The Body Speaks to Us Before Illness Does

Farzollah Gholizadeh and Fariba Bayrami

What is clinical diagnosis, and how can outward signs lead us to the body’s inner state?

Sometimes the body starts sending signals long before an illness shows itself through severe pain, weakness or an abnormal test result.

The colour of the face changes. The tongue becomes coated. The skin dries out or becomes overly oily. The eyes lose their usual clarity. The nails become brittle or change colour. The hair changes. The lips take on a different colour. Breath odour changes. Sleep, appetite, thirst, sweating or elimination change.

Most of us see these changes but pass over them without a second thought.

Sometimes we buy a cream for dry skin, use mouthwash for bad breath, paint over a discoloured nail, drink coffee for tiredness; but we don’t ask ourselves:

Why did this change happen?

That question is the beginning of “clinical diagnosis”.

What does clinical diagnosis mean?

Clinical diagnosis means recognising a person’s condition through observation, questioning, touch, listening and putting the signs together.

Before laboratories, ultrasound, CT scans and today’s advanced devices existed, the physician obtained most of his information from the patient himself.

He looked. He listened. He asked questions. He felt the pulse. He examined the skin. He looked at the tongue and the eyes. He paid attention to breathing. He examined the urine, the stool and other secretions. And then he put all of this information together.

This is exactly the medical history and physical examination on which a large part of medicine still rests today.

The difference is this: today the physician can complete and confirm clinical findings with laboratory tests and more precise diagnostic tools.

So clinical diagnosis does not stand against laboratory tests.

Clinical diagnosis tells us where to look more carefully; a test can measure or confirm part of what we find.

Why should internal organs affect how we look on the outside?

At first glance it may seem strange.

The liver is inside the abdomen; what does it have to do with the skin? How can the stomach affect the tongue or the breath? Why should the state of the blood show on the lips, the skin or the nails?

The answer lies in a simple principle:

The body is not a collection of separate parts; it is an interconnected system.

Skin, hair, nails, tongue and eyes depend for their life on blood, oxygen, water, nutrients, hormones and the normal working of the internal organs.

If one of these factors changes for a while, its traces sometimes appear in the body’s visible tissues too.

That is why, when assessing an internal illness, a physician may also look at the patient’s eyes, skin, mouth, nails or feet.

The face is not just our appearance

The face is one of the first places where changes in the body can be seen.

Pallor, yellowing, unusual redness, swelling, dryness, skin changes or a loss of vitality can each carry information.

But the key point in reading signs is this:

We should compare a person’s present appearance not with other people but with their own normal appearance.

One person’s naturally dark skin is not an illness. Another person’s naturally fair skin is not an illness either.

What matters more is change.

If someone who has always had rosy cheeks is gradually growing pale, that change is worth looking into.

The eyes are not only for seeing; they can be seen too

Sometimes the eye itself gives a clue.

The physician may pay attention to the white of the eye, the inner surface of the eyelid (its mucous membrane), the pupil, the area around the eye and even eye movements.

Yellowing of the whites of the eyes can lead us to examine bilirubin, the liver and the bile ducts.

Paleness of certain mucous membranes, together with other signs, can draw attention to the state of the blood.

Swelling around the eyes can also have different causes.

But the same principle applies:

A sign is a clue; it is not a definitive diagnosis.

The tongue: one of the body’s most accessible mirrors

We only need to open our mouth, and one of the most easily observed organs of the body is in front of us.

The colour of the tongue, its coating, moisture, dryness, cracks, swelling, tooth marks, spots, sores and the quality of the saliva can all be observed.

In Sina–Unani medicine, the tongue and mouth were considered together with the quality of digestion, the humours and other signs.

Today we also know that some oral diseases, nutritional deficiencies and general illnesses can show signs on the tongue and the lining of the mouth.

But the real skill is not to say:

“A white tongue means such-and-such a disease.”

The real skill is being able to ask:

Is the whiteness in the tongue itself, or in the coating on it? Is the coating thick or thin? Is the tongue dry or moist? How long has this been going on? And what other signs come with it?

That is clinical thinking.

The skin: the body’s largest visible page

The skin covers almost the whole body and so offers the observer a great deal of information.

One can pay attention to:

Colour, warmth, moisture, dryness, thickness, elasticity, sweating, itching, spots, pimples, swelling and surface blood vessels.

For example, pallor can in some cases draw our attention to the state of the blood.

Marked yellowing of the skin and eyes can indicate that the liver and bile ducts need to be examined.

Thick, velvety darkening in some of the body’s skin folds can be seen alongside insulin resistance.

Bluish discoloration of the lips or skin can draw attention to oxygenation.

That is why observing the skin is an important part of the examination in today’s medicine too.

The nail: where the body’s past sometimes leaves a trace

The nail grows slowly.

This means that some past disturbances can remain on the nail for a while.

Colour, shape, thickness, brittleness, lines, pits, growth rate and how well the nail holds to its bed can all give clues.

Sometimes a change in the nail is simply the result of a knock, detergent or a local infection.

But sometimes several nails change at the same time; then the body’s general condition must also be taken into account.

Even in a modern medical examination, nails and mucous membranes can be part of the search for clues to a general illness.

Hair is part of the story too

Hair is not independent of the body’s general condition either.

A sudden change in shedding, dryness, brittleness, thickness or the way it grows can be influenced by different factors such as nutrition, hormones, the thyroid, stress, illness, medication and genetics.

But just as with the nail, an illness cannot be diagnosed from a single hair.

What matters is the pattern.

The lips and mouth have messages too

Lip colour, dryness, cracks, sores, swelling, the state of the gums, breath odour, the taste in the mouth and the amount of saliva are also part of the examination.

Today’s medicine also accepts the oral examination as part of the general examination; some findings in the mouth can be the first sign of a general illness.

So the mouth is not just where the teeth are.

Sometimes what happens in the mouth leads us to ask questions about another part of the body.

Urine and stool: the body’s reports on itself

People today usually flush straight after using the toilet.

Yet the old physicians gave great importance to urine and stool.

Colour, amount, frequency, smell, consistency and changes in these give information about the body’s fluid status, the digestive system, the kidneys, the urinary tract and the general condition.

In the classical sources of Sina–Unani medicine, examining the urine was also an important part of the science of signs; historical studies show that physicians such as al-Razi, Ibn Sina and Jurjani paid attention to the colour, consistency, amount, frequency, smell and sediment of urine.

It is true that laboratories today offer far more detailed analysis. But devices alone cannot catch some important clues; here the eye and clinical judgement of an experienced, skilled physician make the difference.

The pulse: a voice heard through the fingers

The pulse is one of the oldest clinical diagnostic tools in the history of medicine.

Ibn Sina gave the pulse special importance; he examined its speed, strength, size, regularity and quality in different conditions. Historical sources show that a large section of the Canon is devoted to the pulse and its use in examination.

The pulse remains part of the clinical examination today, even though new devices make it possible to measure heartbeat and rhythm precisely.

Sometimes a device shows a number; but the practitioner’s skilled hand notices in which person, and under which conditions, that number appeared.

Voice, movement and even the way someone walks can give information

Clinical diagnosis is not only looking at the skin and the tongue.

Sometimes even the way a person enters the room gives information.

Do they walk with energy, or with effort? How is their breathing? Is their voice strong or weak? Do their hands tremble? Are their movements quick or slow? Is their face symmetrical? How are their awareness and attention?

In the modern clinical examination too, general appearance, breathing, the colour of skin and mucous membranes, swelling in the limbs and many other observable signs are part of assessing the patient.

How does Sina–Unani medicine look at this?

One of the key features of Sina–Unani medicine is that it looks at the person as a whole.

In this view the only question is not:

“Which organ is ill?”

The question is wider:

“How has this person’s overall condition changed?”

What is the temperament like? How are heat and moisture? How is digestion? How is sleep? How are appetite and thirst? How is elimination? What does the pulse say? How have the complexion, skin, tongue and eyes changed?

That is why a “sign” (alamat) gains meaning together with “evidence” (dalil).

In his medical works, Ibn Sina also stressed the importance of gathering all the signs and drawing on clinical observation; historical research shows that the science of signs and differential diagnosis form an important part of his medical writings.

Don’t jump from one sign to one disease

This is perhaps the most important principle in this article.

A white tongue does not always mean a particular disease. A brittle nail does not always mean a particular deficiency. Puffiness under the eyes does not always mean kidney disease. A bitter taste in the mouth does not mean liver disease. Dry skin does not necessarily mean a Sevdavi temperament. A pimple on the face does not necessarily mean a problem with a particular internal organ.

Why?

Because one sign can have dozens of causes.

And conversely, one illness can produce dozens of signs.

Clinical diagnosis means finding the pattern.

What does “pattern” mean?

Suppose a person only has dry skin.

The information we have is still very little.

But now imagine that the same person has dry skin, always feels cold, has hair that has also become dry, has less energy, is constipated, and their weight has changed compared with before.

We are no longer facing “a single sign”.

A pattern is taking shape.

Or think of someone else whose tongue has changed, who has grown pale, tires quickly, gets short of breath climbing stairs, and whose nails have also changed compared with before.

Again, the value of the signs taken together is far greater than that of each sign on its own.

This is what we can call reading the body.

Where does temperament fit into this story?

In Sina–Unani medicine, temperament is like the background on which the signs appear.

Two people can eat the same meal but not react in the same way.

Two people can live in the same climate, yet one constantly feels warm and the other constantly feels cold.

One person’s skin is naturally drier, another’s more moist.

So to understand a change, we first need to know what that person’s normal state is like.

Temperament helps us to know exactly this personal background.

But temperament, too, is not diagnosed from a single sign.

Skin colour, how the body feels to the touch, body build, sleep, activity, reaction to heat and cold, the quality of elimination and many other features are assessed together.

Can every disease be diagnosed just by looking?

No.

And knowing this limit is also part of diagnostic skill.

Some diseases may give no obvious outward sign for a long time.

High blood pressure, disorders of blood fats, the early stages of some cancers and many other diseases may not be diagnosable just by looking at a person.

On the other hand, a single outward sign can have several different causes.

That is why a definitive diagnosis may require blood tests, imaging, a biopsy or other investigations in addition to observation and examination.

Even in dermatology, where observation is extremely important, some lesions need a biopsy or additional tests to be diagnosed.

Good observation does not replace science; good observation is the beginning of science.

Read the body like a book, not like a word

If you open a book and read only one word on the page, you cannot understand the story.

The body is the same.

The skin is one page. The tongue another. The nails, hair, eyes and lips are other pages. Pulse, sleep, appetite, thirst, urine, stool, sweating and mood are other chapters of the same book.

The mistake happens when we tear out a single page and think we have understood the whole story.

Clinical diagnosis is reading the different pages and finding the connections between them.

Everyone should know their body’s language to some degree

The aim of learning the science of signs is not for everyone to become their own doctor, or to fall into health anxiety at every small change.

The aim is much simpler and much more valuable:

To know our own normal body.

To know what our skin is usually like. To know what our tongue looks like. To know how our nails grow. To know what our normal sleep and appetite are. To know what has changed compared with the past.

When we know our body’s normal state, we notice meaningful changes earlier.

Five golden questions for reading any sign of the body

When you notice a change, ask five questions before drawing any conclusion:

• Was this feature always there, or is it new?
• Is it local, or is it seen in several parts of the body?
• What other signs appeared during the same period?
• What makes it better, and what makes it worse?
• Do these changes together form a particular pattern?

These five simple questions make a big difference between seeing and clinical observation.

From “seeing” to “understanding”

We all have eyes and we all see the body.

But clinical observation is a skill that can be learned.

Two people can look at the same tongue; one just says “white”, while the other notices what colour the body of the tongue is, what colour the coating is, how thick it is, whether the tongue is dry or moist, swollen or normal, and how these findings relate to digestion and other signs.

Two people can see the same nail; one sees only a spot, while the other asks: Where did this spot start? Has it moved as the nail grew? Is one nail affected, or all of them? Has the colour of the nail bed changed too? And has the person’s skin, hair or general condition changed as well?

This distance between seeing and understanding is an important part of the science of signs.

Before the body shouts, it sometimes whispers

Everyone understands severe pain. Everyone notices a high fever. Everyone sees bleeding.

But the art of observation begins where the body has not yet started to shout.

A small change in colour, a change in the tongue, a line on the nail, unusual dryness of the skin, a change in sleep, a change in appetite, a change in elimination, or several small signs coming together.

None of these necessarily means illness.

But sometimes it is exactly in these ways that the body tells us:

“Something has changed compared with before; pay closer attention.”

Conclusion: the art of reading the body’s signs

Clinical diagnosis is turning scattered observations into a meaningful picture.

That is, knowing what we will see, where to look, how to look, which question to ask, and above all, how to put several signs side by side.

Sina–Unani medicine has a rich heritage on observation, the pulse, and the signs and evidence of disease. Ibn Sina too stressed the importance of using all the senses to recognise disease and of examining the patient and the body’s secretions.

Diagnostic tools are far more advanced today, but one principle still holds:

Illness doesn’t happen only in the laboratory; it happens in a person.

And that person needs to be seen, listened to, touched, asked questions, and have their changes recognised.

Skin, tongue, eyes, lips, hair and nails are each a piece of the puzzle. Pulse, sleep, appetite, digestion, elimination, thirst, sweating and general condition are the other pieces.

No single piece shows the picture on its own.

But when the pieces fall into place, their meaning becomes clear.

Before the body shouts with illness, it sometimes speaks through signs. The art of clinical diagnosis is learning the language of those signs.

For those who want to learn this language in more depth

What you have read in this article is only an introduction to the wide world of “Elaim & Delail” (signs and evidence).

How to examine the skin, hair, nails, lips, tongue, mouth, eyes, nose, secretions, pulse and other signs; how to tell the underlying temperament apart from changes caused by illness; and above all how to put several signs together into a meaningful clinical pattern all require step-by-step training.

Dr Kalan’s “Elaim & Delail” book and course (currently in Turkish) cover this sign language of the body in a structured, practical way.

The aim is not to memorise a list of “sign = disease”.

The aim is to learn: to see the body, to recognise the signs, to find the connections, and to open a window from the outside onto a better understanding of the inside.

Not sure what your own normal looks like? Start with the free temperament test.

References

• Ibn Sina. Al-Qanun fi al-Tibb; sections on signs, evidence, temperament, pulse, urine and diagnosis.
• Al-Razi, Muhammad ibn Zakariya. Al-Hawi fi al-Tibb; sections on clinical observation and differential diagnosis.
• Jurjani, Sayyid Ismail. Dhakhira-yi Khwarazmshahi.
• Aqili Khorasani, Muhammad Husayn. Khulasat al-Hikma.
• Nayernouri T. Avicenna and clinical experiences in Canon of Medicine.
• Shoja MM, Tubbs RS. The history of anatomy in Persia. Journal of Anatomy. 2007.
• Historical studies on the place of pulse, urine, signs and clinical observation in the works of Ibn Sina, al-Razi and Jurjani.
• Clinical medicine sources on physical examination and the skin, oral and nail signs of systemic disease.
• Dr Kalan scientific and educational sources.