TCM Diagnosis Study Guide PDF

Traditional Chinese Medicine Diagnosis Study Guide TRADITIONAL CHINESE MEDICINE Diagnosis Study Guide Qiao Yi, M.D. (China), M.P.H., L.Ac. Al Stone, L.Ac., D.A.O.M. EASTLAND PRESS ------- - ------ -- --., SEATTLE Copyright 2008 by Qiao Yi and Al Stone Published by Eastland Press, Inc. P.O. Box 99749 Seattle, WA 98139, USA www.eastlandpress.com All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without the prior written permission of the publisher, except where permitted by law. Library of Congress Control Number: 2008934266 ISBN: 978-0-939616-64-0 Printed in the United States of America 2 4 6 8 10 9 7 5 3 1 Book design by Gary Niemeier TABLE OF CONTENTS Introduction _Mit...... 1 The Main Studies in TCM Diagnosis, 2 The Principles of TCM Diagnosis, 6 Chapter One: Inspection ~"tt...... 9 Inspection of the Whole Body, 11 Inspection of Spirit (~+ Shen), 11 TWO: Inspection of Facial Complexion, 17 T H R E E: Inspection of Body Appearance, 24 ONE: Inspection of Local Areas, 32 Inspection of Eyes, 32 TWO: Inspection of Ears and Nose, 46 THREE: Inspection of Teeth, Gums, and Throat, 49 FOUR: Inspection of Lips and Mouth, 51 FIVE: Inspection of Skin, Hair, and Nails, 59 ONE: Infant Finger Examination, 66 Inspection of Excreta and Secretions, 70 Tongue Inspection, 83 Questions and Answers for Deeper Insight into Inspection, 123 vi Chapter Two: Listening (Auscultation) and Smelling (Olfaction) ~ ~t...... 135 Listening (Auscultation), 136 Smelling (Olfaction), 159 Questions and Answers for Deeper Insight into Smelling and Listening, 163 Chapter Three: Inquiry It, ~ 167 Introduction, 168 Scope of Inquiry, 169 Present Symptoms and the Ten Questions, 172 Chills and Fever, 173 TWO: Sweating, 180 THREE: Pain, 188 F 0 U R: Symptoms of the Head and Body, 196 FIVE: Symptoms of Ears and Eyes, 204 SIX: Inquiring about Dietary Information, 208 SEVEN: Inquiry into Defecation and Urination, 216 E I G H T: Inquiry into Sleep, 226 NINE: Inquiry into Women's Conditions, 233 TEN: Inquiry for Children, 250 ONE: Questions and Answers for Deeper Insight into Inquiry, 251 Chapter Four: Palpation tJJ~t...... 271 Pulse Examination, 272 Introduction, 272 TWO: Normal Pulse (Physiological Pulse), 277 THREE: Abnormal Pulse (Pathological Pulse), 283 FOUR: Twenty-Nine Common Pathological Pulses, 291 FIVE: Distinguishing Among Pathological Pulses, 320 SIX: Female Pulses, 325 ONE: Palpation, 327 Methods of Body Palpation, 327 TWO: The Scope of Palpation, 328 ONE: Questions and Answers for Deeper Insight into Palpation, 338 vii III TCM Diagnosis Comprehensive Examination...... 359 III Answer Key: TCM Diagnosis Comprehensive Examination...... 397 Bibliography, 405 PREMODERN TEXTS, 406 CONTEMPORARY TEXTS, 407 Authors, 409 Peer-Review Committee, 410 INTRODUC,TION II CONTENTS The Main Studies in TCM Diagnosis, 2 The Principles of TCM Diagnosis, 6 tJt"Ma 2 Introduction INTRODUCTION #t~ Diagnosis in traditional Chinese medicine (TCM) involves the examination of the body for the purpose of diagnosing disease and differentiating patterns under the guidance of the basic theories of TCM. It is a bridge that connects the fundamental studies of TCM with all branches of clinical medicine and includes inspecting the manifestations, analyzing the changes, understanding the pathomechanisms, and predicting the transformation of diseases. The Main Studies in TCM Diagnosis TCM diagnosis consists of two major areas of study, "examination and testing" (~:t zhen) and "decision and judgment" (I¥JT ducm). Examination and testing techniques are used to collect information from the patient. Decision and judgment uses this information, which is sorted, analyzed, synthesized, and reasoned on the basis of TCM theory. inspection smelling & listening Zhen: examination and testing. Uses four different examination techniques to collect data inquiry palpation TCM Diagnosis (Zhen Duan) disease identification Dulin: decision and judgment pattern differentiation Chart 1 Scope of TCM diagnosis The processes in TCM diagnosis include: examination and testing, disease identification, and pattern differentiation. I examination r-- collects - -. - symptoms (data) decision and judgment I disease identification pattern differentiation Chart 2 Diagnosis process Introduction I. 3 EXAMINATION AND TESTING The process of examination uses various methods to inspect the patient in order to collect information relating to changes in health. These methods include inspection, inquiry, listening and smelling, and palpation, which are generally known as the "four pillars': (1) Inspection utilizes the practitioner's visual sense to observe abnormal changes in the patient's spirit, complexion, appearance of the tongue, and secretions and excreta in order to understand and predict pathological changes in the internal organs. (2) Listening and smelling (auscultation and olfaction) utilizes the practitioner's sense of hearing to assess the patient's physiological and pathological sounds. Smelling odors arising from the patient also informs the diagnostic process. (3) Inquiry utilizes conversation to gain insight into the patient's condition through the responses of the patient or their representative. The patient's symptoms, the cause or predisposing factors of disease, the history (onset, development, and treatment) of the disease, the patient's living environment (social and geographic), and personal relationships are all collected to assist in the naming of the disease or differentiation of the pattern. (4) Palpation utilizes the sense of touch to feel, press, or palpate areas of the patient's body, includ- ing the pulse, in order to obtain information regarding the patient's physiological and pathological condition. II. DISEASE IDENTIFICATION Disease identification is the process by which a more exacting assessment of a patient's condition can be made based on the patient's signs and symptoms. After further analysis and judgment, disease identification can be made. (1) Disease (1% bing) is a deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of signs and symptoms whose etiology, pathology, anatomical location, and prognosis may be known. A disease is a summary of the distinct features of a disorder including the process and life cycle of pathologic development. When a pathogenic factor ($ ~ xii qi) attacks the body, the anti pathogenic qi (..iE ~ zheng qi) will struggle against it. At this point, the normal physiology and relative equilibrium of the body's qi, blood, zlmg fu organs, channels and collaterals are disrupted. Manifestations of reduced vitality, limited or total loss of activity, and a series of signs and symptoms may appear. During this process, the antipathogenic qi will always give rise to a struggle between impair and repair, dysfunction and accommodation, in a dynamic manner that reflects the relative strength of the pathogenic factor and the anti pathogenic qi. (2) Disease name. The name of the disease itself represents an additional specificity. It is a summary of the pathology and an abstract of the disease process that may include its etiology, pathomecha- 4 Introduction nism, and signs and symptoms. The name of the disease may also provide insight into the nature of the disease, such that its incidence, evolution, outcome, and prognosis may be further inferred. 1';9 n5 and.Ym~~lN~)--------"".~llaw or trend I attack zang fiJ organ or channel Pathogens r---- and ~ (etiology) enter (location) r-- causes - -. antipathogenic qi struggles against pathogenic factors (pathology) Chart 3 Disease definition In the history of traditional Chinese medicine, more than 4,000 disease names have been documented. Naming a disease is valuable not only for the purpose of diagnosis, but also for classification. Some diseases are named on the basis of their pathological shape or symptoms, such as edema, jaundice, cough, or asthma. Others are named for the pathology, such as restless organ disorder (zemg zew). Some diseases are named for the zemgJU organ or structure that is involved, such as Lung abscess, or chest painful obstruction (bi); and some are named for their etiology, such as sunstroke or "fright wind" (jingjeng). Disease named by pathological shape or symptoms: edema, jaundice, vomiting, diarrhea named by pathology: restless organ disorder (zang zao) named by zang fiJ organ: Lung abscess, chest painful obstruction (bi) named by etiology sunstroke, "fright wind" or infantile convulsions Uing (eng) Chart 4 Disease name etymology III. PATTERN DIFFERENTIATION Pattern differentiation is the process by which clinical information (obtained from the examination) is analyzed, synthesized, and inferred, leading to a clear representation of a particular phase of a disease in a TCM pattern. (1) Pattern (~ zheng) is a combination of signs and/or symptoms that forms a distinct clinical pic- ture indicative of a particular disorder. It is the summary of environment, pathogens, pathological location, pathogenesis, condition of the antipathogenic qi, signs and symptoms, and the constitution of a patient. It is based on the information obtained by the four examination methods. The pattern comprehensively and concretely reflects the nature and features of a disease at a given stage. Thus, the pattern reflects the essence of a disease at the moment of the assessment. Introduction 5.-p definition A T T E R N example: - made up of a group of related signs and symptoms, reflects the pathogen, pathogenesis, location, nature, and severity of the disease reflects the development of a disease and pathological changes during a given stage exterior wind cold excess pattern Pathogen: wind cold Location: exterior Nature: cold r- Pathogenesis: wind cold attacks the exterior Antipathog enic q i state: excess Chart 5 Pattern definition (2) Signs and symptoms (:biAA. zheng zhuimg) are the abnormal phenomena which deviate from the normal physiological range that are associated with a disorder, such as fever, cough, or headache. Signs and symptoms reflect the body's pathological changes. They include 1) symptoms, which are defined as subjective feelings of discomfort; and 2) signs, which are objective data obtained by the practitioner through examination. The signs and symptoms reflect the presence and stage of pathological change and are important indicators for the identification of disease and the differentiation of patterns. signs and ~ symptoms abnormal feelings or serve as basis discomfort, and/or to identify the data obtained by ~ disease and practitioner through differentiate examination the pattern - signs: pale face, red tongue, slippery pulse symptoms: headache, pain, nausea Chart 6 Signs and symptoms (3) Pattern differentiation. Over the course of thousands of years of clinical practice, practitioners developed many methods of differentiation, such as eight-principle differentiation, six-stage differentiation, four-level differentiation, and etiology differentiation. These methods are a summary of the pathological tendencies and the understanding of patterns from different perspectives. Each method has its special emphasis, and they are related to and supplemented by each other. The following chart summarizes the most commonly used methods of differentiation and their relationships. 6 Introduction ~ ~.Q iI six stages exterior.. four levels time I levels Triple Burner zang fO (1) structures cO' =r CD - ~ channels "'C ::::!. ::J o "6' 0.0. _.0 !!l -g a:;: CD 0 hot iii ar cg ~ C/I qi, blood, body fluids etiology anti pathogenic qi disorder c'i" exopathogenic _ _..... attack Chart 7 Different methods of pattern differentiation and their relationships The Principles of TCM Diagnosis Diseases are very complex processes. Clinical manifestations can be true or false, mild or severe, or latent or active. Disease symptoms can be primary or secondary. Sometimes there may be two disease processes unrelated to each other. Some symptoms may appear early while others only appear later in the disease process. Given all of these variables, the practitioner must be very vigilant to discover the root or essence of the disease. Application of the following three principles is necessary to make an accurate diagnosis for an effective treatment strategy. 1. HOLISTIC ApPROACH Holism is a fundamental concept of TCM. The holistic approach in diagnosis refers to the comprehensive consideration of the human body and its natural surroundings. This has two aspects: The human body as a whole. The human body is an organic whole. The internal zcmg fo organs are the center of the body. The outer parts such as the limbs, five sensory organs, nine orifices, skin, muscles, vessels, and tendons and bones are all linked to the zimg fo organs through channels and collaterals. During the· diagnostic process, special attention is paid to the interrelation and interaction between local pathological changes and the maladjustment of the whole body; Local pathological changes may affect the whole body and pathological changes of the whole body may, in turn, be reflected locally. External disorders may penetrate into the interior or pathological changes of the internal organs may manifest externally. The unification of the human body and its surroundings. Human beings are affected by such natural conditions as weather and other environmental influences. When there are abnormal changes in the natural environment, or when the human body fails to adapt itself to such changes, pathological change will certainly occur in the body. Introduction 7 II. ApPLICATION OF THE FOUR EXAMINATION METHODS IN COMBINATION During the clinical examination, the four diagnostic methods should be used together in order to arrive at a reliable diagnosis, since each of these methods plays its special part in assessing health and gathering clinical information. Each of the sensory organs has a unique function in the diagnostic process. Inspection (observation), listening and smelling, and palpation are applied to the examination of the patient by means of the practitioner's visual sense, hearing, smelling, and tactile sensation. Additionally, inquiring summarizes the patient's feelings and allows them to describe the onset and development of a disease. In other words, each of the four examination methods supplements the others. III. COMBINING DISEASE IDENTIFICATION WITH PATTERN DIFFERENTIATION Differentiating the pattern after a disease has been identified is an intrinsic part of the practice of TCM. In order to make an accurate diagnosis, one should first determine the disease and then differentiate the pattern on the basis of the patient's signs and symptoms. Both the disease and the pattern represent a summary of the environment, pathogens, pathological location, pathogenesis, the strength of the antipathogenic qi, signs and symptoms, and constitution of the patient based on the information gathered during the four examinations. However, disease and pattern are two different diagnostic concepts. The disease represents the entire course of pathological changes associated with an illness. Over the course of a disease, the pathogenic qi battles with the antipathogenic qi, however this process is dynamic and the presentation will therefore undergo continuing changes in accordance with certain rules. By contrast, the pattern describes the pathology at a particular stage of the disease, where there is a certain configuration in the battle between the pathogenic factor and anti pathogenic qi that can be treated. A single disease can evolve through multiple patterns, and the same pattern can be found in multiple diseases. For this reason, the full course of pathological and predictable changes of a disease cannot be grasped through pattern identification alone. On the other hand, if one identifies only the disease, but not the pattern, treatment cannot be undertaken since the treatment principle is based on the differentiation of the particular pattern, and not the overall disease. Identification of the disease combined with pattern differentiation enables one to grasp the essentials of the disease more comprehensively in order to make an accurate diagnosis and thereby establish an effective treatment principle and make an accurate prognosis. 8 Introduction Pattern at stage A Pattern at stage B Pattern at stage C t t t Disease through time Treatment A Treatment B Treatment C Chart 8 Relationship of disease to pattern through time Chapter One INSPECTION "M ~:t CONTENTS 1: Inspection ofthe Whole Body, 11 SECTION ONE: Inspection of Spirit (# Shen) , 11 Inspection of Facial Complexion, 17 TWO: THREE: 2: Inspection of Local Areas, 32 SECTION ONE: Inspection of Eyes, 32 Inspection of Ears and Nose, 46 TWO: THREE: FOUR: FIVE: Inspection of Body Appearance, 24 Inspection of Teeth, Gums, and Throat, 49 Inspection of Lips and Mouth, 51 Inspection of Skin, Hair, and Nails, 59 SECTION 3: Infant Finger Examination, 66 SECTION 4: Inspection of Excreta and Secretions, 70 SECTION 5: Tongue Inspection, 83 SECTION 6: Questions and Answers for Deeper Insight into Inspection, 123 10 Chapter One: Inspection INSPECTION fl ~~ Inspection is the very first assessment used when the initial patient/practitioner contact occurs. This process continues through the diagnostic process: the way in which a patient answers questions or responds is an important aspect of her spirit, as are the actual answers that diagnostic interactions may provide. 1. DEFINITION Inspection is an examination method which employs the practitioner's visual sense to observe abnormal changes in the patient's spirit, complexion, body, tongue, secretions and excreta in order to understand and predict pathological changes of internal organs. II. FUNDAMENTAL THEORY OF INSPECTION In the human body, internal organs and the exterior of the body are closely connected and related through the channels and collaterals, and through the qi and blood. The face and tongue have an especially close relationship with the ztmg fo organs, because all channels and collaterals pass through or connect in the tongue and face. In addition, all five zeing organs open to an orifice in the head. Excreta and secreted substances are produced by activities of the internal organs. As such, they can manifest pathological changes of the internal organs. Therefore, through inspection of the external changes of the body, one can know the condition of the internal organs and understand their pathowhich states logical changes. This process is described in The Divine Pivot, Chapter 47 (~:fI& that "Observing the outside manifestations in order to understand the organs inside, so as to identify the diseases:' 0 *a) III. CLINICAL SIGNIFICANCE Inspection allows one to assess the essence and qi, the state of pathological change, transformation of the illness, prognosis, thermal nature of the pathogenic factor, state of antipathogenic qi, and the zeingfo organs involved. IV. THE SCOPE OF INSPECTION Inspection includes five major areas: 1) inspection of the whole body, which includes inspection of spirit, facial complexion, and body appearance 2) inspection of local areas, which include the head, face, five sense organs, body, skin, and extremities 3) inspection of the infant's index finger 4) inspection of excreta and secretions 5) inspection of the tongue, which includes inspection of the tongue body and its coating. Inspection ofthe Whole Body 11 Section 1 Inspection of the Whole Body One: Inspection of Spirit (;fO/ Shen) Inspection of spirit means to observe whether the patient's mental state is normal, whether the consciousness is clear, the movements harmonious, and whether reactions are timid in order to determine whether there is a state of excess or deficiency in the dmg ju organs, yin, yang, qi and blood; and the progno'sis of disease. I. DEFINITION Spirit: spirit is the general manifestation of the vital activities of the human body, and the outward sign of the relative strength of qi and blood of the zCmgju organs. The vital activities are divided into two meanings: broad sense: describes the total external manifestations of the life activities of the human body which are the reflections of zCmgju organ functions. This may be thought of as general vitality and can be seen in the pulse, tongue, complexion, etc. narrow sense: describes mental activities, including consciousness and cognition. II. THEORY OF INSPECTION OF SPIRIT (1) The Origin of Spirit The Divine Pivot states: "The combination of two kinds of essences (essence [~ jlng] of the father and mother) forms the spirit:' "Spirit is the essence of qi and fluids:' This means that spirit is formed from a combination of two kinds of congenital essences. Afterwards, spirit is supported and enriched by acquired essence. Mother's Essence r combine - \ Father's Essence , forms Spirit + nourishes and enriches Chart 1.1.1 Origin of Spirit 12 Chapter One: Inspection (2) The Manifestation of Spirit Spirit dominates the entire body's activity. It can be seen in various manifestations such as facial expression, eye movement, mental state, physical activity and reactivity, voice, tongue, and pulse. (3) The relationship between essence, qi, and spirit Essence is the original substance (source) of human life. It makes up the human body. Essence is composed of congenital essence, which is inherited from the parents, and acquired essence, which is produced from food by the Stomach and Spleen. Qi denotes the essential substances of the human body which maintain its vital activities the functional activities of the zcmgju organs and other tissues. Spirit is the manifestation of all life activities. broad sense: describes the total external manifestation of vital activities which reflect the functions of the viscera narrow sense: describes mental activities including consciousness and cognitive activities. Essence, qi, and spirit are called the "three treasures:' Essence is the source of life, qi is the force of life, and spirit is the controller and manifestation of life. They work as a single whole, physically and functionally, and are inseparable. The coitus of parental essences produces life. Then the mental and physical activities (spirit) manifest. After spirit is formed, it is enriched and nourished by qi and blood, and in turn generates and supplies acquired essence. Chart 1.1.2 Relationships between Spirit and Essential Substances In general, essence is the source of life, one has the essence first and then spirit. Qi and blood maintain life, and spirit is the manifestation of life. Qi, blood, and essence are the material basis of spirit. When there is sufficient qi, blood, or essence, the person will have spirit; if there is insufficient qi, blood, or essence, the person will lack or lose spirit. Inspection of the Whole Body 1--_.... 1 congenitalt--=-=..:.:.:.:.:._ "':':':::==:::.....j essence acquired essence 13 "---l Chart 1.1.3 Relationships between Essence, Qi, and Spirit III. NORMAL SPIRIT Normal spirit refers to being full of vigor, which is reflected in sufficiency of both essence and qi. Normal spirit gives one bright and vivid eyes, clear consciousness and speech, quick responses, resonant voice, radiant complexion with natural expressions, and a freely movable and flexible body. IV. CLINICAL SIGNIFICANCE OF INSPECTION OF SPIRIT Observation of spirit plays an important role in TCM diagnosis. It can help the practitioner understand: the condition of the essence and qi the state of the pathological changes the transformation of the illness the prognosis. II Having Spirit Lack of Spirit Essence and Qi sufficient insufficient or failure State of Disease mild severe Transformation from having to lacking: worse from lacking to having: better Prognosis good poor Clinical Significance I Table 1.1.1 Clinical Significance of Inspection of Spirit V. METHOD OF INSPECTION OF SPIRIT In order to observe spirit, attention should be placed on the patient's facial expression, mental state, physical activity, language, breathing, reactivity, etc. Special emphasis should be put on eye movement because of the following: 14 Chapter One: Inspection the eye is regarded as the window of the Liver the eye is the messenger of the Heart all the essence and qi of the five zrmg and six fu organs rise and pour into the eyes. VI. CLINICAL MANIFESTATION OF SPIRIT Clinically, spirit can be manifested as having spirit, fatigued spirit, and lack of spirit, which can be further divided into subcategories based on the severity of the lack of spirit. These categories include loss of spirit, false spirit, and spirit disturbance. (1) Having spirit (:fr# you shen) the normal physiological state when the patient is full of vigor, reflected in a sufficiency of both essence and qi. DEFINITION: patient is alert with bright and vivid eyes, clear consciousness and speech, quick responses, resonant voice, radiant complexion with natural expressions, and a freely movable and flexible body. MANIFESTATION: patient's essence has not been exhausted and the condition of the zrmg fu organs has not fallen into severe disorder, even though there may be illness. INDICATION: CLINICAL SIGNIFICANCE: the illness is not serious and the prognosis is favorable. (2) Fatigued spirit (#~ shen pI) a mild manifestation of lacking spirit. Fatigued spirit and lacking spirit differ only in degree of severity. Fatigued spirit is between having spirit and lacking spirit. DEFINITION: listlessness, lassitude, poor memory, weak and low voice, aversion to speaking, fatigue, slow and awkward actions. The main symptom of fatigued spirit is poor memory. MANIFESTATION: INDICATION: deficiency pattern, usually caused by Heart and Spleen deficiency or Kidney yang defi- ciency. CLINICAL SIGNIFICANCE: allows one to judge whether the state of qi is in a state of excess or deficiency. (3) Lack of spirit (Y # shao shen) A pathological state wherein deficiencies or disturbances undermine the calm or fullness of the spirit, which manifests in any of the following three presentations: - A. Loss of Spirit (* ~f shz shen) the patient's loss of spirit, which reflects an exhaustion of the essence, deficiency of qi, and weakness of vitality. DEFINITION: MANIFESTATION: patient has dull eyes, slow and awkward action, blurred vision, dull complexion and Inspection of the Whole Body 15 facial expression, heaviness of the body, obtuse actions and responses, mental confusion or even unconsciousness, delirium and hallucinations. patient's qi has been exhausted, essence has declined, functional activities are insufficient, and the disease is severe. INDICATION: CLINICAL SIGNIFICANCE: the disease is severe and the prognosis is unfavorable. - B. False Spirit (1R# jia shen). an apparent indication of improvement in which the patient suddenly improves during the terminal stage when the patient's essence and qi are extremely debilitated because of chronic disease or serious illness. The sudden appearance of apparent health is a transitory state that precedes death of the patient. DEFINITION: the extremely weak patient in a critical condition is listless, unconscious, with dull eyes; has a dislike of speaking, low and feeble voice, dull complexion, and anorexia. Yet the patient suddenly feels better, has clear consciousness, bright eyes, louder voice, flushed cheeks, and improved appetite. MANIFESTATION: exhaustion of antipathogenic qi and impending failure of yin and yang, in which yin fails to restrain yang, and the yang is separating from the yin. INDICATION: CLINICAL SIGNIFICANCE: imminent death. - C. Spirit Disturbance (#aL shen lucm) The spirit disturbance is also a manifestation of lack of spirit but the pathogenesis is totally different from the type caused by essence, blood, or antipathogenic qi exhaustion. Spirit disturbance means that consciousness is obscured or lost. This condition is usually found in one of the following patterns. These patterns are caused by unique etiologies and pathogenesis. Although these patterns are manifestations of 'lack of spirit: they are not necessarily critical conditions.... a) Irritability and restlessness (iii 8l jan ZtlO) SYMPTOMS: (fan) irritability, restlessness, hot and heavy sensations in the chest; (zao) feverish sensa- tion and irritability causes the patient to prefer nudity and even drives the patient to jump into water PATHOGENESIS: pathogenic heat in the Heart, Lung, or Kidney... b) Restless organ disorder (ali zcmg zao) mental depression, possible hallucinations, disorientation, frequent attacks of melancholy and crying spells, frequent bouts of yawning, no loss of consciousness SYMPTOMS: PATHOGENESIS: Heart and Liver blood deficiency 16 Chapter One: Inspection... c) Hysteria (a f;--~ bCii he bing) chronic depression, apathy with aversion to speaking, mumbling to one's self, insomnia, anorexia, sleepwalking SYMPTOMS: PATHOGENESIS: Heart and Lung yin deficiency... d) Yin madness Ui dian) chronic depression, aversion to speaking or mumbling to one's self, laughing, or crying inappropriately SYMPTOMS: PATHOGENESIS: stagnant phlegm misting the Heart orifices, or Spleen and Heart deficiency... e) Yang madness (~kudng) raving with obscenities, madness and restlessness, singing loudly and favoring high places, wandering naked, hitting people or destroying things SYMPTOMS: PATHOGENESIS: phlegm fire disturbs the mind... f) Epilepsy (1'i!il xidn) sudden syncope with drooling saliva and spasms of the limbs. There is a short blackout or period of confused memory, odd changes in the way things look, sound, smell or feel. After the symptoms pass, the patient manifests no abnormality. SYMPTOMS: PATHOGENESIS: Liver wind with phlegm or phlegm fire disturbing the Heart II Having Spirit Loss of Spirit False Spirit Complexion bright hues and moist sheen dim hues and dull sheen dull sheen with sudden fluShed cheeks Eyes alertness, vivid colors, twinkling eyes dull colors with blurred vision dull colors but suddenly lustrous clear speech and consciousness, agile responses unconsciousness or delirium unclear consciousness with a sudden change for the better Motion and Response freely movable, quick responses slow movements and responses suddenly responsive Respiration even rapid, feeble, or with difficulty feeble, but suddenly strengthening Diet good poor poor, but suddenly improving Signs Mental Status Table 1.1.2 Comparison of Having Spirit, Loss of Spirit and False Spirit I Inspection ofthe Whole Body VII. 17 SUMMARY OF INSPECTION OF SPIRIT Indicates sufficient essence, mild illness, and good prognosis. Indicates a deficiency syndrome, usually caused by Heart and Spleen, or Kidney yang deficiency. fatigued spirit Spirit loss of spirit false spirit spirit disturbance Indicates exhausted essence, severe illness, and poor prognosis. A pseudo phenomenon, indicates crisis stage. Psychological and emotional disorders due to various etiologies and pathologies. Chart 1.1.4 Summary of Clinical Manifestation of Spirit Two: Inspection of Facial Complexion Inspection of the facial complexion means to inspect and examine the color and sheen of the facial skin in order to understand the condition of the qi, blood, and zimgfo organs. I. INTRODUCTION (1) Definition: Facial color: the color of the skin. Skin color is associated with blood and yin. Color on the face can directly reflect the ebb and flow of the blood and the condition of the blood circulation. Under pathological circumstances, it can reflect the different characteristics of the zimgju organs and their pathological changes. Facial sheen: the luster of the skin. Skin luster is associated with qi and yang. Luster is the exterior manifestation of the essence qi of the zimgju organs. (2) Theories of Facial Complexion Diagnosis The Heart dominates the blood vessels; its luster is reflected on the face. The Divine Pivot states that "the qi and blood of the twelve primary channels and the three-hundred-sixty-five connections ascend to the face:' All six yang channels rise up to the face, especially the foot yang ming Stomach channel. Therefore, there are abundant channels and blood vessels on the face. Thus facial colors not only manifest the Heart's condition but also the functions of all other organs. Facial color is derived from yin blood and facial luster from the spirit. Complexion is the outward manifestation of the condition of the five zimg organs. 18 Chapter One: Inspection yin, blood I~---- generate - - - - - I.. ~ facial color Normal Facial Complexion essence, yin, qi 1--'-:7----i spirit luster Chart 1.1.5 Physiology of Normal Facial Complexion (3) The Correspondence of Portions of the Face with the Zimg Fit Organs Each of the zimgju organs has a corresponding location on the face. Observation of the facial complexion should be integrated with inspection of localized facial regions. There are two different arrangements, one according to Basic Questions (-t f,,') and the other according to The Divine Pivot ( :I :fJ&). Liver (wood) Small Intestine Kidney (water) Chart 1.1.6 Portions of the Face Corresponding to the Zang FiJ Organs According to Basic Questions (left) and the Divine Pivot (right) (4) Normal Facial Complexion normal facial complexion refers to the facial color and luster of a person in a healthy physical condition. Because of different genetic pools, facial color and skin color have many variations. DEFINITION: CHARACTERISTICS: bright, moist, and lustrous. qi and blood are sufficient and the functional activities of the zimgju organs are in good condition. INDICATION: the color and texture of the complexion can vary in accordance with different constitutions, geographic environments, seasons, weather, and profession. Normal facial skin color can be classified as follows: CLINICAL MANIFESTATION AND PHYSIOLOGICAL VARIATION: host or governing (zhu) color: the normal facial skin color of one's race, it remains unchanged during life. guest or visitor (ke) color: the slight change of facial skin color, which follows seasonal changes. Inspection of the Whole Body Seasons Spring Summer Late Summer Autumn Winter Origin channels collaterals muscles skin marrow Complexion blue-green red yellow white (pale) black (dark) 19 Table 1.1.3 Guest Complexions transient normal complexion: changes in the complexion due to different working conditions, climates, living environments, diet, sexual activity, and emotions. Normal Complexion Common features include brightness and luster. host complexion the color from time of birth guest complexion seasonal changes in color transient normal complexion temporary changes in color and sheen due to environmental, physical, or emotional activities Chart 1.1.7 Normal Complexion and its Manifestations (5) Clinical Significance of Inspection of Complexion Observation of the complexion will help the practitioner: recognize the location of pathological change and judge the condition of the pathogenic and anti pathogenic qi differentiate the thermal nature of the pathological change identify the organs and channels involved make a prognosis (6).Method of Facial Complexion Diagnosis In order for the practitioner to obtain the most accurate data from the patient, one must pay attention to the following variables: time: early morning is the best, or at a time after the patient has calmed down environment: quiet and without stimulation light: natural light II. CLINICAL MANIFESTATIONS OF PATHOLOGICAL FACIAL COMPLEXIONS (1) Definition: the facial complexion of a sick person. It may be said to include all the abnormal col- ors, as well as a pathological brightness and sheen. 20 Chapter One: Inspection (2) Scope of Abnormal Facial Complexion Abnormal facial complexion includes abnormal facial color and sheen. - A. Abnormal facial color in different races, facial' color and skin color have many variations, although in general, the normal facial color should be a harmonized mixture of the five different colors. When a single color dominates, it indicates a pathological change.... A) SINGLE COLOR DOMINATES: normal facial color should be subtle and gentle. A sharply contrasting color on the skin indicates a disorder of the qi, blood, or zcmgfo organs.... B) OBVIOUS EXPOSURE OF COLOR: facial colors should change slightly following the changes of the seasons. Color changes inconsistent with the seasons indicate pathology.... C) COLOR CHANGES ARE INCONSISTENT WITH CHANGES IN THE SEASONS: - B. Abnormal facial sheen Withered and dim is a pathological change of the facial sheen. This indicates a deficiency or failure of the essence qi. Abnormal Facial Complexion single color dominates abnormal facial color sharply contrasting color color disagrees with season abnormal facial sheen Chart 1.1.8 Scope of Abnormal Facial Complexions (3) Pathological Facial Complexion and Indications - A. The five colors and their associated diseases is ascribed to wood. It governs in spring, is the color of wind, and is related to the Liver and Gallbladder organs.... A) BLUE-GREEN Blue..oreen Complexion Distinguishing Features Indications Pathogenesis blue-green wind dark blue-green (black) cold sudden appearance blue-green pain blue-green-purple stasis Blood doesn't fill up the vessels (which are naturally blue-green) in the face due to obstruction or contraction of the blood vessels. Table 1.1.4 Blue-green Facial Color and its Indications I Inspection of the Whole Body 21 is ascribed to fire. It governs in summer, is the color of heat, and is related to the Heart and Small Intestine organs.... B) RED Red Complexion Distinguishing Features Indications Pathogenesis red over entire face excess heat red cheeks deficiency heat superficial zygomatic flush with pale face beneath floating yang heat accelerates the flow of blood and fills vessels leading to the appearance of the red color I Table 1.1.5 Red Facial Color and its Indications is ascribed to earth. It governs in late summer, is the color of dampness, and is related to the Spleen and Stomach organs.... C) YELLOW ~--------------------~I Yellow Complexion Distinguishing Features Indications bright orange yellow yang type jaundice smoky hazy yellow yin type dim luster yellow dampness dull pale color yellow cold damp in middle burner pale color yellow Spleen qi deficiency puffy pale color yellow Spleen qi deficiency with water accumulation Pathogenesis damp heat obstructs and steams the bile to the surface dampness accumulates which limits Spleen's transportation function leading to a lack of blood rising to the face, a slightly pale or yellow color ensues. Table 1.1.6 Yellow Facial Color and its Indications is ascribed to metal. It governs in autumn, is the color of dryness, and is related to the Lung and Large Intestine organs.... D) WHITE (PALE) White (Pale) Complexion Distinguishing Features Indications Pathogenesis pale blue-green cold cold contracts blood vessels which prevents color from appearing on face pale white qi deficiency bright white yang deficiency pale white and withered yellow blood deficiency pale white without sheen bleeding qi or blood deficiency gives rise to a loss of nourishment of the face which causes the pale color Table 1.1.7 Pale Facial Color and its Indications I 22 Chapter One: Inspection is ascribed to water. It governs in winter, is the color of cold, and is related to the Kidney and Bladder organs.... E) BLACK (DARK) Black (Dark) Complexion Pathogenesis Indications Distinguishing Features I internal cold dark black channels and blood vessels spasm and contract causing the blood to stagnate and thus darken Kidney yang deficiency dry scorched black Kidney yin deficiency black eye sockets, swollen lower eyelid phlegm damp purple black blood stasis Table 1.1.8 Dark Facial Color and its Indications - B. Qualities ofabnormal color When pathological colors manifest on the face, besides differences in color, there are also differences in such qualities as location, brightness, thickness, and concentration. II Quality Description Indicatlol'ls deep color hidden inside skin internal pattern floating color visible superficially exterior pattern bright (clear) color is clear and distinct yang pattern dull (dim) color is dark and dim yin pattern thin (faint) color is shallow and light qi deficiency color is deep and thick excess pattern color is dispersed or scanty new or mild disease accumulated color enduring or serious disease Location Brightness Thickness thick (extreme) scattered Concentration concentrated Table 1.1.9 Qualities of Abnormal Facial Color and their Indications - C. Abnormal sheen CLINICAL MANIFESTATION: INDICATIONS: withered ("perishing"), dim, lusterless, and dry. exhaustion of essence, loss of spirit, imminent death, and poor prognosis. I Inspection of the Whole Body III. SUMMARY OF INSPECTION OF FACIAL COMPLEXION host color color and sheen from time of birth guest color slight seasonal changes in color and sheen normal variations temporary color changes due to environment, physical, or emotional activities determines the condition (full I exhausted) of the essence and the state of the spirit (having I lacking spirit) red dominant t - - - - - - - - - - - - f - - - t color color manifests the condition of the blood and the etiology (heat, cold, etc.) that may effect the blood circulation heat blue-green wind, cold, pain, blood stasis yellow Spleen disorder, damp, jaundice white (pale) cold, qi or blood deficiency black (dark) Kidney disorder, cold, blood stasis interior or exterior location deep or floating brightness bright or dull yin or yang thickness thin or thick excess or deficiency concentration concentrated or scattered. Chart 1.1.9 Summary of Inspection of Facial Complexion severity of illness 23 24 Chapter One: Inspection Three: Inspection of Body Appearance Inspection of the body appearance includes observing the body and its bearing. Body shape and bearing reflect the condition of the zimgfu organs, the status of yin and yang, and the state of qi and blood. 1. INTRODUCTION (1) Definition Form of the body or "body shape": This refers to the external form and constitution of the individual which can be described as robust (strong), weak, corpulent (fat) or emaciated (skinny). Bearing or "movement": This refers to the posture and movements of the body, both the entire body, and also the individual parts such as eyes, face, mouth, limbs, or fingers. (2) Physiology of the Body Appearance Body appearance includes body form and body bearing. Bones, muscles, sinews, skin, and visible blood vessels are the basic elements for inspection of body form as well as the bearing of movement. Kidney produces marrow and controls the bones. Spleen dominates the muscles and the four limbs. Liver dominates the sinews. Lung dominates the skin and hair. Heart dominates the blood vessels and houses the spirit. This is how TCM connects the body appearance to the condition of the internal organs. Hence, when the functions of zrmg fu organs are sound, the physical body is strong and replete. When zimgfu organs are damaged, the physical body is weak. I Heart ~ spirit ~ dominates activities blood vessels ~ nourish tissues Spleen ~ muscle ~ supports structure, movement Lung ~ skin ~ provides protection Kidney ~ bone ~ supports structure, movement Liver ~ sinews ~ enables movement B 0 0 y A p P E A R A N C E Chart 1.1.10 Internal Organs and Body Appearance (3) Normal Body Appearance Body appearance includes the form (figure, shape) and the bearing (posture and movement). The normal body form should be neither too tall nor too short, neither too fat nor too slim. There should be no swelling, distension, or deformation. The normal bearing should be natural and relaxed, flexible in movement, and quick in response. Inspection of the Whole Body 2S (4) Clinical Significance of Body Appearance Inspection Inspection of the body's appearance helps the practitioner: understand the function of zilngju organs know the condition of yin and yang know the condition of qi and blood II. INSPECTION OF THE BODY FORM The body form refers to the exterior form and to the constitution of an individual. Every individual is born with a certain constitution and consequently a certain body shape. There is a tremendous variety of body shapes. There are three aspects to consider when examining the physical appearance of a patient: constitution, long-term changes, and short-term changes. (1) Constitutional Body Shapes according to the Five Phases Constitution means the fundamental physical and mental make-up of the individual. Five constitutional types can be identified, each referring to one of the five phases. According to The Divine Pivot, Chapter 64 (if:fl& ~ 1%.:::... 1L A), identifying a particular type can be useful in determining the character and prognosis of any disease. 0 + Body Type and Bearing Phase Facial Color Characteristics Strength tall, thin body; fairly broad shoulders, strong and straight back wood green hard workers, tendency to over think or worry bones and sinews quick, energetic, and active; tend to be unconcerned about material wealth, fond of beauty, have short lives blood vessels and blood meticulous, rational, independent and strong willed, a capable leader and manager lungs and voice small pointed head, or pointy chin, curly hair, or little hair, small hands, walks fast broad and square shoulders, triangular white face, strongly built body, walks slowly and deliberately large head and rounded body, large abdomen, strong thighs and wide jaws, walks without lifting feet round face and body, long spine fire red metal white earth yellow water soft white calm and generous, not very ambitious, good interpersonal skills sympathetic and slightly lazy, loyal to their work colleagues; aware, sensitive, and sometime psychic Table 1.1.10 Constitutional Body Shape and Five Phases muscles digestive system 26 Chapter One: Inspection (2) Long-term Changes in Physical Appearance Long-term changes in physical appearance are usually related to the constitution of the individual, the condition of congenital essences, and acquired essence (nutrition). - A. Weight: fatness and thinness can reflect the relative exuberance or debilitation of the yin, yang, qi, and blood of the body. Generally speaking, the obese patient will have excessive phlegm while the thin patient will have abundant fire. Body Form Indications overweight obese, moves slowly phlegm damp accumulation with qi deficiency underweight thin and dry body, muscles are emaciated qi and blood deficiency, or yin deficiency with fire emaciation muscles are emaciated, bones are thin, skin is dry and shriveled, muscles have wasted away critical condition, qi and essence exhausted, zang ftJ organ failure I Table 1.1.11 Inspection of the Body Weight and its Indications - B. Height: tallness and shortness can reflect the condition of the congenital and acquired essences. One must also remember to compare "normal" height and weight to the genetic pool from which the observed patient comes. Body Form Indications tall tall and strong sufficient essence short short, delayed development insufficiency of congenital or acquired essence I Table 1.1.12 Inspection of the Body Height and its Indications - C. Deformation: joints, spine, or other parts of the body structure. Usually indicates congenital insufficiency and/or poor nourishment after birth, and manifests as Spleen/Kidney depletion and softness of the bones. (3) Short-term Changes in Physical Appearance Short-term changes in the physical appearance are usually related to pathological changes in the body. Changes are the result of the struggle between the pathogenic factors and antipathogenic qi. These short-term changes reflect the condition of the zimgju organs. Inspection of the Whole Body 27 - A. Swelling DEFINITION: enlargement due to accumulation of water, blood, or pus. edema: subcutaneous retention of fluid which leads to puffiness of the head, face, eyelids, limbs, abdomen, or even the whole body. It usually happens bilaterally, but can also be unilateral. swelling: to grow larger; to dilate or extend the exterior surface or dimensions. Usually happens unilaterally, or just local areas with pain or skin color change; occasionally may arise bilaterally. the pathogenesis of swelling is due to the dysfunction of water metabolism. This dysfunction can be related to zrmg fo organ disorders or obstruction caused by blood stasis or phlegm accumulation. PATHOMECHANISM: ~ en c transforms & trans orts." Z (") rovides essential heat an transforms -I edema 6 z o." ~'-t m :;c s:: m ~ o r- III (j) obstructs local qi and ~----------~----------------~ body fluid circulation s:: swelling blood stasis Chart 1.1.11 Pathogenesis of Edema and Swelling SYMPTOMS AND INDICATIONS: Swelling Edema Symptoms Indications usually unilateral, or highly localized with pain and change in skin color blood stasis or phlegm stagnation abrupt onset, starts from the upper portion of the body, puffy face and eyelids wind damp attack slow onset, usually found in the lower portion of the body Spleen and/or Kidney yang deficiency Table 1.1.13 Swelling, Edema, and their Indications I 28 Chapter One: Inspection - B. Joint deformities joint shape changes characterized by swelling with or without redness; deformity, and limited range of motion; accompanied by soreness, pain, numbness and heavy sensations. DEFINITION: when bone loses strength, joints deform. Kidney governs the bones, so Kidney deficiency is the major cause of joint deformities. Healthy bones need the nourishment of qi, blood, and marrow. If qi, blood, or marrow is insufficient, the bones can weaken and cause joint deformities. There are two causes for qi, blood, or marrow deficiency. One is pathogenic wind, cold, or damp invasion which obstructs the channels and collaterals. The second is a zcmg fu organ deficiency, especially of the Kidney. PATHOMECHANISM: pathogenic wind, cold, and damp invades channels and collaterals qi and blood obstructed + Kidney deficiency transforms into heat swelling with redness doesn't transform Into heat swelling without redness..... I ~ deformed joints t-------~ Chart 1.1.12 Pathogenesis of Joint Deformation SYMPTOMS AND INDICATIONS: Symptoms Indications one or multiple joints with redness damp heat, or wind damp heat usually involves lower limbs, bilateral, swollen without redness damp, or cold damp usually involves multiple small joints on the hands and feet Kidney deficiency with cold damp I swelling deformity Table 1.1.14 Swelling, Deformity, and their Indications III. INSPECTION OF BEARING AND MOVEMENT Inspection of bearing includes observing the body's posture (static) and movement (dynamic). Normal bearing should be natural and relaxed, with flexible movement and quick responses. (1) The Yin and Yang of Eight Pathological Bearings Bearing or movements can be described in terms of yin and yang. Generally speaking, yang governs movement; yin governs stillness. Observation of the patient's movement or lack thereof can provide insight into the nature of their condition. Inspection of the Whole Body Animation Movement Strength Lying Position Posture movement strong face up extended stillness weak face down flexed 29 Table 1.1.15 Organization of Bearing by Yin and Yang (2) Pathological Bearing and Movement - A. Internal Wind Pattern involuntary movements such as convulsions, tremors, shaking, spasms, twitching, quivering, deviation of the mouth or eyes, and hemiplegia. DEFINITION: internal wind is a spasm of the muscles and tendons. Movement and posture is the coordinated function of the muscle, sinews, and bones. Under healthy conditions, muscles and sinews are nourished by body fluids and blood. Any condition that results in the loss of nourishment to the muscles and sinews can give rise to contractions or spasms. Conditions that cause this lack of nourishment include excessive heat injuring the body fluids; yin or blood deficiency due to dysfunction of ding fu organs; and pathogens such as phlegm or blood stasis obstructing the channels and collaterals. PATHOMECHANISM: I I I exuberant heat injures body fluids yin or blood deficiency pathogens obstruct the channels II I I- muscles and sinews lose nourishment ~ contraction and spasm....... internal wind syndrome Chart 1.1.13 Pathomechanisms of Interior Wind Pattern SYMPTOMS AND INDICATIONS: Body Bearing and Movement Indications convulsive spasms, hypertonicity of the limbs, tremors, shaking, clenched jaw, opisthotonus in severe cases damp heat toxin, or wind damp heat deviated eyes and mouth, facial paralysis or hemiplegia phlegm damp obstructing channels twitching, quivering Kidney deficiency with cold damp Table 1.1.16 Pathological Body Bearing and Movement and their Indications 30 Chapter One: Inspection - B. Atrophy Disorder (1i 1'1E. wei zheng) limpness, weakness and lack of strength of the limbs; or inability to lift limbs, but not due to pain. In severe cases, muscle atrophy may occur. DEFINITION: normal movement and posture depend on the strength ofthe bones and contraction of the muscles and sinews. Pathomechanisms for atrophy disorder include Spleen and Stomach deficiency in which the muscles lose their nutrition; Kidney deficiency where the bones become desiccated and the marrow is reduced; or when the Kidney fails to nourish the Liver giving rise to sinews that are deprived of nourishment. Pathogenic factors that obstruct the flow of qi and blood in the channels can also deprive structures of nourishment, leading to atrophy disorder. PATHOMECHANISM: Spleen and Stomach deficiency I-~f-----t~ muscles lose nutrition Liver yin deficiency sinews lose nutrition Kidney deficiency bones lose strength atrophy disorder Chart 1.1.14 Pathomechanisms of Atrophy Disorder SYMPTOMS AND INDICATIONS: Body Bearing and Movement Indications heavy, cumbersome limbs that are limp & lack strength, they may be slightly swollen or numb with sensations of heaviness, more likely occurring in the lower limbs damp heat gradually worsening weakness and wilting of the limbs, over time muscles lose strength or even atrophy Spleen and Stomach deficiency usually effecting the lower limbs, bilateral or unilateral, chronic and gradual onset, numbness, without pain Liver and Kidney yin deficiency Table 1.1.17 Atrophy Disorder and its Indications Inspection of the Whole Body IV. SUMMARY OF INSPECTION OF BODY ApPEARANCE constitution B 0 determines the character and prognosis of any disease D B 0 D y A R A N C E ~I five phase types I height y long-term changes weight F reflects the condition of the congenital and aquired essence deformities 0 R swelling M short-term changes A p p E I reflects the condition of the zang fiJ organs B 0 D y joint deformities yang active, strong movement, face up, stretched position general principles yin tranquil, weak movement, face down, curved position B E A R wind syndrome involuntary movements I N G abnormal bearing atrophy disorder difficult movement Chart 1.1.15 Summary of Body Appearance I I 31 32 Chapter One: Inspection Section 2 Inspection of Local Areas One: Inspection of Eyes Inspection of the eyes means to observe and examine the spirit, color, shape, and bearing of the eyes in order to assess the patient's spirit, the thermal nature of any pathogens, and the condition of the zimgfu organs. 1. INTRODUCTION (1) Eye Inspection Theories - A. Eye and Zcmgfu Organ Relationship The eye is the gathering place of essence qi (~f\. jing qi) from the five zcmg and six fu organs. The Divine Pivot, Chapter 80 (11 {1& :k ~ ~~) says "The essence from the five zimg and six fu flows upwards to irrigate the eyes:' The Heart houses the spirit, and the capability to identify and visually distinguish items depends on the normal activities of the spirit. The Heart is also the organ that governs the blood. It is the Heart qi that provides the power to maintain normal blood circulation, which supplies nourishment to the eye. The eyes are the orifice of the Liver. The function of the Liver is to store the blood and control the sinews to maintain the eyes' normal vision and movement. Blood is the nutritive resource for the eyes, therefore the Spleen's function of generating blood and the Kidney's function of storing essence are directly related to the normal functioning of the eyes. The dispersing and descending function of the Lung maintains smooth qi circulation, which provides the power to maintain blood circulation. Because of this, the Lung is also indirectly related to the eyes. 0 Inspection of local Areas ~ ~ 1~7YI 1?j\1 ~ dominates dominates generates controls ! stores ~ dominates t I essence I " 33 JI ~ /\. nourishes / provides the eyes with: flexible movement glittering, bright, shiny appearance ability to distinguish objects clear vision Chart 1.2.1 Eye and Zang FiJ Organ Relationships - B. Five Wheels Theory The theory of five wheels describes the relationship between the zang fu organs and the eyes. It divides the eyes into five different parts or "wheels" in which each part is related to a different organ. These relationships not only describe anatomical and physiological connections, but also serve to reflect the pathological changes which make the five wheels diagnostically significant. This theory was originally documented in The Divine Pivot: "The refined energies of the five dmg and the six fu of the human body pour upward to the eyes to enable one to see. The nest of the refined energy is the eye, the essence of the bone is the pupil, the essence of the sinews is the iris, the essence of blood is in the superficial veinules of the two canthi and the eye sockets, the essence of the breathing air of the body is the white of the eyes, the essence of the muscle is in the eyelid and surrounding flesh; when the refined energies of the sinews, bone, blood, and qi combine in the channels and collaterals of the eye, it forms the ocular system:' II Corresponding Part of Eye ZSng Fu Organs blood wheel inner and outer canthus Heart / Small Intestine qi wheel sclera Lung / Large Intestine wind wheel iris Liver / Gallbladder waterwheel pupil Kidney / Urinary Bladder flesh wheel eyelids and surrounding muscle Spleen/Stomach Five Wheels Table 1.2.1 Five Wheels I 34 Chapter One: Inspection - C. Eye and Channels Relationship The connection between the eyes and zimg fu organs is dependent on the channels and collaterals. All twelve channels and collaterals are in direct or indirect connection with the eyes. I Eye Areas Originates at eyes Terminates at eyes Passes through eye region Musculotendon meridian I Channels II Channel and Collateral Pathway Foot SMo Yang arises from the outer canthus Foot Tai Yang arises from the inner canthus Foot Yang Mfng originates lateral to the ala nasi (U 21), ascends to inner canthus, meets BL channel at BL 1 Hand SMo Yang a branch emerges anterior to the ear and reaches the outer canthus to link with the Gallbladder channel Hand Tai Yang a branch reaches the inner canthus to link with the BL channel, a branch passes through the outer canthus to enter the ear Foot Yang Mfng divergent channel of the Stomach runs upward lateral to the nose and connects wtih the eye before joining the Stomach channel R(Jn Mai curves around the lips, passes through the cheek, and enters the infraorbital region. Yang Qiao channel ascends along the neck to the corner of the mouth, from which it then enters the inner canthus Yin Qiao channel from the zygoma, it reaches the inner canthus and communicates with the yang qiao channel Hand SMo Yin ascending portion of "Heart system" runs alongside the esophagus to connect with the "eye system" Foot Jue Yin ascends along the posterior aspect of the throat to the nasopharynx and connects with the "eye system" Hand Shao Yang musculo-tendon meridian joins with the foot fai yang to form a muscular net around the eye Foot Yang Mfng musculo-tendon meridian joins with the foot fai yang to form a muscular net around the eye I Table 1.2.2 Eye and Connected Channels and Collaterals (2) Eye and Corresponding Parts of Zimg Fit Organs As a further development of the five wheels theory, in modern times we associate specific parts of the eye structure with internal organs. The two canthi are associated with the Heart. The sclera corresponds to the Lung. The iris is associated with the Liver. The pupil corresponds to the Kidney. The eyelids and tissues immediately surrounding the eye are associated with the Spleen. Inspection of local Areas 35 Kidney Spleen (eyelids & surrounding tissue) Illustration 1.2.1 Eye and Corresponding Zang Fu Organs (3) Normal Eyes The normal eye should glitter and shine with clear and sharp vision, as well as flexible movement of the eyeballs. There is no swelling or ulcers on the eyelids; both eyes are the same size, and the eyelids freely open and close. (4) Scope of Eye Inspection Inspection of the eyes includes observing their spirit, color, shape, and bearing. eye spirit eye color Eye Inspection eye shape eye bearing Chart 1.2.2 Scope of Eye Inspection (5) Clinical Significance of Eye Inspection Eye inspection enables the practitioner to: identify pathogenic factors and their thermal nature identify involved zimgfo organs understand the conditions of zimg fo organs make a prognosis. 36 Chapter One: Inspection II. EYE INSPECTION (1) Inspecting the Spirit of the Eyes the spirit of the eyes is the external manifestation of the zcmgfu organs. The spirit manifests in the vision, shape, and bearing (movement) of the eyes. It reflects the condition of the dmg fu organs and indicates the severity of the illness. DEFINITION: CLINICAL SIGNIFICANCE: inspecting the spirit of the eyes can assist in making a prognosis. under normal circumstances, essence qi from the five dmg and sixfu all flow upward to nourish the eyes, which allows them to clearly distinguish things, appear bright and shiny, and move flexibly. When there is a dmg fo organ disorder, especially of the Kidney and Liver, essence and blood are unable to nourish the eyes. The eyes then lose their spirit and look dull and dim; eyesight is diminished, and the eyes move sluggishly. PATHOMECHANISM: normal or mildly impaired function impaired function sufficient..-..... insufficient _ Having spirit Loss of spirit Chart 1.2.3 Pathomechanism of the Eye Spirit Physiological and Pathological Eye Spirit and its Indications Manifestation Indications Prognosis Having spirit clear vision; bright and shiny luster, distinguishable iris, pupil, and sciera, flexible movement, little tear or eye secretion sufficient Liver and Kidney qi, mild illness good prognosis, curable disease Loss of spirit poor vision; dull luster, turbid hue in the sclera, iris and pupil borders are indistinguishable, dull luster, no tears or eye secretion insufficient Liver and Kidney qi, severe illness poor prognosis, disease difficult to cure Table 1.2.3 Inspecting Eye Spirit and its Indications I Inspection of Local Areas 37 (2) Inspecting the Color of the Eye in general, this refers to the colors found on the sclera. Eye color may also be extended into the iris and pupil. The normal color of the eyes should be white in the sclera; slightly red at the inner and outer canthi; brown (or blue, green, gray, etc.) in the iris; and black in the pupil. All colors should be clearly distinguishable. DEFINITION: CLINICAL SIGNIFICANCE: changes in eye color often signify pathogenic factors and their pathogenesis. redness in the eyes indicates pathogenic heat invading the body. Heat injures the blood vessels and causes bleeding. It also pushes blood upward to fill the blood vessels, giving rise to a red color. PATHOMECHANISM: White eye color indicates a lack of blood to fill the vessels. This can be due to qi or blood deficiency, or yang deficiency with cold, which obstructs the blood vessels and leads to insufficient blood. Yellow eye color indicates that the Liver and Gallbladder channels are obstructed by dampness, qi, or blood stasis. In each case, the stagnation generates heat, which steams bile in the Liver and Gallbladder, which rises up to the eyes. Black eye color is caused by extreme heat consuming the body fluids and concentrating the blood, which gives rise to the darker color. The color black is associated with Kidney failure by virtue of its five phase correspondence. Blue-green indicates wind or Liver dysfunction. The blue-green color is associated with wind and the Liver by virtue of its five phase correspondence. pathogenic heat injures blood vessels, or causes blood to rise upward Liver I Gallbladder channels obstructed by pathogens; heat ensues, bile steams upward to manifest in eyes insufficient blood fails to fill up the channels and Eyecolor~------n-o~u~ri~sh~th-e-e-y-es-,-o-r~tu~rn~id~Ph~1e-g-m~de-p-o-s~it-o-n~th-e-e-y-e--~ heat causes bleeding or severely injures body fluids and concentrates the blood, or Kidney failure Liver function disorder creates wind, or pathogenic cold obstructs the blood vessels Chart 1.2.4 Pathomechanisms of Eye Color 38 Chapter One: Inspection Pathological Changes of Eye Color and their Indications - A. Yellow: yellow on the sclera that may extend to the iris and pupil. Yellow signifies dampness. II Other Symptoms Indications pale yellOW, gradually becoming bright yellow orange yellow urine, yellow tongue coating damp heat pale yellow, sometimes effects the vision fatigue, loose stools blood deficiency dull yellow color, chronic abdominal bloating, cold limbs cold damp golden yellow color of the eye and body, acute onset fever, irritability, constipation toxic heat dim dull yellow difficult urination, abdominal distention qi I blood stagnation Yellow Color I Table 1.2.4 Yellow Eye Color and its Indications - B. Red: excessive redness on the inner or outer canthus, or on the sclera; red vessels may also appear over the entire eye. Red signifies heat. II Red Color Other Symptoms Indications red in the canthus area excessive tearing, irritability, red tongue, dark urine heat in the Heart redness and swelling in the entire eye headache, easily angered rising of Liver fire or exterior wind heat red in the sclera of the eyes sore throat, cough heat in the Lung red in the iris and pupil of the eye eye pain, headache, dark urine excess heat in the Bladder red that may extend into the pupils dizziness, tinnitus, scanty tongue coating yin deficiency with heat blue-green or purple red vessels on the sclera pain from physical trauma traumatic injury red eyes upon awakening that clear up later bleeding, thirst blood level heat Table 1.2.5 Red Eye Color and its Indications I Inspection of Local Areas 39 - C. Blue-green: blue-green on the sclera or iris. Blue-green signifies wind and cold. blue-green color in the sclera blue-green on pupil, dry and dim sclera Other Symptoms Indications severe headache, nausea, irritability, restlessness wind fire attacking the eyes vertex headache, aversion to cold, desires warmth cold stagnation, pain dizziness, tinnitus, insomnia, poor memory Kidney yin deficiency I Table 1.2.6 Blue·green Eye Color and its Indications - D. Black: black on the sclera. Black signifies water. =~I I Other Symptoms Indications black on the sclera which resembles crab eyes severe pain, bitter taste in the mouth accumulation of excess heat black eye sockets dizziness, poor memory, tinnitus, irritability, scanty coating Liver and Kidney deficiency black on the sclera, dim and dull eyeball feeble respiration, profuse sweating of oily sweat zang fli organ qi depletion :===B=Ia=Ck=C=o=lo=r I Table 1.2.7 Black Eye Color and its Indications - E. White: white on the inner or outer canthus is pale; the iris or pupil may also be white. White signifies deficiency. II Other Symptoms indications white ring around iris obesity, dizziness, stifling sensation in chest turbid phlegm iris color gradually lightening dim vision, cold limbs, loose stools and frequent urination yang deficiency with cold cloudy white iris dizziness, tinnitus, irritability, red tongue body, thirst Liver and Kidney deficiency pale white blood vessels in the canthus of the eyes fatigue, dizziness, dry skin, pale tongue and face qi and blood deficiency White Color Table 1.2.8 White Eye Color and its Indications I 40 Chapter One: Inspection (3) Inspecting the Shape of the Eye also called "appearance" of the eyes. This refers to the outward appearance of the eyes' shape. The normal eye shape should be the same size on both sides. There is no swelling or ulcers on the eyelids. The eyelids open and close easily and flexibly. DEFINITION: changes in the shape of the eye usually reflect the state of the qi (excess/deficiency) and the pathogenic factor (heat, dampness, etc.) CLINICAL SIGNIFICANCE: normal eye shape requires the nourishment of qi, blood, and body fluids, as well as the normal functioning of the muscles and sinews to support the eyes' position in the skull. If qi, blood, or body fluids are insufficient due to an attack of exogenous pathogens or zrmg fu organ deficiency, then the eyes, and the muscles and sinews around the eyes, will lose nourishment and support, which will cause the eyes to sink inward. If an accumulation of excessive pathogens fights with exuberant antipathogenic qi, this can push the eyeballs outward, leading to exophthalmia. Dampness may also accumulate around the eyes, giving rise to local swelling. PATHOMECHANISM: exopathogenic attack zang ftJ organ dysfunction " sunken eyes / loses nourishment abnormal...·t---~a~ndrs~u~p~po~rt~~-- eye shape heat accumulates or damp accumulates· swollen eyes exuberant antipathogenic qi struggles wtih excessive pathogens, qi pushes eyeballs outward bulging eyes Chart 1.2.5 Pathomechanisms of Pathological Eye Shape Pathological Changes of Eye Shape and their Indications - A. Exophthalmia: Also called "bulging eyes:' this refers to the protrusion of the patient's eyeball on one or both sides. Exophthalmia usually indicates a condition of excess. Inspection of local Areas Description II Indications protruding eyeballs, headache, red tongue, yellow greasy tongue coating protruding eyeballs with dyspnea or asthma with an inability to lie flat, palpitations protruding eyeballs with swellings in the neck I Liver yang rising Lung qi stagnation distention headache and dizziness, irritability, easily angered qi stagnation with heat dizziness, tinnitus, five center heat, red tongue, scanty coating yin deficiency with relative yang excess headache, diplopia (double vision), purple tongue body with spots on the lateral margins 41 qi and blood stagnation Table 1.2.9 Bulging Eyes and their Indications - B. Sunken Eyes Sunken eyes means that the eyeball has sunken deeper into the eye socket. It usually indicates a condition of deficiency. Description following severe or chronic illness, the eyeball gradually sinks deeper into the eye socket qi deficiency sudden onset of sunken eyes, follows severe vomiting, diarrhea, or loss of blood Spleen deficiency with Liver excess chronic or critical condition, the eyeball sinks inward relatively deeply, suggests unfavorable prognosis yin and yang depletion Table 1.2.10 Sunken Eyes and their Indications - C. Swollen Eyes Swollen eyes means that the eyelid (upper, lower, or both) is swollen; it may be accompanied by redness and wet skin. It usually indicates dampness or water retention. 42 Chapter One: Inspection Description sudden onset, red and swollen eyelids, pain and itching, may include open sores wind heat toxin redness and swelling with itching or'slight pain, recurrent attacks, none of the symptoms are severe latent heat in the Spleen puffiness without pain, shiny eyes without color change edema, water retention slow swelling of the eyelid without pain or inflammation, visible on both upper and lower eyelid Spleen deficiency with damp bags beneath the eyes Spleen and Kidney deficiency in the elderly Table 1.2.11 Swollen Eyes and their Indications (4) Inspecting the Bearing of the Eye also called the state of the eye, this refers to the movement and bearing of the eyeball and eyelid. Normal eye bearing means that the pupils are of equal size, 3-5 mm in diameter, and are responsive to light. In general, movement of the eyeballs should be flexible and agile. DEFINITION: inspection of the eye bearing can help to identify the thermal nature of the pathogens and their pathogenesis. CLINICAL SIGNIFICANCE: normal eye bearing depends on the normal functioning of the muscles and sinews. Therefore abnormal functioning of the muscles (spastic or flaccid) and sinews (spasms) are the pathomechanisms of pathological eye bearing. Spasms of the muscles or sinews can be due to either exopathogenic attack (wind or heat) or to qi and blood deficiency, where the muscles and sinews lack nourishment. Flaccidity of the muscles and sinews is usually due to zcmgju organs dysfunction, especially the Kidney and the Liver. PATHOMECHANISM: exopathogenic attack zang fa organ dysfunction \... / Y dysfunction of the muscles or sinews + eyelid drop muscle I sinews become flaccid abnormal muscle I sinews eye bearing spasm strabismus eyelid twitching deviated eye Chart 1.2.6 Pathomechanisms of Pathological Eye Bearing I I I Inspection of Local Areas 43 Pathological Changes of Eye Bearing and their Indications - A. Strabismus The eye cannot look straight, or deviates to one side or the other. This can happen in one eye or both eyes. II Description sudden onset, usually upon arising from sleep, eyeball deviated to one side, no redness or swelling, usually happens in only one eye, may be accompanied by deviated mouth, headache, dizziness, and aversion to wind Indications I wind attack in the collaterals sudden onset, eyeball deviates to one side and is difficult to move, usually happens in one eye, accompanying symptoms include nausea, vomiting, fatigue, tightness in chest, greasy tongue coating, slippery pulse damp phlegm obstructing the collaterals both eyeballs deviate to one side or upward, high fever, headache, possible coma, convulsion, red tongue, wiry rapid pulse wind heat flaring upwards unilateral or bilateral deviation of the eyeball, red color in sclera, accompanying symptoms include headache, bitter taste in mouth, irritability, numbness in the limbs, wiry pulse Liver wind onset following traumatic injury blood stagnation congenital onset, unilateral or bilateral, sometimes with delayed development and mental retardation benign birth defect or essence deficiency Table 1.2.12 Strabismus and its Indications - B. Eyelid spasms Also described as "eyelid twitching:' this refers to the involuntary unilateral spasms of the eyelid. It may also radiate to the eyebrow. Description frequent involuntary spasm, dry and itchy eyes, pale face and lips, thready pulse eyelid spasms with frequent blinking, eyelid feels heavy and tired, poor appetite, fatigue, flabby tongue occasional eyelid spasm; red, painful, or itchy eyes, may have sores surrounding eye; may be accompanied by headache, fever, chills, and floating pulse blood deficiency Spleen and Stomach qi deficiency wind he;:lt attack Table 1.2.13 Eyelid Spasms and their Indications 44 Chapter One: Inspection - C. Eyelid Drop Also known as "blepharoptosis;' this refers to the drooping of the upper eyelid and difficulty in keeping the eye open completely. The upper eyelid may block half or more of the eye. slow onset; patient reports difficulty in keeping eye open, may be accompanied by fatigue and organ prolapse acute onset, upper eyelid suddenly drops, may be accompanied by local itching or numbness eyelid drop, usually following traumatic injury qi sinking wind attacking the collaterals qi and blood stagnation Table 1.2.14 Blepharoptosis and its Indications - D. Platyeo ria Platycoria refers to dilation of the pupils, where the diameter increases to more than 5 mm. It usually indicates exhaustion of the Kidney essence, which fails to pour upward to the eyes to contract the pupils. It is usually a sign of the terminal stage of a disease. It is sometimes seen in glaucoma patients as well. -E. Myosis Myosis refers to contraction of the pupils, the diameter of the pupils decreases to less than 2 mm. It usually indicates flaring-up of Liver and Gallbladder fire. Myosis may also indicate an overdose of chuan wu tou (Aconiti Radix Preparata), cao wu tou (Aconiti Kusnezoffii Radix), zhi fit zl (Aconiti Radix lateralis preparata), or poisonous mushrooms. Inspection of Local Areas III. SUMMARY OF INSPECTION OF THE EYES ,EYE INSPECTION with spirit spirit indicates the condition of the zang ft1 organs and severity of illness without spirit red color indicates etiology and pathogenesis mild, curable disease, good prognosis critical stage, bad prognosis heat white deficiency, cold syndrome yellow dampness, Spleen dysfunction blue-green black wind, Liver dysfunction water accumulation, Kidney dysfunction bulging excess condition sunken deficiency condition swollen dampness, Spleen dysfunction shape indicates state of the antipathogenic qi and nature of pathogens strabismus platycoria bearing myosis indicates state of the antipathogenic qiand nature of pathogens blepharoptosis eyelid spasm Chart 1.2.7 Summary of Eye Inspection. wind, Liver dysfunction terminal stage illness, glaucoma poison qi sinking, Spleen dysfunction wind due to either excess or deficiency 4S 46 Chapter One: Inspection Two: Inspection of Ears and Nose I. INSPECTION OF THE EARS The Kidney opens to the ears. All six yang channels travel into or around the ears. They are a gathering place for the channels and collaterals. Through the channels and collaterals. the ears connect with the five zlmg. the six fo. and the entire body. Therefore. inspection of the ears not only helps one to know the pathological changes of the Kidney and Gallbladder. but the condition of the entire body. (1) Inspection of Ear Shape The normal ear shape should be of average size without dryness or scaling. Healthy ears are also free of sores. boils. or swellings. Ear Shape Indications small and thin ear insufficient congenital essence or Kidney qi dry helix with scales blood stasis sores, boils, or swelling and redness on the helix wind heat or Liver and Gallbladder fire I Table 1.2.15 Pathological Changes of Ear Shape and their Indications (2) Inspection of Ear Discharge The appearance of a small amount of ear wax is considered normal. however the appearance of yellow or white pus. or blood. are considered pathological. Ear Discharge Indications earwax normal discharge yellow or white pus Kidney yin deficiency fire with damp heat in the Liver and Gallbladder channels blood heat in blood Table 1.2.16 Pathological Changes in Ear Discharge and their Indications I Inspection of Local Areas 47 (3) Inspection of Ear Color and Sheen The normal ear color and sheen should not favor any of the five colors or appear withered, parched, or burnt. Ear Color and Sheen withered and parched helix five colors Indications I exhaustion of Kidney qi white sudden onset of wind cold, or cold green-black excruciating pain black Kidney failure red excess heat or damp heat red collateral on the back of the ear that feels cold to the practitioner's touch prodrome of measles yellow damp heat accumulation in Kidney Table 1.2.17 Pathological Changes in the Color and Sheen of the Ear and their Indications II. INSPECTION OF THE NOSE The Lung opens to the nose. The nose is the sense organ for smelling and is the passageway of inhalation and exhalation. It is located in the center of the face (analogous to the middle burner) and is associated with earth; for these reasons, it is governed by the Spleen. Air is inhaled into the body, and stored in the Heart and Lung. When there is a disorder of the Heart and Lung, the nose will be congested. The yang ming channels of hand and foot, as well as the hand tai yang channel, all directly connect to the nose. Inspection of the nose will not only help us understand the pathological changes of the Lung, Spleen, and Stomach, but also to judge the excess or deficiency of the dmg fu organs and the condition of the Stomach qi. Knowing the condition of the Stomach qi can ultimately inform the prognosis. (1) Inspection of Nose Shape The normal nose shape should be neither swollen nor sunken or shrunken. There should be no sores or missing nasal tissues. Flaring nostrils can arise in the presence of pathological changes to the Lung. 48 Chapter One: Inspection Nose Shape Indications swollen nose excess condition sunken insufficient antipathogenic qi, deficiency condition nasal polyp stagnated heat in yang ming channel ulcerous and sunken nasal septum syphilis sunken nasal septum with loss of eyebrows leprosy flaring nostrils with high fever wind heat or phlegm heat accumulation in the Lung, or asthma flaring nostrils during critical stage of illness Lung failure I Table 1.2.18 Pathological Changes of Nose Shape and their Indications (2) Inspection of Nasal Discharge The normal nose should lack any particular discharge. When there is discharge, its color and consistency can provide insight into pathological changes of the Lung. Indications Nasal Discharge epistaxis (nosebleed) nasal discharge I heat injury to the Lung and Stomach clear and thin wind cold attack yellow or turbid wind heat attack chronic and turbid internal damp Table 1.2.19 Pathological Changes of Nasal Discharge and their Indications (3) Inspection of Nasal Color and Sheen The normal color and sheen of the nose should be supple and moist without a predominance of any of the five colors listed below. I Nasal Color and Sheen withered five colors I Indications exhaustion of Spleen and Stomach qi, severe disease white Lung disorder, bleeding, or qi and blood deficiency blue-green abdominal pain or excess cold black water retention due to Kidney deficiency red heat in the Spleen and Lung channels, if deep red or purple with acne, it indicates alcoholism yellow internal damp heat, or constipation due to Spleen yang deficiency Table 1.2.20 Pathological Changes in the Color and Sheen of the Nose and their Indications I Inspection of Local Areas 49 Three: Inspection of Teeth, Gums, and Throat Teeth are the surplus of bone, and bone is governed by the Kidney. Therefore, the growth, changes, and failure of the teeth are all directly related to the function of the Kidney. The yang ming channels of hand and foot pass through the gums. Hence, inspection of the teeth and gums contributes to understanding Kidney, Stomach, and Intestinal disorders. I. INSPECTION OF TEETH Normal teeth should be bright, moist, and clean without tartar. All the teeth should be present. Teeth Inspection II white color yellow black I tartar shape I Description Indications white with a moist sheen, bright and clean Kidney qi flourishing white, dry, without sheen Kidney yin exhaustion gradually yellows with age normal physiology sudden change to yellow Kidney deficiency dull yellow, like soy bean Kidney failure purplish black, like black bean exhaustion of both yin and yang grimy yellow evaporated Stomach turbidity burnt and dry Kidney & Stomach yin exhaustion delayed appearance of baby or adult teeth in children essence deficiency teeth grow at deviated angles, or missing teeth insufficient yang ming qi loss of teeth among adults, receding gums with exposure of the roots of the teeth flaming upward of defiCiency fire due to Kidney yin deficiency Table 1.2.21 Pathological Changes of the Teeth and their Indications I SO Chapter One: Inspection II. INSPECTION OF THE GUMS Normal gums should be moist, pink, and free of bleeding, ulcers, or swellings. I Gums Inspection II red color Description I shape I Indications red with moist sheen normal deep red with swelling excess heat in the yang ming pale gums blood deficiency pale, atrophied gums Kidney deficiency line between teeth and gums mercury poisoning pale blue I I swollen gums Stomach fire flaming upwards ulcerations or bleeding bleeding with pain & swelling bleeding Stomach fire flaming upwards deficiency fire flaming upwards chronic bleeding without pain Spleen qi deficiency Table 1.2.22 Pathological Changes of the Gums and their Indications III. INSPECTION OF THE THROAT The throat is the gateway to the Lung and Stomach and the passageway for breath and food. The throat is also the structure that produces the voice. The Liver channel ascends along the posterior aspect of the throat to the nasophrynx; the Gallbladder channel rises up the throat; and the Kidney channel enters the Lung, runs along the throat, and terminates at the root of the tongue. In addition, the Stomach, Heart, Small Intestine, Spleen, Lung, Large Intestine, Pericardium, Conception Vessel (ren mai), Governing Vessel (du mai), and Penetrating Vessel (chong mai) are all directly or indirectly connected to the throat. Hence, changes in the throat can reflect internal zangfu organ disorders. The normal throat should be pink to red in color, moist with normal breathing sounds, and permit smooth swallowing. Appearance of Throat II Indications red color, swelling and pain excess heat syndrome slightly red, slight swelling, and pain Kidney yin deficiency with deficiency fire flaming upward unilateral or bilateral redness, swelling, severe pain, possible ulceration, white or yellow pustules tonsillitis due to toxic heat in Lung and Stomach, putrefying flesh grayish white pseudo-membrane in the throat which cannot be removed, or if scraped off, causes bleeding diphtheria Table 1.2.23 Pathological Changes of the Throat and their Indications I Inspection of local Areas 51 Four: Inspection of Lips and Mouth Inspection of the lips involves examining their color, moisture, shape, and bearing, which reflect the state of the qi and blood and the body fluids. This will enable the practitioner to identify pathogenic factors and to make a prognosis. I. INTRODUCTION (1) Lip Inspection Theory The Spleen opens to the mouth and manifests externally on the lips. The Stomach channel encircles the lips, the Large intestine channel curves around the upper lip, the Liver channel curves around the inner surface of the lips, and the Governing Vessel (du mai) circulates inside the lips. Hence, the condition of the lips not only reflects the functioning of the Spleen, but also of the Stomach, Large Intestine, Liver and Governing Vessel (du mai)o The appearance of the lips is supported by the Heart, Spleen and Stomach, whose relationship to the blood gives rise to the lustrous red color of the lips. The Kidney, Lung, and Spleen all provide the body fluids which are necessary to moisturize the lips; and the Spleen and Liver govern the muscles and tendons, which enable the lips to move flexibly. Heart. Spleen. Stomach ~ red color, luster body fluids ~ moisture, luster blood Kidney. Lung. Spleen I----I~ Spleen. Liver I muscles, tendons ~ Normal Lips flexible Chart 1.2.8 Physiology of the Lips (2) Normal Lips Normal lips are red, lustrous and moist, neither swollen, nor atrophied, and neither deviated, nor shaking. Their movement is free and flexible. Normal lip appearance reflects Stomach qi sufficiency, harmonized qi and blood, and no disturbing pathogenic factor. (3) Clinical Significance of Lip Inspection Inspection of the lips can help the practitioner: identify pathogenic factors, and their thermal nature understand the condition of the Spleen, Stomach, and other zangjU organs understand the condition of the body fluids predict a disease prognosis. 52 Chapter One: Inspection (4) Scope of Lip Inspection When looking at the lips, the practitioner should assess the color, luster, moisture, shape, and bearing (movements) of the lips. color, luster, moisture Inspection of Lips shape bearing Chart 1.2.9 Scope of Lip Inspection II. CLINICAL MANIFESTATION OF PATHOLOGICAL CHANGES OF THE LIPS (1) Lip Color normal lips should have a lustrous, moist, fresh red color. This indicates sufficient Spleen and Stomach qi as well as blood and yin. Lip color usually depends on the quantity and quality of the blood. DEFINITION: CLINICAL SIGNIFICANCE: to assess the condition of the qi and blood, and the thermal nature of any patho- genic factors. color of the lips depends on the condition of the qi and blood. When qi and blood are sufficient to fill the lips, the color is red and bright. If the lips are overfilled, the color will be a deep red. When there is not enough blood to fill the lips, they will look pale. PATHOMECHANISM: black lips stagnated blood darkens I~ lack of blood blood stagnation concentrates red color I + purple lips I ~I excessive blood overfills I + deep red lips I Chart 1.2.10 Pathomechanisms of Pathological Lip Colors pale lips Inspection of local Areas Pathological Changes in Lip Color and their Indications - A. Pale lips: the color is much more pale than normal. Description Indications Pathomechanism pale lips and tongue blood deficiency pale lips with fatigue qi deficiency pale withered lips, usually seen in critical conditions qi depletion red is the color of blood, when blood deficiency fails to fill the lips, or qi deficiency cannot push the blood up to the lips, they'll lose red color pale lips and face, with sensations of cold deficiency cold blood lacks the power to push or cold causes vessels to contract Table 1.2.24 Pale lips and their Indications - B. Deep Red lips: the color is more red than normal. Description Indications Pathomechanlsm dry and crimson lips interior heat bright red lips heat toxin crimson lips deficiency heat the color of heat and fire is red; heat injures and concentrates the yin and blood cherry colored lips gas poisoning toxin damages the blood cell changing its color Table 1.2.25 Deep Red Lips and their Indications - C. Purple lips: the color is purple. Description Indications pale purple lips Heart yang deficiency cold bluish purple lips excess cold purple lips with dark spots or greenish purple lips blood stagnation cold causes the vessels to constrict and blood to stagnate, when blood stagnates locally, the purple color ensues deep red purple lips heat in the nutritive or blood levels heat consumes blood or body fluids which causes blood to accumulate Pathomechanlsm Table 1.2.26 Purple Lips and their Indications 53 54 Chapter One: Inspection - D. Blackish lips: the color looks greenish or blackish, with a dull intensity. Description Indications greenish black lips extreme cold gray lips qi depletion purplish black lips with dark spots qi and blood stagnation cold causes the vessels to constrict and blood to stagnate, when blood stagnates locally, the purple color ensues deep purple with green tint excessive Stomach heat heat consumes the body fluids and causes blood to concentrate Pathomechanism Table 1.2.27 Blackish Lips and their Indications (2) Lip Shape lip shape refers to the general appearance of the lips. Normal lip shape should be free of swelling, atrophy, peeling, or erosion. The surface of the lips should be smooth and moist. DEFINITION: CLINICAL SIGNIFICANCE: the lip shape can help identify the pathogens and reflect the condition of the qi and blood. normal shape of the lips requires sufficient qi, blood, and body fluids for nourishment, and normal functioning of the muscles and sinews for support. Hence, if qi, blood, or body fluids are insufficient due to an exogenous pathogenic attack or dysfunction of internal organs, the lips will become dry and peeled. If the muscles or sinews are impaired by exogenous factors or suffer a loss of nourishment due to internal organ dysfunction, the lips may become swollen or eroded. PATHOMECHANISM: I eroded lips 1"- flesh is putrified by heat heat i~flames ~ tissues yin deficiency or heat injures body fluids + chapped and dry lips + peeled lips Chart 1.2.11 Pathomechanisms of Lip Shape swollen lips 1 Inspection of Local Areas SS Pathological Changes of Lip Shape and their Indications - A. Swollen lips: the lips are swollen, and their color is red or overly shiny. Description and Symptoms Indications red swollen lips with a dry mouth, red tongue, dry yellow coating toxic heat in Spleen and Stomach red swollen lips with poor appetite, red tongue, yellow greasy coating damp heat itching and swollen lips; with clear discharge and burning pain after broken "lip wind" due to Stomach fire pale swollen lips, lips that are dim and lusterless; cold limbs, thready and weak pulse qi depletion I Table 1.2.28 Swollen Lips and their Indications - B. Chapped and dry lips: the lips are very dry, even cracked. Description Indications Lung I Stomach chapped lips, thirst with desire to drink chapped lips, no thirst chapped lips, thirst but with little desire to drink I excess interior heat Spleen I Large Intestine nutritive or blood levels food stagnation chapped lips, thick yellow coating, belching dry mouth and throat, dry nose, red and dry lips, red tongue with scanty coating yin deficiency with dryness dry mouth and lips, dark purple lip color, thirst with no desire to swallow, black or purple spots on the lips or tongue blood stagnation dry and cracked lips, no thirst, pale lips and tongue, cold limbs deficiency cold Table 1.2.29 Chapped Lips and their Indications - C. Peeled lips: the lips are peeled and dry, and slightly swollen with cracks; mostly seen in the lower lip. Description and Symptoms Indications peeled lips without color change, red tongue, yellow coating Spleen heat peeled red lips, dry mouth and thirst, irritability, red tongue, scanty coating yin deficiency Table 1.2.30 Peeled Lips and their Indications I 56 Chapter One: Inspection - D. Erosion: marked by white tissue in mouth sores. There is a stabbing pain when the white tissue is removed, beneath which is raw tissue with a reddish color. Description and Symptoms Indications eroded lips, irritability, red tongue body, yellow coating excess interior heat usually arises after febrile disease, erosion of the lips, dry red tongue, scanty coating yin deficiency with heat eroded lips, anorexia, red tongue, greasy yellow coating damp heat in the Spleen Table 1.2.31 Eroded Lips and their Indications (3) Lip Bearing lip bearing is also called the state of the lips. It refers to the movements and relaxed state of the lips. Normal lips should open and close flexibly and voluntarily, without deviation or twitching, tightness or drooling. The lips are relaxed and flexible. DEFINITION: the bearing of the lips can help identify the pathogens and reflect the condition of the zcmg fu organs. CLINICAL SIGNIFICANCE: the bearing of the lips is dependent upon the muscles and sinews. When the muscles around the mouth are flaccid, it can lead to a drooping mouth, drooling, or a mouth that cannot close. If the sinews and muscles around the mouth spasm due to malnutrition or a pathogenic attack of wind, there could be tightness, lockjaw, twitching, or deviation of the mouth. PATHOMECHANISM: open mouth internal zang deficiency deficiency flaccid muscles opened r-::---:-:--~----I mouth '---+---1 drooping mouth fa drooling muscle or tendon spasm or flaccidity t - -..... excess spastic muscles closed mouth tight mouth lockjaw t exopathogen ic attack wind spastic tendons twitching mouth -I bearing L...-_~';';';";;;-:-_ _ _ Chart 1.2.12 Pathomechanisms of Lip Bearing deviated mouth Inspection of Local Areas 57 Pathological Changes of Lip Bearing and their Indications - A. Tight mouth: the lips are rigid and spastic, causing tightly pouting closed lips which impede the ability to eat and drink. Description and Symptoms Indications usually seen in neonatal patients, tight mouth with spasm of limbs and opisthotonus excess wind ("umbilicus wind") usually seen in the late stage of a critical condition, tight mouth, cold limbs deficiency wind I Table 1.2.32 Tight Mouth and its Indications - B. Lockjaw: the mouth and teeth close tightly, and cannot open. Description and Symptoms Indications lockjaw, opisthotonus, limb spasms, chills and fever exterior wind toxin (tetanus) usually associated with a high fever, limb spasms, may be accompanied by dysentery wind due to excess heat hemiplegia, lockjaw, coma in some cases wind stroke sudden attack, twisted limbs, recovers after a few minutes wind phlegm (epilepsy) neonatal patient, bluish face color, cold body excess cold Table 1.2.33 Lockjaw and its Indications - C. Deviated mouth: the mouth is twisted to one side, usually accompanied by deviation of the eye. Description and Symptoms Indications mouth or eyes twisted to one side, usually no other symptoms wind attack in the co"aterals sudden loss of consciousness, deviated eyes, mouth, or tongue, hemiplegia wind stroke deviated mouth and eye, burning pain, earache accompanied by headache, bitter taste in the mouth, red face heat toxin injures co"aterals Table 1.2.34 Deviated Mouth and its Indications S8 Chapter One: Inspection - D. Open mouth: the mouth remains open and cannot close. Description and Symptoms Indications patient's mouth remains open with high fever, red face, thirst, canker sore excess heat open mouth breathing, shortness of breath, cough with foamy sputum Lung deficiency with phlegm stagnation sudden attack, open mouth, drooling with mucus, loss of consciousness wind phlegm (epilepsy) Table 1.2.35 Open Mouth and its Indications - E. Lip droop: the lips hang down and cannot close. Description and Symptoms Indications drooping lips, fatigue, pale tongue with white coating middle qi sinking lips droop or excessive flaccidity, usually occurring after chronic diarrhea or dysentery, cold limbs, low back pain Spleen/Kidney yang deficiency I Table 1.2.36 Lip Droop and its Indications - F Lip twitching: the lips tremble, twitch, or shake involuntarily. Description and Symptoms Indications lips shake or tremble; pale lips, face, tongue; weak pulse Spleen qi deficiency lips twitching or shaking, pale lips and nails, thin pulse wind due to blood deficiency Table 1.2.37 Lip Twitching and its Indications - G. Involuntary drooling: there is copious saliva, mucus in the corner of the mouth, or drooling. Description and Symptoms Indications involuntary drooling, profuse watery saliva, aggravated by cold Spleen deficiency profuse saliva in the mouth with occasional drooling, cough with foamy sputum, pale tongue Lung deficiency with cold mostly seen in children, involuntary drooling, red lips and tongue, possible canker sores Spleen heat deviated mouth and tongue, drooling, hemiplegia wind stroke sudden attack, drooling, loss of consciousness wind phlegm (epilepsy) Table 1.2.38 Involuntary Drooling and its Indications I Inspection of Local Areas S9 III. SUMMARY OF LIP INSPECTION Lips pale lips red lips lip color lip shape manifests the condition of the blood or pathogens (heat, cold, etc.) that may affect blood circulation manifests the condition of the body fluids and nature of pathogenic factors deep red reflects muscles' condition, etiology, or zang fU organ condition heat/toxin blood stagnation black lips extreme stagnation or heat swollen lips toxic heat eroded lips heat peeled lips dryness chapped dry lips dryness drooping mouth drooling lip bearing heat purple lips open mouth opened mouth qi/blood deficiency excess heat deficiency Spleen deficiency or wind stroke tight mouth wind lockjaw wind closed mouth twitching mouth deficiency deviated mouth wind mouth bearing Chart 1.2.13 Summary of Lip Inspection Five: Inspection of Skin, Hair, and Nails I. INSPECTION OF SKIN The skin covers the entire surface of the body. It is irrigated by the body's blood vessels and collaterals, and correlates with the Lung internally. Skin is the external manifestation of qi and blood. Defensive qi circulat

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