Four examinations

The four examinations are inspection, listening and smelling, inquiry, and palpation. Listening and smelling are regarded as one examination for the simple reason that the Chinese word 闻 wén has both meanings. Thus, in reality there are five.

Origins

The four examinations are traditionally attributed to the legendary Biǎn Què (扁鵲). Examinations involving inspection, listening, inquiry, and palpation are described in the Nèi Jīng. However, the clearest first reference to these in Chinese as 望聞問切 wàng wén wèn qiè is found in the 61st Difficult Issue of the Nàn Jīng : Anybody who looks and knows it is to be called a spirit; anybody who listens and knows it is to be called a sage; anybody who asks and knows it is to be called an artisan; anybody who feels the vessels and knows it is to be called a skilled workman (望而知之谓之神, 闻而知之谓之圣, 问而知之谓之工, 切脉而知之谓之巧。 Wàng ér zhī zhī wèi zhī shén, wén ér zhī zhī wèi zhī shèng, wèn ér zhī zhī wèi zhī gōng, qiè mài ér zhī zhī wèi zhī qiǎo).

Over the centuries, the four examinations have been continually enriched and refined in every aspect, notably the complexion, the tongue, and the pulse.

Content

The four examinations cover the following items.

• Inspection consists in observing the patient’s spirit (signs of vitality), tongue, complexion, and overall appearance, as well as excreta.
• Listening and smelling involves observing the quality of voice, enunciation, and verbal expression, listening to breathing and coughing sounds, and smelling the body and excreta.
• Inquiry involves questioning the patient about the chief complaint, the present symptoms and how they have developed, any previous treatments, and prior history of illness. The inquiry examination includes items of the listening and smelling examination that might not be conveniently accessible in the clinic.
• Palpation comprises taking the pulse and palpating relevant body parts.

While biomedicine relies on quantifiable objective signs more than on unmeasurable subjective symptoms, Chinese medical diagnosis observes no strictly quantifiable signs and relies completely on naked-sense observations and subjective information provided by the patient.

Note that the information provided under each of the examinations is copious and complex and that the traditional four-examinations system means that some aspects of the body are treated somewhat disconnectedly under more than one of the examinations, depending on the sense by which they are gathered. Given this, it is useful to summarize the main symptoms in general-to-specific and head-to-toe order. See the items below.

Classified List of Common Symptoms

• Symptoms 1, general
• Symptoms 2, complexion
• Symptoms 3, tongue
• Symptoms 4, pulse
• Symptoms 5, head and neck
• Symptoms 6, body and limbs
• Symptoms 7, lumbus and knees
• Symptoms 8, chest and rib-side
• Symptoms 9, stomach and abdomen
• Symptoms 10, stool and urine
• Symptoms 11, two yīn
• Symptoms 12, men and women
• Symptoms 13, infants and children

Correlating All Four Examinations

Because any given symptom may have several distinct known causes, the true nature of the patient’s condition can only be identified thorough investigation of all the symptoms displayed or subjectively experienced by the patient and careful analysis to spot common causes. Hence, accurate diagnosis requires correlating all four examinations (四诊合参 sì zhěn hé cān). In some cases, not all items in each of the examinations produce useful information. For example, many patients have no abnormalities of breathing, urine, stool, sweating, menstruation, or sleep. Nevertheless, the practitioner includes all the major items to ensure a complete and accurate understanding of the patient’s condition. In this process, the examination of the tongue and the pulse are of special importance, because whatever the patient’s condition, these invariably reveal useful information.