Section 2　Inspection of the Circumstances of Various Parts of the Body

Based on the inspection of the circumstances of the entire body, inspection of the circumstances of various parts of the body is used to closely examine some regional areas to obtain necessary clinical data, according to the pathological conditions in the patient. It can increase the understanding of the pathogenic condition more deeply and intimately and can also fill any gaps left in the inspection of the circumstances of the entire body.

Inspection of the Head and Face

Inspection of the Head

Inspection of the head includes the shape of the head, fontanel, mobility of the head and condition of the hair. By observing the head one can understand the state of the kidney and brain as well as the excess or deficiency of thezang-fu essence.

The head is the dwelling place of the essence-spirit, or the head is the place where the brain and marrow are housed. The brain is the sea of marrow and marrow is developed from essence, which is stored in the kidney. The hair is the outward manifestation of the kidney and an extension of blood. The head is the meeting place of all the yang channels. Three yang channels of the hand and foot anddu mai all extend to the head. The liver channel of the footjueyin and theren mai also nourish the head. Theyangming channels andren mai extend to the front of the head, thetaiyang channels anddu mai extend to both sides of the head, and the liver channels of the footjueyin have connections up to the eyes and top of the head. The essence of allzang-fu organs comes up to nourish the head. Therefore, inspection of the head will help to examine the state of the kidney, brain and the condition of thezang-fu essence.

The changes of the head circumference in developing stages: a newborn's head is about 36 cm, at six months is 43 cm, at one year is 46 cm, at two years is 49 cm, and at three years is 50 cm. The head circumference then adds 1.5 cm from four to ten years and then will reach 56 cm at eighteen years; after this there is nearly no change. If it obviously exceeds this range, it is called a big head; on the contrary, if it is less than this, it is called a small head. It does not matter if the head is big or small, if the person has a normal intelligence and development, it usually has no pathological significance.

1. Shape of the Head

Big head: A bigger head with smaller face, low intelligence and late closure of cranial sutures in children, which is usually caused by innate deficiency, deficiency of the kidney yang and fluid retention in the brain.

Small head: If a child has a small head with a round top, early closure of the fontanel and is mentally of low intelligence, it is a sign of insufficiency of kidney essence and maldevelopment of the skull.

Square-formed head: Protrusion of the forehead with a flat top and square-formed head in children often results from insufficiency of kidney essence or weakness of the spleen and stomach and mal-development of the skull; this anomaly is usually seen in rickets or congenital syphilis.

2. Fontanel

The fontanel is the space between the skull bones of infants, due to the loose-fitting joints of the skull. It includes the anterior fontanel and posterior fontanel. The posterior fontanel is shown as a triangle and is closed by the postnatal period at two to four months. The anterior fontanel is diamond-shaped and is closed at twelve to eighteen months after birth. These two fontanels are the main regions in the clinical examination of the head.

Protrusion of the fontanel: If the fontanel protrudes out, it is called a bulging fontanel. A bulging fontanel relates to an excess pattern and may be caused by a heat pathogen of warm disease attacking upward, malnutrition of marrow or fluid retention in the skull. It may be seen in hydrocephalus, where there is an increase in the volume of cerebrospinal-fluid in the skull. However, when an infant is crying, the temporary protrusion of the fontanel is normal.

Sunken fontanel: A sunken fontanel relates to a deficiency pattern and is seen in children with vomiting and diarrhoea leading to consumption of body fluids; in shortage of qi and blood and insufficiency of congenital essence or marrow. However, if a sunken fontanel is found in infants younger than six months then this is considered normal.

Retarded closure of the fontanel: This is commonly a manifestation of a shortage of kidney qi and mal-development and usually seen in children with rickets. Here it often involves five kinds of flaccidity (head, neck, hands and feet, muscles, mouth), five kinds of retardation (standing, walking, hair, teeth, speech) as well as other manifestations. Retarded closure of the fontanel may also be seen with other causes e.g. hydrocephalus.

3. Mobility of the Head

Involuntary shaking of the head or tremor in both children and adults indicates internal stirring of liver wind or deficiency of qi and blood and under-nourishment of the spiritessence.

4. Hair

The growth of the hair is closely related to the exuberance or deficiency of kidney qi and conditions of the essence and blood. Consequently, the inspection of hair can help to understand the state of kidney qi or exuberance or insufficiency of essence and blood. The normal person has strong black, brown, red or blonde, luxuriant and lustrous hair, which is a sign of sufficient kidney qi and adequate essence and blood.

Dry, thin, grey-yellow or white hair with loss of hair may indicate shortage of essence and blood and can be seen in patients after a chronic and serious disease.

Sudden patchy or elliptical loss of hair is known as alopecia areata, which is caused by blood deficiency or wind attack.

Thin hair in young people along with signs of dizziness, forgetfulness, aching of the lumbar region and knee joints may result from kidney deficiency.

Greasy hair with pruritus (unpleasant sensation causing desire to scratch) and desquamation on the scalp is usually caused by dryness, which results from heat in the blood.

White hair in young people accompanied by symptoms of kidney deficiency may signify kidney deficiency. White hair with symptoms such as insomnia and forgetfulness are often caused by exhaustion of blood and essence.

Very thin hair in children (or no hair for a long time after birth), accompanied by growth retardation, results from congenital deficiency and damage of kidney-essence.

In children, sparse, brittle and thin hair, which is not luxuriant, is often due to malnutrition.

Inspection of the Face

The facial inspection means observation of the whole face including the forehead. The face is the outward manifestation of the heart; it is also the location of the ascending glory of thezang-fu's essential qi. According to inspection of the face, we can understand excess or debilitation of thezang-fu's essential qi and related pathological changes.

1. Facial Swelling

A. Facial puffy swelling is often seen in water-swelling illnesses or it can be a part of generalised edema. Yang edema, which firstly arises around the eyelids and face and has a rapid onset, often results from external contraction of a wind pathogen, which causes impairment in the descending and dispersing functions of the lung. A white face with slow onset edemaindicates yin edema, which is typically caused by spleen and kidney yang deficiency leading to overflowing of water-damp. Swollen purple blue-green face and lips, palpitations and hasty breathing, indicate heart and kidney yang deficiency or blood stasis with pathogenic fluid attacking the heart.

B. Facial swelling with hot pain, where colour fades when pressed and the eyes are nearly closedcould be facial erysipelas (acute infectious inflammation). If the head is extremely swollen like a pot, it is called swollen-head infection, which is mostly due to inner heat, exuberance of blood heat, epidemic infection, upper fire toxin, or inward invasion of toxin.

2. Cheek Swelling

A. Swelling in one or both cheeks below the ear-lobes without a clear borderline, when pressed, there is a sensation like kneading dough and/or pain, it is mumps. This is a warm toxin caused by an exogenous pathogenic factor, which is often seen in children.

B. If there is a red skin swelling in front of the ear, under the zygomatic bone but above the jaw bones, with fever, chills and pain, this will be suppurative parotitis, which results from upward attack in theyangming by a heat pathogen.

3. Emaciated Face with High Cheek Bones

If the patient has an emaciated face with high cheek bones, hollow eye sockets, often accompanied by withering of the major bones, wasting and sagging of the major masses of flesh, it is caused by debilitation of qi and blood, essential qi exhaustion and belongs to the critical stage of chronic diseases.

4. Deviation of the Face and Mouth

A. If there is deviation of the face and mouth to one side but without half-body paralysis, demonstrating relaxed muscles of the injured side of the face, disappearance of the forehead wrinkles, inability to close the eyes and/or ptosis (drooping of the upper eyelid), a shallow naso-labial groove, change of mouth angle with lips at an inclined angle, this will be damage to the collaterals caused by the wind-pathogen.

B. If there is an inclined mouth angle accompanied by half-body paralysis, it will be wind-stroke due to ascendant hyperactivity of liver yang and blockage of the channels by wind-phlegm.

5. Unusual Facial Expressions

A. Frightened and fearful face: the patient's emotional facial expression is contorted, frightened and fearful, which is often seen with convulsions in children; rabies; goiter; tumour, etc.

B. Sardonic smile: is due to facial spasm, which is seen in umbilical wind or tetanus, etc.

C. Leonine (lion-like) face: is usually seen in leprosy, which also manifests as thickening of the skin, and disfiguring skin nodules (lumps and bumps).

Inspection of the Five Sense Organs

1. Inspection of the Eyes

Significance:

The eyes are the orifices related to the liver and the emissary of the heart. All the essence-qi of thezang-fu organs rises upwards into the eyes. Thus, inspection of the eyes may help one understand excess or decline of theshen/spirit and essence-qi.

Theory of the five wheels (rings):

? The pupil pertains to the kidney, and is called the water wheel (or ring);

? The brown, green or blue part of the eye (iris) pertains to the liver, and is called the wind wheel;

? The white part (sclera) pertains to the lung, and is called the qi wheel;

? The inner and outer canthus pertain to the heart, and is called the blood wheel;

? The eyelid pertains to the spleen, and is called the muscle wheel (Fig. 2-5).

Contents:

In inspecting the eyes, attention should be paid to theshen of the eyes, colour of the eyes, shape of the eyes and movements of the eyes.

(1) Spirit of the eye

A. With spirit: The eyes are bright, shiny and have sufficient lubrication. Eyes with spirit are clear and sparkling, the coloured and white parts of the eyes are clearly demarcated. This condition shows that the disease is mild and easily cured.

B. Without spirit: Dull and inflexible eyes, loss of brilliance, blurred vision, and insufficient lubrication; this situation shows that the disease will be difficult to treat.

(2) Colour of the eye

In normal conditions the veins of the conjunctiva and canthus are ruddy, the sclera is white as porcelain, the colour of the iris is vibrant and the cornea is transparent and without colour.

A. Red, swollen and painful eyes belong to an excess heat pattern.

B. A red canthusindicates excessive heart-fire.

C. Redness of the white part of the eye indicates lung fire.

D. A yellow colourindicates jaundice.

E. Red and swollen eyelids with ulcerationare due to spleen fire.

F. Redness and swelling in the entire eyeis due to liver fire or wind-heat in the liver channel.

G. A pale canthusindicates blood deficiency.

H. If above and below the eyelids is bright this indicates phlegm-rheum disease.

I. Dark eyelids reflect kidney deficiency.

J. If the cornea is muddy with grey and white colouring it is called a nebula, which indicates an invasion by toxin in the black (pupil) part of the eyes, excessive fire of liver and gallbladder attacking upward, damp-heat sweltering or yin deficiency resulting in vigourous fire, etc.

K. When the medial angle of the eye appears to have a light-yellow plaque in the elderly, it is fat pigmentation, which is caused by damp-heat brewing internally or excessive drinking.

L. If there is a grey-white turbid circle around the cornea, it is called an old circle, which is often seen in the elderly and is caused by liver and kidney deficiency.

(3) Form of the eye

A. Swelling in the eye and eyelid:

Puffy swelling in the eye and eyelid just like when first getting up in the morning and puffy face are the beginnings of edema. The swelling of eyelids may be due to spleen deficiency and heat. If there is acute swelling of the eyelids and the eyelids are red, this is due to heat in the spleen; if the onset is slow and the eyelids are not red but soft, it is caused by spleen deficiency.

B. Sunken eye socket:

Sunken eye socket is often due to exhaustion of thezang-fu's essence, and this is a serious sign.

C. Membranous screen or opacity of the eye (nebula):

A spotted screen generated in the pupil and obstructed vision is usually due to heat toxin, damp-heat or phlegm-heat; it also develops from the six pathogenic factors, stagnation of the seven emotions and deficiency of thezang essence or injury. Typically, if there is a visual disorder but the shape of eye is normal, it will be an internal eye disease which is usually due to seven-emotion internal damage, deficiency of qi and blood, shortage of liver and kidney or yin deficiency with exuberant fire. Generally speaking, external disorders mostly are of an excess pattern and internal disorders are of a deficiency pattern.

D. Bulging of the eye:

Bulging of the eyes accompanied by panting breath is lung distension, which is caused by turbid phlegm obstructing the lung, lung failing to govern diffuse and descent. Swelling of the neck (front part) and eye bulging is goiter, caused by wood constraint transforming into fire, binding of phlegm and qi. A single eye bulging indicates a critical disease.

E. Canthus outcrop creeping over the eye (pterygium):

When red vessels and the canthus outcrop creep horizontally from the white part of the eye toward the pupil, this is usually due to wind-heat obstructing the lung and heart channels, stasis of channels or collaterals, steaming of damp-heat or kidney yin deficiency with heart fire flaring-up.

F. Sty and cinnabar (red) eye:

A sty refers to the generation of a small boil like a wheat kernel at the side of the eye, with a little redness, swelling and slight pain. If the red swelling of the eyelid is more severe, this is called "cinnabar eye".

(4) Movements of the eyes

The shape of the pupil in healthy people is round. Its diameter is about 2-5 mm in the natural light. It is sensitive to light and the eyeballs can move freely. In inspecting the movements of the eyes, one should pay attention to the pupil, eyeball and eyelid.

A. Miosis:

Miosis is a medical term for constriction of the pupil. In this condition the diameter of the pupil is below two millimetres. It is usually due to exuberant heat of the liver and gallbladder. It is also caused by poisonous substances, such aschuān wū (Radix Aconiti),c?o wū (Radix Aconiti Kusnezoffii), toadstools and other wild mushroom that are often poisonous, organo-phosphate pesticides, etc.

B. Mydriasis:

Mydriasis is a dilated condition of the pupil of the eye. In this condition the diameter of the pupil is greater than five millimetres. It is caused by exhaustion of the kidney essential qi, and usually refers to a critical illness. If both pupils become completely dilated, this is one of the indications for clinical death. If just one pupil is dilated, it can be due to wind-stroke, craniocerebral trauma or glaucoma; it also indicates other serious illnesses.

C. Staring straight ahead:

Staring straight ahead is a sign of unconsciousness, which may due to exhaustion of thezang-fu essential qi and usually occurs in the critical stage of the disease.

D. Upward staring:

This condition refers to upward staring with failure of the eyes to move, rigidity and spasm of the neck, and arched-back rigidity, indicating a fatal sign oftaiyang channel disease.

E. Strabismus:

This means abnormal alignment of the eyes, and is due to internal stirring of liver wind, since the eyes are related to the liver channel of footjueyin.

F. Disorder of closing eyes:

Bilateral disorder of the eyes closing is often caused by goiter tumour. However, one-sided disorder of an eye closing is often caused by wind-strike involving the collaterals.

G. Sleeping with eyes open:

This is due to deficiency of the spleen and stomach and shortage of qi and blood. Deficiency of the spleen leads to failure of the clear yang ascending and then it can cause a lack of nourishment for the eyelids and the eyes are unable to open or close.

H. Drooping of the upper eyelid (blepharoptosis, also referred to as ptosis):

This is often caused by inherent deficiency, usually spleen and kidney deficiency. Single ptosis is usually due to deficiency of the spleen qi or external injury.

2. Inspection of the Ears

The ears are associated with the kidneys and are the place where many meridians converge. Many disorders in thezang-fu organs, channels and body forms can be reflected on the ears. Inspection of the ears is particularly helpful for diagnosis of kidney essence disorders and pathological changes of theshaoyang channel.

For a healthy person, the helix (auricle) is red and moist with lustre, which is a sign of sufficiency of qi and blood.

Abnormal ears:

(1) Colour and texture

A. A pale auricle is ascribed to deficiency of qi and blood.

B. A red swollen auricle accompanied by running of purulent fluid from the ear is usually due to damp-heat of the liver and gallbladder or an upward attack of a heatpathogen.

C. A blue-black ear is a sign of exuberant internal yin-cold or an acute pain pattern.

D. A scorching dry-black ear signifies extreme loss of kidney essence and exhaustion of kidney yin; it is a critical sign of a severe disease.

E. At the beginning of childhood measles, there is a cold feeling at the auricle, and small red spots at the back of the ear.

(2) Form and movement

A. A thin, dry and withered auricle indicates shortage of congenital kidney essence.

B. A scorched dry and withered ear signifies exhaustion of kidney essence and refers to a critical disease.

C. During a prolonged illness, blood stasis may cause a dry and chapped auricle.

(3) Pathological changes in the ears

A. Running of purulent fluid from the ear (otopyorrhea) indicates liver-gallbladder damp-heat fuming and steaming. In the later stage, it often belongs to kidney yin deficiency and deficiency fire flaming upward.

B. If there are small neoplastic lumps in the external auditory canal, this may be caused by ascending counter-flow of damp-heat and phlegm-fire with qi and blood stagnation.

C. Redness, swelling and pain in the external auditory canal indicates binding constraint of pathogenic heat.

3. Inspection of the Nose

The nose is the opening of the lung and the passageway of inhalation and exhalation. The bridge of the nose relates to the liver, the tip of the nose corresponds to the spleen, the wings of the nose reflect the stomach, and the stomach channels of the footyangming are distributed over the sides of the nose. The nose itself is related to thezang-fu organs, particularly to the lung, spleen and stomach. Accordingly, inspection of the nose is helpful to examine the pathological changes of the lung, spleen and stomach, and to understand the excess or deficiency of the stomach qi.

The normal colour of the Chinese nose is yellow-red and moist, with a bright shining glow, which means sufficient stomach qi.

Abnormal noses:

(1) Colour of the nose

A. A light yellow and moist appearance on the tip of the noseindicates a failure of the stomach qi or the stomach qi returning again.

B. A sombre and withered noseindicates stomach qi failure and belongs to the dangerous illness.

C. A white colour on the tip of the noseindicates deficiency of qi or blood, or loss of blood.

D. A red colour on the tip of the nosemeans heat in the lung and spleen channels.

E. A green-blue nosesuggests deficiency cold or abdominal pain.

F. If the tip of the noseis dark and dry, it may be due to deficiency of the stomach qi and indicates a critical disease.

G. A black nose indicates kidney deficiency or extreme yin-cold.

(2) Form and movement of the nose

A. Red swelling and pain of the nose is usually caused by stomach heat or heat in the blood.

B. A red nose with acne-like pustules on the tip of the nose is called rosacea, which is mostly caused by accumulation of heat in the lung and stomach.

C. Collapse of the bridge of the nose is often seen in syphilis.

D. Collapse of the bridge of the nose (saddle nose deformity) with the loss of eyebrows is usually a critical condition in leprosy.

E. Flaring nares (nostrils or nasal passages) is due to obstruction of the lung by heat or asthma. If the onset is slow with asthmatic breathing, it is a sign of depletion of lung qi functions in dispersing and descending.

(3) Pathological changes in the nose

A. Stuffy nose with running of clear nasal discharge indicates wind-cold.

B. Stuffy nose with running of turbid nasal discharge indicates wind-heat.

C. Stuffy nose with the smell of fish and turbid nasal discharge is called sinusitis, which is caused by externally-contracted wind-heat or upward attack of a stagnated gallbladder channel.

D. Bleeding in the nose (epistaxis)mostly relates to the lung and stomach brewing into heat and then burning the nasal vessels.

E. Soft, translucent, smooth small lumps in the nares, which are blocking the nares and hindering the breath, are called nasal polyps and are caused by damp-heat blockage in the nose.

4. Inspection of the Mouth and Lips

The spleen opens into the mouth and manifests in the lips. Theyangming channels of the hand and foot encircle the mouth and lips. Consequently, inspection of the mouth and lips can aid to the diagnosis of pathological changes of the spleen and stomach.

Normal lips are red and moist, which indicates sufficiency of stomach qi, qi and blood harmony. In healthy person, the mouth and lips can open and close freely with concordant movement.

Abnormal mouth and lips:

(1) Colour of the lips

A. Light white: blood deficiency or loss of blood.

B. Deep red: excessive heat.

C. Red, swelling and dry: extreme heat.

D. Cherry colour: gas poisoning.

E. Blue-green and purple: blood stasis pattern.

F. Blue-green and black: excessive cold or extreme pain.

(2) Form of the mouth and lips

A. Dry and fissured or chapped lips: damage of body fluid.

B. Mouth and lips ulcers: steaming of accumulated heat in the spleen and stomach.

C. Angle of mouth drooling: deficient spleen and exuberant dampness in infants; wind-strike in adults.

D. Flat philtrum, mouth and lips rolling and unable to cover the teeth: spleen qi exhaustion, dangerous illness.

E. Grey-white small ulcers inside the lips and on the mucous membranes of the mouth with a red flush around them, burning pain, or erosion all over the mouth which are both called aphthae: accumulated heat of the heart and spleen steaming upward.

F. White patches like snowflakes in the mouth and on the tongue of infants: thrush, foul turbid qi steaming upward to the mouth.

(3) Movement of the mouth and lips

A. Open (the mouth opens but does not close): a deficiency pattern.

B. Clenched jaw (the mouth closes but there is difficulty in opening): an excess pattern. This can also be seen in convulsive disease, infant's convulsions, tetanus, etc.

C. Pursed (the upper and lower lips pursed-together): struggle of pathogenic qi andzheng (healthy) qi. This can also be seen in umbilical wind or tetanus.

D. Deviated (one side of the mouth relaxed and inclined): wind-phlegm obstructing the collaterals. This can be seen in wind-strike.

E. Shaking (cold shudders and chattering jaws, tense rocking and shaking): yang decline and cold exuberance or severe struggle of pathogenic qi andzheng qi. This can be seen in the shiver sweating of cold damage or malaria breaking out.

F. Stirring (frequent and involuntary mouth opening and closing): the manifestation of stomach-qi weakness.

5. Inspection of the Teeth and Gums

The teeth are the surplus of bones and the bones are governed by the kidney. The gums are the places where theyangming channels of the hand and foot are distributed; therefore, observation of the teeth and gums can help to examine the pathological changes of the stomach and kidney and alterations of the fluid. This observation has an important significance for pattern identification.

The normal teeth appear as white, moist and strong, which is the manifestation of sufficient kidney qi and body fluid. If the gums are light-red and moist, it is the manifestation of sufficient stomach qi, qi and blood in harmony.

Abnormal teeth and gums:

(1) Teeth

A. Dry teeth: damaged stomach yin.

B. Teeth are bright and dry like stone: extreme heat of theyangming, damage of body fluid.

C. Teeth are like withered bone: exhaustion of the kidney yin, essence not nourishing upward.

D. Teeth are sparse, loosening, exposure of the roots of the teeth: kidney deficiency or deficiency fire flaming upward.

E. Teeth are dry, yellow and fall out: exhausted bone; associated with critical illness.

F. Parched teeth with sorde (dark brown or nearly black crusts): extreme heat of the stomach and kidney but qi and fluid unexhausted.

G. Parched teeth with no sorde: extreme heat of the stomach and kidney, qi and fluid exhausted.

H. Clenched jaw: wind-phlegm blocked collaterals or extreme heat generating wind.

I. Grinding of the teeth: extreme heat generating wind, this will be seen as part of a convulsive disease.

J. Grinding of the teeth in sleep: stomach heat or parasite accumulation.

(2) Gums

A. Pale gums: blood deficiency or loss of blood.

B. Red, swollen and painful gums with bleeding: exuberance of stomach fire or stomach fire flaming upward.

C. Pale and receding gums: kidney deficiency or insufficiency of stomach yin.

D. Light swollen and bleeding gums without redness and pain: spleen deficiency, blood failing to be secured and contained; or kidney deficiency, deficient fire flaming upward.

E. Gums are inflamed, discharge of fetid pus, even the lips are corroded, and the teeth are falling out: serious pattern of ulcerative gingivitis, mostly caused by externally contracted pestilence and the accumulated toxin attacking upward.

6. Inspection of the Throat

The pharynx is distinct from the larynx. The pharynx is divided into three parts:

?Nasopharynx (above the palatal plane, back of the nasal cavity);

?Oropharynx (extending from the oral cavity and soft palate, under the palatal plane, on the superior border of the pharynx);

?Laryngopharynx also called laryngeal pharynx, (under the oropharynx, in front, it connects to the laryngeal cavity, and the inferior part connects to the oesophagus).

The soft palate extends downward and forms two layers of mucous membrane, respectively called the anterior palatine arch and posterior palatine arch. The tonsils are located in the gap, which is located between the palatine arches. The rear of the posterior palatine arch is called the posterior wall of the pharynx. The larynx is located under the laryngopharynx and connects to the windpipe. The throat is the passage of the lung and stomach and the passageway of breathing and eating; the kidney channel also connects with the throat. Therefore, by inspection of the throat one may understand the pathological changes of the lung, stomach and kidney.

A normal throat is light-red, moist, not painful, no swelling, has unobstructed breathing, normal pronunciation, and smooth swallowing.

Abnormal throat:

(1) Red and swollen throat

A. Deep red, obvious swelling and pain: extreme heat.

B. Tender red, mild swelling and pain: deficiency of kidney yin and deficient fire flaming upward.

C. Pale red, diffuse swelling: collection of phlegm-damp.

D. One or both sides of the throat are red, swollen and painful, accompanied by yellow white purulent spots, which are easily cleaned off: tonsillitis, mostly caused by extreme heat of the lung and stomach, steaming by fire toxin.

E. The throat is red, swollen, with abnormal protrusion of the tonsils, severe pain, cold and heat: throat abscess, caused by accumulated heat of thezang-fu and external pathogens, heat toxin settling in the throat.

(2) Purulent throat

A. The throat is deep red and swollen, abnormal protrusion of the tonsils, persistent high fever: the pus has emerged.

B. The throat is light red, diffuse swelling with unclear boundaries, which mitigates the pain until the pus emerges, thus there is indistinct pain: the pus has not emerged.

(3) Ragged throat

A. Superficial and dispersed ulcers: slight heat of the lung and stomach or deficient fire flaming upward.

B. Flaky or hollow ulcers: extreme heat of the lung and stomach.

C. Chronic ulcers in red or pale colour: a deficiency pattern.

(4) Pseudomembrane

A. The surface of the throat and ulcers are covered with a layer of yellow-white or pale membrane. It is loose and thick, easily cleaned off, and will not arise again after being cleaned off: stomach heat, mild pathogenic condition.

B. A grey-white pseudo-membrane on the throat that is difficult to remove, bleeding appears when it is removed and it will recur: white throat (diphtheria), heat toxin of the lung and stomach has damaged yin.

Inspection of the Body

Inspection of the body includes the inspection of neck, chest and hypochondrium, abdomen, waist and back.

Normally the neck should be erect and symmetrical with active movements and the trachea located in the middle. The laryngeal protuberance is prominent in the male (Adam's apple) but not visible in the female. The carotid artery pulse is not easily seen at rest.

The thoracic cavity is made up of the breast, sternum, ribs and spinal column. The heart and lung are located within the thoracic cavity, which relates to the upperjiao, and it is the place ofzong (gathering) qi. The breasts are located on the front of the thorax and relate to the stomach channel, but the nipples relate to the liver channel. The area from the armpit down to the twelfth rib, the rib-sides, is the place where the liver and gallbladder circulate. Inspection of the chest and hypochondrium may help one understand the pathological changes of the heart or lung as well as the excess or decline of thezong qi and various breast diseases.

The thorax is an oval-shape, and left to right diameter is greater than the anteroposterior diameter (about 1.5:1). The normal breathing is relaxed and the rhythm is regular, about 16~18 breaths in one minute.

The abdomen means the place below the xiphoid process and above the pubis on the frontal side of the body. It belongs to the middle and lowerjiao, and the liver, spleen, kidneys, gallbladder, stomach, large intestine, small intestine, bladder and uterus are located within it. This is a place where all channels circulate, for this reason the inspection of the abdomen may help one examine the pathological changes of the internalzang-fu organs and excess or deficiency of the qi and blood.

The back of the trunk is the spinal column. The back is the house of the heart and lung. The waist is the house of the kidneys. Thedu mai passes through the spine in the midline. The bladder channel of the foottaiyang travels on both sides of the waist, and the back-shu points of thezang-fu organs are located along it. Thedai mai (belt vessel) runs around the waist and abdomen and bundles all the channels of the yin and yang. A normal waist and back are symmetrical and are able to bend and turn actively. The spine is in the middle when holding a straight posture, cervical and lumbar segments are slightly curved forward and thoracic and sacral segments slightly curved backward; but there is no lateral curvature. Inspection of the waist and back is helpful for understanding the pathological changes of thezang-fu channels.

1. Neck and Nape

(1) Unilateral or bilateral lumps like a tumour below the laryngeal protuberance, large or small, one or both sides, moving upward or downward accompanied by swallowing:

goiter, stagnation of liver qi and retention of phlegm.

(2) Cervical cluster nodules like beans or like a rosary:

(scrofula), yin deficiency of the lung and kidney; deficient fire flaring, the fluid forming the superficial nodules; wind, fire or seasonal pathogens causing accumulation and stagnation of qi and blood forming nodules in the neck and nape.

(3) Contracted or stiff neck (neck rigidity)

A. Tight and strained neck, uncomfortable, aversion to cold with fever: wind-cold attacking thetaiyang channel, disturbance of channel qi.

B. Stiff neck and inability to bend, high fever, loss of consciousness and convulsions: fire pathogen of warm disease attacking upward or cerebrospinal damage.

C. Stiff neck accompanied by dizziness: yin deficiency and yang hyperactivity or disturbance of channel qi.

D. Stiff neck with pain after sleeping: crick in the neck, mostly due to incorrect posture during sleep, stagnation of channels and collaterals qi.

(4) Softness of the neck, and no strength for raising the head

A. In children: inherent deficiency, deficiency of kidney essence, or acquired constitution deprived of nourishment. Dysplasia (abnormal tissue development) can be seen in children with rickets.

B. Softness of the neck after a long term or serious illness, nutation (nodding habitually and involuntarily), deep hollowing of the eye sockets: exhaustion of thezangfu's essence, which belongs to a critical illness.

(5) Pulsation of the neck artery

A. Clearly visible at rest: liver-kidney yin deficiency, ascendant hyperactivity of liver yang.

B. Visible in semi-reclining or sitting position, especially in lying down: edema or abdominal distension.

2. Chest and Hypochondrium

(1) Form

A. Flat chest: yin deficiency of the lung, qi and yin deficiency, or weakness.

B. Barrel chest: lung distension, cough with asthma, lung-kidney qi deficiency.

C. Pigeon breast, funnel chest: inherent deficiency, acquired constitution deprived of nourishment, insufficiency of kidney qi, dysplasia.

D. Asymmetry of both sides of the bony thorax:

a. One side of the bony thorax is sunken: sequellae of lung atrophy, pleural rheum or surgery on the lung.

b. One side of the bony thorax is uplifted: pleural rheum or pneumothorax, etc.

E. Breasts are red, swollen, warm and painful, inhibited lactation, possibly even with ulceration and pus, aversion of cold and heat: acute mastitis, mostly due to stagnation of liver qi and stomach heat or external pathogens.

(2) Breath

A. Prolonged inspiratory phase: hard inspiration due to acute throat disorder, diphtheria, etc.

B. Prolonged expiratory phase: expiratory dyspnoea, asthma, lung distension, etc.

C. Shortness of breath, thorax moves up and down noticeably: excessive heat pattern.

D. Weak breathing, thorax moves up and down, but not noticeably: deficient-cold pattern.

E. Irregular rhythm of breath: lung qi deficiency, critical stage of illness.

3. Abdomen

(1) Abdominal distension

A. Abdominal distension with emaciation of the limbs: tympanites (gases in the abdomen), stagnation of the liver qi, obstruction by dampness and blood stasis.

B. Abdominal distension with general edema: edema, disturbances of the lung, spleen, kidney, water and dampness flowing over the skin.

C. Local abdominal distension: accumulations and gatherings.

(2) Abdominal retraction

A. Emaciation of the body: spleen and stomach deficiency, insufficiency of qi and blood.

B. Scaly, thin skin of the abdominal wall, scaphoid (sunken) abdomen: exhaustion of essential qi, critical stage of illness.

(3) Exposure of blue tendons over the abdominal wall:

drum distension, stagnation of the liver qi and blood stasis.

(4) Blue or black navel of the newborn, local hardness:

critical pattern of umbilical wind.

(5) Red, swelling, erosion or suppuration in the navel of the infants:

umbilical sores, mostly caused by not cleaning the umbilicus which gives rise to damp-heat accumulation.

(6) Acromphalus (abnormal protrusion of the navel) with edema and drum distension:

deficiency of spleen and kidney, critical illness.

4. Waist and Back

(1) Humpback or tortoise back:

deficiency of the kidney qi, mal-development, or vertebral illness, old age.

(2) Bending back and flagging shoulders:

debilitation ofzang-fu's essential qi.

(3) Contraction and pain of the lumbar region, limitation of movements:

invasion of cold-damp; or tumbling down and sudden sprain or contusion.

(4) Arched-back rigidity accompanied by rigidity of the neck and nape, convulsion of the limbs:

internal stirring of liver wind, tension of the sinews, can be seen in tetanus.

(5) Skeletonization, extreme emaciation causing the spine to protrude like a saw:

spinal malnutrition, a manifestation of the damage of thezang-fu essence, chronic and intractable diseases.

Inspection of the Four Limbs

The four limbs include the shoulders, elbows, wrists, palms, fingers of the upper limbs and the thighs, knees, ankles, metatarsus and toes of the lower limbs. The relationship between the four limbs andzang-fu are:

? The lung governs skin and body hair,

? The heart governs blood and vessels,

? The liver governs tendons,

? The kidney governs bones,

? The spleen governs muscles and four limbs.

All of the fivezang organs have relationships with the four limbs, especially the spleen. According to the relationship of the four limbs and channels and collaterals: the three yin and three yang channels of the hands circulate in the upper limbs, and the three yin and three yang channels of the feet flow in the lower limbs. Therefore, inspection of the four limbs may help one understand the pathological changes of the channels andzang-fu organs.

1. Form

(1) Muscle dystrophy:

flaccidity, hemi-paralysis due to wind-stroke, etc. Muscle weakness mostly caused by deficiency of qi and blood or blockage of the channels and collaterals, when the four limbs are deprived of nourishment.

(2) Four limbs edema:

edematous disease.

(3) Knees swelling

A. Knees are red, swollen, and painful with inhibited bending and stretching: heatbì, wind-damp transforming into heat.

B. Knees are swollen and tibias are emaciated, just like the knees of the crane (a type of bird): crane's-knee wind caused by persistent cold-damp, deficiency of qi and blood.

C. Knees are dark purple, with diffuse swelling, and are painful: external injury, damage of the knee-caps or joints.

(4) Exposure of blue vessels on the legs:

internal invasion of cold-dampness, blood stasis in the channels.

(5) Malformation of the lower limbs

Knees: genu varum ('O') or bow legs; genu valgum ('X') or knock knees; feet: pes varus or deviation outward; pes valgus or deviation inward: insufficiency of earlier congenital constitution, deficiency of kidney qi or acquired constitutional deprivation of nourishment, dysplasia (abnormal development of tissue due to any number of many possible causes).

(6) Deformity of the fingers??

A. Shuttle shape of the finger joints, activities are limited: accumulation of winddampness, contracture of the tendons and channels.

B. Clubbing of the fingers: qi deficiency of the heart and lung, blood stasis and obstruction by dampness.

2. Movements

(1) Limbs paralysis:

flaccidity disease, wind stroke, paraplegia, etc.

(2) Convulsive spasms of the four limbs:

internal stirring of liver wind, spasms of the sinews and vessels.

(3) Contracture of the hands and feet??:

stagnation of the cold-pathogen, or qi and blood deficiency unable to nourish tendons and channels.

(4) Trembling of the hands and feet:

blood deficiency unable to nourish tendons and channels, or excessive intake of alcohol, or forewarning of stirring wind.

(5) Wriggling of the hands and feet:

qi deficiency of the spleen and stomach, unnourished tendons and channels, or yin deficiency generating wind.

(6) Restlessness of the hands and feet:

exuberance of internal heat, heat harassing the heart spirit.

(7) Touching the bedclothes, feeling and smoothing the bed, groping in the air and pulling invisible strings:

the manifestation of the loss of spirit, a sign of critical illness.

Inspection of the Anterior and Posterior Yin (Genitals and Anus)

The anterior yin is the genitals and the posterior yin is the anus. Inspection of the anterior yin in males includes observation of the penis, scrotum and testes for disorders such as indurations, swelling, ulcers and any abnormality in form and colour. Inspection in females should be of the external genitalia. Any intimate examination should have a definite indication and the examination should be carried out with suitable respect, an additional professional person should always be present to safeguard both the patient and the practitioner.

1. Anterior Yin

(1) Swelling of the scrotum or vagina (vulvar, swelling)

A.

a. Swelling of the scrotum which is transparent is called watershàn (hydrocele);

b. Swelling of the scrotum, which is not transparent but hard is due to the small intestine falling into the scrotum; it is called foxshàn (severe inguinal hernia): Hernias are usually caused by stagnation of the liver qi, exertion of standing for a long time, or invasion of cold-damp.

B. Superficial swelling of anterior yin: edema.

C. Redness, swelling and pain of the scrotum or vagina: damp-heat pouring down via the liver channel.

(2) Contraction of the anterior yin:

retracted genitals, cold congealing in the liver channel, spasms and contraction.

(3) Eczema on the anterior yin:

eczema on the scrotum or labia vulvae, pruritus and burning pain, moist or effusing fluid: scrotal wind, pudendal eczema, caused by damp-heat pouring down via the liver channel, external attacking of a wind pathogen.

(4) Sores on the anterior yin

A. Sores on the anterior yin or stiff and with diabrosis (ulcerative perforation), rotten smell, effusing ichor (acrid, watery discharge) or blood: pudendal sores, mostly caused by damp-heat pouring down via the liver channel or syphilis.

B. Sores on the anterior yin, which is stiff and looks like a cauliflower, bad smell: cancer, difficult to cure.

(5) Protrusion of the female yin, just like a pear:

vaginal protrusion, spleen deficiency and sinking of the middlejiao qi, or resuming work immediately after delivery.

(6) Abnormal testis: small testis or tender testicles in little boys:

dysplasia (abnormal development of tissue) or sequellae of mumps.

2. Posterior Yin

(1) Anal abscess:

redness, swelling, pain, diabrosis (perforated ulcer) and effusing ichor (acrid, watery discharge) around the anus. This is caused by damp-heat pouring down, or an external pathogen blocked around the anus.

(2) Haemorrhoids:

soft lumps inside or outside the anus, mostly caused by damp-heat accumulated and obstructed in the intestines, blood heat or blood stagnating around the anus.

(3) Anal fissure:

elongated and lacerated ulcer on the mucous membrane of the anal canal accompanied by small ulcers. This is painful, with bleeding on defecation and may be caused by heat in the blood and dry intestines, dry stool, with injury during difficult defecation.

(4) Anal fistula:

an abnormal, narrow, tunnel-like passageway that connects the remains of an old anal abscess to the surface of the skin. The reasons are the same as those for anal abscesses and haemorrhoids.

(5) Proctoptosis:

prolapse of the rectum or the mucus membrane of the rectum from the anus, commonly due to deficiency and sinking of middlejiao qi.

Inspection of the Skin

Skin is distributed over the surface of the body and connected to the lung. Skin is the defending barrier of the body and nourished by the qi and blood of thezang-fu organs through the channels. Therefore, the invasion of external pathogens or disorders of the viscera can be reflected by the skin. Thus, observation of the changes of the colour, lustre and form of the skin has an important significance in diagnosis.

1. Abnormal Colour of the Skin

Normal skin is moist and lustre, it is the manifestation of sufficient essential qi and body fluid.

(1) Red skin

If the skin suddenly turns red as if covered in cinnabar (vermilion in colour), this is called erysipelas. Red wandering toxin developing all over the body, firstly like a red cloud, then usually transmigrating or floating over the body along with swelling and pain, is mostly caused by hyperactivity of heart fire, attack of wind-heat, or carbuncles of children. If it develops from the leg, it is called 'leg erysipelas'; if from the head, it is called 'head erysipelas'. Redness and swelling of the lower limbs is usually caused by internal accumulation of the kidney fire, or damp-heat pouring down.

(2) Yellow skin

Yellow colouration on the skin, face, eyes and nails, indicates jaundice. Jaundice can be divided into yang jaundice and yin jaundice.

A. In yang jaundice, the yellow colour is fresh and bright like an orange and it accompanies dark yellow sweat and urine, with thirst and a yellowish greasy tongue coating. It is usually caused by damp-heat in the liver and gallbladder, or in damp-heat spleen and stomach pathologies.

B. In yin jaundice, the yellow colour is dusky like ashes and it accompanies chills, tastelessness in the mouth and a white greasy tongue coating. It is usually caused by colddamp of the spleen and stomach.

(3) Purple-black skin

The skin is yellow with a dusky blacknes which is called black jaundice or jaundice due to sexual intemperance. It is mostly caused by overexertion damaging the kidney.

(4) Vitiligo

White spots appear on the skin of the limbs, face, etc. They are large or small with a clear boundary and have a chronic course of development. It is called white patch wind and caused by invasion of wind-damp, qi and blood disharmony, and blood not nourishing the skin.

2. Abnormal form of the Skin

(1) Dry skin

The skin is dry and lustreless, even chapping and scaling. This is due to damage of yin fluids or deficiency ofying blood not nourishing the skin.

(2) Dry, scaly skin

The skin is dry and rough just like the scales of a fish; it is commonly due to blood stasis not nourishing the skin.

(3) Sclerotic skin

The skin is rough, thick and sclerotic, with swelling, loss of elasticity, inability to move easily and loss of activity. It may be caused by exterior pathogens, or deficiency of yang and blood with lack of nourishment of the skin, which is caused by the disordered emotions, inappropriate eating, blood stasis, etc.

3. Inspection of Maculopapular Eruptions or Rashes

Maculopapular eruptions are the skin signs of systemic diseases. Maculae and papulae are different.

Maculae refer to crimson or blue-green purple patches spreading underneath the skin, whichcannot be felt by the hand; when one rubs them, they are stable (will not become paler) even after pressing. Maculae can be divided into yang maculae and yin maculae.

Papulae are red, and their shape are small like a pine-kernel and they are slightly raised on the skin, whichcan be felt by the hand when stroked, and they will fade when pressed. Papulae can be divided into measles, wind papulae and concealed papulae. At the same time as using the appearance of rashes to assist in diagnosis it is important to pay attention to the favourable or unfavourable indications of maculae and papulae.

(1) Maculae

A. Yang maculae:

The yang maculae are reddish or purplish, like silk in texture or clouds across the skin. They are accompanied by fever, dysphoria (ill at ease, restlessness, fidgety behaviour), fast pulse and manifestations of an excessive heat pattern. They are caused by invasion of an external warm-heat pathogen, with exuberant heat driving into theying (nutritive) and blood levels e.g. meningitis.

B. Yin maculae:

The yin maculae are blue-green purple in colour, developing without a determined location and are accompanied by a white complexion, cold limbs, deficient pulse, cold feelings, etc. They are due to spleen deficiency failing to govern blood or yang exhaustion causing cold accumulated in the qi and blood.

(2) Papulae

A. Measles:

The measles papulae are pink in colour and have the appearance and size of hemp seeds, appearing first over the hairline and face, gradually extending to the trunk and four limbs and disappearing after full eruption. Firstly there are cough, sneezing, snivelling, tearing of the eyes, cold ears, and red threads appearing behind the ears. After three or four days papule dots appear. This is a common contagious disease in children; mostly due to the exterior wind-heat pathogen.

B. Wind papulae:

The wind papulae are light red in colour, small in size, with a sparse distribution; there is itchy skin and mild symptoms, with slight fever or no fever. It is caused by seasonal wind-heat pathogen.

C. Concealed papulae:

These are light red or white in colour, ranging in size from hemp seeds to sesame seeds but feeling more like blossom petals, protruding suddenly on the skin, with clear borders, sometimes concealed and sometimes visible; itching occurs and patches appear after being scratched. This is often caused by a wind pathogen striking or hypersensitiveness.

(3) Favourable or unfavourable indications of the maculae and papulae

A. Maculopapular eruptions:

a. Mild and favourable pattern:

There is fever with, red rashes appear firstly on the chest and abdomen, gradually extending to the four limbs. Spirit-orientation is clear and fresh after abatement of fever. This indicates the positive likelihood of the pathogens being dispelled.

b. Severe and unfavourable pattern:

There are thick, deep red or purplish black rashes, appearing firstly on the four limbs and extending to the chest and abdomen with incessant high fever and even coma. This is caused by pathogens prevailing overzheng (healthy) qi and internal sinking of pathogenic qi.

c. Dangerous pattern:

The maculopapular eruptions are black, dark and withered rashes.

B. Measles:

a. Favourable pattern:

There is fever, slight sweat, exhaustion, red and lustrous rashes, which disappear after abatement of fever.

b. Unfavourable pattern:

There is high fever, no sweat, light or dark red or red-purple spots unable to erupt. This is caused by external blockage of wind-cold, internal excess of heat pathogen, deficiency and sinking of thezheng qi.

c. Dangerous pattern:

When the rash suddenly disappears and the patient is in coma with panting, this indicates internal sinking of measles toxin.

4. Inspection of Skin Blisters

Vesicles appear clustered together or scattered over the skin. They can be differentiated as miliaria alba, chickenpox, pyretic sores, eczema, etc.

A. Miliaria alba:

There are small white blisters as small as grains of sand, transparent, protruding on the skin, containing a small amount of watery fluid, often seen on the chest, abdomen or neck and occasionally on the four limbs, not seen on the face. Accompanied by hidden fever. This is due to the internal retention of damp-heat and incomplete perspiration.

B. Chickenpox:

There are pink eruptions on the skin of the infant which soon change to oval shape blisters or pustules. The tip of the pox is pointed and has no central depression, the root is round and red, a bright, thin shell which is easy to break open. The spots are unequal in size, accompanied by slight aversion to cold with fever. This is caused by internal retention of damp-heat and belongs to the common contagious diseases in paediatrics.

C. Pyretic sores:

Around the corner of the mouth, border of the lips and sides of the nose there are clusters of small blisters like millet. The sensation is burning ache. These are often seen as equivalent to cold sores or herpes. These are due to external invasion of wind-heat or accumulation of heat in the lung and stomach.

D. Eczema:

Red spots all over the body frequently changing to papulae and blisters, which have an effusion after rupture and become moist sores dissipated over the surface. This is caused by accumulation and stagnation of damp-heat with wind-pathogen depressing damp in the muscles and skin.

5. Inspection of Sores and Ulcers

The most common sores and ulcers that can be seen in the skin, muscle, tendon and bone include carbuncles, cellulitis, boils, furuncles, etc.

A. Carbuncles:

The skin has local redness and swelling, which feels hot and painful with tenderness at the root of the eruptions; this belongs to a yang pattern. The characteristic of carbuncles is that the skin is susceptible to ulceration and then healing in different areas, thick pus appears after opening of the sores and it is easily healed. It is mostly caused by accumulation of damp-heat, stagnation and stasis of qi and blood.

B. Cellulitis:

Inflammation of the soft or connective tissue of the skin in which a thin, watery exudate spreads through the cleavage planes of interstitial tissue spaces; it may lead to ulceration and abscesses, it belongs to a yin pattern. The character is one of difficulty in dispersing with ulcerating and healing alternately, with thin liquid pus; it is difficult to heal. It is caused by deficiency of the qi and blood, accumulation and stagnation of yincold.

C. Boils:

The local skin is red, hot and painful, slightly raised on the skin, like a bean, nut kernel or olive pip in size, possibly with a purulent head. Boils are mostly seen on the face, hands and feet; they are full of pathogenic toxin and on the whole easily dispersed. Boils are due to external invasion of wind pathogen and fire toxin with accumulation of pathogen.

D. Furuncles:

The part of skin affected is small, often a single hair follicle. The furuncle is round in form, red and swollen, has mild heat and pain; healing occurs after ulceration and release of pus. Furuncles belong to the category of minor symptoms and are due to external invasion of heat-pathogen or accumulation of damp-heat.