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The Four Pillars and Eight Principles of Diagnosis

The Four Pillars and Eight Principles of Diagnosis

The Four Pillars of Diagnosis  |   Looking   |   Listening   |   Touching   |   Asking

The Eight Principles of Diagnosis   |  Determining the Diagnosis

 

The heart of holistic care is the idea that the whole is the sum of its parts, or that each individual area of the body can provide insight to the condition of the whole. In Traditional Chinese Medicine (TCM) this is taken seriously and is evident from the first moment of interaction with a patient. The process a TCM practitioner uses to settle on a diagnosis for a patient involves many different layers. 

Two key theories of thought to dive into are the Four Pillars of Diagnosis and the Eight Principles of Diagnosis. The Four Pillars outline the different types of examination a TCM practitioner will use to gather information about a patient’s condition. The Eight Principles explain the ways in which the practitioner might categorize and explain their given diagnosis.

The Four Pillars of Diagnosis

TCM practitioners implement holistic care into their very process of diagnosis, through a set of guidelines called the Four Pillars of Diagnosis, sometimes called the four examinations. These four pillars include looking, listening, touching, and asking. 

Each category starts broad and works its way in. More specifically, the categories define the afflictions a patient is experiencing. At the end of the examination, the TCM practitioner can use the clues gathered from each of the four parts to determine a diagnosis and course of treatment to restore balance to the patient.

Looking

We know what you’re thinking…looking sounds like an overly simplistic way of diagnosing an illness or condition. You might be familiar with a Western medical professional inspecting a wound, skin irregularity or infection. A TCM practitioner may have a similar, surface level approach at first, they’re looking for signs pointing to internal issues. While it may sound basic, it can actually be incredibly involved.

Looking can apply to everything from a patient’s body type, to their hair, skin, limbs, and nails. However, some of the areas that reveal the most about a person are often located on the face. Step one is the shade and quality of the skin. Ever notice how people get paler and develop a sweat when they feel nauseous? Or become red and hot if overheated or feverish? The shifting in skin tone, texture, and moisture level, among other details can provide key information. 

Beyond the general look of the face, the practitioner might inspect individual facial features like the nose, eyes, or tongue. Continuing on with the idea of holistic healthcare, it’s believed that each feature on the face is directly linked to an internal organ. For example, the nose can provide clues to the health of the lungs and spine while the eyebrows represent the liver and gallbladder. 

The tongue and the ear are two areas of the face that are deemed “complete systems” as they can contain quite a lot of information about nearly every part of the body. Both of these areas are commonly examined. The tongue is the primary site of diagnosis as it shows areas of strength and weakness. There are different zones of the tongue connected to the main organ groups. The Heart is represented by the tip, the Spleen by the center of the midline and the Kidneys and Intestines by the back. The tongue is checked and analyzed based on the color, texture, coating, size and shape, any impressions, and amount of moisture. 

All of these factors combined are used when determining a diagnosis. The ear is also seen by TCM practitioners as being segmented based on internal organ zones. Branches of major nerves like the vagus nerve are found in the ear and account for its role as a microsystem. Some practitioners will treat issues located in other parts of the body directly from the ear using acupuncture or seed treatments.

Smelling and Tasting

But wait, there’s more. Or rather, there used to be. Smelling and tasting used to be included as common factors to determine the diagnosis of patients in some cases under the pillar of listening. While some practitioners may still include these tests, the culture and style of modern life has deemed these far less common. 

In previous times, however, they weren’t unheard of. Some practitioners were trained to detect irregularities in the taste of their patient’s urine. One example of this is the diagnosis of diabetes due to a noticeably sweeter taste to the urine. You can see why this test got the axe in current times, right? 

Smelling is certainly more common than taste. TCM practitioners who operate with smell might ask you to recall certain smells of urine, feces, or the breath, or take a whiff for themselves. It’s believed that bad breath is linked to excess heat in the stomach, while especially smelly excrement might mean that there’s dry-heat in the large intestine. 

 

Beyond the general look of the face, the practitioner might inspect individual facial features like the nose, eyes, or tongue. Continuing on with the idea of holistic healthcare, it’s believed that each feature on the face is directly linked to an internal organ. For example, the nose can provide clues to the health of the lungs and spine while the eyebrows represent the liver and gallbladder. 

The tongue and the ear are two areas of the face that are deemed “complete systems” as they can contain quite a lot of information about nearly every part of the body. Both of these areas are commonly examined. 

The tongue is the primary site of diagnosis as it shows areas of strength and weakness. There are different zones of the tongue connected to the main organ groups. The Heart is represented by the tip, the Spleen by the center of the midline and the Kidneys and Intestines by the back. The tongue is checked and analyzed based on the color, texture, coating, size and shape, any impressions, and amount of moisture. All of these factors combined are used when determining a diagnosis. 

The ear is also seen by TCM practitioners as being segmented based on internal organ zones. Branches of major nerves like the vagus nerve are found in the ear and account for its role as a microsystem. Some practitioners will treat issues located in other parts of the body directly from the ear using acupuncture or seed treatments.

Smelling and Tasting

But wait, there’s more. Or rather, there used to be. Smelling and tasting used to be included as common factors to determine the diagnosis of patients in some cases under the pillar of listening. While some practitioners may still include these tests, the culture and style of modern life has deemed these far less common. 

In previous times, however, they weren’t unheard of. Some practitioners were trained to detect irregularities in the taste of their patient’s urine. One example of this is the diagnosis of diabetes due to a noticeably sweeter taste to the urine. You can see why this test got the axe in current times, right? 

Smelling is certainly more common than taste. TCM practitioners who operate with smell might ask you to recall certain smells of urine, feces, or the breath, or take a whiff for themselves. It’s believed that bad breath is linked to excess heat in the stomach, while especially smelly excrement might mean that there’s dry-heat in the large intestine.

Listening

The idea of listening in TCM goes far beyond listening to a heartbeat through a stethoscope as you might have experienced in Western medical offices. TCM practitioners listen to a patient’s speaking voice to determine many things about a patients’ condition. 

Based on the Five Elements system, each “organ system” in the body is connected and can be described by many (what may seem like) random words and phrases. Diagnoses based on listening to the tone, timbre, and strength of the voice can be described as shouting, laughing, singing, weeping, or groaning. Each of these correlate with one of the Five Elements and can unveil details about a condition and its source. 

If your voice is said to have the quality of a shout, the corresponding element is wood. Shouting is described as being filled with energy and power whether they are relaxed or agitated, particularly at the beginning of sentences. Laughing is considered connected to the element of fire. There’s a sense of dichotomy to the sound of fire; the voice may feel on the edge of telling a joke or breaking some bad news. Regardless, it carries excitement that makes people lean in to listen. 

The idea of a voice that sings doesn’t necessarily mean the person is a trained vocalist. Singing is connected to the earth element and carries a sense of soothing, reassuring groundedness. People with sing tend to have peaks and valleys in their tone quality. The weeping quality is connected to metal. If you have a weeping voice, your tone might go lower at the end of phrases, or you have a voice that’s rough sounding. The final descriptor is groaning, which is a water descriptor. Just like a rushing river, groaning voices are steady, and often rather monotonous. While their energy might shift, the tone stays within a close range.

Based on the Five Elements system, each “organ system” in the body is connected and can be described by many (what may seem like) random words and phrases. Diagnoses based on listening to the tone, timbre, and strength of the voice can be described as shouting, laughing, singing, weeping, or groaning. Each of these correlates with one of the Five Elements and can unveil details about a condition and its source. 

If your voice is said to have the quality of a shout, the corresponding element is wood. Shouting is described as being filled with energy and power whether they are relaxed or agitated, particularly at the beginning of sentences. Laughing is considered connected to the element of fire. There’s a sense of dichotomy to the sound of fire; the voice may feel on the edge of telling a joke or breaking some bad news. Regardless, it carries excitement that makes people lean in to listen.

 

The idea of a voice that sings doesn’t necessarily mean the person is a trained vocalist. Singing is connected to the earth element and carries a sense of soothing, reassuring groundedness. People with sing tend to have peaks and valleys in their tone quality. The weeping quality is connected to metal. If you have a weeping voice, your tone might go lower at the end of phrases, or you have a voice that’s rough sounding. The final descriptor is groaning, which is a water descriptor. Just like a rushing river, groaningi voices are steady, and often rather monotonous. While their energy might shift, the tone stays within a close range.

Infographic:
Shout – Wood
Laugh – Fire
Sing – Eart
Weep – Metal
Groan – Water

Touching

Sometimes referred to as “palpitation”, the examination of the pulse is one of the details most heavily relied on by ancient practitioners, as well as the pillar that is least often understood by modern practitioners of Chinese medicine. It’s important to note that in Eastern medicine there are many different areas to access and analyze the pulse and that not every practitioner agrees on the exact numbers involved in defining the pulse.

Pulse diagnosis looks at the depth, quality, rate and rhythm of the pulse. This includes the movement of blood in the vessels, the tension and shape of the blood vessel and the tension of the tissues surrounding the artery. The length of the pulse within the three positions on each arm is also considered. 

The radial artery, found through the wrist, is the most common location by which the pulse is assessed. There are three different points on each arm that can be checked. These correspond to different organ systems. There are also three different depths, or pressures, with which to check the pulse. These depths are referred to as either superficial (light, low pressure), middle, or deep (stronger, steady pressure). A floating pulse is even more superficial, bounding up to reach the surface in acute conditions.

The positions are not the only feature that is noted.  The more important observation is the pulse quality. There are classically 28 pulse qualities. For instance a slippery pulse has the sensation of pearls in a bowl. This may actually be the sensation of feeling lipids in the blood.  A surging pulse indicates the heat of fever. A wiry pulse is tight and indiciates psychological pressure when found in the Liver position.

A normal, healthy pulse is said to be steady and consistent. It should be soft and calm, but not faint and not experience extreme changes in either direction. Some of the most commonly used pulse descriptors in TCM include terms like: floating, surging, string-like, hollow, stirred, hidden, and skipping. While many of these adjectives seem unrelated to your pulse, they help describe the pace, strength, energy, and other qualities that can inform a practitioner’s diagnosis. 

Most common pulse qualities used in TCM – from Bin Hu Mai Xue and Zhen Jia Zhen Gyan:

  • Floating
  • Sunken
  • Low
  • Rapid
  • Surging
  • Fine
  • Vacuous
  • Replete
  • Long
  • Short
  • Slippery
  • Rough
  • String-like
  • Tight
  • Soggy
  • Moderate
  • Faint
  • Weak
  • Dissipated
  • Hollow
  • Drumskin
  • Firm
  • Hidden
  • Stirred
  • Intermittent
  • Bound
  • Skipping
  • Racing

Pulse diagnosis looks at the depth, quality, rate and rhythm of the pulse. This includest the movement of blood in the blood vessels, the tension and shape of the blood vessel and the tension of the tissues surrounding the artery. The length of the pulse within the three positions on each arm is also considered. 

The radial artery, found through the wrist, is the most common location by which the pulse is assessed. There are three different points on each arm that can be checked. These correspond to different organ systems. There are also threetwo different depths, or pressures, with which to check the pulse. These depths are referred to as either superficial (light, low pressure), middle or deep (stronger, steady pressure). A floating pulse is even more superficial, bounding up to reach the surface in acute conditions.

The positions are not the only feature that is noted.  The more important observation is the pulse quality. There are classically 28 pulse qualities. For instance a slippery pulse has the sensation of pearls in a bowl. This may actually be the sensation of feeling lipids in the blood.  A surging pulse indicates the heat of fever. A wiry pulse is tight and indiciates psychological pressure when found in the Liver position.

However, don’t be fooled by what may sound like a simple system. Depending on the specific style and training of your practitioner, there can be between 28 and up to hundreds of locations to gauge the pulse and up to 12 depths to check. In addition to the pulse locations and depth, another factor comes into play; pulse quality. There are said to be somewhere between 23 and over 30 different ways to categorize the quality of the pulse. A normal, healthy pulse is said to be steady and consistent. It should be soft and calm, but not faint and not experience extreme changes in either direction. Some of the most commonly used pulse descriptors in TCM include terms like: floating, surging, string-like, hollow, stirred, hidden, and skipping. While many of these adjectives seem unrelated to your pulse, they help describe the pace, strength, energy, and other qualities that can inform a practitioner’s diagnosis.

Most common pulse qualities used in TCM – from Bin Hu Mai Xue and Zhen Jia Zhen Gyan

  • Floating
  • Sunken
  • Low
  • Rapid
  • Surging
  • Fine
  • Vacuous
  • Replete
  • Long
  • Short
  • Slippery
  • Rough
  • String-like
  • Tight
  • Soggy
  • Moderate
  • Faint
  • Weak
  • Dissipated
  • Hollow
  • Drumskin
  • Firm
  • Hidden
  • Stirred
  • Intermittent
  • Bound
  • Skipping
  • Racing

Asking

The fourth pillar of diagnosis is asking. This is probably one of the most familiar methods of healthcare assessments to those used to Western medicine. In TCM, many practitioners base their process of asking around what’s known as The Ten Questions. These are designed to capture a holistic snapshot of the patient’s lifestyle, habits, and potential needs (that many patients may not realize they need!). 

Though they claim to only include 10 questions, in most cases, you can expect quite a few more. Questions will revolve around subjects like locations of pain, energy levels, details around daily digestion, thirst, and bowel movements, and quality of sleep. Additional questions might be asked regarding details about the menstruation cycle, sweat, mental health, emotional health, personal relationships, or career.

Based on your answers to these initial questions, the TCM practitioner might be inspired to ask a few follow up questions for clarity and specificity. Questions about the specific location of pain, types of pain (whether it’s sharp or dull), or the duration of discomfort (among others) might be asked to help narrow down the diagnosis.

Though they claim to only include 10 questions, in most cases, you can expect quite a few more. Questions will revolve around subjects like locations of pain, energy levels, details around daily digestion, thirst, and bowel movements, and quality of sleep. Additional questions might be asked regarding details about the menstruation cycle, sweat, mental health, emotional health, personal relationships, or career.

Based on your answers to these initial questions, the TCM practitioner might be inspired to ask a few follow up questions for clarity and specificity. Questions about the specific location of pain, types of pain (whether it’s sharp or dull), or the duration of discomfort (among others) might be asked to help narrow down the diagnosis.

The Eight Principles of Diagnosis

In Traditional Chinese Medicine, the Eight Principles are used to describe the qualities and characteristics of a disease or condition. This can include the location, nature, cause and further definition of what’s going on in the body. The principles are actually four pairs of equal, yet opposite instances. A patient should present one side of each of the four pairs, resulting in a more specific diagnosis when all four qualities are put together.

Interior vs. Exterior

The first two principles are interior and exterior. This one is quite easy to guess based on their names. An interior condition is one that occurs in the internal organs of the zang-fu systems or within the blood, qi, or bones. Interior conditions are believed to be caused by imbalances triggered from within, such as intense and prolonged emotions, or energy shifts.

By contrast, exterior conditions affect the outer layers of the body like the skin, hair, nails, or meridians. It is believed that most of these issues come from outside pathogens like the weather food and drinks, and lifestyle choices. The symptoms of both interior and exterior can vary depending on the total combination of diagnosis. It’s impossible to pinpoint the symptoms without knowing which four of eight principles a patient possesses.

Deficiency vs. Excess

These two principles are used to describe the root imbalance that’s causing issues in the body. If it’s an imbalance of the qi, blood, or other fluids (‘jinye’ in Chinese), the condition will likely be considered a deficiency. When a patient is deficient in qi or blood, it means that the body likely isn’t nourished enough or there is a blockage preventing normal functioning. Often, you’ll notice a qi or blood deficiency is occurring when you feel very low energy, poor circulation, general weakness, and pale skin. 

On the other end of the spectrum, excess issues are typically caused by negative outside influences like stress, emotion, or temperate conditions. Often one of the Six Excesses is noted as being tied to a condition labeled excess. These include wind, cold, heat, dryness, dampness, and summer heat. Each of these terms describes the nature of the condition. 

For example, if the pathogen arrives suddenly and moves through the body, it’s likely described as a wind condition (like the cold or flu). On the other hand sufferers of dry coughs, skin, or chapped lips are said to be dealing with the dryness excess. The resulting symptoms of both a deficiency and excess depend on their alignment with the other principles. 

Cold vs. Heat

While this might be confusing now that we’ve heard about the Six Excesses above, try to think of these two principles as the description of the most basic nature of the condition. Exactly as you might expect, the cold factor often manifests as literal chills, cold limbs, poor circulation, cold sweats, and a pale face. Heat tends to present itself with fevers, dry mouth, thirst, and pink or red face and eyes. The difference in symptoms between a patient experiencing heat or cold, with patterns of either exterior or interior can be drastically different! 

Heat plus exterior often results in symptoms like a quick pulse, fever, chills, sore throat, or dehydration. But heat combined with interior is often much less intense, resulting in a slow pulse, desire for cold drinks and food, and clear urine (meaning a high retention of moisture). The same is true of the cold combinations. Cold with an exterior patterned condition will likely result in a tight, rapid pulse, body aches and chills, fever, and headaches. On the other hand, cold with interior conditions might look like nausea, stomach pain, vomiting, and diarrhea.

Yin vs. Yang

Yin and yang is the final pair of descriptors of the Eight Principles. These are in fact the yin and yang you might already be familiar with. They describe the qi that flows through all things, living and nonliving. There are a set of qualities, objects, and descriptive phrases that are aligned with each, and these also include the first six of the Eight Principles.

Yin and yang in this process essentially tally up the first three sets, which should align with either yin or yang. Yin tends to comprise of interior, deficient and cold, while yang symptoms often show as exterior, excessive and hot. While it might appear as though a patient should have a series of symptoms aligning solidly on one side or the other, it’s not always that cut-and-dried. Luckily TCM practitioners are specially trained to figure out the answer!

Determining the Diagnosis

After all those layers of questioning and inspecting, a TCM practitioner should have a clear answer, right? Not necessarily. While there are many pieces to the puzzle being unearthed through the Four Pillars and Eight Principles of Diagnosis, they might not all fit together on the surface. A TCM practitioner looking at these clues might have elements of opposite or conflicting information revealed that they must then sort out.

It’s important to note that even after going through these processes, a TCM practitioner might want to do some specific testing around potential problem areas in order to make a final diagnosis. They may also want to consult with the patient’s Western medical primary doctor or other specialists to get a full picture of the issues and other treatments currently underway. 

It takes extensive training and practice to master the art of diagnosis in Chinese medicine. TCM practitioners learn to differentiate between the signs they pick up on; which fit together and which don’t. Once they’ve figured out the problem, they can then plan a treatment to fix it. Treatment plans in TCM generally include a combination of acupuncture or acupressure massage, herbal supplements or tinctures, and lifestyle or diet adjustments.

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