In Traditional Chinese Medicine (TCM), observation (wang zhen) is the first of the four diagnostic methods, emphasizing its importance as stated, “To know by observation is called spirit (shen).” This highlights the significance of observation in TCM.
This article will introduce gynecological observation from three aspects: observing the shape and color, tongue coating, and the eyes, ears, mouth, and nose. It is detailed and authentic, worthy of collection and frequent review.
1Observation of Shape and ColorShape refers to the body’s form; color refers to the complexion and skin tone. The external manifestations of shape and color can help understand whether the internal organ functions are normal and the various pathological conditions that may arise.When a woman first visits, except for those with long-term internal injuries, severe hemorrhage, or those who are more than three months pregnant, there are special shapes that can be observed at a glance. Other constitutions and disease types can generally be divided into the following seven categories:1. Obese Type:This type is characterized by obesity, a complexion that is whiter and more lustrous than average, full muscle fat, thick palms, and short fingers. Although they appear robust, careful observation reveals the presence of qi deficiency or spleen deficiency. Symptoms may include shortness of breath upon exertion, easy sweating, dizziness, and lower back soreness; some women may also have difficulty conceiving.Clinically, this body type often accompanies internal dampness of the spleen, feelings of heaviness in the head and limbs, phlegm, or excessive white discharge, and if there is liver heat, they may feel irritable and have a heavy head; those with yang deficiency may also exhibit significant cold intolerance.2. Yin Deficiency with Excess Heat Type:This type is characterized by thin muscles, a sallow complexion, lack of subcutaneous fat, dry or hot skin, bright eyes, and red lips. Symptoms include palms feeling hot or afternoon tidal fever, often accompanied by tinnitus, dizziness, dry mouth, dry cough, and night sweats; severe cases may lead to menstrual irregularities. Menstrual cycles are generally early with scanty flow, or early with heavy flow, and as the condition progresses, the menstrual blood may become dry and scant.3. Qi and Blood Deficiency Type:This type presents as thin body, weak muscles, pale complexion with little redness, dry and rough skin, thin palms, and in severe cases, sunken palms, pale and uncolored nails and lips; often accompanied by poor appetite or indigestion, easy fatigue, and frequent cold intolerance, or low-grade fever. This body type, if untreated for a long time, may lead to deficiency and lung issues.4. Liver Qi Stagnation Type:Characterized by yellowish thin body, subtle bluish tinge on the face, and visible veins on the forehead and temples, but not bulging, or lymph nodes on both sides of the neck, with a depressed spirit, difficulty in being impulsive, and if eating less, easily feeling hungry; overeating leads to abdominal distension, sometimes accompanied by fullness in the sides, and a tendency to sigh (deep breaths). The tongue often shows a straight line in the center, initially just a line, but over time it deepens and widens into a groove.Accompanying symptoms include irregular menstrual cycles, dark and stagnant menstrual blood, abdominal pain, palpitations, irritability, and excessive sadness. Middle-aged women often experience breast tenderness before menstruation, and in severe cases, this can lead to infertility.5. Liver Heat and Spleen Dampness Type:Characterized by a flushed face with oily dark color, easily agitated spirit, quick temper, and impatience; excessive movement leads to fatigue. This body type is smaller than the obese type but lacks firmness. Red lips and tongue edges, with a white greasy or yellow greasy coating, dry mouth with little desire to drink. Common complaints include abdominal fullness and irritability, heavy limbs, yellowish-white discharge, and irregular menstrual cycles. Head heaviness, dizziness, and lower back soreness are common symptoms of this body type.6. Spleen and Kidney Yang Deficiency Type:This type is characterized by a body that is fat but not firm, soft muscles, pale and dull complexion, or signs of edema, sparse eyebrows, and lips and nails that are not rosy; the tongue is swollen and pale, with little energy and cold intolerance, or back cold, requiring more clothing than usual.Movement is slow, and quick walking leads to fatigue or shortness of breath; often accompanied by lower back pain, poor appetite, loose stools, late menstruation with scanty flow, pale color, and dull abdominal pain, with clear and thin discharge, and many may suffer from infertility.7. Long-term Liver and Kidney Deficiency Type:This type presents as nutritional disorders, fatigue, poor appetite, thin muscles, yellowish and dry skin, especially a grayish face, thin and dark ear rims, and a depressed spirit, showing a unique state of decline; severe cases may present with subcutaneous edema.This type often experiences amenorrhea; if there is frequent vaginal bleeding, increased discharge with foul odor, or abdominal pain, or swelling in the face and lower limbs, consider the possibility of cervical or uterine cancer.The above seven types are commonly seen in gynecological clinical practice and are presented for reference.2Observation of Tongue CoatingThe tongue and coating should be observed separately:Observing the tongue involves examining its color, shape, and texture; observing the coating involves examining the color and thickness of the coating on the tongue surface.The tongue reflects the rise and fall of qi and blood, while the coating indicates the depth of pathogenic factors.1. Observing the Tongue:In general, a swollen and firm tongue indicates excess, while a bright red or purple tongue indicates heat; a yellow coating indicates excess, and excess and heat are often found together. A relaxed, tender tongue with a central groove indicates deficiency, while a pale tongue indicates cold, and a thin white coating indicates deficiency; deficiency and cold can also be seen together. However, in clinical practice, there can be cases of excess with cold or deficiency with heat, which require comprehensive analysis with overall symptoms and pulse condition.A dry tongue indicates fluid deficiency, while a moist tongue is normal.Stagnant blood often presents as a dark purple tongue; it may appear dry but feel moist to the touch, while qi deficiency with fluid damage shows a thin white coating, appearing moist but feeling dry.Regardless of whether the tongue is red, purple, pale, or dark, a moist and vibrant tongue is a good sign; regardless of the presence of coating, a withered tongue indicates internal injury to essence and blood.A tongue that cannot extend indicates a brain issue; a stiff tongue that does not move freely indicates a problem in the liver meridian (including neurological issues).For example, teeth marks on the tongue often indicate spleen and kidney deficiency; many women with spleen deficiency and excessive discharge often have a swollen tongue with prominent teeth marks. Severe infectious diseases, malignant tumors, hyperthyroidism, and serious diseases of the lungs, liver, and kidneys often present with a bright red and shiny tongue.This indicates that changes in tongue quality and color relate to organic lesions in the internal organs.For instance, patients with acute pelvic inflammatory disease often show a swollen tongue with a thick coating; during treatment, if the thick coating changes to a thin white coating, it often indicates improvement; if abdominal pain decreases but the coating does not change, it indicates that the condition has not improved and may worsen. This is also a corroborative sign.Additionally, some women suffering from convulsions and prolonged stomach pain often have a light blue tongue, indicating stagnant blood in the liver or qi stagnation. Therefore, any bluish color on the tongue surface indicates a blood issue, often associated with stagnant blood syndrome.Furthermore, a tongue that appears like a red persimmon, or like a peeled pig kidney, or like a dry and shriveled lychee, with an outer layer that is either as white as snow or pale white like rotten residue, or resembling crushed rice grains, or with small ulcerated spots, indicates severe deficiency of the internal organs’ essence and qi.2. Observing the Coating:The coating on the tongue is like green moss growing on wet soil. The moss on the soil grows due to moisture rising; the coating on the tongue arises from damp-heat in the spleen and stomach.Thus, it is called “coating.”Normally, a healthy tongue has a thin layer of floating white or floating yellow coating, which is thicker in summer but not overly thick or stagnant.If a thick white greasy coating covers the entire tongue, it indicates fullness and stagnation in the stomach, leading to poor appetite. Pregnant women with damp-heat in the spleen and stomach often show this coating, indicating a specific coating for morning sickness.A yellowish-white thick greasy coating, or grayish-yellow in the tongue, often indicates damp-heat stagnation in the lower jiao, commonly seen in patients with chronic pelvic inflammatory disease.Grayish-black coating is often seen in typhoid fever and warm diseases indicating internal excess and heat; a black and moist tongue indicates a cold syndrome, which will not be discussed here.In gynecology, black coating often indicates blood stasis; gray coating indicates blood stasis with phlegm. Women suffering from febrile diseases are most likely to develop black coating due to the mutual accumulation of heat and blood, especially during menstruation or postpartum when there is residual lochia, leading to blood and heat stagnation, resulting in black coating.Medical texts often differentiate between moist and delicate black coating and dry and cracked coating to distinguish between cold and heat; I often see black coating with blood stasis, which, although there is internal heat, does not present with dryness (except in heavy smokers, where black coating may easily become dry). This indicates that there is no true heat, but rather lung and stomach fluid damage.Postpartum grayish-black coating must consider internal blood stasis; if there are symptoms of chills and fever, one must guard against confusion and delirium (blood stasis syndrome); if there are no chills or fever, there is often accumulated heat in the chest and sides, or abdominal masses, leading to internal restlessness and insomnia (heat and blood stasis syndrome).There is also a type of stasis coating, where the tongue color and coating appear normal, but there are purple-black spots hidden beneath the coating, either on the sides or in the center of the tongue; if few, there may be two or three spots, but if many, there may be more than ten spots. This indicates the presence of blood stasis in a certain area.If the tongue has black coating and is stiff, with difficulty in speech, or if the body feels heavy and cannot turn, or if one side cannot sleep, this indicates a critical condition.In summary, regardless of whether the coating is yellow, white, or gray-black, most are excess conditions and are generally easier to treat. If there are changes in tongue quality, it often indicates internal injuries due to qi and blood deficiency or stasis, and may even indicate organic lesions in the internal organs.This is a summary of tongue coating observation.3Observation of the Eyes, Ears, Mouth, and Nose1. The Liver Opens to the Eyes.
The essence and qi of the five organs and six bowels all ascend to the eyes, which are connected to the brain, the brain being the sea of marrow, and the essence of marrow is the pupil.
Thus, the eyes are related to the internal organs, with a closer relationship to the brain, kidneys, and liver.Whenever the eyes lack brightness, it indicates kidney deficiency; this is often seen in cases of prolonged nervous exhaustion and women’s irritability that does not improve. Sudden loss of vision during severe uterine hemorrhage or postpartum hemorrhage indicates yang qi collapse; dim vision indicates yin qi collapse; both are critical conditions.Regardless of whether there are internal injuries or external pathogens before or after childbirth, if the eyes can recognize people, the condition is mild; if the eyes cannot recognize people, the condition is severe. In cases of excess syndrome, if the eyes cannot recognize people, treatment is possible; in cases of qi and blood deficiency, if the eyes cannot recognize people, treatment is difficult.Dilated pupils indicate internal injury due to qi exhaustion, while constricted pupils indicate blood stasis in the brain or marrow depletion, which may also relate to liver and kidney exhaustion.Red veins in the sclera and flushed cheeks indicate yin deficiency with excess heat; deep red veins covering the sclera indicate excess heat in the heart and liver channels, while pale red indicates deficiency heat; accompanied by headache indicates liver fire rising. A deep blue sclera indicates liver channel stagnation heat, while a yellow sclera indicates jaundice, indicating spleen channel damp-heat; swollen eyelids and yellow eyes indicate accumulated heat from prolonged cough or prolonged vomiting during pregnancy, with spleen and stomach deficiency heat rising.Black spots on the upper eyelids and sunken eyes indicate stagnant blood in the liver and spleen; dark circles under the eyes often indicate phlegm, dysmenorrhea, amenorrhea, or previous phlegm-damp conditions.Protruding eyeballs indicate excess liver qi, excessive liver yang, and a quick temper; protruding eyeballs may also be seen in toxic hyperthyroidism.Strabismus indicates gradual liver heat stirring wind, which may further lead to convulsions in the limbs; this is often seen in women with eclampsia before childbirth.Eyes that are fixed (both eyes looking upward) indicate severe heat evil entering the brain, which is one of the critical signs.Sunken eyes with a yellow and thin face often indicate prolonged bleeding or leakage, indicating liver, spleen, and kidney deficiency.Sunken eyes may also be seen in severe vomiting and diarrhea, indicating severe dehydration.2. The Nose is the Opening of the Lungs (Lungs Open to the Nose).According to the Jin Kui Yao Lue:
“If the tip of the nose is blue, abdominal pain occurs, and if it is cold, death is imminent; if it is slightly black, there is water qi…; blue indicates pain, black indicates labor…”
Since blue indicates stagnant blood, if the nose and surrounding areas appear blue, accompanied by abdominal pain and cold intolerance, it indicates that cold qi is combined with stagnant blood, leading to abdominal pain, often seen in late menstruation or amenorrhea, which is a reliable diagnostic indicator; as for being a sign of imminent death, it is not necessarily so.If the nose or surrounding areas appear slightly black, it indicates the presence of water qi (water qi refers to phlegm, indicating that there is water retention in the chest and lungs) and is synonymous with the previously mentioned dark circles under the eyes.A bluish-black nose bridge, besides phlegm and water qi, often indicates spleen and kidney deficiency with cold, leading to lower back pain, discharge, or blood stasis symptoms. The term “black” refers to the face; labor refers to chronic internal injury symptoms. This is primarily due to kidney essence deficiency, presenting with initial fatigue and weakness, lower back pain, and poor appetite; later, it may lead to dizziness, confusion, and anemia.Initially, the face may appear yellowish and then dark and stagnant like bronze or black lead; ancient TCM texts refer to this condition as “black dampness,” which corresponds to modern medicine’s chronic adrenal insufficiency.Additionally, if the nostrils appear like coal tubes, both dry and dark, this indicates heat injuring the lung channel, often seen in febrile diseases with high fever, leading to lung fluid depletion and impending lung failure. In postpartum women, if lochia does not discharge, or if the placenta does not deliver and blood stagnates, black qi may appear in the mouth and nose, accompanied by wheezing and nosebleeds, indicating that qi is reversing with blood, leading to critical conditions.3. The Spleen Opens to the Mouth, and Its Manifestation is in the Lips, Thus Both the Mouth and Lips are External Manifestations of the Spleen.If the spleen and stomach function normally, besides having well-developed and firm muscles, the lips are rosy; conversely, if the muscles are thin, the lips are pale and lack luster.Pale lips indicate spleen and stomach deficiency, leading to qi and blood deficiency, which can affect menstruation and pregnancy; women’s postnatal disorders often arise from this.Furthermore, the Chong and Ren meridians nourish the mouth and lips. Whenever a woman has abundant qi and blood in the Chong and Ren meridians, the lips appear vibrant; if there is deficiency in the Chong and Ren, the lips appear withered or swollen.From the health of the mouth and lip muscles, as well as the brightness and luster of their color, one can infer the rise and fall of qi and blood in the Chong and Ren meridians, further speculating whether there are any lesions in the uterus.Clinically, women with prolonged bleeding or chronic diarrhea often present with dry and pale lips, and the area around the mouth and face may show swelling (referred to as “lip reflection” in medical texts), and in severe cases, the complexion may appear yellowish or dark. In such cases, the condition is often serious, and one must consider whether there are cancers in the reproductive or rectal areas.On the other hand, if the area around the mouth shows a bluish tinge, or if there are purple or dark spots on the lips, this often indicates liver and spleen disharmony, blood stasis leading to amenorrhea, or abdominal masses.4. The Ears are the External Opening of the Kidneys, Reflecting the Essence and Qi of the Kidneys.Of course, this relates to hearing, and the foot Shaoyang meridian runs around the ears, thus there is a greater supply of qi and blood.In observation, if the ear rims are rosy and the ear lobes are well-developed, this indicates health; if the ear rims are small and thin, with a pale or dry yellow color lacking luster, this indicates deficiency of essence and blood; if the ear rims are dry and dark, this indicates weakness of essence and blood; if the ear rims are dry and shriveled, accompanied by hearing loss, this indicates long-term kidney essence deficiency, with blood and fluids depleted; elderly women with prolonged menstrual bleeding often exhibit this phenomenon.
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【Copyright Statement】: This article is excerpted from New TCM (1976) | Author: Xu Rongzhai, copyright belongs to the relevant rights holder, reposting is for learning and communication purposes only. If you have symptoms, please consult a professional physician in a timely manner. Thank you!
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