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Xia Yuzhu stated: Observation, Auscultation and Olfaction, Inquiry, and Palpation are indeed indispensable to physicians. This holds true for adult internal medicine (Da Fang Mai), but in pediatrics, observation is primary, inquiry follows, auscultation and olfaction are secondary, and palpation is virtually non-existent. The classics state: "Diagnosing through palpation is called 'Qiao' (skill)." However, since the six pulse positions in children are not fully developed, there is no pulse to feel, and thus "Qiao" has no application. "Diagnosing through inquiry is called 'Gong' (competence)." For infants who cannot yet speak, there is nothing to ask; even when they can speak, they often do not answer truthfully. Thus, inquiry is not always necessary, and "Gong" finds no use. "Diagnosing through auscultation and olfaction is called 'Sheng' (sagehood)." When a child first falls ill, their voice may remain normal, but after prolonged illness, vital energy dissipates, leading to changes in voice. In such cases, there is little to hear, and "Sheng" cannot be demonstrated. Furthermore, texts mention that a weak cry indicates the exhaustion of Yin, yet some cries are weak without indicating Yin exhaustion. This is merely due to being stuck on the superficial sound without determining whether Lung Qi is exhausted or not. Therefore, I assert that observation should be primary. One might ask: "The organs are hidden and their principles subtle; where does observation begin?" I reply: Although the organs are hidden, their manifestations in the sensory orifices and facial colors are comprehensive; although the principles are subtle, their signs displayed on the limbs and five senses are evident. As stated in the *Zhong Yong* (Doctrine of the Mean), "What is manifest contains the hidden." Can these manifest subtleties not illuminate each other? Thus, internal diseases in children must manifest externally; the external is the manifestation of the internal. By observing the form and examining the orifices, one naturally knows the disease. Applying tuina and medication accordingly yields results as swift as an echo responding to a sound.

Inside the body are the Five Zang Organs: Heart, Liver, Spleen, Lung, and Kidney. Since the Zang organs themselves cannot be observed directly, we observe their "biao" (external indicators) and orifices. The tongue is the biao of the Heart: redness or purpleness indicates Heart Heat; swelling with blackness indicates extreme Heart Fire; pale white indicates Deficiency. The nose tip and gum beds are the orifices of the Spleen: red and dry nose indicates Spleen Heat; sallow yellow indicates Spleen failure; red and swollen gums indicate Spleen Heat; ulceration indicates Stomach Fire. The lips are the orifices of the Spleen and Stomach: red/purple indicates Heat; pale white indicates Deficiency; black like lacquer indicates the exhaustion of Spleen/Stomach Qi; deviation of the mouth corner to the left indicates Liver Wind; to the right indicates Spleen Phlegm. The nostrils are the orifices of the Lung: dryness indicates Heat; clear runny nose indicates Cold. The ears and teeth are the orifices of the Kidney: tinnitus indicates Disharmony of Qi; pus in the ear indicates Kidney Heat; teeth resembling soybeans (indicating developmental issues) indicates exhaustion of Kidney Qi. The eyes are the orifices of the Liver: fierce gaze with moving eyeballs indicates Wind; fixed gaze with immobile eyeballs indicates impending exhaustion of Liver Qi. Subdividing the eye parts further relates them to the Five Zang Organs: The black pupil belongs to the Liver; pure yellowing is a ominous sign. The white sclera belongs to the Lung; bluish color indicates injury to Liver Qi; pale yellow indicates accumulation in the Fu organs; dark yellow indicates Damp-Heat in the Lung. The pupil belongs to the Kidney; lackluster appearance with yellowing indicates Kidney Qi Deficiency. The outer canthus belongs to the Large Intestine; ulceration indicates Wind in the Lung. The inner canthus belongs to the Small Intestine; ulceration indicates Heat in the Heart. The upper eyelid belongs to the Spleen; swelling indicates Spleen injury. The lower eyelid belongs to the Stomach; bluish color indicates Cold in the Stomach. Loose closure of both eyelids exposing a seam indicates extreme Deficiency of the Spleen and Stomach.

The face has five regions corresponding to the Five Zang Organs: The forehead belongs to the Heart (Li Fire); the left cheek belongs to the Liver (Zhen Wood); the right cheek belongs to the Lung (Dui Metal); the area below the lips belongs to the Kidney (Kan Water). The Zang organs are interior (Li), and the Fu organs are exterior (Biao). The Small Intestine is the Biao of the Heart: short, yellow, painful urination indicates Heart Heat; clear, long, free urination indicates Deficiency. The Stomach is the Biao of the Spleen: red lips with vomiting indicate Stomach Heat; sallow white lips with vomiting indicate Stomach Deficiency; normal lip color with vomiting suggests Food Injury affecting the Stomach. The Large Intestine is the Biao of the Lung: constipation indicates Fire in the Lung; if the Lung has no Heat but constipation persists, it must be Blood Dryness, and purgatives must not be used; rectal prolapse indicates Lung Deficiency. The Gallbladder is the Biao of the Liver: bitter taste indicates Liver Excess; fright upon hearing sounds indicates Liver Deficiency. The Bladder is the Biao of the Kidney, located to the right of the Qi Sea below the navel. It is described as having a name but no form. Tendon swelling and pain indicate Cold Qi from the Kidney entering the Bladder.

There are five facial colors: Red corresponds to the Heart; red face indicates Heat. Cyan corresponds to the Liver; cyan face indicates Pain. Yellow corresponds to the Spleen; yellow face indicates Spleen injury. White corresponds to the Lung; white face indicates Cold. Black corresponds to the Kidney; black face without luster indicates exhaustion of Kidney Qi. If the facial color differs from usual, and the colors of the orifices match the facial color, then the Deficiency or Excess of the Zang and Fu organs will be accurately diagnosed.

Tu Weisheng commented: Mr. Xia Yuzhu's treatise on observing forms to verify syndromes is largely complete regarding general pediatric conditions, showing unique insight. However, his assertion that palpation, inquiry, and auscultation are unnecessary for children is overly rigid and deviates from common practice. Not all sick children have undeveloped pulses making palpation impossible; not all cannot speak making inquiry useless; not all lie making inquiry unreliable; not all lose their voices making auscultation futile. Even if a child has undeveloped pulses, cannot speak, lies habitually, or has lost their voice due to chronic illness, relying solely on palpation and auscultation is insufficient. However, parents holding the child daily are always present. Is it not possible to inquire about their diet and lifestyle? Therefore, I say Xia Yuzhu's argument is too rigid. How should we handle such cases? We should rely on observation and inquiry while setting aside palpation and auscultation, as most physicians rely on inquiry for treatment.

Regarding tinnitus indicating Qi disharmony, this is true for children, but tinnitus is mostly due to Kidney Deficiency. Children vary in congenital endowment and organ interactions. One cannot claim that because children lack adult desires, they cannot suffer from Kidney Deficiency. Regarding the statement that a lusterless pupil with yellowing indicates Kidney Deficiency, it would be better to change "yellow" to "scorched/dry." Many children have yellow complexions, which do not necessarily indicate Kidney Deficiency; conversely, those with Kidney Deficiency do not necessarily have yellow complexions. When Kidney Water is exhausted and fails to nourish hair, what is the external sign? It appears as scorched, dry, sparse hair forming tufts. If yellowing is equated with Kidney Deficiency, people might misdiagnose all yellow-complexioned sick children as having Kidney Deficiency, while failing to identify those with scorched, tufted hair.

His view that the upper eyelid belongs to the Spleen and the lower to the Stomach is not entirely wrong, but assigning the upper to the Stomach and lower to the Spleen is more appropriate, based on the principle that Yang is above and Yin is below. His claim that clear, long urination indicates Small Intestine Deficiency requires accompanying symptoms to confirm Deficiency, as clear urination is generally normal. His statement that Zang are interior and Fu are exterior aligns with traditional conventions and should not be heavily criticized. Yin and Yang are complementary; each Fu pairs with a Zang. Except for the Pericardium (Hand Jueyin) pairing with the Sanjiao (Hand Shaoyang), which many do not know, people commonly refer to the Five Zang and Six Fu. Since we know the Sanjiao exists and has a pair, we should correct previous misconceptions.

His claim that the Bladder is the Biao of the Kidney and has a name but no form is erroneous. Ancient texts attributed "name but no form" to the Sanjiao because its nature was unknown; actually, internally, it refers to the fatty membranes connecting the upper, middle, and lower Jiao organs, and externally, the white membranes separating fat and muscle. The Bladder, however, has both name and form. It is the residence where the Kidney manages water. Through fire steaming water transformation, fluids rise to become Jin Ye (Body Fluids) and spread outward as Wei Qi (Defensive Qi). If transmitted by Kidney Pathogenic Heat, urinary flow becomes obstructed, leading to retention (Long Bi) or incomplete emptying with turbidity (Lin Zhuo). If Kidney Fire fails, symptoms include cold accumulation, distension, and pain in the lower abdomen, or excessive/incontinent urination. Ancients observed that animal bladders shrink after death and could not distinguish openings, leading to the misconception that it has an upper opening but no lower one. They failed to realize the upper opening connects within the lower Jiao membrane network. To say it has no form ignores its distinct physical existence. Finally, his mention of tendon swelling and pain is confusing. Does he refer to the external genitalia or the tendons of the body? The Liver governs tendons, whereas the Bladder does not.