Traditional Chinese Medicine (TCM) theory can only demonstrate its value through practice. Practice without theoretical guidance is blind and cannot lead to independent development and innovation.
In clinical practice, the integration of theory and practice requires a long process of accumulation and repeated exploration to achieve a comprehensive understanding, transforming into practical knowledge and diagnostic skills, which in turn promotes the updating and development of theory.
Based on the classics, learning from various schools, and drawing on the strengths of many, this is fundamental. The comprehensive application of multiple specialized knowledge to construct a diagnostic and treatment system based on syndrome differentiation, principles, formulas, and treatment methods is essential for problem-solving. Understanding the common and variable aspects, and applying flexible methods are clinical skills that transform theory into knowledge and skills. This is how one can achieve proficient use of theory, knowledge, and skills. Here, I will share my personal clinical experiences focusing primarily on internal medicine.
Observation (Wang Zhen)
Observation includes aspects such as complexion and form, with a particular emphasis on color diagnosis and tongue diagnosis.
When first entering clinical practice, one often considers inquiry as the foremost of the four examinations, making it difficult to grasp the essence of observation. However, with extensive practice, one can gradually appreciate the truth of “knowing by observation” and the insights of “five color diagnosis” surpassing the observation of spirit, form, and movement.
1. Color Diagnosis (Se Zhen)
Color diagnosis, also known as “five color diagnosis,” primarily involves observing the complexion of the face, with other areas being analogous. By observing the luster and dullness of the facial color, one can assess the vitality of the organs and the state of qi and blood, as the qi and blood of the twelve meridians all rise to the face, showing corresponding changes in pathological conditions. Regardless of the five colors, the common basic characteristics distinguishing good from bad are: good is bright and subtle, while bad is dark and exposed.
At the same time, it is necessary to further relate to the eight principles of syndrome differentiation to grasp the different natures of pathological changes.
For example:
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Seeing red on the face, if it is real, the face is red; if it is deficient, the cheeks are flushed;
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Seeing blue on the face, if it is cold, the complexion is bluish; if it is hot, the complexion is red-blue.
The Suwen (Plain Questions) states that judging a patient’s fortune based on facial color indicates:
It points out:
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“Blue like a green feather indicates life,
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Red like a rooster’s comb indicates life,
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Yellow like a crab’s belly indicates life,
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White like pig fat indicates life,
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Black like a bird’s feather indicates life;”
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“Blue like grass indicates death,
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Yellow like bitter orange indicates death,
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Black like coal indicates death,
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Red like blood indicates death,
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White like dry bones indicates death.”
These are quite specific.
In special circumstances, one can also determine the disease of a specific organ based on its corresponding location on the face, combined with the different colors, to assess the pathological changes of that organ and their interactions. However, the overall facial color should be the primary focus, with localized observations as a supplement, and one should not mechanically correlate them; unique manifestations can be analyzed accordingly.
The Neijing (Inner Canon) provides two specific methods for observing the five organs on the face, as follows:
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Forehead corresponds to the heart,
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Nose corresponds to the spleen,
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Left cheek corresponds to the liver,
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Right cheek corresponds to the lung,
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Chin corresponds to the kidney.
This seems simpler than the method described in the Ling Shu (Spiritual Pivot).
Observing the eyes is an important aspect of facial observation. One must look for whether the eyes are spirited or lack spirit, bright or dull, and also pay attention to their pathological characteristics. Swollen eyelids may indicate wind invading the lung or spleen deficiency with damp accumulation; bulging eyes may indicate liver fire or phlegm-stasis obstructing the channels; squinting may indicate wind-fire, while direct or upward gaze may indicate phlegm-stasis clouding the spirit orifice; unequal pupil size may indicate cerebral water-stasis; bright blue eyes that move flexibly may indicate a strong liver constitution; red and congested eyes may indicate excess heart and liver fire; deep yellow eyes may indicate liver-gallbladder damp-heat; pale and dry eyes may indicate blood deficiency; dark circles around the eyes may indicate phlegm-stasis or kidney deficiency; yellow spots in the inner canthus may indicate phlegm-damp stasis.
2. Tongue Diagnosis (She Zhen)
Tongue diagnosis primarily involves observing the tongue body, tongue coating, shape, and moisture. Since the meridians of the five organs all connect to the tongue, relying on qi, blood, and body fluids to nourish it, tongue diagnosis allows for direct observation of the pathological conditions of the corresponding organs, the balance of qi and blood, and the nature and depth of pathogenic factors.
When observing the tongue coating, attention should be paid to the color of the coating and the changes in the tongue body.
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Tongue body pale red indicates a healthy person,
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Pale white indicates qi and blood deficiency,
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Bright red indicates excess heat damaging yin,
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Blue-purple indicates blood stasis.
The coating color can be white, yellow, or gray-black:
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White coating indicates exterior conditions or cold,
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Thin white and moist indicates a healthy person,
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Thin white and dry indicates exterior condition with fluid damage,
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Thin white and slippery indicates cold-damp,
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Thick white indicates damp turbidity, phlegm retention, or food accumulation,
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Putrid coating indicates damp-heat and turbid accumulation.
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Yellow coating indicates interior conditions or heat,
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Thin yellow indicates that the pathogenic heat is not yet severe, just entering the interior;
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Greasy yellow indicates damp-heat accumulation or food accumulation transforming into heat;
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Yellow and sticky indicates damp-turbidity and phlegm-heat congealing;
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Yellow and dry, even scorched yellow indicates dry heat damaging fluids;
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Pale yellow and moist indicates damp accumulation of phlegm.
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Gray-black coating, if dry, indicates interior heat; if moist, indicates interior cold;
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White greasy gray-black with a moist tongue indicates yang deficiency with cold-damp and phlegm retention;
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Yellow greasy gray-black indicates long-standing damp-heat, while scorched black and dry indicates extreme heat with fluid depletion.
At the same time, one should also observe the moisture and dryness of the coating to assess the internal balance of fluids and their distribution.
In clinical practice, the analysis of tongue diagnosis should also pay attention to the following points:
① Differentiate between external and internal injuries, focusing on key aspects.
For acute febrile diseases, the emphasis is on observing the tongue coating to understand the nature of the disease, the rise and fall of pathogenic and righteous qi.
For chronic internal diseases, the emphasis is on observing the tongue body to understand the deficiency and excess of qi and blood in the organs, the characteristics of the syndrome, and the nature of the pathogenesis.
② The same tongue coating can vary in severity regarding the balance of pathogenic and righteous qi, deficiency and excess, cold and heat:
For example, a white greasy tongue coating indicates cold-damp, but the degree of greasiness can vary significantly, which must be used to judge the severity of dampness; the same yellow greasy tongue coating indicates damp-heat, with deep yellow and thick indicating deep damp-heat accumulation, while a central accumulation forming putrid indicates a stasis condition, and if it is dry with little moisture, it indicates a damage to yin.
③ Distinguish the true and false attributes of the pathogenesis:
The same black coating, if black and moist, indicates internal cold; if black and dry with cracks, it indicates extreme heat.
④ Pay attention to the complex intermingling of pathogenesis:
For example, a tongue coating that is both yellow and white often indicates a mixture of cold and heat, or that a warm pathogen has just entered the interior, indicating a simultaneous exterior and interior condition. A tongue body that is pale and moist with little fluid often indicates a deficiency of both righteous qi and yin.
⑤ Distinguish the five organ correspondence method on the tongue:
It is generally believed that “the tip of the tongue corresponds to the heart, the center corresponds to the spleen and stomach, the sides correspond to the liver and gallbladder, and the root corresponds to the kidney” (Bi Hua Yi Jing). While this has reference value in clinical practice, it should not be applied mechanically.
In summary, the tongue is closely related to the changes in the heart and stomach:
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Since the tongue is the sprout of the heart, observing the color and quality of the tip of the tongue can often reveal the conditions of the heart;
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The tongue is a mirror of the stomach, and the tongue coating is produced by the qi of the spleen and stomach rising, thus observing the color and quality of the coating can often reveal the conditions of the spleen and stomach.
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As for the lung’s corresponding area, while there is no clear definition, combining with the tongue correspondence method in the Shang Han Zhi Zhang, it seems to be located between the tip of the tongue and the center of the tongue, where the upper part relates to the heart and lung, and the center relates to the lung and stomach.
Observing the shape of the tongue body is also an important aspect.
Examine the age and tenderness to differentiate between excess and deficiency; observe the thickness to differentiate between yang deficiency, water dampness, or yin and blood deficiency.
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A tongue with cracks indicates depletion of essence, blood, and yin fluids;
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A tongue with prickles indicates excess heat in the organs, while teeth marks on the sides indicate deficiency of yang qi and internal dampness;
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A tongue that is shriveled indicates extreme heat damaging yin, while a long-term shriveled tongue indicates deficiency of qi and blood;
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A stiff tongue indicates excess heat damaging yin, or phlegm obstructing the channels;
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A deviated tongue indicates internal wind with phlegm, obstructing the channels;
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A rolled tongue indicates cold congealing the channels, or phlegm obstructing the root of the tongue, or heat damaging fluids;
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A tongue with prominent veins underneath that are blue-purple indicates blood stasis.
Observing the tongue coating, tongue body, and tongue state, while each has different pathological focuses, must be analyzed comprehensively in clinical practice to improve diagnostic accuracy.
Auscultation (Wen Zhen)
Auscultation is a diagnostic method that uses hearing and smell to understand the disease and provide evidence for syndrome differentiation.
Listening to sounds:
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If the voice is hoarse, or if there is a complete loss of voice, it often indicates a real condition for acute onset, while a long-term illness that gradually worsens often indicates a deficiency, or a combination of righteous deficiency and pathogenic excess.
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Delirium or nonsensical speech indicates excess, often due to phlegm-fire obstruction;
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Clear speech or solitary speech often indicates severe injury to the heart qi, or qi stagnation with phlegm obstruction;
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A stiff tongue often results from phlegm obstructing the channels.
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In patients with wheezing, wheezing is primarily characterized by rapid breathing, while coughing is characterized by a phlegm sound in the throat; wheezing must accompany shortness of breath, while shortness of breath does not necessarily accompany wheezing; wheezing with a loud, coarse sound indicates excess, while wheezing with a sound like snoring, weak breath, and worsening with movement indicates deficiency;
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Shallow breathing or insufficient breath indicates deficiency, which is different from shortness of breath characterized by rapid and short breaths that are not continuous, indicating a difference between deficiency and excess.
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Frequent, intense coughing, paroxysmal, with a loud and urgent sound often indicates an external excess condition;
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Light, intermittent coughing, with a low sound and weak breath often indicates an internal deficiency condition;
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Chronic cough leading to wheezing indicates persistent coughing at night, with insufficient breath.
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Vomiting should be differentiated based on whether food is immediately vomited, morning food vomited in the evening, and the urgency of vomiting to distinguish deficiency and excess;
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Frequent and loud hiccups indicate excess, while low and weak hiccups that occur intermittently indicate deficiency.
Smelling odors:
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If there is a sour, rotten smell from the mouth, it indicates gastrointestinal stagnation;
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A putrid smell from the mouth with gum ulceration indicates dental disease;
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Coughing up foul-smelling purulent blood indicates lung abscess;
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Foul breath in febrile diseases or foul sweat indicates severe epidemic toxins;
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A corpse-like odor from the body indicates a critical condition of organ failure.
In conjunction with disease differentiation, for example, the foul odor from the mouth in uremia, the liver odor in hepatic coma, the sweet smell of rotten apples in diabetic ketoacidosis, and the bloody smell in patients with hemoptysis.
Currently, in clinical practice, modern diagnostic methods and techniques should also be employed to extend our sensory capabilities and gather more information. For example, using a stethoscope to examine heart and lung conditions, listening for bowel sounds; using a sphygmomanometer to measure blood pressure, etc.
Furthermore, listening to the patient describe their condition and understanding their suffering is also closely related to auscultation.
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