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Local observation diagnosis, also known as sectional observation diagnosis, is based on overall observation diagnosis, focusing on certain local areas of the patient’s body for detailed observation according to the condition or diagnostic needs. Since overall pathological changes can reflect in local areas, local observation helps to understand the overall pathological situation.
(1) Observation of the Head and Face
1. Observation of the Head: The observation of the head mainly involves examining the shape, dynamics, and the color and quality of the hair. This helps to understand the pathological changes in the brain and kidneys, as well as the state of Qi and blood.
(1) Observation of Head Shape: In children, an excessively large or small head shape, accompanied by intellectual disability, is often due to congenital insufficiency and kidney essence deficiency. An enlarged head shape may be caused by hydrocephalus. When observing a child’s head, it is essential to examine the fontanelle. If the fontanelle is sunken, it is termed “sunken fontanelle,” indicating fluid damage and insufficient brain marrow; if the fontanelle is bulging, it is termed “self-filling,” often due to excessive heat evil, indicating a disease of the brain marrow; if the fontanelle fails to close in a timely manner, it is termed “open fontanelle,” indicating insufficient kidney Qi and developmental issues. Whether in adults or children, an inability to control head shaking is a sign of internal liver wind movement.
(2) Observation of Hair: In normal individuals, hair is usually thick, black, and lustrous, indicating abundant kidney Qi. Sparse or slow-growing hair indicates kidney Qi deficiency.
Yellow, dry hair, and hair loss after prolonged illness often indicate insufficient essence and blood. Sudden patchy hair loss is caused by blood deficiency and wind. Hair loss in adolescents is often due to kidney deficiency or blood heat. Premature graying in youth, accompanied by forgetfulness and soreness in the lower back and knees, indicates kidney deficiency; if there are no other pathological signs, it is not considered a disease.
In children, hair that is knotted like a tassel is often seen in malnutrition.
2. Observation of the Face: The observation of facial complexion has been discussed previously. Here, we focus on changes in facial shape. Facial swelling is often seen in edema.
Swelling of the parotid gland, either unilaterally or bilaterally, that suddenly enlarges and is painful to touch, often accompanies sore throat or hearing loss, is usually due to warm toxin, seen in mumps. Facial asymmetry, with the mouth and eyes skewed, often indicates a stroke. A frightened expression on the face is commonly seen in children with convulsions or rabies patients, while a grimacing expression is seen in tetanus patients.
(2) Observation of the Five Organs
Observation of the five organs involves examining the eyes, nose, ears, lips, mouth, gums, and throat. Abnormal changes in these organs can provide insights into visceral diseases.
1. Observation of the Eyes: The observation of the eyes mainly focuses on their spirit, color, shape, and state.
(1) Eye Spirit: The presence or absence of spirit in the eyes is a key focus. Clear vision, vibrant inner content, and abundant spirit light indicate the eyes are spirited; if the sclera is cloudy, the pupil is dull, lacking brilliance, and the light is floating, the eyes lack spirit.
(2) Eye Color: If the eyes are red, it indicates heart fire; if the sclera is red, it indicates lung fire; if the sclera shows red vessels, it indicates yin deficiency with excess fire; if the eyelids are red, swollen, and ulcerated, it indicates phlegm fire; if the entire eye is red and swollen with tears in the wind, it indicates liver channel wind heat. If the eye discharge is pale white, it indicates blood deficiency. Yellowing of the sclera indicates jaundice. Black discoloration around the eyes indicates kidney deficiency with water retention or cold dampness.
(3) Eye Shape: Slight swelling of the eyes, resembling a sleeping silkworm, indicates the initial stage of edema; elderly individuals with facial swelling often have kidney Qi deficiency. Sunken eye sockets indicate depletion of yin fluids or exhaustion of essence. Bulging eyes with shortness of breath indicate lung distension; protruding and swollen eyes indicate goiter.
(4) Eye State: If the eyes are fixed and cannot move, it is termed “eye reversal,” often seen in convulsions, spasms, or severe cases of spirit exhaustion. Crossed eyes indicate internal liver wind movement. Drooping eyelids, termed “eyelid failure,” often indicate congenital eyelid failure due to congenital insufficiency, with both spleen and kidney deficiency. Asymmetrical drooping of one or both eyelids often indicates acquired eyelid failure due to spleen Qi deficiency or post-traumatic Qi and blood disharmony, leading to obstruction of the vessels. Dilated pupils often indicate exhaustion of kidney essence, a sign of impending death.
2. Observation of the Nose: The observation of the nose mainly involves examining its color, shape, and secretions.
(1) Nose Color: A bright and moist nose indicates that the stomach Qi is intact or has recovered after illness. A red nose tip indicates lung heat; a white nose indicates Qi deficiency and blood insufficiency; a yellow nose indicates internal damp heat; a blue nose often indicates abdominal pain; a slightly black nose indicates internal water retention.
A dry and cracked nose tip indicates spleen and stomach deficiency, where the stomach Qi cannot nourish the nose. A dry nostril indicates internal heat due to yin deficiency or dryness invading the lungs; if the nose is dry and bleeds, it is often due to excessive yang in the upper body.
(2) Nose Shape: A red nose tip or nose with papules often indicates rosacea, caused by stomach fire affecting the lungs, leading to blood stasis in the lung vessels. Growths inside the nostrils that block airflow, termed “nasal polyps,” are often due to wind heat stagnation in the lung channel. Frequent flaring of the nostrils during breathing indicates “nasal flaring.” If this persists, it indicates a critical condition of lung and kidney Qi deficiency; if it is a new condition, it often indicates lung heat.
(3) Nasal Secretions: Clear nasal discharge indicates an external wind-cold; turbid nasal discharge indicates an external wind-heat; foul-smelling turbid nasal discharge indicates nasal phlegm, often due to external wind-heat or heat accumulation in the gallbladder channel.
3. Observation of the Ears: The observation of the ears should focus on their color, shape, and internal conditions.
(1) Auricular Regions and Visceral Connections: Certain specific areas on the auricle correspond to various parts of the body, resembling an inverted fetus in the womb, with the head at the bottom and limbs at the top. When a certain part of the body has a pathological change, corresponding areas on the auricle may exhibit congestion, discoloration, papules, blisters, desquamation, ulceration, or tenderness, which can be referenced during diagnosis.
(2) Ear Color: Normal ear color is slightly yellow and rosy. A predominantly white ear color often indicates a cold syndrome; a blue-black ear color often indicates pain; a black and dry ear rim indicates extreme kidney essence deficiency, where essence fails to nourish; redness in the ear rim with a cool ear base often indicates a precursor to numbness. A rosy ear color is ideal; any yellow, white, blue, or black discoloration indicates a pathological condition.
(3) Ear Shape: Normal ears are thick and moist, indicating sufficient congenital kidney Qi. If the auricle is thick, it indicates excess; if it is thin and small, it indicates deficiency. Enlarged ears indicate excess evil; thin ears indicate deficiency of righteous Qi. Thin and red or black ears indicate kidney essence deficiency. A dry ear rim is often seen in lower consumption syndromes. An ear rim with irregularities is often seen in chronic blood stasis. Atrophy of the ear rim indicates a critical condition of kidney Qi exhaustion.
(4) Internal Ear Changes: Pus in the ear indicates suppurative otitis, caused by damp heat in the liver and gallbladder, accumulating over time. Growths inside the ear resembling a goat’s nipple are termed “ear polyps”; those resembling jujube pits that protrude outside the ear and are painful to touch are termed “ear protrusions,” both caused by liver channel fire or kidney channel fire, or heat accumulation in the stomach.
4. Observation of the Mouth and Lips: The observation of the lips requires attention to their color and dynamic changes.
(1) Observation of the Lips: The clinical significance of lip color diagnosis is similar to that of facial color, but due to the thin and transparent mucosa of the lips, their color is more pronounced. Normal lips are red and moist. Deep red lips indicate excess or heat; pale red lips often indicate deficiency or cold; dry and cracked deep red lips indicate extreme heat injuring fluids; tender red lips indicate yin deficiency with excess fire; pale white lips often indicate deficiency of both Qi and blood; bluish-purple lips often indicate deficiency of yang Qi and stagnation of blood flow. Dry, cracked lips indicate fluid damage, leading to loss of moisture. Ulcerated lips often result from heat accumulation in the spleen and stomach, causing burns from heat evil. Ulceration inside the lips, with pale red color, indicates upward fire; sores at the lip corners, red and swollen, indicate heat accumulation in the heart and spleen.
(2) Observation of the Mouth: The observation of the mouth should focus on its shape: a closed mouth that is difficult to open indicates “locked jaw”; if the mouth is closed and speech is difficult, accompanied by limb convulsions, it often indicates convulsions or severe cases of wind stroke; if accompanied by hemiplegia, it indicates a stroke affecting the heart. A tightly closed mouth indicates “mouth closure,” often seen in children with umbilical wind or adults with tetanus. A skewed mouth, either left or right, indicates a stroke. An open mouth that cannot close indicates “mouth opening”; if the mouth is open and air only escapes without returning, it indicates impending lung Qi exhaustion.
5. Observation of the Teeth and Gums: The observation of the teeth and gums should focus on their color, shape, and moisture changes.
(1) Observation of the Teeth: Teeth that are not moist indicate fluid damage. Dry teeth indicate stomach fluid damage; teeth that are dry like stones indicate extreme heat in the stomach and intestines, severely damaging fluids; dry teeth like withered bones indicate exhaustion of kidney essence, failing to nourish the teeth; loose and sparse teeth with exposed roots often indicate kidney deficiency or upward fire. Grinding teeth during sleep often indicates internal liver wind movement. Teeth grinding during the day often indicates stomach heat or accumulation of parasites. Teeth with cavities and foul odor often indicate dental caries, commonly referred to as “worm teeth.”
(2) Observation of the Gums: Red and moist gums are normal. Pale white gums indicate blood deficiency; swollen or bleeding gums often indicate upward fire in the stomach. Slightly red and swollen gums that are not painful, or bleeding between the teeth, often indicate insufficient kidney yin with upward fire; pale white gums that are not swollen or painful, with bleeding between the teeth, indicate spleen deficiency unable to control blood. Ulcerated gums with foul-smelling blood indicate dental disease.
6. Observation of the Throat: Symptoms of throat diseases are numerous; here we only introduce general observable content. If the throat is red, swollen, and painful, it often indicates heat accumulation in the lungs and stomach; if red and swollen with yellow-white necrotic spots, it indicates deep heat toxin; if it is bright red and tender with mild swelling, it indicates excess fire due to yin deficiency.
If both sides of the throat are red and swollen, protruding like papillae, it is termed “papillary throat,” indicating excessive heat in the lungs and stomach, with external wind evil accumulating. If there is a gray-white membrane in the throat that cannot be wiped away, and wiping causes bleeding, it is termed “diphtheria,” which is infectious and is also known as “epidemic throat.”
(3) Observation of the Body
The observation of the body includes the neck, chest, abdomen, waist, back, and the front and back of the lower yin.
1. Observation of the Neck: The neck connects the head and trunk, with the front referred to as the neck and the back as the nape. The observation of the neck should focus on shape and dynamic changes.
(1) Shape Changes: If there are lumps or tumors in the area under the jaw that move with swallowing, with unchanged skin color and no pain, and are persistent and non-ulcerated, it is termed “goiter,” commonly known as “big neck.” If there are lumps on the side of the jaw that feel like beads, with unchanged skin color and initial tenderness, it is termed “lymphadenopathy.”
(2) Dynamic Changes: If the neck is weak and lacks strength, it is termed “neck weakness.” If the back of the neck is stiff, and it is difficult to bend forward or turn sideways, it is termed “stiff neck.” If stiffness occurs after waking, it is termed “wry neck.” Stiffness of the neck with a bowing posture often indicates internal liver wind movement.
2. Observation of the Chest: The area above the diaphragm and below the collarbone is referred to as the chest. Observation of the chest should focus on shape changes.
In normal individuals, the chest is symmetrical and moves freely during breathing. If a child’s chest protrudes forward and outward, becoming deformed, it is termed “chicken breast,” often due to congenital insufficiency and postnatal imbalance, leading to inadequate nourishment of the bones. If the chest appears barrel-shaped, with cough, wheezing, and emaciation, it indicates phlegm heat obstructing lung Qi. If the patient experiences fullness between the ribs, with pain upon coughing, it is often seen in cases of fluid retention in the chest. If there are hard lumps in the ribs, resembling beads, it is termed “rickets,” due to kidney essence deficiency, leading to soft and deformed bones. Localized redness and swelling of the breast, even ulceration and pus, indicate breast abscess, often due to liver Qi stagnation, leading to obstruction of milk flow.
3. Observation of the Abdomen: The area below the diaphragm and above the pelvis is referred to as the abdomen. The observation of the abdomen mainly examines changes in its shape.
If the abdominal skin is tense and distended like a drum, it is termed “distension.” If the abdomen is high in both standing and lying positions, and is soft upon palpation, it indicates Qi distension.
If the abdomen is distended when standing but flat when lying down, it indicates water distension. If the abdomen is sunken like a boat, it is termed “abdominal depression,” often seen in chronic illness with severe deficiency of spleen and stomach Qi, or in new illnesses with loss of yin fluids. If an infant has a mass protruding from the navel, with shiny skin, it is termed “umbilical protrusion,” also known as umbilical hernia.
4. Observation of the Back: The back refers to the posterior part of the trunk from the nape to the waist. The observation of the back mainly focuses on shape changes.
If the spine protrudes backward, it is termed “humpback,” often due to insufficient nourishment during childhood, leading to deformity of the spine. If the patient has a stiff neck and the back is bent forward like a bow, it is termed “bowing posture,” often seen in tetanus or convulsions. Boils, carbuncles, sores, and toxins that occur on the back are collectively referred to as “back sores,” often due to fire toxin stagnating in the muscles.
5. Observation of the Waist: The waist refers to the posterior part of the trunk below the ribs and above the iliac crest. The observation of the waist mainly focuses on shape changes.
If there is pain in the waist, making it difficult to turn, it is termed “waist stiffness,” which may be due to external cold and dampness invading, obstructing Qi, or due to trauma leading to blood stasis. If there are water blisters on the skin of the waist, clustered like beads, it is termed “waist fire blister.”
6. Observation of the Front Yin: The front yin, also known as the “lower yin,” refers to the external genitalia and urethra of both genders. The front yin has reproductive and urinary functions.
(1) Scrotum: If the scrotum is enlarged, painless, and the skin is transparent, it indicates water hernia. If the scrotum is enlarged, painful, and firm, it indicates inguinal hernia. If there is a mass inside the scrotum that retracts into the abdomen when lying down and descends when standing, it is termed “fox hernia.”
(2) Penis: If the penis is soft and retracts into the abdomen, it is termed “penile retraction,” often due to deficiency of yang Qi or external cold condensing the meridians. If the penis has hard lumps, ulcerates, and discharges pus, it is often seen in syphilis or other infectious diseases.
(3) Female Genitalia: If there is a protrusion resembling a pear in the female genitalia, it is termed “prolapsed uterus,” often due to insufficient middle Qi, fatigue after childbirth, or weakness in lifting, leading to the uterus descending outside the vulva.
7. Observation of the Back Yin: The back yin refers to the anus, also known as the “spirit gate,” which has the function of defecation. The observation of the back yin should focus on prolapse, hemorrhoids, and anal fissures.
Prolapse of the rectum outside the anus is termed “rectal prolapse.” If there are protrusions around the anus, with pain and even bleeding during defecation, it indicates hemorrhoids; those occurring outside the anus are termed external hemorrhoids; those occurring inside are termed internal hemorrhoids; those occurring both inside and outside are termed mixed hemorrhoids. If hemorrhoids ulcerate and do not heal for a long time, leading to the formation of a fistula around the anus, it is termed “anal fistula,” which may have branches connecting to the rectum. If there is a fissure in the anus, causing pain and bleeding during defecation, it is termed “anal fissure.”
(4) Observation of the Four Limbs
The four limbs refer to the two lower limbs and two upper limbs. The observation of the four limbs mainly examines the shape and color changes of the hands, feet, palms, wrists, fingers, and toes.
1. Observation of the Hands and Feet: If the hands and feet are stiff and difficult to flex and extend, it is often due to cold condensing the meridians. If they are flexed but cannot be extended, it indicates tendon spasms; if they are extended but cannot be flexed, it indicates joint stiffness. Convulsions in the hands and feet are often seen in cases of excessive heat or internal liver wind movement; raising hands and feet indicates excessive internal heat disturbing the spirit. Unsteady shaking of the hands and feet indicates deficiency of both Qi and blood, leading to internal wind movement. Muscle atrophy in the limbs is often due to spleen Qi deficiency and insufficient nourishment of the blood. Hemiplegia indicates paralysis. Weakness in the feet, termed “lower weakness,” indicates lower limb weakness. Swelling in the shins or ankles, leaving a mark when pressed, indicates edema.
2. Observation of the Palms and Wrists: Dry, cracked skin on the palms, with pain and peeling, is termed “goose palm wind.”
3. Observation of the Fingers and Toes: If the fingers are spasmodic and cannot be straightened, it is termed “chicken claw wind.” Swelling and deformity of the finger and toe joints, with difficulty in flexion and extension, often indicate long-standing rheumatism or deficiency of liver and kidney. If the skin of the toes is purple-black, with foul discharge, and the flesh is not fresh, it indicates gangrene.
(5) Observation of the Skin
The observation of the skin should focus on color and shape changes.
1. Color
The skin can exhibit five colors, and the five-color diagnosis is also applicable to skin observation. Commonly seen and significant clinical manifestations include redness and yellowness.
(1) Red skin: Sudden redness of the skin, resembling being dyed, is termed “erysipelas.” It can occur on any part of the body, initially appearing bright red and often moving unpredictably, sometimes covering the entire body. Redness on the head and face is termed “head fire erysipelas,” redness on the trunk is termed “erysipelas,” and redness on the ankles is termed “flowing fire.” Due to different locations, colors, and causes, there are various names, but all erysipelas belong to excessive heart fire, often combined with wind-heat evil.
(2) Yellow skin: Yellowing of the skin, face, and nails indicates jaundice. It is divided into two main categories: yang jaundice and yin jaundice. Yang jaundice is bright yellow, like orange, often due to damp heat in the spleen and stomach. Yin jaundice is dark yellow, like smoke, often due to cold dampness obstructing the spleen and stomach.
2. Shape
(1) Skin that is swollen and puffy, leaving indentations when pressed, often indicates excessive water retention. Dry and shriveled skin often indicates fluid damage or deficiency of essence and blood; rough, dry skin resembling scales is termed “scaly skin,” often due to blood stasis obstructing nourishment.
(2) Pustules: Skin eruptions resembling small beans are termed “pustules.” They often accompany external pathogenic conditions, including smallpox and chickenpox.
(3) Rashes: Spots and rashes are skin lesions that are symptoms during the disease process. Spots are red, large, and flat under the skin, not palpable. Due to different pathogenesis, there are distinctions between yang spots and yin spots. Rashes resemble chestnuts, are red and raised, and are palpable; due to different causes, they can be classified as measles, rubella, hidden rashes, etc.
(4) White patches and blisters: White patches and blisters are elevated skin lesions; blisters contain fluid, while white patches are small papules.
(5) Boils, carbuncles, sores, and abscesses: These are all surgical lesions that can be diagnosed on the skin’s surface. The distinctions are as follows: lesions that are larger, red, swollen, hot, and painful are termed boils. If the swelling is diffuse without a head, with a flat base and unchanged skin color, it is termed carbuncle. If the lesion is smaller, initially resembling a grain, with a hard base, numbness or itching, and later turning white and painful, it is termed a furuncle. Lesions that are superficial, small, round, and not very painful, easily suppurating, and healing after pus drainage are termed abscesses.
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Observation of the Tongue
The observation of the tongue is one of the five organ observations. However, its content is very rich and has developed into a specialized tongue diagnosis, thus warranting a separate section for elaboration.
Tongue diagnosis primarily focuses on tongue observation, but also includes tongue sensation (taste) diagnosis and palpation. Tongue observation is a diagnostic method that involves examining the tongue’s appearance. The tongue’s appearance consists of the color and shape of the tongue body and coating.
Observation of Excretions
Observation of excretions involves examining the patient’s secretions and excretions, such as phlegm, vomit, urine, saliva, sweat, tears, and vaginal discharge. This section focuses on the observation of phlegm, vomit, and urine, examining their color, quality, shape, and quantity to understand the related visceral changes and the nature of pathogenic Qi. Generally, excretions that are clear and thin often indicate cold or deficiency syndromes; yellow and thick excretions that are turbid and unclean often indicate heat or excess syndromes; if the color is black and contains lumps, it often indicates stasis syndrome.
Observation of Children’s Fingerprints
Fingerprints are the veins that appear on the front edge of the palms of children’s index fingers. The method of diagnosing diseases by observing changes in children’s fingerprints is called “fingerprint diagnosis,” which is only applicable to children under three years old. Fingerprints are a branch of the Taiyin Lung channel, thus having similar significance to pulse diagnosis.
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