containing true yang, while the left kidney contains true yin. When true yin is deficient, it leads to rising false fire, flushed cheeks and red cheeks, lips appearing as if painted with rouge, dry mouth and throat, bone-steaming heat, five-heart vexation, night sweats and nocturnal emissions, a red tongue with little coating, and a fine, rapid pulse. When true yang is deficient, it results in a pale complexion, spontaneous sweating and fatigue, loss of appetite, shortness of breath and reluctance to speak, feeling cold and afraid of cold, abdominal bloating and loose stools, diarrhea at dawn, impotence and nocturnal emissions, heavy and tired legs, a swollen tongue with tooth marks, a thin white coating, a large but weak pulse, and a weak pulse at the cun position.

(3) Loss of Yin and Loss of Yang

The “Plain Questions·On the Flow of Vital Energy to Heaven” states: “When yin and yang separate, vital energy ceases.” Loss of yin and loss of yang represent the imminent separation of yin and yang, serving as dangerous syndromes that appear during disease progression and marking the inevitable path toward death. At such times, it is imperative to make an accurate diagnosis and take immediate, decisive action to implement the most rapid and effective rescue measures, in order to turn danger into safety.

The clinical manifestation of loss of yin includes chest tightness and shortness of breath, warm hands and feet, hot skin, thirst for cold drinks, salty and sticky sweat, a red tongue without moisture, and a fine, rapid pulse.

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Part One: Academic Thought

The clinical manifestation of loss of yang includes a pale face, cold limbs, feeling cold and afraid of cold, spontaneous sweating, a pale and swollen tongue, and a floating, hollow or extremely weak pulse.

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(Shanghan in the narrow sense), with Mahuang Tang as the representative formula; if accompanied by sweating and a slow pulse, it is classified as Zhongfeng, with Guizhi Tang as the representative formula; if accompanied by thirst, it is classified as Wenbing, for which no formula was prescribed in the "Shanghan Lun."

According to the Eight Principles differentiation, the syndromes of Taiyang syndrome can be categorized as follows: Shanghan refers to wind-cold exterior excess, Zhongfeng refers to wind-cold exterior deficiency, and Wenbing refers to wind-heat exterior syndrome. The first two types have clearly defined treatment methods and formulas in the "Shanghan Lun," while the third type, Wenbing, had its treatment methods and formulas proposed later by the Warm Disease School, with representative formulas such as Sangju Yin and Yinqiao San (both from "Wenbing Tiaobian").

(2) Yangming Syndrome

High fever, intense thirst, profuse sweating, and a large, forceful pulse are symptoms of the Yangming meridian syndrome; fullness, distension, dryness, and solid accumulation are symptoms of the Yangming fu syndrome. The representative formula for the meridian syndrome is Baihu Tang; the representative formula for the fu syndrome is Chengqi Tang (including Dachengqi Tang, Xiaochengqi Tang, and Tiaowei Chengqi Tang).

From the perspective of the Eight Principles differentiation, Yangming syndrome falls under the category of interior excess heat syndrome. When the excess heat is more concentrated in the meridians, it is classified as Yangming meridian syndrome; when the excess heat is more concentrated in the fu organs, it is classified as Yangming fu syndrome. The meridian syndrome indicates that the excess heat is dispersed throughout the meridians, while the fu syndrome indicates that the excess heat is concentrated in the fu organs—the former is intangible, while the latter is tangible. "Pi" refers to epigastric fullness and hardness, "man" refers to abdominal distension, "zao" refers to dry, hard stools, and "shi" refers to abdominal pain due to fullness.

(3) Shaoyang Syndrome

Bitter taste in the mouth, dry throat, dizziness, alternating chills and fever, chest and flank fullness and discomfort, irritability and nausea, reluctance to eat—these are the symptoms treated with Xiao Chaihu Tang; if accompanied by headache, chills, and fever, it is considered a Shaoshao combined syndrome, treated with Chaihu Guizhi Tang; if accompanied by constipation and thick yellow tongue coating, it is a Shaoyang-Yangming combined syndrome, treated with Da Chaihu Tang.

According to the Eight Principles differentiation, Shaoyang syndrome is a semi-exterior, semi-interior syndrome. Among the seven symptoms of Shaoyang, as long as one symptom is present, a diagnosis of Shaoyang syndrome can be made. This syndrome is relatively common; many of the systemic reactive syndromes associated with subacute and chronic inflammation in modern medicine fall into this category.

(4) Taiyin Syndrome

Abdominal fullness with vomiting, inability to eat, worsening of diarrhea, and intermittent abdominal pain—these are the symptoms treated with Lizhong Tang. From the perspective of the Eight Principles differentiation, this syndrome belongs to spleen-stomach deficiency-cold syndrome.

(5) Shaoyin Syndrome

The defining features of Shaoyin syndrome are a weak and fine pulse and an overwhelming desire to sleep—treated with Sini Tang. From the perspective of the Eight Principles differentiation, this syndrome belongs to heart-kidney yang deficiency syndrome, with severe yang deficiency potentially leading to yang collapse, requiring urgent resuscitation. Sini Tang is well-suited to this condition. From a modern medical standpoint, this syndrome reflects peripheral circulatory failure.

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(6) Jueyin Syndrome

Thirst, palpitations, burning sensation in the heart, hunger without appetite, and vomiting of worms after eating—these are the symptoms treated with Wumei Wan.

The clinical manifestations of Jueyin syndrome are quite complex, and there is still no consensus among physicians throughout history regarding this syndrome. The above-mentioned symptoms represent only one set of symptoms among many possible manifestations of Jueyin syndrome, and people often regard this set of symptoms as the representative symptoms of Jueyin syndrome. From the perspective of the Eight Principles, this syndrome is a mixed cold-heat syndrome; from a modern medical standpoint, it is classified as intestinal or biliary ascariasis.

The Six Meridians differentiation is the essence of the "Shanghan Lun." It describes six different stages through which external pathogenic cold invades the body and penetrates inward: first attacking the Taiyang meridian, then the Yangming meridian; it is also possible to bypass the Taiyang meridian and directly attack the Yangming meridian. Alternatively, one can move from the Yangming meridian back to the Taiyang meridian, or from the Shaoyang meridian to the Taiyin, Shaoyin, or Jueyin meridians. The "Shanghan Zabing Lun" was compiled at the end of the Eastern Han Dynasty and was scattered during times of war. Although it was later revised by Wang Shuhe, its original complete form remains unverifiable. Throughout history, physicians such as Fang Youzhi and Yu Jiayan have expressed regret over this situation, with Yu using the metaphor of "cutting up beautiful brocade and patching it with scraps of old cloth" ("Shanglun Pian") to describe the shortcomings in the work. Contemporary physician Yan Derun stated: "As for the three yin meridians, they are not actually passed down in practice" ("Shanghan Lun Pingshi"). Lu Yuanlei believed: "Since we consider the whole-body deficiency-cold syndrome as Shaoyin, and the gastrointestinal deficiency-cold syndrome as Taiyin, there is no other type of deficiency-cold syndrome that could reasonably be classified as Jueyin. Therefore, the designation of the six meridians must be artificially imposed, which is a case of forcing a square peg into a round hole" ("Shanghan Lun Jinshi"). The criticisms raised by these physicians regarding the Six Meridians differentiation demonstrate the need for further refinement and development of this diagnostic method.

However, the prescriptions and syndromes revealed by the Six Meridians remain timelessly valuable and have been used for thousands of years without decline, a point on which all physicians throughout history have agreed without exception.

2. Wei-Qi-Ying-Xue Differentiation

This system divides exogenous febrile diseases according to their progression into four stages: Wei phase, Qi phase, Ying phase, and Xue phase.

Wei Phase | > Headache, fever with chills (more heat than cold), thirst and dry throat, cough, | > “Wei” refers to the defensive qi, which protects the body from external pathogens. The “Qi” phase involves the invasion of pathogenic factors into the body's interior, affecting the lungs and other organs. The “Ying” phase represents the stage where pathogenic factors begin to damage the body's yin, causing symptoms such as dry mouth and throat, and fatigue. The “Xue” phase is the final stage, where pathogenic factors severely damage the blood, leading to symptoms like bleeding, confusion, and even coma. | > “Wei” refers to the defensive qi, which protects the body from external pathogens. The “Qi” phase involves the invasion of pathogenic factors into the body's interior, affecting the lungs and other organs. The “Ying” phase represents the stage where pathogenic factors begin to damage the body's yin, causing symptoms such as dry mouth and throat, and fatigue. The “Xue” phase is the final stage, where pathogenic factors severely damage the blood, leading to symptoms like bleeding, confusion, and even coma. | > | > High fever, intense thirst, profuse sweating, abdominal distension and pain, severe constipation, red tongue with dry coating | > “Qi” refers to the invasion of pathogenic factors into the body's interior, affecting the lungs and other organs. The “Ying” phase represents the stage where pathogenic factors begin to damage the body's yin, causing symptoms such as dry mouth and throat, and fatigue. The “Xue” phase is the final stage, where pathogenic factors severely damage the blood, leading to symptoms like bleeding, confusion, and even coma. | > | > Hot flashes, restlessness, tongue with little red and thin coating, rapid and fine pulse—treated with Qing | > | > Hot flashes, restlessness, confusion, convulsions, rashes, and various bleeding symptoms—treated with An Gong Niu Huang Wan and Zixue Dan (both from “Wenbing Tiaobian”). +----------+ Qi Phase | +----------+ Ying Phase | +----------+ Xue Phase |

This differentiation was proposed by the warm disease scholar Ye Tianshi, who built upon the foundation of the "Inner Canon" concerning Wei, Qi, Ying, and Xue, while also drawing inspiration from Zhang Zhongjing's Six Meridians differentiation and combining it with his own extensive clinical experience.

The Wei phase essentially corresponds to the Taiyang syndrome in the Six Meridians differentiation, but focuses more on the invasion of pathogenic heat into the surface layer; the Qi phase is basically equivalent to the Yangming syndrome in the Six Meridians, but through elaboration on the retention of pathogenic factors in the Three Jiao, it adds aspects related to heat in the chest, lungs, liver, and kidneys.

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The syndromes of the Wei phase seem to better encapsulate clinical manifestations than the Yangming syndrome in the Six Meridians; the Ying phase is a further deepening and development of the Qi phase, with its main characteristic being that excessive heat damages the yin; the Xue phase is a further development of the Ying phase, with its main characteristic being that excessive heat damages the yin while simultaneously causing heat to enter the pericardium, forcing the blood to flow abnormally, and leading to more severe clinical manifestations such as heat-induced wind movement.

3. Three Jiao Differentiation

This system classifies exogenous febrile diseases according to their site of onset and severity, dividing them into upper, middle, and lower jiao syndromes.

(1) Upper Jiao

Hand Taiyin Lung Syndrome | > Headache, fever with chills (more heat than cold), spontaneous sweating and thirst, cough, floating and rapid pulse or a particularly strong pulse at the cun position—indicating the need to release the exterior and disperse the pathogenic factors. | > For the lungs, use Sangju Yin or Yinqiao San. | > | > Tongue with dark red color, confusion or speech impediment, indicating the need to clear the heart and open the orifices—use Angong Niu Huang Wan or Zixue Dan (from “Wenbing Tiaobian”). +----------------+ Hand Jueyin Pericardium Syndrome |

(2) Middle Jiao Syndrome

Foot Yangming Stomach Syndrome | > Fever, thirst, and a large pulse—indicating the need to drain the fire and save the yin—use Baihu Tang or Baihu Plus Ginseng Tang. Foot Taiyin Spleen Syndrome | > Feeling heavy as if wrapped in a blanket, body heat not rising, body pain and heaviness, chest tightness and nausea, greasy tongue coating and slow pulse—indicating the need to clear heat and remove dampness—use Sanren Tang (from “Wenbing Tiaobian”) or Huopu Xialing Tang (from “Wenbing Tiaobian”).

(3) Lower Jiao Syndrome

Foot Shaoyin Kidney Syndrome | > Body heat and red face, hands and feet warmer than the back of the hand, restlessness and insomnia, chapped lips and dry mouth—indicating the need to nourish yin and blood—use Zhibo Di Huang Tang (from “Zhinyin Mai Zhi”) or Qiju Di Huang Tang. Foot Jueyin Liver Syndrome | > “Deep heat, deep chill, constant trembling in the heart, limbs twitching, even convulsions”—indicating the need to nourish the liver and calm the wind—use Da Ding Feng Zhu or Sanjia Fu Mai Tang (both from “Wenbing Tiaobian”).

The Three Jiao differentiation was created by the warm disease master Wu Jutong. The upper jiao syndrome is equivalent to the Taiyang in the Six Meridians and the Wei phase in the Wei-Qi-Ying-Xue differentiation, but it adds symptoms such as confusion, speech impediment, and limb numbness caused by heat entering the pericardium, fully reflecting the characteristic of heat-related diseases (especially severe acute infectious diseases) that can spread to the pericardium. The middle jiao disease is equivalent to the Ming in the Six Meridians and the Qi phase in the Wei-Qi-Ying-Xue differentiation, but it also adds the middle jiao damp-heat syndrome caused by the combination of dampness and heat in the foot Taiyin spleen, thereby supplementing the deficiencies of the Six Meridians and the Wei-Qi-Ying-Xue differentiation and appropriately reflecting the clinical characteristics of gastrointestinal infectious diseases such as intestinal typhoid and chronic dysentery. The lower jiao syndrome is equivalent to the Ying and Xue phases in the Wei-Qi-Ying-Xue differentiation, and also has some characteristics of the Jueyin syndrome in the Six Meridians.

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Joy Anger Sorrow Thinking

Excessive joy harms the heart and disperses qi. Extreme anger harms the liver and causes qi to reverse. Constant sorrow harms the lungs and causes qi to stagnate. Excessive thinking harms the spleen and causes qi to stagnate.

Grief Fear Shock

Grief harms the heart and lungs and causes qi to condense. Fear harms the kidneys and leads to qi and blood deficiency. Shock harms the heart, kidneys, liver, and gallbladder and causes qi to become chaotic.

The concept of etiology in traditional Chinese medicine is mainly based on the aforementioned Six Evils and Seven Emotions. The former are external pathogenic factors, while the latter are internal pathogenic factors. These internal and external factors work together to form the main framework for etiological differentiation in Chinese medicine. In addition, there are also factors such as improper sexual activity, dietary and labor fatigue, and injuries caused by insects, animals, and sharp objects, which are referred to as neither internal nor external factors and play only a secondary role in etiological differentiation. In recent years, some scholars have proposed new pathogenic factors such as air pollution, chemical drugs, and radioactive dust, which deserve further research and are of great significance for enriching and developing the theory of etiology in traditional Chinese medicine. ("Sino-Western Combined Research," March 1997)

Pei Zhengxue’s Internal Medicine Prescription System

The internal medicine prescription system is the mainstream of traditional Chinese medicine prescriptions. The so-called internal medicine prescriptions essentially refer to all oral herbal decoctions. On the one hand, these decoctions serve as the primary method for treating internal medicine diseases and have been refined over thousands of years, forming the main framework of internal medicine treatment in traditional Chinese medicine. On the other hand, they also play a very important role in treating non-internal medicine diseases. This fully embodies the holistic view of traditional Chinese medicine that treats external diseases internally, internal diseases externally, upper diseases below, and lower diseases above—a unified approach to treating the entire body. The internal medicine prescription system can generally be divided into the following six major systems: Mahuang-Guizhi system, Chaihu system, Baihu-Chengqi system, Four Gentlemen-Four Substances system, Six Flavors-Di Huang system, and Sangju-Yinqiao system.

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In addition, the trio of herbs Ma Huang, Fu Zi, and Xi Xin forms Ma Huang Fu Zi Xi Xin Tang, which is the main prescription for yang deficiency and cold invasion. It treats headache, fever with chills, lack of sweating, and a deep, fine pulse. Recently, some people believe that this formula is highly effective against all viral common colds, especially suitable for patients with weak constitutions and low blood pressure, and also has certain effects on sinusitis. If you remove Xi Xin from this formula and add Gan Cao, you get Ma Huang Fu Zi Gan Cao Tang, which has the same effect as Ma Huang Fu Zi Xi Xin Tang but weaker ability to release the exterior and dispel cold.

2. Guizhi Tang-like Formulas

Guizhi Tang is known as the "king of all formulas," originating from the "Shanghan Lun." It consists of Guizhi, Bai Shao, Gan Cao, Sheng Jiang, and Da Zao, and is primarily used to treat headache, fever with chills, sweating, and a floating, slow pulse—this is the wind-cold exterior deficiency syndrome, which corresponds to what modern medicine calls a common cold. The main significance of this formula is not in treating the common cold itself, but rather in using its modifications and adaptations to treat a wide range of internal diseases related to autonomic nervous system dysfunction. If you add Hou Pu and Xing Ren to this formula, you get Guizhi Plus Hou Pu Xing Ren Tang, which treats wind-cold asthma; if you add Ge Gen, you get Ge Gen Tang, which treats wind-cold exterior deficiency combined with stiffness in the neck and shoulders; if you remove Bai Shao, you get Guizhi Without Bai Shao Tang, which treats exterior deficiency combined with a rapid pulse and chest fullness; if you add Fu Zi, you get Guizhi Plus Fu Zi Tang, which treats limbs that are slightly stiff and difficult to bend and stretch. In addition to the above direct modifications of Guizhi Tang, there are also three groups of formulas that are widely used clinically and have proven efficacy, and are generally still considered Guizhi Tang-like formulas.

(1) Ling Gui Zhu Gan Tang-like Formulas

This formula consists of Fu Ling, Gui Zhi, Bai Zhu, and Gan Cao, and is primarily used to treat reversed fullness in the epigastric region, upward rushing qi, dizziness upon standing, and shaking of the body—this is a spleen-deficiency phlegm-damp syndrome. From a modern medical perspective, this syndrome may include heart disease, heart failure, and gastrointestinal dysfunction. If you remove Gui Zhi from this formula and add Gan Jiang, you get Shen Zhu Tang, which treats cold-damp injury and lower back pain; if you remove Bai Zhu and add Da Zao, you get Fu Ling Gui Zhi Gan Cao Da Zao Tang, which treats palpitations below the navel and the urge to run like a wild boar; if you remove Bai Zhu and add Fang Ji and Huang Qi, you get Fang Ji Fu Ling Tang, which treats skin edema, swelling of the limbs, water retention in the skin, and trembling of the limbs; if you remove Bai Zhu and add Sheng Jiang, you get Fu Ling Gan Cao Tang, which treats typhoid and sweating without thirst.

(2) Wu Ling San-like Formulas

This formula consists of Fu Ling, Zhu Ling, Bai Zhu, Ze Xie, and Gui Zhi, and is primarily used to treat exogenous wind-cold and internal accumulation of dampness. The main clinical manifestations are headache, fever with chills, difficulty urinating, and generalized edema. From a modern medical perspective, this formula can be applied to all patients with edema, including cardiac edema, hepatic edema, and renal edema. If you remove Gui Zhi from this formula, you get Si Ling San, which treats edema and also addresses internal dietary issues, short and reddish urine, and loose stools. If you remove Gui Zhi and Bai Zhu and add A Jiao and Huashi, you get Zhu Ling Tang, which treats painful urination, difficulty in passing urine, and bloating in the lower abdomen. If you add Yin Chen, you get Yin Chen Wu Ling San, which treats damp-heat jaundice and difficulty urinating. If you remove Gui Zhi and Ze Xie, you get Zhu Ling San, which treats conditions above the diaphragm and those who vomit and crave fluids. If you add Chen Sha, you get Chen Sha Wu Ling San, which treats difficulty urinating; if you add Cang Zhu, you get Cang Zhu Wu Ling San, which treats cold-damp; if you add Qiang Huo, you get Yuan Rong Wu Ling San, which treats accumulated heat in the middle jiao; if you add Sheng Shi, Huashi, and Han Shui Shi, you get Gui Ling Gan Lu Yin, which clears heat from the six fu organs; if you add Ren Shen, you get Chun Ze Tang; and if you add Gan Cao, you get the Four Gentlemen, which is also called Chun Ze Tang, both of which can treat cases of thirst without illness or thirst after recovery.

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This formula can treat cold extremities caused by diseases in various systems of the body. Later physicians, through clinical application, believed that the above indications could be summarized as balancing yin and yang inside and out, with the aim of harmonizing yin and yang within the body and alleviating cold extremities. From a modern medical perspective, this syndrome is often caused by autonomic nervous system dysfunction, which can result from diseases in various systems of the body. In addition, Si Ling San can also balance the liver and spleen. By "balancing the liver and spleen," we mean treating disharmony between the liver and stomach. The essence of liver-stomach disharmony is that the liver wood overcomes the earth, manifested clinically as bitter taste in the mouth and dry throat, irritability, chest and flank fullness, lack of appetite, and abdominal distension. From a modern medical perspective, this formula can treat chronic stomach diseases and chronic liver diseases. If you add Xiang Fu and Chuan Xiong to Si Ling San, you get Chaihu Shu Gan San, which is the preferred prescription for liver depression and flank pain, suitable for all liver-related pain. If you remove Zhi Shi and Bai Shao and add Dang Gui, Huang Jing, Hong Hua, Chuan Shan Jia, Da Huang, and Tao Ren, you get Fu Yuan Huo Xue Tang, which is effective for treating blood stasis and flank pain, suitable for all traumatic chest pain and costochondritis.

3. Xiaoyao San-like Formulas

The representative formula of this group is Xiaoyao San (from "Heji Ju Fang"), composed of Dang Gui, Bai Shao, Bai Zhu, Fu Ling, roasted Gan Cao, Chaihu, baked Sheng Jiang, and peppermint, and is the main prescription for treating liver depression and spleen deficiency. The clinical indications are bitter taste in the mouth and dry throat, irritability, chest and flank fullness, abdominal distension, loss of appetite, and general fatigue. From a modern medical perspective, this formula is suitable for chronic liver disease, stomach disease, gallbladder disease, and bile duct disease. In addition, according to the theory that the liver governs the Chong and Ren channels, this formula is the main prescription for regulating menstruation, suitable for periods that come early, late, or irregularly. According to the theory that the liver opens the orifices, this formula is also the main prescription for treating eye diseases in traditional Chinese medicine, suitable for retinal diseases and retrobulbar optic nerve diseases. If you add Dan Pi and Shan Zhi, you get Dan Zhi Xiaoyao San (from "Neike Zhaoyao"), which treats liver depression and excessive fire.

If you add Shu Di, you increase the function of nourishing yin and replenishing blood, resulting in Black Xiaoyao San (from "Yilüe Liushu · Nüke Zhiyao"), which treats liver depression and spleen deficiency, as well as qi and blood deficiency. If you remove Bai Shao and Bai Zhu and add Chuan Xiong, Cang Zhu, and Gou Ding, you get Yi Gan San (from "Jing Yue Quanshu"), which treats liver depression and restlessness, and insomnia at night.

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"The pulse is normal, the body feels hot but not cold, joints ache and feel uncomfortable, and sometimes there is vomiting." This formula is also used to treat rheumatoid arthritis, accompanied by fever and elevated ESR. If you add Cang Zhu, you get Baihu Plus Cang Zhu Tang (from "Huoren Shu"), which treats rheumatoid arthritis, joint swelling and pain, headaches as if wrapped in a blanket, chest discomfort and heat, and thirst without drinking. If you add Antelope Horn and Rhinoceros Horn (now banned, can be replaced with water buffalo horn), you get Lingxi Baihu Tang (from "Wenre Jingwei"), which treats exogenous warm diseases, simultaneous fire and blood, high fever and thirst, and confusion and delirium. If you add Xuan Shen and Rhinoceros Horn, you get Hua Ban Tang (from "Wenbing Tiaobian"), which treats heat entering the blood, delirium, rashes, and dark red tongue with thick yellow coating. If you remove Zhi Mu and add Ban Xia, Dong, Ren Shen, and Zhu Ye, you get Zhu Ye Shi Gao Tang, which treats residual heat that has not yet cleared, dual damage to qi and yin, manifested as high body temperature, dry mouth and thirst, weakness and lack of energy, and tendency to vomit due to qi reversal. From a modern medical perspective, this formula is suitable for all post-febrile conditions, where patients exhibit obvious autonomic nervous system dysfunction and sympathetic nervous system hyperactivity.

2. Chengqi Tang-like Formulas

Most of these formulas originate from the "Shanghan Lun," with Dachengqi Tang as the representative formula, composed of Dahuang, Mang Xiao, Zhi Shi, and Hou Pu—four herbs that treat Yangming fu syndrome, characterized by pi, man, zao, and si.

From a modern medical perspective, this formula can be modified and adapted to treat all acute abdominal conditions, including appendicitis, intestinal obstruction, cholecystitis, and pancreatitis. If you remove Mang Xiao from Dachengqi Tang, you get Xiaochengqi Tang, which treats chest and abdominal pi, old yellow tongue coating, and slippery pulse. If you remove Zhi Shi and Hou Pu and add Gan Cao, you get Tiaowei Chengqi Tang, which treats abdominal pain that refuses to be pressed, old yellow tongue coating, and slippery pulse. If you remove Mang Xiao and add Qiang Huo, you get Sanhua Tang (from "Huo Fa Ji Yao"), which treats stroke and urinary obstruction. If you remove Zhi Shi and Hou Pu and add Lian Qiao, Huang Qin, Peppermint, and Shan Zhi, you get Liang Ge San (from "Ju Fang"), which treats lung and stomach fire, manifested as chest and diaphragm discomfort, dry stools, coughing up blood, sores on the tongue, and yellow tongue with fast pulse. If you remove Zhi Shi, Hou Pu, and Gan Cao and add Gan Sui, you get Da Xian Xiong Tang, which treats large chest syndrome, manifested as pain from the heart down to the lower abdomen, unbearable proximity, dry stools, dry tongue, and slight heat. Da Xian Xiong Tang adds Ting Li Zi and Xing Ren, processes honey into pills, and becomes Da Xian Xiong Wan, which has similar effects to Da Xian Xiong Tang but milder action, suitable for cases where the onset of the syndrome is relatively slow. Tiaowei Chengqi Tang adds Tao Ren and Gui Zhi, becoming Tao Ren (core) Chengqi Tang, which treats bladder blood accumulation, manifested as urgent abdominal contraction, with the person acting crazy, self-medicating, and having bloody stools.

3. Xie Xin Tang-like Formulas

Xie Xin Tang originates from the "Jin Kui Yao Lue," composed of Dahuang, Huang Lian, and Huang Qin—three herbs that treat various pathological changes caused by internal fire, such as high fever, constipation, reddish urine, thick yellow tongue coating, fast pulse, chest discomfort, jaundice, vomiting, nosebleeds, and boils. From a modern medical perspective, this formula is suitable for various infections, boils, abscesses, sepsis, cholecystitis, pancreatitis, pelvic inflammatory disease, dysentery, as well as aplastic anemia, leukemia, thrombocytopenic purpura, hypertension, gastric ulcers, and chronic gastritis. In recent years, reports from various regions indicate that this formula is particularly effective for upper gastrointestinal bleeding. If you add Zhi Ke and Mu Xiang, you get Bile Duct Stone Removal Soup No. 2 (Dalian Medical College), which treats gallstones and cholecystitis. If you add Zhi Shi, Bai Zhu, Fu Ling, and Ze Xie, you get Zhi Shi Dao Chi Tang (Li Dongyuan), which treats damp-heat blockage in the gastrointestinal tract and red-and-white diarrhea. If you add Fu Zi, you get Fu Zi Xie Xin Tang, which treats epigastric pi and cold sweat.

Pei Zhengxue’s Traditional Chinese Medicine—Discussion on TCM Theory and Clinical Cases, published by Heji Book Publishing House

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This section outlines the clinical applications of "different diseases treated as the same" in Traditional Chinese Medicine. By analyzing and categorizing the external manifestations of diseases, TCM has established the principle of treating different diseases with the same therapeutic approach when they share common characteristics. For example, the Buzhong Yiqi Tang formula for tonifying the spleen and replenishing qi can be used to treat conditions caused by qi deficiency, such as anemia, purpura, leukemia, and gynecological bleeding; it can also be used to treat conditions caused by qi deficiency leading to downward collapse, such as hypotension, uterine prolapse, gastric ptosis, and myasthenia gravis; and it can even be used to treat conditions caused by qi deficiency resulting in fever, such as low-grade fever. Similarly, the Shenqi Wan formula for warming and tonifying kidney yang can be used to treat conditions caused by yang deficiency and water excess, such as chronic nephritis, heart failure, and malnutrition-related edema; it can also be used to treat conditions caused by kidney yang deficiency and inability to contain qi, such as chronic bronchitis, emphysema, and bronchial asthma. In addition, this formula can also treat prostatitis, gynecological leukorrhea, diabetes, and systemic lupus erythematosus.

Previous Academic Thoughts

The following are some examples of how the principle of "different diseases treated as the same" is applied in clinical practice:

1. Buzhong Yiqi Tang (Tonifying the Spleen and Replenishing Qi):

   • Used to treat conditions caused by qi deficiency, such as anemia, purpura, leukemia, and gynecological bleeding.
   • Used to treat conditions caused by qi deficiency leading to downward collapse, such as hypotension, uterine prolapse, gastric ptosis, and myasthenia gravis.
   • Used to treat conditions caused by qi deficiency resulting in fever, such as low-grade fever.

2. Shenqi Wan (Warming and Tonifying Kidney Yang):

   • Used to treat conditions caused by yang deficiency and water excess, such as chronic nephritis, heart failure, and malnutrition-related edema.
   • Used to treat conditions caused by kidney yang deficiency and inability to contain qi, such as chronic bronchitis, emphysema, and bronchial asthma.
   • Additionally, this formula can also treat prostatitis, gynecological leukorrhea, diabetes, and systemic lupus erythematosus.

These examples demonstrate the broad applicability of the principle of "different diseases treated as the same" in TCM, allowing for effective treatment of a wide range of conditions by addressing their underlying causes and symptoms.

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