One of the four examinations. In inspection, the practitioner observes the patient’s general physical appearance, paying special attention to any part relevant to the presenting condition. Apart from observing the patient’s spirit, overall appearance, and complexion, the practitioner also carefully examines the tongue, which can provide invaluable information about the state of the bowels and viscera.

Inspecting the Spirit

In the context of diagnosis, spirit refers to the degree of vitality of the patient. Thus, the term is here used in a sense different from that of the spirit as stored by the heart. The spirit as vitality is reflected in the patient’s facial expression, complexion, bearing, and general state of consciousness. It also takes account of the quality of voice, enunciation, and verbal expression, which, of course, strictly belong to the listening and smelling examination.

Spiritedness, Spiritlessness, and False Spiritedness

It is said, If the patient is spirited, he is fundamentally healthy; if he is spiritless, he is doomed. Conditions of the spirit fall into three fundamental categories: spiritedness, spiritlessness, and false spiritedness.

Spiritedness (有神 yǒu shén)

Patients who have bright eyes, normal bearing, clear speech and who respond coherently to inquiry, are said to be spirited, indicating that right qì is undamaged and the complaint is relatively minor. Although certain aspects of the patient’s health may be seriously affected, swift improvement may be expected.

Spiritlessness (无神 wú shén)

Spiritlessness can occur in both vacuity and repletion patterns and manifests in slightly different ways:

Vacuity of right qì: Spiritlessness attributable to vacuity of right qì manifests in listlessness of essence-spirit, dark facial complexion, torpid (i.e., dull and lifeless) expression, slow reactions, incoherent response to inquiry, dull eyes, faint low voice and halting speech, faint breathing or forceless panting, severe emaciation, and abnormal bearing and difficult movement. In severe cases, there can be clouded spirit, which is partial or total loss of consciousness.

Exuberant evil: Spiritlessness occurs with other disturbances of the spirit in several evil repletion patterns:

• yáng brightness (yáng míng) (yáng míng) disease patterns in cold damage manifesting in clouded spirit, delirious speech, agitation, picking at bedclothes (循衣摸床 xún yī mō chuáng, unconscious, fumbling movements of the hands, called carphologia in biomedicine) or groping in the air and pulling invisible strings (撮空理线 cuō kōng lǐ xiàn), where a comatose patient reaches into the air, sometimes spreading the fingers and sometimes drawing them together, as if pulling at strings.
• Phlegm-fire harassing the heart manifesting in mania and agitation (or manic agitation), and in serious cases delirious raving, accompanied by vigorous heat effusion, rough breathing, and phlegm rale in the throat.
• Heat entering the pericardium manifesting in clouded spirit, delirious speech, and manic agitation together with vigorous heat effusion.
• Extreme heat engendering wind in infants and children manifesting vigorous heat effusion, clenched jaw, and convulsions. This is it is called acute fright wind, which is the result of extreme heat engendering wind (this may be observed in influenza or encephalitis B).
• Liver yáng transforming into wind stirring manifesting sudden clouding collapse (sudden clouding of the spirit that makes the patient fall to the ground), which leaves the patient with hemiplegia and impaired mental faculties is seen in wind stroke (stroke, apoplexy).
• Phlegm clouding the heart spirit manifesting in spiritlessness, sudden clouding collapse, foaming at the mouth, and occasional squealing like a pig or goat constitutes an epileptic seizure. This occurs when wind carries phlegm upward to obstruct the clear orifices (wind-phlegm). It is observed in epilepsy patients.

False Spiritedness (假神 jiǎ shén)

False spiritedness usually occurs in enduring or severe illness and extremely severe cases of essence-spirit debilitation. If, suddenly, in a condition characterized by taciturnity, a low voice, halting speech, and an extremely dull or dark facial complexion, the patient becomes strangely garrulous and his cheeks unusually red as if smeared with oil paint, this new condition is said to be one of false spiritedness. This is sometimes described in Chinese as the last radiance of the setting sun (回光反照 huí guāng fǎn zhào), or in English as the final flicker of the candle or a dying flash. Such conditions are critical and should not be mistaken for improvement. False spiritedness implies a superficial improvement in certain aspects of the patient’s mental state that does not accord with other aspects of the condition. It is a sign that the patient’s condition will soon deteriorate dramatically and therefore demands special attention.

Spirit Abnormalities

Note that some abnormalities of the spirit overlap with spiritlessness discussed above.

Spirit abnormalities (神的异常 shén de yì cháng) or spirit-mind abnormalities (神志异常 shén zhì yì cháng) refers to any state of the spirit, temporary or lasting, in which the patient does not react normally to stimulus, does not think or speak coherently, or has abnormal moods (chronic emotional states) and difficulty relating to others or coping with daily life. The term includes clouding collapse, which occurs in epilepsy; manic agitation and delirious speech occurring in febrile disease; and spirit-mind abnormalities such as occur in mania and withdrawal and in feeble-mindedness. Spirit abnormalities are explained in terms of various vacuities, qì depression, phlegm, and fire conditions involving disturbance of the heart spirit. Spirit abnormalities were traditionally described in terms of talking to self, jumping over walls and climbing onto roofs, casting off one’s clothes and running around, violent and destructive behavior, nonsensical talk, and chiding and cursing or laughing and weeping, regardless of who is present.

Deranged spirit (神乱 shén luàn): Severe spirit abnormalities.

Agitation (躁 zào, 躁動不安 zào dòng bù ān), manic agitation (狂躁 kuáng zào), manic derangement (狂乱 kuáng luàn): Agitation means pronounced fidgetiness (i.e., constant changes in posture and nervous movements). Manic agitation and manic derangement mean agitation with signs of deranged spirit. It manifests in frantic movements, reduced sleep, profuse dreaming, nonsensical talk, and beating and cursing people regardless of who is present. It occurs in mania disease and is usually attributable to qì depression transforming into fire that boils liquid into phlegm and then combines with the phlegm to harass the heart spirit.

Clouded spirit (神昏 shén hūn): Partial or total loss of consciousness occurring in heart disease or disease affecting the heart in the following conditions:

• when insufficiency of yáng qì disperses the heart spirit;
• when fire harasses the heart spirit; or
• when phlegm obstructs the orifices of the heart.

Clouded spirit can occur in vacuity and repletion patterns: Vacuity patterns include desertion patterns and fulminant desertion of heart yáng. Repletion patterns include heat entering the pericardium, bowel heat patterns, heat toxin attacking the heart, summerheat patterns, phlegm-fire clouding the spirit, extreme heat engendering wind, wind-phlegm internal block patterns (as in wind stroke). Mild forms of clouded spirit are described in such terms as torpid essence-spirit (精神迟钝 jīng shén chí dùn) or unclear spirit mind (神志不清 shén zhì bù qīng).

Clouding collapse (昏倒 hūn dǎo), also called sudden clouding collapse (猝然昏倒 cù rán hūn dǎo): Sudden clouding collapse means sudden clouding of the spirit that makes the patient fall to the ground.

• When this is accompanied by drooling and foaming at the mouth, upward-staring eyes, squealing sounds, and convulsions that disappear when the patient regains consciousness, this is an epileptic seizure, which is explained as liver wind carrying phlegm counterflow to obstruct the clear orifices.
• If the patient loses consciousness without the above-mentioned signs and regains consciousness but is left with hemiplegia (paralysis of one side of the body), the disease is wind stroke (i.e., stroke in the sense of cerebrovascular accident in biomedicine).

Clouding reversal (昏厥 hūn jué) Sudden loss of consciousness attributable to major disturbance in the movement of qì.

Tetanic reversal (痉厥 jìng jué): Sudden loss of consciousness occurring in tetanic disease (diseases marked by severe spasm).

Listlessness of essence-spirit (精神萎靡 jīng shén wěi mí): A severe lack of mental energy occurring in severe vacuity patterns such as yáng collapse or yīn collapse. It is a sign of spiritlessness.

Indifference of spirit-affect (神情淡漠 shén qíng dàn mó): Also called indifferent facial expression (表情淡漠 biǎo qíng dàn mó). Lack of interest in the world, as visible in an indifferent facial expression and bearing. It is seen in yáng collapse, feeble-mindedness, and in mania and withdrawal.

Torpor of essence-spirit (精神迟钝 jīng shén chí dùn): Mental dullness, cognitive deficiency, as in poor ability to solve problems. It is a sign of feeble-mindedness or poor development, usually related to insufficiency of kidney essence.

Affect-mind depression (情志优郁 shén zhì yōu yù): A depressed emotional and mental state marked by moodiness, depressed anger (irritability, grumpiness), excessive worry, and emotionality (unusual laughing or weeping). It is associated with depressed liver qì, which results from deficient free coursing. It is sometimes visible on face-to-face contact.

Worry and fear: Severe worry and fear that make a patient afraid to stay in a room alone and that are accompanied by heart palpitation and hasty breathing usually occur in vacuity patterns. They are commonly caused by gallbladder qì vacuity and insufficiency of blood depriving the heart-spirit of nourishment. They are observed in the traditionally recognized conditions of inferiority-timidity (卑惵 bēi dié) and visceral agitation (脏躁 zàng zào)..

Gallbladder timidity (胆怯 dǎn qiè): Also called gallbladder timidity and susceptibility to fright (胆怯易惊 dǎn qiè yì jīng) or qì timidity (气怯 qì qiè). Shyness, fearfulness, and lack of confidence and courage attributed to disturbance of the gallbladder’s governance of decision-making. It is often accompanied by susceptibility to fear and fright, heart vexation, insomnia, and profuse dreaming or nightmares. It is observed in gallbladder qì vacuity and in liver-gallbladder patterns involving heat.

Inspecting the Skin and Flesh

Skin

The state of the skin provides information about the state of the fluids and essence-blood. In some cases, it can indicate the presence of blood stasis.

• Dry skin is attributable to damage to fluids or to depletion of essence-blood.
• Skin that is dry and rough, forming scales, is called encrusted skin, and is a sign of blood vacuity with blood stasis.
• Yellowing of the body and eyes (身目发黄 shēn mù fā huāng) is a sign of jaundice due to damp-heat or cold-damp affecting the liver and gallbladder. A bright coloration like tangerines is attributed to damp-heat, while a dull coloration is attributed to cold-damp.
• The skin of the face is discussed further ahead under Facial Complexion.

Red Thread Marks (红缕赤痕 hóng lǚ chì hén):

Small red markings on the surface of the skin composed of red thread-like lines up to a few millimeters long radiating from a central point. Red thread marks are a sign of blood amassment creating distension. They are called spider nevi in biomedicine.

Puffy Swelling (浮腫 fú zhǒng)

Puffy swelling is the name given to the condition in which the face, limbs, and sometimes the whole body are swollen and enlarged, without any redness or pain on pressure. It indicates water swelling, which is the name given to the disease so manifesting. Two kinds are distinguished: yīn water and yáng water.

• Yīn water is attributable to disorders of the kidney, lung, and spleen, and usually affects the lower limbs first (although there may be slight swelling of the eyelids at onset).
• Yáng water is attributable to water-damp and externally contracted wind, cold, dampness, heat, damp-heat or summerheat, causing non-diffusion of lung qì and triple burner congestion that prevent the free flow of water down to the bladder. Yáng water is a repletion pattern characterized by swelling of the face and upper limbs first, and is attended by aversion to cold, heat effusion, cough, painful swollen throat, and rough voidings of scant urine.

For various types of swelling, see general palpation.

Prominent Veins (青筋暴露 qīng jīn bào lù)

Enlarged blood vessels raised above the surface of the body beneath the skin. It corresponds in biomedicine to varicose veins, which appears mostly on the lower legs, or caput medusae, which appears on the abdomen. They are associated with blood stasis.

Bruising (瘀青 yū qīng)

A bruise is an injury from a blow or impact that does not break the skin but damages the blood vessels causing blood to escape and give the affected area a green-blue coloration. Bruises are one form of blood stasis. A tendency to bruise easily is a sign of qì or blood vacuity.

Maculopapular Eruption (斑疹 bān zhěn)

Macules and papules, loosely referred to colloquially as rashes, are skin conditions that erupt in the course of externally contracted disease such as measles, chickenpox, and wind papules (rubella, German measles), as well as in certain internal damage and miscellaneous diseases.

• Macules are red or purple patches under the skin, with no elevation. They indicate a severe condition.
• Papules are red and slightly elevated. They indicate a mild condition and are mostly attributed to evil heat depressed in the lung and stomach that fails to discharge outward and instead enters provisioning-blood and forces the blood to move.
• Macules and papules appearing together usually mean a severe condition.

A distinction is made between favorable and unfavorable maculopapular eruptions:

Favorable patterns: These are characterized by an eruption that is evenly distributed, of medium density, red in color, spreading from the chest and abdomen out toward the limbs, and that is accompanied by generalized heat effusion and disappears as the heat effusion abates.

Favorable patterns are observed where the disease takes its course in a patient whose right qì is strong.

Unfavorable patterns: Here, an eruption is unevenly distributed, with dense areas where the macules or papules merge and with a deep-red or purple coloration, spreading from the limbs to the chest and abdomen. Initially, there is no heat effusion, but as the eruption spreads toward the chest, generalized heat effusion develops, and consciousness becomes unclear. These are signs that the evil qì, owing to poor resistance of right qì, has fallen inward to the interior.

Unfavorable patterns occur in patients whose right qì is weak and fails to resist the evil, allowing it to fall inward (enter the interior).

Internal damage and miscellaneous diseases may present with maculopapular eruptions, mostly indicating blood heat. If they continually appear and disappear, are purplish-red in color and if signs of blood heat are absent, they indicate the failure of qì to contain the blood or qì vacuity complicated by blood stasis. Deep-seated eruptions do not blanch when pressure is applied. Well-defined eruptions have clear edges and may be characterized by localized tissue necrosis. If the edges are not well-defined, and the color fades under pressure, the condition is mild.

Measles (麻疹 má zhěn)

Measles is a contagious disease most commonly occurring in children below the age of puberty. It mostly occurs at the end of winter or beginning of spring. The disease starts like a common cold, with cough, sneezing, runny nose with clear snivel, tearing, and heat effusion. After 2–3 days, a rash appears on the buccal mucosa (inside the mouth, on the cheek). After 3–4 days, the rash spreads. It is peach pink in color, in the form of papules shaped like sesame seeds. On the outside of the body, it starts on the hairline behind the ears, gradually spreading to the forehead, trunk, and limbs.

Chickenpox (水痘 shuǐ dòu)

The Chinese medical term for chickenpox is, literally translated, water pox. It is an externally contracted febrile disease. It is characterized by blisters that can cover the whole body. The blisters are oval in shape, are shallow, vary in size, and easily rupture. They usually have no tip, although they sometimes have a depression at the apex. They contain clear thin fluid. They do not crust and leave no scars, unless scratched. Note that pox (痘 dòu) loosely refers to any disease marked by pustules or papules that leave scars.

Rubella (German Measles)

In Chinese medicine, rubella is known as wind papules (风疹 fēng zhěn). It manifests in the form of a pale-red rash composed of small, densely distributed papules associated with itching. It is attributed to external contraction of wind evil.

Prickly Heat (痱子 fèi zi, 痱瘡 fèi chuāng)

Also called heat rash. A rash that takes the form of red papules that soon turn into small blisters associated with heat sensation and itching. It affects the face, neck, arms, chest, abdomen, and thighs. It is common in hot humid conditions in summer, especially among infants and children. It is attributed to summerheat-damp preventing the normal discharge of sweat. In biomedicine, this is called miliaria rubra (紅粟疹 hóng sù zhěn), which is explained as sweat trapped under the skin by clogged sweat ducts.

White Sweat Rash (白㾦 bái pèi)

Also called miliaria. White sweat rash consists of small white vesicles on the skin. These are usually small like millet seeds, elevated, slightly translucent, and without any change in skin coloration. White sweat rash often occurs in damp warmth patterns or summerheat-warmth. It is usually located on the neck but may spread to the upper arms and abdomen. It only occurs when there is sweating. Although its appearance usually indicates that damp-heat can escape from the body, it also shows that dampness evil is thick and sticky and resists transformation. For this reason, there is recurrent outthrust.

Favorable patterns: When white sweat rash takes the form of clear, plump vesicles, it is a positive sign that the damp-heat is not trapped in the body. This corresponds to miliaria crystallina, also called sudamina (汗疹 hàn zhěn), in biomedicine. White sweat rash is usually associated with heat effusion. When the vesicles rupture, they exude a yellow fluid with a putrid odor. When the heat effusion abates, the vesicles dry and flake off.

Unfavorable patterns: In severe cases, the vesicles turn a dull white and contain no fluid. This is called dry sweat rash (枯㾦 kū pèi) and signifies exhaustion of qì and liquid.

Eczema (濕疹 shī zhěn)

A usually localized condition of the skin characterized by red patches, itching that swiftly develops into papules and blisters that on rupturing exude fluid, giving way to red, moist, ulcerating areas of skin.

Eczema arises when damp-heat combines with externally contracted wind evil and lies depressed in the skin.

Sores (疮疡 chuāng yáng)

The main kinds of sores are welling-abscesses, flat-abscesses, clove sores, and boils are as follows. A more complete list can be found under diseases 10, external medicine.

Welling-abscess (痈 yōng): A welling-abscess takes the form of a large swelling with a clearly circumscribed base. It is hot, red, and painful. It is a yáng pattern that results from congestion of qì and blood. It occurs when patients suffering from damp-heat brewing internally contract evil toxin. This causes provisioning-defense disharmony and obstruction of the channels and network vessels. The resulting congestion allows the welling-abscess to form.

Flat-abscess (疽 jū): A flat-abscess is a diffuse swelling without any change in skin color and without a head. It is not hot and is associated with little pain. This is a yīn pattern. It arises as a result of qì and blood vacuity with congealing cold phlegm or when wind toxin and accumulated heat in the five viscera flow into the flesh and fall into the sinew and bone.

Clove sore (疔 dīng, 疔疮 dīng chuāng): A small hard sore with a deep root like a clove or nail, appearing most commonly on the face and ends of the fingers. A clove sore arises when fire toxin enters the body through a wound, and then heat brews and binds in the skin and flesh. It may also arise when anger, worry, and preoccupation or excessive indulgence in rich food or alcohol gives rise to internal heat that then accumulates in the bowels and viscera and effuses outward to the skin. Sometimes, a clove sore may have a single red threadlike line stretching from the sore toward the trunk. Clove sores can develop into a clove sore running yellow (疔疮走黄 dīng chuāng zǒu huáng), that is, one that becomes black without pus and causes the sore toxin to penetrate the blood aspect, giving rise to high fever, shiver sweating, a red or crimson tongue, rough yellow tongue fur and a pulse that is surging and rapid or slippery and stringlike. This corresponds to septicemia in biomedicine.

Boil (癤 jié): Boils are small round swellings with mild heat, redness, and pain. Their root does not penetrate deep into the flesh. They easily suppurate and rupture, before healing quickly. They are attributed to congestion of qì and blood that arises when summerheat-damp becomes depressed in the skin or when damp-heat brewing in the viscera effuses out to the skin.

Acne (粉刺 fěn cì): Acne is a skin condition marked by blackheads (comedones) or red papules (pimples) that are mostly found on the face, that can be squeezed to produce an oily, chalky substance, and that can develop into pustules. Acne is most common in young people. In severe cases, pimples may be large, red, and swollen and coalesce and spread to the neck, shoulders, and back. Acne is attributed to brewing lung-stomach heat fuming the face, causing heat and stagnation of the blood. It is often found to be related to excessive consumption of rich food.

Cinnabar toxin (丹毒 dān dú): A disease characterized by sudden localized reddening of the skin, giving it the appearance of having been smeared with cinnabar; hence the name. It corresponds to (erysipelas) and some forms of cellulitis in biomedicine. Cinnabar toxin usually affects the face or lower legs. It is most common among children and the elderly and most prevalent in spring and summer. Cinnabar toxin arises when damaged skin and insecurity of defense qì allow evil toxin to enter the body and give rise to heat in the blood aspect, which becomes trapped in the skin. If the toxin is accompanied by wind, the face is affected (wind-heat); if accompanied by dampness, the legs are affected (damp-heat). Note that the Chinese term丹毒 dān dú has been adopted as the biomedical equivalent of erysipelas, but the original Chinese concept is wider in meaning, notably including cellulitis.

Lower-limb fire flow (下肢流火 xià zhī liú huǒ) is the type of cinnabar toxin that affects the lower legs and feet. It is marked by localized painful redness and swelling. It is attributed to damp-heat. It includes diabetic foot identified in biomedicine in diabetes mellitus.

Nails

The nails are the surplus of the sinews. Their condition reflects the state of liver yīn blood.

Pale nails (爪甲色淡 zhǎo jiǎ sè dàn): Nails that are pale in color with large white moons. They are the result of liver blood vacuity depriving the nails of nourishment.

Lusterless nails (爪甲不荣 zhǎo jiǎ bù róng): Nails that lack a fresh bright coloring and luster. They are the result of liver blood vacuity depriving the nails of nourishment. A more serious condition of dry nails (爪甲干枯 zhǎo jiǎ gān kū) is attributable to severe depletion of liver blood and liver yīn.

Inspecting Body and Bearing

This part of the examination involves inspecting the patient’s body to see whether it is thin or fat, strong or weak, and observing the patient’s physical movement.

Body

Inspection of the body chiefly provides information about the patient’s constitution and the state of the spleen and stomach.

Development and strength

• A strong body is marked by broad and full chest, large bones, firm flesh, strong sinews, and moist lustrous skin. People with such a body will be found to have great energy and a good appetite. They have healthy bowels and viscera, abundant qì and blood, and a great ability to avoid illness and recover from illness quickly when they do fall ill.
• A weak body is characterized by a narrow chest, small fine bones, emaciation, weak sinews, dry lusterless skin, poor essence-spirit, and poor appetite. People with a weak body have weak bowels and viscera, have poor resistance to disease, are prone to illness, and do not recover quickly from illness.

Body type: How fat or thin a patient has an important bearing their health. Usually this is judged intuitively by the patient’s appearance. Nowadays, Body Mass Index (BMI) calculated by the weight-to-height ratio provides a more accurate assessment, although this does not take account of constitution.

A person is fat or obese if they have a sagging belly and drooping flesh, while a person is emaciated when their sinews and bone (e.g., sinews of neck, collar bone, and ribs) are clearly visible.

• Obesity with soft flabby flesh, poor appetite, tendency to avoid physical movement, lack of strength for physical movement, breathing difficulty at the slightest exertion is described as exuberant physique and vacuous qì (形盛气虚 xíng shèng qì xū). This is often seen in yáng vacuity and spleen vacuity patients susceptible to phlegm, rheum, water, and dampness collecting internally. When visceral qì disorders develop, phlegm and qì become congested, giving rise to dizziness and in severe cases wind stroke. Hence, it is said that obese people are prone to phlegm-damp and wind stroke.
• A stocky build with firm flesh, good appetite, healthy spirit, and physical strength is a sign of a strong body and abundant qì. It is not considered morbid. Illness in people with this body type usually takes the form of repletion patterns or heat patterns and is of short duration.
• A lean body with abundant energy, healthy spirit, physical strength, and good resistance to illness is healthy.
• A thin body with lack of strength, shortness of breath, and laziness to speak are usually found to suffer from earlier-heaven insufficiency with qì and blood vacuity.
• A thin body with large food intake usually indicates yīn vacuity with effulgent fire and is seen in dispersion-thirst and goiter.
• A thin body with red cheeks and dry skin usually indicates insufficiency of yīn-blood depriving the body of nourishment and is seen in the latter stages of warm disease and in pulmonary consumption. Hence it is said that thin people are prone to vacuity fire and to consumption cough. If they are confined to bed for a long time and their bones become like firewood (i.e., matchsticks), this indicates a critical condition of depletion of essential qì and desiccation of qì and humor.

Posture and Bearing

The posture a patient adopts, especially when lying, and the way a patient moves (or fails to move) provide important information about the yīn-yáng nature of the condition, the presence of internal wind, impediment (bì), or wilting (wěi).

Yīn and yáng patterns

• Flailing of the limbs, agitation (more physical movement than normal), talkativeness, and a tendency to throw off clothing are signs attributable to yáng patterns of heat or repletion.
• A patient who assumes a curled-up lying posture, has little desire to talk, tends to add extra layers of clothing, and displays heavy sluggish movements is suffering from a yīn pattern of cold or vacuity.

Signs associated with liver wind stirring internally and tetanic disease: Various forms of what is called spasm in biomedicine appear in tetany (also called tetanic disease), fright wind, and wind strike. Liver wind stirring within is the pathomechanism by which these conditions most commonly arise, although lockjaw, a specific tetanic disease, is attributed to contraction of wind toxin through wounds. See tetany, fright wind, wind stroke, and lockjaw.

• Deviated eyes and mouth (口眼喎斜 kǒu yǎn wāi xié) : The face and eyes pulled to one side of the face. This is seen in wind stroke and facial paralysis.
• Convulsions (抽搐 chōu chù) : Also called tugging and slackening (瘈瘲 chì zòng). Rapid involuntary movement of the limbs. Because it is caused by internal wind, it is often called tugging wind (抽風 chōu fēng). It is observed in fright wind attributable to extreme heat stirring wind, in lockjaw attributable to external wind toxin damage, and in epilepsy patterns, which are attributed to wind-phlegm. Convulsions with clouded spirit are called tetanic reversal (痉厥 jìng jué).
• Arched-back rigidity (角弓反张 jiǎo gōng fǎn zhāng): Backward arching of the back, called opisthotonos in biomedicine. It occurs most commonly in fright wind attributable to extreme heat engendering wind, in lockjaw attributable to external wind toxin damage, and other tetany patterns.
• Clenched jaw (牙关紧闭 yá guān jǐn bì) : A tightly closed jaw, called trismus in biomedicine. This occurs most commonly in fright wind attributable to extreme heat engendering wind, in tetanic disease (including lockjaw attributable to external wind toxin damage), and in wind stroke attributable to liver yáng transforming into wind.
• Jerking sinews and twitching flesh (筋惕肉膶 jīn tì ròu shùn) is sporadic movement of body parts, including twitching of the eyes (tic). Wriggling of the extremities (手足蠕动 shǒu zú rú dòng) is gentle movements of the hands or fingers and feet or toes. Tremor of the extremities (手足震颤 shǒu zú zhèn chàn) is quivering motions of the extremities. These are all mild signs of liver wind stirring internally.
• Unsteady gait (步履不正 bù lǚ bù zhèng, 步履不稳 bù lǚ bù wěn) is the inability to walk smoothly and straight, indicating liver yáng transforming into wind.
• Shaking of the head (头摇 tóu yáo) is a sign of liver yáng transforming into wind.
• Hemiplegia (半身不遂 bàn shēn bú suì) is paralysis of one side of the body that occurs in wind stroke (i.e., stroke, apoplexy), attributable to liver wind stirring internally (liver yáng transforming into wind).

Signs associated with impediment (bì) include hypertonicity of the sinews (see below), swelling, rigidity, or deformed joints (关节变形 guān jié biàn xíng) that impede movement.

Signs associated with wilting (wěi): Limp weak limbs lacking in strength is a sign of wilting patterns (wěi zhèng).

Miscellaneous

• Hypertonicity of the sinews (筋脉拘挛 jīn mài jū luán), also called hypertonicity of the limbs (四肢拘急 sì zhī jū jí), is tension in the sinews marked by inhibited bending and stretching. It is often attributed to liver blood vacuity, but there are numerous other causes: cold-damp, external contraction of wind-cold; damp-heat; exuberant heat; and yáng collapse and humor desertion. It may occur in impediment (bì).
• Stiff nape (项强 xiàng jiàng) is stiffness and discomfort in the back of the neck. In liver disease, it is a sign of liver yáng transforming into wind. Stiff nape may also be caused by externally contracted wind-cold or wind-damp, by damage to liquid by evil heat, or by wind toxin entering wounds (lockjaw). When severe, it is often referred to as rigidity of the nape and neck (颈项强直 jǐng xiàng jiàng zhí), which is associated with extreme heat engendering wind or with lockjaw, which is caused by external wind toxin damage.
• Cramps of the lower legs (小腿转筋 xiǎo tuǐ zhuàn jīn) in patients suffering from severe vomiting and diarrhea is a sign of cholera.

Inspecting the Complexion

Inspection of the complexion may involve inspecting the complexion of the whole body. In practice, the practitioner is mostly concerned with the facial complexion, which often accurately reflects the state of qì and the blood. The Líng Shū (Chapter 4) states, The qì and blood of the twelve primary channels and the 365 network vessels [i.e., all the channels and network vessels of the body] rise to the face.

The color of the complexion is classified according to the five colors corresponding to the five phases: green-blue, red, yellow, white, and black. These are basic colors from which the infinite gamut of hues is derived. When applied to the human complexion, they take on relative significance. Thus, two people who, when healthy, have vastly different skin colors may be both described as having a white complexion when suffering from a certain disease even though the actual color is quite different. White here refers to a relative paling compared with the individual’s healthy complexion. A healthy Chinese complexion is of a pale ocher hue with a light reddish luster, though it may darken markedly when exposed to the sun and wind. The five colors are applied mutatis mutandis to the skins of all races.

Inspecting the complexion of the entire body involves paying attention to the presence of maculopapular eruptions and sores. See also Inspecting the Skin and Flesh above.

Significance of the Facial Complexion

The diagnostic significance of the facial complexion rests on the understanding that it reflects the health of qì and blood, the presence of disease evils, the locus of illness among the bowels and viscera, and the severity of illness.

Qì and Blood

The complexion reflects the health of qì and blood. A ruddy complexion with a moist sheen means that qì and blood are abundant. A lusterless pale-white complexion is a sign of insufficiency of qì and blood. A dull green-blue or purple complexion reflects qì stagnation and blood stasis.

Disease Evils

A red complexion indicates heat. White indicates cold. Green-blue or purple indicates qì stagnation and blood stasis. A bright yellow complexion and whites of the eyes indicates damp-heat.

Locus of Disease

The Nèi Jīng describes two schemes linking the complexion to the health of the bowels.

Color-viscus correspondence: Green-blue corresponds to the liver; red to the heart, yellow to the spleen, white to the lung, and black to the kidney. Under normal circumstances, the five colors appear faintly in the skin and sheen, reflecting how they are duly contained within (含蓄 hán xù) and not showing through excessively. When a bowel or viscus is affected by illness, its corresponding color shows through clearly. This is called the exposure of the viscus’s true color (真脏色外露 zhēn zàng se4 wài lòu).

Correspondence of regions of the face to the bowels and viscera: Th e Nèi Jīng offers two schemes correspondence between regions of the face and the bowels and viscera.

The most complex of these two schemes, presented in the Líng Shū (Chapter 49), isolates the following primary areas, each with a special name, as shown in the image below. FaceRegionsLingShù9

A: Court (廷 tíng): The forehead.

B: Gate Tower (阙 que4): The glabella (the area between the eyebrows).

C: Bright Hall (明堂 míng táng): The nose.

D: Shelter (蔽 bì): Lateral cheek area at the level of the auditory meatus.

E: Fence (藩 fán): Lateral cheek area at the level of the ear lobe.

F: Ear lobe (引垂 yǐn chuí).

G: Wall (壁 bì): Lateral cheek area close to the angle of the mandible.

H: Base (基 jī): Area either side of the chin.

On the basis of these regions, the following correspondences (see image below):

• Court (廷 tíng) reflects the head and face.
• Above the Gate Tower (阙上 que4 shàng), also called the Hall of Impression (印堂 yin4 táng), reflects the throat.
• Below the Gate Tower (阙下 que4 xia4), also called the Lower Extreme (下极 xia4 jí) or Mountain Root (山根 shān gēn), reflects the heart.
• Below the Lower Extreme (下极之下 xia4 jí zhī xia4) reflects the liver. Either side of this area corresponds to the gallbladder.
• Below the Liver (肝下 gān xia4), also called the Tip of the Nose (准头 zhun3 tóu, 鼻端 bí duān) or King of Face (面王 miàn wáng), reflects the spleen.
• Center (中央 zhōng yāng), also called Below the Cheekbone (颧下 quán xia4) reflects the large intestine.
• Either Side of the Large Intestine (挟大肠 xié da4 cháng), i.e., the lower lateral region of the cheek, reflects the kidney.
• The region above the King of Face, i.e., the area either side of the nose above its tip, reflects the small intestine.
• The region below the King of Face, also called Human Center (人中 ren2 zhōng) or philtrum, reflects the bladder and the uterus.

A simpler scheme presented in Sù Wèn (Chapter 32) is as follows:

• Forehead: Heart
• Nose: Spleen.
• Left cheek: Liver.
• Right cheek: Lung.
• Chin: Kidney.

These correspondence schemes are highly detailed and complex. They are not commonly used systematically in modern clinical practice. They are included in modern Chinese textbooks out of reverence for the Nèi Jīng .

Severity and Prognosis

A bright and moist color that is contained and not exposed, with a moist sheen is called a benign complexion and is a sign of abundant qì and blood, and healthy essence-spirit. It means that the condition is mild and that the prognosis is good. A dry complexion of dull coloration in which the true color is exposed is called a malign complexion, indicating that qì and blood are lacking and that the bowels and viscera as well as essence-spirit are severely debilitated. This is a sign of deep and severe illness with a poor prognosis.

Color and sheen have relative significance. Color is yīn and governs the blood. It reflects the state of the blood and blood flow, as well as indicating the nature and locus of illness. Sheen is yáng and governs qì. It reflects the essential qì of the bowels and viscera and the state of the fluids. Hence, color and sheen must be considered together. As regards prognosis, the presence or absence of sheen is often of greater significance than color.

Normal and Morbid Complexions

Normal Complexions (常色 cháng se4)

The complexion of a healthy person is described as being moist, lustrous, and contained (含蓄 hán xù). A slightly moist and lustrous complexion means the essence is abundant, the spirit is healthy, qì and blood are plentiful, and bowel and visceral function is normal. Contained means that, whatever skin pigmentation a person has, it has a healthy coloration that appears to emanate faintly from below the skin rather than being fully exposed. This is a sign that stomach qì is abundant and essential qì is contained within, rather than discharging outward. Normal complexions include the governing complexion and visiting complexions.

Governing complexion (主色 zhu3 se4): The governing complexion is the one we are born with. It is part of our constitution and remains fundamentally unchanged throughout our life. An ancient scheme of classifying constitutions according to the five phases posits that metal-type people have white skin, wood-type people have a green-blue complexion, water-type people have a slightly blackish complexion, fire-type people have a slightly red complexion, and earthy-type people have a slightly yellow complexion.

Visiting complexion (客色 ke4 se4): A visiting complexion is a transient variation in the complexion that arises from causes other than illness.

• Weather: The complexion naturally changes with the seasons. Thus, the complexion is slightly green-blue in spring, red in summer, yellow in late summer, white in autumn, and black in winter.
• Diurnal cycle: In the daytime, defense qì floats to the exterior, making the complexion red and moist. At night, defense qì sinks into the interior, making the complexion slightly paler and drier.
• Physical exertion: Running and other forms of physical exertion cause the complexion to redden.
• Food and drink: Alcoholic beverages cause the network vessels to dilate, making the facial complexion and the eyes red. After eating, stomach qì is abundant, giving a sheen to the complexion. Excessive eating reduces stomach qì, so the complexion loses its sheen and becomes slightly dry.
• Affect-mind: Changes in a person’s emotional state can affect the complexion. Some of the changes are not obvious, but it is worth taking note of them. Joy makes spirit qì expand so that the face becomes slightly red. Anger makes the liver qì move cross-counterflow, giving the complexion a green-blue tinge. Worry makes qì concentrate in the center, causing the complexion to become heavy and sunken. Thought causes qì to bind in the spleen, making the complexion yellow. Sorrow makes qì disperse in the interior, causing the sheen to diminish. Fear causes essence-spirit to stir and be fearful so that the complexion becomes white.

Morbid Complexions (病色 bìng se4)

Changes in the complexion that are not attributable to changes in the visiting complexion are considered morbid. Morbid complexions are dull and exposed. Dull means lacking in moistness and luster, signifying debilitation of the essential qì of the bowels and viscera and stomach qì failing ascend to give the face a luxuriant healthy glow. Exposed means that a complexion color is showing through on the surface. It is the outward appearance of a disease color or the true visceral color. Morbid complexions vary depending on the severity, depth, and nature of the illness, but they generally reflect the nature of the illness and the bowels or viscera affected, as will be discussed under Complexion Color below. A distinction is made between benign and malign complexions.

Benign complexion(善色 shàn se4): A benign complexion retains some brightness and luster. Even though there is illness manifesting in pronounced changes in color, a healthy sheen remains, indicating that the essential qì of the bowels and viscera have not been severely debilitated, and stomach qì is still able to ascend to provide the face with luxuriance. This is often described as qì arriving (气至 qì zhì) or getting through. Benign complexions are seen in new illness (illness of recent onset), mild illness, and yáng patterns.

Malign complexion(恶色 e4 se4): A malign complexion is dry and dull. It means the essential qì of the bowels and viscera is severely debilitated, and stomach qì is unable to ascend to provide the face with luxuriance. This is often described as qì not arriving. Malign complexions are seen in enduring illness, severe illness, and yīn patterns.

Complexion Color

Inspection of the facial complexion in modern practice mostly focuses on its color. The basic colors are white, green-blue, red, yellow, and black, but these come in various gradations.

White Complexions (面色白 miàn se4 baí)

A white facial complexion indicates vacuity, cold, or loss of blood. Distinction is made between pale-white, bright-white, and somber-white shades.

Pale-white complexion (面色淡白 miàn se4 dàn baí) means a general lack of color in the face.

• A lusterless pale-white complexion, sometimes with a tinge of yellow (withered-yellow complexion) is a sign of dual vacuity of qì and blood.
• When accompanied by emaciation, it is a sign of provisioning-blood depletion.

Bright-white complexion (面色㿠白 miàn se4 huang3 baí) describes a very white complexion. It indicates yáng vacuity. When accompanied by vacuity puffiness that does not spring back after being pressed, it is attributed to yáng vacuity water flood (excess water in the body attributable to kidney yáng vacuity).

Somber-white complexion (面色苍白 miàn se4 cāng baí) is white with a slight green-blue hue.

• Fulminant desertion of yáng qì: A somber-white facial complexion that appears suddenly is a sign of fulminant desertion of yáng qì (in conditions called shock in Western medicine).
• Internal cold: A somber-white complexion may also accompany severe abdominal pain or shivering attributable to interior cold. In this case, it is a sign of yīn cold congealing and stagnating.
• Wind-cold: A somber-white complexion may also be observed in externally contracted wind-cold marked by aversion to cold, shivering, and severe abdominal pain attributable to interior cold.
• Roundworm: Grayish-white macules may be seen in infantile roundworm, known as worm macules.

Green-Blue Complexions (面色青紫 miàn se4 qīng zǐ)

A green-blue facial complexion arises as a result of severely inhibited flow of qì and blood owing to severe insufficiency of yáng qì, to exuberant cold, or to inhibited qì dynamic. Yáng qì vacuity and exuberant cold are causes of blood stasis, so a green-blue complexion characterizes blood stasis attributable to these causes. Furthermore, because when there is stoppage, there is pain, a green-blue complexion is often observed in patients suffering from pain. Thus, a green-blue complexion is observed in blood stasis patterns, cold patterns, pain patterns, and fright wind (a disease in infants marked by convulsions and loss of consciousness). In biomedicine, green-blue complexions are seen in pulmogenic heart disease and asphyxia, cardiac failure, and cirrhosis of the liver.

• Yáng vacuity may be marked by a pale green-blue complexion.
• Fulminant desertion of heart yáng manifests in a grayish-green-blue complexion and green-blue or purple lips, with heart palpitation, oppression in the chest, and heart pain.
• Chest impediment manifests in a grayish-green-blue complexion with green-blue or purple lips, with oppression and pain in the heart region, which is mostly attributable to heart yáng vacuity with resulting blood stasis. Phlegm and cold are also possible factors. The pain is often described as stabbing pain in the vacuous lǐ (the apical pulse).
• Cold, either externally contracted or arising internally, can present with somber-white complexion with a slight green-blue hue, accompanied by headache, generalized pain, or pain in the chest or abdomen.
• Lung qì block with severe restriction in the flow of qì and blood can present with a dark purplish-green-blue or purple complexion. This is seen in conditions that biomedicine diagnoses as pulmogenic heart disease and asphyxia.
• Kidney failing to absorb qì, which manifests in panting, can be marked by a green-blue complexion.
• Fright wind: In children, a pronounced green-blue coloration around the stem of the nose, between the eyebrows, or around the lips is a sign of fright wind. If it is green-blue verging on somber white, it is chronic fright wind; if it is green-blue with a reddish hue, it is acute fright wind attributable to extreme heat engendering wind.

Red Complexions (面色红 miàn se4 hong2)

A red facial complexion is one that is redder than normal. It indicates heat. Heat makes the blood more mobile than normal. Because heat naturally bears upward, it forces blood upward to flush the face.

Redness of the whole face (滿面通紅 mǎn miàn tōng hong2) occurs in severe internal heat arising in external contractions. Tidal reddening to a bright-red complexion with vigorous heat effusion at 3–5 p.m. is seen when external evils penetrate the interior, giving rise to what is called a yáng míng (yáng míng) bowel pattern in cold damage theory and gastrointestinal heat bind in warm disease theory.

Tidal reddening of the cheeks (两颧潮红 liang3 quán cháo hong2): Also called postmeridian reddening of the cheeks (午后颧红 wu3 hòu quán hong2), or just reddening of the cheeks (quán hong2). It is a slight flushing confined to the area of the cheekbones, usually occurring in the late afternoon and evening each day. It is a sign of yīn vacuity with internal heat.

Cheeks a floating-red color as if dabbed with rouge (两颧泛红如妆 liang3 quán fàn hong2 rú zhuāng) refers to fluctuating pink patches on the cheeks, understood to be like something floating just below the surface of water. It is a complexion that suddenly replaces a somber-white complexion in enduring illness when vacuous yáng strays upward. This pattern is called upcast yang or vacuous yáng floating astray, which is a critical sign of imminent outward desertion of yáng qì.

Yellow Complexions (面色黄 miàn se4 huáng)

A yellow facial complexion indicates spleen vacuity with brewing dampness.

Withered-yellow facial complexion , one that is pale yellow, dry, and lusterless like withered leaves, is a sign of spleen-stomach qì vacuity and insufficiency of qì and blood.

Jaundice: A yellow complexion is a sign of jaundice in patients whose whites of the eyes (sclerae) and skin of the whole body are yellow.

• A bright orange-yellow like the color of tangerines is called yáng yellowing or yáng jaundice, and is caused by damp-heat.
• A dark, smoky yellow is called yīn yellowing or yīn jaundice. It is attributed to depressed cold-damp causing obstruction that prevents qì and blood from providing luxuriance.

Yellow swelling (黄胖 huáng pàng): A yellow complexion with puffy swelling is called yellow swelling, a disease attributed to the spleen failing to move and transform water-damp, which then floods the skin and flesh. It is usually caused by excessive loss of blood or depletion of qì and blood after major illness, or by spleen-stomach damage resulting from intestinal parasites. It may be seen in conditions known in biomedicine as ancylostomiasis (hookworm infestation), anemia, and malnutrition.

Black Complexions (面色黑 miàn se4 heī)

A black facial complexion indicates severe kidney vacuity, blood stasis, cold patterns, or water-rheum.

A black complexion indicates intractable or severe illness affecting the kidney. Black jaundice, described in the Jīn Guì Yao4 Lue94, is a condition associated with kidney vacuity and blood stasis and is hard to cure.

Black is the color of exuberant yīn cold and water or of congealing and stagnating qì and blood. The kidney is the viscus of fire and water and is the root of the yīn and yáng of the whole body. When kidney yáng is vacuous, water-rheum fails to be transformed. Consequently, yīn cold and water become exuberant, the blood is deprived of warmth, the vessels become tense so that blood does not move freely, and the facial complexion turns black.

• A dull pale blackish facial complexion (面色黑暗淡 miàn se4 àn dàn) is usually a sign of kidney vacuity.
• A dry parched black facial complexion (面黑干焦 miàn heī gān jiao1) usually indicates depletion of kidney essence and kidney yīn with vacuity fire scorching yīn.
• A soot-black facial complexion (面色黧黑 miàn se4 lí heī) with encrusted skin (dry coarse scaly skin) is attributable to blood vacuity with blood stasis.
• Black complexion around the eye sockets (眼眶周围发黑 yǎn kuāng zhōu weí fa1 heī) may reflect either phlegm-rheum arising from kidney vacuity water flood or cold-damp pouring downward and causing vaginal discharge.

In biomedicine, a soot-black facial complexion may be seen in chronic hyperadrenocorticism or in the final stages of cirrhosis of the liver. A dark-gray complexion may be seen in chronic kidney dysfunction. A purple-black complexion may occur in chronic cardiopulmonary dysfunctions.

Ten Principles for Inspecting the Complexion

The ten principles of inspecting the complexion were developed in the Qīng from statements in the Nèi Jīng .

Floating and sunken (浮沉 fú chen2): Floating describes a morbid complexion that appears in the exterior skin. It reflects an exterior pattern. Sunken describes a morbid complexion that is hidden within the skin, reflecting an interior pattern.

Clear and turbid (清浊 qīng zhuo2): Clear describes a complexion that is clear and bright. It reflects a yáng pattern. Turbid describes a murky dull complexion. It is primarily associated with yīn patterns. When a complexion changes from clear to turbid, it reflects yáng pattern giving way to a yīn pattern. When a turbid complexion becomes clear, it reflects a yīn pattern converting into a yáng pattern.

Faint and strong (微甚 weī shèn): Faint describes a complexion that is shallow and pale. It is associated with vacuity. Strong means deep and pronounced. It is associated with repletion. When a faint complexion becomes strong, this is vacuity converting into repletion. When a strong complexion becomes faint, this is repletion converting into vacuity.

Diffuse and dense (散抟 sàn tuán): Diffuse describes a sparse, thinly spread coloration, which is associated with a new illness (illness of recent onset) or with an illness that is about to resolve. Dense describes a complexion color that is thickly distributed, deep and stagnant. It is associated with enduring illness or with evils that are gradually gathering. When a dense complexion becomes diffuse, an enduring condition is about to resolve. A diffuse complexion growing in density indicates evil gathering in a condition of recent onset.

Lustrous and perished (泽夭 zé yao1): Lustrous means moist and shiny. It means that essential qì has not been debilitated and that the illness is mild and easy to treat. Perished means dry and dull. It means essential qì is already debilitated and that the illness is severe and hard to treat. When a lustrous complexion becomes perished, it means that the illness is severe, and the patient’s condition is becoming critical. When a perished complexion becomes lustrous, it means a favorable turn in severe illness. In terms of benign and malign complexions previously discussed, a lustrous complexion is benign, while a perished complexion is malign.

Infant’s Finger Examination

The infant’s finger examination involves observing the appearance of the veins just below the surface of the skin on the radial palmar aspect of the index finger. It is only applicable to infants under three years of age. Subsequent natural thickening of the skin makes the veins indistinct.

The finger examination provides supplementary diagnostic data that is especially useful in judging the severity of an illness. It helps compensate for difficulties of the pulse examination attributable to the infant’s very short radial pulse, which can only be taken with a single finger. It also helps to compensate for the disturbance of the pulse that results from the distress commonly experienced by children in unfamiliar surroundings.

Bars

The finger is divided into three segments called bars.

• Wind bar (风关 fēng guān): This is the first segment, from the metacarpophalangeal joint to the proximal interphalangeal joint.
• Qì bar (气关 qì guān): This is the second segment, from the proximal interphalangeal joint to the distal interphalangeal joint.
• Life bar (命关 mìng guān): This is the final segment, from the distal interphalangeal joint to the fingertip.

Method

The examination should be conducted in good light. The practitioner holds the child’s fingertip using her thumb and index finger. Then, using the other thumb, she gently rubs from the finger from the tip downward several times. This makes the veins more distinct.

Significance

In healthy infants, the veins appear as dimly visible, pale purple to reddish-brown lines. Generally, they are visible in the wind bar only.

Depth: Veins that are especially distinct and close to the surface indicate an exterior pattern. If the veins are bright red, they indicate contraction of an external evil. If they are located at a deeper level, an evil is present in the interior.

Color: Purplish-red veins indicate heat; green-blue veins indicate wind-cold, fright wind, a pain pattern, food damage, or ascendant counterflow of phlegm and qì. Black generally indicates blood stasis. A stagnant appearance of the veins indicating impaired blood flow throughout the veins is associated with repletion patterns such as phlegm-damp, food stagnation, or binding depression of evil heat.

Location: If the veins are distinct in the wind bar, the condition is relatively mild. If they are also distinct in the qì bar, the condition is more severe. Extension of visible veins through all the bars to the fingertip indicates a critical condition.

In sum, the depth of the veins indicates the depth of penetration to the interior. Red indicates heat; green-blue indicates cold; pale indicates vacuity; and a stagnant appearance indicates repletion. The degree of penetration from the wind to the life bars indicates the severity of the condition.

Tongue Examination

See tongue examination.

Inspecting the Head, Face, and Neck

Head

In infants, attention is paid to the size of the head and to the fontanels to determine whether development is normal or not. In any patients, the hair, face and cheeks, eyes, nose, mouth and lips, teeth and gums, throat, ears, and the neck and nape are of importance.

Head size: In infants, an excessively large or small head with low intelligence is usually attributable to earlier-heaven insufficiency and depletion of kidney essence.

Fontanels: Infants under the age of one year require inspection of the fontanels.

• A depressed anterior fontanel, called depressed fontanel, means insufficiency of kidney essence.
• A bulging anterior fontanel, called bulging fontanel, is usually a sign of fire evil attacking upward in warm disease; it may also be attributable to accumulation of fluid. Note that it is normal for the fontanel to bulge temporarily when the infant cries.
• If the fontanels fail to close by the age of one and a half, this is called retarded closure of the fontanel gates (囟门迟闭 xìn mén chí bì). As a disease name, it is known as ununited skull (解颅 jiě lú). This is attributable to depletion of kidney qì resulting from insufficiency of the earlier-heaven constitution or to enduring illness and lack of nourishment after birth.

Shaking of the head (头摇 tóu yáo), whether in children or adults, is a sign of liver wind stirring internally.

Hair

The hair is the surplus of the blood and the bloom of the kidney.

• Graying of the hair and hair loss (发脱 fǎ tuō) are normal in advancing years and is a sign of the waning of kidney essence. In a minority of younger individuals, graying is not pathological if no other signs of related disease are present. Premature graying of the hair has little clinical significance, although there are Chinese medical treatments for it.
• Scant dry hair indicates insufficiency of kidney qì or debilitation of qì and blood.

Face and Cheeks

The most important signs are facial swelling, swelling of the cheeks, deviated eyes and mouth, and the grimace of lockjaw.

Swelling of the cheeks: Diffuse, hot swelling of one cheek or one cheek after the other, with a red sore swollen throat, swelling of the neck, and deafness indicates mumps (traditionally also called toad-head scourge).

Facial swelling without heat is a sign of water swelling. Distinction is made between yīn water and yáng water.

• Yīn water starts from the lower limbs, and gradually spreads upward to the face.
• Yáng water, which is much less common, starts from the upper body and gradually spreads to the lower body. See water swelling.

Deviated eyes and mouth (口眼歪斜 kǒu yǎn wāi xié)

When one side of the face is tight and distorted, while the other side is affected by numbness and tingling, this is called deviated eyes and mouth. The tight and distorted side is the healthy side, and the side affected by numbness and tingling is the affected side, that is, the side affected by obstruction of qì and blood. In the absence of any other signs, this is attributable to wind locally striking the channels and is relatively mild. If it is accompanied by hemiplegia and unclear spirit-mind, it is a sign of wind striking the bowels and viscera, which is more serious.

Grimace: A strange grimace accompanied by other signs of tetanic disease together with a history of a wound indicate lockjaw.

Eyes

Inspecting the eyes most often involves observing the spirit (vitality) and the physical appearance of the eye and surrounding area.

Parts of the eye: The traditionally recognized parts of the eye and their associations with the viscera are the following:

• The pupil, also called the water wheel (水轮 shuǐ lún), belongs the kidney.
• The dark of the eye (iris), also called the wind wheel (风轮 fēng lún), belongs to the liver.
• The white of the eye (sclera), also called the qì wheel (气轮 qì lún), belongs to the lung.
• The canthi, also called the blood wheel (血轮 xuè lún), belong to the heart.
• The eyelids, also called the flesh wheel (肉轮 ròu lún), belong to the spleen.

The eyes as the expression of the spirit: Inspecting the eyes most often involves observing the spirit. It is said that the essence of the bowels and viscera flow up to the eyes. This is based on the observation that the eyes to some extent reflect the state of the organs. Furthermore, the eyes connect through to the brain, which is said to be the sea of marrow, and the essence of marrow is the pupil spirit (the pupil and the clear matter that fills the eyeball).

• When the pupils are normal in enduring or severe illness, the condition can still be treated.
• Conversely, if a patient has lusterless eyes, and tends to keep the eyes shut, taking no interest in the world or if the eye spirit (expression of emotion in the eyes) is abnormal, the condition is critical.

Physical appearance of the eyes: Attention is paid to the orientation of the eyes, dilation of the pupils, and the color of the whites of the eyes (sclerae).

• Forward-staring eyes (瞪目直视 deng4 mu4 zhí shì) with clouded spirit indicates a critical condition of expiration of bowel and visceral essential qì.
• Upward-staring eyes (两目上视 liang3 mu4 shang4 shì) and squinting (斜视 xié shì): Upward-staring eyes, also called upcast eyes (戴眼 daì yǎn) means that both eyes look fixedly upward and are unable to move. Squinting is when both eyes look fixedly to one side or the other. Both conditions are attributable to severe conditions of liver wind stirring internally. Squinting of one or both eyes may be due to earlier-heaven causes.
• Bulging eyes (眼球外突 yǎn qiú waì tu1) are usually caused by binding depression of phlegm-fire.
• Dilatation of the pupils (瞳孔散大 tong2 kong3 san4 da4) in severe illness may be a sign of imminent death.
• Contraction of the pupils (瞳孔缩小 tong2 kong3 suō xiao3) may occur in wind stroke (as a result of intracerebral hemorrhage).
• Red eyes (目赤 mu4 chì), as visibly seen in the whites of the eyes (sclerae) and colloquially often described as blood-shot eyes (as from conjunctival hyperemia), are usually attributable to externally contracted wind-heat (wind-fire eye) or epidemic toxin (heaven-current red eye), both also being referred to as fire eye. These forms are equivalent to acute conjunctivitis or scleritis in biomedicine. Other causes include liver fire flaming upward, ascendant hyperactivity of liver yáng, liver-kidney yīn vacuity, or hyperactive heart fire. In some cases, it is associated with copious eye discharge (目眵 mu4 chi1).
• Yellowing of whites of the eyes (sclerae) indicates jaundice due either to damp-heat or less commonly cold-damp.
• Exposure of the eyeballs (露睛 lu4 jing1) is failure of the eyes to fully close. In clouded sleep, it indicates severe spleen-stomach debilitation and is seen in children after severe vomiting and diarrhea, and notably in chronic spleen wind (慢脾风 man4 pí fēng). Chronic spleen wind, which occurs in young children when severe vomiting or diarrhea weakens right qì, manifests in closed eyes, shaking head, dark green-blue face and lips, sweating brow, clouded spirit, hypersomnia often with exposure of the eyeballs, reversal cold of the limbs, and wriggling of the extremities.

Eyelids and surrounding area: Attention is paid to the color of the skin and to swelling, as well as to whether the eyes are sunken or bulging.

• Dark rings around the eyes (眼圈晦暗 yǎn quān huì an4) indicate kidney vacuity. A darker coloration around the eyes is normal in certain dark-skinned people (notably from the Asian subcontinent).
• Green-blue or purple rings around the eyes (眼圈青紫 yǎn quān qing1 zǐ) indicate intraorbital bleeding.
• Sunken eyes (目窠上微肿 mu4 ke1 neì xian4) indicate a serious condition of damage to liquid or humor desertion.
• Slight puffiness around the eyes (目窠微肿 mu4 ke1 wei1 zhong3) may indicate incipient water swelling. However, debilitation of kidney qì in advancing years may be reflected in slackening and puffiness of the lower lids, which in most cases does not constitute a sign of illness.
• Drooping eyelids (眼睑下垂 yǎn jiǎn xia4 chuí): Called blepharoptosis in biomedicine. Drooping of both eyelids is mostly attributed to earlier-heaven insufficiency and depletion of the spleen and kidney. Drooping of both eyelids is usually due to spleen qì vacuity or to external injury.
• Twitching of the eyelids (目膶 mu4 shun4) is usually attributed to external or internal wind.

Sty (针眼 zhen1 yǎn) and cinnabar eye (眼丹 yǎn dān): A small red swelling of the upper or lower eyelid with a yellow tip is a sty. More generalized swelling of the eyelid is called cinnabar eye. Both are caused by wind-heat evil toxin or spleen-stomach heat rising to the attack the eyes.

External obstruction (外障 waì zhang4): Any condition of the eyelids, canthi, white of the eye (sclerae), or dark of the eye (iris) that obstructs vision. External obstructions include painful red swollen eyes (e.g., wind-fire eye), tearing, eye discharge, dryness of the eyes, and excrescences of the canthi (excrescence creeping across the eye). Most involve fire or phlegm, and less frequently, liver-kidney yīn vacuity with vacuity fire flaming upward or spleen qì vacuity.

Internal obstruction (内障 neì zhang4): Also called eye screen (目翳 mu4 yi1). Any condition of the pupil and inner eye obstructing vision. This includes green wind internal obstruction (绿风内障 lu94 fēng neì zhang4), which corresponds to glaucoma, and coin screen (圆翳 yuan2 yì), which corresponds to cataract.

Coin screen (圆翳 yuan2 yì): A round white opacity covering the pupil below the surface of the eye, so called because it resembles a silver coin. It is one form of internal obstruction. It is usually attributed to insufficiency of the liver and kidney with yīn vacuity damp-heat or liver-channel wind-heat attacking upward. This is one of several conditions that corresponds to cataract in biomedicine.

Excrescence creeping across the eye (胬肉攀睛 nu3 ròu pān jing1): A gray-white fleshy growth at the canthus that progressively grows over the eye, in severe cases partially affecting vision. It corresponds to pterygium in biomedicine. It arises when heat congesting the heart and lung channels cause qì stagnation and blood stasis. It may also result from yīn vacuity with effulgent fire.

Ears

The ears are the outer orifice of the kidney. The ear region is also the meeting place of several channels: The foot lesser yáng (shao4 yáng) gallbladder channel, the foot greater yáng (taì yáng) bladder channel, and the foot yáng ming2 (yáng ming2) stomach channel. Inspection of the ears mostly concerns the auricle, which is the projecting external part of the ear, and the helix, which is the rim of the auricle.

Color

• Moist red auricles are a sign of plentiful qì and blood.
• Pale auricles indicate depletion of qì and blood.
• Red swollen auricles indicate liver-gallbladder damp-heat or heat toxin attacking the upper body.
• Green-blue or blackish auricles are seen in people with exuberant internal yīn cold with severe pain.
• Burnt-black auricles indicate depletion of kidney essence, which is seen in severe illness or in advanced-stage warm disease, causing depletion of kidney yīn or in patients with lower-burner dispersion-thirst.
• Red veins appearing behind the ears and palpable cold at the base of the ear are signs that herald measles.

Form

• Thin small auricles indicate earlier-heaven depletion and insufficiency of kidney essence.
• Withered helices (the outer rims of the auricle) and shrinking of the lobes in enduring or serious illness is a sign of qì and blood depletion and impending expiration of kidney qì.
• Encrusted skin (rough, dry, scaly skin) on the helices indicates enduring blood stasis.

Interior

• Discharge of pus from inside the ear is called purulent ear (聤耳 ting2 er3), which is attributed to liver-gallbladder damp-heat. In the advanced stages, it can turn from a repletion pattern into a vacuity pattern of insufficiency of kidney yīn with vacuity fire flaming upward.
• Excessive accumulation of earwax is called ceruminal congestion (耵耳 ding1 er3), which is traditionally ascribed to wind-heat. According to modern, factors include poor aural hygiene, inflammation, and reduced movement of the lower jaw in the elderly (jaw movement normally helps to keep the ears free of wax).

Nose

Mouth, Lips, and Jaw

Attention is paid to the color and moistness of the lips, drooling, sores, and spasm.

Color and moistness of the lips

• Pale lips are a sign of dual vacuity of qì and blood or of cold.
• Parched dry lips indicate damage to liquid.
• Red lips indicate vacuity or repletion heat. The deeper the red the more intense the heat. If the lips are also parched and dry, this means damage to liquid.
• Green-blue or purple lips appear in blood stasis or cold patterns, indicating impaired flow of qì and blood.
• Blackness around the mouth indicates that the kidney is on the verge of expiration.
• White speckles like millet seeds on the inside of the lips may indicate worm accumulation.
• Gaping mouth with closed eyes and limp hands is a sign of qì desertion.

Drooling (流涎 liú xian2). See also drool below under Inspecting Eliminated Matter at the end of this entry.

• Drooling from the corners of the mouth during sleep generally indicates spleen vacuity or stomach heat. In infants, this may be a sign of intestinal worms.
• Drooling from one side of the mouth is associated with deviated mouth in facial paralysis.

Mouth and tongue sores (口舌生疮 kǒu shé shēng chuang1): Sores on the mouth and tongue usually indicate hyperactive heart fire.

Clenched jaw (牙关紧闭 ya2 guān jin3 bì) occurs mostly in repletion patterns of liver wind stirring internally.

• It mostly occurs in tetanic disease (including lockjaw) and fright wind.
• It is observed with foaming at the mouth and sudden clouding collapse in epileptic seizures.
• It occurs with deviated eyes and mouth and phlegm rale in the throat in wind stroke.

Other anomalies

• Gaping corners of the mouth and shrinkage of the philtrum signify imminent desertion of right qì.
• Ulceration of the lips is usually attributable to heat brewing in the lung and stomach or to vacuity fire flaming upward.
• Sores at the side of the mouth that are red and painful are usually attributed to heat in the heart and spleen channels.
• Pursed lips in infants is a sign of umbilical wind.
• Twitching of the corners of the mouth may portend the stirring of wind.

Teeth and Gums

The teeth are the surplus of the bone, which belongs to the kidney. The stomach is connected to the gums. Hence, disease of the teeth and gums is associated with the kidney and the stomach.

• Dry teeth indicate damage to liquid by intense heat. Teeth as dry as old bones indicate exsiccation of kidney yīn.
• Black, eroded areas of the teeth indicate tooth decay.
• Loosening of the teeth (齿松 chǐ song1, 牙齿松动 ya2 chǐ song1 dong4) occurs in insufficiency of kidney essence and in liver yīn vacuity.
• Vacuity swelling of the gums, that is, slight swelling of the gums that pits when pressure is applied, indicates kidney vacuity.
• Bleeding gums may be attributable to intense stomach heat, the spleen failing to control the blood or kidney yīn vacuity.
• Painful swollen ulcerating gums (牙龈肿痛溃烂 ya2 yin2 zhong3 tong4 kuì lan4): Mainly caused by intense stomach heat.
• Gaping gums (牙龈宣露 ya2 yin2 xuān lu4) is exposure of the roots of the teeth, often associated with swelling, bleeding and putrefaction. It is associated with intense stomach heat or with insufficiency of kidney qì.
• Grinding of the teeth (齘齿 xiè chǐ) is technically called bruxism in biomedicine. Occurring in infants and children during sleep usually means stomach heat, intestinal worms, or gān accumulation (malnutrition).

Throat

The pharynx is the upper part of the throat, which is partly visible at the back of the mouth. Inspection of the throat is mostly concerned with red sore swollen throat or throat nodes. In Chinese texts, sore throat as a disease category is often referred to as throat impediment (喉痹 hóu bì), reflecting how the condition makes swallowing difficult. The Chinese equivalent of sore throat is (喉咙痛 hóu lóng tòng), but in Chinese medical texts, symptom descriptions pertaining to inspection are usually more detailed, indicating redness, swelling, pain, dryness, and the presence of any other anomalies.

• A painful red swollen throat is usually attributable to lung or stomach heat flaming upward in warm disease.
• Painful red swollen throat nodes (喉核 hóu hé, tonsils) are a sign of throat moth (喉蛾 hóu é), also called baby moth (乳蛾 rǔ é), which corresponds to tonsillitis in biomedicine. This is caused by of lung-stomach heat flaming upward. The additional presence of yellowish-white putrefaction speckles indicates heat toxin.
• A dry painful red pharynx with only slight swelling indicates yīn vacuity with effulgent fire.
• A slightly red and slightly swollen sore throat with grayish-white putrefaction speckles or patches that are not easily removed may indicate diphtheria. It is attributable to dryness-heat scorching lung-stomach yīn liquid.
• A white membrane covering the lining of the throat indicates diphtheria.

Neck and Nape

Problems associated with the neck include goiter, scrofula, and phlegm nodes, and stiff nape. Man’s Prognosis is a pulse felt on the neck that is sometimes used in diagnosis.

Lump at the front of the neck (颈前有肿块 jǐng qián yǒu zhǒng kuài) taking the form of a diffuse swelling on one or both sides of the anterior aspect of the neck that moves up and down as the patient swallows indicates goiter (瘿病 yǐng bìng, 瘿瘤 yǐng liú), colloquially known as fat neck or big neck (颈粗 jǐng cū, 大脖子 dà bó zi) in Chinese. Goiter is attributed to various factors including depressed liver qì, phlegm, blood stasis, and/or heat. See goiter.

Bean-like lumps at the side of the neck (颈侧有肿块如豆 jǐng qián yǒu zhǒng kuài) are observed in scrofula (瘰疬 luǒ lì), which is mostly attributed either to lung-kidney yīn vacuity with vacuity fire scorching the fluids and condensing them into phlegm, which binds at the neck, or to wind externally contracted wind-fire seasonal toxin binding at the neck.

Stiff nape (項強 xiàng jiàng): Stiff nape may be visible to the practitioner when it inhibits movement of the head, but it is a subject for the inquiry examination. It has the following significances:

• Stiff nape with mild pain, accompanied by aversion to cold and floating pulse, is attributable to wind-cold invading the greater yáng (tài yáng) channel.
• Stiff nape with aversion to cold and heat effusion, head heavy as if swathed, aching limbs, fixed heavy joint pain, white tongue, and floating pulse is attributed to external contraction of wind-damp.
• Stiff nape with pronounced pain, accompanied by vigorous heat effusion and clouded spirit, is attributable to warm-heat evil scorching yīn humor, depriving the sinews of nourishment.
• Stiff nape after waking is called crick in the neck (torticollis in Western medicine) and is attributable to poor sleeping posture.
• Stiff nape with dizziness, distension in the head, headache, numbness of the limbs, and unsteady gait indicates liver yáng transforming into wind.
• Severe stiff of the nape, referred to as rigidity of the nape and neck (颈项强直 jǐng xiàng jiàng zhí), is associated with extreme heat engendering wind observed in wind fright. It may also be a sign of lockjaw, which is caused by a virulent form of external wind called wind toxin.

Man’s Prognosis (人迎 rén yíng): The places where the pulse can be felt at the external carotid artery is called Man’s Prognosis, which is an acupuncture point (rén yíng, ST 9). This term refers to the pulse felt at the external carotid artery. When Man’s Prognosis pulse is conspicuously strong and accompanied by cough, panting, or water swelling, this is usually attributable to heart-lung qì debilitation or heart-kidney yáng debilitation.

Inspecting the Chest, Abdomen, Back, and Lumbus

Chest

A normal chest is symmetrical and has a left-right diameter that is greater than the front-back (anteroposterior) diameter, although in children and the elderly, the front-back diameter may be equal or greater than the left-right diameter.

Flat chest (扁平胸 biǎn píng xiōng): A chest having front-back diameter less than the left-right diameter. This is often seen in patients with lung-kidney yīn vacuity or dual vacuity of qì and yīn.

Barrel chest (桶狀胸 tǒng zhuàng xiōng): A chest having a greater front-back diameter that is equal to or greater than the left-right diameter. It is seen in pulmonary distension and is mostly due to enduring conditions of cough and panting, which damage the lung and kidney, resulting in lung vacuity with qì counterflow.

Pigeon chest (鸡胸 jī xiōng) and funnel chest (漏斗胸 lòu dǒu xiōng): Pigeon chest, called chicken chest in Chinese, is the protrusion of the lower part of sternum giving the appearance of a chicken breast. Funnel chest is a concave depression of the sternum. Both due to earlier-heaven insufficiency or poor later-heaven nutrition affecting bone development.

String-of-pearls rib-side (胁如串珠 xié rú chuàn zhū). Protuberances of the ribs forming a line running down the side of the chest. It is often seen in rickets.

Breathing

The normal rate of respiration is 16–18 times per minute. Men and children tend to breathe with their abdomen, while women tend to breathe with their chest. For more information about breathing, see listening

• Increased chest breathing and decreased abdominal breathing indicates an abdominal disorder. It is seen in drum distension patients and in patients with accumulations and gatherings. It may also be seen in pregnancy.
• A decrease in chest breathing and an increase in abdominal breathing indicate a chest disorder. It is seen in pulmonary consumption, suspended rheum, and people who have suffered chest injuries.
• Asymmetrical breathing in which there is greater movement on one side of the chest is seen in suspended rheum or what biomedicine calls lung tumors.
• Prolonged inhalation means that inhalation is difficult. This is accompanied by abnormal depressions above the sternum, in the supraclavicular fossae, and between the ribs.
• Prolonged exhalation means that exhalation is difficult. This is accompanied by abnormal gaping mouth and bulging eyes and inability to lie flat. It is seen in wheezing disease and in pulmonary distension.
• Hasty breathing with pronounced expansion and contraction of the chest is mostly seen in repletion heat patterns arising when evil head and phlegm-turbidity invade the lung and disturb the lung’s depurative downbearing and diffusion function.
• Faint breathing with indistinct movement of the chest is mostly seen in vacuity cold patterns arising as a result of depletion of the lung qì or qì-vacuity constitution.
• Irregular breathing where breathing goes from deep to shallow and stops before starting again or where breathing just pauses now and again indicates a severe condition of debilitation of lung qì.

Abdomen

The main morbid signs are concave abdomen, bulging abdomen prominent green-blue vessels, and umbilical anomalies.

Concave abdomen (腹部凹陷 fu4 bu4 ao1 xiàn). A concave or depressed abdomen is one in which, when the patient lies on his back, his abdomen is lower than the line running from the sternum to the pubic bone.

• A concave abdomen with general emaciation is attributable to severe spleen-stomach vacuity with insufficiency of qì and blood or to excessive vomiting and diarrhea in disease of recent onset causing major damage to liquid and humor.
• A concave abdomen with encrusted skin, in severe cases allowing the spine to be felt, is seen in highly emaciated bedridden patients and indicates expiration of essential qì.

Abdominal obesity (腹部肥胖 fu4 bu4 feí pàng) is a sign of qì vacuity and gathering of dampness and phlegm, which can lead to wind stroke.

Bulging abdomen (腹部膨隆 fu4 bu4 peng2 lóng). A visibly distended abdomen is one in which, when the patient lies on his back, his abdomen is higher than the line running from the sternum to the pubic bone.

• If it is accompanied by emaciated limbs, it is usually drum distension disease, which arises when depressed liver qì and dampness give rise to static blood.
• If the abdomen is distended and there is generalized swelling, this is usually water swelling disease, which arises a result of disorders of the lung, spleen, and kidney causing water-damp to spill into the flesh.
• Localized distension in the abdominal region is a sign of concretions, conglomerations, accumulations, or gatherings (abdominal masses).

Enlarged abdomen with prominent green-blue vessels (腹大青筋暴露 fu4 dà qing1 jīn bao4 lu4): A bulging abdomen with protruding blood vessels like varicose veins is usually attributed to liver depression and blood stasis. It arises from persistent stagnation of liver qì and spleen vacuity with damp obstruction. It is seen in severe cases of drum distension disease.

Back and Lumbus

Deformities of the spine : These include kyphosis (hunchback, humpback), scoliosis (abnormal sideways curvature), lordosis (excessive inward curvature of the lower back), and flat back (lack of curvature). These are attributed to depletion of kidney qì, poor development, diseases of the spine, external injury, poor posture, or aging.

Spinal gan1 (脊疳 ji3 gan1): Extreme emaciation in which the spine appears like a saw. It indicates depletion of the essential qì of the bowels and viscera and is seen in chronic conditions.

Inspecting the Limbs

Abnormal Form

Atrophy of the limbs: Atrophy of one or all limbs with lack of strength is usually attributed to qì-blood depletion or obstruction of the channels and network vessels depriving the limbs of nourishment. It is seen in wilting disease.

Swelling of the limbs or whole body or often swelling of the ankles only is water swelling disease. When finger pressure is applied, the flesh does not normally rebound immediately.

Enlarged swollen knees

• Enlarged red swollen knees with difficulty bending and stretching are seen in heat impediment (热痹 re4 bì), which develops when wind and dampness remain depressed for a long time and transform into heat.
• Enlarged swollen knees with emaciated calves is called crane’s-knee wind (鹤膝风 he4 xī feng1), which is mostly attributed to cold-damp lodging for a long time with qì-blood vacuity.

Deformities of the legs: These include knock-knee, bowleg, inversion of the foot (pes varus), and eversion of the foot (pes valgus). These are all attributed to poor development resulting from earlier-heaven insufficiency or poor later-heaven nourishment and resultant weakness of kidney qì.

Prominent green-blue vessels (青筋暴露 qing1 jīn bao4 lu4) on the lower limbs, commonly known as varicose veins, are attributed to invasion of cold-damp and blood stasis in the network vessels.

Deformed fingers: Enlarged finger joints with inhibited movement are a sign of impediment (bì).

Abnormal Movement

See Inspecting Body and Bearing above.

Inspecting the Two Yīn

The two yīn are the genitals (anterior yīn) and anus (posterior yīn).

Anterior Yīn

Inspection of the anterior yīn in males involves inspection of the penis, scrotum, and testicles for possible swellings, lumps, sores, or other anomalies. In women, it involves inspecting the labia and clitoris.

Painful swollen testicles (睾丸肿痛 gao1 wán zhǒng tòng) with redness of the scrotum is a sign of liver-gallbladder damp-heat pouring downward.

Swelling of the scrotum (阴囊肿大 yīn náng zhǒng dà): Swelling of the scrotum without redness or itching may indicate yīn swelling, water mounting, or foxlike mounting.

• Yīn swelling (阴肿 yīn zhǒng) is a local manifestation of severe generalized water swelling. This is easily distinguished from the following types of swelling of the scrotum by the presence of water swelling in other parts of the body.
• Water mounting (水疝 shui3 shàn), corresponding to scrotal hydrocele in biomedicine, is a swollen scrotum that feels full of water that appears orange and translucent under a light transmission test. In the light transmission test, a sheet of non-translucent paper is rolled into a tube, and one end of it is pressed against one side of the scrotum. When a flashlight is pressed against the other side of the scrotum, the amount of light appearing in the paper tube indicates the degree of translucence of the scrotum. In water mounting, the paper tube shows an orange light, indicating a high degree of translucence. It is attributed to water-damp pouring downward or to contraction of wind, cold, or damp evils.
• Foxlike mounting (狐疝 hú shàn): Also called mounting qì (疝气 shàn qì) or slumping mounting (㿗疝 tuí shàn); corresponds to inguinal hernia in biomedicine, is a soft swelling of the scrotum that disappears when the patient lies flat. Unlike water mounting, the light transmission test reveals no translucence. This is caused by the small intestine descending into the scrotum when the patient stands and retracting when the patient lies flat. It is attributable to liver depression, cold-damp, damp-heat, qì vacuity, or prolonged standing or walking.

Retracted scrotum (阴囊收缩 yīn náng shoū suo1): Shrinking of the contents of the scrotum and partial withdrawal into the abdominal cavity. It occurs in cold stagnating in the liver vessel and in other cold patterns, such as yáng desertion. It can also occur when yáng míng (yáng míng) heat enters the reverting yīn (jué yīn) channel.

Scrotal itch (阴囊瘙痒 yīn náng sao4 yang3), often associated with redness, burning sensation, or scaling indicates scrotal eczema as diagnosed in biomedicine.

Dampness and itching of the genitals (阴部湿痒 yīn bu4 shī yang3): Also called genital damp itch. Itching of the genitals with redness, swelling, dampness, and exudation is mostly attributable to liver-gallbladder damp-heat pouring down through the channels.

Pudendal itch (外阴瘙痒 wài yīn sao4 yang3): Itching of the female external genitals or vagina. It is attributed to liver-gallbladder damp-heat pouring downward or liver-kidney yīn vacuity.

Prolapse of the uterus (子宫下垂 zi3 gōng xià chuí): Also called yīn protrusion (阴挺 yīn tǐng) and eggplant disease (茄子病 qié zi bìng). Protrusion of the vagina through the vulva. It is usually attributable to spleen vacuity qì fall. It often results from taxation damage due to childbirth.

Posterior Yīn

Inspection of the posterior yīn requires the patient lie on their side with legs bent toward the abdomen so that the buttocks can be pulled apart easily to reveal the anus. The examination involves looking for redness and swelling, hemorrhoids, anal fissures, and fistulas.

Anal fissure (肛裂 gang1 lie4): A split in the perianal skin and or in mucous membrane within the anus, causing pain on defecation. It is usually attributable to hard bound stool and straining on defecation.

Hemorrhoids (痔 zhì, 痔疮 zhì chuang1, 痔核 zhì hé): The protrusion of blood vessels on the inside or outside of the anus, often accompanied by constipation and the passage of fresh blood. A distinction is made between internal and external hemorrhoids.

• Internal hemorrhoids are those that are hidden inside. These in the early stages do not protrude from the anus, but they cause bleeding. When the condition becomes more severe, they may protrude from the anus on defecation and be associated with pronounced bleeding. The bleeding may manifest in the form of fresh blood, but it may simply turn the stool a dark purple color that may be confused with having eaten beets, red amaranth, or other foods that color the stool.
• External hemorrhoids are those normally visible from outside. These are associated with a sagging or abnormal sensation and pain.

A patient may suffer from internal and external hemorrhoids at the same time. Both are attributable to the same causes. A distinction is made between vacuity and repletion patterns, the latter being the more common.

Vacuity patterns are caused by long sitting, standing, or walking, enduring dysentery or diarrhea, constipation and straining to defecate, or center qì fall in pregnancy.

Repletion patterns are the result of damp-heat or blood heat and intestinal dryness. In repletion patterns, hemorrhoids may manifest in heat signs, such as constipation, reddish urine, thirst, a red tongue with yellow fur, and a rapid pulse.

Anal welling-abscess: (肛痈 gang1 yōng): Redness and elevated swelling around the anus with pronounced pain, possibly with rupturing to exude pus, is usually attributable to damp-heat pouring downward or external contraction of heat toxin.

Anal fistula (肛瘘 gang1 lòu): This is a pipe-like lesion between the perianal skin and the inside of the anus or rectum. It develops from an anal welling-abscess or from hemorrhoids that fail to heal. It is associated with pain, itching, and exudation of pus. The causes are as for anal welling-abscess and hemorrhoids.

Prolapse of the rectum (脱肛 tuo1 gang1): Protrusion of the rectum through the anus. In mild cases, prolapse happens during defecation to retract after evacuation. In severe cases, it can only be retracted with a helping hand. It is usually attributable to spleen vacuity qì fall.

Inspecting Eliminated Matter

Eliminated matter includes phlegm, nasal mucus, tears, drool and spittle, vomitus, stool, and urine. Sweat is dealt with under inquiry (Inquiry About Sweating).

Phlegm (痰 tán)

Phlegm is the mucus expelled from the lung and airways. Inspection of phlegm focuses on color, consistency, and quantity. It can reveal information about the state of the bowels and viscera and the presence of disease evils. The presence of phlegm causing obstruction of the airways is often referred to as phlegm congestion (痰壅 tán yōng). Phlegm in the airways causing cough is sometimes called phlegm cough (痰嗽 tán sòu).

• Clear thin white phlegm is usually cold phlegm. It arises when cold evil damages yáng qì, and liquid congeals and gathers to form phlegm, or when spleen yáng is insufficient and fails to transform water-damp so that dampness gathers to form phlegm, which invades the lung.
• Thick white or yellow phlegm is usually heat phlegm. It arises when evil heat invades the lung and boils the fluids into phlegm.
• Scant sticky phlegm that is difficult to expectorate is dryness phlegm (see phlegm-rheum patterns). It arises either when dryness evil invades the lung and damages lung liquid or when lung liquid is depleted owing to other causes. In either case, the result is impaired depurative downbearing of the lung failing to keep the airways free.
• Copious glossy white phlegm that is easy to expectorate is damp phlegm (see phlegm-rheum patterns)). It arises when the spleen, owing to failure of movement and transformation, allows water-damp to collect internally and gather to form phlegm, which invades the lung.
• Expectoration of pus, blood, and phlegm that has a fishy smell is a sign of pulmonary welling-abscess, which is attributable to heat toxin brewing in the lung and causing putrefaction and suppuration.
• Expectoration of blood-flecked phlegm or coughing of pure blood is attributed to fire-heat scorching the network vessels of the lung, which usually occurs in patients suffering from lung yīn depletion or liver fire invading the lung. In these patterns, expectoration of purplish-black blood may indicate a blood stasis complication.
• Phlegm congestion can also occur in wind stroke and fright wind.

Nasal Mucus (鼻涕 bí tì)

Also called snivel. The mucus produced in the nose. It is the humor of the lung.

• Nasal congestion (鼻塞 bí sè) and runny nose with clear snivel (流清涕 liú qīng tì) mean non-diffusion of lung qì and usually occurs in initial-stage common cold attributable to wind-cold.
• Runny nose with turbid yellow nasal mucus (流黄浊涕 liú huáng zhuó tì) is attributable to external contraction of wind-heat.
• Clear thin snivel thickening and turning yellow may indicate a recovery from common cold.
• Persistent foul-smelling turbid yellow snivel accompanied by recurrent headaches generally indicates deep-source nasal congestion (鼻渊 bí yuān), which roughly corresponds to paranasal sinusitis or chronic rhinitis in biomedicine and which is usually attributable to lingering wind-heat or wind-cold or to gallbladder heat.
• Incessant runny nose is called sniveling nose (鼻鼽 bí qiú). It is attributable to wind-cold fettering the lung.

Tears

See inquiry (Inquiry About Hearing and Vision).

Drool and Spittle

Chinese medicine recognizes two forms of saliva: a thin form called drool, which is associated with the spleen, and a thicker frothy form called spittle, which is associated with the kidney.

Drool is fluid of the mouth that keeps the mouth moist and aids digestion. Because of its connection with digestion, inspection of drool helps in the diagnosis of spleen and stomach disease.

Spittle is the frothy mucus that can be spat out. Spittle is the humor of the kidney. In practice, it is also found to be related to the spleen and stomach.

Drool (涎 xián)

• Copious drool is a sign of spleen-stomach vacuity cold. It arises when the spleen and stomach are vacuous and qì fails to warm and transform liquid.
• Sticky drool in the mouth is a sign of spleen-stomach damp-heat. It arises when damp-heat encumbers the center burner and impairs splenic movement and transformation, which allows damp turbidity to flood upward.
• Drooling from the corners of the mouth in infants, often called dribbling, usually means a vacuous spleen failing to contain liquid. It can also indicate stomach heat with worm accumulation.
• Drooling in sleep is attributable to stomach heat, abiding food, or phlegm-heat brewing internally.

Spittle (唾 tuò): Copious spittle can arise when kidney yáng is insufficient and fails to provide warmth, qì transformation is weakened, and water evil floods upward into the mouth. It can also arise when fluid ascends counterflows and spills into the mouth as a result of cold in the stomach, abiding food, or stagnant damp evil in the spleen.

Vomitus

Vomiting is a manifestation of the stomach qì ascending counterflow. It can occur in both externally contracted disease and in internal damage and miscellaneous disease.

• Vomitus that is clear and thin accompanied by cold pain in the stomach duct and abdomen is due to stomach yáng vacuity or cold stagnating in the stomach and intestines, preventing proper ripening and rotting. In either case, liver qì invading the stomach may also be a factor.
• Vomitus that takes the form of clear water and phlegm-drool (clear thin fluid from the stomach that is slightly elastic like mouth drool) and that is accompanied by the sound of water in the stomach duct and sensations of glomus and distension indicates cold rheum collecting in the stomach.
• Vomitus containing largely undigested food is usually attributable to food damage occurring when voracious eating and drinking damages the stomach and spleen (food accumulation). The vomitus may be sour and putrid.
• Vomitus that has a sour taste and putrid odor, if not due to food accumulation, indicates stomach heat or liver-gallbladder damp-heat. Severe heat may make the vomitus foul and turbid with a pronounced fetid odor.
• Vomiting of yellow or green bitter water is attributable to depressed heat or damp-heat in the liver and gallbladder.
• Vomiting of yellow water may indicate yellow swelling (seen in patients biomedically diagnosed with hookworm infestation, anemia, or malnutrition).
• Vomiting of worms indicates roundworm accumulation.
• Vomiting of blood (吐血 tù xuè): Vomiting of fresh blood or dark-purple clots with food residues is attributable to accumulated heat in the stomach or to liver fire invading the stomach, possibly with blood stasis in the stomach. It is caused by heat damaging the stomach’s network vessels, causing them to rupture. When the bleeding is severe, the blood is expelled quickly so that the blood has a fresh appearance. When bleeding is less severe, it clots before being ejected, taking on a purple appearance that reflects blood stasis. Note that in older texts, the Chinese term 吐血 tù xuè sometimes referred ejection of blood via the mouth regardless of origin (stomach or lungs); hence the alternative translation blood ejection.
• Vomiting of pus and blood (吐脓血 tù nóng xuè) indicates a stomach welling-abscess.

Stool (大便 dà biàn)

Normal stool is pale brown in color (in Chinese it is described as yellow) and is formed (i.e., it holds together in lumps). Attention is paid mostly to consistency and contents.

Sloppy stool (便溏 biàn táng); watery stool (大便水樣 dà biàn shui3 yang4): Sloppy stool, referring to unformed or loose stool, is classically described as resembling duck slop (鸭溏 ya1 táng), i.e., duck droppings. Note that sloppy stool refers only to the consistency. It differs from diarrhea in that it is not necessarily associated with increased frequency of defecation. Watery stool is very thin sloppy stool, mostly consisting of water.

• Sloppy stool is most commonly associated with spleen qì vacuity, spleen yáng vacuity, spleen-kidney yáng vacuity, cold-damp encumbering the spleen, or damp-heat brewing in the spleen.
• Watery stool that is thin and clear arises when contraction of external cold-damp or the consumption of raw or cold foods causes splenic movement and transformation failure and impaired separation of the clear and turbid.
• Stool containing improperly digested food is often referred to as grain failing to transform (完谷不化 wán gu3 bù huà). It is usually sloppy or watery. If there is increased frequency, it is called clear-grain diarrhea. It is attributable to spleen-kidney yáng vacuity, spleen vacuity, or large intestine vacuity. Occurring with watery stool, it may indicate cold-damp.
• Malodorous thin sloppy yellow stool is associated with damp-heat.
• Brown stool like rice gruel, with a fetid odor, is usually attributable to damp-heat or summerheat-damp damaging the stomach and to abnormal conveyance in the large intestine.
• Worms in the stool indicate worm accumulation.

Hard bound stool (大便硬结 dà biàn ying4 jie2): Hard bound stool or dry bound stool is densely compacted stool with little water content. Note that hard bound stool is often but not necessarily associated with constipation, which is decreased frequency of defecation.

• Hard bound stool commonly results from heat bind, that is, repletion heat binding in the large intestine and damaging liquid. It is usually accompanied by generalized heat effusion and a red face.
• Dry bound stool resembling sheep droppings evacuated with difficult defecation is caused by intestinal dryness from intestinal liquid depletion or heat binding in the intestines. It is sometimes associated with stomach reflux and dysphagia-occlusion (噎膈 ye1 ge2, usually, severe constriction of the esophagus).
• Sticky stool containing blood and pus (mucus), frequently evacuated in small amounts, with tenesmus, is a sign of dysentery.

Bloody stool (便血 biàn xuè): Also called blood in the stool, and in traditional literature descent of blood (下血 xià xuè, a term that may also refer to bleeding via the vagina), and hematochezia in biomedicine. Note that the term hemafecia is sometimes used in English-language Chinese medical texts, but it is not recognized by standard English dictionaries. Loss of blood through the anus, with varying amounts of stool. It may be attributable to distal or proximal bleeding.

• Distal bleeding (远血 yuan3 xuè) is bleeding far away from the anus; it is characterized by stool followed by blood, with the blood being dark purple in color or black and tarry. This is usually attributable to heat damaging the network vessels of the stomach causing frenetic movement of hot blood or to the spleen failing to control the blood. Glossy blackish sloppy stool is also generally associated with bleeding in the upper digestive tract.
• Proximal bleeding (近血 jin4 xuè) is bleeding close to or at the anus (the descending colon or below). It is characterized by blood followed by stool or stool mixed with blood, the blood usually being bright in color. This is attributable to heat damaging the network vessels of the intestines and is sometimes called intestinal wind bleeding or intestinal wind descent of blood (肠风下血 cháng feng1 xià xuè). It may also be attributable to bleeding hemorrhoids or anal fissure.

Pus and blood in the stool (大便脓血 dà biàn nóng xuè): The presence of blood and pus-like matter in the stool, usually accompanied by abdominal pain, frequent defecation, and tenesmus. It is a chief sign of dysentery.

Urine (小便 xiao3 biàn, 尿 niaò)

Urine is normally pale yellow in color. Excessively dark-colored urine is attributable to the action of heat reducing the fluids in the body. It traditionally referred to, depending on the severity, as yellow urine or reddish urine. Excessively pale urine is attributable to the action of cold preventing normal reduction of fluids in the body. It is usually referred to as clear urine. Since urine can easily change color temporarily in response to heat and cold in the environment and variations in intake of fluid, changes in urine color can be judged as pathological only if based on extended observations over several days.

• Long voidings of clear urine (小便清长 xiao3 biàn qīng cháng) usually with physical cold and cold limbs are often associated with cold.
• Short voidings of yellow urine (小便黄短 xiao3 biàn huáng duan3), where yellow urine means slightly darker than normal but not as severe as reddish urine, is attributable to vacuity heat or milder forms of repletion heat.
• Short voidings of reddish urine (小便短赤 xiao3 biàn duan3 chì) are attributed to heat, usually repletion heat. When accompanied by painful urination, urinary urgency, and frequent urination, they indicate damp-heat in the lower burner. Painful urination attributable to damp-heat constitutes damp-heat strangury.
• Bloody urine (尿血 niaò xuè) is urine with the bright-red coloring of blood. It is called hematuria in biomedicine. It differs from reddish urine, which is concentrated urine with a reddish-brown color. If urination is uninhibited, bloody urine is attributable to heat accumulation in the bladder damaging the blood network vessels (small blood vessels); if urination it intermittent and accompanied by occasional passing of stones and severe pain, this is stone strangury attributable to damp-heat in the lower burner. Bloody urine with painful urination but without damp-heat signs may be qì strangury, which is attributed to qì vacuity or qì stagnation. Other causes of bloody urine include yīn vacuity with effulgent fire causing frenetic movement of hot blood or dual depletion of the spleen and kidney preventing the blood from being contained. Bloody urine may indicate conditions diagnosed as cancer in biomedicine, so patients should be referred for testing.
• Turbid urine that is milky in appearance, often described in Chinese as being like water in which rice has been washed (米泔水 mi3 gān shui3), may be due to damp-heat in the lower burner or spleen-kidney vacuity. Turbid urine associated with painful inhibited urination is ascribed to damp-heat. Without painful urination, turbid urine is ascribed to kidney vacuity, spleen vacuity qì fall, or spleen-kidney vacuity. In the latter case, the patient is often increasingly weak and emaciated. Turbid urine due to damp-heat is traditionally called unctuous strangury (膏淋 gao1 lin4). The term white turbidity (白浊 baí zhuó) is often, but not necessarily, used specifically to denote the vacuity condition. Note that healthy urine may be slightly turbid. Only urine that is turbid on urination and remains turbid when left to stand is pathological. Urine that is turbid on urination and that clears when left to stand does not necessarily indicate morbidity. Similarly, clear urine that turns murky when left to stand is not considered pathological.