Section Two: Local Observation Diagnosis
Concept: Based on the overall observation diagnosis, this method involves in-depth and detailed observation of certain local manifestations of the patient according to the condition and diagnostic needs, to assess the disease.
Significance: ① Observing abnormal changes in local areas can diagnose corresponding local diseases and also helps to understand overall pathological changes. ② Familiarity with the physiological state of each local area and its connection with the organs can help infer clinical significance.
I. Observation of the Head and Face
(1) Observation of the Head: Observe the shape, dynamics, and fontanelle of the head to assess the vitality of the kidney, brain, and organ essence.
1. Head Shape – Infants
The head circumference of a newborn is about 34cm; at 6 months about 42cm; at 1 year about 45cm;
at 2 years about 47cm; at 3 years 48.5cm; at 5 years about 50cm; significantly exceeding this range indicates a large head, while the opposite indicates a small head.
① Large Head: Congenital (kidney essence) deficiency, accumulation of fluids in the brain.
② Small Head: Congenital (kidney essence) deficiency, developmental issues.
③ Square Skull: Forehead protrudes laterally, flat top, skull appears square, seen in rickets and syphilis.
2. Dynamics: Head shaking – internal wind
3. Fontanelle: Unclosed cranial sutures – infants
The posterior fontanelle is triangular and typically closes between 2-4 months after birth; the anterior fontanelle is diamond-shaped and typically closes between 12-18 months after birth.
① Bulging Fontanelle: Fontanelle protrudes – excess syndrome (heat, fluids, brain disease)
② Sunken Fontanelle: Fontanelle sinks – deficiency syndrome (fluid, qi, blood deficiency)
③ Delayed Closure: Late closure of the fontanelle – rickets
(2) Observation of Hair: Observe the color and density of hair to assess the strength of kidney qi and the vitality of essence and blood.
1. Color
Black, thick, and lustrous hair – strong kidney qi, sufficient essence and blood; yellow, sparse, and dry hair – deficiency of essence and blood.
2. Hair Loss
Patchy hair loss (Alopecia areata) – blood deficiency with wind; white hair – kidney deficiency (congenital); children’s hair clumping like tassels – malnutrition.
(3) Observation of the Face: Observe the shape of the face to understand related pathological changes.
1. Abnormal Facial Shape
(1) Facial Swelling
Facial edema, unchanged skin color: edema
Facial redness and swelling, color like painted red, with heat and pain: “Head Fire Dan”
Severe swelling of the head, facial swelling, inability to open eyes, accompanied by high fever, thirst, and yellow tongue coating indicates “Big Head Plague.” (Infectious disease)
(2) Parotid Swelling
Unilateral or bilateral swelling of the parotid area centered around the earlobe, with unclear edges, soft or painful upon palpation indicates “Mumps.” (Infectious disease)
If the jaw and chin area are swollen and painful, with limited mouth opening, accompanied by chills and fever, it indicates “Jaw Fire.” (Yangming heat toxin)
(3) Facial Emaciation: Emaciated face – chronic disease in critical condition, loss of spirit
(4) Facial Asymmetry: Stroke
2. Special Facial Appearances
“Fearful Appearance” – child convulsions, rabies
“Bitter Smile” – newborn umbilical wind, tetanus
“Lion Face” – leprosy
II. Observation of the Five Senses (Spirit and Shape) – Understand the common and variable conditions of related organs
(1) Observation of the Eyes (Liver, Five Organs)
Five Wheel Theory: Pupil – kidney (water wheel); iris – liver (wind wheel); canthus – heart (blood wheel);
White of the eye – lung (qi wheel); eyelids – spleen (flesh wheel)
1. Eye Color
(1) Red, swollen, and painful eyes – excess heat
① Entire eye red and swollen: wind-heat attacking the liver channel. ② Both canthi red and painful: heart fire flaring up. ③ White of the eye red: lung fire. ④ Eyelid edges red and ulcerated: spleen channel damp-heat.
⑤ White of the eye red: red eye, fire eye. ⑥ White of the eye red and hot, with excessive discharge, light sensitivity, and infectious nature is called “Heavenly Red Eye.”
(2) Yellowing of the white of the eye: jaundice.
(3) Pale canthus: blood deficiency.
(4) Dark circles: kidney deficiency.
(5) Grayish-white cloudiness of the iris: cataract.
2. Eye Shape
(1) Swollen eyelids
Edema, unchanged skin color or shiny: edema.
Red and swollen: ① If the eyelid edges are swollen like millet, red, itchy, and painful, easily forming pus, it is called a stye. ② If the entire eyelid is swollen, red like painted red, hot like fire, and easily forms pus, it is called eye dan.
(2) Sunken eyes: acute vomiting and diarrhea injuring fluids; chronic illness with qi and essence exhaustion.
(3) Protruding eyes
Protruding eyes with wheezing belong to lung distension, phlegm obstructing the lung, and lung qi not dispersing; protruding eyes with neck swelling belong to goiter, liver qi transforming into fire, phlegm and qi stagnation.
3. Eye State
Pupil constricted or dilated.
Eyes staring (staring, squinting, or looking sideways).Sleepy with eyes open, eyelids drooping.
(2) Observation of the Ears – kidney, liver, gallbladder, etc.
1. Color
(1) Moist or dry
Ear rim black and dry: kidney essence deficiency
(2) Color
Ear rim pale white: qi and blood deficiency; ear rim red and swollen: liver and gallbladder damp-heat, or heat toxin attacking upward; ear rim bluish-black: internal cold or severe pain.
Children with red veins on the back of the ear: signs of measles.
2. Shape
(1) Enlarged and red ear: excess evil qi, often belonging to Shaoyang fire attacking upward.
(2) Small and thin ear: congenital deficiency, insufficient kidney qi; thin and dry ear: deficiency of righteous qi, exhaustion of kidney essence or insufficient kidney yin; atrophied ear: kidney qi exhausted.
(3) Ear rim with ridges: chronic illness with blood stasis.
3. Inner Ear Changes
(1) Pus in the ear: ear pus, early stage liver and gallbladder damp-heat, later stage kidney yin deficiency, with deficiency fire attacking upward.
(2) Red and swollen ear canal, protruding like millet: ear boil (heat evil)
(3) Observation of the Nose – lung, spleen, stomach, etc.
1. Color (white, red, blue, black), Luster (bright, dull)
Blue nose tip – abdominal cold pain; yellow nose tip – internal damp-heat; white nose tip – blood loss; red nose tip – heat in spleen and lung channels.
Dark red or blood vessel expansion around the nose, accompanied by papules, pustules, or nasal polyps, is called “Alcoholic Nose.”
(2) Swollen Nose Tip
Red and swollen nose tip with pus: stomach heat or blood heat.
(3) Nose and surrounding skin color dark red or blood vessel expansion, accompanied by papules, pustules, or nasal polyps, is called “Alcoholic Nose.”
(2) Nose Column Collapse: syphilis, leprosy.
(3) Nose Wings Flapping: nostrils flapping due to rapid breathing.
3. Inner Nose Changes
Clear nasal discharge: external wind-cold, nasal congestion
Thick nasal discharge: external wind-heat, nasal inflammation.
Nosebleed: epistaxis – wind-heat invading the lung, dry evil injuring the lung; liver fire invading the lung, stomach fire blazing; spleen not controlling blood; “reversed menstruation.”
Growths in the nose: nasal polyps: damp-heat.
(4) Observation of the Lips – spleen and stomach
1. Observation of the Mouth
(1) Salivation: child spleen deficiency with excess dampness, adult stroke with mouth deviation.
(2) Mouth Ulcers:
Superficial yellow-white ulcers on the oral mucosa, with surrounding redness and local burning pain, are mouth ulcers, often due to heart-spleen heat accumulation, or yin deficiency with excess fire.
Recurring mouth ulcers, varying in severity, with pale ulcer surface, mild pain, accompanied by fatigue, and loose stools, often indicate insufficient middle qi.
(3) Thrush: children with white patches all over the oral cavity and tongue, resembling a goose’s mouth, also known as “Snow Mouth.”
(4) Dynamics: “Six States of the Mouth”
Mouth Open: mouth cannot close, deficiency, indicating impending lung qi exhaustion.
Mouth Locked: teeth tightly closed, excess, seen in stroke, seizures, convulsions.
Mouth Pursed: lips tightly gathered, seen in newborn umbilical wind, tetanus.
Mouth Twisted: mouth corners deviated, indicating wind evil invading the channels, stroke.
Mouth Trembling: quivering jaw, malaria.
Mouth Moving: frequent opening and closing, stomach deficiency; mouth corners twitching, indicating moving wind.
2. Observation of the Lips (Color and Shape)
Lip color pale white: blood deficiency.
Lip color deep red: excess heat.
Lips blue-purple: blood stasis.
Lips blue-black: excess cold, extreme pain.
Lips dry and cracked: fluid damage.
Lips ulcerated: spleen-stomach heat accumulation, excess fire attacking upward.
Chapped corners of the lips: heart-spleen heat accumulation.
(5) Observation of Teeth and Gums – kidney, stomach, intestines
1. Observation of Teeth (Diagnosis in Warm Disease)
(1) Shape and Color
Dry teeth: stomach yin has been injured.
Teeth dry as stone: severe yangming heat, significant fluid damage.
Dry as withered bone: kidney yin exhausted, essence not nourishing, severe illness.
(2) Dynamics
Teeth tightly clenched: liver wind moving internally.
Grinding teeth during sleep: stomach heat, food stagnation, accumulation of parasites, etc.
2. Observation of Gums
(1) Color: pale gums – blood deficiency. Red and swollen gums – stomach fire.
(2) Shape:
Gum tissue atrophied, tooth roots exposed, teeth loose, often with bleeding and pus, called “Tooth Decline,” due to deficiency fire burning, insufficient qi and blood;
Gums ulcerated, with foul-smelling blood, teeth falling out, and foul breath, called “Tooth Gangrene,” due to stomach heat accumulation, further affected by wind-heat or epidemic toxins.
(3) Gum Bleeding: gum bleeding, stomach and intestines with excess heat, stomach and kidney fire attacking upward, or spleen not controlling blood.
(6) Observation of the Throat – lung, stomach, kidney
1. Redness and Swelling
(1) New illness with deep red throat, severe swelling and pain, often belongs to excess heat syndrome.
(2) Chronic illness with light red throat, mild swelling and pain, often belongs to yin deficiency syndrome.
(3) Light red, diffuse swelling of the throat, mild pain, often due to phlegm-damp accumulation.
(4) One or both sides of the throat with red swollen protrusions, shaped like nipples, or like silkworms, with yellow-white purulent secretions, throat pain indicates “Throat Moth,” also known as “Throat Moth.”
(5) Red and swollen throat, severe pain, difficulty swallowing and speaking, with chills and fever indicates “Throat Abscess.”
2. Ulceration
New illness with superficial scattered ulceration in the throat, surrounding redness indicates light lung-stomach heat; if ulceration is extensive or depressed, surrounding redness indicates lung-stomach fire toxin accumulation;
Throat ulceration with superficial scattered lesions, recurring, surrounding light red, often indicates deficiency fire attacking upward; extensive depression, surrounding pale or white, not healing for a long time often indicates qi and blood yang deficiency.
3. Pseudomembrane
Throat ulceration with a yellow-white or gray-white necrotic membrane on the surface is called a pseudomembrane. If the pseudomembrane is loose and thick, easily wiped away, it indicates a mild condition;
If the pseudomembrane is tough, not easily wiped away, causes bleeding when forcibly removed, or regenerates after removal, accompanied by barking cough and wheezing, it indicates a severe condition, “Diphtheria.”
III. Observation of the Neck
1. External Shape
(1) Goiter: swelling in the front of the neck at the throat, unilateral or bilateral, with a lump protruding, can move up and down with swallowing.
Pathogenesis: liver qi stagnation, phlegm accumulation
(2) Lymphadenopathy: lumps in the skin and membrane outside the neck, under the jaw, or behind the ear, resembling beans, clustered like beads. (Larger ones belong to lymphadenopathy, smaller ones belong to lymphadenitis)
Pathogenesis: lung and kidney yin deficiency, deficiency fire refining phlegm. External wind-fire with toxins carrying phlegm.
2. Dynamics
Stiff neck – wind-heat attacking upward, or taiyang channel syndrome
Soft neck – kidney qi deficiency, or critical illness
Neck pulse:
Quiet and prominent – liver yang rising (hypertension), edema disease
Angry and distended when lying down – asthma, zhengchong (heart and kidney yang deficiency, water qi invading the heart)
IV. Observation of the Body
(1) Observation of the Chest and Flanks – heart, lung, liver
1. Flat Chest – lung and kidney yin deficiency or both qi and yin deficiency
2. Barrel Chest – lung and kidney deficiency, phlegm accumulation
3. Pigeon Chest – congenital deficiency, postnatal malnutrition
4. Funnel Chest: the lower part of the sternum and the connected costal cartilage are sunken inward, resembling a funnel. – congenital deficiency
5. Ribs like beads: thickening and enlargement at the connection of the ribs and cartilage, resembling beads. – congenital deficiency, postnatal malnutrition (rachitic chest: seen in rickets)
6. Asymmetrical Chest: one side of the chest cavity is sunken, intercostal spaces narrowed, indicating lung atrophy or post-surgical changes; one side of the chest cavity is bulging, intercostal spaces widened, indicating pleural effusion or pneumothorax.
7. Breast Abscess: red, swollen, hot, painful breasts during lactation, with poor milk flow, may rupture and ooze pus. Often due to liver qi stagnation, stomach heat obstruction, or external evil toxins.
(2) Observation of the Abdomen
1. Abdominal Distension: when lying supine, the abdominal wall is significantly higher than the line connecting the sternum to the pubic bone.
Only abdominal enlargement, with emaciated limbs, belongs to drum-like distension, often due to liver qi stagnation and spleen deficiency, qi stagnation, blood stasis, and damp obstruction.
Abdominal enlargement, with generalized edema, belongs to water retention, often due to lung, spleen, and kidney imbalance, water and dampness overflowing.
2. Abdominal Depression: when lying supine, the anterior abdominal wall is significantly lower than the line connecting the sternum to the pubic bone, also known as scaphoid abdomen.
3. Visible Blue Veins on the Abdomen: indicates severe distension.
(3) Observation of the Back and Waist
1. Spinal Kyphosis
2. Spinal Scoliosis
3. Lordosis
4. Spinal Ulcer
5. Stiffness of the Waist
V. Observation of the Limbs
(1) External Shape
1. Limb Edema: edema disease.
2. Joint swelling, burning pain, limited movement, seen in heat bi, due to long-standing wind-damp transforming into heat.
Knee swelling, thigh and calf atrophy, resembling a crane’s knee, called crane knee wind, often due to prolonged cold dampness, qi and blood deficiency.
(2) Dynamics
Limb Atrophy:
Muscle atrophy of the limbs, tendons relaxed, weak and powerless, severe cases may lead to paralysis. Often seen in atrophy disease.
If one side of the upper and lower limbs is paralyzed, it is called hemiplegia, often seen in stroke patients; if both lower limbs are paralyzed, it is often seen in paraplegic patients.
VI. Observation of the Two Yin
(1) Observation of the Anterior Yin
Scrotal Swelling – hydrocele: scrotal edema; inguinal hernia: hernia
Prolapse – uterine prolapse: spleen deficiency
Genital Eczema – liver and gallbladder damp-heat descending
(2) Observation of the Posterior Yin
Anal Abscess – damp-heat descending or external heat toxin
Anal Fissure – dryness and heat
Hemorrhoids – wind-dryness damp-heat
Anal Fistula – similar to anal abscess, hemorrhoids
Rectal Prolapse – middle qi descent
VII. Observation of the Skin
(1) Abnormal Color
Redness – erysipelas (head fire dan, flowing fire, red travel dan)
Yellowness – jaundice: yang jaundice, yin jaundice
Darkness – kidney yang deficiency
White Spots – vitiligo: wind-damp invasion, qi and blood not nourishing
(2) Shape
1. Dryness: yin fluids exhausted, or nutrient blood deficiency.
2. Scaly Skin: dry, rough skin resembling fish scales, due to long-standing blood stasis, skin not nourished.
3. Edema: divided into yin and yang. Pressing feels like mud: edema (yang water, yin water); pressing returns quickly: qi distension (qi mechanism not smooth).
(3) Skin Diseases (rashes, blisters, sores, acne)
1. Rashes
(1) Spots: deep red or bluish-purple, flat on the skin, do not hurt when touched, do not fade when pressed.
Yang Spots: spots in patches, either red or purple, with accompanying fever, facial redness, rapid pulse, often due to excessive heat evil, pressing on the nutrient blood.
Yin Spots: spots of varying sizes, light red or dark purple, sparse, often pale face, fatigue, weak pulse, often due to qi not containing blood.
(2) Rash: red or purplish-red, millet-sized raised spots on the skin, hurt when touched, fade when pressed.
Measles: rash like peach red, resembling millet, first appearing at the hairline and face, gradually extending to the trunk and limbs, then fading in the order of appearance.
Wind Rash: light red rash, small and sparse, with mild itching.
Urticaria: sudden appearance of varying sizes, shapes, and clear boundaries, red or pale papules, with itching, merging into patches, appearing and disappearing rapidly.
2. Blisters – damp-heat
(1) Chickenpox: pink spots on the skin quickly turning into oval small blisters, which later crust over. Full tops without umbilication, bright and clear, thin fluid, easily broken, varying sizes, appearing in batches.
(2) White Blisters: white small blisters on the skin, clear like millet. Seen in damp-warm diseases.
(3) Heat Sores: clusters of millet-sized blisters at the junction of the skin and mucous membranes around the lips, nose, and genitals, with burning and itching.
(4) Shingles: on one side of the waist or chest, initially burning and painful skin, followed by clusters of blisters from millet to soybean size, arranged like a belt, with local pain.
(5) Eczema: red spots on the skin, itching, quickly forming papules and blisters, oozing after breaking, forming red, moist, and ulcerated surfaces.
3. Sores
(1) Boils: red, swollen, large, tightly bound, burning pain. (Yang syndrome)
Characteristics: easy to resolve when not pus-filled, easy to rupture when pus-filled, thick and sticky pus, easy to heal. Often due to damp-heat fire toxin, qi and blood stasis.
(2) Abscess: initially with millet-sized pus heads, burning red swelling pain, easily spreading to deeper tissues, with successive increase in pus heads, called head abscess, belonging to yang syndrome. External heat evil fire toxin, internal organ toxins, condensing on the skin surface.
Diffuse swelling without heads, unchanged skin color, little pain, difficult to resolve, difficult to rupture, difficult to heal, easily injuring muscles and bones, called non-head abscess, belonging to yin syndrome. Qi and blood deficiency, cold phlegm stagnation.
(3) Pustule: small like millet, deep-rooted and hard, resembling a nail, numb and painful, often occurring on the face, hands, and feet. Deep and easily spread.
(4) Furuncle: small and round, shallow-rooted and localized, mild redness and swelling, easily forming pus, healing after pus drainage.
5. Acne
Occurs on the face, chest, and back, with papules resembling needles, can squeeze out white, rice-like fluid, also known as “Comedones” or “Acne.”
Caused by wind-heat obstructing the lung channel; or due to excessive consumption of rich, greasy, spicy foods, leading to stomach heat, damp-heat forming internally, steaming on the face.