JOURNAL OF CHINESE MEDICINE NUMBER 48 MAY 1995

CLINICAL ASPECTS OF TONGUE DIAGNOSIS

by Giovanni Maciocia

ne of the most useful aspects of tongue diagnosis is that the tongue body colour nearly always shows the true character of the disharmony. This is especially helpful in complex and contradictory conditions, some examples of which will be described below. Our discussion will be articulated in four parts: The tongue body colour always shows the true condition The tongue does not necessarily show the whole condition When the tongue takes precedence over the pulse and symptoms When not to follow the tongue
THE TONGUE BODY COLOUR ALWAYS SHOWS THE TRUE CONDITION

The colour of the tongue body is the most important and reliable aspect of tongue diagnosis because it always shows the true condition. This is especially useful in those situations where there are confusing manifestations of heat and cold, and of deficiency and excess. Some examples will clarify the importance of this aspect of tongue diagnosis. Kidney yin and Kidney yang deficiency When there is deficiency of both Kidney yin and yang (which is relatively common, especially in women) the clinical manifestations may be contradictory. For example, a woman may suffer from backache, frequent and pale urination, cold feet, slight oedema of the ankles (all signs and symptoms of Kidney yang deficiency), as well as night sweats (a symptom of Kidney yin deficiency). On the other hand, another woman may suffer both from night sweats, hot flushes, dry throat and eyes (all symptoms of Kidney yin deficiency), and from cold feet and pale urine (symptoms of Kidney yang deficiency). Both of these conditions are more likely to appear in women over forty. Unless the pulse is clearly floating and empty, signifying Kidney yin deficiency, or very deep and slow, denoting Kidney yang deficiency, it may not be of much help in differentiating between the two conditions. In fact, in both Kidney yin and Kidney yang deficiency the pulse may simply be weak at both proximal positions. Thus, in such contradictory conditions, the colour of the tongue body is vital in determining the true character of the

disorder. If the tongue body colour is pale, Kidney yang deficiency predominates, and if it is red, Kidney yin deficiency predominates. In the former case one should tonify and warm the Kidney yang, and in the latter nourish the Kidney yin. The importance and significance of the tongue body colour is such that one can safely choose the treatment strategy based upon it. The following brief case history serves to highlight this principle. A woman of 45 had been suffering from night sweats and severe hot flushes for several weeks. While these two symptoms pointed to yin deficiency, she also felt cold in general, her feet were cold, urination was frequent and pale, and, most of all, the body of her tongue was very pale. This indicated that she suffered from a deficiency of both Kidney yang and Kidney yin, with a predominance of the former. Because of this, I adopted the treatment principle of tonifying and warming the Kidney yang and used direct moxibustion with seven moxa cones on Guanyuan REN-4. Although this technique would appear to have been contraindicated by her hot flushes, the results were excellent: the hot flushes which she had suffered for six weeks were stopped with just one treatment. Emotional Problems Where there are emotional disorders the tongue is a very reliable indicator of the true origin of the problem. Generally speaking, for long-standing emotional disorders either the whole tongue or only the tip becomes red. This is due to the fact that every emotional strain (whatever the type of emotion) upsets the normal rising and descending of qi, which over time will stagnate. Long-standing stagnation of qi, on the other hand, leads to heat or fire. Because the Heart houses the spirit, which is affected by all types of emotions, Heart heat or Heart fire will develop. And because the tongue is the offshoot of the Heart, and its tip specifically corresponds to the Heart, either the whole tongue or only its tip will become red. It is for this reason that a red tip to the tongue is such a common finding in long-standing emotional disorders. However, although emotional problems are by far the most common cause of a red tip to the tongue, they are not the only cause. In a few cases the tip of the tongue may

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become red due to overwork. Barring this reason, which is fairly rare, a red tip to the tongue is therefore a very reliable indicator that the basis of disharmony is emotional in nature. Thus, in the course of examining a patient, it is essential to observe whether or not the tongue (or its tip) is red, and the extent of its redness. A careful examination of the tongue, and its integration with the pulse, always provides reliable information about the origin of a disharmony. For example, a person may be very depressed, tired, move very slowly and speak in a decidedly low voice, all of which would suggest a condition of deficiency and the presence of such emotions as sadness or grief. However, if the tongue is dark red with redder sides and tip, this definitely indicates that anger rather than sadness is the cause of the depression. On the other hand, although a person may look restless and anxious, if the tongue is not red, or only slightly red on the tip, sadness or grief may be the real cause of the disharmony. Let us take an example of a different situation: a person may look very anxious and be restless, but if the tongue is pale this indicates that the spirit is restless from a general deficiency of qi and blood, which in this case affects the spirit and causes an emotional disturbance, rather than the other way round. The Heart crack (see illustration 1) is another reliable indicator in emotional problems. If a person is subject to considerable emotional stress with severe anxiety and mental restlessness and has a red tongue, the presence of a Heart crack (in the midline extending to just behind the tip) indicates that the patient has a constitutional tendency to a Heart pattern, and that the problem will therefore be more difficult to treat. If, however, the same manifestations appear with no Heart crack, the condition is not so deeply rooted and should be easier to treat.

Spleen yin, the manifestations of which generally include those of Spleen qi deficiency plus a dry mouth, dry lips and dry stools. If the deficiency of Spleen yin is severe there may also be some symptoms of heat from deficiency, such as a feeling of heat in the face.

Illustration 2

With Stomach yin deficiency the tongue also presents very clear and reliable signs: either a wide crack in the midline in the centre of the tongue (see illustration 3) or small scattered cracks (see illustration 4). Occasionally the tongue may show such cracks even though there are no Stomach symptoms. In my experience such cracks are always diagnostic of a Stomach pattern which can be treated preventively before the appearance of symptoms.

Illustration 3

Illustration 1

Illustration 4
THE TONGUE DOES NOT NECESSARILY SHOW THE WHOLE CONDITION

Spleen yin and Stomach yin deficiency Sometimes the tongue may show a certain condition very clearly even though other signs and symptoms are absent. In these cases the tongue signs are such clear evidence that they may be relied upon and the patient may be given preventive treatment. Two cases in point are Spleen yin or Stomach yin deficiency. With Spleen yin deficiency the tongue has very distinct small transverse cracks on the sides (see illustration 2) and is generally dry. This indicates long-standing deficiency of

Although the tongue body colour shows the true condition of the patient, it should be remembered that it does not necessarily show the whole condition. It needs to be integrated with other aspects of the disharmony, chiefly the pulse, complexion and symptoms. A patients disharmony is a complex of various patterns, each of them manifesting more fully in a particular sphere of clinical manifestations. We therefore need to use tongue diagnosis dynamically in

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conjunction with other manifestations and not merely to confirm the diagnosis. A few examples will clarify this concept. A woman may suffer from Liver blood deficiency leading to Liver yang rising, which causes headaches. Her tongue may be pale, reflecting the blood deficiency, and her pulse wiry, reflecting the rising of Liver yang. If she has other symptoms of Liver yang rising, such as a slightly red complexion and a dry throat, when we integrate these symptoms with the wiry pulse we may be baffled by the pale colour of the tongue. ln fact, most books will say that with Liver yang rising, the tongue (or its sides) will be red. However, if we understand the principle that the tongue may show only a part of the configuration of patterns, we realise that the tongue is reflecting the deficiency of Liver blood, and the pulse and symptoms the rising of Liver yang. Liver Blood deficiency (Pale tongue) Liver yang rising (Wiry pulse, red face etc.)

some years. The tongue would have been pale initially, and become red and peeled with the onset of Liver yin deficiency. Liver yin deficiency will, of course, manifest with its own characteristic signs and symptoms, but some of those associated with Liver blood deficiency may remain. In this case the tongue is unable to show both conditions because it obviously cannot be both pale (Liver blood deficiency) and red (Liver yin deficiency) at the same time. Here we say that Liver blood deficiency has been incorporated within Liver yin deficiency. We must therefore pay attention to the symptoms and nourish Liver blood as well as Liver yin.
WHEN THE TONGUE TAKES PRECEDENCE OVER THE PULSE AND SYMPTOMS

The example of a tongue when there is a deficiency of both Kidney yin and Kidney yang has already been discussed above. In that case the tongue reflects only part of the configuration of patterns, i.e., the predominant deficiency: Kidney yang deficiency (Pale tongue, feeling cold) and Kidney yin deficiency (Night sweats etc.)

Another striking example of how the tongue may reflect only part of a condition occurs in skin diseases. In many cases of chronic skin disease there is wind-heat, damp-heat or heat in the blood (or a combination thereof) which causes the skin lesions to become very red, itchy and hot to the touch. With such striking manifestations of heat in the skin one would expect the tongue to be red. However, because there is often a background of blood deficiency in chronic skin diseases, the tongue is often pale. If we disregarded the principle that the tongue may show only one aspect of a configuration of patterns, we would again be baffled. Blood deficient and dry (Pale tongue) Heat in the blood (Red-hot-itchy kin lesions)

Another very common case in which the tongue reflects only one aspect of a disorder is that of Spleen qi deficiency leading to dampness or phlegm. In women, Spleen qi deficiency also frequently leads to blood deficiency and dryness. While one would therefore expect the tongue to be thin and dry, in fact it is nearly always found to be pale, swollen and with a sticky coating. This occurs because the tongue is reflecting the Spleen qi deficiency and dampness/ phlegm, but not the blood deficiency. Yet another case in which the tongue does not show the whole condition is when a certain pattern is incorporated within another. For example, Liver blood deficiency may evolve into Liver yin and/or Kidney yin deficiency after

In many instances the treatment strategy should be based on the appearance of the tongue rather than the symptoms. Some examples will clarify this concept. Many patients will present with localised heat signs even though the underlying condition is characterised by yang deficiency or cold. Although it is imperative that the heat signs be treated, the underlying condition, as evidenced by the appearance of the tongue, must be the primary focus of treatment. Consider the following case history A 35-year-old woman had been suffering from inflammation and swelling of the left eye; the sclera was red and the eye always felt irritated. All of these symptoms clearly pointed to heat affecting the eye. Her tongue, however, was very pale and she had other signs and symptoms of Spleen yang deficiency. In modern China the tendency in such cases is to completely ignore the tongue and follow the symptoms. As a matter of fact, this patient (a practitioner of acupuncture) had been treated with Chinese herbs while studying in China. But not only had this failed entirely to help the eye, it had also made her worse in other ways, causing diarrhoea and abdominal pain. I examined one of the packets of herbs which she had brought back and noticed that the ingredients were all coldbitter herbs to drain fire from the eyes. In treating this patient I followed the principle of giving precedence to the appearance of the tongue and treated the patient accordingly. I therefore prescribed a formula to tonify Spleen qi, adapted with the addition of a few herbs which gently clear heat from the eyes. This not only produced an improvement in her general condition, but also helped the eye. An example of a contradiction between the tongue and symptoms has already been described above, in which the symptoms showed heat in the blood and the tongue showed blood deficiency and dryness. Although in such cases it is important to address the condition of heat in the blood, nourishing and moistening of the blood should not be overlooked. Patients suffering from carcinoma of the lung may develop a fever followed by symptoms of dryness, such as a dry throat. Very often, however, the tongue is pale, toothmarked and has a sticky coating, which are indications of Spleen qi deficiency and dampness. In this case one should not nourish the yin (in accordance with the symptoms) but

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tonify the Spleen qi and resolve dampness (in accordance with the appearance of the tongue).
WHEN NOT TO FOLLOW THE TONGUE

There are cases when one needs to base the treatment strategy on the symptoms rather than the tongue, at least initially. Heat and cold can coexist and there are cases when the symptoms show heat but the tongue shows cold. In most cases it is better to deal with the heat first and the cold later. This is especially desirable when heat and cold coexist in the same system, e.g., Bladder and Kidneys. A very common example would be that of a patient suffering from urinary problems from damp-heat in the Bladder, but with an underlying deficiency of Kidney yang. The former pattern would cause signs and symptoms of heat, such as burning on urination and dark urine, while the latter pattern will present with such symptoms as backache and feeling cold. This situation is common in women with urinary symptoms or men with prostate problems. In such cases, initially at least it is necessary to ignore the tongue and clear the damp-heat from the lower burner. Another example is that of cases when all the signs and symptoms except the tongue point to a certain condition. It may be that the patient has reached a period of life, usually in the mid-forties, when the tongue is about to change colour. For example, a woman of 44 may suffer from frequent and pale urination, oedema of the ankles, a feeling of cold, diarrhoea, backache, dizziness and tiredness, and her pulse may be very weak at both proximal positions: all of these signs and symptoms point clearly to Kidney yang deficiency, and the tongue should accordingly be very pale. If it is not, we are probably seeing the patient at that moment in time when the condition is just about to change from yang to yin deficiency. This example, taken from an actual case, illustrates the principle in diagnosis of looking not only at the horizon, but also over the horizon, i.e., not regarding the clinical manifestations as static at a given point in time, but being aware of the time scale and how the condition is changing over time.
This article is extracted from Chapter 8 of the forthcoming revised edition of Tongue Diagnosis in Chinese Medicine by Giovanni Maciocia, published by Eastland Press. This new edition, containg much new material, will be available from early June. Giovanni Maciocia, Eastland Press.

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