Auditory Examination
Auditory examination includes listening to sounds and smelling odors. Listening to sounds refers to the examination of the patient’s voice, speech, breathing, coughing, vomiting, belching, sighing, sneezing, and bowel sounds. Smelling odors refers to detecting various smells emitted from the patient’s body, as well as from secretions, excretions, and the environment of the sickroom.
The practice of auditory examination has been recorded since the era of the Huangdi Neijing (Yellow Emperor’s Inner Canon). The Suwen: Yin Yang Ying Xiang Da Lun first proposed the theory that the five sounds correspond to the five organs; the Suwen: Mai Yao Jing Wei Lun further used sounds, speech, and breathing to assess the balance of Zheng Qi (Upright Qi) and the presence of Xie Qi (Evil Qi). The Shanghan Lun and Jinkui Yaolue also emphasized the patient’s language, breathing, wheezing, coughing, vomiting, belching, and moaning as key components of auditory examination. Later practitioners expanded the scope of auditory examination to include abnormal odors from the mouth, nose, and various secretions and excretions. The fundamental principle is that various sounds and odors are produced during the physiological and pathological activities of the organs, thus reflecting their physiological and pathological changes.
1. Listening to Sounds
The production of sound is the result of the coordinated activity of the lungs, throat, epiglottis, tongue, teeth, lips, and nose. The lungs are the driving force behind sound production, as they govern the Qi of the body; when Qi moves, sound is produced. The throat is the organ of sound production, and sound must emerge from the throat; other organs play a regulating role in sound. Abnormal changes in sound are primarily related to lung Qi, but the kidneys govern the intake of Qi, and thus the movement of Qi must ascend from the kidneys to the tongue to produce sound. Pathological changes in other organs can also affect the lungs and kidneys through the meridians. Therefore, listening to sounds can not only diagnose diseases related to the organs involved in sound production but can also further assess changes in the internal organs based on variations in sound. Generally, in the case of new or minor illnesses, the sound remains unchanged; only in chronic or severe illnesses does the sound change.
1. Normal Sounds
The voice of a healthy person, despite individual differences, is natural, harmonious in tone, and balanced in strength; these are common characteristics of normal sounds. Due to differences in gender, age, and physical constitution, the voices of normal individuals also vary: males typically have deep and hoarse voices, females have high and clear voices, children have sharp and crisp voices, and the elderly have deep and resonant voices.
The voice is also related to emotional changes. For example, when happy, the voice is joyful and relaxed; when angry, the voice is fierce and urgent; when sad, the voice is sorrowful and intermittent; when joyful, the voice is smooth and slow; when respectful, the voice is upright and serious; when loving, the voice is gentle and harmonious. These sounds, triggered by momentary emotional responses, are also within the normal range and are not related to disease.
2. Pathological Sounds
(1) Sound Production: The five sounds are Jiao, Wei, Gong, Shang, and Yu, and the five voices are Hu, Xiao, Ge, Ku, and Shen, which correspond to the liver, heart, spleen, lungs, and kidneys, respectively. Under normal circumstances, these reflect changes in emotions; in pathological conditions, they reflect changes in the five organs. In particular, changes in emotional states often manifest as abnormal expressions in the voices of laughter, crying, and moaning, as well as changes in tone, which can be used to infer corresponding organ pathologies.
Hoarseness and loss of voice can vary in severity; mild cases may present as a raspy voice, while severe cases may result in complete loss of voice. In new illnesses, hoarseness or loss of voice is often associated with excess conditions, typically due to external invasion of wind-cold or wind-heat, where cold and heat attack the lungs, or phlegm and turbidity obstruct the lungs, leading to the inability of lung Qi to disperse, resulting in the so-called “Jin Shi Bu Ming” (the metal does not resonate). In chronic cases, hoarseness or loss of voice is often associated with deficiency conditions, commonly due to internal injury of vital Qi, lung and kidney Yin deficiency, and deficiency fire scorching metal, leading to dryness of fluids and damage to the lungs, resulting in difficulty in producing sound, known as “Jin Po Bu Ming” (the metal is broken and does not resonate). Violent anger and shouting can also injure the throat, leading to hoarseness or loss of voice, which is also due to the consumption of Qi and Yin. In cases of pregnancy with loss of voice, it is often due to the obstruction of the kidney’s vital Qi by the fetus.
A loud and powerful voice, continuous in nature, with a light front and heavy back, often indicates strong physique and abundant Qi; in illness, this often indicates excess or heat conditions. If one is affected by wind, cold, or dampness, there may be nasal congestion and a heavy, turbid voice. A weak and low voice, intermittent in nature, with a heavy front and light back, or a soft and clear voice, often indicates a weak constitution; in illness, this often indicates deficiency or cold conditions.
Snoring during sleep often indicates obstruction of the airways and is not always pathological. If one is in a deep sleep and snoring continuously, with involuntary urination, it may indicate a critical condition of stroke affecting the organs. Continuous moaning often indicates pain or fullness; frowning and moaning often indicate headaches; moaning while holding the heart or abdomen often indicates chest or abdominal pain; holding the jaw may indicate tooth pain. A silent voice, with joyful exclamations, may indicate bone joint disease or deep-seated illness; a muffled voice may indicate disease in the heart and diaphragm. Sudden exclamations, with sharp sounds and fearful expressions, often indicate a condition of fright wind. Night crying in children often indicates fright as a disease, or heat in the heart and spleen meridians, or cold in the spleen causing abdominal pain.
(2) Speech: Silence and reticence often indicate deficiency or cold conditions; restlessness and excessive speech often indicate heat or excess conditions. Speech that is light, slow, and low, with a desire to speak but unable to do so, is known as “Qi being robbed,” indicating a significant deficiency of central Qi.
Speech that is slurred indicates obstruction of the clear orifices by wind-phlegm, or blockage of the meridians by wind-phlegm.
Disordered speech indicates confusion of the spirit, also related to heart disease, with variations in deficiency and excess.
Delirium indicates unclear consciousness and incoherent speech, often associated with heat disturbing the heart spirit. This is commonly seen in warm diseases invading the pericardium or excess conditions of the Yangming organ, with variations of blood heat, stasis, dry stool, or phlegm coagulation.
Weak voice also indicates unclear consciousness, with repetitive speech, intermittent and weak voice, indicating significant injury to heart Qi and scattered spirit, a deficiency condition.
Talking to oneself, mumbling continuously, stopping when seeing others, and lacking continuity is called “Du Yu”; disordered speech, with awareness after speaking, is called “Cuo Yu”; both Du Yu and Cuo Yu indicate insufficient heart Qi and a deficiency of spirit nourishment.
Manic conditions involve laughing, cursing, and nonsensical speech, often climbing and singing, or running away without clothes. This indicates an excess condition of Yang heat, often seen in phlegm-heat disturbing the heart or in febrile diseases with blood symptoms. (3) Breathing: If the patient breathes normally, it indicates a physical illness without Qi involvement; abnormal breathing indicates both physical and Qi illness. If external pathogenic Qi is excessive, breathing may be coarse and rapid, indicating heat or excess conditions. If internal injury leads to insufficient Zheng Qi, breathing may be weak and slow, indicating deficiency or cold conditions. Coarse breathing indicates excess, while weak breathing indicates deficiency; however, in chronic illnesses where lung and kidney Qi is about to be exhausted, coarse and intermittent breathing may indicate a false excess condition; in warm diseases, if heat is in the pericardium, weak and heavy breathing may indicate a false deficiency condition. Weak and difficult breathing, with shortness of breath, insufficient to sustain life, indicates significant injury to the original Qi and a critical condition of separation of Yin and Yang. Clinical manifestations of pathological breathing also include wheezing, asthma, shortness of breath, and other symptoms.
“Asthma” is characterized by difficulty in breathing, shortness of breath, and urgency, with severe cases showing mouth breathing, shoulder lifting, and flaring nostrils, indicating an excess condition with rapid onset, coarse sound, and high-pitched breathing, often due to lung heat or phlegm retention. Deficiency asthma develops slowly, with low and weak sounds, anxiety, shortness of breath, and exacerbation with movement, but with a tendency to take long breaths, indicating lung and kidney deficiency and inability to regulate Qi.
“Wheezing” is characterized by rapid breathing resembling asthma, with high-pitched and intermittent sounds, often accompanied by phlegm sounds in the throat, frequently occurring and difficult to cure. This is often due to internal phlegm, combined with external cold, trapped in the muscles, leading to phlegm retention. It can also be caused by external pathogens, failing to disperse, trapped in the lung meridian. Long-term residence in cold and damp areas or excessive consumption of sour, salty, or cold foods can also trigger asthma.
Asthma and wheezing often occur simultaneously, hence the term asthma is commonly used. Regarding the distinction between asthma and wheezing, in Yubo’s Medical Canon, it states, “Asthma is characterized by a hoarse sound in the throat like a waterfowl, while wheezing is characterized by rapid breathing that cannot be sustained.”
“Shortness of breath” refers to the inability of lung Qi to disperse, leading to a blockage in the throat and rapid breathing. Coughing and shortness of breath may occur, often accompanied by expectoration of turbid phlegm, but the patient cannot lie down, indicating phlegm retention in the chest; if Yin deficiency and excessive fire are present, it may lead to throat discomfort; if external pathogens are trapped in the skin, lung Qi is obstructed, leading to swelling.
“Shallow breathing” refers to weak and short breaths, insufficient to sustain life, with a rapid count and inability to connect, resembling asthma but without shoulder lifting, and no phlegm sounds in the throat. Shallow breathing should be differentiated between deficiency and excess; if phlegm is retained in the chest, it may lead to thirst, pain in the limbs, and a deep pulse, indicating an excess condition; if lung Qi is insufficient, it may indicate a weak body and shortness of breath, with difficulty in urination. In cases of cold damage, abdominal distension may lead to shortness of breath, indicating internal excess; if the abdomen is soft and distended, it may also indicate internal excess but with a deficiency condition.
“Weak breathing” also known as Qi deficiency, refers to weak, short breaths, low in sound, timid, and not continuous like shortness of breath, indicating a generally unchanged physical state. Weak breathing indicates various deficiencies and insufficiencies, reflecting a weak constitution.
(4) Coughing: Coughing is commonly seen in lung diseases, but it is also closely related to changes in other organs. Based on the sound of the cough and accompanying symptoms, one can differentiate between cold-heat and deficiency-excess conditions.
A tight and muffled cough often indicates cold dampness. For example, a heavy and turbid cough with clear and thin phlegm, accompanied by nasal congestion, often indicates external wind-cold. A low cough with abundant phlegm that is easy to expel indicates a cold cough, damp cough, or phlegm retention.
A clear and crisp cough often indicates dryness and heat. For example, a dry cough without phlegm, or with only a small amount of sticky mucus, indicates a dry cough or heat cough.
A cough with a low sound, thick yellow phlegm that is difficult to expel, dry and painful throat, and nasal heat indicates lung heat. If the cough is obstructed, it often indicates that lung Qi is not dispersing.
A cough that continues for a moment often indicates wind. A paroxysmal cough, with continuous sounds, may lead to vomiting blood, and at the end, it may produce a sound like a heron, known as “Dun Ke,” also called “Whooping Cough.” This is commonly seen in children and indicates lung excess, often due to wind pathogens and phlegm retention, leading to heat and obstructing the airways. In cases of diphtheria, the cough may sound like a dog barking, often indicating lung and kidney Yin deficiency, with fire toxins attacking the throat.
Weak coughing, with a low sound, expelling white foam, and accompanied by shortness of breath, indicates lung deficiency. If coughing worsens at night, it often indicates kidney water deficiency; if it worsens in the morning, it may indicate spleen deficiency or cold dampness in the large intestine.
(5) Vomiting: Vomiting can be categorized into three types: vomiting, dry heaving, and expulsion. Vomiting refers to the expulsion of sound and material; dry heaving refers to sound without material, also known as “Huo”; expulsion refers to material without sound. All three indicate upward reversal of stomach Qi, and the sound of vomiting can help differentiate between cold-heat and deficiency-excess conditions.
Vomiting due to deficiency-cold presents slowly, with weak sounds, and expels clear phlegm; vomiting due to excess-heat presents more violently, with loud sounds, and expels thick yellow phlegm or sour or bitter substances; in severe cases, heat may disturb the spirit, leading to projectile vomiting. Some cases of vomiting require further examination through observation, inquiry, and pulse diagnosis to determine the cause. For example, food poisoning requires tracing dietary intake; cholera presents with vomiting and diarrhea; regurgitation with morning food being vomited in the evening indicates stomach Yang deficiency or deficiency of both spleen and kidneys, leading to inability to digest food; dry mouth with a desire to drink, but vomiting after drinking, indicates water reversal, which may be due to Taiyang water retention or phlegm retention; vomiting due to chest fullness and abdominal distension, with constipation, indicates dryness in the intestines, leading to upward obstruction; vomiting due to Qi stagnation, with chest fullness and rib pain, often indicates liver Qi invading the stomach; stomach abscess may lead to vomiting of pus and blood.
(6) Hiccups: Hiccups, known as “Huo” before the Tang Dynasty, are characterized by involuntary sounds produced by the upward reversal of stomach Qi. The duration, pitch, and intervals of hiccups can be used to diagnose cold-heat and deficiency-excess conditions.
In new illnesses, the sound of hiccups is strong, often indicating cold or heat pathogens affecting the stomach; in chronic cases, the sound is low and weak, indicating impending exhaustion of stomach Qi.
Frequent, strong, and high-pitched hiccups often indicate excess heat; low, long, and weak hiccups, with infrequent sounds, often indicate deficiency-cold; hiccups that rise up, with low and timid sounds that cannot reach the throat or intermittent sounds, indicate spleen and stomach Qi deficiency, with upward reversal of Qi, also indicating deficiency-cold. Hiccups that are neither high nor low, with a short duration, and the patient is clear-headed without other accompanying symptoms, may indicate eating too quickly or a temporary reaction to wind-cold, which can resolve spontaneously.
(7) Belching: Known in ancient times as “Yi,” belching is the sound produced by Qi rising from the stomach to the throat, also indicating upward reversal of stomach Qi. Occasional belching after meals is not pathological; however, if it has a sour and rotten odor, accompanied by fullness in the chest and abdomen, it indicates undigested food and Qi stagnation in the stomach; if the belching is loud and frequent, and accompanied by flatulence, it indicates liver Qi invading the stomach, often fluctuating with emotional changes.
Low and deep belching, without sour or rotten odors, and poor appetite, often indicates spleen and stomach weakness, commonly seen in chronic illnesses or the elderly. Cold pathogens affecting the stomach may also lead to belching; after sweating, vomiting, or purging, if stomach Qi is not harmonized, it may also lead to persistent belching.
(8) Sighing: Sighing is a sound associated with emotional disorders. When emotions are repressed, a long sigh or short exhalation may bring comfort. This often arises from feelings of injustice or emotional distress, indicating stagnation of liver Qi.
(9) Sneezing: Sneezing occurs when lung Qi rises to the nose, often seen with external wind-cold. If external pathogens have been trapped for a long time and suddenly result in sneezing, it may indicate a favorable sign of recovery.
(10) Bowel Sounds: Bowel sounds are gurgling noises from the abdomen. The location and sound can help identify the location and nature of the disease. If the sound is in the epigastric area, like a bag of liquid, vibrating with sound, standing or walking, or pressing on it, the sound may indicate phlegm retention in the stomach; if the sound is in the abdomen, like a hungry stomach, it may decrease with warmth or food, and worsen with cold or hunger, indicating deficiency of the middle burner; if the bowel sounds are thunderous, it may indicate excess wind, cold, or dampness, leading to abdominal distension and diarrhea; if cold is severe, it may lead to abdominal pain and limb coldness with vomiting.
2. Smelling Odors
Smelling odors can be categorized into two types: the odors from the body and the odors from the sickroom, both of which are related to the disease. The odors from the sickroom arise from the body itself or from excretions, and the odors can indicate the severity of the disease.
1. Body Odors
(1) Breath: A normal person does not emit foul odors while speaking; if there is bad breath, it often indicates digestive issues, dental caries, or poor oral hygiene. If the breath has a sour odor, it indicates undigested food; if it has a foul odor, it indicates stomach heat; if it has a putrid odor, it often indicates ulcers or necrotic lesions. (2) Sweat Odor: If a patient has a noticeable sweat odor, it indicates that they have been sweating. If the sweat has a fishy smell, it indicates that wind-damp-heat has been trapped in the skin, causing the fluids to evaporate. (3) Nasal Odor: If there is foul-smelling nasal discharge that is persistent, it indicates nasal cavity disease. (4) Body Odor: It is necessary to check if the body has ulcers or necrotic lesions.
Some abnormal odors can be perceived by the patient themselves. Therefore, for abnormal odors from secretions such as phlegm, urine, and menstrual discharge, inquiries (to the patient or their family) can provide insights. For example, coughing up turbid phlegm with a foul odor indicates lung abscess; foul-smelling stools indicate heat; fishy-smelling stools indicate cold; yellow, turbid, and foul-smelling urine often indicates damp-heat; sour-smelling flatulence often indicates food stagnation; foul-smelling menstrual discharge indicates heat; fishy-smelling menstrual discharge indicates cold.
2. Sickroom Odors
In the early stages of an epidemic disease, there is often a foul odor that can be sensed; in mild cases, it may linger around the bed curtains, while in severe cases, it may fill the entire room. A sickroom with a putrid or corpse-like odor indicates organ failure and a critical condition. A sickroom with a bloody odor often indicates a patient suffering from blood loss. There are also specific odors in the sickroom, such as the smell of urine (ammonia), often seen in late-stage edema; the smell of rotten apples (ketone odor), often seen in diabetes patients, both indicating critical conditions.
Editor: Yang Wenjie, Physician Email: [email protected]