The First Diagnostic Method
First impressions are very powerful, and exert a lasting influence. This is true not just in human relations, but also in medicine and diagnosis.
Visual diagnosis is the first diagnostic method, because the diagnostic process starts the very moment the patient walks into the doctor's office, and meets the physician face to face. That first impression leaves an indelible imprint on the physician's mind, and begins the process of "sizing up" and observing the patient for general characteristics of humor, temperament and constitutional type.
Consciously or otherwise, all subsequent information received in the diagnostic process will be weighed and measured against these initial visual impressions and observations of the patient. Sometimes the subsequent diagnostic data collected will confirm and corroborate these initial visual impressions, but often, subsequent data will mitigate, alter, or modify these initial impressions. The old saying that you can't always tell a book by looking at its cover holds true for medical diagnosis as well.
But, the physician's first visual impressions provide a basic framework or initial point of departure for the whole process of diagnostic inquiry. If subsequent diagnostic findings don't confirm the visual first impressions, the physician must ask himself, "Why not?"
Developing a Clinical Eye
Everyone has visual first impressions upon meeting someone that give us certain feelings or perceptions about that person's personality traits or character. In fact, it's virtually impossible not to do so; we do it all the time.
The physician not only receives these general personality impressions, but has also trained himself to observe and notice certain visual signs and clues that are indicative of the person's health condition, both innate and constitutional as well as acquired. In other words, he has developed a clinical eye.
The clinical eye of the physician is trained to be more objective, detached and dispassionate than the average layperson. In general, it moves methodically from the generalities of the patient's overall frame and physique, behaviors and mannerisms to increasingly more detailed, specific signs and clues. As with general personality signs and impressions, some of these visual signs and clues can really grab the physician's attention by their sheer distinctiveness, vividness or intensity.
The physician's clinical eye must learn how to distinguish between visual signs that are indicative of the patient's innate constitutional nature and temperament, and signs indicative of acquired conditions or imbalances of humor and temperament. There is no easy or set formula for doing this, other than to be perceptive and observant and learn it gradually through clinical experience. The physician must learn to compare and contrast what he actually sees in the patient with what he visualizes as being normal or healthy for him or her.
Observation and Inspection
Visual diagnosis covers all signs and traits that are visually observable in the patient. The face, however, is a specialized aspect of visual diagnosis in Greek Medicine, which will get its own page.
Other diagnostic modalities in Greek Medicine also depend chiefly on observation and inspection. These are principally diagnosis of the tongue, the urine, and the stool.
But general visual diagnosis brings it all together. It is the clinical observation of the patient as a whole - the totality of his/her physis.
General Behavior, Mannerisms and Demeanor
Perhaps the most general aspect of visual diagnosis is observation of the patient's basic behavior, mannerisms and demeanor. These most frequently indicate the patient's constitutional nature and temperament, but under certain circumstances can also indicate acquired conditions and their nature and temperament. Brief descriptions of the four basic types follow:
Choleric: Forceful, dynamic, energetic, vehement. Flamboyant, expressive, dramatic, bold. Restless, agitated, impatient. Irritable, angry, contentious.
Sanguine: Poised, elegant, sophisticated, refined. Chic, stylish. Enthusiastic, optimistic, sociable, outgoing. Curious, playful. Sensual, indulgent, coquettish, flirtatious.
Melancholic: Quiet, cool, reserved. Detached, objective, withdrawn. Cautious, prudent, circumspect. Ascetic, stoic, spartan. Rigid, inflexible. Lonely, alienated, grief stricken. Pensive, moody, melancholy.
Phlegmatic: Relaxed, languid, easygoing. Good natured, trusting. Slow, passive. Sentimental, sensitive, affectionate. Subjective, self-absorbed. Steady, stalwart.
Incoherent, mindless, distracted or compulsive behaviors and mannerisms are generally not a good sign. Hippocrates noted that if he saw a patient mindlessly fumbling or fiddling with their sheets or bedclothes, they wouldn't have long to live. Any other strange, anomalous or idiosyncratic behavior may, upon careful contemplation of its implications, provide a valuable clue to the patient's diagnosis and treatment.
Posture and Physique
The patient's posture and how they hold themselves can tell the physician a lot. The most basic differentiation to be made in the posture is between high and low energy and vitality levels.
The physician should look for any signs of leaning or slouching, as these are the main indicators of a low energy or vitality level. Generally, a proud, erect bearing and emphatic mannerisms indicate a high energy and vitality level.
The two other main dimensions of posture to consider are display, or projection, and body armoring. Is the patient displaying or projecting a certain part of his/her anatomy? If so, you can bet that that part of the body and its functions are important and held in high esteem by the patient.
Conversely, is the patient hiding or sheltering a certain part of his/her anatomy? If so, chances are that the patient feels weak or vulnerable in that part.
Body armoring can also manifest as stiffness or rigidity, or as the deposition of insulating fat over the sensitive or vulnerable parts to be protected. Stiffness and rigidity are often discernible in the patient's general posture, gait and bearing. The classic sign of a rigid, inflexible attitude and approach to life is a military posture, with the chin and neck tucked in, and the spine ramrod straight.
In terms of physique, the basic parameters of the Four Basic Qualities are as follows:
Hot: Leanness, low levels or absence of fat, or adipose tissue. Good tone of the flesh and muscles. A broad, barrel shaped chest. Abundant and/or curly body hair.
Cold: Corpulence; high levels of fat, or adipose tissue. Lax or flabby tone of the flesh and muscles. A narrow or concave chest. Scanty body hair, which tends to be straight.
Dry: Lean, wiry, compact physique. Good definition and prominence of muscles, veins, sinews, tendons. Knobby, prominent joints; hollowed out flesh and muscles common. Emaciation with extreme dryness.
Wet: Pudgy, plump, rounded physique. Poor definition or absence of visible muscles, veins, sinews, tendons. Dimpled joints, not prominent. Dimpled, rumply flesh, cellulite, stretch marks. Poor tone of the sinews, tendons, fascia, flesh, muscles. Swelling, puffiness, edema.
The typical physique patterns of the Four Temperaments are as follows:
Sanguine: Elegant, statuesque, well-proportioned. Luxuriant, abundant flesh, with good texture and tone. Veins, sinews, muscles, tendons not prominent. Well developed around the hips, thighs and buttocks. Abundant body hair in men.
Choleric: A lean, compact, wiry physique, with good muscle tone and definition. A broad barrel chest. Prominent veins, sinews, tendons. Abundant, curly body hair in men. Prominent joints, but not excessively so. Chest, arms, upper body more developed than hips, legs, lower body.
Melancholic: Slender, lean; can be thin or emaciated. Prominent, well-defined veins, tendons; muscles are well defined, but can also be lean or emaciated. A narrow or concave chest; ribs often prominent. Prominent, square or knobby joints and bone structure. Can have a rigid, military posture.
Phlegmatic: Corpulent, stout, heavyset; tends towards obesity. Lax or flabby muscle tone, with poor definition. Puffy or pudgy. Dimpled joints; poorly defined or absent tendons, sinews, veins. Dimpled flesh, cellulite. Water retention in lower body; swollen feet and ankles common. Can have visible but not prominent bluish veins.
In addition, each of the Four Temperaments has certain parts of the body where it tends to hold or put on excess weight. These weight distribution patterns are as follows:
Sanguine: In the hips, thighs, loins, midsection. In the gluteals and buttocks.
Choleric: In the upper body - chest, upper arms, under the arms, and in the belly.
Melancholic: In the midriff and on the sides, over the hips. Weight gain the least of all the Four Temperaments.
Phlegmatic: All over, but especially in the lower body, below the waist. Weight gain usually the greatest of all the Four Temperaments.
Complexion, or Skin Color
The Four Humors, in their normal proportions, go to give the skin its normal, healthy color. Healthy skin color is mostly pink, or a relatively balanced blend of red and white, contributed by the moist, flourishing Sanguine and Phlegmatic humors, respectively, with slight tints of yellow for yellow bile, and brown for black bile thrown into the mix.
The characteristic complexions, or skin colors, for the Four Temperaments are as follows:
Choleric: Red if heat predominates, and yellow or sallow if bile predominates. Skin texture rough and dry.
Sanguine: A healthy pink - the perfect blend of red and white. A flushed or blushing complexion from an abundance of blood. Creamy, smooth skin texture.
Melancholic: Dark, dusky, olive colored or swarthy. A dull yellow or pasty complexion. Thick or leathery skin texture.
Phlegmatic: Pale or pallid; white. Fair. Moist, smooth skin.
Skin texture isn't normally considered to be visible. But to the perceptive physician, it can be. Moistness or dryness, smoothness or roughness of the skin can be observed as well as felt.
The skin colors I described earlier are those for the pure temperaments, or constitutional types. But often, the clinical picture is mixed, with humors and temperaments vying for supremacy. In such cases, the skin colors will also be mixed, as an artist mixes colors on his palette. Here are some other skin colors that are clinically significant:
Orange: Indicates a mixed predominance of blood and yellow bile.
Green: Indicates the predominance of morbid green forms of yellow bile, like Leekgreen or Verdigris bile.
Purple: Indicates the presence of stagnant and/or poorly oxygenated blood; also called cyanosis. A bluish purple indicates a deficiency of the Innate Heat; a reddish purple favors blood stagnation.
Pale: Aside from coldness, can also indicate a deficiency of blood, or anemia, if other corroborating signs and symptoms are also present.
Cachexic: A very sickly skin color, a combination of sallow, or yellow, with tints of green, brown and/or ashen gray. Indicates a profound disturbance or dyscrasia of the humors; usually seen in patients with cancer or other terminal diseases.
The presence of small, fine spider nevi, visible capillaries, or angiomas (small red spots) indicates a congestion of blood beneath the skin. Often seen in moderation in those of a Sanguine temperament. If these discolorations are also purple, the blood congestion is complicated by blood stagnation and/or cyanosis.
The nails are usually reliable indicators of health or disease conditions prevailing in the body. Certain nail signs act as basic parameters of one's health condition, whereas others are more specific indicators of pathology.
Perhaps the most basic parameter is nail color. Generally, the color of the nails follows that of the overall complexion pretty closely. The ideal is to have nails that are a healthy Sanguine pink; this shows a good, robust perfusion of blood through the organs and tissues. Pail nails, or nails that remain pale for too long ofter they're squeezed, usually indicate an anemic condition, or blood deficiency. Purplish nails indicate cyanosis, or stagnation and/or poor oxygenation / vitalization of the blood.
The visible semilunar rings that radiate outwards from the bases or the cuticles of the nails are another important indicator of the general circulation and vitalization of the blood. If the circulation and vitalization of the blood is good and robust, these crescent shaped rings will project a considerable distance outwards from the base of the nail. If this circulation and vitalization are poor, these rings will project only a small distance from the nail base, or cuticle, or may not be visible at all.
Nail thickness and sturdiness are a reliable indicator of the patient's overall nutritional status. Most specifically, they indicate how well the patient is metabolizing and assimilating protein, and the overall health and condition of the bones and connective tissue. Thin, flimsy or brittle nails indicate problems or deficiencies in these nutritional factors. Thin, flexible nails can also be an indicator of a Choleric temperament and constitutional makeup as well.
Clubbed nails are usually associated with chronic weakness and deficiency of the vital organs - the heart and lungs. If blood circulation and oxygenation are also poor, the nails will be purple, or cyanotic.
White spots on the nails show a deficiency or poor assimilation of calcium, and also zinc. As the nail grows, these spots will gradually move outwards from the base towards the tip.
Longitudinal ridges or striations on the nails show a malabsorption of vital nutrients.
Bitten nails are a sign of nervousness or a nervous temperament.