Traditional Chinese Medicine (TCM) places great emphasis on observation diagnosis. The primary focus during clinical diagnosis is to observe the patient’s demeanor, physique, and certain specific manifestations to understand the nature and severity of the disease.
The key to observation diagnosis is first to observe the spirit.
If the patient has bright, lively eyes, clear speech, abundant energy, a rosy complexion, and coordinated movements, they are said to have a good spirit; conversely, if their gaze is dull, reactions are slow, speech is low, energy is depleted, and expressions are apathetic, they are considered to have lost their spirit. A strong vital energy indicates a vibrant spirit; a deficiency in vital energy leads to fatigue.
If a patient exhibits severe symptoms but maintains a good spirit, it indicates that the righteous qi is not weakened, suggesting a generally favorable prognosis; on the contrary, if the symptoms are mild but the spirit is weak, it indicates a tendency towards weakness of the righteous qi, suggesting a poor prognosis.
However, in critical illnesses, a temporary improvement in spirit or a flushed complexion can indicate a dangerous sign of yin-yang conflict, suggesting that “a floating spirit indicates danger,” and caution is warranted.
Next, observe the color: the complexion reflects the vitality of the internal organs. Clinically, one can differentiate based on the richness or pallor of the color. If the qi and blood are abundant, the complexion is rosy and vibrant; if qi and blood are deficient, the complexion appears pale and dull. A pale complexion indicates blood loss, a sallow complexion indicates deficiency, and a flushed complexion indicates exhaustion.
When the internal organs are diseased, the facial complexion may also change accordingly; for example, a patient with spleen disease often has a sallow complexion, while a patient with lung disease may appear pale, a patient with heart disease may have a red complexion, a patient with liver disease may appear greenish, and a patient with kidney disease may have a grayish-black complexion.
Additionally, different colors can indicate various causes and symptoms, as noted in the “Lingshu: Five Colors” which states, “black-blue indicates pain, yellow-red indicates heat, and white indicates cold.”
However, color observation must be combined with the other three diagnostic methods; for instance, a pale complexion may indicate blood deficiency; if there are no factors of blood loss, one should consider fear, as fear can lead to qi descent and blood loss, resulting in a spirit that follows the qi. A pulse that feels like tangled threads, a complexion that alternates between pale and red, and an unsettled spirit are also signs to consider; there may be feelings of shame or guilt, which can lead to qi contraction and a wandering spirit, necessitating careful clinical examination.
Observation of the patient’s spirit and color should be conducted in natural light, from a distance of about ten steps, to see the true condition.
Observation of Physique
As for the body, it requires detailed differentiation. Well-developed muscles indicate abundant stomach qi, while a thin physique indicates weak righteous qi. Dry skin suggests a prognosis, while hair loss indicates a loss of righteousness.
Excess qi: the body appears light, enjoys movement, is prone to anger, laughter, and shouting.
Insufficient qi: the body appears heavy, prefers to lie down, is silent, and exhibits gloom and worry.
Observation of Posture
The different postures and positions of the patient are closely related to the disease. For example, sitting and leaning forward indicates shortness of breath, while sitting with one leg down indicates lower back pain. Strong convulsions indicate excess, while weak convulsions indicate deficiency. “Yang is active, while yin is passive.” If the patient is light and can turn, with warm hands and feet, and desires to see people, it is often a yang disease, which is easier to treat; if the body is heavy, cannot turn, with cold hands and feet, fatigue, closed eyes, and reluctance to see people, it indicates a yin disease, which is harder to treat.
Observation of ColorVerse
Observation of color has no other technique, it focuses on the spirit and qi. Excess conditions are often red and bright, while deficiency conditions are pale and floating. Locations must be clearly defined, and the interactions of generation and restriction must be carefully considered. Both auspicious and ominous signs can be predicted, with floating yang noted in the heart.
The forehead, heart, chin, and nose correspond to the spleen; the left cheek corresponds to the liver, and the right cheek corresponds to the lung. The liver is associated with green, the lung with white, the heart with red, the spleen with yellow, and the kidney with black, indicating their interactions.
In cases of prolonged illness and deficiency without external pathogens, if a sudden flush appears on the face, it indicates that the original yang is floating to the surface, a sign of imminent death.
A complexion that is red like vermilion indicates abundant qi, but there may also be a contraction. A naturally red face without illness should not be considered pathological. A new illness with a red face and aversion to heat indicates an excess of pathogenic fire. A long-term illness with a lack of spirit and a red face indicates a depletion of yang, a sign of impending collapse. A color resembling a rooster’s comb is auspicious, while a color resembling bruising is fatal.
A complexion that is green with spirit and abundant qi may also have a contraction. A naturally green face should not be considered pathological. If the face turns green due to illness, it indicates liver disease. A spirited appearance indicates a strong liver, while a lack of spirit indicates a weak liver. A color resembling emerald feathers is auspicious, while a color resembling withered grass is ominous.
A complexion that is white with spirit and abundant qi may also have a contraction. A naturally white face should not be considered pathological. If the face turns white due to illness, it should be evaluated in the context of the disease. A white complexion with spirit indicates abundant lung qi, while a white complexion without spirit indicates lung deficiency. A color resembling pig fat is auspicious, while a color resembling withered bones is dangerous.
A complexion that is yellow with spirit and abundant qi may also have a contraction. A naturally yellow face should not be considered pathological. If the face turns yellow due to illness, it should be evaluated in the context of the disease. A yellow complexion with spirit indicates abundant stomach accumulation, while a yellow complexion without spirit indicates a sign of weak qi. A bright yellow is auspicious, while a dusty yellow is ominous.
A complexion that is black with spirit and abundant qi may also have a contraction. A naturally black face should not be considered pathological. If the face turns black due to illness, it should be evaluated in the context of the disease. A black complexion with spirit indicates strong kidney qi, while a black complexion without spirit indicates weak kidney qi. A color resembling bird feathers is auspicious, while a color resembling coal is dangerous.
This discussion of the five colors’ abundance and deficiency also involves generation and restriction. The forehead corresponds to the heart, while black qi is to be feared. The nose corresponds to earth, while green is alarming. The chin is yellow and indicates water disease; the left cheek is white and indicates liver injury, while the right cheek is red and indicates fire damage. The changes in qi and color are manifold, and the mechanisms of brightness and darkness can be referenced.
Excess qi: the observed color is purple-red, with lips like vermilion, indicating restlessness. If the color does not match the disease, one should prioritize the disease over the color.
Insufficient qi: the observed color is stagnant and dark, pale and without spirit, with lips and mouth appearing black and blue. If the disease does not match the color, one should be cautious.
Observation of Breath
Excess qi: the breath is coarse, exhaling steam, and the speech is strong.
Insufficient qi: the breath is weak, short, and cold, with soft speech.
Observation of Saliva
Excess qi: there is continuous salivation, a hot mouth, and a desire for water, indicating stomach fire.
Insufficient qi: there is continuous salivation, a cold mouth, and a desire for hot soup, indicating stomach cold.
Observation of Skin and Hair
Excess qi: the skin is dry and rough, hair is brittle, and the skin is itchy.
Insufficient qi: the skin is smooth and moist, hair is lustrous, and although the skin may be thin, there are no signs of dryness or itchiness.
Identifying Sores
Excess qi: the sores are red, swollen, raised, painful, and restless; a spirited person indicates a carbuncle.
Insufficient qi: the sores appear normal in color, swollen without pain, and a lack of spirit indicates a boil.
Identifying Pox
Excess qi: the pox are purple-red, or accompanied by spots, with a dry tongue, red lips, and constipation.
Insufficient qi: the pox are gray, flat, and sunken, with chills, pale lips, and loose stools.
Identifying Eye Diseases
Excess qi: the eyes are red, swollen, painful, with tears, and restlessness.
Insufficient qi: the pain and swelling are not severe, and while there may be many symptoms, there is no significant suffering.
Observation of Teeth
In clinical practice, observing the tongue must be accompanied by observing the teeth. The teeth are the remnants of bone, nourished by marrow.
In all heat diseases, if the front teeth are dry, it indicates that pathogenic heat is in the qi level, and the stomach yin is injured, requiring a cooling and moistening treatment.
If the teeth are black and dry, it indicates extreme yangming heat, and the stomach fluid is about to dry up, requiring urgent treatment to clear heat and rescue yin.
If the teeth are white like withered bones without moisture, it indicates injury to both qi and fluids, and depletion of kidney yin, requiring treatment to tonify qi, nourish yin, clear heat, and detoxify.
Swollen and painful gums or red and purple gums indicate yangming stomach fire attacking upward, requiring treatment to drain heat and cool the blood.
If the gums are not swollen, but the teeth appear to bleed, the teeth are loose, it often indicates kidney fire rising, requiring a focus on strengthening water.
Grinding or clenching teeth often indicates extreme heat and wind, requiring treatment to clear heat and extinguish wind. It may also indicate spleen deficiency and qi deficiency leading to involuntary movement. Careful differentiation is necessary in clinical practice.
Observation of the Tongue
Tongue diagnosis is a characteristic and valuable experience of traditional Chinese medicine, and is an essential part of observation diagnosis. The disease’s “meridians,” “internal organs,” “wei, qi, ying, blood,” “yin, yang, exterior, interior, cold, heat, deficiency, excess” must all be reflected on the tongue, which serves as an important basis for differentiation.
When differentiating the tongue, if one overly emphasizes the five colors corresponding to the five organs, or divides the organs by location, it is a mechanical application of the five-element theory. Clinical assessment of disease mechanisms must rely on pulse diagnosis, comprehensive and detailed consideration of all specific circumstances, and flexible mastery to avoid errors; one cannot rely solely on tongue diagnosis to determine the condition.
For example, in the following situations:
White Coating on the Tongue
If a patient presents with a white coating on the tongue but does not exhibit symptoms such as headache, body aches, fever, chills, or aversion to heat, one should not hastily conclude a superficial condition or a plague. Instead, one should investigate the pulse, voice, daily activities, and whether the spirit is present, as these will provide clues to the condition; one must not be reckless. If there is a superficial condition, then treatment can proceed according to the method for resolving superficial conditions.
Yellow Coating on the Tongue
If a patient presents with a yellow coating on the tongue, whether it is dry yellow, moist yellow, old yellow, or black yellow, but does not exhibit symptoms such as lightness, aversion to heat, irritability, desire for cold drinks, or constipation, one should not hastily conclude that there is extreme heat. Instead, one should consider the possibility of yang deficiency, where the true qi cannot rise, and the treatment method will be found within that context. If symptoms such as lightness, aversion to heat, foul breath, irritability, desire for cold drinks, or constipation are present, then one should proceed to purge without delay.
Black Coating on the Tongue
If a patient presents with a black coating on the tongue, whether it is dry black, blue-black, or moist black, one should not hastily treat it as a yin condition. If the person exhibits symptoms such as lightness, aversion to heat, foul breath, irritability, desire for cold drinks, or constipation, then one should proceed to purge without delay. If the person is quiet, speaks little, has closed eyes, desires to lie down, and has normal bowel movements, then one should restore yang without delay.
In summary:
Excess qi: the tongue may appear yellow, dry white, purple-red, black-yellow, or completely dry black, with restlessness and a desire for cold drinks.
Insufficient qi: the tongue may appear blue and slippery, moist yellow, moist black, dry black, or have a mix of blue and yellow, or yellow and white, with a moist tongue, and the person is quiet, speaks little, and prefers warm drinks.
Observation of the Lips
The lips belong to the foot taiyin spleen and also to the foot yangming stomach. Dry lips indicate dryness, cracked lips indicate heat, chapped lips indicate extreme heat, moving lips indicate wind, pale lips indicate blood loss, blue lips indicate pain (indicating internal cold), and excessive salivation indicates spleen deficiency. An open mouth that cannot close indicates severe collapse, while tightly clenched teeth indicate a solid closure. In clinical practice, one must consider the overall condition of the body to determine whether to moisten, clear, warm, or tonify, and treat according to the symptoms.
Observation of the Eyes
Red eyes indicate fire, but must be accompanied by dry tongue and thirst, with a strong pulse, indicating excess fire, requiring treatment to drain fire.
If the eyes are red, with flushed cheeks, and the pulse is deep and thin, with heat in the palms and soles, this indicates deficient fire. If the pulse is strong but without strength upon palpation, it also indicates false heat.
If the eyes are yellow, this indicates damp-heat accumulation, potentially leading to jaundice, and must be accompanied by symptoms such as difficulty urinating, abdominal fullness, thirst without desire to drink, requiring treatment to clear heat and drain dampness.
If the eyes are yellow, with normal urination, dark stools, and a hard, painful abdomen, this indicates blood stasis, requiring treatment to invigorate blood and eliminate stasis.
If the eyes are yellow, with cold body temperature, no thirst, and a deep, thin pulse, this indicates yin jaundice, requiring treatment to warm the spleen and drain dampness.
If the eyes have dry tears, this indicates excessive liver and gallbladder fire, requiring treatment to clear the liver and drain the gallbladder.
If the eyes have watery tears, this indicates wind, and treatment must be differentiated; one cannot treat purely with fire, and one must avoid excessive use of bitter, cold, and cooling herbs.
If the eyes appear dull and fixed, this indicates phlegm, requiring treatment to resolve phlegm.
If the eyelids are black, this also indicates phlegm; cold phlegm requires warming methods, while hot phlegm requires clearing methods.
If the eyes are clear and calm, this often indicates a non-fire condition, and one should not recklessly use cooling herbs.
If the eyes do not recognize people, this indicates a yangming excess condition, which must be accompanied by confusion and delirium, with a yellow or black tongue coating, cracked lips, loose stools, and yellow urine, indicating a need to clear and purge.
If there is a deficiency of the shaoyin, the pulse will be deep and thin, with a weak voice, restlessness, clear urination, and shallow breathing, indicating a difficult condition, requiring restoration of yang.
If the eyes appear vacant and do not recognize people, this indicates a complete loss of liver qi.
If the eyes are looking upwards, this often indicates liver wind.
If the eyes are fixed and do not move, resembling fish eyes or cat eyes, this indicates a complete loss of the essence of the five organs.
If the eyelids are sunken, this indicates a complete loss of spleen qi.
All of the above are critical conditions.
If the eyes cannot open, this indicates severe heat in both yangs, with red threads resembling a net; the foot taiyang corresponds to the upper eye, while the foot yangming corresponds to the lower eye. Heat causes the tendons to stretch, hence the eyes cannot open.
Dilated pupils indicate a deficiency of shaoyin water, with excessive wood and fire, requiring treatment with bitter, draining, sour, and cooling herbs to drain liver fire and strengthen kidney water. One must avoid using excessively dry and bitter cold herbs, as they can harm the organ’s qi.
Constricted pupils indicate excessive yang harming yin, with damage to both the liver and kidney meridians, leading to weakened original qi that cannot rise, requiring treatment to suppress yang and nourish yin, and one must not drain yang, as this would further damage the original qi.
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