INSPECTION in TCM 四診:望

Inspection中醫

四診望

Inspection is a method to examine the patient by observation of the expression, appearance, color, and abnormal changes of secretion and excretion, etc.

1. Observation of the Mind

This is to observe the patient's spirit, clearness of consciousness, coordination and vigor of movements, and keenness of response in order to judge the excess or deficiency of yin, yang, qi, and blood in the zang-fu organs and make a prognosis of the disease condition.
Strength of Spirit: The patient is in good spirits, the body resistance and functions of the zang-fu organs are normal, therefore the patient has a good prognosis. Generally speaking, the patient is in good spirits, behaves normally with a sparkle in the eye, and has a keen response.
Loss of Spirit: The patient is spiritless, indifferent in expression, has dull eyes and a sluggish response, or may even be unconscious or have a mental disturbance. This shows damage to the body resistance, a severe disease condition, and a poor prognosis.

2. Observation of the Complexion

Observe the color and luster of the facial region. Generally, a lustrous complexion with normal color indicates ample qi and blood, and a mild disease with a good prognosis. If the complexion is deep in color and withered, this indicates a serious disease condition with damage to the qi and essence, and a difficult treatment with poor prognosis.
White Color: A white color is the sign of a qi and blood deficiency. A pale complexion indicates a yin excess with yang deficiency. A qi deficiency manifests a lusterless and pale complexion and is accompanied by swelling. A pale emaciated face indicates a blood deficiency. A sudden pale complexion with cold sweat is the sign of sudden prostration of yang qi due to febrile diseases caused by exogenous pathogenic wind-cold.
Yellowish Color: a yellowish color is the sign of spleen deficiency and damp accumulation. A complexion that is yellowish, withered and lusterless indicates a qi deficiency of the spleen and stomach. A yellowish, flabby complexion is the sign of damp accumulation due to spleen dysfunction of transportation and transformation. The yellow color of the face, eyes, and skin indicates jaundice. In traditional Chinese medicine a bright orange yellow is diagnosed as yang jaundice caused by pathogenic damp-heat; dark yellow in yin jaundice due to pathogenic cold-damp.
Red Color: Redness indicates excessively full blood vessels due to excessive heat. A red complexion is mostly due to the fever of a common cold, or may be a heat syndrome due to excessive yang in the zang-fu organs. Malar flush with bright red color indicates xu heat syndromes due to yin deficiency and yang preponderance.
Bluish Color: Bluish color indicates syndromes of cold, pain, and blood stasis or convulsion, and is the manifestation of qi and blood obstruction in the channels. Pathogenic cold causes stagnation of qi and blood leading to pain. Children's high fever also shows a bluish complexion, the symptoms of acute convulsion.
Black Color: Black color indicates kidney deficiency, humor accumulation, and blood stasis. This is the manifestation of excessive cold and water, or stagnation of qi and blood. If the complexion is as black as bronze, it is mostly due to an extreme weakness of kidney yang and cold accumulation manifesting as xu-cold syndromes. A dark dray color around the eyes denotes phlegm-humor syndrome due to kidney deficiency. This leads to a dysfunction of the water metabolism or leukorrhea, due to the downward flowing of kidney essence. A dark gray malar can be seen in patients with frequent urination due to kidney deficiency. A dark gray complexion indicates prolonged stagnation of blood such as a consumptive disease with blood deficiency accompanied by menoplania or amenia.

3. Observation of the Tongue [舌苔]

The tongue is the mirror of the body. Harmony and disharmony are reflected in the tongue’s color, moisture, size, coating and the location of abnormalities.
Healthy Organ Systems and a lack of External Pernicious Influences produce a healthy tongue, which is pinkish red, neither dry nor too wet, fits perfectly within the mouth, moves freely and has a thin white coating.
Imbalances in the Organ Systems and/or invasion by Pernicious Influences produce an unhealthy tongue. External Pernicious Influences produce changes in the tongue coating. Interior problems, such as Organ System or Essential Substance disharmonies, produce changes in the tongue body.
When examining the tongue, the Chinese medicine doctor looks at the color of the tongue body, its size and shape, the color and thickness of its coating or fur, locations of abnormalities, and moistness or dryness of the tongue body and fur. These signs reveal not only overall states of health but correlate to specific organ functions and disharmonies, especially in the digestive system. To evaluate the tongue accurately, always do the examination in natural light.
Tongue Body:
The tongue body is a fleshy mass and has color, texture, and shape independent from the apparent qualities of the tongue coating. A pale tongue body indicates deficient Xue, Qi, or Yang or Excess Cold. An overly red tongue body indicates Excess Heat. A purple tongue indicates that Qi and/or Xue are not moving harmoniously and are stagnant. Pale purple means the Stagnation is related to Cold. Reddish purple is related to Stagnation of Heat. When the tongue is black or gray, it indicates extreme Stagnation; if black and dry, that indicates extreme Heat Stagnation; if black and wet, that indicates extreme Cold Stagnation. Bright red indicates Deficient Yin or Excess Heat. Dark red indicates Excess Heat. Cracks in a red tongue indicate Deficient Yin or Heat Injuring the Fluids. If the tongue is pale and cracked, there is Deficient Qi or Xue. Thorny eruptions of the buds on the tongue alert the doctor to Heat or Stagnant Xue.
Tongue FurThe tongue’s coating is best described as moss or fur. It arises when the Spleen causes tiny amounts of impure substances to drift upward to the tongue. When the Spleen and stomach are in balance, there is a uniform density of fur, with a slightly thicker area in the center of the tongue. Thick fur indicates excess. Thin fur is related to deficiency during illness, but is normal if you are well. Fur that is wet indicates Excess Jin-Ye (fluids) and/or a Deficient Yang. Dry fur is a sign of Excess Yang or Deficient Jin-Ye. A greasy fur is a sign of mucus or dampness in the body. If the fur looks peeled off or missing, it reveals Deficient Spleen or Yin or fluids. White, moist fur indicates Cold. Yellow fur means Heat. However, white fur, resembling cottage cheese, points to heat in the Stomach. Gray/black fur with a red body is associated with extreme Heat; gray/black fur with a pale body is a sign of extreme Cold.
Size and Shape:
The healthy tongue rests comfortably in the mouth. It is neither too small nor too large. If a tongue is enlarged and flabby, it indicates Deficient Qi. If, in addition to being enlarged and flabby, the tongue has scalloped (or tooth marked) edges, then it indicates dampness due to Deficient Qi or stagnation of fluids. If the tongue is enlarged and hard, it is a sign of Excess. If it swells so that it fills the mouth and is deep red, that means Excess Heat in Heart and Spleen are a problem. A small, thin tongue can indicate Deficient Yin or Xue.
Movement
A trembling, pale tongue indicates Deficient Qi. A flaccid tongue that is pale often reveals extreme Qi or Xue Deficiency. A flaccid tongue that is deep red reveals severe Yin Deficiency. A trembling, red tongue indicates interior Wind. If the tongue sits off-center in the mouth, early or full-blown Wind stroke may be present. A rigid tongue accompanies an Exterior Pernicious Influence and fever. This may indicate the invasion of the Pericardium by Heat and Mucus Obstructing the Heart Qi.
Location of Abnormalities:
The location of disturbances on the tongue is vivid indications of where disharmonies in the mind/body/spirit are located. Certain organs are associated with the Upper, Middle and Lower Triple Burner, which are in turn associated with the front, middle and back sections of the tongue. For example, if there are red spots on the front third of the tongue, which is associated with the Upper Burner, this indicates that there is Heat in the Lungs. If the tip of the tongue is red, that indicates Heat in the Heart. Menstrual cramps, when associated with Stagnant Xue, are often accompanied by purple spots on the edges of the tongue in the Liver/Gallbladder area.
The Role of Tongue Diagnosis:
Not all tongue irregularities are indications of disharmony, however. Food and drugs may change the coating or color of the body of the tongue. For example, coffee yellows the coating and Pepto-Bismol turns the tongue black.
Furthermore, some people have minor, unchanging cracks on their tongue, which are considered normal. Others are born with what is called a geographic tongue, which is covered with severe cracks and covered with hills and valleys. This is considered normal by some practitioners, but a sign of congenital disharmony by others.
The way a tongue appears is not an absolute indicator of the location of the disharmony, but when taken as part of an overall pattern that includes a complete evaluation, it offers strong clues to the location of disharmony Tongue Proper.
Tongue inspection is objectively reliable but beware of food dye!

Pale Tongue: Indicates xu and cold syndromes or symptoms due to yang qi deficiency and insufficiency of qi and blood.
Red Tongue: Indicates heat syndromes, mostly shi types of disease caused by interior heat, or symptoms of fire preponderance due to yin deficiency.
Deep Red Tongue: Denotes the excessive heat seen in febrile disease due to invasion of exogenous pathogenic heat which as been transmitted from the exterior to the interior of the body. It also can be seen in miscellaneous diseases due to a preponderance of fire caused by yin deficiency, or seen in diseases of accumulated fire in the liver channel.
Purplish Tongue: Shows the syndrome of blood stagnation. A tongue with purplish spots or petechiae also indicates blood stagnation.
Tongue Appearance Flabby Tongue:

A flabby tongue body with teeth marks on the margin and pale in color indicates a yang deficiency of the spleen and kidney leading to accumulation and obstruction of phlegm-dampness. A flabby tongue with a deep red color indicates excessive pathogenic heat attacking the heart and spleen.
Thin and Small Tongue:

This indicates consumption and deficiency of blood and yin. A thin and small tongue with a pale color denotes deficiency of both qi and blood. A thin dry tongue with a deep red color is mainly due to a preponderance of fire and great exhaustion of body fluids.
Rigid Tongue:

Seen in febrile diseases due to the invasion of exogenous pathogenic heat transmitted into the pericardium or due to an obstruction of pathogenic phlegm. It may also be seen in high fever leading to consumption of body fluids and preponderance of pathogenic heat. It is a prodrome of wind-stroke (cerebral stroke).
Deviated Tongue:

This is a prodrome of wind-stroke.
Cracked Tongue:

Cracks on the tongue with deep red color indicate excessive heat. A cracked pale tongue indicates insufficiency of yin and blood. However, a cracked tongueof long term duration without any other symptoms can be considered normal.
Tongue Coating

In the first place, the properties of tongue coating should be examined.
Thinness and Thickness: Generally, if substantial pathogenic factors such as damp, phlegm or food accumulation occur and cause obstruction, they further affect the spleen and stomach leading to the ascent of turbid qi and forming of a thick tongue coating. A white thin tongue coating is formed if nonsubstantial pathogenic factors such as wind, heat, dryness, or cold attack the body; or if the pathogenic factors stay on the body surface; or if body resistance is weak during the disease development.
Moistness and Dryness: The normal tongue coating is moist, which indicates that plenty of body fluid is flowing upward. If the tongue coating is dry, it is due to body fluids failing to moisten the tongue. A dry tongue coating may also be present in some febrile diseases where pathogenic heat consumes the body fluid. A slippery tongue coating may be due to pathogenic damp-humor floating over the tongue surface.
Sticky and Curdled Tongue Coating: A sticky coating is due to hyperactivity of endogenous pathogenic phlegm and damp rising to the tongue, and is mostly seen in diseases caused by pathogenic damp-heat or phlegm-humor. A curdled tongue coating is the outcome of food accumulation in the stomach leading to the ascent of turbid qi to the tongue surface. It is also seen in disease caused by phlegm-damp.
Peeled Tongue Coating: Mostly due to deficiency of qi and yin. If peeled tongue is accompanied by a sticky coating, it indicates a complicated disease condition to which the body resistance is weakened.
No Tongue Coating: Changes in the tongue coating indicate fluctuation in the disease condition. For example, if a qi deficiency of the stomach is manifested by no tongue coating at an early stage, the tongue coating will reappear after the stomach qi is recovered. If a disease has no tongue coating, then suddenly appears, this indicates a perversive flow of stomach qi, or excessive pathogenic heat. If a disease has a tongue coating at the beginning which disappears abruptly, this indicates stomach yin fluid has decreased. If a thick coating gradually turns into a thin white coating, this indicates that pathogenic qi is being gradually weakened, and the disease condition is becoming milder.
Generally, an observation of the thinness and thickness of the tongue coating will indicate the depth of pathogenic qi. The tongue's moistness or dryness shows the body fluid condition. The degree of curdling and stickiness of the tongue coating indicates the dampness of the stomach and spleen. The appearance or disappearance of tongue coating signified the cure or worsening of the disease condition.
Color of Tongue Coating White Coating: Indicates exterior-cold syndromes. A white and thin coating is seen mostly in exterior syndromes, while a white and thick coating appears in interior-cold syndromes. If there is a powder-like whitish coating covering the tongue surface, it is caused by the internal accumulation of summer-humid heat and is usually seen at the onset of pestilential diseases.
Yellow Coating: Indicates interior and heat syndromes. A light yellow tongue coating is seen in cases of slight fever. A deep yellow color indicates high fever. Brownish tongue coatings represent an accumulation of pathogenic heat.
Grayish Coating: Denotes interior-heat syndrome or interior-cold syndrome. A grayish black and slippery coating on the tongue usually indicates symptom-complex due to cold-damp in the interior. A grayish, yellow, and sticky tongue coating usually indicates the accumulation of damp-heat. Grayish and dry tongue coatings are usually due to the consumption of body fluid by excessive heat.
Black Coating: This is often seen at the serious and dangerous stage of disease, and indicates extreme heat or cold. A black, yellow, and dry coating with thorns on the tongue surface usually denotes consumption of body fluid by extreme heat. A black and slippery tongue coating shows excessive cold due to yang deficiency.
Commonly seen tongue signs
Pale tongue, tender, slightly larger than normal Thin, white Qi deficiency//Pale, tongue normal in size or slightly shrunken Slightly dry, thin, white Blood deficiency//Pale, and enlarged and tender, teeth impression on the sides Damp and moist with much fluid, white and thick Yang depletion causing internal collection of cold-dampness//Pale Thin, white, peeled center Insufficient stomach yin//Pale Yellow, slimy Weakness of spleen and stomach//Pale red Thin, white, moist Normal or invasion by wind-cold evils//.Pale red Red tip with white fur Flaming up of heart fire//Red, rough Yellow Retention of heat//Red, prickles Thick, yellow, dry Extreme heat in the interior//Red Dry in center of the tongue Heat scorching the stomach fluids//Red Yellow and slimy Dampness and heat in the qi (vital energy) aspect//Red Thick, yellow and glossy Dampness and heat distending and stagnating in the spleen and stomach//Red Little or no fur Yin deficiency causing virtual fire, deficiency in qi (vital energy) and yin//Deep red (crimson), prickles Thick, yellow Heat evil entering the blood//Deep red Dry with cracked fur Heat evil burning yin//Deep red Black fur Extreme retention of heat//Deep red, shrunken Dry, little or no fur Long term yin eficiency.//Deep red. Yellow and slimy. Internal heat acompanied with phlegm and dampness accumulation//Dark red Bruised spots or patches blood stasis with heat//Pale purple, tender, Glossy damp, moist, Internal cold flourishing.Purple, with bruised spots or patches white. Internal accumulation of blood stasis.//Blue-green and purple Yellow and dry Extreme exhaustion of yin and blood, internal exuberance of virtual fire//Green-blue White and glossy Serious cold syndrome//