The Four Examinations (Chinese Medicine Diagnosis, Part 1)

One of the major strengths of Chinese medicine is its ability to diagnose imbalance. It does this via the 4 Examinations or 4 Diagnoses, Inspection/Looking, Listening/Smelling, Inquiry/Asking and Palpation (pulse, abdomen, channels).

Over the next series of posts, I will present an outline of my teaching notes on these examinations.

1. Inspection, “Looking examination”
a. looking at the form of a person, how they’re built, how they carry themselves: their form, their bearing. individual structure; the complexion, the sense organs; you look at their Shen, their eyes
b. tongue

2. Listening and Smelling exam.
a. We listen to the quality of someone’s voice, the quality of the sounds they make; the quality of a cough, quality of respiration; coughing, wheezing.
b. And then we smell, we use our nose. The pictogram of smell is actually to taste the air around them. And we smell any unusual odors. Probably the hardest one to describe when we start talking about that. Overall, we’re going to smell unusual odors.

3. Inquiry or Asking exam.
a. We’re going to ask questions from head to toe. We’re going to ask a lot about the chief complaint, the onset of the chief complaint, plus the progression of the illness (the clinical course of the chief complaint – what have they done, how did it start, what’s the past history, how has it changed?)
b. Ten Questions. symptoms overview in terms of Chinese Medicine. We ask about their temperature, how they feel – whether they’re hot or cold. We ask whether or not they sweat, we ask about any problems with their head or dizziness. We ask about their hearing, we ask about their respiratory system. We ask about their appetite, their taste. We ask about their digestion and elimination – we ask about bowels, we ask about urine. We ask about any pain that they have. And for women, we ask about their menstrual cycle. It’s basically a patient’s subjective response to questions regarding their condition.

4. Palpation Exam or Touching.
a. We palpate the chest, the abdomen, the limbs. We palpate the channels and acupuncture points.
b. Pulse: very detailed at the radial artery, the pulses on both sides


Diagnosis involves using your eyes, ears, nose and mind plus your hands to touch. Must be present you’re your patients to find out what’s wrong with them. The goal is to determine a pattern of disharmony.


Inspection:

STRUCTURE
Bone structure, shape, form – Jing. Long-term changes. Then, flesh, nourishment – Qi. Medium term changes. Then, complexion – Shen. Momentary changes. The Three Treasures.

SPIRIT
Shen is about engaging in the world, in terms of interactions, communication, appropriateness. It’s about participation in this world. It’s a combination of the Jing and the Shen. It’s a combination of the facial expression, complexion, the quality of the voice. But when we’re looking just at Shen, we’re looking at somebody who either has Spirit or does not have Spirit. And then we have something called False Spirit.

When someone has Spirit or has Shen, what you’re really seeing is someone who’s bright-eyed and chipper; respond coherently to questions. It means that their True Qi is unchanged, that their vitality is not really being taxed completely and their prognosis is good. Even if they’re in a lot of pain, even if they seem to have a serious illness, their prognosis is good because their Shen is still present and clear. So, they are present, they are able to respond to you appropriately.

Now someone who lacks Spirit (Weismann likes to refer to this as Essence Spirit Debilitation – he always combines the Jing in there). They have a severe lack of either mental vigor or physical vigor. Usually they have a dull facial complexion, a dull look to their eyes. There might be abnormal speech or abnormal responses to questions. Now there’s a lot of space between these two. But you either have someone who has spirit or you have someone without spirit. When someone is without Spirit, their prognosis is very poor because they’re not there to work with you.

False Spirit
Worst prognosis is something called False Spirit. Now, False Spirit is not someone trying to be happy when they’re sad – that (person) still has Spirit. False Spirit is very, very specific. False Spirit is really the last, flickering light of a dying individual. It’s when someone who is at death’s door, without other changes, all of a sudden becomes spirited; all of a sudden becomes alert and active and engaged without any other real significant changes. If somebody’s going to get better, that happens slowly, they slowly come into themselves, they slowly regain their appetite. When someone all of a sudden, who’s at death’s door, turns lucid and clear and hungry and available. This is called False Spirit. When Yang and Yin are separating and Yang rises to the surface, which gives that last burst of energy before death. It could be 2 weeks, it could be 2 days, but the prognosis is not good. Usually it’s associated with something called the Grease Paint Smear – along the places you have a malar flush, it looks like oil paint, like a red smear right here (across cheeks). It’s bright red, much more of a vibrant color. This is a time usually when death is imminent. It’s time to say goodbye.


COMPLEXION - COLORS
Complexion reflects the state of Qi and Blood.
First, you look at the texture, the luster of the skin. Healthy skin should have a shine to it, should have a luster, but should not be oily. Unhealthy is usually oily or dry: dry being usually deficient or having more vacuity and oily being more of a repletion state. If it’s just shiny, it means the stomach Qi is good. If it’s too shiny, it’s oily and there’s repletion. If it’s dull there’s usually some insufficiency, usually the stomach Qi is not forming the fluids well.

Green/Blue (Qing – the color of dragon scales). Wood. Liver or Wind. Or it’s associated with congealed Blood or congealed Qi. Qi and Blood Stasis. Around the eyes, around the mouth, around the sense organs… the temples, especially for the liver, the gall bladder, the gall bladder meridian area, between the eyes. But usually around the sense organs, where the bones come up, and around the mouth. You’ll see lips turn blue: blood stasis; when you have a heart attack or poor circulation.

Red. Fire. Heat patterns.
Vacuity heat: malar flush. Usually afternoon.
Full heat: whole face is red.
False Spirit red, which is that strip of great paint.

Yellow. Earth. Dampness or with Vacuity, usually. Spleen not transforming fluids properly. You often will call this sallow, kind of like a pale yellow, puffy skin. Sallow. It’s usually associated more with Spleen/Stomach vacuity.

Jaundices in Chinese Medicine. Yang type jaundice and a Yin type jaundice.
Yin type jaundice. It’s called Cold Damp Yin Jaundice – it’s usually associated more with some disharmony of the Spleen, Spleen Damp Coldness. Person just looks yellow, not yellow sclera. It’s the color of yellow and usually in Western Medicine you’re going to be seeing something like cirrhosis of the liver or pancreatic cancer, chronic hepatitis. Basically… the organs are getting taxed in a more malingering way where the tissue is actually drying out. It’s a Cold Damp Yin type jaundice.

Yang type jaundice. Yang type jaundice is a Damp Heat Yang jaundice. More associated with the liver. The person has yellow skin and yellow sclera (the whites of the eyes). This is more hepatitis or acute gallbladder attack or gallstones.

What you see mostly is some people come in and they look kind of yellow, diagnose someone as jaundice, it’s usually stomach and spleen deficiency – it’s not uncommon. It’s kind of a yellow, sallow color to the skin.


White. Metal. pale. White usually indicates Cold or Vacuity. Now, the major thing here is what kind of moisture somebody has. If you have someone who comes in and they have a bright white complexion and they’re real puffy; bright white and there’s swelling. This usually is some sort of Qi or Yang Vacuity. So basically we have the Qi not transforming – so you have a bright white, puffy complexion as opposed to a lusterless, dry, white face, not puffy, but almost drawn. That’s more Blood deficiency. That’s more vacuity of blood. I like to say a withered complexion, that drawn look.

If somebody turns white suddenly, that sudden white, is usually associated with Faint, shock… it’s usually some sort of Yang Qi Desertion: Yang Qi just leaving through the feet, leaving the face white. Also, it can be associated sometimes with pain, but it’s the Yang Qi deserting.

Gray/Black/Purple. Kidneys, Water. And that usually means Kidney vacuity or Blood Stasis. Because a lot of those dark colors are just that purple, lingering for a long time – it starts looking gray or black. So Kidney Insufficiency or we have that kind of congealed blood kind of purple that turns black.

Facial Diagnosis according to the

Su Wen and Ling Shu:





Problems on the cheeks, both cheeks, if it’s not on one side, then you’re looking more at the Lungs. If the cheeks are puffy, we’ll say it’s more phlegm in the Lungs. Another place we look is something called a flaring ala nasi. The flaring ala nasi and with red around it, we’ll see as Lung Heat. Usually if the sores are more inside the nostrils, it’s more Large Intestine. But the nostrils should be even shaped. If they’re too small, that’s a constitutional weakness in the Lung. If they’re very large, they tend to also have ______________.

The nose is associated with the spleen. It should be well-formed, well-shaped. If it’s swollen, we tend to be looking at Stomach Spleen Dampness and Heat. A bulbous nose, from alcohol indulgence, Dampness and Heat. The size and the shape of it is more Spleen. If it’s white, if the nose is too pale, that’s usually Qi insufficiency of the Spleen. Some say it’s a Heart condition, too. There’s differences of opinion.

Liver. Usually when we’re looking at the liver, we’re looking more at the area, the frown lines (between the eyes). A large one is said to be a liver disharmony, especially if it’s red in excess. And two smaller ones, that could be called more Gallbladder. Right above the nose, like where the glasses fit, that’s more spleen. If that’s more white, that could be the digestive system getting cold. Liver is really right between the eyes. Also, the eyebrows are said to be the liver also. And the shape of them… one big solid one is said to be very angry…nice shaped ones have a nice disposition. The other place to look for liver and gallbladder is usually in the temples, where the gallbladder channel passes through. But we do look at the heart up here (forehead), too.

Ears. The ears are the opening to. Good big earlobes mean a really good, strong constitution, long life. Shouldn’t be attached. If they’re dry and withered, it’s often a sign that the Kidney Jing is very weak. If they’re red, it’s heat; if they’re blue, it’s cold. If they’re black it’s exhausted. All the meridians connect at the ear at some point.

We see the kidney underneath the eyes – so puffy eyes, swollen eyes are usually kidney disharmony. Puffy is usually the Qi insufficiency. By the time it gets black we’re usually looking at Blood Stasis. The other place to see the Kidneys is in the chin. A good, strong chin is supposed to be a solid foundation. This is supposed to be the reproductive area, too, like the pelvis, and they kidney’s associated with reproductive capacity by storing the Jing. Outbreaks here are also very common for women premenstrually; urinary tract infection, you’ll find that over here, prostatitis in men. Cleft chins – thought to be associated with sexual virility. So a cleft chin, also associated with good strong reproductive capacity.

Filtrum (between the nose and mouth), especially in women, becomes very important. It’s associated with the reproductive system. Usually a crease here (horizontally, between nose and mouth), you’ll see that problem with women who have hysterectomies. In older people you’ll see a vertical line.. as people age, that’s more Yin insufficiency – the little tiny ones. With hysterectomy it’s a sudden onset and that’s more like a big crease. As you get older, it’s more like a puckering.

Lips and mouth are the opening of the Spleen, usually associated with Stomach, Spleen. If they’re pale, usually you’re looking at cold, insufficiency. If they’re redder than normal, you’re looking at heat. If they’re dry and scorched you’re looking at drying of fluid. If they are Qing colored, that blue/green, you’re usually looking at pain, cold or stagnation of blood. If they’re chapped, you’re looking at either Stomach or Spleen heat. The corners of the mouth.. Upper lip being more associated with the stomach, and large intestine being the lower lip. Sometimes can be thought of as the whole thing being the Spleen. The corners of the mouth I’ve been taught at different times as being the small intestine… I’ve also read where the corners were associated with the Kidney.

Excessive salivation means the Spleen is weak or there’s Stomach Heat.
Mouth Askew or open, that’s usually thought to be Spleen weakness.
Can’t close your mouth, that’s great weakness.
Paralysis, when you’re pulling off to one side, that’s Wind. So when you have one side of the mouth, one side of the face drooping, that’s Internal Wind.

Jowls. Weakness in the legs. If this is the urinary tract (chin), then these are the legs (jowls). So if you have jowls, it’s weakness in the legs.

Teeth – ends of the bones – usually associated with Kidney, excess of bone. Usually weak teeth, gums that are swollen, red; usually Stomach Fire. It could be Yin deficiency from the Kidney. Loose teeth….

Hair is the magnificence or the opening, or shows the state of the Kidneys. But it’s also associated with the Glory of the Blood. It means, it tells you about the Kidney Qi and tells you about the state of the Blood. Usually if it falls out easily, you’re dealing with Jing Insufficiency or you’re dealing with dry Blood. You see this a lot with women who have been dieting. When it comes out in patches, usually the blood is being affected by Wind. Then you also have jing insufficiency as congenital baldness. Post-chemotherapy, you’re seeing heat that’s dried up the blood and also impacts the Jing.

Now the other thing you need to know is the Ling Shu. And it’s very different, it takes the whole body… and all the Yin and Yang organs are right here (nose). And I will not ask you to be able to draw it out. I would just like you to know where they are generally. Just be able to recognize on a picture….



FIVE WHEELS
The pupils should be normal, they should have some luster; should show some interest in the world. Five wheels shows the state of the different organs. The upper lid is thought to be associated with the Spleen. The lower lid is thought to be associated with the Stomach. The canthii, inner and outer canthus (corners), they’re going to be associated with the heart. The sclera, the white of the eye, that’s associated with the Lung. The coloring of the eye, the iris, is associated with the Liver. In iridology this (iris) is what they look at to diagnose the whole body. The very center of the eye, the black area (pupil), that’s associated with the Kidneys. This is called the Five Wheel Cycle.



So if you have red sclera, you might have Lung Heat. But you also might have Liver Fire or Heart Fire… Dark rings around the eyes, we talked about Kidney vacuity. Swelling under the eyes, slight puffiness, we have edemas due to Kidney insufficiency. Now in old age kidneys deplete – that’s normal – and what happens to the eyes? Most of the time you’ll see puffiness and that’s fairly normal. Bulging of the eyes – that’s phlegm; Phlegm Fire.

FORM AND BEARING
So Form and Bearing refers to how you’re built and how you carry yourself. Form means your physical aspects. Bearing is how one moves through the world. Now, when dealing with form, we’re dealing with the 3 constitutional things we talked about before. Constitutional ties with Jing being associated with the bone and long term changes. We talked about the Shen… Again, just like there’s many different constitutional types and there’s many different ways of reading the face, there’s very different form, like how your hands shake, how your ear’s shaped, you know, diagnosing through all these things. And then we talked about long term changes being the Qi and Flesh. And we talked about short term changes being the Complexion and Shen.

FORM
We’re going to look at these constitutional types, Forms. This is what you inherit. You have the earth character, Earth type, who has a large head with a fleshy, wide jaw. Usually they’re going to be tending toward a sallow complexion, tending towards overlarge bodies, but not always. Usually Earth types are either Damp or Deficient if they’re going to be out of balance. With Damp, you usually see fleshiness without support underneath: they say large physique with vacuous Qi. It’s not just size though. But we have the idea of fleshiness, flesh being associated with Spleen and Stomach. So you have this idea of large physique with vacuous Qi being Earth type, but also Stomach/Spleen Deficiency, where you can’t put on weight.

Now very few people will have just one of these. You have mixtures…

Metal – Metal types have broad shoulders usually, strong build, triangular face. Metal people have “hands like piano players”, long delicate fingers. And metal types are also very impeccably dressed, very sleek, put together, discriminating. Remember we talked about metal cutting through things. Harsh critics.

Water types have round faces and round bodies and really long spines. Usually more a tendency toward being “intense”.

Fire type has a small face, pointy head, balding usually. They usually have small hands. These people are said to have good lives, but short ones. Very fast, fun-loving individuals; know how to throw a good party.

And the last is Wood, which has a tall, slender, wiry body; very muscular. Very lithe and muscular. A tendency toward a kind of squarer head and a tall, slender, very wiry body.

But overall, you want…somebody who has a good, well-developed, strong body means a strong constitution. A poorly developed, emaciated body means a weak constitution.

BEARING
How to carry yourself. All the movement; of the whole and all the body parts.

Agitated movements, rapid movements, jerky movements all indicate conditions that are more Replete, more Yang and more Hot. Slow movement, dislike of movement, sleeping curled up – this indicates more Cold, Vacuity and Yin condition.

Twitching, convulsions, deviation(deviation of the mouth, deviation of the eyes), shaking – they actually all indicate Yang excess conditions, but they also indicate Liver Wind. Dizziness can also be Liver Wind. A lot of times migraines are associated with Liver Wind. If we’re blood deficient, wind can take the space of Blood. They say nature abhors a vacuum, so if there’s not enough blood, wind comes in. Pronounced forceful contractions, that’s really a Repletion of Heat. Milder contractions, you’ll see more Vacuity and Wind. Contractions are all Wind.

Shaking can be, you either have wind or you have Qi deficiency. You see it with the tongue. You see it with a muscle. If I tell you to hold your hand up – after a while your hand’s going to start shaking… your Qi is deficient and you can’t hold it up anymore.