Editor: Xiao Yaotong
The ancients said, “To know by observation is called spirit.” How can we enhance the accuracy of diagnosis through observation? Today, let us learn from the clinical experience of Dr. Wei Changchun in observation diagnosis.
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In TCM diagnosis, the four examinations and eight principles are fundamental, with observation being the most important. A detailed observation can provide a preliminary understanding of the severity and prognosis of the condition, which is of practical value.
1. Observation of the Face
In observation diagnosis, the face is of primary importance.
If the face appears bluish, it indicates pain. Generally, a dark bluish complexion, a slow pulse, a pale red or pale white tongue, and a thin white or slippery white coating without fever suggest stagnation of qi, spleen dysfunction, and obstruction of qi flow, leading to fullness and pain in the chest and abdomen. It is advisable to promote the movement of qi in the chest.
If the complexion is dark bluish, with a large pulse, shortness of breath, spontaneous sweating, and loose stools without fever, it often indicates a severe deficiency of the spleen and kidneys due to prolonged illness, requiring urgent measures to tonify qi, restrain sweating, and stabilize the condition.
If a woman has a pale bluish complexion with sunken eye sockets, it indicates cold stagnation and blood stasis.
If a child has a pale bluish complexion, delayed speech and movement, and although plump, lacks color in the face, and is prone to diarrhea and colds, it suggests congenital deficiency of yang qi, requiring warming of the three burners and tonification of the spleen and kidneys.
Individuals who have been vegetarian for years may show malnutrition, with a complexion that is pale with a bluish tint, and may have edema and shortness of breath, indicating qi deficiency and damp retention.
If there is an external pathogen, the face may appear red and tender with a white tint, resembling a slight intoxication, with a pulse that is large and rapid at the cun position, while the chi pulse is weak and slow, and the tongue is bright red with a moist surface and no coating. This indicates a deficiency of the lower source, with floating yang rising, resembling a false heat condition, and should not be mistaken for a true heat condition.
If the face is completely red, with a rapid pulse, a deep red tongue, thick yellow coating, thirst, and constipation, it indicates excessive dryness and heat in the stomach and intestines. It is advisable to clear and resolve hidden heat and urgently nourish yin.
In both cases, the complexion appears red, but the nature of the condition differs significantly between deficiency and excess. Careful consideration and discernment are necessary during diagnosis to avoid mistakes.
If a long-term illness leads to a delicate and rosy complexion with bright red cheeks, a rapid and slippery pulse, it indicates true yin deficiency and rising fire, historically referred to as “peach blossom syndrome,” which is a sign of tuberculosis.
Individuals who are thin with prominent cheekbones, especially with a history of lung obstruction or hemoptysis, should be treated with a comprehensive approach, addressing both the symptoms and the root cause, ensuring that exterior treatments do not hinder the underlying deficiency, and preserving the source without allowing external pathogens to invade. The ancients included nourishing substances in exterior-dispersing formulas and added exterior-resolving herbs in nourishing formulas, which reflects this principle.
Internal injuries often present with a sallow, lifeless complexion, lacking vitality, or a yellowish pallor, or a bluish, dull, and dry appearance; while external pathogens often present with a red or yellow complexion, or an oily sheen, indicating a more robust spirit.
Dark circles around the eyes are often caused by anger and stagnation. Symptoms may include fullness in the chest and abdomen, dizziness, irritability, and insomnia, and treatment should focus on relieving stagnation, regulating qi, and soothing the liver and stomach.
Sunken eye sockets with a sallow complexion indicate deficiency of central qi, or prolonged diarrhea, suggesting deficiency of both spleen and kidneys.
A pale complexion with a bluish nose often indicates abdominal pain or diarrhea, suggesting a condition of deficiency-cold, and treatment should focus on warming and tonifying the yang of the spleen and kidneys.
If a child has a bluish nose and frequently experiences diarrhea and crying, this indicates spleen deficiency, and treatment should focus on strengthening the spleen and resolving accumulation.
2. Observation of the Lips
The lips are associated with the spleen and are the foundation of muscle. By observing the color and texture of the lips, one can infer spleen-related diseases.
Dry and chapped lips often indicate food accumulation.
Purple and dark lips, along with a peculiar temperament and irritability, indicate disharmony of the spleen and qi stagnation, and treatment should focus on regulating qi and blood, and harmonizing the liver and spleen.
Pale lips with a yellowish face, vomiting of saliva, and reduced appetite indicate weakness of the stomach and inability to transform and transport, and treatment should focus on warming the middle and stopping vomiting.
Lips that are pale yellow with abdominal fullness indicate internal damp-heat and inability to transform, and treatment should focus on resolving dampness.
Red and purple lips indicate blood stasis with heat; if there is pain due to parasitic accumulation, cooling blood and detoxifying methods should be used.
Ulcerated lips with vomiting, headache, and abdominal pain indicate parasitic accumulation.
Bright red lips with symptoms of hemoptysis, irritability, and constipation indicate stomach heat, and treatment should focus on clearing heat, harmonizing the stomach, and removing stasis.
3. Observation of the Nose
Dry nostrils indicate heat in the yangming channel, and prolonged dryness may lead to the risk of epistaxis.
Dry nostrils that are black like coal, with symptoms of confusion or high fever, indicate deep yang toxin heat, and treatment should focus on cooling blood and detoxifying.
Flared nostrils in children indicate that the evil heat cannot be expelled and is trapped in the lungs, which is a sign of severe pneumonia; in adults, it often indicates phlegm-heat obstructing the lungs. Treatment should focus on clearing heat, transforming phlegm, and opening the lungs. In cases of prolonged illness with a pale complexion, sweating, and cold limbs, flared nostrils indicate a deficiency of lung qi.
In postpartum women, black nostrils often indicate a critical condition due to retained lochia, requiring immediate support for the vital spirit and expulsion of blood stasis.
A black and cold nose indicates deficiency-cold; a bluish nose indicates kidney deficiency, often accompanied by lumbar soreness and nocturnal emissions in men, and leukorrhea or uterine cold in women, requiring warming of kidney qi.
4. Observation of the Teeth
The teeth are the remnants of the kidneys, and the gums are the collateral of the stomach.Heat pathogens can dry up stomach fluids and deplete kidney essence; if the disease penetrates deeply, it may lead to bleeding. Yang blood appears purple like dry lacquer, while yin blood appears yellow like sauce. Treatment for yang blood focuses on clearing the stomach; treatment for yin blood focuses on rescuing the kidneys.
Teeth that are dry and shiny like beans indicate severe stomach heat, and treatment should focus on clearing and draining.
If the teeth appear like dry bones, it indicates depletion of kidney and stomach fluids; if the upper half remains moist, it indicates that water is not ascending and fire is not descending. Urgent measures should be taken to clear fire and rescue water until the dry areas become moist.
Grinding teeth indicates a wind-heat convulsion. If it is a single grinding, it indicates stomach heat and aggressive qi; if grinding is accompanied by a tight jaw and a weak pulse, it indicates either a decline of stomach qi or internal wind invading the collaterals, or a deficiency of water and excess of wood, indicating a sign of extreme deficiency presenting as excess.
If the teeth are covered in a grayish paste, it indicates that the stomach lacks qi and dampness is obstructing, which is often a critical condition.
Initially, if the teeth bleed clear blood and are painful, it indicates dental inflammation due to stomach fire; if there is no pain, it indicates internal liver fire.
Teeth that are dry and without residue are critical; if they are dry but have residue, it indicates kidney heat and stomach dampness, which can be treated with slight purging or by clearing the stomach and nourishing the kidneys.
5. Observation of the Hands
Clubbed fingers indicate pulmonary tuberculosis.
Fingernails with ridges often indicate liver disease.
Dark bluish nails often indicate anemia, and may also belong to a deficiency-cold condition. Purple nails indicate blood stasis. The color of the nails indicates blood coagulation.
In individuals with chronic illness, although they may be emaciated, if the fleshy part of the palm (thenar) is prominent, the condition may be treatable; if other areas have sufficient muscle but the thumb and index finger are flat and sunken, the condition is critical and difficult to treat.
6. Observation of the Tongue
In general, a normal tongue should be rosy and moist.
A pale red tongue often indicates deficiency; a pale white tongue indicates deficiency of original yang; a deep red tongue indicates heat; a bright red tongue indicates heat entering the nutritive and blood levels in external conditions, while in internal injuries, it indicates damage to the five organs and depletion of yin fluids.
A tongue that is smooth and devoid of coating indicates deficiency of liver and kidney yin. If it suddenly shows a floating white coating upon external invasion, avoid using pungent and drying dispersing methods; instead, provide mild flavors to clear and diffuse lung qi. Once the qi is unblocked, the external condition will resolve, and the white coating will recede, after which nourishing and supportive agents can be administered.
A pale tongue with a white coating often indicates deficiency-cold, but there may also be cases of phlegm-heat obstruction, presenting with chest tightness and irritability, requiring the use of slightly bitter and cold agents to penetrate.
Once the hidden pathogen is expelled, the tongue may turn red, and the coating may either turn yellow or completely disappear. At this time, chest tightness will ease, and irritability will settle. If the diagnosis is unclear and deficiency-cold treatments are mistakenly applied, it may lead to a sudden change in symptoms.
A tongue with a smooth surface and a thin coating on the edges indicates injury to the stomach yin and insufficient fluids. Avoid using pungent and drying agents, and ensure that stomach fluids are adequately supported.
A tongue with a pale coating and cracks indicates damage to both qi and yin of the spleen and stomach. If there is an external pathogen, it is necessary to supplement with nourishing agents to prevent exacerbation of both internal and external conditions.
If the tongue is dry with prickly spots and horizontal lines, it indicates transformation of food into fire.
A thick yellow coating covering the tongue generally indicates a heat condition.If symptoms include fullness in the chest, qi counterflow, abdominal distension after eating, clear and prolonged urination, and loose stools, it indicates middle qi deficiency and qi stagnation.
A thick yellow and greasy coating indicates that clear qi is not rising and turbid qi is not descending. Avoid using bitter and cold purging methods; instead, use light methods to eliminate excess, aromatic agents to awaken the spleen and stomach, and once the coating gradually transforms, then proceed with sweet and warm tonics for the spleen and stomach.
A red tongue often indicates internal heat.
A red tip indicates heart fire; red on both sides indicates hidden heat; if the upper half has a white coating and the lower half is pure red, it indicates a raging heart fire, requiring urgent administration of large doses to clear the heat from the nutritive level, without concern for the white greasy coating.
Small red spots on the tongue are often due to emotional distress, indicating internal fire. The more spots present, the more severe the distress.
A pale red tongue with small red spots indicates weakness of the spleen and stomach, often accompanied by indigestion, stomach pain, and tidal fever.
A deep red tongue with small red spots indicates yin deficiency and blood heat, often accompanied by emotional distress.
A bluish-purple tongue often indicates chronic injury or blood stasis; if there is a new illness, attention should be paid to treating the underlying stasis.
A dry red tongue without moisture often indicates yin deficiency and blood heat, but may also be due to phlegm obstructing the qi mechanism, preventing fluids from ascending. At this time, it is important to inquire about the comfort of the chest, whether there is distension or fullness, whether the head is clear or dizzy, and whether bowel movements are regular or obstructed to confirm the diagnosis.
A bright red tongue with a shiny surface, resembling a mirror, is often a sign of a critical condition. In cases of external pathogens, it indicates a pre-existing yin deficiency and blood heat, with new heat entering the blood level. Immediate administration of large doses of cooling blood-clearing agents is necessary for urgent treatment. If it is due to internal obstruction, such as esophageal obstruction or liver cirrhosis with ascites, it indicates exposure of true qi and depletion of yin fluids, which is a critical sign.
A bright red tongue with a white greasy coating (commonly known as rice flower coating) indicates damage to both qi and fluids, and internal failure; if there is prolonged diarrhea with inability to eat, accompanied by hiccups, it indicates counterflow of qi and inability to retain.
A pale red, swollen tongue with a white slippery coating often indicates qi deficiency and insufficient original yang, but may also indicate phlegm-dampness.
A tender red tongue with teeth marks on the edges indicates weakness of the spleen and blood deficiency, often accompanied by indigestion, stomach pain, and tidal heat.
A dark-colored tongue often indicates blood stasis. A bluish tongue indicates cold stasis in the liver; a purple tongue indicates heat stasis; a bluish-purple tongue at the root indicates stasis in the lower jiao, often associated with conditions like hernias.
A pale white, dry tongue with cracks in the elderly, with shortness of breath and no heat, indicates weakness due to damage to both qi and fluids, requiring urgent use of warming and nourishing agents.
Black coating indicates the presence of cold or heat.
A gray-black coating with a pale red, moist tongue indicates a sign of deficiency-cold; a swollen tongue indicates spleen-cold, while a short and round tongue indicates kidney-cold.
If a tongue has a dry, black coating with a deep red, dry, and lack of moisture, it indicates a heat condition: if there is thirst with a preference for hot drinks, it indicates yangming dryness-heat; if thirst leads to coldness and pain in the heart, it indicates a jueyin condition. Additionally, there are cases of spleen yang deficiency with dampness, which may also present with black coating, but the tongue remains pale and not dry.
Disorders of the spleen and stomach qi mechanism often present with colored coatings.For example, after eating olives, the coating may turn black; after eating loquats, it may turn yellow; after consuming vinegar, it may turn gray, and various coatings may appear after taking medications. It is important to inquire about what has been consumed to determine the cause and avoid misdiagnosis.
In cases of infectious diseases, appropriate medication will lead to the tongue coating changing from white to yellow, from yellow to retreating, and then to a new thin white coating, which is a favorable sign; if the medication is inappropriate, the coating may change from yellow to white, from white to black, which is an unfavorable sign. A sudden disappearance or rapid change without gradual transformation indicates a critical condition.
In general, individuals with strong stomach qi have a soft tongue, and their conditions are easier to treat; if stomach qi is absent, the tongue becomes hard, and the condition is difficult to treat. For example, in cases of stroke affecting the organs, the tongue may become difficult to articulate; in cases of typhoid fever, the tongue may become short, both of which are critical signs. If there are external pathogens such as damp-heat or summer heat, and the tongue is hard and silent, it often indicates a condition of excess heat in the stomach that requires urgent treatment.
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▍Copyright Statement:
▶This article is excerpted from “Selected Clinical Experiences of Wei Changchun,” compiled by Zhejiang Chinese Medicine Hospital and published by Zhejiang Science and Technology Press, October 1984.Image source: Public Image Library.
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▶This article involves formulas and medicines that should be used under the guidance of a qualified TCM practitioner; do not self-medicate.
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