Eight principles differentiation
Eight principles differentiation is a technique used in clinical practice to help understand the nature of the TCM issues we are faced with. It breaks down the presenting signs and symptoms into eight categories:
- Internal (interior) – are we faced with a problem that involves the Zang-Fu organs?
- External (exterior) – is the problem more related to muscles and classed as External?
- Hot – are there signs of heat?
- Cold – are there signs of cold?
- Excess (Full) – do the signs and symptoms show signs of Excess (e.g. Damp, Phlegm, Stagnation?)
- Deficient (Empty) – do the signs and symptoms show signs of Deficiency (e.g. fatigue, weakness?)
- Yin – is this a Yin condition (e.g. slow onset)?
- Yang – is this a Yang condition (e.g. sudden onset)?
Internal
With the Interior, or Internal category, the disharmony has reached below the level of the skin, muscles and channels to affect the Blood or the Zang-Fu organs.
Disharmonies at the Interior level can take a longer time to treat before a noticeable change occurs than a disharmony at the Exterior level (for example an acute stiff neck may start to resolve at around the third or fourth treatment as opposed to nine to ten treatments for an interior disharmony).
External
With the Exterior category, we are looking to see whether the signs and symptoms reflect a disharmony of the skin, muscles or channels, or whether they reflect a deeper level of imbalance that has affected the Zang-Fu and would then be categorised as ‘Interior’.
In the Exterior case, an External Pathogenic Factor has managed to get past the Defensive Qi (Wei-Qi) and has entered the level of skin, muscle or channel.
Skin level is classed as more superficial, followed by the muscle level and then channel level. At the initial or acute stage, the signs and symptoms reflect the pathogen at the skin or muscle level.
This manifests as stiffness and aching in the muscles with specific symptoms reflecting the pathogen. For example, an invasion by a Cold pathogen would give rise to stiffness as Cold causes contraction or no sweating.
No sweating is due to the Cold impeding the flow of Wei-Qi which regulates the opening and closing of the pores.
If the external pathogen is not cleared from the skin or muscle level it can, over time, lead on to conditions such as Bi Syndrome and manifest as problems with the joints such as osteoarthritis.
Hot
With Hot, we are looking to identify whether it is Empty-Heat, due to a Yin Deficiency and therefore a lack of Yin to cool the body down, or Full Heat where the Yin is intact, but Yang has built up.
Cold
With Cold, we are looking to identify whether it is Empty-Cold (due to a Yang Deficiency) or Full Cold (where the Yang is intact, but Yin substances such as Phlegm or Damp have built up).
Excess (Full)
With Full conditions, the Qi remains intact and battles with the pathogenic factor which then gives rise to the presenting sign and symptoms.
There is generally an External Pathogenic Factor involved, but we also need to bear in mind that in clinical cases, a Full condition can arise from an underlying Zang-Fu imbalances such as patterns of Qi, Blood or Body Fluid stagnation.
Full-Cold
Full Cold is sometimes referred to as Yin Excess. However, Yin is never in excess, so how can this condition arise?
The Yin Excess refers to the build-up of Yin substances such as Body Fluids, Phlegm and Damp. As they accumulate, they further cool the body down.
This condition usually starts with an invasion of Cold that has penetrated to the Zang-Fu level and affected the Stomach, Liver, Bladder or Large Intestine.
The Cold also slows down the circulation of Yang, which affects the transportation and transformation of body fluids leading to symptoms of loose stools, clear and abundant urine and no thirst. The reduced circulation of Yang also causes the chilliness, cold limbs.
The pulse has also become deep due to the reduced Yang circulation, full to indicate the Full condition and tight to reflect the pain.
The tongue is pale to show the lack of Yang circulating and develops a thick white coat to reflect the Full condition.
Full-Heat
With Full-Heat we are typically looking at a condition of Excess – the heat being caused by an excess of Yang due to the build-up of Qi, Blood, Damp, or Phlegm.
This is in contrast to Empty-Heat which is due to an underlying deficiency of Yin.
One thing to note is that an underlying deficiency of Qi, Blood or Body Fluids can lead to a Full Heat condition. This is based on the principle of Yin transforming into Yang.
Typical symptoms of Full-Heat include fever, thirst as body fluids become dry, red eyes due to the rising heat, constipation as the stools become drier and dark and scanty urine due to heat drying up body fluids.
The pulse becomes rapid as Heat speeds things up and is also Full to reflect the Excess condition.
The excess heat also causes a condition called Heat in the Blood which can also manifest in skin conditions as redness (as in some forms of eczema and rosacea).
Pain associated with Full Heat may be described as burning or searing, again reflecting the association with heat.
The aetiology of Full Heat is usually associated with an excessive consumption of spicy foods, long standing emotional problems that may lead to Qi stagnation which then leads onto Heat, or External Pathogenic Factors that have turned into Heat.
Whilst many of the Zang-Fu can have Full Heat patterns associated with them, in clinical practice, we typically see the Heat arising from Liver, Heart or Stomach pathologies.
The Heart can be affected strongly by Heat and we talk about the Shen becoming disturbed resulting in agitation and disturbed behaviour.
The treatment principle is to clear the Heat with points being selected to address the underlying organ imbalances.
Deficient (Empty)
Empty is a method to indicate that the signs and symptoms are the result of an underlying deficiency of Qi, Blood, Yin or Yang, or some combinations of these.
It is important to note that with the Empty category, no external pathogenic factor is involved – if it were, we would say it was a Full pattern as the External Pathogenic Factor would add something extra rather than it being a case of something being depleted or lacking.
The key to resolving which organ or organs are affected is to look at any general signs and symptoms of Empty and then any specific signs and symptoms relating to individual organs.
For example, tiredness and a lack of appetite may point towards Stomach Qi deficiency or abdominal bloating with heaviness in the legs may indicate Spleen Qi deficiency.
Empty-Cold
Empty-Cold is due to a deficiency of Yang in which the warming and moving action of Yang has been affected. The main organs that can lead to Yang deficiency are the Spleen, Kidney and Heart.
The signs and symptoms of Empty-Cold can be quite general (such as cold limbs, feeling cold all the time) but there will be some that help hone the diagnosis towards a particular organ.
So, if an underlying Spleen Yang deficiency was suspected, there could be signs of abdominal bloating or loose stools or Damp in addition to the general signs of Cold.
The cause of the sweating, even though the person feels cold and not hot, is due to the Wei-Qi, which is related to Yang and specifically Kidney Yang, being unable the opening and closing of the pores and thereby causing the person to sweat. In this case they would still feel Cold but would also be sweating.
There is clear and abundant urine as fluids are not being transformed or transported due the Yang deficiency and also as the Bladder closing function, which relies on Kidney Yang, becomes weaker.
The pulse is deep, slow and weak as there is not enough Yang to lift and strengthen the pulse and also give it the impetus to move. The tongue is pale which reflects a deficiency with a thin white coat indicating signs of cold.
The treatment principle here is to Tonify Yang which will clear the Cold. The point prescription chosen must also address the underlying Yang imbalance in the organs identified as being Yang deficient.
Empty-Heat
Empty-Heat is due to an underlying Yin deficiency that leads to a relative excess of Yang. Note in this case, that Yang has not increased to create excess Heat.
As the Yin has become deficient, or Empty, the Yang has stayed the same, but as there is less Yin available to cool the body, this lead to signs of Heat due to the deficiency of Yin.
With Empty-Heat, the symptoms of Heat become more prominent towards the late afternoon, evening and night time which are times when Yin should be rising and becoming stronger.
Therefore a person may start to feel warm, restless and sweaty as the sun sets. They may also start feeling slightly anxious at this time as well which is due to the rising heat affecting the Heart and disturbing the Shen.
The heat may become prominent on the chest, palms and soles of the feet which is also known as Five Palm Heat. The Empty-Heat can also dry up body fluids, leading to dry stools and the urine becoming scanty and darker.
The pulse is floating due to the Empty-Heat lifting the pulse upwards and is empty reflecting the underlying deficiency. The tongue become red to reflect heat and is peeled as the heat burns off the coating.
The main organs affected by Yin deficiency are the Liver, Heart, Lungs and Kidneys.
There will be some presenting signs and symptoms that will help to pinpoint one or more of these organs:
- If the deficiency is due to Liver Yin, there may be signs of irritability or headaches (such as migraine);
- If it’s Heart Yin deficiency, there may be signs of mental restlessness and insomnia as the Empty-Heat disturbs the Shen;
- With Lung Yin deficiency there may be a malar-flush (rosy-cheeks) and a dry cough.
- With Kidney Yin deficiency there may be dull lower back pain, weak bones and joints, memory and/or hearing problems.
The treatment principle would be to Tonify Yin to clear the Empty-Heat with the points used reflecting any underlying organ pathology.
